Trust Board Papers - iow.nhs.uk

Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public (Part 1)

to be held on

Wednesday 6th April 2016

at

9.30am - Seminar Room,

Earl Mountbatten Hospice, Halberry Lane,

NEWPORT, Isle of Wight, PO30 2ER

Staff and members of the public are welcome

to attend the meeting.

*Excellent patient care

Our vision and goals guide us; our values underpin everything we do

Quality care for everyone, every time

Our Values

*Work with others to keep improving

our services

*A positive experience for

patients, service users and staff

*Skilled and capable staff

*Cost effective, sustainable services

Improve mortality rate Prevent avoidable

harm *Improve care of: - older people - people with

dementia - children and

young people Implementation and monitoring the effectiveness of the sepsis care bundle

*Create and maintain partnerships with other organisations so that we can deliver excellent care *Develop an

integrated IT infrastructure *Develop 24/7 and 7

day services *Improve communication with patients and carers

*Improve what people think of their care *Improve how staff

feel about work *Provide Excellent

End of Life Care

*Improve the culture of the organisation to improve patient experience

All staff continue to develop All staff understand

how their contribution helps to achieve our Vision *Develop our

workforce to embrace integration and co-production

*Improve the Discharging Planning Process

* Design services to deliver best practice within our resources * Ensure value for

money for each service * Develop efficient

and effective processes with minimal waste

Reduce Incidence of Patient Harm

Goa

ls

Prio

ritie

s

QI QI QI QI QI

Working “Beyond Boundaries” to be the preferred choice for sustainable integrated care

*Starred items have direct links to

http://intranet/uploads/General/Graphics/Isle%20of%20Wight%20NHS%20TrustCOL.jpg

The next meeting in public of the Isle of Wight NHS Trust Board will be held on Wednesday 6th April 2016 commencing at 9.30am in the Seminar Room at the Earl Mountbatten Hospice, Halberry Lane, Newport, Isle of Wight, PO30 2ER. Staff and members of the public are welcome to attend the meeting. Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given.

AGENDA

Indicative Timing

No. Item Who Purpose Enc, Pres or Verbal

This meeting will be recorded for the purposes of assisting in preparing the minutes and actions from the meeting.

09:30 1 Apologies for Absence, Declarations of Interest and Confirmation that meeting is Quorate

1.1 Apologies for Absence: Mark Pugh, Executive Medical Director (Oliver Cramer, Deputy Medical Director to deputise); Katie Gray, Executive Director of Transformation & Integration

Chair Receive Verbal

1.2 Confirmation that meeting is Quorate No business shall be transacted at a meeting of the Board of Directors unless one-third of the whole number is present including: The Chairman; one Executive Director; and two Non-Executive Directors.

Chair Receive Verbal

1.3 Declarations of Interest Chair Receive Verbal 09:35 2 Minutes of Previous Meetings 2.1 To approve the minutes from the meeting of the Isle of Wight

NHS Trust Board held on 2nd March 2016 and the Schedule of Actions.

Chair Approve Enc A

2.2 Chairman to sign minutes as true and accurate record 2.3 Review Schedule of Actions Chair Receive Enc B 09:45 3 Chairman’s Update 3.1 The Chairman will make a statement about recent activity Chair Receive Verbal 09:50 4 Chief Executive’s Update 4.1 The Chief Executive will make a statement on recent local,

regional and national activity. CEO Receive Enc C

5 WORKFORCE 5.1 Employee Recognition of Achievement Awards CEO Receive Pres

5.2 Employee of the Month CEO Receive Pres 5.3 Staff Story CS Receive Pres

10:00 6 QUALITY (PATIENT SAFETY, EXPERIENCE & CLINICAL EFFECTIVENESS)

6.1 Presentation of this month's Patient Story CEO Receive Pres

6.2 Quality Governance Committee Chair Report QGC Chair

Receive Enc D

6.3 Quality Improvement Plan / Framework Progress Report EDN Approve Enc E 6.4 Reports from Serious Incidents Requiring Investigation (SIRIs) EDN Receive Enc F 6.5 Safer Staffing report - 6 monthly report EDN Receive Enc G 7 STRATEGY & PLANNING 7.1 Strategy Update CEO Receive Verbal 7.2 Principal Risk Register (Board Assurance Framework) CS Approve Enc H 7.3 Human Resource Strategy EDFHR Approve Enc I 7.4 Indicative Capital Plan 2016/17 EDFHR Approve Enc J 7.5 Operating Plan 2016/17

EDN Receive Enc K

Meeting in public on 6th April 2016 Isle of Wight NHS Trust Board – Page 1

mailto:[email protected]

8 PERFORMANCE 8.1 Finance, Investment, Information & Workforce Committee

Chair Report FIIWC Chair

Receive Enc L

8.2 Performance Report EDFHR Receive Enc M 8.3 Chief Operating Officers Report including Winter Plan COO Receive Enc N 9 GOVERNANCE 9.1 Non Consolidation of Charitable Funds 2014/15 Accounts EDFHR Approve Enc O 9.2 Top Key Issues & Risks arising from Sub Committees for

raising at Trust Board. Minutes Included: Minutes of the Quality Governance Committee held on 29th March 2016 Minutes of the Finance, Investment, Information & Workforce Committee held on 29th March 2016

CS Enc P

10 Any Other Business Chair 11 Joint Working on End of Life Strategy – Trust & Hospice 11.1 Chief Executives presentation CEO/

Hospice CEO

Receive

Pres

12 Questions from the Public Chair 13 Issues to be covered in private. The meeting may need to move into private session to discuss

issues which are considered to be ‘commercial in confidence’ or business relating to issues concerning individual people (staff or patients). On this occasion the Chairman will ask the Board to resolve: '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', Section 1(2), Public Bodies (Admission to Meetings) Act l960.

The items which will be discussed and considered for approval in private due to their confidential nature are:

Chief Executive's Update on Hot Topics Fight for the Wight Campaign Employee Relations Issues Medical Staffing Update by NED lead. Clinical Claims Report 14 Date of Next Meeting: The next meeting of the Isle of Wight NHS Trust Board to be

held in public is on Wednesday 4th May 2016 in the Conference Room - School of Health Science Building, St Mary's Hospital, Newport, IW PO30 5TG

Following the conclusion of the agenda items in Part 1 of the Trust Board, the Board will now convene as Corporate Trustee

1 Board Convened as Corporate Trustee 12:30 1.1 Minutes of the Charitable Funds Committee Meeting held on

15th March 2016 EDFHR Approve Enc Q

Meeting in public on 6th April 2016 Isle of Wight NHS Trust Board – Page 2

Minutes of the meeting in Public of the Isle of Wight NHS Trust Board held on Wednesday 2nd March 2016 at the

Conference Room, School of Health Science, St Mary’s Hospital, Newport, IW PO30 5TG

PRESENT: Eve Richardson Trust Chair David King Non-Executive Director Charles Rogers Non-Executive Director (SID1) Jane Tabor Non-Executive Director Karen Baker Chief Executive Chris Palmer Executive Director of Financial & Human Resources Mark Pugh Executive Medical Director Alan Sheward Executive Director of Nursing Nikki Turner Deputy Chief Operating Officer In Attendance: Mark Price Company Secretary Emma Topping Communications & Engagement Manager

For item 16/T/027 Elizabeth James – Team Co-ordinator/Occupational Therapist - CSRT2 Ute Sinclair Stroke Nurse Specialist Rhiannon Baxter Healthcare Assistant – Poppy Unit Deborah Johnson Sister – Poppy Unit Carey Mc Shane – Ward Sister – Rehab Unit Georgina Littlejohn – Ward Sister – Stroke Unit Natalie Mew Matron Russ Chapman Maintenance Craftsman Glenn Wilson Maintenance Craftsman Kevin Sherwin Maintenance Craftsman Mike Wood Technical Support Assistant – Estates Kevin Bolan Associate Director of Estates Becca Burr Chief Paediatric Speech & Language Therapist Nicholas Furmidge Healthcare Assistant Lynsey Burden Learning Disability Liaison Nurse Tina Woodward Integrated Midwife Diane Hall Midwife Lucie Carroll Quality Advisor – SEE3 Mandy Blacker Business Manager For item 16/T/028 Laura Ferguson. Staff Nurse – Osborne Ward Karen Webb Deputy Sister – Osborne Ward Louise Wall Senior Staff Nurse – Osborne Ward Observers: Linda Fair Patient Council Minuted by: Lynn Cave Board Governance Officer Members of the Public in attendance:

There were no members of the public present. A representative from the IW County Press also attended

Minute No.

1 Senior Independent Director 2 Community Stroke & Rehab Team 3 Patient Safety, Experience & Clinical Effectiveness Team

Enc A

IOW NHS Trust Board Meeting Pt 1 2nd March 2016 1

16/T/022 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND

CONFIRMATION THAT THE MEETING IS QUORATE The Chair welcomed the representative from the Patient Council.

Apologies for absence were received from Katie Gray, Executive Director of Transformation and Integration; Shaun Stacey, Chief Operating Officer, Jessamy Baird, Non-Executive Director; Nina Moorman, Non-Executive Director and Lizzie Peers, Non-Executive Financial Advisor The Chairman announced that the meeting was quorate. Declarations of Interest were received from Charles Rogers and the Executive Director of Financial & Human Resources in their role as Directors of Wightlife Partnership.

16/T/023 MINUTES OF PREVIOUS MEETING Minutes of the meeting of the Isle of Wight NHS Trust Board held on 3rd February

2016 were reviewed and approved.

16/T/024 REVIEW OF SCHEDULE OF ACTIONS The Board received the schedule of actions and the following updates were provided:

a) TB/193 – ICT Task & Finish Group: The Chief Executive would be updating

the Board within Part 2 of the meeting.

b) TB/196 – Trust Capacity Plan: It was agreed that although this was included within the Winter Resilience Report (see 16/T/039) that further monitoring needed to be undertaken and therefore the action would remain open with further updates to come in the Chief Operating Officer’s monthly report.

c) TB/197 – Mental Health Act Hospital Managers Training: The Company

Secretary advised that dates were being finalised with the Chair of the Mental Health Act Scrutiny Committee.

16/T/025 CHAIR’S UPDATE

The Chair reported that there was a lot of activity occurring nationally and she attended a very constructive Chairs/CEO dinner at which Simon Stevens, CEO of NHS England spoke. He is aware of the work the Island is progressing within the My Life a Full Life programme and is very supportive. She also reported that she had attended with the Chief Executive the launch of the new NHS Improvement Authority which brings together Monitor and TDA. The aim is to reduce bureaucracy and create a spirit of collaboration which will foster ‘can do’ attitudes and a learning environment with earned autonomy. The Chair advised that she has continued with her visits around the Trust and was very impressed with the creative approach she viewed within the Pharmacy department. She advised that it would be good to see this method of working extended into the community pharmacy services. She attended this week and spoke at the launch meeting of the Island’s End of Life Care Strategy which was hosted by the Earl Mountbatten Hospice with a range of partners, the high sheriff and other supporters. She confirmed that everyone was committed to the implementation of the strategy as is the Board. The Isle of Wight NHS Trust Board received the Chair’s Update

16/T/026 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented the report and highlighted the following:

National

i. Industrial Action: Further action planned in March and April. Locally the Chief Executive and Executive Medical Director had met with junior doctors to discuss issues of concern.


ii. New Care Models/My Life a Full Life programme: Simon Stevens, Chief Executive of NHS England is very interested in this programme which aligns well with the new Sustainable Transformation Plan being rolled out nationally.

Local

iii. Estates Strategy: An all island estate plan is being developed which is due to be completed by end of March 2016.

iv. System Pressures and Safer Start Week: The week went well with the Trust achieving some improved response times. There are a number of lessons which have been learnt and will be reviewed. Thanks go to Age UK and the Red Cross for their part in the week.

v. Staff Survey: This has now been published and the Board will be receiving a

presentation after the Board meeting today.

vi. Stay Well This Winter: The 111 service advert is being shown across the Island as well as on local transport. NHS England are keen for the IW model to be rolled out across the country.

vii. Listening into Action: A ‘Pass It On’ event was held where a video on

mental health services was screened highlighting life changing and innovative projects.

viii. Appointments: Congratulations to Linda Fair who has been reelected Chair

of the Patient Council and who will be supported by Doreen Britten as Vice Chair. The Executive Director of Nursing is joining the Patient Council as the Executive Lead. Jenni Edgington has been appointed Head of Nursing & Quality for Ambulance, Urgent Care & Community Clinical Business Unit and Emergency Department Consultant Thomas Lawal-Rieley has been appointed as IW Foundation Programme Director4

ix. New Nurses: A further 15 Filipino nurses have joined us and are all very

enthusiastic about being here. Congratulations to HR team for all their work in their recruitment.

The Isle of Wight NHS Trust Board received the Chief Executive’s Update

WORKFORCE 16/T/027 EMPLOYEE RECOGNITION OF ACHIEVEMENT AWARDS The Chief Executive presented the Employee Recognition of Achievement Awards:

This month the nominations were as follows: Category 2 – Employee Role Model:

• Elizabeth James – Team Co-ordinator/Occupational Therapist - CSRT5 • Rhiannon Baxter – Healthcare Assistant

Category 3 – Going the Extra Mile:

• Carey Mc Shane – Ward Sister – Rehab Unit • Georgina Littlejohn – Ward Sister – Stroke Unit • Russ Chapman – Maintenance Craftsman

4 This post overseas the education of doctors during their first two years of practice. 5 Community Stroke & Rehab Team


• Glenn Wilson – Maintenance Craftsman • Kevin Sherwin – Maintenance Craftsman • Mike Wood – Technical Support Assistant – Estates • Becca Burr – Chief Paediatric Speech & Language Therapist • Nicholas Furmidge, Healthcare Assistant • Tina Woodward – Integrated Midwife • Lucie Carroll – Quality Advisor – SEE6

The Chief Executive congratulated all recipients on their achievements The Isle of Wight NHS Trust Board received the Employee Recognition of Achievement Awards

16/T/028 EMPLOYEE OF THE MONTH The Chief Executive presented the Employee of the Month Award:

Employee of the Month – February 2016: Laura Ferguson. Staff Nurse – Sevenacres The Isle of Wight NHS Trust Board received the Employee of the Month Award

QUALITY (PATIENT SAFETY, EXPERIENCE & CLINICAL EFFECTIVENESS) 16/T/029 PATIENT STORY The Chief Executive introduced the patient story which focused on the Discharge

Lounge. The film highlighted the use of the unit from a variety of perspectives. The Executive Director of Nursing confirmed that the film had been shared with staff and made available on the intranet. It has also been reviewed by the Quality Governance Committee who reviewed comments made and in particular those regarding the timeliness of Pharmacy activity. It was found that our Pharmacy provides TTOs 39% within 1 hour of request and 83% within 2 hours which was higher than other Trusts within our area. It was noted that a change in procedure is being explored to improve these times further. Jane Tabor asked if there was data available on the capacity usage of the Discharge Lounge. The Executive Director of Nursing advised that data was available and would be included within the Quality Report.

The Isle of Wight NHS Trust Board received the Patient Story

16/T/0030 QUALITY GOVERNANCE COMMITTEE CHAIR REPORT David King reported on the Quality Governance Committee (QGC) meeting held on

24th February 2016 He highlighted the following areas: Patient Safety

• Pressure Ulcers • Hospital acquired infections • Nutrition

Patient Experience • Poppy Unit • Bereavement Survey

Clinical Effectiveness • Mortality

6 Patient Safety, Experience & Clinical Effectiveness Team


• Oncology

The Isle of Wight NHS Trust Board received the Quality Governance Committee Chair Report

16/T/031 QUALITY IMPROVEMENT FRAMEWORK MONTHLY UPDATE The Executive Director of Nursing reported that work continues within the 6 domains

of Leadership Visibility, Reluctance to simplify measurements, Deference to expertise, Accountability (reward/address bad behaviours), Deep engagement of staff/share and learning and Teamwork. He outlined the results within the report and highlighted key aspects. He stressed that it was important that the Quality Improvement Plan is not just a ‘tick box’ exercise but that it is embedded within the organisation. To this end it would be reviewed and presented to Board at the April Board meeting. Action Note: Reviewed Quality Improvement Plan to be presented to the Board on 6th April.

Action by: EDN Jane Tabor asked what the plans were for falls and pressure ulcers. The Executive Director of Nursing advised that these sat now with the Clinical Business Units who were taking procedures forward to embed within the local practice of the individual areas and where regular monitoring for compliance would take place. Jane Tabor also asked what the plans were for walkabouts. The Company Secretary confirmed that this would be discussed at the next Seminar. The Isle of Wight NHS Trust Board received the Quality Improvement Framework Monthly Update.

16/T/032 REPORT FROM SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIs)

The Executive Director of Nursing reported on the Serious Incidents Requiring Investigation (SIRIs). He reported that one SIRI was reported to the Isle of Wight CCG during January 2016 which was for Poppy Unit – Patient Fall (fractured arm). At the time of writing this report there were: 23 open SIRI’s - 7 of which were overdue with a further 3 overdue with the CCG for consideration of closure. The Executive Director of Nursing confirmed that together with the Executive Medical Director, he was working with the clinical teams to drill down what caused the harm in these cases so that quicker learning can be passed on and procedures tightened up. The Isle of Wight NHS Trust Board received the report from Serious Incidents Requiring Investigation (SIRIs)

16/T/033 SAFER STAFFING REPORT The Executive Director of Nursing reported that the Trust did not meet its locally set

target of 90% average fill rate for nurse staffing for the day shifts. (85.7% for registered nurses in the day and 89.4% for health care assistants in the day) during the month. He advised that these figures included our bank and agency staffing. We are achieving 69% of our registered bank requests, 71% of our Health Care Assistants (HCA) bank requests and 89% of our agency requests. Plans in place for recruitment of staff include the arrival of our recruited staff from the Philippines which will reduce vacancies by 15 in March and 14 in May. This will make an impact on our safer staffing, however it will not be sufficient, and particularly as there will be further staff leaving and retiring during the year. Further recruitment plans are under consideration. There has been a recruitment drive for Health Care Assistants during December which has added staff to the nurse bank. Charles Rogers queried if the report could have more qualitative data included and the Chief Executive also asked if more detail on the vacant posts could be available. The Executive Director of Nursing advised that the 6 monthly report which would be seen


at the next meeting would provide this information Linda Fair, Patient Council was invited to comment by the Chair and asked if the ‘home for lunch’ programme was still active. The Executive Director of Financial & Human Resources confirmed that it was but that discharge planning went beyond this programme. Linda Fair also noted that on a visit to St Helens ward she had seen staff using a tablet very effectively and had received feedback from staff that they preferred it to using paper. The Isle of Wight NHS Trust Board received the Safer Staffing Report

16/T/034 MORTALITY & END OF LIFE REPORT The Executive Medical Director presented the current SHMI7 data which showed the

SHMI at its lowest level in the last 4 years at 1.0. He gave an overview of the various factors relating to deaths within the organisation such as day, location, time and length of stay prior to death. He confirmed that all deaths are reviewed and outlined the use of the Priorities of Care plans (PoCs) which are now used instead of the Liverpool Care Pathway. The Executive Medical Director advised that the second quarterly bereavement survey data had been collated and confirmed that there was a good response. He outlined the scope of the questions and that positive feedback had been received from those who responded. The Chair advised that there was a national awareness week in May and suggested that an event be co-ordinated with local partners. Action Note: The Executive Medical Director to explore scope for an event with the Earl Mountbatten Hospice and local partners.

Action by: EMD David King commented that he had viewed a news article which related to whether there was sufficient communication prior to death. He also questioned the level of trained staff on the wards The Executive Medical Director confirmed that all deaths were reviewed in detail and these included the use of PoCs, national guidelines and all results were recorded. In relation to the trained staff on the wards, he confirmed that all wards had End of Life Champions who had received specialist training but that all staff received mandatory training in this area and that this was delivered in a range of methods both via classroom and e-learning since September and that levels of compliance were being monitored closely. The Isle of Wight NHS Trust Board received the Mortality and End of Life Report

16/T/035 QUALITY PRIORITIES 2016/17 The Executive Director of Nursing presented the report and advised that following

stakeholder consultation the five quality priorities have been defined within the SEE headings:

1. PATIENT SAFETY • Implementation and monitoring the effectiveness of the sepsis care

bundle • Reduce incidents of patient harm

2. CLINICAL EFFECTIVENESS • Improve the discharge planning process • Improve communication with patients and carers

3. PATIENTS EXPERIENCE

7 Summary Hospital-level Mortality Indicator


• Improve the culture of the organisation to improve patient experience

He requested that the Board endorse the quality priorities for 2016/17 to be published in the Trust’s Quality Account. The Isle of Wight NHS Trust Board approved the Quality Priorities 2016/17

STRATEGY & PLANNING 16/T/036 TRUST STRATEGY The Chief Executive advised that the strategy would be discussed at Board Seminar

on 15th March and would be presented for approval on 30th March. It would be implemented from 1st April and would be used within the appraisal process and linked to the Trust’s Goals & Priorities for 2016/17. The Isle of Wight NHS Trust Board received the Trust Strategy update

16/T/037 PRINCIPAL RISK REGISTER (BOARD ASSURANCE FRAMEWORK) The Company Secretary introduced the report and confirmed that there were currently

7 risks which were now being reported via the DATIX system. He stated that the enclosure did not detail the action plan for each risk but this will be expanded for the next meeting. He advised that at present not all data has been updated but that the Executives had now received the necessary training on the system and would now be updating using DATIX henceforth. He also confirmed that an 8th risk would be added to the Principal Risk Register following discussion within the Executive team on capacity and capability. The Chief Executive confirmed to the Board that all risk actions were being progressed although not shown on the current action plan. She acknowledged that the report needs to be more user friendly. The Chair expressed her disappointment that the report had been presented as work in progress and requested that it be more robust before the Board is asked to approve it. The Company Secretary responded that the report will be revised for the next Board meeting taking into account the comments made. The Isle of Wight NHS Trust Board received the Principal Risk Register

16/T/038 FOUNDATION TRUST PROGRAMME The Company Secretary advised that the paper had been discussed at Board Seminar

and revised as agreed. He outlined that the Foundation Trust Programme had not been active for the past 18 months and requested that the Board approve the closure of the Foundation Trust Programme and the Foundation Trust Programme Board which is a sub-committee of the Board. He confirmed that the Trust Membership programme would continue and would be developed in conjunction with the My Life a Full Life programme. He advised that the national focus had changed towards Foundation Trusts with the Foundation Trust model now not the only option for NHS Trusts. The Chair confirmed that the Strategic Partnership Agreement with the IW Council had recently been signed and together with the development of the national Sustainability Transformation Plan this was a positive move forward as the Foundation Trust model does not promote integrated working. She confirmed the Trust’s commitment to this ethos and the My Life a Full Life Programme. The Company Secretary requested that the Board approve the following recommendations:

(i) The closure of the FT Programme and removal of the FT Programme Board from the Board Sub-Committee structure;


(ii) The continued development of our public membership as an NHS Trust with the My Life a Full Life programme and for any future organisational form, and the approval of a recurrent budget for this of £36k.

(iii) The need to consider options for future organisational forms with partners as part of the My Life a Full Life Programme/Vanguard programme.

The Isle of Wight NHS Trust Board approved Foundation Trust Programme report and the closure of the Foundation Trust Programme

PERFORMANCE 16/T/039 PERFORMANCE REPORT The Executive Medical Director presented the Performance Report.

Highlights

• 90% of stay on Stroke Unit and High Risk TIA8 fully investigated & treated within 24 hours above target both in month and year to date

• Ambulance Category A Red 2 calls response time <8 minutes and <19 minutes above target

• Cancer targets achieved for: Symptomatic Breast Referrals Seen <2 weeks, Patients receiving subsequent surgery <31 days, Cancer diagnosis to treatment <31 days and Cancer Patients treated after screening referral <62 days

• % Patients waiting < 6 weeks for diagnostics achieving the target • No new cases of MRSA9 • Mental Health Care Programme Approach targets achieved • Summary Hospital level Mortality Indicator

Lowlights

• 3 Grade 4 Pressure Ulcers in January (14 year to date) • 3 new cases of C.Diff in January (20 year to date) • Referral To Treatment Time - % Incomplete pathways below 92% target • 1 Zero tolerance 52 week wait (incomplete return) • Staff sickness remains above plan • Emergency care 4 hour standard remains below target • Cancer - Patients seen <14 days after urgent GP referral, Urgent referrals to

treatment <62 days and Cancer Patients receiving subsequent Chemo/Drug <31 days below target

• Theatres utilisation below target • Ambulance Category A Red 1 calls response time <8 minutes below target • Financial Position impacted by activity and performance • 6 cancelled operations on/after day of admission (not rebooked within 28

days) • 21 formal complaints in month (207 year to date) • Workforce pressures + pay costs in excess of plan • Governance Risk Rating of 11 for January 2016

A discussion took place and the following issues were raised:

8 Transient Ischaemic Attack (also known as 'mini-stroke') 9 Methicillin-resistant Staphylococcus Aureus (bacterium)


i. Contingency Bed Funding: David King asked if a reason was given by the

CCG for refusing the additional requested funding for these areas. The Executive Director of Financial & Human Resources outlined the current position and advised that discussions were taking place with the CCG and that updates would be provided once these had concluded. She stressed that the Trust was experiencing pressures due to the inability to move patients through the whole Island system and the inability to perform elective surgery was impacting on income.

ii. Ambulance Targets: Jane Tabor queried why the targets were now showing

Red whereas in previous months these had consistently been Green, and in particular the data for 111 call backs. The Executive Medical Director advised that there were a number of underlying issues and he would investigate and report back.

Action Note: The Executive Medical Director would investigate underlying issues causing the current failure of ambulance targets.

Action by: EMD

iii. C.Diff Targets: Jane Tabor commented that the target seemed to be high. The Executive Medical Director advised that the targets are set nationally.

iv. Elective Waiting Lists: David King asked if the number of patients on the

waiting list had increased due to recent operational pressures. The Executive Medical Director confirmed that both orthopaedic and general surgery lists have reduced and urology remains the same. He advised that the Chief Operating Officer would review and report back to the Board next meeting within his monthly update. David King asked if the report could show which patients chose to have their elective surgery with a mainland provider.

Action Note: The Chief Operating Officer to review elective surgery waiting times and report trends on specific areas including details of patients who have chosen to have their elective surgery with a mainland provider within his monthly report.

Action by: COO The Isle of Wight NHS Trust Board received the Performance Report

16/T/040 WINTER PLAN PROGRESS REPORT The Deputy Chief Operating Officer reported that the Trust’s Winter Resilience

Programme is designed to deliver interdependent system wide capacity and activity to improve patient flow for our non-elective and elective patients to enable them to receive their treatment in the right place at the right time. Delivery of this Programme is monitored weekly against activity and financial plans both internally within the Trust and jointly through the System Resilience Group (SRG) structure The Deputy Chief Operating Officer gave an overview of the Poppy Unit occupancy and advised that patient feedback on the unit was very positive. She highlighted the challenges to ambulance performance and meeting the targets for emergency care standards as well as issues with the underperformance of theatre utilisation. She confirmed that there was improvement in the elective work in orthopaedic and general surgery theatre work but that urology still continued to be an issue. She explained how these issues were planned to be resolved and improvements from April were planned. The Deputy Chief Operating Officer advised that in relation to finance formal approval has been sought from the CCG for the winter costs incurred in total. Further negotiations are taking place regarding the cost of contingency beds which have been opened throughout the financial year due to bed pressures (approx. £844k Oct to Mar forecast & £269k for April to Sept). She confirmed that additional options for capacity beyond the end of March would be discussed over the coming days. Jane Tabor commended the report and stated that there were a number of good initiatives shown. She asked what was needed to ensure that these are sustained.


The Chief Executive confirmed that a good start had been made and now it was important for the staff to take ownership of the relevant processes. Jane Tabor also asked if additional resources were needed to enable elective appointments to be booked. The Chief Executive advised that the process to book an operation is a very complicated process which included a wide range of factors including staff, equipment, medical supplies etc., and needed a degree of training. The Deputy Chief Operating Officer advised that new staff are in place but will take a period of time before they are fully proficient and advised that the new manager is now in place together with nurses to support. The Deputy Chief Operating Officer also advised that in relation to the emergency care standard new Emergency Care Pathway managers have been in post providing cover 7 days per week. She advised that the staff working on this will be potentially leaving at the end of the month but will be leaving a legacy of completed revised processes within Medical Assessment Unit and Emergency Department. Jane Tabor requested that a discussion on patient flow and key access targets could be a topic for Board Seminar. Action Note: The Company Secretary to arrange a session on patient flow and key access targets at a future Board Seminar

Action by: CS The Isle of Wight NHS Trust Board received the Winter Plan Progress Report

16/T/041 FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE (FIIWC) CHAIR REPORT

Charles Rogers presented the report from Finance, Investment, Information and Workforce Committee on 23rd February 2016 and highlighted the following: Human Resources

• Safer Staffing. • Sickness Absence. • Medical Staffing. • Raising Concerns at Work (Whistle Blowing) Policy.

Financial • Financial Performance Report 2015/16. • Business Planning. • Procurement Service Contract.

The Isle of Wight NHS Trust Board received the Finance, Investment, Information and Workforce Committee Chair Report

GOVERNANCE 16/T/042 TOP KEY ISSUES AND RISKS ARISING FROM SUB COMMITTEES FOR RAISING

AT TRUST BOARD The Company Secretary presented the Top Key Issues and Risks report which

included items from the Quality Governance Committee, Finance, Investment, Information & Workforce Committee and Audit & Corporate Risk Committee. The full minutes of the meeting were circulated for information. The Isle of Wight NHS Trust Board received the Top Key Issues and Risks arising from Sub-Committees


16/T/043 AUDITOR PANEL TERMS OF REFERENCE AND APPOINTMENT OF CHAIR OF

AUDITOR PANEL The Company Secretary presented the terms of reference for the Auditor Panel and

requested that these were approved. The Chair nominated David King to be Chair of the Auditor Panel which he accepted. The Isle of Wight NHS Trust Board approved the Terms of Reference for the Auditor Panel and approved the appointment of David King as Chair of the Auditor Panel

16/T/044 ANY OTHER BUSINESS There was no other business.

16/T/045 DATE OF NEXT MEETING The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board to be

held in public is on Wednesday 6th April 2016 at the Earl Mountbatten Hospice, Halberry Lane, Newport, IW PO30 2ER. There will also be an extraordinary meeting of the Board on Wednesday 30th March 2016 to approve the 2016/17 Annual Plan and Budget. This will be held in the Large Meeting Room, 1st Floor – South Block, St Mary’s Hospital, Newport, IW PO30 5TG

The meeting closed at 12.40pm Signed………………………………….Chair Date:…………………………………….


Enc B

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ISLE OF WIGHT TRUST BOARD Pt 1 (Public) - April 15 - March 16ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

02-Sep-15 15/T/163vi TB/176 Appraisals: The Chief Executive agreed toensure that TEC is monitoringand seeking improvements inthe level of appraisals.

CEO (EDTI)

28/10/15 - This is scheduled for TEC on 9/11/15 andwill be reported back to the Board at the Decembermeeting.03/12/15 - TEC will be reviewing during December andJanuary and will report back for February Board.15/12/15 - The Executive Director of Transformationand Integration confirmed she was leading on this andwill report back in February.26/01/16 - Due to the sickness of the ExecutiveDirector of Transformation and Integration this hasbeen deferred until March.03/02/16 - The Executive Director of Financial &Human Resources confirmed that she was now pickingthis up and seeking a significant improvement by theend of 2015/16.29/03/16 - The Executive Director of Financial &Human Resources confirmed that this is now beingprogressed as part of the Staff Experience Group.Aiming for all staff to have appraisals April - June 2016.Appraisal paperwork has been updated.

TEC 04-Nov-15 31-Mar-16 Progressing

04-Nov-15 15/T/228 TB/188 Older Persons Nurse Fellowship Update

Company Secretary to arrangefor Di Goring to present anupdate at Seminar inapproximately 6 months.

CS On Seminar Forward Plan for May 16 Seminar 17-May-16 17-May-16 Progressing

Non Executive Financial Advisor: Lizzie Peers (LP)

Executive Director of Nursing (EDN) Deputy Director of Nursing (DDN) Chief Operating Officer (COO)

Non Executive Directors: Eve Richardson (Chair) Charles Rogers (CR) Nina Moorman (NM) David King (DK) Jane Tabor (JT) Jessamy Baird (JB)

Key to LEAD: Chief Executive (CE) Executive Director of Financial & Human Resources (EDFHR) Executive Director of Transformation & Integration (EDTI) Executive Medical Director (EMD)

Company Secretary (CS) Board Governance Officer (BGO) Head of Communications (HOC)

Head of Corporate Governance (HCG)Business Manager for Patient Safety, Experience & Clinical Effectiveness (BMSEE)Deputy Director of Informatics (DDI)

Enc B

31/03/20162 of 3

Date of Meeting




Committee


Progress RAG

Date Closed

15-Dec-15 15/T256 TB/192 Discharge Summaries The Executive Medical Director to ask the Deputy Medical Director for a plan to improve the completion of discharge summaries

EMD 19/01/16 - the Deputy Medical Director has established a group and is planning a change in the process to achieve significant improvement from April 2016.03/02/16 - The Executive Medical Director provided an update and confirmed he was confident that there would be a an improvement in the completion of discharge summaries.23/02/16 - Meetings have been held with key stakeholders; a GP survey has been distributed; work is in progress to review process with key staff; action plan is being developed.29/03/16 - The Deputy Medical Director wil provide a verbal update at the Board meeting

06-Apr-16 06-Apr-16 Progressing

15-Dec-15 15/T/255 TB/193 ICT Update - Actions for Task & Finish Group

It was agreed to include cost savings as efficiencies as key goals and the Chair asked that the expertise of primary care and what was emerging in the My Life work be included in the Task & Finish Group

CEO(EDTI)

22/02/16 - The Chief Executive to give an update on the ICT Task & Finish Group at the March Board meeting02/03/16 - ICT Task & Finish Group: The Chief Executive would be updating the Board within Part 2 of the meeting.29/03/16 - First meeting took place on 15 March 2016

Task & Finish Group

15-Mar-16 06-Apr-16 Progressing

03-Feb-16 16/T/010 TB/194 Principal Risk - Cost Effectiveness

The Executive Director of Financial & Human Resources agreed to review the principal risk on cost effectiveness to include a 2016/17 forward look

EDFHR 23/02/16 - The prinicipal risks are currently being reviewed and updated to reflect these aspects.29/03/16 - Update to the Principal Risks for this month includes this

06-Apr-16 06-Apr-16 Completed 29-Mar-16

03-Feb-16 16/T/010 TB/195 Principal Risk - Capacity & Capability

The Company Secretary to respond to Jane Tabor on the capacity and capability risk she has raised..

CS 22/02/16 - Company Secretary confirmed to Jane Tabor that the Executive team have discussed and proposed that this is the subject of another principal risk to place on the Principal Risk Register. This will be included on the Principal Risk Register report for the April Board meeting.29/03/16 - Incorporated in Prinicpal Risk Register for 6 April meeting


03-Feb-16 16/T/015 TB/196 Trust Capacity Plan The Chief Operating Officer toreport on the Trust CapacityPlan for 2016/17 at the 2nd

March Board meeting.

COO 23/02/16 - This is included in the Winter Plan report to the March Board meeting. This action is now closed.02/03/16 - It was agreed that although this was included within the Winter Resilience Report (see 16/T/039) that further monitoring needed to be undertaken and therefore the action would remain open with further updates to come in the Chief Operating Officer’s monthly report.

06-Apr-16 06-Apr-16 Progressing

03-Feb-16 16/T/19 TB/197 Mental Health Act Hospital Managers Training

The Company Secretary to agree with the Chair a suitable date for the Mental Health Act Hospital Managers training to be undertaken to ensure maximum attendance by Non-Executive Directors.

CS 23/02/16 - The Company Secretary has proposeddates to the Chair of Mental Health Act ScrutinyCommittee02/03/16 - The Company Secretary advised that dateswere being finalised with the Chair of the Mental HealthAct Scrutiny Committee.29/03/16 - This is now scheduled for Wednesday 27April 16

MHASC 06-Apr-16 06-Apr-16 Completed 29-Mar-16

Enc B

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Date of Meeting




Committee


Progress RAG

Date Closed

02-Mar-16 16/T/031 TB/198 Quality Improvement Plan Reviewed Quality ImprovementPlan to be presented to theBoard on 6th April.

EDN 29/03/16 - This is on the agenda for 6 April meeting 06-Apr-16 06-Apr-16 Completed 29-Mar-16

02-Mar-16 16/T/034 TB/199 End of Life Event The Executive Medical Directorto explore scope for an eventwith Earl Mountbatten Hospiceand local partners.

EMD 29/03/16 - Executive Medical Director to discuss thisfurther with the Chair

06-Apr-16 04-May-16 Progressing

02-Mar-16 16/T/039ii) TB/200 Ambulance Targets: The Executive Medical Directorwould investigate underlyingissues causing the currentfailure of ambulance targets.

EMD 29/03/16 - This action is covered in the Chief OperatingOfficers report to the 6 April Board


02-Mar-16 16/T/039iv) TB/201 Elective Waiting Lists The Chief Operating Officer toreview elective surgery waitingtimes and report trends onspecific areas including detailsof patients who have chosen tohave their elective surgery witha mainland provider within hismonthly report.

COO 29/03/16 - This action is covered in the Chief Operating Officers report to the 6 April Board


02-Mar-16 16/T/040 TB/202 Patient Flow & Key Access Targets

The Company Secretary toarrange a session on patientflow and key access targets ata future Board Seminar

CS 29/03/16 - To be scheduled at a future seminar with agreement of the Chair

Seminar 19-Apr-16 19-Apr-16 Progressing

REPORT TO THE TRUST BOARD (Part 1 - Public)

ON 6th April 2016 Title Chief Executive’s Report Sponsoring Executive Director Chief Executive Officer Author(s) Head of Communications and Engagement Purpose For information Action required by the Board: Receive X Approve Previously considered by (state date): Trust Executive Committee Mental Health Act Scrutiny Committee Audit and Corporate Risk Committee Remuneration & Nominations

Committee

Charitable Funds Committee Quality Governance Committee Finance, Investment, Information & Workforce Committee

Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: This report is intended to provide information on activities and events that would not normally be covered by the other reports and agenda items. This report covers the period 23rd February to 29th March 2016. Executive Summary: This report provides a summary of key successes and issues which have come to the attention of the Chief Executive over the last month. The report covers the following issues:

• Council Budget Setting • System Pressures and Industrial Action • Further Junior Doctors Industrial Action • Beacon Health Centre and GP recruitment • Trust Membership Scheme • My Life a Full Life Health and Care System Redesign • Pharmacy • Age Friendly Island • Trust Strategy 2016 - 2021 • Awards • Mock CQC Inspection • Staff Survey • Key points arising from the Trust Executive Committee

For following sections – please indicate as appropriate: Trust Goal (see key) All Trust goals Critical Success Factors (see key) All Trust Critical Success Factors Principal Risks (please enter applicable BAF references – e.g. 1.1; 1.6)

None

Assurance Level (shown on BAF) Red Amber Green Legal implications, regulatory and consultation requirements

None

Date: 29th March 2016 Completed by: Andy Hollebon, Head of Communications

Enc C

Page 1 of 8

Chief Executive’s Report covering the period 23rd February to 29th March 2016

Local Council Budget Setting Isle of Wight Council has set its budget for 2016/17. The Trust responded formally to the proposals and full details of the budget and council tax adopted by Full Council, can be found at www.iwight.com/meetings. It’s good news that some of the options identified by the Council – such as the closure of The Gouldings and The Adelaide – won’t be happening this year. However whilst they have a reprieve this year, it can only be a matter of time unless we can fix the health and care system on the Island with the redesign process we are entering now. System Pressures and Industrial Action There were significant pressures in the care system during the first three weeks of March but with the enormous effort that has been put in by staff, the local authority and colleagues at the Red Cross and voluntary organisations we managed to stabilise the position. Some really difficult decisions had to be made around cancelling elective surgery and reviewing outpatient clinics and day surgery and those decisions haven’t been made based on bed numbers but have been necessary to ensure the safety of our patients which remains our highest priority. The emergencies are still coming into the hospital and we must ensure we have sufficient clinical and nursing staff available to care for those really quite poorly patients whilst keeping quality of care high. The Junior Doctor’s industrial action which took place from 8am on Wednesday 9 March to 8am on Friday 11 March placed additional strain on the system but with the support of everyone including the Junior Doctors we coped. There were increased pressures over Easter and we moved from Amber to Red. There is no single reason for the increase in the number of patients coming in and it’s a similar picture across the water for colleagues in Portsmouth and Southampton. We know that our GP colleagues are also experiencing pressure and we are continuing to work together to manage the demand on health and social care services across the Island. I would like to personally thank everyone who has been involved in managing these pressures. In terms of capacity, we are working to ensure that we provide the right capacity for the number of admissions through these pressures. Whilst this work continues, it has been agreed that Poppy Ward will stay open for another three months. We’re looking into the reasons why there was such a peak in people using the Beacon Centre. We have asked the public to think hard before accessing hospital services and encouraging them to self-manage where possible, seek advice from a pharmacist, or their own GP or call 111 before using our acute services. We need our staff to also be delivering these important messages as this will undoubtedly help to ease some of frustrations we are currently experiencing. Further Junior Doctors Industrial Action It has been announced that further industrial action is planned as follows: • 08:00hrs on 6th April to 08:00hrs on 8th April – emergency cover only • 08:00 to 17:00hrs on 26th and 27th April – full withdrawal As I write this report plans are being put in place for the 6th to 8th April. A full withdrawal for 18 hours across two days planned for later in April may have a greater impact and we are currently assessing whether we will need to cancel any services during that period.

Page 2 of 8

http://track.vuelio.uk.com/z.z?l=aHR0cDovL3d3dy5pd2lnaHQuY29tL21lZXRpbmdz&r=6005569856&d=1562730&p=1&t=h&h=00d28263f00dcd18b5c1892c0d6f127a

Beacon Health Centre and GP recruitment

You will have read in the County Press about the problems we face recruiting GPs to the Island and how that is impacting on the Beacon Centre and other practices. The impact of this on the Beacon Centre is such that there will be a greater focus on triaging patients and those with less urgent conditions will have to wait longer. We are publicising this widely. There are lots of things Islanders can do to help themselves – better planning to ensure they get their repeat prescriptions on time or booking appointments with their doctor for blood pressure tests. Making use of pharmacists for both health advice and over the counter treatments and there is much our local pharmacists can do under the Pharmacy First scheme. Most importantly we want to encourage Islanders to ring NHS 111 before they do anything unless they have a 999 emergency. If they do ring 111 we are confident we can ensure that they get to the right place at the right time for the right treatment! Please help us to get this message out.

Trust Membership Scheme Following the Trust Board meeting on 2nd March the County Press carried a rather misleading article on the closure of our Foundation Trust programme. Although the closure of the FT programme was formally approved at Board, the piece in the paper failed to recognise that we will continue to be a public membership organisation. This is important because we have already attracted 5,400 public members who are very engaged in the future of our services. The decision to close the FT programme has come about because the political and healthcare landscape has changed vastly since the Trust launched the programme in 2012. You can read our full public statement on our website (http://www.iow.nhs.uk/default.aspx.locid-02gnew0ai.Lang-EN.htm) My Life a Full Life Health and Care System Redesign As part of our move towards further integration, staff and the general public are being asked to think about how we can shape the Island’s health and care services around people’s needs in the future. It really is time for staff, volunteers and the public to have a say on redesigning services. An event for professionals and two for members of the public have already been publicised. A number of staff-specific sessions are also being organised and details of these will be published in due course. These events are only the starting point of discussions and consultations will continue for the rest of this year. More information is attached to this report. If you have any feedback you can email [email protected]. It is a year since the My Life a Full Life programme was identified as a ‘new model of care’ by NHS England and you can read about the progress made in the My Life a Full Life Updates which are widely circulated and can be found at http://www.mylifeafulllife.com/news-updates-2.htm. Pharmacy

The founder, President and CEO of Omnicell visited the Island during March to see how our Pharmacy Department has pioneered the use of IT and robots in the delivery of pharmacy services. It is widely recognised that we have one of the most advanced Pharmacy Departments in the country on the Island so well done to Gill Honeywell and the Pharmacy team.

Age Friendly Island

I went to the launch of Age Friendly Island which is an exciting new partnership funded by the National Lottery aiming to make the Isle of Wight a truly great place to grow old, encourage better relations between generations, while also tackling social isolation. Currently 24% of people living on the Isle of Wight are over 65, and by 2021 this is expected to rise by 28%, meaning the Isle of Wight has more older adults than school aged children. Age Friendly Island will play a key role in

Page 3 of 8

http://www.hampshirelpc.org.uk/webfm_send/3890

http://www.iow.nhs.uk/default.aspx.locid-02gnew0ai.Lang-EN.htm

mailto:[email protected]

http://www.mylifeafulllife.com/news-updates-2.htm

http://www.omnicell.co.uk/

http://agefriendlyisland.org/

planning for the needs of this growing older population. I was particularly inspired by the work of Southern Vectis and Tower House Surgery.

The partnership is made up of organisations committed to building an island that values, respects, engages and actively supports older people, with the voice of older residents at the heart. As part of this initiative the Isle of Wight will strive to become the first rural area in the UK to join the World Health Organisations (WHO) Global Network of Age Friendly Cities and Communities. This international movement was established to help create inclusive and accessible environments for older people, and will be engaging islanders to see older people as a valuable resource to their communities and society.

Trust Strategy 2016 - 2021

Age Friendly Island ties in well with our new Trust Strategy which was approved by the Trust Board on 30th March and is titled Working ‘Beyond Boundaries’ to be the preferred choice for sustainable integrated care. We have defined our strategic priorities, the things we will do, as follows: -

1. Align sustainable services to the needs of our patients, carers and people who use our services by

a. Designing efficient and effective treatment and care pathways b. Maximising the person’s experience c. Providing 24/7 community services for the range of people with mental health

needs d. Providing services across the seven days of the week

2. Become a centre of excellence for the care of older people 3. Provide excellent end of life care 4. Become excellent in the provision of dementia services 5. Become excellent in the provision of health and care services to children and young

people

And we have stated our strategic enablers which are:

1. A workforce embracing integration 2. Efficient processes with minimum waste 3. An IT Infrastructure and Processes geared to enabling effective delivery and

support, aligned with the My Life a Full Life priorities 4. Land and buildings which are fit for purpose

The strategy is owned by the Trust Executive Committee. It is intended to guide all service and operational plans on the strategic direction of the Trust with clear links to the Island’s overarching My Life a Full Life programme.

Awards Excellence and innovation by staff, volunteers and partners was recognised at the KPMG/KM&T Isle of Wight NHS Trust Awards 2016 on 11th March. For the first time, the public were encouraged to vote for their favourite entries in seven of the nine categories with the winners announced on the evening as follows: • Improving Services for Children and Young People, sponsored by INPS

Winner – New children’s services at the Earl Mountbatten Hospice

Page 4 of 8

http://www.who.int/ageing/projects/age_friendly_cities_network/en/

http://www.who.int/ageing/projects/age_friendly_cities_network/en/

http://www.iow.nhs.uk/about-us/our-trust-board/2016-board-papers.htm

Runners-up – Evening parent craft classes (Health Visiting team) ‘Bring me sunshine appeal’ for Children’s Ward

• Improving Services in Acute Care, sponsored by KM&T

Winner – Medicines Helpline (Pharmacy) Runners-up - Overseas Adaptation Course New Endoscopy Unit

• Improving Services in the Community, sponsored by Spectrum Housing

Winner – Coffee, cake, condoms and contraception (Sexual Health team) Runners-up - The SSKIN Bundle Productive Community Services programme

• Improving care, working with partners to implement the My Life a Full Life programme,

sponsored by CGI Winner – Pop-up clinics by the Independent Living Centre Runners-up – Securing the My Life a Full Life bid Health and Wellbeing Roadshows (Community Action IW/My Life a Full Life)

• Improving Services in Mental Health, sponsored by KPMG

Winner – The Memory Service Runners-up - Four Season’s Garden, St Mary’s Hospital Sevenacres 72-hour assessment unit

• Supporting Excellence in Healthcare behind the scenes, sponsored by 3663

Winner – Overseas Nurse Recruitment Runners-up - Reusable sharps containers Health checks by Chamber Health (Occupational Health)

• Excellence in voluntary organisation support for healthcare, sponsored by Ryhurst

Winner – Gardening volunteers Runners-up - Chaplaincy volunteers Earl Mountbatten Hospice volunteers

• Improving services in Ambulance (non-voting category), supported by My Life a Full Life

Winner – Neighbourhood Community Responder Scheme • Excellence in Research and Development (non-voting category), sponsored by the University

of Portsmouth Winner – Hepatitis C Care Team

Team and individuals were also recognised for their contributions with the following awards: • Carisbrooke Award for excellence by a non-clinical Band 4 and below

Winner – Jemma Hogan, Specialist Administrator in Occupational Therapy • Wight Award for most outstanding volunteer

Winner – Malcolm Martin, volunteer in the Macular Degeneration Clinic • Osborne Award for excellence by a non-clinical Band 5 and above

Winner – Charles Joly, Environmental/Sustainability and Waste Manager • Leadership Award for non-clinical staff member

Winner – Diane Adams, Head of Operations, Clinical Support, Cancer & Diagnostics Business Unit

Page 5 of 8

• Sandy Reed Rosebowl award for healthcare assistants or nursing auxiliaries who have demonstrated significant success as part of an NVQ programme Winner – Jo Hadcroft

• Solent Award for the most outstanding team

Winner – Ambulance Commercial training team • Vectis Award for excellence by a doctor

Winners – Dr Will Alfred, Dr David Bicknell and Dr Lucy Bailey • Leadership Award for clinical staff member

Winner – Louise Webb, Matron for Critical Care Services • Medina Award for allied healthcare professionals for excellence and innovation in practice

Winner – Lara Watson, Pelvic Floor Specialist Physiotherapist and her team • Island Award for outstanding achievement by a nurse or midwife

Winner – Patience Wells, Staff Nurse on Children’s Ward • Listening into Action/Staff Experience Award

Winner – Vicki Haworth, Clinical Team Leader for Crisis Resolution At the end of the evening, all those attending the event chose the ‘winner of winners’ by selecting their favourite from all of the voting categories. The overall winner was then presented with the Chair’s Diamond Award by Trust Chair Eve Richardson and representatives from principal sponsors KPMG and KM&T. • Chair’s Diamond Award

Winner – The Earl Mountbatten Hospice for new children’s services Mock CQC Inspection During the past month we ran another mock Care Quality Commission (CQC) inspection with around 14 volunteers. We did consider cancelling the session because of the current pressures, but it’s even more important that when we are experiencing such pressure that we are absolutely sure about the quality of care we are providing to our patients. Part of the day included a talk by the Director of Nursing at Health Education England, Professor Lisa Bayliss-Pratt who was visiting the Island to support the work we are doing on new and dynamic roles, including discussions on the new role of Associate Practitioner. She told us that every member of staff she spoke to was knowledgeable and enthusiastic. In fact, she commented that we don’t know how good we really are on the Island, with a ‘can do’ attitude, leading edge pharmacy and technology which is helping people to do their jobs better. Such encouraging feedback and great comments from a national leader proves that we are doing the right things. Staff Survey The results of the National Staff Survey for 2015 have been released and managers have been briefed on their findings. They make for a mixed picture – some things have improved whilst other areas have deteriorated. You can read the results on our intranet by clicking here http://intranet.iow.nhs.uk/Home/Strategic-Commercial/Communications/Annual-Staff-Survey-2015 Clearly, we have work to do in many areas, despite the strides we have already taken to try and make improvements. The Staff Experience Group, led by Executive Director for Financial and Human Resources Chris Palmer, has a clear grasp of these issues and is already looking at ways to respond to the daily challenges you have told us about through the survey. Whilst they are a driving force to make things better, it is still really important that you are involved in this

Page 6 of 8

http://intranet.iow.nhs.uk/Home/Strategic-Commercial/Communications/Annual-Staff-Survey-2015

improvement process. The group will, among other things, work towards three priorities; improving the health and wellbeing of staff, ensuring everyone has a meaningful and timely appraisal and ensuring clarity around who is who in the new organisational structure. Our Quality Champions will also be actively involved, helping us to take forward the feedback in the Staff Survey relating to Quality of Care. I’m confident with your help, we can pull together and really make a difference to the working lives of staff. Key Points Arising from the Trust Executive Committee The Trust Executive Committee (TEC) – comprising Executive Directors, and Clinical Business Unit representatives meets every Monday. The following key issues have been discussed at recent meetings: 25th February 2016 • Procurement Service Contract – approved by TEC • Foundation Trust Programme – received by TEC • Haematology Options Paper – approved by TEC • Medical Staffing Deep Dive undertaken 3rd March 2016 • MPTT Services Non Recurrent Funding Request – TEC approved to submit to the CCG • Orthopaedic Power Tools and Associated Consumables – TEC approved 10th March 2016 • Urology Business Case – TEC approved • GEANS Project (Admiral Nurses) – TEC approved • Dementia UK – Service Collaboration Agreement – TEC approved • In-house Integrated Wheelchair Service & Maintenance Business Case – TEC approved for

submission to the CCG 17th March 2016 • Junior Doctor Contract Summary and Implementation Plan – TEC approved • Mental Health Crisis Resolution Home Treatment Team Single Point of Access Business Case

– TEC approved with amends Karen Baker Chief Executive Officer 29th March 2016

Page 7 of 8

Caring for our Island: Time to Act

The My Life a Full Life programme is calling on Islanders to help shape the future of the Isle of Wight’s health and care services. The call comes as the programme publishes a new leaflet – Caring for our Island: Time to act – which sets out some of the significant challenges facing the island and why everyone should get involved in shaping the changes to come. The pressures facing the island mean that health and care services will have to look at doing things differently in the future.

Changes to the way people live and want to access care, combined with some of the financial challenges faced by the island, mean that there is a need to consider how we’re providing care and what we want from the system in the future.

This call to action marks the start of the next phase for My Life a Full Life as it undertakes a redesign of the island’s system of health and care in the coming months. The team now wants to hear from members of the public, as well as those working in health and care services, about their views on what matters to them and what they think might need to change.

People can visit www.mylifeafulllife.com/time-to-act.htm to comment online or can pick up a leaflet at a number of council and NHS locations around the island and send in their comments by 27th May.

The first in a number of public events to gather feedback from the public were held last week with around 75 people attending over the two days. The events generated much good, lively discussion and people were able to share their thoughts with us about the areas where we should be prioritising our support. A formal consultation setting out proposals for change is planned for later in the year. There will also be further opportunities for staff and volunteers across the My Life a Full Life partner organisations to share their views – more details soon!

Did you know?......

Amongst the Island’s many health and care challenges:

• A quarter of the Island’s population is over the age of 65 compared with 16.6% in England overall.

• About 70% of hospital beds on the Island are currently occupied by people over the age of 65.

• Growing pressure on social care services means the Island needs to recruit 100 additional carers in order to look after people in need.

• People under the age of 75 on the Island have worse than expected outcomes for cancer, compared with other parts of the country.

• In 2011, over 32,000 people on the Island were estimated to have an undiagnosed or unrecorded long term condition.

Doing nothing is not an option...it’s Time to Act!

Page 8 of 8

http://www.mylifeafulllife.com/time-to-act.htm


ON 6 April 2016

Title Report from Chair of Quality Governance Committee

Sponsoring Executive Director

Nina Moorman, Chair of Quality Governance Committee

Author(s) Nina Moorman, Chair of Quality Governance Committee

Purpose To receive the report for the Chair of the Quality & Clinical Performance Committee

Action required by the Board:

Receive X Approve

Previously considered by (state date and outcome):

Sub-Committee Dates Discussed Key Issues, Concerns and Recommendations from Sub Committee

Audit and Corporate Risk Committee

Charitable Funds Committee Finance, Investment, Information & Workforce Committee

Mental Health Act Scrutiny Committee

Quality Governance Committee 29/03/2016 Remuneration & Nominations Committee

Turnaround Board

Please add any other committees below as needed Staff, stakeholder, patient and public engagement:

Not applicable Executive Summary:

The Chair of the Quality Governance Committee will report on the following areas as discussed at the meeting held on 29 March 2016. Patient Safety:

• Pressure Ulcers • Healthcare acquired infections • Serious Incidents requiring investigation (SIRIs)

Patient Experience: • Safer Staffing

Clinical Effectiveness: • Clinical Audit

Corporate Quality Issues: • CQUINs (Commissioning for Quality and Innovation) • Mock CQC inspection

Recommendation to the Trust Board: The Board is recommended to receive the assurance report by the Chair of the Quality Governance Committee

Attached Appendices & Background papers Report

Enc D

For following sections – please indicate as appropriate:

Trust Goals & Priorities Principal Risks (BAF) Legal implications, regulatory and consultation requirements

Date: 29 March 2016 Completed by: Chair of the Quality Governance Committee

Quality Governance Committee

Assurance Report for Trust Board

6 April 2016

Compiled following the QGC meeting on 29 March 2016 1 Patient Safety 1.1 Pressure Ulcer incidence within the hospital remains unacceptable high – a quality

improvement collaborative is underway but is yet to show positive results. In the community improvement has been maintained. The CCG have decided not to fund the nurse trainer working in the community after March which is likely to affect the collaborative work programme involving practice nurses and care home staff. Assurance negative for hospital setting, further detailed review due April 26th 2016.

1.2 Healthcare acquired infections. There have been 2 new cases of Clostridium difficile on the same ward bringing to total for the year to 22 cases in 14 patients. There have been no further relapsed cases since the faecal transplant. We discussed the effectiveness of cleaning with hydrogen peroxide vapour and a programme of systematic deep cleaning of all wards is planned, together with increased use of isolation facilities in the refurbished MAAU. There has been an increase in catheter related infections.

Assurance negative – deep dive into HCAI due in May.

1.3 Serious Incidents requiring investigation (SIRIs). We review all new SIRIs monthly and the numbers remain low and manageable but the committee are concerned about the length of time for resolution. The Governance Review by Capsticks recommended change and we looked at the new draft flow chart and suggested further changes to speed up the process while still investigating appropriately. We will continue to monitor.

2 Patient Effectiveness 2.1 Safer staffing. We reviewed the 6 monthly report on safer staffing and commended the

achievement of standards and the links to quality. We recommend that action is taken to recruit to additional WTE 29 posts in addition to addressing our significant vacancy rate. We were made aware of a similar situation amongst medical staff, both junior and Consultants with a 40% vacancy rate in Medicine. [The Royal College of Physicians has just reported that 40% of Consultant Physician posts Nationally are unfilled, mostly due to lack of candidates]. A Medical workforce action group has been formed to explore alternative methods of recruitment. Assurance negative – for discussion with FIIWC and Board.

3 Clinical Effectiveness 3.1 Clinical Audit The National hip fracture database is an audit of a range of best practice

interventions for patients over 65 who have a fractured hip and require surgery and is reported quarterly. We reviewed an update which shows that our patients have an improved wait time to operation and better than average 30 day mortality than a year ago. Assurance positive.

4 Corporate Quality Issues 4.1 CQUINs (Commissioning for Quality and Innovation) are schemes that link income to the

achievement of quality improvement goals. There are National and local CQUINs and I will report on what is included for 16/17 next month but the committee were dismayed to hear that the locally agreed CQUINs which were on target have not progressed effectively in the 3rd and 4th quarters of 15/16 and we will not achieve the income promised. The loss of focus has been put down to the internal reorganisation.

4.2 Mock CQC inspection – a limited repeat mock inspection took place on March 11th and a

number of significant improvements were noted in stroke care, protected mealtimes and staff engagement, but improvement still required in the use of Computer Aided Dispatch, protected medication rounds, and the condition of the estate. Follow up will be through an action tracker.

Dr Nina Moorman Chair Quality Governance Committee 30 March 2016

REPORT TO THE TRUST BOARD (Part 1 – Public)V10 Page 1


ON 6TH APRIL 2016

Title Quality Improvement Plan/Framework Progress Report


Alan Sheward, Executive Director of Nursing

Author(s) Deborah Matthews, Lead for SEE; Mandy Blackler; Business Manager

Purpose Receive for assurance


Receive Approve X

Previously considered by (state date):

Sub-Committee Dates Discussed

Key Issues, Concerns and Recommendations from Sub Committee

Trust Executive Committee



Mental Health Act Scrutiny Committee Remuneration & Nominations Committee

Quality Governance Committee 29/03/16 Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: Executive Summary & Analysis: In 2014 the Trust was inspected by the Care Quality Commission (CQC), the outcome of which was the development of a Quality Improvement Plan for recovery from the position identified by the CQC. In 2015 the Quality Improvement Framework was developed as an enabler to deliver not only the remaining actions from the original QIP, but also the progression of our onward quality improvement journey. This paper describes how we are in transition from the old QIP recovery plan, using methodologies identified within the QIF, to delivery of our new and ongoing Quality Improvement Plan. The new QIP describes 20 areas for quality improvement that link into the new Quality Priorities for 2016/17 and into the Trust goals. Leads have been identified for each of the 20 domains and key performance indicators are in development for these. Future reporting will give performance against the KPIs for each of the 20 domains and will only include a detailed analysis if there is a drop in performance or if this has been specifically requested.

Recommendation to the Board:

The Board is recommended to approve the transition from the original recovery Quality Improvement Plan into the new Quality Improvement Plan

Enc E


Attached Appendices & Background papers For following sections – please indicate as appropriate:

Trust Goals & Priorities

The work underway within the new QIP is linked directly to all five of the Trust goals

Principal Risks (BAF) Areas of the BAF affected: Quality, strategy and planning, culture

Legal implications, regulatory and consultation requirements

Date: 30.03.16 Completed by: Mandy Blackler, SEE Business Manager

1

Isle of Wight NHS Trust Executive Director of Nursing

Quality Improvement Plan/Framework Progress Report

1. SITUATION

1.1. The Isle of Wight NHS Trust is licenced by the Care Quality Commission (CQC) to deliver care

and services in line with the CQC Fundamental Standards of Care. 1.2. The Trusts vision is Quality Care for Everyone Every Time. 1.3. The Trust has been working on an ambitious journey of Quality Improvement (QI) since 2014.

This includes the completion of a number of actions that arose following the Care Quality Commission Chief Inspector of Hospitals (CIH) assessment in June 2014 with the Trust receiving the final report in September 2014.

1.4. The Trust will conclude the required actions by May 27th 2016 with all actions, in response to the CQC CIH visit, concluded.

1.5. It is unclear at the current time if the Trust will be in a position to declare compliance with the outstanding enforcement action related to staffing. CA7.0 – Staffing in the Stroke and Rehabilitation Units. An explanation for this is given further in this report.

1.6. The Trust will move from a responsive Quality Improvement Plan (QIP) to a progressive Quality Improvement Plan (QIP). It is envisaged the progressive QIP will be delivered over the coming 2-5 years. However, it will be reviewed monthly and annually to ensure the Quality Improvement Plan remains contemporaneous. The Quality Improvement Framework (Quality Improvement Strategy and Methodology) will support the delivery of the longer-term (2-5 years) Quality Improvement Plan.

1.7. This will bring to an end the CQC responsive plan (also known as the QIP) 1.8. The Trust will continue to seek assurance against the sustained delivery of the CQC

improvement actions through a variety of assurance measures including Board Walkabout Visits, Mock CQC inspections and the Ward Accreditation Programme (WAP)

2. BACKGROUND

2.1. In June 2014, the Care Quality Commission (CQC) carried out a planned inspection of the Isle of Wight NHS Trust. The Inspection was attended by 72 inspectors. This resulted in 102 actions for the Trust, from which the Quality Improvement Plan (QIP) was developed. The Recovery Quality Improvement Plan (QIP) covered 5 key themes:

2.1.1. Governance 2.1.2. End of Life 2.1.3. Recruitment and Retention 2.1.4. Clinical Leadership 2.1.5. Patient Flow

2

2.2. Table 1 demonstrated progress against the required 102 actions.

Action November 2015 March 2016 Position

No Completed Outstanding No Completed Outstanding

Enforcement 13 13 0 13 13 0

Compliance 38 37 1 38 37 1

Must do 10 10 0 10 10 0

Should do 41 27 14 41 39 2

Totals 102 87 15 102 99 3

Table 1

2.3. Following declaration of compliance against the 13 enforcement actions in December 2014, the Executive Management Team led an improvement plan to achieve the compliance actions. The plan for delivery was shared with the Trust board on 4th March 2015.

2.4. To improve the monitoring and delivery of the actions required addressing the areas identified, the Trust developed a Quality Improvement Plan (QIP). This was a recovery plan in direct response to the actions required by the Care Quality Commission (CQC).

2.5. In addition to the Quality Improvement Plan (Response to the CQC actions) the Trust developed an underpinning Quality Improvement Framework (QIF). Approved at the Trust Board on 2nd September 2015, the QIF is an underlying enabler that supports the delivery of a Quality Improvement approach. It clearly identified the ingredients required for the delivery of high quality care.

2.6. We are now at the stage of only having one compliance action (Safer Staffing) and two ‘should do’ actions (clear red flag system in Ambulance and Community Mental Health Operational Policy) outstanding.

2.7. We are now in a transition period, moving from the QIP recovery plan following the CQC visit, utilising the techniques and strategies described within the QIF into the new QIP.

3. ASSESSMENT

3.1. The new Quality Improvement Plan (QIP) (Appendix 1) embraces 20 domains, which address the CQC fundamental standards of care. Each of the 20 domains has a designated lead at a corporate level. However, some leads exist within the Clinical Business Units (CBUs). These align with the five new Quality Priorities for 2016/17 which in turn feed into the Trust goals. The Quality Priorities were approved at the 2nd March 2016 Trust Board meeting.

3.2. Appendix 1 clearly shows links to 3.2.1. The five key themes from the original QIP recovery plan 3.2.2. Executive leads 3.2.3. Quality Priorities 3.2.4. The Quality Improvement Framework as the enabler 3.2.5. Governance reporting arrangements 3.2.6. The 20 domains

3.3. This ensures that the original QIP is not lost and is successfully merged into the new QIP.

The original QIP recovery plan is now business as usual and the new QIP not only monitors the actions from the old QIP under each of the 20 domains, but also moves our quality improvement journey forward.

3

3.4 Each of the 20 domains in the new QIP are timetabled into the SEE Committee’s rolling

agenda (Appendix 2). 3.5 The lead for each domain will bring an Assurance and Mitigation report for review on a

quarterly basis. Reporting to SEE Committee will also include details of actions undertaken, impact and assurance.

3.6 This will feed through to Quality Governance Committee and then on to Trust Board. 3.7 KPIs are being developed for each of the 20 domains 3.8 Safety aspects e.g. falls, pressure ulcers etc are also monitored via the Quality Report that

goes to SEE Committee and Trust Board. 3.9 It has been agreed that any aspect that is RAG rated as red for three consecutive months will

initiate a deep dive/QI project to rectify the position. 4. RECOMMENDATIONS . 4.1 It is recommended that Trust Board approve this transition from the old recovery QIP into the

new QIP . Alan Sheward Executive Director of Nursing Report Author: Mandy Blackler Business Manager 30th March 2016

4

Appendix 1

5

Opperational Lead

C.Puntis

FUNDAMENTAL STANDARDS D.Matthews

J.Hazeldine

M.Pugh

COMPLAINTS

Q3Q1 Q2

SAFEGUARDING

D.Goring

G.Smith

M. Ould

MORTALITY & MORBIDITY

END OF LIFE

CANCELLED OPPERATIONS

SEPSIS to include surgical site infections and catheter infections

NUTRITION

M.Connaughton

C.Palmer

S.Stacey

DISCHARGES

EMERGENCY READMISSIONS

MIXED SEX ACCOMMODATION

CANCELLED APPOINTMENTS

SAFER STAFFING

S.Stacey

S.Johnston

S.Stacey

K.Robinson

S.Stacey

S.Stacey

Deliv

erin

g Q

ualit

y Ca

re

S.Stacey16

Patie

nt E

xper

ienc

e

15

Patie

nt S

afet

y

9

S.Stacey

14

M. Price

K.Gray

13

V.Flower

S.Stacey

V.Flower

T. Cloke

PATIENT EXPERIENCE

SIRIs

M. Price

M. Price

Nov

Q4

OctSepAug

S.Ward

S.Moody

DOLS / MCA

DEMENTIA

FALLS

PRESSURE ULCERS

HCAI

L.Moody

Dec FebComments

MarJan

Quality Assurance Schedule 2016/17

No

6

K.Gray

12 M. Price

8

11

10

2

K.Gray

5

1

K.Gray

3

4 K.Gray

17

K.Gray

7

20 M. Price

M.Pugh

JulyJuneMayAprilExec Lead

19 M.Pugh

S.Stacey

K.Gray

18

Appendix 2


6th April 2016

Title Serious Incident Requiring Investigation (SIRI) Activity Report (February2016 data)

Sponsoring Executive Director Alan Sheward, Executive Director of Nursing Author(s) Karen Kitcher, Quality Assurance Lead (SEE Team) &

Deborah Matthews Lead for Patient Safety, Experience & Clinical Effectiveness (SEE)

Purpose To provide Trust Board with information concerning the number of SIRI’s formally reported within February 2016, the ongoing number that are yet to be completed and the lessons learnt from investigations recently closed.

Action required by the Board: Receive X Approve Previously considered by (state date):


Key issues, concerns & recommendations from Sub Committees



Charitable Funds Committee

Finance, Investment, Information & Workforce Committee


Remuneration & Nominations Committee

Quality Governance Committee 29 March 2016

Please add any other committees below as needed:

Board Seminar

Patient Safety, Experience & Clinical Effectiveness Group 23 March 2016 Staff, stakeholder, patient and public engagement:

Clinical Business Units (CBU) are required to schedule a table top discussion of SIRI findings at the end of each investigation to inform the final report prior to formal submission of the report to the Isle of Wight Clinical Commissioning Group (CCG) - to ensure lessons learnt are identified and actions for dissemination are agreed. Implementation of this methodology is progressing. To support the scheduling of activities and meetings, SEE circulate a timetable of requirements to key stakeholders at the outset of the formal SIRI notification to a service. The investigation commissioning manager is responsible for working with SEE to ensure any required clinical audit is shaped around the outputs from a SIRI and lessons learnt are heard and understood across the wider organisation. Executive Summary & Analysis: This report provides an overview of the Serious Incident Requiring Investigation (SIRI) activity during February 2016. Serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive investigation and response.

Enc F

Five SIRI’s were reported to the Isle of Wight CCG during February 2016.

1. Patient Fall (Fracture) – Stroke Unit 2. Grade 4 Pressure Ulcer – District Nursing 3. Never Event (Medicine Administration) – Whippingham Ward 4. Follow-up delay – Cancer Services 5. Potential failure to act on results – Cancer Services

At the time of writing this report there were: 27 open SIRI’s - 8 of which were overdue with a further 5 overdue with the CCG for consideration of closure. During February 2016, and at the time of reporting, the IW CCG had closed 1 SIRI case. LESSONS LEARNT – from the one closed case during February details of lessons learned are detailed within the enclosed report. There are 54 outstanding action plans the breakdown of these by CBU is also detailed within the report. Recommendation to the Board: To receive for information and comment where indicated. Attached Appendices & Background papers: Nil



Goals • Excellent Patient Care • Working with others to keep improving our services Quality Priorities • Reducing incidents of patient harm

Principal Risks (BAF) 2.6


• The NHS England SIRI Framework and Policy (2015) explains the responsibilities and actions for dealing with Serious Incidents. It outlines the process and procedures to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.

• Timescale – a single timeframe (60 working days) is described for the completion of investigation reports, to allow providers and commissioners to monitor progress in a more consistent way. This also provides clarify for patients and families in relation to completion dates for investigations.

• Timeframes from formal reporting of a SIRI to submission of the finalised report to the CCG are in the majority of cases running outside of the 60 working day standard. Actions are being taken to more formally monitor and manage delays.

Date: 19 March 2016 Completed by: Karen Kitcher, Quality Assurance Lead (SEE Team) & Deborah Matthews, Lead for Patient Safety, Experience & Clinical Effectiveness (SEE)

Page 2 of 7

Serious Incident Requiring Investigation (SIRI) Activity Report Trust Board

February 2016 data

1. NEW INCIDENTS REPORTED AS SIRIs:

1.1 During February 2016 the Trust reported 5 Serious Incidents to the Isle of Wight Clinical Commissioning Group (CCG). Below is a summary of these incidents:

Category/ subject

Under whose care

Summary Incident Date

Date reported as a SIRI

Date report due to be sent to Commissioners

Patient fall Stroke Unit Fractured leg 13.01.16 01.02.16 27.04.16

Pressure ulcer District Nursing

Grade 4 pressure ulcer

22.12.15 04.02.16 03.05.16

Never Event Whippingham ward

Wrong route administration of medication

01.02.16 08.02.16 Already sent to Commissioners

Screening/follow-up issue

Cancer Services

Delay in follow-up

27.01.16 25.02.16 24.05.16

Potential failure to act upon results

Cancer Services

Potential delay in treatment

15.02.16 25.02.16 24.05.16

1.1.1 PRESSURE ULCERS – COMMUNITY: in line with arrangements under the new SIRI

Framework (March 2015), 1 new case was identified and reviewed at a table top review during February; the evidence suggested this was a diabetic foot ulcer, rather than a pressure ulcer, therefore not SIRI reportable. Other cases were reviewed during February and these were updates of previous clustered cases to ensure all actions completed. The individual teams continue to review grade 1 and 2 pressure ulcers and report the learning from these on local templates; the information from this learning exercise is graphed, to identify trends – example attached.

Page 3 of 7

0 5 10 15 20 25

Deterioration of condition

Palliative Care/end of life

Deterioration in mental capacity

Safeguarding issues

No onward referral to other specialities

Decline in mobility

Footwear related

Equipment/advice declined

Refusal to change lifestyle choices

Catheter related

Poor documentation

Poor history taken

Delay in acquiring equipment

Breakdown in communication

Wheelchair/Equpment issues

Previous falls

Examination declined

Patient using own equipment

PRESSURE ULCERS GRADE 2 CLUSTERED (across all district nursing teams)

Jan-16

Dec-15

April - Nov 2015

0

2

4

6

8

10

12

14

16

18

20

Documentedevidence of advice

given

Detaileddocumentation

Holistic assessment Equipment obtainedin a timely way

Goodcommunication with

patient/carer

Catheter care wellmanaged

Referral to otherspecialities/agencies

Good Practice - relating to pressure ulcer care (Grade 2s)

April - Nov 2015

Dec-15

Jan-16

1.1.2 PRESSURE ULCERS – ACUTE: the same procedure of clustering pressure ulcers is also

being rolled out across all ward areas with support from the Quality Manager for the Chief Operating Officer’s team. Most ward areas have been briefed (with just 3 areas outstanding) and the relevant paperwork has been introduced in these areas. Instruction and a flow chart have also been shared, so the ward areas can continue to review and learn from all Grade 1 and 2 pressure ulcers under their care. In addition, a collaborative meeting has been set up to review the learning around hospital acquired pressure ulcers. The first meeting is to be held at the end of March, chaired by the Lead for Patient Safety, Experience and Clinical Effectiveness

Page 4 of 7

SIRIs COMMUNITY & MENTAL HEALTH

OTHER CORPORATE AREAS

CBU 1 Surgery, Women's &

Children's

CBU 2Medicine

CBU 3Clinical Support, Cancer & Diagnostics

CBU 4Ambulance, Urgent Care, Community

CBU 5Mental Health & Learning Disabil ities

• With Coroner 0 0 0 0 0 0 0 0• With Directorate 0 2 0 0 1 0 0 1• With Quality team 0 0 0 0 0 0 0 0• With Execs 0 1 0 0 0 0 0 0• With Commissioner 1 5 0 0 0 0 0 0• Returned from Commissioner - further work

1 1 0 0 0 0 0 0

TOTAL OVERDUE 2 9 0 0 1 0 0 1

• With Coroner 0 0 0 0 0 0 0 0• With Directorate 0 0 0 3 2 2 3 0• With Quality team 0 0 0 0 0 0 0 0• With Execs 0 0 0 1 0 0 0 0• With Commissioner 0 0 0 2 1 0 0 0• Returned from Commissioner - further work

0 0 0 0 0 0 0 0

TOTAL CURRENT 0 0 0 6 3 2 3 0TOTAL NUMBER OF OPEN CASES 2 9 0 6 4 2 3 1 27

how many ongoing SIRIs (auto) 18

HOSPITAL & AMBULANCE

OVERDUE CASES

CURRENT CASES

1.1.3 SLIPS/TRIPS/FALLS – COMMUNITY: falls in community continue to be clustered; some of

the findings that may have contributed to a fall include: patient’s cognitive difficulties/erratic behaviour, patient not wishing to following advice given and patient mobilising unsupervised. Some of the remedial actions identified are:

• The role of care navigators: holistic support for a range of needs – loneliness, grief,

financial support, bridging the gap between health and social care. Currently based in the community within localities. A supporting role to community rehab beds was discussed

• Patient information leaflet on falls prevention produced and now being ratified • Poster aiming to support delivery of the message that preventing falls on site is a care

priority • Review of care plans to include multifactorial falls risk assessment • Update of Hospital assessors paperwork to facilitate working together to understand the

role and what information is helpful to create safe transitions to community • Alert cards – to be used for duration of patient’s stay, to help keep the right walking aid

with the right person and help staff identify a patient’s mobility status quickly • Introduction of a post-fall documentation form

1.1.4 SLIPS/TRIPS/FALLS – ACUTE: some of the findings identified during falls clustering in acute

services that may have contributed to a fall have been: dementia/confusion, patients not following advice, 1:1 nursing not consistently available, patient’s own sight problems, patients out of sight in side rooms. In terms of remedial action: one ward area has contacted mental health with a view to acute staff spending time with mental health staff to help develop skills in close supervision of dementia patients. Review of potentially using CCTV in MAAU.

Page 5 of 7

2. CURRENT POSITION: 2.1 This table provides the current status of open SIRIs as of 17 March 2016. 2.2.1 Listed below are the SIRI cases that are overdue (at the time of producing this report 17

March 2016) and their current status: (From this point forward CCG = Clinical Commissioning Group) DESCRIPTION Directorate/

Speciality Incident Date

Reported as SIRI

Date to be submitted to CCG (first presentation)

CURRENT STATUS

Unexpected death

Emergency Dept/Mental Health

06.08.15 12.08.15 04.11.15 16.03.16 - further edits required on final report (sent to clinical business unit); Panel review meeting to be arranged by CBU

Patient fall St Helens Ward

20.08.15 (actual) 17.09.15 (review)

17.09.15 11.12.15 15.03.16 – Exec’s queries/comments forwarded to CBU for clarity on main report.

Delayed diagnosis

General Surgery

16.09.15 22.10.15 19.01.16 15.03.16 - Updated final report sent with Head of Quality & Nursing for approval.

Grade 3 pressure ulcer

Stroke/General Rehab

25.09.15 (actual) 17.11.15 (decision to report as SIRI)

18.11.15 15.02.16 08.03.16 – A Panel meeting to review final report had to be re-arranged as only two limited attendance due to operational pressures (new date 21.03.16)

Patient fall Mental Health in-patient (Shackleton)

05.11.15 10.11.15 05.02.16 04.03.16 – panel convened; final report with Lead Nurse for Mental Health

3. CLOSED SIRI CASES 3.1 During February 2016, and at the time of reporting, the IW Clinical Commissioning Group had

advised on one closure of a SIRI case. Listed below are the lessons learned from the closed SIRI case:

AREA SUBJECT SUMMARY Lessons Learned In or out of time

when submitted to CCG (first presentation)

Inpatient area

Patient fall Fracture in neck

Learning from the post fall management - staff are required to update Re: Falls Policy and note how after a fall they can access equipment required for safe movement; Nurse in charge to robustly assess all patients prior to lifting transfer for suitability;

Out of time

Page 6 of 7

4. OVERVIEW OF SIRI SUBJECTS logged since April 2012 – to end February 2016

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105

Admission of under 18 to Adult MH WardAllegation against HC professional

Ambulance IssueCritial Care Transfer

Child DeathC diff & Health Acquired InfectionCommunicable Disease / Infection

Confidential Information LeakDeath in Custody

Delayed DiagnosisDrug Incident

EscapeFailure to act upon test results

Hospital Equipment FailureHospital Transfer concerns

major incident/suspension of servicesMRSA Bacteraemia

Never EventOther

Venous Thromboembolism (PE/DVT)Pressure ulcer grade 3Pressure ulcer grade 4Safeguarding Children

Surgical ErrorSub-optimal care of deteriorating patient

Slip, Trip, FallSafeguarding Vulnerable Adult

Unexpected DeathUnexpected Neonatal death

SUBJECTS of SIRIs April 2012 - end February 2016

April 2012-March 2013



April 2015 - March 2016OTHER = 7

x 3 clinical issuesx 2 delay in appointingx 1 equipment issuex 1 screening/follow-up issue

5 COMPLETED SIRI CASES – ACTION PLANS OUTSTANDING; as well as ongoing SIRI action plans that are currently “in-time” action plan leads are required to monitor and update on progress/completion of all actions within the required timeframes. Outstanding finalised action plan status as of 17 March 2016 is detailed below. These are actively being pursued and as each one is completed will be forwarded to the Patient Safety, Experience and Clinical Effectiveness Group for final sign off, as per procedure.

How many action plans

overdue for completion Ambulance, Urgent Care & Community 24 Mental Health and Learning Disabilities 6 Clinical Support, Cancer & Diagnostics 0 Medicine 10 Surgery, Women’s & Children’s Health 14

Alan Sheward Executive Director of Nursing 30th March 2016 Prepared by: Karen Kitcher, Quality Assurance Lead, 17 March 2016 with updates from; Deborah Matthews, Lead for Patient Safety Experience & Clinical Effectiveness, 24 March 2016.

Page 7 of 7

REPORT TO THE TRUST BOARD (Part 1 – Public) Page 1


ON 6th APRIL 2016 Title Six Monthly Safer Staffing Report Sponsoring Executive Director

Alan Sheward, Executive Director of Nursing

Author(s) Sarah Johnston, Deputy Director of Nursing Purpose To provide the Board with the six monthly safer staffing report as identified

by the NHS England, in line with the National Quality Board publication ‘How to ensure the right people with the right skills are in the right place at the right time’


Receive Approve X Previously considered by (state date): Trust Executive Committee Mental Health Act Scrutiny

Committee

Audit and Corporate Risk Committee Remuneration & Nominations Committee

Charitable Funds Committee Quality Governance Committee Due 29th April Finance, Investment & Workforce Committee

Please add any other committees below as needed Other (please state) Staff, stakeholder, patient and public engagement: Matrons, Ward Managers and their deputies are involved in the Safer Staffing café’s to be able to describe and understand the requirements. Ward Managers review monthly data in relation to staffing, provide the Acuity and Dependency work for their area and will review this report as part of the safe staffing discussions. Executive Summary: The National Quality Board (NQB) issued requirements of Trust Boards in relation to safe staffing. This report provides information to the Board to enable the Board to understand the status of achievement against the requirements. Monthly reports have been provided to the Trust Board as part of the Integrated Performance report. This report is the overarching 6 monthly report which includes the inpatient staffing review and recommendations for nurse staffing undertaken in January and February 2016. A six monthly report is required to be provided to the Board following an establishment review using evidence based tools. We have utilised the Shelford Tool for review of acuity and dependency for inpatient acute areas. Safe staffing cafés are in place to ensure all areas are incorporated into regular review, and to ensure scrutiny of staffing establishments and management. The Board are required to approve the staffing levels for the organisation going forward. The Executive Director of Nursing (EDoN) recommends the Registered Nurse establishment increase approved by the Board in September 2015 is maintained reflecting the required increase from 400.93 Registered Nurse and Midwife WTE (cost £16,831,000) in 2015/16 to 429.93 Registered Nurse and Midwife WTE (cost £17,739,000) for 2016/2017. This covers Acute Inpatient wards only. Mental Health areas have not been reviewed and therefore no change is recommended in this report. This recommendation results in an additional 29 WTE registered Nurses at an increased cost of £908,000. This cost has been built into Ward based establishments for 2016/17. For following sections – please indicate as appropriate:

Trust Goal (see key) Quality, Workforce Critical Success Factors (see key) CSF 1, CSF 2, CSF 9, CSF 10

Enc G


Principal Risks (please enter applicable BAF references – eg 1.1; 1.6)

Assurance Level (shown on BAF) Red Amber Green Legal implications, regulatory and consultation requirements

None

Date: 23rd March 2016 Completed by: Sarah Johnston, Deputy Director of Nursing


Executive Director of Nursing Six Monthly Safer Nurse Staffing Report

April 2016 1 INTRODUCTION 1.1 The National Quality Board (NQB) issued guidance to optimise nursing, midwifery and care staffing

capacity and capability. The document ‘How to ensure the right staff with the right skills are in the right place at the right time’ identified ten expectations for organizations’ to deliver.

1.2 Expectation 1 identifies the requirement for the Trust Board to take full responsibility for the quality

of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability.

1.3 In order to achieve this NHS England has set out requirements for reporting to the Trust Board. The

Board receives a monthly report indicating planned and actual hours for nurse staffing. This information is currently included in the monthly Trust board integrated report. In addition a 6 monthly report which evaluates staffing capacity and capability over the previous 6 months, and forecasts the likely requirements for the next six months is required; the Board received the first 6 monthly report in June 2014. The 6 monthly reviews should be based on evidenced based tools and discussion with ward or service leads. Boards are required to sign off the establishment for all clinical areas, articulate the rationale and evidence for agreed staffing establishments, and understand the links to key quality and outcome measures. (p 11 NQB guidance).

1.4 The Board have been fully engaged with the process for setting new establishments following the

initial work undertaken to review requirements utilise the Shelford Acuity and Dependency Tool, and the subsequent discussions in relation to funding and recruitment.

1.5 The National Institute for Clinical Excellence (NICE) guidelines for nurse staffing in acute areas

were launched by NICE in June 2014. The organisation is working to achieve compliance with all of these recommendations or making it clear to the Board when the Trust is non-compliant with the recommendations i.e. where professional judgement prevails.

2 DELIVERY ON REQUIREMENTS 2.1 NATIONAL QUALITY BOARD (NQB) REQUIREMENTS 2.1.1 The NQB sets out what is expected in a six monthly staffing paper to the Board in relation to the

establishment review. 2.1.2 For ease of understanding those expectations are set out in summary below. A RAG rating is

provided to indicate how far we are with being able to provide adequate data in a meaningful way for analysis.


Table 1 List of expected information provided in the six monthly report. The difference between current establishment and recommendations following the use of evidence based tools

G Appendix A Table 1

What allowance has been made in establishments for planned and unplanned leave

G 22% uplift has been accounted is accounted for in establishments

Demonstration of the use of evidenced based tools

G Appendix B The Shelford Tool for acute Inpatient areas has been completed during Jan 2016

Details of any element of supervisory allowance that is included in establishments for the Sister/Charge Nurse

G All Inpatient Acute areas have 100% Ward Manager supervisory allowance planned for in the rotas however this is only deliverable if the ward is fully established. Mental Health areas do not have this built into rota’s as safer staffing review was not taken forward in Mental Health after NICE guidelines were halted.

Evidence of triangulation between the use of tools and professional judgment and scrutiny

G The Safer Staffing Cafés are planned for 2016/2017. Rota reviews incorporate the Ward Manager and Matron’s professional judgement in order to consider any changes required.

The skill mix ratio before the review and recommendations after the review

G Appendix A, Table 1 We are aiming to achieve 65/35 registered to non- registered split with a minimum of 60/40

Details of any plans to finance any additional staff required

G Appendix A, Table 2 includes the additional 29 RN’s to be funded for 2016/2017

The difference between the current staff in post and current establishment and details of how this gap is being covered and resourced

G Appendix C

Details of workforce metrics – e.g. data on vacancies (short and long term) sickness/absence, staff turnover, use of temporary staffing solutions, (split by bank/agency/extra hours and overtime)

G Appendix C

Information against key Quality and outcome measures e.g. data on safety thermometer or equivalent for non-acute settings, serious incidents, healthcare associated infections (HCAI’s) complaints, patient experience/satisfaction and staff experience/satisfaction

G Appendix D

2.2 NICE GUIDANCE 2.2.1 We are working towards full compliance with NICE guidance. The Director of Nursing team agreed


an escalation process approved in January 2016. However, a further review is required to ensure this is workable for staff. This will be revisited and finalised by end of May 2016. The models for assessing community staffing are in place with community teams. We are aiming to include community nursing in the 6 monthly reviews during 2016/17. A review of our Allocate MAPS system and how staff use this has taken place during March 2016 and plans are being developed to improve management of staffing and reporting. Once use of the system we can plan to invest in ‘Safe Care’ an Allocate module that enables easy visible management of staffing resource.

2.2.2 Red flag system: The ‘red flag’ system includes specific safety indicators and is either related to number of staff

available for a shift, or an incident or issue e.g. delay in giving pain relief, or unplanned omission of medication. It is not utilised as a main source of capturing impact of short staffing. Datix is widely recognised as the tool for documenting incidents. The use of the red flags will be reviewed over the next six months alongside the use of MAPS. Compliance with the use of Red Flags is poor. The Deputy Director of Nursing is currently using this in association with the Trust incident Datix system.

2.2.3 Maternity:

The Maternity Unit is compliant with all requirements of the National Institute for Clinical Excellence (NICE) guidelines for Maternity: the Unit currently works to Birth Rate Plus guidance and meets requirements for nurse to patient ratio’s for labour with 98 – 100% achieved. The ratio of midwife to mothers is 1:32 which is higher than the recommendation of 1:28 by RCM and higher than neighbouring Trusts when benchmarked. Maternity services on the island however benefit from an integrated service and the Head of Midwifery provides assurance of the standards and indicators achieved in the service. Key performance indicators such as training are green rated and there is no concern about this higher ratio and this will continue to be reviewed through the safer staffing café’s.

2.3 CONTACT HOURS 2.3.1 The principle of reviewing direct contact time with the patient by nurses has been piloted in areas

across the region. The Trust did have a pilot of the approach in the General Rehab ward, the team found the approach time consuming and confusing and we have decided not to take this forward in other areas. This is a similar approach to other areas in the region.

2.3.2 It is likely that all organisations will be requested to report on contact Hours per person by day in Q1

or Q2 of 2016. Currently we monitor the number of hours for each ward per month for day and night and by registered and non-registered staff. It is important that we are confident in our data in MAPS and the use of MAPS to enable us to collate this accurately, hence the review initiated and follow up actions.


3 ESTABLISHMENT REVIEW 3.1 ACUITY AND DEPENDENCY 3.1.1 The organisation is utilising the Shelford Model to review Acuity and Dependency. This tool enables

staff to measure the acuity of care (e.g. intravenous anti-biotics, high level of monitoring, ventilation or respiratory support) and the level of dependency of a patient ( two people to mobile, needs help with eating and drinking). We are then able to calculate a WTE nursing requirement for the number of patients in that ward. The WTE figure includes all nurses (registered and non-registered) and is used as a benchmark or guide, in conjunction with professional judgement.

3.1.2 Below is the information from the January 2016 review alongside previous reviews.

The review applies to acute wards only therefore Mental Health is not included, neither is ITU, Emergency Department. The tool is not tailored to MAAU areas however we do use to provide a benchmark.

3.1.3 The number of beds is shown by each ward area for the time of the review. This has varied due to

the capital works programme, reconfiguration of ward areas, and the use of contingency beds over the winter period.

3.1.4 Acuity and Dependency Recommendations - Tracking table

WARDS beds Jan-14 beds Jun-14 beds Feb-15 beds Jun-15 beds Jan-16

Average of available results

COLWELL 28 41.98 28 41.46 28 43.18 28 43.00 28 40.36 42.00 STROKE 26 38.96 26 39.36 26 36.14 26 31.48 26 38.71 36.93 REHABILITATION* 30 42.65 26 35.32 30 46.38 26 35.92 26 34.44 38.94 WHIPPINGHAM* 21 33.85 27 47.75 27 41.75 27 38.80 24* 36.90 39.81 ALVERSTONE 16 14.00 16 18.73 19 24.81 16 12.18 16 9.80 15.90 LUCCOMBE 20 29.78 21 30.39 21 30.17 21 30.61 21 28.38 29.87 ST HELENS 15 15.68 27 38.61 15 23.58 15 15.47 15 18.43 22.35 MOTTISTONE 10 7.87 10 11.02 10 10.28 10 9.34 10 7.23 9.15 CCU/CCU STEPDOWN 18 25.35 18 21.42 18 24.30 18 22.38 18 26.7 24.03 APPLEY* 28 34.29 18 28 30.97 32.63 MAU 23 23 28 41.40 28 29.9 24 34.4 35.23 TOTAL 235 284.41 222 284.06 240 321.99 215 269.08 212 306.32 326.8433 * Beds increased and decreased during the reporting period

3.2 PROFESSIONAL VIEW 3.2.1 Items taken into consideration to provide an overall position include;

· Patient turnover during the day · Level of staff ability i.e. newly registered staff and levels of supervision of staff required · Level of safety/effectiveness risk i.e. high number of falls or complaints · Provision of 1:1 for enhanced needs on an ad hoc basis

3.2.2 Providing 1 to 1 enhanced care needs is not managed as effectively as it could be and we are

looking at national guidance and partner organisations to see where we can improve going forward. It is difficult to provide one to one care due to availability of staff, and specialized training and skills can be needed which are not available. An operational staffing group is being set up to review this, looking at our current demand, best practices and approaches across the region, and to consider recommendations on approach.

3.3 RECOMMENDATIONS FOR STAFFING LEVELS


3.3.1 The recommendations for staffing can be found in Appendix A, Table 1. The recommendations include the additional 29 staff agreed with the Board in September 2015 which was not funded during 2015/2016. This was largely due to unavailability of staff to fill the funded posts. These have been added to the relevant establishment in 2016/2017

3.3.2 The Acuity and Dependency scores have been added to App A Table 1 for completeness however

for areas that have changed establishment over time, bed base and patient group it is impossible to truly benchmark their scores against the staffing requirements owing to such changes that include the size of the Ward at the time of measurement may be different to the actual required ward size. Smaller wards still require 2 Registered Nurses 24/7 in line with the Safer Staffing principles.

3.3.3 Overall, the recommendations match the Acuity and Dependency scores with the larger ward

recommendations being slightly lower than Acuity and dependency requirements and the small wards requiring higher than Acuity and Dependency scores suggest. This is expected as smaller wards still require 2 registered nurses to be available for all shifts. The exception is CCU and CCU stepdown. This area averages 24 in its Acuity and Dependency rating and has 36 staff. This is due to the requirements from the cardiac service as staff cover a variety of additional patient management that requires skilled support. Over April and May we are continuing daily Acuity and Dependency in CCU and CCU Stepdown, monitoring to capture this additional activity and confirm we are assured this staffing level is truly required.

3.3.4 The Stroke Unit and rehab unit have been under particular scrutiny following the Care Quality

Commission (CQC) review where the Trust has an outstanding compliance action for its safer staffing requirements. The establishment for 2016/2017 enables the wards to run their rota with a small deficit of 7.5 and 5 hours per week respectively, although a requested twilight shift will not be in place. This is a much improved position for Registered Nurses in these areas.

3.3.5 The Emergency Department is an area that has raised a recent concern about the level of staffing

being adequate for the future after a period of high demand. In addition this area is the high risk area for staffing as has only minimal staffing with little or no flexibility to accommodate sickness absence if this is an issue. This is the only area where this is the case. A Head of Nursing & Quality (HONQ) has been appointed to this Business Unit. There are planned Safer Staffing Café’s in the month of April 2016 to cover the Emergency Department and all Community Nursing. A significant challenge lies in the provision of Paediatric Nurses to the Emergency Department. The Board is minded to reflect on this being an area which received an enforcement action in the past. Although compliance was achieved in relation to the presence of Paediatric Trained nurses, owing to staff turn over the department is currently non-compliant with the previous enforcement action. The HONQ is currently undertaking a risk assessment on the impact this is having on children who attend the department.

3.3.6 The recommendations for establishments remain the same. Following a sustained period of

measure (3 Years) the EDoN is minded to move away from a 3 year plan of investment, and for the Trust Board to support the decision taken in September 2016 for the investment of 29wte. This will be funded in establishment for 2016/2017.

3.3.7 The recommendations and financial implications are identified at Appendix A, Table 2. The

Registered Nurse budget increases from £16,831,000 to £17,739,000 4 MANAGING CURRENT SHORTFALLS 4.1 Details of staff currently in post and vacancies are provided at Appendix C, Table 1. At month 10

there were 101 vacancies across safer staffing areas and theatres, including registered and non-registered staff. The RN vacancy at Month 10 for the safer staffing areas and theatres is 63.

4.2 RECRUITMENT 4.2.1 We have now recruited 36 Registered Nurses from the Philippines and a further 14 are planned to

arrive in May. This will complete our current international recruitment. Further international


recruitment is being considered. 4.2.2 We continue to be proactive in recruiting newly qualified staff. We have recently campaigned for

more staff to return to practice with opportunities for funding but were only able to recruit 2 staff. 4.2.3 The Trust in association with Portsmouth University is supporting the Training of 150 RN’s to the

South Region. Practice placements and opportunities on the Island will support a more sustained supply of RN’s in the future. However, in the short term gap will need to be addressed. A plan for additional international recruitment is underway with interviews in the Philippines commencing July 2016.

4.3 TEMPORARY STAFFING 4.3.1 The Trust had 726.8 WTE funded posts in the establishments for our Inpatient acute and MH areas

(i.e. safer staffing areas) and 625.2 WTE in post as of Month 10 (Jan 2016). There are 101.6 WTE vacancies across these areas which as an overall percentage reflects a 14% vacancy rate. This is the highest this has been since 2012. Bank nursing shifts are planned to cover the majority of these gaps.

4.3.2 Bank Nurses are utilised by all wards to cover shortfalls. Fill rates of 78% was achieved for

registered nurse requests over the six month period of this report. Appendix C Table 2.

This breaks down as below

Total shifts requested Filled Unfilled

% Fill rate

RN 3696 2896 806 78%Agency RN 1282 1173 109 91%

HCA 7947 6282 1665 79%


4.3.3 Agency staffing is utilised for the winter resilience areas and is now managed within agency rules set out in September 2015. These rules set out an hourly rate cap on payments to nursing agencies. A ceiling for agency utilisation which should not exceed 3% of our nursing budget is currently being breached. The cause of this is largely due to the opening of contingency and emergency beds. The Trust is coming under increasing pressure to bring its utilization back in line with the national requirements. This has been implemented in steps however the expectation is from March 2016 the cap should be in place. A cap on the payments to agency nurses came into force in March 2016. The impact of this is that agency nurses are in a less favorable financial position and we may see agency availability for NHS shifts decline. This has not been the case over the past 6 months however impact is being felt in other organisations in the region.

4.3.4 Appendix C Table 3 shows the peaks of bank and agency in those areas with additional beds or

supporting Poppy by transferring substantive staff and replacing with bank or agency. 4.4 MANAGING RISK 4.4.1 Contingency beds (Poppy ward) and overflow bed areas on Whippingham and Appley have meant

significant pressure of staffing resource. Agency Nurses have been utilised for Poppy, and staff have been deployed to the most appropriate area to ensure agency nurses are dispersed with regular staff. Bank nurses have been utilised for other areas but there has not always been adequate resource available and at times there has been gaps that have had to be filled with agency or managed with reduced resource.

4.4.2 These three areas (Poppy, Whippingham, and Appley) are currently considered high risk areas.

Appley Ward has also been in the process of re-establishing the team and adding in new staff. The new Matron is providing assurance to SEE Committee of achieving standards and high quality care with growing confidence.

4.4.3 The impact of managing our resources is monitored via the monthly Unify report. The Planned v

Actual staffing hours for Registered Nurses and Health Care Assistants, by day and night, over the 6 month period, can be found at Appendix C, Table 4. There has been a drop in RN and HCA hours delivered during the day. This has been below our locally set target of 90% from July 2015 to December 2015

4.4.4 Regular staff have undertaken additional hours to support ward areas but this is not sustainable and

increasing sickness levels need to be observed. 4.4.5 Recruitment strategies are under review, to enable the increased establishments to have best

opportunity to fill shifts with substantive staff. It is not cost effective or desirable to utilise agency to manage gaps. In the longer term there is also work on skill mix and the development of the non-registered roles in place.

5 WORKFORCE DATA Workforce data report is supplied Appendix C 5.1 Data is supplied to demonstrate the average Sickness and Turnover for the six months from Jul

2015 to Dec 2015 for each Inpatient Acute and Mental Health area see Table 5 & 6. 5.2 Sickness is a significant issue for nurse staffing. Back to work interviews and sickness management

is expected however current reviews are indicating limited assurance in these areas and ward mangers are being required to address this. A practical session is being set up with HR and nursing to engage ward managers in the different approaches and to ensure they are fully conversant with the policies and their practical implementation. The recommendations and actions following the review of the use of the Trusts electronic rostering system are urgently required.

6. RECOMMENDATIONS


6.1 The Trust Board is recommended to receive the 6 monthly report and assure themselves that appropriate actions are being taken

6.2 The Trust Board is recommended to agree the nursing establishments going forward for 2016/2017 6.3 The Trust Board is recommended to approve the report Alan Sheward Executive Director of Nursing 30th March 2016 Prepared by Sarah Johnston Deputy Director of Nursing March 2016

Appendix A Table 1

Current establishment, recommended establishment, and average Acuity and Dependency scores for Inpatient Acute Wards

Ward beds current RN establishment

recommended RN establishment

current HCA establishment

recommended HCA establishment

current establishment

total WTE

recommended establishment

total WTE

Acuity and dependancy review

output Skill Mix achievedAlverstone 16 12.73 13.00 6.32 6.32 19.05 19.32 15.90 66/34Luccombe 21 14.57 16.50 12.87 12.87 27.44 29.37 29.87 55/45Colwell 28 16.58 24.18 15.31 15.52 31.89 39.70 42.00 60/40Appley 22 3.69 18.50 12.45 13.00 16.14 31.50 32.63 57/43Whippingham 16 25.83 13.50 8.00 8.00 33.83 21.50 38.91 61/39St Helens 15 15.17 13.50 11.69 9.00 26.86 22.50 22.35 58/42ITU 6 39.06 40.00 4.26 4.06 43.32 44.06 90/10CCU/Step down 18 31.32 31.00 6.66 6.66 37.98 37.66 24.03 82/18Mottistone 10 12.40 13.20 2.80 2.80 15.20 16.00 9.15 81/19Rehab 26 16.18 20.00 16.77 16.77 32.95 36.77 38.94 53/47Stroke 26 20.50 24.50 12.96 13.37 33.46 37.87 36.93 63/37Childrens 19.39 22.00 4.98 4.98 24.37 26.98 81/19NICU 9 12.44 13.06 5.60 5.60 18.04 18.66 69/31Maternity 42.72 42.72 18.57 18.57 61.29 61.29 70/30MAU 22 24.17 27.36 11.88 13.00 36.05 40.36 35.23 67/33ED 29.77 32.50 8.40 9.00 38.17 41.50 78/22Afton 12 12.79 12.79 11.00 11.00 23.79 23.79 54/46Osborn 19 17.46 17.46 11.00 11.00 28.46 28.46 61/39Seagrove 8 14.07 14.07 14.33 14.33 28.40 28.40 50/50Shackleton 7 11.43 11.43 15.40 15.40 26.83 26.83 43/57Woodlands 11 8.66 8.66 5.73 5.73 14.39 14.39 60/40Totals 400.93 429.93 216.98 216.98 617.91 646.91

Table 2 Additional RN’s funded for Acute Inpatient areas 2016/2017

Ward

WTE £'000 WTE WTE WTE £'000 WTE £'000Afton Ward 12.79 578 12.46 (0.33) 0.00 0 12.79 578Alverstone Ward 12.73 512 10.29 (2.44) 0.27 8 13.00 521Appley Ward (22 beds) 3.69 180 12.56 8.87 14.81 463 18.50 644Colwell Ward 16.58 632 14.20 (2.38) 7.60 238 24.18 869CCU 31.32 1,248 29.05 (2.27) (0.32) (10) 31.00 1,238Emergency Department 29.77 1,267 (29.77) 2.73 85 32.50 1,352General Rehabilitation Ward 16.18 656 11.60 (4.58) 3.82 120 20.00 775Intensive Care Unit 39.06 1,728 30.56 (8.50) 0.94 29 40.00 1,758Luccombe Ward 14.57 623 12.27 (2.30) 1.93 60 16.50 684Medical Assessment Unit 24.17 1,057 22.18 (1.99) 3.19 100 27.36 1,157Maternity 42.72 2,154 42.07 (0.65) 0.00 0 42.72 2,154Mottistone 12.40 201 11.96 (0.44) 0.80 25 13.20 226NICU 12.44 576 (12.44) 0.62 19 13.06 595Osborne Ward 17.46 727 16.86 (0.60) 0.00 0 17.46 727Paediatric Ward 19.39 782 20.37 0.98 2.61 82 22.00 863Seagrove Ward 14.07 609 12.00 (2.07) 0.00 0 14.07 609Shackleton Ward 11.43 458 8.80 (2.63) 0.00 0 11.43 458Woodlands 8.66 389 7.66 (1.00) 0.00 0 8.66 389St Helens Ward 15.17 625 (15.17) (1.67) (52) 13.50 572Stroke Unit 20.50 854 17.98 (2.52) 4.00 125 24.50 980Whippingham Ward (16 beds) 25.83 974 13.47 (12.36) (12.33) (386) 13.50 588Total 400.93 16,831 306.34 (94.59) 29.00 908 429.93 17,739

RN Annual Budget Aug15 M5

RN In Post

Dec15 M9*

RN Variance

Additional RN Posts

Proposed RN Annual Budget

Apr16 M1

Appendix B

Acuity and Dependency

Acuity and Dependency over 6 periods of measurement

-

5

10

15

20

25

30

35

40

45

50

55

Acuity and Dependancy scores over 2014-2016

Jan-14

Jun-14

Feb-15

Jun-15

Jan-16

Medical Wards

Appley

55 28

434

0 0

Acuity and Dependency Appley

0

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CCU (Acute & Stepdown)

Colwell

MAAU

Surgical

44

54

182

52

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Luccombe

St Helens

198

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Elective and Trauma

0

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3

02468

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84

110

187

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Appendix C Table 1 Current establishment at Month 10 with variance and percentage vacancy NB Whippingham and Appley establishments are in process of moving back from their temporary establishments put in place for capital works programme

Funded Establishment

In post (Contracted) Variance

Vacancy as a % of overall Budget

MAAU Total 63.28 55.1 8.18 13.0%Luccombe 27.84 24.54 3.3 12.0%Colwell 36.1 28.03 8.07 22.0%Appley 59.17 25.53 33.64 57.0%Whippingham 21 24.19 -3.19 0.0%Stroke 37.46 30.89 6.57 18.0%ITU 43.12 39.42 3.7 8.6%CCU 36.52 34.31 2.21 6.1%ED 40.77 36.96 3.81 9.4%Theatres 38.47 37.07 1.4 13.0%Alverstone 19.82 16.98 2.84 14.3%St Helens 20.5 16.85 3.65 17.8%Mottistone 15.2 13.96 1.24 8.2%General rehab 37.27 25.83 11.44 30.7%Afton 23.79 24.06 -0.27Osbourne 28.06 26.86 1.2 4.3%Seagrove 29.2 25.53 3.67 12.6%Shackleton 27.76 23.06 4.7 16.9%Woodlands 14.39 11.86 2.53 17.6%Paediatrics 26.98 27.01 -0.03NICU 18.81 17 1.81 9.6%Maternity 61.29 60.16 1.13 1.8%

Totals 726.8 625.2 101.6

M10 BI (Finance Reporting)

Table 2 Bank and Agency Fill rate July 2015 – Dec 2015

0

1000

2000

3000

4000

5000

6000

7000

8000

RN Agency RN HCA AgencyHCA (filledby agency

RN)

Total

Filled

Table 3 Staff in post and use of Agency and Bank to support gaps

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00Jul 15 - Dec 15 Average FTE Figures

Budget Total FTE

In post FTE

Excess FTE

Overtime FTE

Bank FTE

Agency FTE

Table 4

Average Fill rates achieved

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%110.0%120.0%130.0%

Average fill rate for Nurses and Midwives Inpatient areas Acute and Mental Health (local target 90%)

Average Fill rate - Registered nurses/midwives (Day) Average Fill rate - Care staff (Day)

Average Fill rate - Registered nurses/midwives (Night) Average Fill rate - Care staff (Night)

Table 5

Average sickness for 6 month reporting period July 2015 – December 2015

Changes made to rota’s to reflect new establishment

Winter pressure period

Table 5a Sickness Absence July - December 2015

Table 6 Average turnover for 6 month reporting period July 2015 – December 2015

1.11%

0.00% 0.00%

1.75%

0.63%

0.00%

0.30%0.35%

0.00%

0.76%

0.20%0.00%

0.76%

0.00%

1.19%

0.46%

1.75%

0.60%

1.13%

2.38%

1.28%

0.00%

1.11%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

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Average Turnover - Jul 15 - Dec 15

YTD

Table 6a Nursing and Midwifery starters and leavers

Table 6b

2012/2013 2013/2014 2014/2015 2015/2016 AverageN&M Inpost (Heads) 966 907 897 889 915

leavers 70 96 81 63 78Turnover 7% 11% 9% 7% 9%

33

68 69 54

70

96 81

63

020406080

100120

2012/2013 2013/2014 2014/2015 2015/2016

Nursing and Midwifery Starters and Leavers 2012 - 2016

Starters Leavers


Afton WardSickness Training

3.41% 96.30%Falls PU

0 0

AlverstoneSickness Training

9.44% 84.70%Falls PU

0 1

ColwellSickness Training15.34% 71.90%

Falls PU4 4

CCUSickness Training

2.10% 89.60%Falls PU

1 2

0.0%

100.0%

200.0%

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Fill

Rate

%Afton Ward

Average fill rate - registered nurses/midwives (day) Average fill rate - care staff (day)Average fill rate - registered nurses/midwives (night) Average fill rate - care staff (night)Target

0.0%

100.0%

200.0%

300.0%


Fill

Rate

%

Alverstone Ward


0.0%

50.0%

100.0%

150.0%


Fill

Rate

%

Colwell Ward


0.0%

50.0%

100.0%

150.0%

200.0%


Fill

Rate

%

Coronary Care Unit



Gen RehabSickness Training

3.96% 86.40%Falls PU

0 0

ITUSickness Training

5.05% 90.20%Falls PU

0 7

LuccombeSickness Training

4.79% 84.70%Falls PU

0 1

MAUSickness Training

2.71% 83.70%Falls PU

2 4

0.0%

50.0%

100.0%

150.0%


Fill R

ate

%General Rehab and Step Down Unit


0.0%

100.0%

200.0%


Fill R

ate

%

Intensive Care Unit


0.0%

100.0%

200.0%


Fill R

ate

%

Luccombe Ward


0.0%

200.0%


Fill R

ate

%

MAAU



MaternitySickness Training

3.42% 83.40%Falls PU

0 0

MottistoneSickness Training13.18% 91.40%

Falls PU0 1

NICUSickness Training

2.10% 89.60%Falls PU

0 0

OsbournSickness Training

0.92% 89.60%Falls PU

1 0

0.0%

100.0%

200.0%


Fill R

ate

%Maternity Services


0.0%

200.0%


Fill R

ate

%

Mottistone Ward

Average fill rate - registered nurses/midwives (day)Average fill rate - care staff (day)Average fill rate - registered nurses/midwives (night)

0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

Neonatal Intensive Care Unit


0.0%

100.0%

200.0%


Fill R

ate

%

Osborne Ward



ChildrensSickness Training

2.67% 75.70%Falls PU

0 0

SeagroveSickness Training

5.11% 86.50%Falls PU

0 1

ShackletonSickness Training

9.31% 96.80%Falls PU

2 0

St HelensSickness Training

0.88% 82.10%Falls PU

0 0

0.0%

100.0%

200.0%


Fill R

ate

%Paediatric Ward


0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

Seagrove Ward


0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

Shackleton Ward


0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

St Helens Ward



StrokeSickness Training10.07% 83.20%

Falls PU1 1

WhippinghamSickness Training

3.10% 67.10%Falls PU

1 2

WoodlandsSickness Training

Falls PU0 0

0.0%

50.0%

100.0%

150.0%

200.0%


Fill R

ate

%Stroke Neuro Rehab


0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

Whippingham Ward


0.0%

50.0%

100.0%

150.0%


Fill R

ate

%

Woodlands



ON 30th March 2016 Title Principal Risk Register (Board Assurance Framework) Report Sponsoring Executive Director

Mark Price, Company Secretary

Author(s) Lucie Johnson, Head of Corporate Governance Purpose 1) To provide an update to the Trust Board in relation to the current

Principal risks identified by the Trust. 2) To ask the Board to approve the inclusion of a further risk on the

Principal Risk Register, relating to the capacity and capability of the Board

3) To ask the Board to formally agree to the closure of the Self Certification process following the alignment of the Board Statements and Licence Conditions with the Trusts Risk Registers.


Receive Approve X

Previously considered by (state date): Sub-Committee Dates

Discussed Key Issues, Concerns and Recommendations from Sub Committee



Charitable Funds Committee

Finance, Investment, Information & Workforce Committee


Remuneration & Nominations Committee

Quality Governance Committee

Please add any other committees below as needed Not applicable.

Staff, stakeholder, patient and public engagement: Not applicable. Executive Summary & Analysis: Principal Risk Register The 7 current Principal Risks, identified are as follows:-

1. Human Resources 2. Financial Resources 3. Strategy and Planning 4. Quality and Harm 5. Culture 6. Local Health and Social Care Economy Resilience 7. Information Communication Technology (ICT)

Board Self Certification Requirement As the Trust Board is aware as it was mentioned in the last Risk Register report to the Trust Board on the 2nd March 2016, the Trust Development Authority have recently written to all Trusts to advise them that it is no longer necessary for Trusts to provide a monthly self-assessment update return in relation to the Board Statements and Licence Conditions. This is seen as a positive step by the Trust as the process was unnecessarily onerous.

Enc H


However, it is acknowledged that a number of risks identified as part of the self-assessment process must not now be lost due to their potential impact on the Trust. Therefore it was proposed that a review has been undertaken, by the Head of Corporate Governance to establish which risks embedded within the self-assessment are already registered on the Trusts Risk Management System. Those not registered will be added to the risk register to ensure that they remain visible to the Board and their Assurance Committees, and appropriate actions are taken to mitigate them into the future. The Head of Corporate Governance proposed to the Board meeting earlier in March that the outcome of this review be included in the Risk paper for the next Board meeting. This review has now been concluded and the attached report on the closure of the Self Certification process, outlines where risks have been realigned and further actions to be taken. The Trust Board is asked to review and approve the proposals made. Indeed, following a discussion at a previous FIIWC meeting and a further discussion during an Executive Governance Review meeting on the 22-2-16 it was been determined that an 8th risk be added to the Principal Risk Register in relation to Board Statement 13 which states that “The Board is satisfied all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability”. This new risk has been added to the Principal Risk Register, and is awaiting Trust Board approval for formal inclusion in the Principal Risk Register. The attached suite of papers includes the following:-

1) Principal Risk Register report, which provides an overview of the 7 current risks, including the number of actions identified in relation to each risk and progress made to date. It also includes the proposed 8th risk for inclusion. It is worthy of note that:-

• No risks have changed score since the last Principal Risk Register report to the Trust Board.

• 2 new actions have been determined, both of which relate to the risk relating to Health and Social Care Economy Resilience.

• 25 actions have been identified to date to address the 7 risks. • 8 actions are regarded as being closed, but closure of these actions has not impacted

on the risk scores. 2) Formal closure of the Board Self Certification Process report.


1) Review the 7 risks currently identified on the Principal Risk Register, and seek further assurance from risk owners as deemed appropriate.

2) Approve the inclusion of the 8th risk as per the attached Principal Risk Register report. 3) Review and approve the proposals made in the Formal Closure of the Board Self Certification

Process report. Attached Appendices & Background papers

1) Principal Risk Register report 2) Formal Closure of the TDA Board Self Certification Process report.

For following sections – please indicate as appropriate: Trust Goals & Priorities

All

Principal Risks (BAF) All Legal implications, regulatory and consultation requirements

Date: 29-3-16 Completed by: Lucie Johnson, Head of Corporate

Governance


Isle of Wight NHS Trust Principal Risk Register Report for the Trust Board 6-4-16

Ref Risk Owner Description Opened Rating (current)

Target score Review date

Anticipated Target/ Completion date

Comments made on Risk Register entry

672

Palmer, Chris - Director of Finance

If the Trust is unable to manage within the revenue and capital financial resources it receives then it may become financially unsustainable. (working towards the £4.6 million deficit plan)

07/10/2015 16

12

29/01/2016 01/04/2016

Updated by Chris Palmer 29-3-16:- All CIP delivered for 2015/16 although reliance on non-recurring savings will impact on 16/17 position. Scrutiny of workforce vacancies continues with improvements in documentation and governance in some Business Units. Cash being positively managed and £1.7m IRWCF secured. Allocation of Capital Resources positive with receipt for sale of Swanmore Road properties now secure. Under delivery of activity, increase in fines and penalties, and unfunded additional cost of agency staffing for contingency beds responding to system wide pressures underpin a significant threat to year end deficit position. Negotiations with IOW CCG have not secured funding for the cost of staffing extra beds or fines incurred as a consequence of System Wide Pressures

Action Planning:-

Description Responsibility ('To') Start date Review Date Date Completed 1) Apply for ITFF (Cash) in excess of IRWCF to mitigate forecast shortfall £1.7m (March 2016) Chris Palmer 07/10/2015 29/01/2016 29/01/2016

2) Ensure allocation of the capital resources subject to property sales Chris Palmer 07/10/2015 02/03/2016 31/03/16

3) Ensure delivery of activity to underpin the income assumptions in the budget Chris Palmer 07/10/2015 29/04/2016

4) Ensure closure of the remaining CIP gap of £2.4m (Month 7) Chris Palmer 07/10/2015 29/04/2016 29/03/2016

676 Baker, Karen - Chief Executive

If the Trust is unable to deliver against the ICT Strategy, then there will be a negative impact on quality, Income, Performance, Information Governance Compliance and Staff morale

10/11/2015 20

tbc

29/01/2016 31/03/2016

Updated by Lucie Johnson 29-3-16:- Updated on behalf of Karen Baker:- The Executive Led ICT Committee (action below) has now been set up, and is being chaired by the Chief Executive in the absence of the Executive Director of Integration and Transformation. This group will review this and other ICT related risks (Corporate Risks) and determine, further actions and assurance mechanisms required. Once determined these action will be added to this risk register entry.

Actions planning:-

Description Responsibility ('To') Start date Review Date Date Completed

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1. Executive Led ICT Committee to be setup Katie Gray 07/10/2015 29/01/2016 21/03/2016

674

Sheward, Alan - Executive Director of Nursing

If the Trusts quality governance processes are not robust and embedded then the Trust may not be able to maintain adequate patient safety, patient experience and clinical effectiveness.

07/10/2015 12

2

26/02/2016 31/03/2016

Updated by Alan Sheward 29-3-16:- Attendance at Quality Governance/Assurance meetings has been poor. Clarity on expectation to be shared with the CBU leads. - Recruitment to Deputy Director of AHP pending outcome of Organisational Change. - Good QI progress with the appointment of Nutritional Nurse Specialist. - 2016/17 CQUINS to be agreed

Updated Alan Sheward 14.03.2016:- SEE leads to review current governance arrangements to ensure quality improvement and quality assurance from Clinical Business Units to Board. -Supportive discussions with NHSI (TDA) to ensure best processes are in place to provide board and committee assurance. -Appointment to Deputy Director of Allied Health Professionals to be completed. - Newly appointed Nutritional Nurse Specialist. - Needs assessment on Falls and Dementia workforce requirements to be completed.

Action Plan:-

Description Responsibility ('To') Start date Review Date Date Completed 1. Roll out of QIF through Trust Business Planning process Andrew Shorkey 07/10/2015 18/03/2016

2. Refresh and Revise Actions to demonstrate compliance with the Trust Quality Improvement Plan Mandy Blackler 15/02/2016 31/03/2016

3. A review of Quality Governance Assurance at Clinical Business Unit Deborah Matthews 14/03/2016 31/03/2016

4. Revise Clinical Governance arrangements Deborah Matthews 07/10/2015 31/03/2016

5. Complete actions identified through QGAF self assessment Mandy Blackler 07/10/2015 31/03/2016

675 Palmer, Chris - Director of Finance

If the Trusts culture does not reflect our core values then we will be unable to deliver our vision and priorities

07/10/2015 16

02/03/2016 31/12/2015

Updated by Chris Palmer 29-3-16:- Staff Survey Results presented at Board and to Senior Managers March 2016. Results published on the Intranet March 2016. Meetings held by CP in interim capacity with Quality

























8

Champions, Staff Experience Group and Health & Wellbeing Group to review findings and identify priority focus areas. Communication methodology discussed so staff can appropriately link actions to staff survey questions for future surveys. Appraisal identified as urgent key focus area, documentation strengthened to incorporate Values & Behaviours discussion. Expectation for Appraisals to be undertaken for all staff during April to June 2016 communicated. Meeting arranged with Talentworks and Execs for 4 April 2016 to provide oversight and training to commence cascade.

Action Planning:-

Description Responsibility ('To') Start date Review Date Date Completed 1. Close down of staff survey group with project completion reports Katie Gray 07/10/2015 18/01/2016

2. Annual staff survey analysis guidance to inform next staff survey report response Katie Gray 07/10/2015 18/01/2016

671 Palmer, Chris - Director of Finance

If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skill set then it will be unable to meet demand

07/10/2015 16

8

02/03/2016 02/05/2016

Updated by Chris Palmer 29-3-16:- Second cohort of overseas nurses arrived successfully. Plans being prepared for a further recruitment drive overseas. Second careers fair planned for 16th April with increased service representation. Employee Assistance Programme contracted for commencement 1 April and communicated to staff. HR Strategy being monitored for delivery via the HR and OD Exec Led Group from 1 April 2016. Revised HR Dashboard Reporting will be pursued through the HR and OD Group.

Action Plan:-


1. Introduce HR Management Group (Exec led) Chris Palmer 07/10/2015 26/02/2016 20/01/2016

2. Refresh the 2014/15 (5 year) Human Resources Strategy. Chris Palmer 07/10/2015 01/03/2016 02/03/2016

















3. Roll out of values based recruitment Chris Palmer 07/10/2015 01/04/2016

4. Undertake further career fairs and promotion of NHS careers through volunteer opportunities Chris Palmer 07/10/2015 02/05/2016

5. Review HR Dashboard reporting Chris Palmer 07/10/2015 02/05/2016


If there is insufficient resilience in the local health and social care economy then we will be unable to deliver safe effective and financially viable care.

07/10/2015 20

tbc

14/03/2016 31/03/2017

Update Lucie Johnson 29-3-16:- Updated on behalf of Karen Baker:- 2 new actions determined as below (MLaFL governance arrangements and Hampshire and IOW Sustainability Transformation Plan). In terms of 1st new action, the Head of Corporate Governance has met with the MLaFL Director for an initial scoping meeting, and has shared the proposed Executive Governance Meeting Structure. MLaFL Director intends to map existing arrangements across key organisations to determine where structures can be merged to provide enhanced efficiencies.

Action Plan:-


1. Internal review of processes Karen Baker 07/10/2015 30/11/2015 25/02/2016

2. System discussion facilitated by the LGA to define governance structures for the MLAFL and HWBB

Karen Baker 07/10/2015 31/05/2016

3. Refresh of admissions and discharge team (with Local Authority) Shaun Stacey 07/10/2015 30/06/2016

4. Closer and more regular work with Commissioners and system lead and system review of priorities including funding.

Karen Baker 07/10/2015 31/03/2016

5. My Life a Full Life Governance Arrangements to be determined and implemented Lucie Johnson 21/03/2016 29/04/2016

6. Hampshire and IOW Sustainability Transformation plan to be developed Karen Baker 29/03/2016 30/06/2016

7. Whole Island System Review being undertaken as part of My Life a Full Life Karen Baker 07/10/2015 31/03/2017












































673

Sheward, Alan - Executive Director of Nursing

If our Trust Strategy is not robust and embedded then staff will be unable to create effective service plans.

07/10/2015 16

6

31/03/2016 29/01/2016

Updated by Alan Sheward 29-3-16:- The Trust is in the final stages of the Business Planning Round. Early attention has been given to the potential strategic drivers including the Strategic Transformation Plan on a national and regional level. My Life a Full Life will clearly impact on the Trust to deliver its strategic plans. This is being considered within the Business planning round with alignment within the plans.

Updated by Lucie Johnson on behalf of Mark Price 29-3-16:- Strategy has been submitted to the Trust Board for approval at its meeting on the 30th March 2016. Prior to this it was approved at the Trust Executive Committee meeting on the 24-3-16. The Strategy includes a section on the process for dissemination and wider communication (Page 20-21).

Action Plan:-


1. Produce Trust Strategic Plan including explicit links with My Life a Full Life KGY 07/10/2015 29/01/2016 30/03/2016

Proposed New Risk for Inclusion in the Trusts Principal Risk Register Ref Risk Owner Description Opened Rating

(current) Target score

Review date Anticipated Target/ Completion date

Comments


If there is not sufficient capacity and capability within the Executive and Non Executive Team, then the Trust will not be able to achieve its strategic ambitions, particularly in relation to my life a full life. The organisational improvements in quality, operational targets and the financial position will not be delivered.

22/02/2016 16

tbd 22/03/2016 tbd





Formal closure of the Board Self Certification, process through aligning the Board Statements and as appropriate with either the Trust Risk Register or Issues Log

Board Statements

There were 14 Board Statements, the table below sets out the status as per the last Trust Board approved TDA submission. Each Statement has been matched to the Trusts Risk Registers to ensure that no risk or issue will be lost following the formal close down of the submission process.

NB the same alignment process will not be facilitated with the Licence Conditions due to the fact that they were all regarded as compliant.

PRR = Principal Risk Register

CRR = Corporate Risk Register

Statement number Specific wording of the statement requirement Status as at last Board approved TDA submission

Currently on risk register, including which tier (Principal, Corporate or Operational) the DATIX reference and the risk owner.

Proposal

Statement 1 The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA's Oversight (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

At Risk PRR 674 re Quality Governance, owned by Alan Sheward. CRR 681, risk re triangulation of incidents, claims, complaints, etc, owned by Deborah Matthews

No further action, as already on risk register, but to be monitored closely by Trust Board and QGC.

Statement 2 The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements.

At Risk CRR 682, re CQC owned by Deborah Matthews No further action, as already on risk register, but to be monitored closely by QGC.

Statement 3 The Board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements

Yes Trust performance in relation to appraisals being completed by financial year end is not quite 100%, however the small number of doctors who do not have an appraisal by this date are tracked to ensure that appraisals are carried out.

Statement 4 The Board is satisfied that the Trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time.

Yes PRR re Financial Resources 672, owned by Chris Palmer, however, this does not relate specifically to going concern issues

Statement 5 The Board will ensure that the Trust remains at all times compliant with regard to the NHS Constitution

At Risk No risk identified. I would suggest this is both a risk and an issue, as it is a fact we don’t have the arrangements to monitor this in place, and this puts us at risk of failing to achieve.

At this point the Trust cannot evidence this, as no analysis of what is required has been undertaken for 3 years. This is both a risk and an issue, as it is a fact we don’t have the arrangements to monitor this in place, and this puts us at risk of failing to achieve. The Trust Board/Executive Team will consider where this will be placed and resourced, and then a CRR will be added and appropriately aligned.

Statement 6 All current key risks have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to

At Risk CRR 692, regarding risk management framework, owned by Lucie Johnson

No further action, as already on risk register, but to be monitored closely by ACRC.

address the issues – in a timely manner Statement 7 The Board has considered all likely future risks and has

reviewed appropriate evidence regarding the level of severity, likelihood of occurrence and the plans for mitigation of these risks.

At Risk In part as per above, but this requires a specific piece of work to be undertaken and should form part of Strategy formation in terms of SWOT/PESTEL etc

To be discussed – part of risk appetite session being planned with the Board

Statement 8 The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily

At Risk PRR re Strategy and Planning 673 currently owned by Alan Sheward (in the absence of Katie Gray) CRR 683 re performance owned by Iain Hendey. CRR re Risk Management 692 owned by Lucie Johnson PRR 674 re Quality Governance, owned by Alan Sheward, but nothing specific re Clinical Risk, however, in part this would also be picked up under CRR 681, risk re triangulation of incidents, claims, complaints, etc, owned by Deborah Matthews

No further action, as already on risk register, but to be monitored closely by Trust Board, FIIWC, QGC, ACRC.

Statement 9 An Annual Governance Statement is in place, and the Trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

Yes We have this in place.

Statement 10 The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) as set out in the relevant GRR; and a commitment to comply with all commissioned targets going forward

At Risk PRR 674 re Quality Governance, owned by Alan Sheward.

Unable to comment on GRR, as not sure where this is at currently. Executive Team to consider whether the risk to achievement on key service targets is adequately covered on the CRR and if not add a new risk.

Statement 11 The Trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit.

Yes CRR 668 re IG Toolkit owned by Lucie Johnson This is logged on the CRR and reporting will be through FIIWC, also TEC are requesting fortnightly updates at this time.

Statement 12 The Board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the Board of Directors; and that all board positions are filled, or plans are in place to fill any vacancies.

Yes Standards of Business Conduct Policy in place, but poorly adopted across the Trust, further work required to address implmentation. All Board positions are currently filled. This should be added to the issues log, rather than the risk register, as this is a fact rather than a possibility.

Statement 13 The Board is satisfied all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability

At Risk Proposed PRR entry to be submitted to April Trust Board for approval (705) owner Karen Baker

No further action, as already on risk register, but to be monitored closely by Trust Board once approved.

Statement 14 The Board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.

At Risk PRR entry 671, regarding Human Resources, owned by Chris Palmer and underpinned by the following CRR entries all owned by Mark Elmore:- Performance management 690 Workforce capacity and capability 567 Workforce performance 688, workforce skill set 687, staffing profile 686

No further action, as already on risk register, but to be monitored closely by Trust Board, FIIWC.



6th April 2016

Title Human Resource Strategy Sponsoring Executive Director

Chris Palmer, Executive Director of Financial & Human Resources

Author(s) Mark Elmore, Deputy Director of Human Resources Purpose For approval Action required by the Board:

Receive Approve X







23/2/16 Recommended for approval


Quality Governance Committee Please add any other committees below as needed Board Seminar 15/3/16 Recommended for approval Other (please state) Staff, stakeholder, patient and public engagement: Since FIIWC first had sight of this document on 6th January 2016 it has been widely circulated across the organisation and comments sought. Comments received, which included support from medics, have been incorporated into the final document. Executive Summary & Analysis: The Workforce Strategy was agreed during 2014 as an appendix to the Integrated Business Plan. With the HR function moving to the Executive Director of Financial and Human Resources we have taken the opportunity to review the current strategy so that it reflects the current portfolio and to recognise new and future ways of working, for example Vanguard and transformation opportunities for the workforce. During January 2016 we took comments from the wider organisation ahead of now seeking agreement to the Strategy in April 2016. We want to ensure that Medical Recruitment, School liaison / Work Experience, Integration opportunities, innovative recruitment and volunteers are all delivered through this Strategy. The “HR Performance Group” will monitor the application of the Strategy, establishing KPI’s for both the HR function and Business Units/Corporate areas to ensure best management and use of our human resource across the organisation.


To approve the updated HR Strategy

Enc I


Attached Appendices & Background papers

HR Strategy For following sections – please indicate as appropriate:


This Strategy will help to support all Trust Goals & Priorities.

Principal Risks (BAF) Quality, Finance, Workforce, Strategy & Planning, Culture, Local Health & Social Care Economy Resilience.


Date: 21 March 2016 Completed by: Mark Elmore, Deputy Director of HR

Isle of Wight NHS Trust Integrated Business Plan 2015 – 2019: Human Resources Strategy

January 2016 Final v1.0 1

Human Resource Strategy

Working ‘Beyond Boundaries’ to be the preferred choice for sustainable integrated

care

Updated February 2016


February 2016 Final v1.0 2

Contents Executive Summary ................................................................................................................................. 3

Increase the health and well-being of our staff: ................................................................................. 4

Building a high performing staff resource: ......................................................................................... 4

Recruiting and retaining our staff: ...................................................................................................... 4

Being recognised as a great place to work: ........................................................................................ 5

Recognising and supporting Diversity and Inclusion: ......................................................................... 5

Implementing and measuring this strategy ........................................................................................ 5

Summary ................................................................................................................................................. 6



Isle of Wight NHS Trust Human Resources Strategy

Figure 1

Executive Summary As recruitment within the NHS becomes increasingly competitive, it is essential that Isle of Wight

NHS Trust create the best possible culture and environment in which our staff can provide quality

services and person focused care. We are striving to be the employer of choice from a local,

national and international workforce perspective, and to find new and innovative ways of recruiting

and retaining staff.

Our strategic intent is that our staff are fundamental to the delivery of our core values illustrated

above. We are committed to putting patients and people using our services first and in working

together with others to ensure people receive the highest standards of care. We must also operate

in a way that prepares all of our staff for the new ways of working that our Vanguard “My Life a Full

Life” brings. Our Strategy will help us to transform our workforce ready to meet this new and

exciting opportunity for delivering Health and Social Care locally.

Alongside our values, goals and priorities (Figure 1) this strategy is influenced by other internal

strategies and key external levers that affect our Trust, including the NHS Constitution and the NHS

financial challenge. The key strategies to consider alongside the Human Resources Strategy are:

Trust Strategy (including the strategic enabler “A workforce embracing integration”)

Long Term Quality Plan

Clinical Strategy “Beyond Boundaries”



Estates Strategy

Information Management & Technology Strategy

Leadership Strategy

Financial Strategy (The Long Term Financial Plan)

Transformation and Quality Improvement Programme

The Integrated Business Plan

Health & Wellbeing Strategy

Risk Management Strategy

This Human Resources Strategy sets out how we will deliver the Goals and Priorities (Figure 1) for

our current and future staff. In particular, and in close liaison with our colleagues in Organisational

Development and Training, we will:

Improve how staff feel about work

Ensure all staff continue to develop

Ensure all staff understand how their contribution helps to achieve our vision

We will achieve this as follows:

Increase the health and well-being of our staff: We will seek to improve the health and wellbeing of our staff, by providing them with an

environment and opportunities that encourage them to lead healthy lives and make choices

that support their wellbeing.

We will treat our employees fairly and consistently through the creation of, and adherence

to, appropriate HR policies.

We will develop and deploy effective employment and management practices, which

alongside excellent communications will provide a robust appraisal, performance

management and revalidation mechanism.

We will provide a safe and trusted environment in which our staff can raise concerns,

through a Freedom to Speak Up Guardian hub.

Building a high performing staff resource: We will provide our staff with the opportunities to develop their individual and team skills

and competencies, harnessing their individual talent, enabling the Trust to deliver the

highest quality services to those receiving our care.

Where necessary and appropriate, we will seek to develop new terms and conditions that

aid retention, support motivation and productivity, and reward performance.

Recruiting and retaining our staff: We will strive to recruit and retain the right number of staff, with the right skills, in the right

place, at the right time.



We will align our workforce plan with the Trust demand, capacity, quality and financial plans

to ensure that appropriate short and longer-term workforce planning decisions are made.

We will succession plan so that wherever possible we are able to secure and develop our

human resource and in close engagement with the schools on the Isle of Wight, offer

opportunities to help grow our workforce for the future.

We will constantly test whether we have the right staffing model reviewing the balance of

permanent or flexible workforce or whether there are partnership opportunities. As part of

this we will support the Trust Strategy in creating a workforce embracing integration with

our partners in My Life A Full Life.

Being recognised as a great place to work: We want to be in the top 20% of NHS employers and have the best possible reputation

locally, and beyond, creating a working environment where staff have the right tools and

support for their role.

We want our staff to be proud to work here and to be able to recommend the Trust as a

place to work and for friends and family to come for treatment. We want staff to not only

identify with their local team, but with the whole organisation as a great place to work.

We will provide policies, processes and Human Resources services with the quality and

expertise to enable our staff to make the Trust a great place to work.

Recognising and supporting Diversity and Inclusion: We will create a culture in which diversity and inclusion are promoted actively and where

unlawful discrimination is not tolerated.

Managing diversity is crucial to being recognized as an employer of choice. We will recognise

that everyone is different, valuing equally the unique contribution that individual

experience, knowledge and skills can make.

We will promote fairness, tackle disadvantage and stigma and ensure that there is no

discrimination, whether direct, indirect or by way of victimisation or harassment, against

existing employees or those wishing to seek employment with the Trust.

Implementing and measuring this strategy This Strategy will be implemented through the HR Performance Group.

Progress will be measured using Key Performance Indicators and reported through the HR

Performance Group and in conjunction with our colleagues in Organisational Development &

Training, improvement will be visible through the results of the Annual Staff Survey.

Using the tables on the following pages our staff, and our managers, will be able to understand how

their efforts will contribute to the achievement of the Human Resources Strategy and delivery of the

Trust’s Goals and Priorities.

The HR Performance Group will ensure that managers and staff are aware of this strategy, what it

means and their contribution. Wherever an opportunity arises we will align Human Resources (HR)

actions to the Trusts Quality and Performance agenda.



Summary This is a strategy that builds on our strengths but also takes us to new ways of working both within

the organisation and through My Life a Full Life. We will recruit, develop and retain our staff so that

we can deliver the transformational challenges and become an employer of choice and be

recognised as a great place to work.



(1) Increase the Health and Well-being of our staff

Summary: To improve the health and wellbeing of our staff, providing them with an environment and opportunities that encourage them to

lead healthy lives and make choices that support their wellbeing. Treating our employees fairly and consistently through the creation of, and adherence to, appropriate HR policies. Developing effective employment and management practices and providing a safe and trusted environment in which our staff can raise concerns.

As Staff, We Will:

As Managers, We Will:

As an Organisation, We Will:

Work in an environment that feels healthy and

safe.

Understand the value of well-being within the workplace and understand our responsibility in maintaining our own health and wellbeing.

Have access to a range of services such as Occupational Health and employee assistance programmes.

Discuss and record with our line manager our own well-being during our annual appraisal.

Take reasonable care of health and safety at work for ourselves, our teams and others, and cooperate with the Trust to ensure compliance with health and safety requirements.

Understand what services are available through Occupational Health to support our health and wellbeing at work, and how to access them.

Be able to raise issues and concerns being confident that they will be taken seriously and acted upon in a timely manner.

Understand our role in delivering Health & Safety Legislation requirements.

Understand our role in managing and influencing the well-being of staff, and support those in their area of responsibility.

Understand how well-being issues link to Trust priorities.

Understand our responsibilities in managing well-being, working time, breaks and absence and how to undertake stress assessments or raise concerns to senior managers.

Be able to access support from experts such as Human Resources and Occupational Health.

Understand the value and impact that appraisal and well-being discussions have on employee health and ensure that this happens for all of our staff.

Listen to, and act upon, staff concerns

Ensure all staff receive appropriate support when returning from sickness (such as return to work interviews)

Plan for an environment that is enhanced to better meet staff needs for changing, rest areas, discussion space and access to IT.

Have a nominated Board member with a lead for Health & Wellbeing who ensures compliance in accordance with legislation

Develop a Health & Wellbeing Strategy.

Demonstrate employee health and well-being has a positive benefit on staff satisfaction rates through the staff survey.

Build the capacity and capability of management at all levels to improve the health and well-being of staff.

Host a Health and Well-being forum with staff side representation.

Act upon concerns raised by staff, ensuring these are effectively responded to within a safe and trusted environment.

Demonstrate that employee well-being and engagement has a good effect on the quality of service, patient care, recruitment and retention.

Demonstrate that our Trust has a robust system for managing stress and health and safety risks with clear accountability.

Consider the wider impacts of well-being, such as travel to work arrangements and the working environment, within the IT and Estates strategies.



(2) Building a high performing staff resource

Summary: Providing staff with the opportunities to develop their individual and team skills and competencies, harnessing their individual talent,

enabling the Trust to deliver the highest quality services to those receiving our care. Developing new terms and conditions that aid retention, support motivation and productivity, and reward performance.

As Staff, We Will

As Managers, We Will

As an Organisation, We Will

Have the opportunity to discuss personal

performance and development in appraisal in a way that provides a clear understanding of what is required in our role.

Have sufficient and regular opportunity to discuss our needs in relation to immediate work responsibilities and broader personal development.

Be able to agree how discussions and meetings relating to this will be structured and conducted, with those responsible for assessing personal performance.

Actively engage in revalidation.

Achieve Trust and personal objectives.

Set clear “SMART” objectives that provide a “clear line of sight” to the Trust-wide goals and priorities.

Set clear “SMART” objectives that will enhance individual performance and meet career development needs.

Implement the Trust’s appraisal guidelines and ensure that the Trust annual percentage of staff having a quality appraisal is achieved.

Review progress on objectives and actions necessary to assure achievement.

Effectively manage the performance of all staff, using Trust policy to address underperformance.

Through practice and policy demonstrate that quality appraisals and revalidation are part of the Trust performance management process.

Demonstrate that performance, where challenged internally and externally, is fair.

Through building a high performing staff resource, achieve standards of care that we are proud of.

Ensure performance standards and performance improvement goals are clearly expressed.

Ensure that staff are appraised and able to undertake their role to the highest possible standard.

Facilitate a culture of staff satisfaction and pride to work here



(3) Recruiting and retaining our staff

Summary: Recruiting and retaining the right number of staff, with the right skills, in the right place, at the right time. Aligning our workforce

plan with the Trust demand, capacity, quality and financial plans and succession planning so that we are able to secure and develop our staff and in close engagement with the schools on the Isle of Wight, offer opportunities to help grow our workforce for the future. We will pursue partnership opportunities and support the Trust Strategy in creating a workforce embracing integration with our partners in My Life A Full Life.

As Staff, We Will



Have opportunities for career progression and

postgraduate training programmes.

Be responsible for developing our skills, maintaining professional requirements and meeting the needs of our roles.

Have flexible working opportunities consistent with the needs of patients and the way people live their lives.

Be treated fairly and equitably when rostered for holidays and unsocial hours to achieve work life balance.

Comply with health and safety requirements in taking breaks and adhere to staffing patterns that ensure safe staffing.

Support those who are here on placements.

Receive reasonable notice for regular rosters.

Act reasonably to respond to urgent safety requirements outside of normal rosters.

Agree an annual Job Plan where required.

Make plans aligning activity, capacity and staffing requirements within the financial budgets we are responsible for.

Match operational staffing plans to safety objectives, budgets, capacity need and requirements for statutory and mandatory training and leave.

Adhere to the standards for safe staffing levels and maintain compliance with regulations through effective management of staff.

Design out long hours working, reducing reliance on regular overtime working and review emergency cover.

Plan the recruitment pipeline including supporting learners, induction of newly qualified staff and maximising the use of graduate and local talent.

Ensure rosters are created and communicated in a timely manner.

Review Job Plans annually.

Have a workforce plan that is fully integrated with financial, activity and quality plans.

Optimise productivity measured by reducing the ratio of paybill to revenue.

Benchmark our staffing with others and learn from productivity opportunities.

Demonstrate compliance with current regulatory requirements.

Partner with education providers and others to deliver and influence the supply of future workforce.

Manage risks to supply of key staff through succession planning and developing attraction strategies.

Provide a positive HR experience for applicants, employees, and retirees and collaborate with departments to recruit, develop, support, and retain diverse and talented employees who are the key to Isle of Wight NHS Trust’s reputation and success.



(4) Being recognised as a great place to work

Summary: To have the best possible reputation locally, and beyond, creating a working environment where staff have the right tools and

support for their role, where staff are proud to work here and to be able to recommend the Trust as a place to work and for friends and family to come for treatment. We will provide policies, processes and Human Resources services with the quality and expertise to enable our staff to make the Trust a great place to work.

As Staff, We Will



Understand the Trust strategy, annual goals and

priorities of the Trust and how our role contributes to their achievement.

Be engaged in setting the work priorities in our ward or department.

Recognise good standards of performance and conduct and as a member of staff apply these consistently.

Be able to raise issues and concerns being confident that they will be taken seriously and acted upon in a timely manner.

Understand the role of representative bodies (eg Staff Partnership Forum & Local Negotiating Committee)

Play our part in improving services by working in partnership with people, the public, and other organisations.

Be clear on the value of partnership working and employee engagement ensuring robust two way communication systems in our service area.

Be aware of our leadership style and how it motivates staff.

Engage appropriate staff side bodies at an early stage when considering organisational change.

Be accountable and make decisions which are communicated effectively to all of our team.

Recognise and acknowledge excellent performance.

Listen to, and act upon, staff concerns, taking them seriously and acting upon them in a timely manner.

Recognise our responsibilities under all of our Policies.

Involve staff in decision making.

Communicate regularly with all staff.

Act upon concerns raised by staff, ensuring these are effectively responded to within a safe and trusted environment.

Provide the appropriate policies, processes and guidance to enable all staff to manage effectively.

Show a Board level commitment to working with staff through positive engagement with our staff side representatives.

Deliver HR services, guidance, and communications that add value for our prospective employees, current employees, and retirees

Provide the capacity and flexibility to manage our employee relations.



(5) Recognising and Supporting Diversity & Inclusion

Summary: The Trust is committed to creating a culture in which diversity and inclusion are promoted actively and where unlawful

discrimination is not tolerated. The Trust recognises that it has a responsibility to work towards building and maintaining an environment on the Isle of Wight which values diversity as it believes this to be ethically right and a socially responsible thing to do.

As Staff, We Will



Understand the value, and implications, of

equality and diversity in the workplace as well as the wider community.

Report and incidents of discrimination and encourage colleagues to do the same.

Demonstrate non-discriminatory conduct at all times.

Not discriminate against patients or staff and adhere to equal opportunities and equality and human rights legislation.

Protect the confidentiality of personal information held unless to do so would put anyone at risk of significant harm.

Work in a workplace free of discrimination, bullying and harassment.

Be aware of the benefits of being an inclusive employer with regard to equality and diversity issues and understand their role in the delivery of non-discriminatory, services.

Create a workplace free of discrimination, bullying and harassment.

Develop and deliver services from the standpoint of achieving equality of access and improve health outcomes for all.

Offer equal opportunities through transparent and inclusive people management processes.

Encourage staff to attend relevant networks if they have a protected characteristic.

Foster links with our local labour market and seek a workforce that reflects the diversity of our local community.

Achieve a people-centred non-discriminatory culture within the Trust.

Achieve compliance with legal requirements of the Equality Act 2010, in particular the Public Sector Equality Duty.

Achieve the objectives of the Equality Delivery System which relate to the performance of the Trust as an employer of choice.

Benchmark using National organisations (such as Stonewall).

Learn from, minimise and successfully reduce claims of discrimination in relation to employment practices of management and staff.

be an inclusive employer attracting people from diverse groups (including ethnic backgrounds, people with a disability (both learning & physical), sexual orientation, different religions or beliefs, gender, age, and other groups as defined by Equality Legislation) taking positive action as necessary to demonstrate benefits.

Have a zero tolerance of bullying and harassment endorsed by signage across the organisation from the CEO.





Our Strategy is underpinned by the NHS Constitution.

NHS Constitution: Values, pledges, employee rights and expectations of staff

NHS Values

Respect and Dignity

We value each person as an individual, respect their aspirations and commitments in life and seek to

understand their priorities, needs, abilities and limits. We take what others have to say seriously.

We are honest about our point of view and what we can and can’t do.

Commitment to quality of care

We earn the trust placed in us by insisting on quality and striving to get the basics right every time:

safety, confidentiality, professional and managerial integrity, accountability, dependable service and

good communication. We welcome feedback, learn from our mistakes and build on our successes.

Compassion

We respond with humanity and kindness to each person’s pain, distress, anxiety or need. We search

for the things we can do, however small, to give comfort and relieve suffering. We find time for

those we serve and work alongside. We do not wait to be asked, because we care.

Improving Lives

We strive to improve health and well being and people’s experiences of the NHS. We value

excellence and professionalism wherever we find it – in the everyday things that make people’s lives

better as much as in clinical practice, service improvements and innovation.

Working together for patients

We put patients first in everything we do, by reaching out to staff, patients, carers, families,

communities and professionals outside of the NHS. We put the needs of patients and communities

before organisational boundaries.

Everyone counts

We use our resources for the benefit of the whole community and make sure that nobody is

excluded or left behind. We accept that some people need more help, that difficult decisions have

to be taken and that when we waste resources we waste others’ opportunities. We recognise that

we all have a part to play in making ourselves and our communities healthier.



NHS Pledges

Provide all staff with clear roles and responsibilities, and rewarding jobs for teams and

individuals that make a difference to patients, their families and carers and communities.

Provide all staff with personal development, access to appropriate training for their jobs and

line management support to succeed.

Provide support and opportunities for staff that maintain their health, well-being and safety.

Engage staff in decisions that affect them and the services they provide, individually and

through their representative organisations and local partnership working arrangements.

Empower all staff to suggest ways to deliver better and safer services for patients and their

families.

Employee Rights

Your rights are there to help ensure that you:

Have a good working environment and flexible working opportunities, consistent with the

needs of patients and with the way that people live their lives;

Have safe and healthy working conditions – free from harassment, bullying or violence;

Have a fair pay and contract framework; receive fair and equal treatment that is free from

discrimination; and

Can raise an internal grievance / seek redress if it is felt that a right has not been upheld.

Expectations of Staff

Accept professional accountability and maintain the standards of professional practice as set

by the appropriate regulatory body applicable to your professional role.

Take reasonable care of health and safety at work for you, your team and others, and co-

operate with employers to ensure compliance with health and safety requirements.

Act in accordance with the express and implied terms of your contract of employment.

Don’t discriminate against patients or staff and adhere to equal opportunities and equality

and human rights legislation.

Protect the confidentiality of personal information you hold unless to do so would put

anyone at risk of significant harm.

Be honest and truthful in applying for a job and carrying out that job.

Maintain the highest standards of care and service, taking responsibility not only for the care

you personally provide, but also for your wider contribution to the aims of your team and

the NHS as a whole.

Take up training and development opportunities provided over and above those legally

required for your post.

Play your part in sustainably improving services by working in partnership with patients, the

public and communities.

Be open with patients, their families, carers or representatives (including if anything goes

wrong).

Contribute to a climate where the truth can be heard and the reporting of, and learning

from, errors is encouraged.



Welcome feedback and address concerns promptly and in a spirit of co-operation, and

View the services you provide from a patient standpoint, involving patients, their families

and their carers in services and working with them, their communities and other

organisations, and making it clear who is responsible for their care.

Source: NHS Constitution

REPORT TO THE Board Part 1 Page 1


ON 6TH APRIL 2016

Title 5 Year Indicative Capital Plan 2016/17 – 2020/21 Sponsoring Executive Director Chris Palmer – Executive Director of Financial & Human

Resources Author(s) John Cooper – Interim Head of Financial Services, Sarah

Gorbutt – Capital Accountant Purpose To inform the Board of the 5 year Indicative Capital Plan. Action required by the Board:

Receive Approve X







29/03/16


Quality Governance Committee Consultation with Staff, stakeholder, patient and public engagement: Executive Summary & Analysis: The initial capital plan source of funding is based on in-year estimated depreciation charges, together with forecast receipts from the sale of assets and any grants or donations. The 2016/17 calculated depreciation does not take into account the results from the latest District Valuer’s revaluation received in mid-March and therefore the 2016/17 amount available to spend may change once asset values have been updated. The final plan will be based on the updated figures. The capital plan, which formed part of the overall financial plan submitted to the TDA on 8th February, has been amended to take into account slippage which has since occurred and which is annotated as b/fwd from 2015/16 on the attachment. Final capital plans will be agreed during the year following prioritisation of schemes and in accordance with delegated limits within the Standing Financial Instructions.


The Board is asked to approve the indicative 5 year capital plan for 2016/17 to 2020/21, ahead of production of final capital plans.

Attached Appendices & Background papers

5 year Indicative Capital Plan. 5

Enc J

REPORT TO THE Board Part 1 Page 2

5

Key Trust Strategic Context:

This report links to the following Trust Goals:

· Cost effective, sustainable services

Principal Risks · Managing within financial resources · Ensuring sufficient cash · Achievement of Capital Resource Limit


Achievement of Statutory Financial Duties

Date: 22/03/2016 Completed by: John Cooper – Interim Head of Financial Services

ISLE OF WIGHT NHS TRUST - CAPITAL PROGRAMME - FIVE YEAR PLAN

Source of Funds2016/17 £000's

2017/18 £000's

2018/19 £000's

2019/20 £000's

2020/21 £000's

Initial Capital Resource Limit based on Depreciation Forecast 2016/17 6,350 5,711 5,335 4,966 4,680

Sale of Properties 250IW Council Civica (b/f 2015/16) 127

Donated Asset 70 70 70 70 70Total Available Source of Funds 6,797 5,781 5,405 5,036 4,750

Application of FundsProjects Carried Forward from 2015/16:Carbon Energy Fund (b/f 2015/16) 1,213Level C Ward Reconfiguration 103IW Council Civica (b/f 2015/16) 127Frontline Ambulance (b/f 2015/16) 101Roll-out of Paris to Community Services (b/f 2015/16) 33Upgrade of Patient Showers Osborne Ward (b/f 2015/16) 30New Projects:Rolling Replacement Programme - Equipment/Ambulances 500 500 500 500 500Rolling Replacement Programme - IM & T 500 500 500 500 500Backlog Maintenance 1,500 4,000 3,500Global Standard 1 Project 1,500Donated Assets 70 70 70 70 70Staff Capitalisation 180 180 180 150 150E-Care Logic 461 468 515 234Contingency 479 63 140 3,582 3,530Total Spend 6,797 5,781 5,405 5,036 4,750

PAPERS TO

FOLLOW

ENC K

OPERATING PLAN 2016/17



ON 6th APRIL 2016 Title Report from Chair of Finance, Investment, Information & Workforce

Committee Sponsoring Executive Director

Charles Rogers, Chair of Finance, Investment, Information & Workforce Committee

Author(s) Charles Rogers, Chair of Finance, Investment, Information & Workforce Committee

Purpose To receive the report on the Finance, Investment, Information & Workforce Committee


Receive X Approve Previously considered by (state date and outcome): Sub-Committee Dates Discussed Key Issues, Concerns and Recommendations from Sub

Committee Audit and Corporate Risk Committee


29/03/16

Mental Health Act Scrutiny Committee Quality Governance Committee Remuneration & Nominations Committee

Foundation Trust Programme Board Turnaround Board Please add any other committees below as needed Staff, stakeholder, patient and public engagement: Not applicable Executive Summary: The Chair of Finance, Investment, Information & Workforce Committee will report on the following areas as discussed at the meeting held on 29th March 2016. Human Resources

· Human Resources Report.

Data Quality/Payment by Results (PbR) · Discharge Summaries.

Contracting

· NHS Shared Business Services (SBS) Contract Update. · Supplies Distribution Service Plan.

Financial

· Financial Performance Report 2015/16. · Delivery of the forecast outcome for the year · Cost Improvement Plan ( CIP) · Cash forecast for year end 2015/16 · Annual Accounts: Going Concern.

Business Planning.

Enc L


Audit and Governance

· Information Commissioners Office (ICO).

Other Items · Trading Accounts – Mottistone.

Recommendation to the Trust Board: The Board is recommended to receive the report by the Chair of Finance, Investment, Information & Workforce Committee

Attached Appendices & Background papers None For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost Effective, Sustainable Services; Skilled and Capable Staff

Principal Risks (BAF) Finance, Workforce, Strategy & Planning Legal implications, regulatory and consultation requirements

Date: 30th March 2016 Completed by: Chair of Finance, Investment, Information & Workforce Committee

1

FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE

MONTHLY ASSURANCE REPORT TO ISLE OF WIGHT TRUST BOARD: 6 APRIL 2016

This report to the Trust Board follows from the March meeting of the Finance, Investment, Information and Workforce Committee (FIIWC) held on 29th March 2016.

1. HUMAN RESOURCES 1.1. Human Resources Report. Temporary staffing increased in February to 235 FTE from 147

FTE the previous month. The increase was no doubt in part driven by the increase in sickness absence to 4.84%. Rostering in safe staffing areas has increased in compliance to 41% in February, up from 19% in January.

Limited Assurance

2. DATA QUALITY/PAYMENT BY RESULTS (PbR) 2.1. Discharge Summaries. It is disappointing to note that at 21st March 2016 there were 492

outstanding discharge summaries, only slightly below the average since reporting began last September. Little progress on this improvement project is being made at present based on the latest data available.

Limited Assurance

3. CONTRACTING 3.1. NHS Shared Business Services (SBS) Contract Update. The Committee noted that the

SBS contract term of six years concludes on 31st March 2017. This contract covers the provision of Financial and Accounting and Payroll services. Work to award of a new contract will start shortly.

Positive Assurance

3.2. Supplies Distribution Service Plan. The Committee received an overview paper for a business case to consolidate and improve the stores delivery service. The plan is to provide efficiencies by using a distribution centre on the mainland that will reduce daily deliveries to the hospital and other Trust sites. The Committee have agreed to the indicative business case and recommend that the project is formalised. The Committee further understands that funding for the project is available from Southampton City Council and that long term savings can be expected.

Positive Assurance

4. FINANCIAL 4.1. Financial Performance Report 2015/16. At month 11 the Trust Forecast Outcome is

currently estimated as: · Best Case £6.4m deficit · Most Likely £6.7m deficit · Worst Case £8.9m deficit

2

4.2. Delivery of the forecast outcome for the year remains dependant on the CCG agreeing to

fund the additional costs for opening contingency beds this year. Limited Assurance

4.3. The Cost Improvement Plan ( CIP) forecast for 2015/16 is to fully achieve. £2.181m

comprising finance budget management and underspends has been added to provide an amended year end forecast of £8.656m providing a positive variance of 156k. Of the £8.656m forecast, £5.777m is non recurrent resulting in a significant carry forward CIP value.

Positive Assurance

4.4. Cash. The forecast for cash at year end 2015/16 is £1.7m (based on continuation of current levels of spend). The Trust borrowed £1.7m from the Department of Health (DoH) in February 2016 which needs to be paid back by 2020. It is likely that access to a DoH loan will be required in 2016/17 although the exact requirement for this remains to be determined.

Positive Assurance for 2015/16 Limited Assurance for 2016/17

4.5. Annual Accounts: Going Concern. The Committee received a paper in support of a

request to formally consider that the Trust is able to prepare year end accounts and report as a Going Concern. In effect this means that the organisation will continue for the foreseeable future and for a minimum of 12 months after the statement of financial position is signed. The Committee considered the supporting paper and recommend that the Trust Board approve the 2015/16 accounts are prepared on a Going Concern Basis.

Positive Assurance

4.6. Business Planning. It was agreed that the Interim Budget Plan for 2016/17 should be recommended to the Trust Board for approval. CIP requirement is for 5.3% efficiency saving resulting in a full year draft financial deficit position of £2.152m.

Limited Assurance

5. AUDIT & GOVERNANCE 5.1. Information Commissioners Office (ICO). The Committee have been advised that a

number of letters have been received by the Trust from the ICO expressing concern about the Trust performance in terms of complying with Subject Access Requests within appropriate timescales. A response has been provided and a plan is in place to improve performance in this area whilst continuing to hold down costs.

Limited Assurance

6. Other Items 6.1. Trading Accounts – Mottistone. At month 11 Mottistone ward made a £152k deficit

compared with budget. Actual income is exceeding direct costs by £277k after taking into account beds occupied by NHS patients. Currently the trading account applies a 10% allocation for overheads which equates to £155k whereas cost of actual overheads are £231k.

Limited Assurance

Charles Rogers, Chair, FIIWC 30th March 2016

Enc MIsle of Wight NHS Trust Board Performance Report 2015/16February 16

Title


Author(s)

Purpose

Action required by the Board: X

Trust Goals:Excellent patient care; Working with others to keep improving our services; A positive experience for patients, service users and staff; Skilled and capable staff; Cost effective, sustainable services

Other (please state)


Trust Vision: Quality care for everyone,everytime

Executive Summary:

This paper sets out the key performance indicators by which the Trust is measuring its performance in 2015/16. A more detailed executive summary of this report is set out on page 4.

Legal implications, regulatory and consultation requirementsNone

Date: Tuesday 29th March 2016 Completed by: Iain Hendey, Deputy Director of Information

Principal Risks (please enter applicable BAF references – eg 1.1; 1.6)

Assurance Level (shown on BAF) Red Amber Green

Staff, stakeholder, patient and public engagement:

Charitable Funds Committee Quality Governance Committee 29/03/2016Finance, Information, Investment & Workforce Committee 29/03/2016 Remuneration Committee

Please add any other committees below as needed

Audit and Corporate Risk Committee Nominations Committee (Shadow)

Isle of Wight NHS Trust Board Performance Report 2015/16

Chris Palmer (Executive Director of Financial & Human Resources) Tel: 534462 email: [email protected]

Iain Hendey (Deputy Director of Information) Tel: 822099 ext 5352 email: [email protected]

To update the Trust Board regarding progress against key performance measures and highlight risks and the management of these risks.

Receive Approve


Trust Executive Committee Mental Health Act Scrutiny Committee

Page 1


Index

34

5-9567

Ambulance, Urgent Care and Community…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………8Mental Health and Learning Disabilities…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………9

1011

12-1812131415

Cancer……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..1617

Theatre Utilisation……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..1819

20-232021222324

25-27252627

28-3928-29

3031-3233-34

3536-37

38394041

Exception Reports…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medicine……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Clinical Support, Cancer and Diagnostics……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Highlights………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Lowlights………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

February 16

Balanced Scorecard - Aligned to 'Key Line of Enquiry' (KLOEs)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Executive Summary…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Performance Summary Pages…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Surgery, Women's and Children's Health…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Pressure Ulcers……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Patient Safety…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Formal Complaints…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….A&E Performance - Emergency Care 4 hours Standard……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Referral To Treatment Times……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Benchmarking of Key National Performance Indicators……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Summary Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other 'Small Acute Trusts'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other Trusts in the 'Wessex Area'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Ambulance Performance……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Quality……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ambulance……………………………………………………………………………………………………………………………………………………………………………………………………………….

Governance Risk Rating…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Glossary of Terms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Statement of Financial Position………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Capital……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Cash…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Cost Improvement Programme…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Income………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Workforce Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Summary - RAG rated based on Out-Turn position………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Sickness…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Overpayments Summary………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Continuity of Service Risk Rating…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Finance Report………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Summary - RAG Rating based on Out-turn position & CIP graph……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Surplus…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Page 2


February 16Balanced Scorecard - Aligned to Our Goals

Excellent Patient Care AreaAnnual

TargetYTD Month Trend

A positive experience for patients, service

users and staffArea

Annual

TargetYTD Month Trend

Cost effective, sustainable

servicesArea

In

month

plan

Annual

TargetYTD

Month

Trend

Patients that develop a grade 4 pressure ulcer TW 14 1 Feb-16 14 Emergency Care 4 hour Standards AUC 95% 88% Feb-16 89% RTT % of incomplete pathways within 18 weeks - IoW CCG TW 92% 89% Feb-16 92% 91%

Patients that develop an ungraded pressure ulcer TW 8 Feb-16 23 Number of patients who have waited over 12 hours in A&E from decision to admit to admission

AUC 0 0 Feb-16 28 RTT % of incomplete pathways within 18 weeks - NHS England TW 92% 87% Feb-16 92% 91%

VTE (Assessment for risk of) TW >95% 99.4% Feb-16 99.3% Ambulance Category A Calls % < 8 minutes AUC 75% 70% Feb-16 74.4% Zero tolerance RTT waits over 52 weeks (Incomplete Return) TW 0 0 Feb-16 0% 5

MRSA (confirmed MRSA bacteraemia) TW 0 0 Feb-16 3 Ambulance Category A Calls % < 19 minutes AUC 95% 92% Feb-16 95% No. Patients waiting > 6 weeks for diagnostics TW <8 0 Feb-16 <100 50

C.Diff(confirmed Clostridium Difficile infection - stretched target)

TW 7 1 Feb-16 21 Number of Ambulance Handover Delays between 1-2 hours AUC N/A 32 Feb-16 183 % Patients waiting > 6 weeks for diagnostics TW <1% 0.0% Feb-16 <1% 0.5%

Clinical Incidents (Major) resulting in harm(all reported, actual & potential, includes falls & PU G4)

TW 30 3 Feb-16 17 % of CPA patients receiving FU contact within 7 days of discharge MH 95% 100.0% Feb-16 96.5% New Cases of Psychosis by Early Intervention Team MH 1 1 Feb-16 18 27

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by investigation)

TW 0 Feb-16 2 % of CPA patients having formal review within last 12 months MH 95% 97.8% Jan-16 96.6% Theatre utilisation CWC / CCD 83% 82% Feb-16 83% 76%

Falls - resulting in significant injury TW 5 0 Feb-16 4 % of MH admissions that had access to Crisis Resolution / Home Treatment Teams (HTTs)

MH 95% 93.8% Feb-16 94.9% Total pay costs (inc flexible working) (£000) TW £9,527 £10,489 Feb-16 £105,362 £110,777

Symptomatic Breast Referrals Seen <2 weeks* CCD 93% 98.6% Feb-16 97.5% All Cancelled Operations on/after day of admission SWC / CCD 14 Feb-16 167 Staff in Post (£000) TW £9,235 £9,154 Feb-16 £103,141 £99,912

Cancer patients seen <14 days after urgent GP referral* CCD 93% 95.8% Feb-16 96.0%

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting

SWC / CCD 0 2 Feb-16 28 Variable Hours (£000) TW £292 £1,335 Feb-16 £1,930 £10,864

Cancer Patients receiving subsequent Chemo/Drug <31 days* CCD 98% 100.0% Feb-16 99.5% Patient Satisfaction (Friends & Family test - Total response rate) TW 4% Feb-16 5% Staff sickness absences TW 3% 4.84% Feb-16 3% 4.22%

Cancer Patients receiving subsequent surgery <31 days* CCD 94% 92.9% Feb-16 98.6% Patient Satisfaction (Friends & Family test - A&E response rate) TW 7% Feb-16 10% Staff Turnover TW 5% 0.62% Feb-16 5% 7.00%

Cancer diagnosis to treatment <31 days* CCD 96% 98.4% Feb-16 99.2% Mixed Sex Accommodation Breaches TW 0 0 Feb-16 59 Achievement of financial plan TW N/A (£0.8m) Feb-16 (£4.6m) (£7.8m)

Cancer Patients treated after screening referral <62 days* CCD 90% 100.0% Feb-16 97.0% Formal Complaints TW <168 21 Feb-16 228 Underlying performance TW N/A N/A Feb-16 (£8.3m) (£10.8m)

Cancer Patients treated after consultant upgrade <62 days* CCDNo measured operational

standard

No patients

Feb-16 33% Compliments received TW N/A 197 Feb-16 3,101 Liquidity ratio days TW N/A N/A Feb-16 1 1

Cancer urgent referral to treatment <62 days* CCD 85% 86.2% Feb-16 82.6% Capital Servicing Capacity (times) TW N/A N/A Feb-16 2 1

Summary Hospital-level Mortality Indicator (SHMI)Apr-14 - Mar-15

TW 1 1.003 Published Jan 2016 N/A Overall Continuity of Services Risk Rating TW N/A N/A Feb-16 2 1

Never events TW 0 1 Feb-16 2 Capital Expenditure as a % of YTD plan TW N/A N/A Feb-16 =>75% 71%

Stroke patients (90% of stay on Stroke Unit) M 80% 82% Feb-16 86% Quarter end cash balance (days of operating expenses) TW N/A N/A Feb-16 =>10 2

High risk TIA fully investigated & treated within 24 hours (National 60%) M 60% 67% Feb-16 73% Debtors over 90 days as a % of total debtor balance TW N/A N/A Feb-16 =<5% 5.9%

*Cancer figures for December are provisional.

Working with others to keep improving

our servicesArea

Annual

TargetYTD Month Trend Skilled and capable staff Area

In month

plan

Annual

TargetYTD Recurring CIP savings achieved TW N/A N/A Feb-16 100% 34.2%

Delayed Transfer of Care (lost bed days) - (MH included) TW N/A 575 Feb-16 2906 Total Workforce (inc flexible working) (FTE's) TW 2608.63 2,902.0 Feb-16 N/A N/A Total CIP savings achieved TW N/A N/A Feb-16 100% 75.8%

Total workforce SIP (FTEs) TW 2496.63 2,667.0 Feb-16 N/A N/A

Variable Hours (FTE) TW 112.0 235.0 Feb-16 1318.7 1,779

Notes

Delivering or exceeding Target

Underachieving Target 1. Patient Safety:

Failing Target Implementation and monitoring the effectiveness of the sepsis care bundle

Reduce incidents of patient harm

Key to Area Code

TW = Trust Wide 2. Clinical effectiveness

SWC = Surgery, Women's and Children's Health Improve the discharge planning process

M = Medicine Improve communication with patients and carers

CCD = Clinical Suppprt, Cancer and Diagnostics

AUC = Ambulance, Urgent Care and Community 3. Patient Experience

MH = Mental Health and Learning Disabilities Improve the culture of the organisation to improve patient experience

QIs under development:

Actual

PerformanceActual Performance

Improvement on previous month

No change to previous month

Deterioration on previous month

Sparkline graphs wil be included in M1

Report to present the trends over time for

Key Performance Indicators

Actual

Performance

Actual

PerformanceActual Performance

Feb-16 =<5%Creditors over 90 days as a % of total creditor balance TW N/A N/A 2.1%

Page 3


Executive SummaryFebruary 16

Excellent Patient Care:

Pressure ulcers: The Pressure Ulcer Collaborative has been operating over the past few months to review of all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the directorates. Whilst there has been a rise in the overall reporting, this has been mainly in the area of grade 1 and 2 pressure ulcers. There are a number of ungradable pressure ulcers that are still under review. The Pressure Ulcer collaborative is also looking at the community and in this setting only two grade 3 pressure ulcers and 1 grade 4 pressure ulcer have been reported during the review period. The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year. C.diff: There has been 1 further case of Healthcare acquired Clostridium Difficile identified in the Trust during February. Our YTD total increased to 21 cases across 13 patients.

No new cases of MRSA within the Trust during February (three cases year to date).

A positive experience for patients, service users and staff:

The Ambulance Service has failed all 3 targets in February 2016. Actions continue in place to address the reporting issues and continuous progress with the Community First Responder project which supports immediately life-threatening calls. The key issues facing the service are its ability to provide a high quality of care against a back drop of system wide pressures and flow of patients through the hospital setting leading to delays in responding at times. Recruitment to paramedic posts is also a challenge.

The Emergency Care 4 hours standard - The 95% target was not achieved in February due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity. The System Resilience Winter Action Plan and ED action plans continue to be monitored weekly and monthly with the Clinical Commissioning Group.

Mixed Sex Accommodation - There were no mixed sex accommodation breaches during February.

We have received 21 formal complaints during February (21 in January).

Skilled and capable staff:

Staff In Post decreased in month by 2 FTE - from 2669 in January 16. The temporary staffing figure, which increased from 147 FTE in January 16 to 235 in February 16, is representative of the increase in sickness absence.

Trust Headcount at the end of February 16: 3119 (Decrease of 8)

Appraisal % at Month 10 is 35.8%, decrease from 41.7% in Month 9, communication has been sent via 10 Minute Team Brief (04-02-16) encouraging Business Units to undertake and log appraisals. Reasons for the 4.9% decrease can be apportioned due to the fact the appraisal % is a rolling %, and that a large number of appraisals undertaken in Jan 15, are not included in the data.

Increase in sickness absence in month to 4.84%. Highest reason for sickness in month is Cold, Cough, Flu - Influenza showing an increase in month by 16%.

Cost effective, sustainable services:

Performance against the 'incomplete' 18wks target continues to underperform at 85.7% against the required 92% standard, and the revised trajectory of 89.9%, due to the high backlog of admitted patients waiting more than 18wks for their treatment.

The percentage utilisation of Main Theatre facilities has increased to 83.6% during February 2016, above the 83% target. Day Surgery Unit utilisation has increased to 79.8% but remains below target; the overall theatre utilisation is at 82.0%. This under performance is due to the continued impact of system wide pressures following the Christmas and New Year period. Emergency activity as well as undertaking urgent operations and cancer operations continues to be prioritised.

The Trust planned for a deficit of £0.654m in February, after adjustments made for normalising items (these include the net costs associated with donated assets).The reported position is a deficit of £0.819m in the month, an adverse variance of £0.165m against plan.The cumulative Trust plan was a deficit of £4.053m, after normalising items. The actual position is a cumulative deficit of £7.791m, an adverse variance of £3.737m.Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.The variance in month includes over performance against the CCG PbR Contract of £0.503m (£1.225m adverse year to date including penalties). In addition to this, there is a favourable £0.030m variance (£0.292m adverse year to date) relating to a phasing issue on the CCG SLA Acute Contract, which will reduce to zero by the end of the financial year.Further benefit of £82k (£620k year to date) has also realised following balance sheet reviews. Weekly reviews and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year end.The Trusts planned forecast out-turn deficit remains at £6.737m, against its original plan of £4.600m. This position is due to the implementation of the system resilience improvement plan with its additional net costs, unachievement of activity income with fines and penalties, and system pressures that the Trust has borne throughout the year. Achievement of £6.737m is also subject to CCG support of £1.967m, and negotiations around this are ongoing and therefore this is high risk.Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in Clinical Business Units on CIP and budget delivery involving business managers have now been extended to Corporate areas.

The Performance Report has been re-aligned to our Goals and the Clinical Business Unit Structure. Further alignment and refinement will be untertaken in future reports. QIs are currently under development and will be added to the report as soon as they are agreed.

Page 4


Performance Summary - Surgery, Women's and Children's Health

Target Actual Target Actual Target Actual Target Actual

MRSA (confirmed MRSA bacteraemia) Feb-16 0 0 0 0 Mixed Sex Accommodation Breaches Feb-16 0 0 0 0

C.Diff (confirmed Clostridium Difficile infection) Feb-16 0 1 No. of Complaints Feb-16 3 27

Clinical Incidents (Major) resulting in harm

(all reported, actual & potential, includes falls & PU G4)Feb-16 0 0 No. of Concerns Feb-16 15 71

Clinical Incidents (Catastrophic) resulting in harm

(actual only - as confirmed by investigation)Feb-16 0 0 No. of Compliments Feb-16 111 217

Falls - resulting in significant injury Feb-16 0 0

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at

the time of reporting

Feb-16 2 28

Emergency 30 day Readmissions Feb-16 3.0% 3.2% All Cancelled Operations on/after day of admission Feb-16 0 14 0 167

Never Events Feb-16 0 1 0 2 Theatre utilisation Feb-16 83% 82.0% 83% 76.5%

No. of Reported SIRIs Feb-16 1 4

Physical Assaults against staff Feb-16 0 4

Verbal abuse/threats against staff Feb-16 1 6


Appraisals Feb-16 52.30%

Plan Actual Plan Actual Target Actual Target Actual

Total SLA Value Jan-16 3,320,563£ 3,311,342£ 34,086,080£ 32,846,741£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS

England)Feb-16 92% 88.6% 92%

Not yet

available

Zero tolerance RTT waits over 52 weeks (Incomplete Return) Feb-16 0 0 0 2

% Sickness Absenteeism Feb-16 3% 2.88% 3% 2.93%

*YTD data from November 2015. Full YTD will be available from April 2016

**The Acute Service Level Agreement performance reports a month behind, therefore figures are from January 2016.

The never event related to wrong route medication. A table top review was held and interim actions put into place while the SIRI was investigated. The staff involved were supported throughout and the systematic issues were addressed.

The cancelled operations, financial underperformance and 18 week RTT position are all interrelated and are a product of poor bed capacity throughout the year due to Medical patients outlying in surgical areas. We expect the work ongoing in Medicine Clinical Business Unit

(CBU) to improve this position for 16/17. Our CBU capacity planning assumes full access to the CBU’s bed stock.

February 16

Balanced Scorecard - Surgery, Women's and Children's Health

Excellent Patient CareLatest

data

In Month YTD* A positive experience for patients,

service users and staff

Latest

data

In Month YTD*

Working with others to keep

improving our services

Latest

data

In Month YTDSkilled and capable staff

Latest

data

In Month

YTD

YTD


services

Latest

data

In MonthIncome**

Latest

data

In Month YTD

Page 5


Performance Summary - Medicine








Falls - resulting in significant injury Feb-16 0 0 No. of Reported SIRIs Feb-16 1 3

Emergency 30 day Readmissions Feb-16 7.3% 8.2% Physical Assaults against staff Feb-16 4 13

Stroke patients (90% of stay on Stroke Unit) Feb-16 80% 81.8% 80% 85.8% Verbal abuse/threats against staff Feb-16 2 5

High risk TIA fully investigated & treated within 24 hours (National

60%)Feb-16 60% 66.7% 60% 73.0%

Never Events Feb-16 0 0 0 0





England)Feb-16 92% 87.2% 92%

Not yet

available





The RTT incomplete pathways for 18 weeks relates to Gastroenterology. The sickness absenteeism relates to the medical wards.

Alternative ways are currently being explored for delivering the RTT targets in Gastroenterology and a paper is being developed for TEC with options and recommendations. An additional weekly evening clinic is taking place for Gastroenterology and 2 new Inflammatory

bowel nurses have now been recruited. All sickness is being actively managed and reviewed in the Safer staffing cafes.

February 16

Balanced Scorecard - Medicine


data



Latest

data

In Month YTD*



Latest

data


Latest

data

In Month

YTD

YTD


services

Latest

data

In MonthIncome**

Latest

data

In Month YTD

Page 6


Performance Summary - Clinical Support, Cancer and Diagnostics








Falls - resulting in significant injury Feb-16 0 0 All Cancelled Operations on/after day of admission Feb-16 2 28

Emergency 30 day Readmissions Feb-16 0.0% 0.7%

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at the time of

reporting

Feb-16 0 14 0 167

Symptomatic Breast Referrals Seen <2 weeks* Feb-16 93% 98.6% 93% 97.5% Theatre utilisation Feb-16 83% 82.0% 83% 76.5%

Cancer patients seen <14 days after urgent GP referral* Feb-16 93% 95.8% 93% 96.0% No. of Reported SIRIs Feb-16 2 2

Cancer Patients receiving subsequent Chemo/Drug <31 days* Feb-16 98% 100.0% 98% 99.5% Physical Assaults against staff Feb-16 1 1

Cancer Patients receiving subsequent surgery <31 days* Feb-16 94% 92.9% 94% 98.6% Verbal abuse/threats against staff Feb-16 0 1

Cancer diagnosis to treatment <31 days* Feb-16 96% 98.4% 96% 99.2%

Cancer Patients treated after screening referral <62 days* Feb-16 90% 100.0% 90% 97.0%

Cancer Patients treated after consultant upgrade <62 days* Feb-16No measured

operational

standardNo patients

No measured

operational

standard33.3%

Cancer urgent referral to treatment <62 days* Feb-16 85% 86.2% 85% 82.6%

Never Events Feb-16 0 0 0 0




Total SLA Value Jan-16 993,782£ 1,101,019£ 10,192,905£ 10,703,434£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS England) Feb-16 92% 97.9% 92%Not yet

available


No. Patients waiting > 6 weeks for diagnostics Feb-16 <8 0 <100 50

% Patients waiting > 6 weeks for diagnostics Feb-16 <1% 0.0% <1% 0.5%




Cancer Breach Analysis

• Non-achievement of the 31 day subsequent surgery standard was due to one patient- led breach who chose to defer treatment.

• Standard is currently achieving year to date. The number of patients treated within this standard is low and one patient can make a significant impact on achievement of the target. The Cancer CNS's work hard to support patients and emphasising importance of not delaying treatment

Cancellation Analysis

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting- targets may not be missed, as the 28 day pathway is ongoing at present so these may be rebooked in time.

Theatre Utilisation Analysis

The theatre utilisation targets were not achieved due to bed capacity both the theatre underutilisation and cancelled appointments were as a result of ongoing bed pressures. The CSCD Management team is fully engaged with improving patient flow and attend daily bed meeting to expedite actions.

February 16

Balanced Scorecard - Clinical Support, Cancer and Diagnostics


data



Latest

data

In Month YTD*

Working with others to keep improving

our services

Latest

data


Latest

data

In Month

YTD

YTD


services

Latest

data

In MonthIncome**

Latest

data

In Month YTD

Page 7


Performance Summary - Ambulance, Urgent Care and Community



C.Diff (confirmed Clostridium Difficile infection - stretched target) Feb-16 0 0 No. of Complaints Feb-16 4 22

Clinical Incidents (Major) resulting in harm (all reported, actual & potential,

includes falls & PU G4)Feb-16 1 2 No. of Concerns Feb-16 17 41

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed

by investigation)Feb-16 0 0 No. of Compliments Feb-16 23 137

Falls - resulting in significant injury Feb-16 0 0 Emergency Care 4 hour Standards Feb-16 95% 87.9% 95% 89.2%

Never Events Feb-16 0 0 0 0Number of patients who have waited over 12 hours in A&E from decision to admit

to admissionFeb-16 0 0 0 28

Category A 8 Minute Response Time (Red 1) Feb-16 75% 70.3% 75% 72.1%

Category A 8 Minute Response Time (Red 2) Feb-16 75% 69.8% 75% 74.6%

Category A 19 Minute Response Time Feb-16 95% 92.4% 95% 94.9%

Number of Ambulance Handover Delays between 1-2 hours Feb-16 32 183







Total SLA Value Jan-16 3,123,681£ 3,190,384£ 31,781,924£ 32,722,757£ % Sickness Absenteeism Feb-16 3% 4.89% 3% 4.20%

Ambulance re-contact rate following discharge from care by telephone Feb-16 3% 10.7% 3% 6.8%

Ambulance re-contact rate following discharge from care at scene Feb-16 2% 1.0% 2% 2.7%

Ambulance time to answer call (in seconds) - median Feb-16 1 1 N/A N/A

Ambulance time to answer call (in seconds) - 95th percentile Feb-16 5 1 N/A N/A

Ambulance time to answer call (in seconds) - 99th percentile Feb-16 14 9 N/A N/A

NHS 111 Call abandoned rate Feb-16 5% 1.4% 5% 1.8%

NHS 111 All calls to be answered within 60 seconds of the end of the introductory

message Feb-16 95% 96.3% 95% 96.3%

NHS 111 Where disposition indicates need to pass call to Clinical Advisor this

should be achieved by ‘Warm Transfer’ Feb-16 95% 95.7% 95% 97.0%

NHS 111 Where the above is not achieved callers should be called back within 10

mins Feb-16 100% 41.2% 100% 38.4%



Emergency Care Standard - The 95% target was not achieved in February due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity. The System Resilience Winter Action Plan and ED action plans continue to be monitored weekly and monthly with the Clinical

Commissioning Group. Safer Start week was held in the Trust between 8th and 15th February 2016 with the aim to reset the service, surrounding processes and improve patient flow. The ECS target sustained above 91% through the week and did achieve 95% on Thursday and it is this success that

the service will look to build on during March. Demand and capacity planning is underway for 2016/17 including revised trajectories for the year; these will be informed by historical activity and performance, as well as the intended impact of the above actions being implemented now and into

quarter 1 of next year. In addition, the impact of our system partners' actions will be incorporated and, once agreed, will be monitored by the System Resilience Group.

Ambulance - The Service has failed all 3 targets in February 2016. Actions continue in place to address the reporting issues and continuous progress with the Community First Responder project which supports immediately life-threatening calls. The key issues facing the service is its ability to provide

a high quality of care against a back drop of system wide pressures and flow of patients through the hospital setting leading to delays in responding at times. Recruitment to paramedic posts is also a challenge.

February 16

Balanced Scorecard - Ambulance, Urgent Care and Community


data



Latest

data

In Month YTD*



Latest

data


Latest

data

In Month

YTD

YTD

Cost effective, sustainable servicesLatest

data

In MonthIncome**

Latest

data

In Month YTD

Page 8


Performance Summary - Mental Health and Learning Disabilities


MRSA (confirmed MRSA bacteraemia) Feb-16 0 0 0 0 FFT - % Response Rate Feb-16 0.5% 0.4%

C.Diff (confirmed Clostridium Difficile infection) Feb-16 0 0 FFT - % Recommending Feb-16 90% 94% 90% 91%


(all reported, actual & potential, includes falls & PU G4)Feb-16 0 1 Mixed Sex Accommodation Breaches Feb-16 0 0 0 0


(actual only - as confirmed by investigation)Feb-16 0 0 No. of Complaints Feb-16 3 7

Falls - resulting in significant injury Feb-16 0 1 No. of Concerns Feb-16 6 13

Never Events Feb-16 0 0 0 0 No. of Compliments Feb-16 21 53




% of CPA patients receiving FU contact within 7 days of discharge Feb-16 95% 100.0% 95% 96.5%

% of CPA patients having formal review within last 12 months Jan-16 95% 97.8% 95% 96.6%

% of MH admissions that had access to Crisis Resolution / Home

Treatment Teams (HTTs)Feb-16 95% 93.8% 95% 94.9%





England)Feb-16 92% 97.2% 92% 98.8%



New Cases of Psychosis by Early Intervention Team Feb-16 1 1 18 27

IAPT – Proportion of people who have completed treatment and

moving to recoveryFeb-16 50% 48.4% 50% 47.8%


- There were 32 admissions to MH Wards in February meeting the criteria for inclusion in this indicator - 30 of these were gatekept by the Crisis Resolution/Home Treatment team.

- The MH/LD Business Unit Leadership meeting has noted that performance against Appriasals is low and recognised this may have been impacted by organisational change and management vacancies in year. This will be discussed by Operations Managers within their own

services and plans put in place to improve performance will be monitored through monthly the MH CBU Leadership Meeting.

- Long term sickness is closely managed and some issues have been resolved over the past couple of months. Mechanisms are in place to support operational managers in relation to management of short term sickness.

- Performance against the IAPT indicator has been impacted by local service configuration whereby Cluster 4 patients are supported in IAPT services (nationally IAPT services work with patients in clusters 1 -3 only ). Cluster 4 patients take a longer period of time to move to

recovery and this is reflected in the performance figures.

February 16

Balanced Scorecard - Mental Health and Learning Disabilities


data

In Month YTD A positive experience for patients,


Latest

data

In Month YTD



Latest

data


Latest

data

In Month

YTD

YTD


services

Latest

data

In MonthIncome**

Latest

data

In Month YTD

Page 9


Highlights

Highlights

Summary Hospital level Mortality Indicator

No new cases of MRSA

% Patients waiting < 6 weeks for diagnostics achieving the target

February 16

90% of stay on Stroke Unit and High Risk TIA fully investigated & treated within 24

hours above target both in month and year to date

Cancer targets achieved for: Cancer 2 wk GP referral to 1st OP, Symptomatic Breast

Referrals Seen <2 weeks, 31 day second or subsequent (drug), Cancer diagnosis to

treatment <31 days, Cancer Patients treated after screening referral <62 days, 62 days

urgent referral to treatment of all cancers

No falls resulting in significant injury

% of Care Programme Approach patients receiving FU contact within 7 days of discharge

above target

Page 10


Lowlights

Lowlights

Staff sickness remains above plan

Emergency care 4 hour standard remains below target

21 formal complaints in month (228 year to date)

Workforce pressures + pay costs in excess of plan

2 cancelled operations on/after day of admission (not rebooked within 28 days)

Financial Position impacted by activity and performance - funding not yet secured for excess cost incurred

All 3 ambulance indicators below target

Governance Risk Rating of 11 for February 2016

Cancer - 31 day second or subsequent (surgery) below target

February 16

Referral ToTreatment Time - % Incomplete pathways below 92% target

1 new case of C.Diff in February (20 year to date)

Theatres utilisation below target

1 Grade 4 Pressure Ulcers in February (14 year to date)

1 Never Event in February

Page 11


February 16Pressure Ulcers

Analysis:

• Trust wide Pressure Ulcer Prevention Group continues to meet. • Deep dives for each directorate going ahead to look at why expected reductions were not achieved last year.• Action plans for pressure ulcer reduction have been reviewed and are being amalgamated into a single master plan for coming year.• Local monthly Tissue Viability and MUST audits are being established by Tissue Viability Service.• Pressure Ulcer Reporting has been handed to Matrons and Locality leads to supervise to develop local ownership of reporting and understanding the scale of the issue.•Work is also ongoing to identify where patients are admitted from their home address who have been receiving non NHS care assistance.

Clinical directorate leads and Tissue Viability Nurse Specialist Mar-16 Ongoing

Commentary:

General: Numbers are reviewed for both the current and previous month and there may be changes to previous figures once validated. Pressure ulcer figures also contribute to the Safety Thermometer and are included within the clinical incident reporting, where any change is also reflected.

Hospital: The Pressure Ulcer Collaborative has been operating over the past few months to review of all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the directorates. Whilst there has been a rise in the overall reporting, this has been mainly in the area of grade 1 and 2 pressure ulcers. There are a number of ungradable pressure ulcers that are still under review. Community: Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). The Clinical Directorates took full responsibility for the management of pressure ulcer incidents in June including approval status and checking for duplicates. This is a move away from overall final responsibility for pressure ulcers incidents sitting with the Nutrition and Tissue Viability Service. Increased awareness is continuing to lead to increased numbers being reported. The Pressure Ulcer collaborative is also looking at the community and in this setting only two grade 3 pressure ulcers and 1 grade 4 pressure ulcer have been reported during the review period. The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year.

The report now separates out Ungradable pressure ulcers as a distinct reporting line so that it is clear that these ulcers (which were previously counted as grade 4s) have not yet been assigned a grade and do not automatically mean that this is an incident that has resulted in patient harm.

Level 3/4 pressure ulcers are likely to reduce on validation. Pressure Ulcers benchmark

Action Plan: Person Responsible: Date: Status:

The graph shows improving trend. In January the Trust has been above the national average.

Quality Account Priority 2 & National Safety Thermometer CQUIN schemes

Prevention & Management of Pressure Ulcers

Page 12


Patient Safety

Commentary: Analysis: Clostridium Difficile infections against national and local targets


MRSA Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTDAcute Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 1 1 0 1 0 0 0 3

Infection Prevention & Control team / Hotel services

Clostridium difficile

There has been 1 further case of Healthcare acquired Clostridium Difficile identified in the Trust during February. Our YTD total increased to 21 cases across 13 patients.

Work continues to raise awareness and highlight actions, including intranet and poster campaigns regarding bowel management with action plans for rapid isolation of suspected cases. The reconfigured Medical Assessment Unit is now in use with increased access to isolation facilities for suspected cases although bed pressures continue to present challenges. Specialist 'BioQuell' intensive (gas fogging) system is now used after surface cleansing following an isolation need before the room is available for reuse.

Methicillin-resistant Staphylococcus Aureus (MRSA)

There have been no cases identified as Healthcare acquired infections during February. However, Public Health England have reallocated a community case as Trust responsibility retrospectively due to communication issues, making the YTD now 3 cases. This case is not allocated to a particular ward. There have been 5 cases identified as developed in the community so far this year.

Action Plan:

Use of BioQuell gas fogging intensive cleaning following surface cleaning between patients where isolation has been in place.

Continued increased education regarding timely sampling of loose stool events and isolation

Use of increased isolation facilities in reconfigured & refurbished MAAU

Person Responsible:

Infection Prevention & Control team with Communications

Continuing

Date:

Feb-16

Feb-16

Feb-16

February 16

Status:

Continuing

ContinuingInfection Prevention & Control team / MAAU Team

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

Total cases 2 6 7 11 14 14 17 17 17 20 21 21

National Target 1 1 2 2 3 3 4 4 5 6 6 7

0

5

10

15

20

25

Isle of Wight NHS Trust C. Difficile cases (Cumulative)

Page 13


Formal Complaints

Analysis: Complaints only

Jan-16 Feb-16 CHANGE RAG rating

2 1 -1

3 0 -3

0 1 1

5 6 1

0 0 0

3 5 2

0 0 0

0 0 0

0 1 1

1 0 -1

0 0 0

0 1 1

0 0 0

0 0 0

2 4 2

0 1 1

1 0 -1

1 0 -1

0 0 0

3 2 -1

0 0 0

In progress

Mortuary

Other (Use with Caution)

Privacy, Dignity and Wellbeing

Prescribing

Person Responsible: Date: Status:

Patient Care

Restraint

Staff numbers

Trust admin/Policies/Procedures

Complaints process is currently being reviewed to ensure complainants are responded to in line with negotiated timescales, and that they receive a high quality response that fully addresses their concerns.

Executive Director of Nursing & Workforce / Business Manager -

Patient Safety; Experience & Clinical Effectiveness

May-16

Commentary:

Action Plan:

Access to treatment or drugs

Admissions and discharges

Appointments

Clinical Treatment

Integrated Care

Facilities

Primary Subject

Values and Behaviours (Staff)

Communication

Waiting Times

There were 21 formal Trust complaints received in February 2016 (21 in the previous month) with 197 compliments received by letters and cards of thanks across the same period.

Across all complaints and concerns in February 2016: Top subjects complained about were: - Clinical treatment (14) - Communication (20) - Patient Care (11)

Top areas complained about were: - Medical Wards (7) - Medical Services (5) - OPARU (5) - Pathology (5) - Occupational Therapy Wheelchair department (5)

Commissioning

Transport (Ambulances)

February 16

Consent

End of Life Care

Page 14


A&E Performance - Emergency Care 4 hours Standard

Commentary: Analysis:

Analysis:

Demand & capacity planning for 2016/17 including revised trajectories Deputy Director - Information Mar-16 In progress

February 16

Action Plan: Person Responsible:

Emergency Care 4 hours Standard

Date: Status:

The 95% target was not achieved in February due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity. The System Resilience Winter Action Plan and ED action plans continue to be monitored weekly and monthly with the Clinical Commissioning Group.

Safer Start week was held in the Trust between 8th and 15th February 2016 with the aim to reset the service, surrounding processes and improve patient flow. The ECS target sustained above 91% through the week and did achieve 95% on Thursday and it is this success that the service will look to build on during March.

Demand and capacity planning is underway for 2016/17 including revised trajectories for the year; these will be informed by historical activity and performance, as well as the intended impact of the above actions being implemented now and into quarter 1 of next year. In addition, the impact of our system partners' actions will be incorporated and, once agreed, will be monitored by the System Resilience Group.

Implementation of Safer Start Week recommendations and actions Head of Operations Feb-16 In progress

Increase focus on local authority bed situation System Resilience Group / Exec on call Mar-16 Ongoing

Daily focus on bed states Matrons Mar-16 Ongoing

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

De

c 1

5

Jan

16

Feb

16

Target not achieved Target achieved Target

Page 15



Analysis:

February 16

Action Plan: Person Responsible: Date:

Cancer Patients receiving subsequent surgery <31 days

Cancer Patients receiving subsequent surgery <31 days – Standard 94% - Performance 92.9%Breach:1 x Skin - Other (Patient choice to defer treatment)

All other Cancer Waiting Times standards have been achieving for February.

Status:

• All individual breaches continue to be reviewed. Root Cause Analysis is carried out. Analysis of reasons for breaches identified no specific trend. Complex pathways and patient choice were noted. • Relevant CNSs to be informed by Booking Clerks in OPARU when delay in appointing occurs. This process has been reinforced by the Operational Manager• Close scrutiny of patient pathway with notification by Cancer Pathways Admin Team to Cancer CNS, OPARU, Secretaries and Operational Managers when delays are noted.• Multi Disciplinary Team to continue to facilitate timely discussions and actions recommended to be followed• Continue escalation process to highlight potential breaches for actions to be taken for Operational Managers via twice weekly performance update • Potential shared breaches to be identified and reported to Operational Managers via twice weekly information submitted for Access Meeting.• Outstanding histopathology reports highlighted to Technical Head. Pathology request forms to be marked CaFT (Cancer Fast Track) – This process to be reinforced by the Operational Managers. Future version of request form to include CaFT box. Outstanding imaging reports highlighted to Diagnostic Imaging twice weekly and ad hoc for MDT meetings

Continuing

Lead Cancer Nurse/CNSs/Cancer Pathways Manager

Operational Managers/MDT Clinicians Mar-16

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Mar

-15

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

Cancer Patients receiving subsequent surgery <31 days

Target achieved Target not achieved Target

Page 16


Ambulance Performance


Analysis:

Apr-16 Ongoing

Mar-16 Ongoing

Mar-16 Ongoing

All paramedics to have one-to-one session to discuss performance targets and reiterate importance of accurate data recording

Performance reports to be developed to extract handover time data from CAD system.Data validation process to be put in place

Using accurate and validated data monitor performance against national handover standards. If shown to be underperforming develop action plan and trajectory to achieve.

Service Delivery Manager, Performance Support Officers, Clinical Support Officers

Service Delivery Manager, Performance Support Officers (Operational) & Performance Support

Officers (Hub)

Head of Ambulance, HOO

Status:

February 16

Action Plan: Person Responsible: Date:

The Ambulance Service has failed all 3 targets in February 2016. Actions continue in place to address the reporting issues and continuous progress with the Community First Responder project which supports immediately life-threatening calls. The key issues facing the service is its ability to provide a high quality of care against a back drop of system wide pressures and flow of patients through the hospital setting leading to delays in responding at times. Recruitment to paramedic posts is also a challenge. The Ambulance Service also delivers the quality of care through its innovative Integrated Care Hub. This continues to create efficiencies in delivery of service and patient satisfaction through 999 and 111 are extremely high. The Integrated Care Hub continues to attract media attention due to the joint working approach being promoted through this approach and the many benefits to patients through this system. The service also continues to work alongside stakeholders from within and outside the Trust and maintaining links with our strategic blue light agencies is moving forward and some positive signs are emerging on joint working.

Introduction of the new CAD has lead to identifying further causes of data anonomolies. Prior to the new CAD it was thought that the data errors were singularly down to technical issues and the new CAD has, together with improved wifi, significantly improved the automation of of arrival and leaving times. This has highlighted that data manually input from crews does at times not enable accurate data. Data validation process to extend beyound the current measure of 120min. This will require a increase in data verification hours.This will be achieved by increasing hours worked from part time to full time. In additon the corporate perfomance team will be trained in the verification process to ensure cover is maintained when absences occur

Continuous monitoring of performance targets, amending REAP (Resourcing Escalatory Action Plans) level as appropriate and sharing status with fellow Senior Managers and increase staffing levels

Service Delivery Manager, Performance Support Officers, Clinical Support Officers Feb-16 Ongoing

OngoingFeb-16Lead Clinical Support Officer and Pathway Lead

Documented Performance Review Meetings (PRM) increased from once daily to three times dailyService Delivery Manager, Performance Support

Officers (Operational) & Performance Support Officers (Hub)

Feb-16 Ongoing

Guidance to be developed for ambulance staff to identify recording process, reiterate importance of recording accurate data and confirm clock starts/stops Service Delivery Manager, Performance Support Officers, Clinical Support Officers Feb-16 Ongoing

0.0%

25.0%

50.0%

75.0%

100.0%

Mar

-15

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

Cat A 8 minutes response time (Red 1)


0.0%

50.0%

100.0%

Mar

-1

5

May

-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Cat A 19 minutes response time


0.0%

50.0%

100.0%

Mar

-15

Ap

r-1

5

May

-…

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Cat A 8 minutes response time (Red 2)


Page 17


Theatre Utilisation

Analysis:

The

Head of Performance Mar-16 Ongoing

February 16

Delivering activity' project commenced and being managed until end of March 2016. Project Lead Mar-16 Ongoing

Commentary

The percentage utilisation of Main Theatre facilities has increased to 83.6% during February 2016, above the 83% target. Day Surgery Unit utilisation has increased to 79.8% but remains below target; the overall theatre utilisation is at 82.0%. This under performance is due to the continued impact of system wide pressures following the Christmas and New Year period. Emergency activity as well as undertaking urgent operations and cancer operations continues to be prioritised.

The system wide winter resilience plan to deliver increased elective activity between October 2015 and March 2016 continues and theatre utilisation will increase during March to facilitate the required level of activity.

Action plan Person Responsible: Date: Status:

Forecast being reviewed with managers to determine trajectory for managing 18 weeks admitted target following impact of previous cancellations. Weekly assurance meeting to monitor RTT. Review of impact of further cancellation on trajectory

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Mar

15

Apr 1

5

May

15

Jun

15

Jul 1

5

Aug

15

Sep

15

Oct

15

Nov

15

Dec

15

Jan

16

Feb

16

DSU

Target failed Target metTarget DSU and Main Total

Page 18


Referral to Treatment Times

Analysis:

February 16

Status:

Head of PIDS Mar-16 In progress

Person Responsible: Date:

Performance against the 'incomplete' 18wks target continues to underperform at 85.7% against the required 92% standard, and the revised trajectory of 89.9%, due to the high backlog of admitted patients waiting more than 18wks for their treatment.

The agreed system wide winter resilience plan securing non elective and elective capacity ensuring all our patients are treated in the right place at the right time is progressing well. This enabled elective activity to resume normal levels, however, there is a seasonal reduction in elective activity during the Christmas and New Year period. The forecasted impact of non elective has continued longer than planned due to system wide pressures, and plans are in place to mitigate this through increased additional activity until the end of March 2016.

Demand and capacity planning is underway for 2016/17 including revised trajectories for the year; these will be informed by historical activity and performance, as well as the intended impact of the RTT improvement plan actions being implemented into quarter 1 of next year.

Commentary:

Demand and capacity modelling, revised forecast and weekly plan for General Managers to deliver services

Development of robust processes and documentation to enable training and awareness of 18 week procedures. Scheduled

PAAU Lead/ Clinical Leads Mar-16 In progress

Head of Performance Apr-16

Rebooking of cancelled operations alongside booking of waiting list backlog

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

Dec

15

Jan

16

Feb

16

RTT Incomplete IoW CCG


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

Dec

15

Jan

16

Feb

16

RTT Incomplete NHS England


Page 19


Benchmarking of Key National Performance Indicators: Summary ReportFebruary 16

Best Worst Eng

Emergency Care 4 hour Standards 95% 98% 71% 87.4% 81.1% 116 / 138 Red Qtr 3 15/16

RTT % of incomplete pathways within 18 weeks 92% 100% 75% 91.7% 87.1% 174 / 182 Red Jan-16

%. Patients waiting > 6 weeks for diagnostic 1% 0% 12% 2.2% 0.0% 1 / 176 Green Jan-16

Ambulance Category A Calls % < 8 minutes - Red 1 75% 78% 60% 69.9% 60.4% 11 / 11 Red Jan-16

Ambulance Category A Calls % < 8 minutes - Red 2 75% 75% 50% 63.3% 75.1% 1 / 11 Green Jan-16

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 75% 50% 63.7% 73.9% 2 / 11 Amber Green Jan-16

Ambulance Category A Calls % < 19 minutes 95% 97% 82% 91.1% 96.1% 2 / 11 Green Jan-16

Cancer patients seen <14 days after urgent GP referral 93% 100% 74% 94.8% 95.6% 88 / 153 Green Qtr 3 15/16

Cancer diagnosis to treatment <31 days 96% 100% 92% 97.9% 100.0% 1 / 156 Green Qtr 3 15/16

Cancer urgent referral to treatment <62 days 85% 100% 0% 83.5% 80.2% 112 / 155 Amber Red Qtr 3 15/16

Symptomatic Breast Referrals Seen <2 weeks 93% 100% 7% 93.4% 96.8% 42 / 133 Amber Green Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days 94% 100% 83% 96.2% 96.2% 111 / 151 Amber Green Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100% 96% 99.6% 99.2% 126 / 143 Green Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 daysNo measured

operat ional standard 100% 0% 90.6% N/A N/A / 148 N/A Qtr 3 15/16

Cancer Patients treated after screening referral <62 days 90% 100% 0% 93.4% 90.2% 114 / 143 Amber Green Qtr 3 15/16

Key: Better than National Target = Green Top Quartile = Green

Worse than National Target = Red Median Range Better than Average = Amber Green

Median Range Worse than Average = Amber Red

Bottom Quartile Red

Data PeriodIW RankNational

Target

National Performance IW

PerformanceIW Status

Page 20


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other 'Small Acute Trusts'February 16

Other Small Acute Trusts

Emergency Care 4 hour Standards 95% 81.1% 23 86.3% 21 92.3% 13 95.4% 1 95.3% 2 88.0% 18 95.2% 4 N/A 94.7% 6 94.6% 7 87.8% 19 91.8% 15 93.0% 12 92.2% 14 N/A 95.1% 5 94.1% 11 N/A 89.2% 17 89.8% 16 81.0% 24 94.1% 8 77.7% 25 84.2% 22 87.8% 20 94.1% 9 94.1% 10 95.3% 3 Qtr 3 15/16

RTT % of incomplete pathways within 18 weeks 92% 87.1%22

96.7%1

91.5%20

93.4%13

94.7%9

94.0%10

95.3%6

N/A 95.0%8

92.3%17

92.0%19

87.8%21

96.0%3

96.3%2

N/A 95.5%5

92.8%15

N/A 95.7%4

93.4%12

N/A 93.4%14

92.3%16

95.1%7

N/A 92.2%18

93.8%11

N/A Jan-16

%. Patients waiting > 6 weeks for diagnostic 1% 0.0%1

0.1%5

6.8%24

0.8%19

0.7%18

0.5%15

0.6%17

N/A 0.1%8

0.0%1

1.0%20

1.5%22

0.0%1

0.5%14

N/A 0.2%10

2.5%23

N/A 0.4%12

0.6%16

0.0%4

0.4%11

0.46%13

0.2%9

N/A 0.1%6

1.0%21

0.1%7

Jan-16

Cancer patients seen <14 days after urgent GP referral 93% 95.6%19

97.2%8

94.2%24

95.9%16

97.2%9

95.3%21

91.1%25

N/A 98.4%2

98.3%3

96.2%14

95.4%20

96.8%10

96.2%13

N/A 98.6%1

95.9%17

N/A 96.3%12

97.9%6

96.4%11

94.9%22

97.3%7

95.8%18

97.9%5

94.7%23

96.2%15

97.9%4

Qtr 3 15/16

Cancer diagnosis to treatment <31 days 96% 100.0%1

99.3%15

98.6%20

99.7%9

99.7%8

97.0%25

99.6%10

N/A 99.0%18

100.0%1

99.0%17

97.4%24

100.0%1

98.4%21

N/A 100.0%1

100.0%1

N/A 99.1%16

100.0%1

97.5%23

99.4%14

99.4%12

97.8%22

99.4%13

98.6%19

99.5%11

100.0%1

Qtr 3 15/16

Cancer urgent referral to treatment <62 days 85% 80.2%21

83.2%18

0.0%26

84.6%17

94.2%1

88.2%10

92.9%5

N/A 93.5%2

91.8%6

89.8%9

81.4%19

90.7%7

87.1%15

50.0%25

87.6%13

80.6%20

N/A 86.5%16

90.4%8

79.7%24

80.0%23

93.5%4

87.5%14

87.9%12

93.5%3

80.2%22

88.0%11

Qtr 3 15/16

Breast Cancer Referrals Seen <2 weeks 93% 96.8%9

92.2%22

95.3%16

96.4%12

96.6%11

94.0%19

85.6%24

N/A 98.2%3

98.0%4

97.7%5

98.6%1

N/A 92.5%20

N/A 96.7%10

96.0%14

N/A 92.4%21

96.2%13

87.9%23

94.7%18

96.9%7

94.8%17

98.3%2

96.0%15

97.5%6

96.9%8

Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days 94% 96.2%19

100.0%1

95.7%21

100.0%1

100.0%1

86.1%25

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

93.3%23

N/A 94.1%22

100.0%1

96.2%19

89.5%24

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 99.2%22

97.2%25

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

99.0%24

99.0%23

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 daysNo measured

operat ional standard N/A 100.0%1

88.6%19

88.9%16

96.3%13

75.0%22

100.0%1

N/A 100.0%1

100.0%1

75.0%22

100.0% 100.0% 88.9%16

N/A 85.2%21

96.6%12

N/A 88.9%16

100.0% 71.4%24

100.0%1

92.5%15

100.0%1

88.0%20

100.0%1

100.0% 95.6%14

Qtr 3 15/16

Cancer Patients treated after screening referral <62 days 90% 90.2%21

100.0%1

60.0%24

93.3%20

100.0%1

71.4%23

100.0%1

N/A 95.8%14

95.5%15

100.0%1

94.4%18

N/A 95.5%15

N/A 97.1%13

93.9%19

N/A 100.0%1

100.0%1

85.7%22

100.0%1

100.0%1

100.0%1

95.3%17

97.5%12

100.0%1

100.0%1

Qtr 3 15/16

Key: Better than National Target = Green R1F ISLE OF WIGHT NHS TRUST RC3 EALING HOSPITAL NHS TRUST RFW WEST MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST RLT GEORGE ELIOT HOSPITAL NHS TRUSTWorse than National Target = Red RA3 WESTON AREA HEALTH NHS TRUST RCD HARROGATE AND DISTRICT NHS FOUNDATION TRUST RGR WEST SUFFOLK NHS FOUNDATION TRUST RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST

Target Not Applicable for Trust = N/A RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST RCF AIREDALE NHS FOUNDATION TRUST RJC SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST RN7 DARTFORD AND GRAVESHAM NHS TRUSTRBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST RCX THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS TRUSTRJD MID STAFFORDSHIRE NHS FOUNDATION TRUST RNQ KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUSTRBT MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST RD8 MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST RJF BURTON HOSPITALS NHS FOUNDATION TRUST RNZ SALISBURY NHS FOUNDATION TRUST

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RBZ NORTHERN DEVON HEALTHCARE NHS TRUST RE9 SOUTH TYNESIDE NHS FOUNDATION TRUST RJN EAST CHESHIRE NHS TRUST RQQ HINCHINGBROOKE HEALTH CARE NHS TRUST out of the 28 other small acute trusts RC1 BEDFORD HOSPITAL NHS TRUST RFF BARNSLEY HOSPITAL NHS FOUNDATION TRUST RLQ WYE VALLEY NHS TRUST RQX HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

National

TargetData PeriodRLQ RLTRJD RJFRFF RFW RGR RJC RQQRNZRNQRN7RMPIW RBD RBT RBZ RC1RA3 RA4 RQXRJNRC3 RCD RCF RCX RD8 RE9

Page 21


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other Trusts in the 'Wessex Area'February 16

Emergency Care 4 hour Standards 95% 81.1% 6 N/A 95.4% 1 91.1% 3 N/A 91.6% 2 85.7% 5 72.4% 7 86.1% 4 N/A Qtr 2 15/16

RTT % of incomplete pathways within 18 weeks 92% 87.1%10

100.0%1

93.4%5

93.1%6

95.4%2

93.7%4

92.0%8

92.1%7

91.3%9

93.9%3

Jan-16

%. Patients waiting > 6 weeks for diagnostic 1% 0.0%1

N/A 0.8%5

1.2%7

0.0%1

5.1%9

1.0%6

0.7%4

2.5%8

0.4%3

Jan-16

Cancer patients seen <14 days after urgent GP referral* 93% 95.6%7

N/A 95.9%5

99.3%1

N/A 97.0%2

95.7%6

96.6%4

96.8%3

N/A Qtr 3 15/16

Cancer diagnosis to treatment <31 days* 96% 100.0%1

N/A 99.7%2

99.1%3

N/A 94.9%7

96.1%6

98.5%5

98.8%4

N/A Qtr 3 15/16

Cancer urgent referral to treatment <62 days* 85% 80.2%7

N/A 84.6%5

85.5%4

N/A 88.8%1

86.7%3

83.8%6

87.1%2

N/A Qtr 3 15/16

Breast Cancer Referrals Seen <2 weeks* 93% 96.8%3

N/A 96.4%4

100.0%1

N/A 100.0%1

91.9%7

94.7%6

96.0%5

N/A Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days* 94% 96.2%4

N/A 100.0%1

97.3%3

N/A 94.3%7

94.9%6

95.6%5

99.0%2

N/A Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days* 98% 99.2%7

N/A 100.0%1

100.0%1

N/A 100.0%1

99.7%5

99.6%6

100.0%1

N/A Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 days*No measured

operat ional standard N/A1

N/A 88.9%4

100.0%1

N/A 58.3%5

95.3%2

54.5%6

92.0%3

N/A Qtr 3 15/16

Cancer Patients treated after screening referral <62 days* 90% 90.2%7

N/A 93.3%4

92.6%5

N/A 98.1%2

95.2%3

90.3%6

98.3%1

N/A Qtr 3 15/16

Key: Better than National Target = Green R1F Isle Of Wight NHS Trust

Worse than National Target = Red R1C Solent NHS Trust

RBD Dorset County Hospital NHS Foundation Trust

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RD3 Poole Hospital NHS Foundation Trust

out of the 10 other trusts in the Wessex area RDY Dorset Healthcare University NHS Foundation Trust

RDZ The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust

RHM University Hospital Southampton NHS Foundation Trust

RHU Portsmouth Hospitals NHS Trust

RN5 Hampshire Hospitals NHS Foundation Trust

RW1 Southern Health NHS Foundation Trust

RDYNational

TargetIW R1C RBD RD3 Data PeriodRDZ RHM RHU RN5 RW1

Page 22


Benchmarking of Key National Performance Indicators: Ambulance PerformanceFebruary 16

Ambulance Category A Calls % < 8 minutes - Red 1 75% 60.4%11

61.7%10

69.6%5

67.4%8

62.9%9

69.3%6

71.9%4

72.0%2

71.9%3

77.8%1

69.0%7

Jan-16

Ambulance Category A Calls % < 8 minutes - Red 2 75% 75.1%1

49.6%11

58.3%10

60.9%8

61.2%7

63.5%5

71.1%4

62.8%6

60.6%9

74.7%2

71.9%3

Jan-16

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 73.9%2

50.1%11

58.8%10

61.1%9

61.3%7

63.8%5

71.2%4

63.3%6

61.3%8

74.9%1

71.7%3

Jan-16

Ambulance Category A Calls % < 19 minutes 95% 96.1%2

82.0%11

88.8%10

92.2%6

89.4%8

89.8%7

93.8%4

93.5%5

88.8%9

97.4%1

94.7%3

Jan-16

Key: Better than National Target = Green

Worse than National Target = Red RX9

RYC

R1F

RRU

RX6

RX7

RYE

RYD

RYF

RYA

RX8 Yorkshire Ambulance Service NHS Trust

North West Ambulance Service NHS Trust

South Central Ambulance Service NHS Foundation Trust

South East Coast Ambulance Service NHS Foundation Trust

South Western Ambulance Service NHS Foundation Trust

West Midlands Ambulance Service NHS Foundation Trust

East Midlands Ambulance Service NHS Trust

East of England Ambulance Service NHS Trust


London Ambulance Service NHS Trust

North East Ambulance Service NHS Foundation Trust

RX6National

Target

IW

PerformanceRX9 RYC RRU Data PeriodRYARX7 RYE RYD RYF RX8

Page 23


Data Quality

Analysis:

February 16

Identfy cause and develop corrective actions for Missing / Invalid Patient Pathway Numbers in the OP Dataset Mar-16 Ongoing

Review of Symphony Data Quality Mar-16 OngoingHead of Information / Deputy Director of Information

Commentary:

Action Plan: Person Responsible: Date: Status:

The information centre carry out an analysis of the quality of provider data submitted to Secondary Uses Service (SUS). They review 3 main data sets - Admitted Patient Care (APC), Outpatients (OP) and Accident & Emergency (A&E).

The latest information is up to December 2015. Overall we continue to have 5 red rated indicators. Three of the red indicators are in the Admitted Patient Care (APC) Dataset, one in the Outpatient Dataset and one in the A&E Attendances Dataset. Two of the three red indicators in the APC dataset are Primary Diagnosis and the HRG4 (Healthcare Resource Grouping). These are linked as you need the diagnosis to generate the HRG and we believe the issues has been resolved and has been improving month on month within the data but will take time to appear as amber or green. The third red indicator is the NHS number, we know this relates to prisoners and is not easy to resolve.

In the Outpatient dataset there are a larger than average number of records with an invalid or missing Patient Patway this will be investigated to see if a cause can be identified.

In the A&E dataset the only one red indicator relatwa to the Departure Time. This relates to patients seen in an A&E clinic and a process has been established to by Information Systems to prompt the department to add the depature time for those patients where it is missing we continue to monitor this closely with a view to this improving in due course.

Page 24


Workforce - Summary - RAG Rating based on Out-turn position

Establishment R Sickness R Turnover & Appraisal R

Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Substantive FTE 2,497 2,667 (170) Year to date 3% 4.22% 1.22% Turnover 0.62%

Temporary Staffing 112 235 (123) In Month 3% 4.84% 1.84% Turnover YTD 7.00%Total Funded FTE 2,609 2,902 (293) Appraisal 36.77%

Vacancies R Overpayment A Rostering R

Recruitment Activity Plan Actual Adherence to forward rostering policy requirement 41%

Vacancy FTE 293 Current Position £ 000 0 93 Units finalising to payroll deadline 97%Safe staffing units > 80% staffed (overall) 100%

February 16

Summary

SIP decreased in month by 2 FTE - from 2669 in January 16. The temporary staffing figure,

which increased from 147 FTE in January 16 to 235 in February 16, is representative of the

increase in sickness absence.

Trust Headcount at the end of February 16: 3119 (Decrease of 8)

Summary

Sickness absence has increased from 4.61% in Jan 16 to 4.84% in Feb 16. Trust wide

highest reason for sickness absence is Cold, Cough, Flu - Influenza showing an increase in

month by 16%.

Estimated Cost of Sickness Absence:

Trustwide £296,290

Ambulance, Urgent Care & Community Services (£76,528)

Clinical Support Cancer & Diagnostic Services (£62,917)

Corporate Services (£57,874)

General Medicines (£22,719)

Mental Health & Learning Disabilities Services (£47,125)

Surgery, Women's & Children's Health Services (£29,127)

Summary

292.76 FTE currently in the recruitment process February 16.

High level of activity from managers recruiting in advance for March 16 intake which is best

practise, and recent granted permission from Scrutiny panel to process vacancies has resulted

an increase in month. Increased data collection process in HR will provide more detail in future

to identify where posts are generated from ie. "like for like replacement", "skill mix" etc. along

with data by Business Unit.

The reasons for recruitment table (below) shows 235.36 FTE in February 16 - this does not

match the 292.76 FTE recruitment activity due to the fact the increased level of information

relating to this began recording in November 15. Moving through the year this will match total

recruitment activity & show exactly what and why positions are being recruited. Majority of

recruitment remains like for like replacement.

Summary

Turnover remains low - marginal increase in month from 0.42% to 0.62% in

February

Appraisal % at Month 10 is 35.8%, decrease from 41.7% in Month 9,

communication has been sent via 10 Minute Team Brief (04-02-16) encouraging

Business Units to undertake and log appraisals. Reasons for the 4.9% decrease

can be apportioned due to the fact the appraisal % is a rolling %, and that a large

number of appraisals undertaken in Jan 15, are not included in the data.

Summary

Reduction in overpayments to £93k £10k in new overpayments, £8.5k due to incorrect Bank

Holiday recording historically.

Underlying factors include:

1. Competing Priorities in units.

2. Lack of understanding regarding potential impacts.

3. Duration of process from completing forms to updating ESR.

At time of lockdown, multiple costs centres were not locked down. Substantial

effort was made to contact areas to get this done as outlined in the rostering

policy.

This month 7 units were removed from the batch list. These units would not have

received enhancements and overtime pay as a result. A new lockdown guide is

now available and a screen added to the corporate screen saver to raise

awareness.

The new organisation build has assisted in targeting appropriate personnel to get

locked down, however more work still needs to occur which is planned with

linkages with finance.

Overpayment information sent to directorates on a monthly basis for review and action.

ESR Employee self service up and running, empowering staff and managers to review and

update their employment records. This will reduce the number of change forms to be

completed by managers for employee personal changes. Drop in sessions have been held to

answer any questions staff may have.

1. Importance of finalising and impacts of not doing so to be re-iterated. This will be

reinforced by staff who will have had pay implications contacting unit managers.

2. System resolution to be implemented by Allocate. Resolution found in other

trusts to be applied here but requires multiple criteria to be adjusted. Allocate are

currently investigating the adjustments required for IOW NHS Trust.

Underlying Causes

The significant majority of overpayments are due to incorrect or late forms. Underlying factors

will include:



3. Duration of process from completing forms to submission.



3. Unit managers timesheets not being finalised by their manager preventing unit

lockdown.

4. Inadequate cover arrangements for finalising during manager absence.

5. System flaw allowing locked units to be unlocked by staff entering web

timesheets

Underlying Causes Underlying Causes

Remedies & Actions Remedies & ActionsRemedies & ActionsReasons for Recruitment FTE

Additional Activity 3.10

Additional Funding 5.40Additional recruitment whilst

Substantive Staff member is recruited 3.00

Extension of Fixed Term 5.80

Like for Like Replacement 190.62

Maternity Cover 0.53

New Post 14.83

Organisational Change 6.63

Unpaid 0.00

Vacancy 4.45

Winter Resilience 1.00

Grand Total 235.36

Active Recruitment by Stage in

Process

Ambulance,

Urgent Care

&

Community

Services

Clinical

Support,

Cancer &

Diagnostic

Services

Mental

Health &

Learning

Disabilities

Services

CorporateGeneral

Medicines

Surgery,

Women's

&

Children's

Health

Services

Trustwide

Out to Advert 6.90 9.80 10.60 2.00 7.00 5.80 42.10

LIVE 52.36 28.49 34.48 32.15 36.13 28.21 211.82

Appointed Awaiting Clearances 8.03 5.37 10.00 8.00 4.44 3.00 38.84

Total 67.29 43.66 55.08 42.15 47.57 37.01 292.76

Page 25


Workforce - Sickness

Trust

The Trust's sickness target is 3%

Currently Sickness Absence rate is 4.84% for February 2016

YTD Sickness Absence is 4.22%.

10 Highest areas within Trust

February 16

Increase in Sickness absence in month from 4.61% to 4.84% - above the 3% target. Trust wide highest reason for sickness absence is Cold, Cough, Flu - Influenza showing an increase in month by 16%.

Gastrointestinal problems showed the largest increase in month by 32%.

Absence Reason Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Variance

S10 Anxiety/stress/depression/other psychiatric illnesses 732.85 841.24 704.58 1044.46 690.25 798.08 1119.58 877.85 1001.37 811.28 711.09 -14.09%

S11 Back Problems 337.59 284.48 378.57 390.20 324.69 283.60 295.93 270.26 262.19 272.44 244.55 -11.41%

S12 Other musculoskeletal problems 302.80 279.37 237.08 317.63 359.69 345.98 539.17 448.90 401.33 462.45 377.48 -22.51%

S13 Cold, Cough, Flu - Influenza 313.49 251.47 198.45 119.72 133.08 221.25 440.60 346.14 360.91 627.13 744.23 15.73%

S25 Gastrointestinal problems 342.90 338.13 485.90 483.44 467.43 428.18 345.06 319.81 278.29 333.09 486.33 31.51%

Sum of FTE Days Lost

Organisation

FTE Days

Available

Sickness

FTE Days

Lost Sickness % Headcount

Transfer of Care J61300 37.12 18.56 50.00% 2

Specialist CAMHS Medics J61830 49.30 23.20 47.06% 2

Medicine Clinical Services J61253 58.00 25.00 43.10% 2

AUCC Management Team J61011 110.20 41.00 37.21% 4

Beacon Dermatology J61708 45.63 15.47 33.90% 2

Mental Health Management Admin J61840 58.00 12.00 20.69% 2

Continuing Healthcare J61241 29.00 6.00 20.69% 1

Paediatric Diabetic Nurse J61373 46.40 9.20 19.83% 1

Clinical Coding J61156 324.41 58.96 18.17% 12

Community Health Management J61422 161.43 29.00 17.96% 7

Page 26


Workforce - Overpayments

February 16

Summary: Overall overpayments figure reduced to £93k. There was £10K in new overpayments in month, £8.5k of this due to incorrect Bank Holiday recording.

Feb-16

Corporate Directorates

Current Employee

Repayments Current Emp

Current Emp -

New Leavers Leavers - New

Allergy & R&D Funded by Income Business Unit

Chief Operating Officer £300 £4,576 £6,796

Finance & Performance Mgt £117 £2,178 £1,967

Strategic & Commercial Directorate £73 £182 £1,873 £93

£490 £6,937 £1,873 £8,856 £0

Page 27


Summary - RAG Rating based on Out-turn position

Continuity of Service Rating R Surplus R Income G

Plan Actual Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Year to date 2 1 Year to date £k (4,053) (7,791) (3,737) Year to date £k 155,131 156,455 1,324

Year end forecast £k (4,600) (6,737) (2,137) Year end forecast £k 169,087 172,710 3,623

February 16

Summary

The Trust is reporting a £0.819m deficit for February 2016, which is an adverse variance of £0.165m against plan.

Cumulatively, there is a deficit of £7.791m as at February 2016, an adverse variance of £3.737m against plan.

Although a deficit in month, this is an improvement against the current trajectory to year end forecast position.

The planned Continuity of Service Rating (CoSR) to month 11 was a '2'. As previously

reported, the actual I&E position has deteriorated significantly from plan and to the end of

February, the Trust is reporting an overall Continuity of Service Rating of '1'. The overall

year to date sustainability risk rating still shows a variance of 1 against plan.

The Trust planned for a deficit of £0.654m in February, after adjustments made for normalising items (these

include the net costs associated with donated assets).

The reported position is a deficit of £0.819m in the month, an adverse variance of £0.165m against plan.

The cumulative Trust plan was a deficit of £4.053m, after normalising items. The actual position is a

cumulative deficit of £7.791m, an adverse variance of £3.737m.

Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.

The variance in month includes over performance against the CCG PbR Contract of £0.503m (£1.225m

adverse year to date including penalties). In addition to this, there is a favourable £0.030m variance

(£0.292m adverse year to date) relating to a phasing issue on the CCG SLA Acute Contract, which will

reduce to zero by the end of the financial year.

Further benefit of £82k (£620k year to date) has also realised following balance sheet reviews. Weekly

reviews and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year

end.

The Trusts planned forecast out-turn deficit remains at £6.737m, against its original plan of £4.600m. This

position is due to the implementation of the system resilience improvement plan with its additional net costs,

unachievement of activity income with fines and penalties, and system pressures that the Trust has borne

throughout the year. Achievement of £6.737m is also subject to CCG support of £1.967m, and negotiations

around this are ongoing.

Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in

Clinical Business Units on CIP and budget delivery involving business managers have now been extended

to Corporate areas.

The Trust planned income in February was £13.936m. The actual reported income is

£14.673m in month, a favourable variance of £0.737m.

The cumulative income plan is £155.131m. The actual position is a cumulative income of

£156.455m, a favourable variance of £1.324m.

This position includes £1.225m provision for estimated contract under performance and

penalties (£0.228m activity and £0.997m penalties).

Page 28


Summary - RAG Rating based on Out-turn position

February 16

Operating Costs (including directorate income) R CIP R Cash A

Plan Actual / Forecast Variance Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Year to date £k (132,659) (136,202) (3,543) Year to date £k 7,759 5,884 (1,875) Year to date £k 3,361 1,145 (2,216)

Year end forecast £k (143,182) (145,820) (2,638) Year end forecast £k 8,500 8,656 156 Year end forecast £k 1,890 1,715 (175)

Capital G Indicators of Forward Financial Risk A

Plan Actual / Forecast Variance Actual Forecast for quarter

Year to date £k (8,010) (5,727) (2,283) Number of indicators breached 4 4

Year end forecast £k (8,180) (7,031) (1,149) Number of indicators 12 12

Indicators breached are:

i) Trust financial performance is on plan

ii) Capital expenditure <75% of plan for the year

iii) Trusts CIP schemes on plan

iv) Continuity of service rating on plan

Strategic Capital schemes includes the larger capital projects.

The MAU Extension and the Endoscopy Relocation scheme have now been completed.

The ICU/CCU project from 2014/15 remains on hold and in Assets Under Construction in

2015/16, no further expenditure on this project has been agreed as yet. The Ward

Reconfiguration of Level C is still on hold with an expectation that this scheme will form

part of the capital programme in 2016/17. Similarly the phasing of the spend of the

funding for the Carbon Energy Fund project has also been changed and will now

commence in 2016/17. These two account for the variance in the actual spend compared

to plan relating to Strategic Capital projects. Slippage on several operational capital

schemes e.g. the replacement ambulance contribute to the year to date underspend.

The cash balance held at the end of February is c£1.1m which is c£2.2m less than planned.

The difference in the planned deficit to the actual figure at month 11 is c£3.7m. This is offset

in cash terms by the underspend of £4.4m on capital expenditure and the variance against

the original budgeted depreciation charges of £340k. Other working capital movements of

£4,296k account for the other reduction in the planned cash balance.

The Trust is reporting a current year overspend against expenditure budget of £3.543m.

Including additional costs relating to the Public Dividend Capital Charge the adjusted

overspend expenditure variance is £3.491m.

The current year net operating costs include £19.066m of directorate income. Excluding

this income source the total costs amount to £155.268m. In addition to the operating costs,

capital charges & finance costs amount to £8.978m.

The in month position for CIP is an achievement of £0.807m against a target of £0.733m, an over

achievement of £0.074m.

Cumulatively there is an achievement of £5.884m with a target of £7.759m. This is an adverse variance of

£1.875m.

The current year forecast is an achievement of £8.656m against a target of £8.500m, an over achievement

of £0.156m. This has been achieved by moving Business Units under spending budgets to CIP

achievements. Although non recurrent, this has the effect of highlighting areas of underspend for review

and scrutiny as potential recurrent CIP to carry forward into 2016/17.

Page 29


Continuity of Service Risk Rating

Year To Date Plan

Rating

Actual

Rating Variance

Continuity of Service Risk RatingsLiquidity Ratio 1 1 0

Capital Servicing Capacity (Times) 2 1 (1)

Continuity of Services Risk Rating for Trust2 1 (1)

Financial Sustainability Risk Ratings from M6 (based on original Plan submission)

I&E Margin Rating 1 1 0

I&E Margin Variance from Plan 3 1 (2)

Overall Financial Sustainability Risk Rating 2 1 (1)

Financial Criteria Weight % Definition Rating categories

4 3 2 1

Liquidity Ratio 1 50% Liquid Ratio (days) Working capital balance x 360 0.0 -7.0 -14.0 <-14

Annual operating expenses

Capital Servicing Capacity Ratio 1 50% Capital servicing capacity (time) Revenue available for capital service

Annual debt service 2.5x 1.75x 1.25x <1.25x

Additional Monitor Risk Ratings

Underlying Performance 1 25% I&E Margin (%) Adjusted Financial Performance Retained Surplus/(Deficit) >1% 0% to 1% 0% to -1% <-1%

Income

Variance from Plan 1 25% Variance in I&E Margin as % of Plan Variance in I&E Margin >0% 0% to -1% -1% to -2% <-2%

Income

The planned Continuity of Service Rating (CoSR) to month 11 was a '2'. As previously reported, the actual I&E position has deteriorated significantly from plan and to the end of February, the Trust is reporting an overall Continuity of

Service Rating of '1'. The overall year to date sustainability risk rating still shows a variance of 1 against plan.

Metric to be scored

February 16

Page 30


Surplus

Base Budget In month Year to date Full Year

Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Surplus / (Deficit) (4,600) (654) (819) (165) (4,053) (7,791) (3,737) (4,600) (6,737) (2,137)



£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Income 166,836 13,936 14,673 737 155,131 156,455 1,324 169,087 172,710 3,623

Pay (114,151) (9,527) (10,489) (963) (105,362) (110,777) (5,414) (114,796) (121,616) (6,820)

Non Pay (47,147) (4,206) (4,151) 54 (44,797) (44,491) 306 (48,883) (47,901) 982

EBITDA 5,538 204 32 (172) 4,972 1,187 (3,785) 5,408 3,194 (2,214)

Depreciation & Amortisation (6,531) (563) (538) 25 (5,783) (5,685) 98 (6,401) (6,303) 98

PDC (3,625) (302) (302) 0 (3,323) (3,323) 0 (3,625) (3,595) 30

Impairment 0 0 0 0 0 0 0 0 0 0

Profit/(Loss) on Asset Disposal 0 0 (0) (0) 0 (46) (46) 0 (46) (46)

Interest Receivable/(Payable) 0 0 (17) (17) 0 (1) (1) 0 (1) (1)

Bank Charges (8) (1) (0) 0 (7) (5) 2 (8) (6) 2

RETAINED SURPLUS / (DEFICIT) (4,626) (662) (826) (164) (4,141) (7,873) (3,731) (4,626) (6,757) (2,131)

Receipt of Charitable Donations for Asset Acquisition (70) 0 0 0 0 0 0 (70) (70) 0

Impairment 0 0 0 0 0 0 0 0 0 0

Depreciation - Donated Assets 96 8 7 (1) 88 82 (6) 96 90 (6)

REVISED RETAINED SURPLUS / (DEFICIT) (4,600) (654) (819) (165) (4,053) (7,791) (3,737) (4,600) (6,737) (2,137)

The Trust planned for a deficit of £0.654m in February, after adjustments made for normalising items (these include the net costs associated with donated assets).

The reported position is a deficit of £0.819m in the month, an adverse variance of £0.165m against plan.

The cumulative Trust plan was a deficit of £4.053m, after normalising items. The actual position is a cumulative deficit of £7.791m, an adverse variance of £3.737m.

Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.

The variance in month includes over performance against the CCG PbR Contract of £0.503m (£1.225m adverse year to date including penalties). In addition to this, there is a favourable £0.030m variance (£0.292m

adverse year to date) relating to a phasing issue on the CCG SLA Acute Contract, which will reduce to zero by the end of the financial year.

Further benefit of £82k (£620k year to date) has also realised following balance sheet reviews. Weekly reviews and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year end.

The Trusts planned forecast out-turn deficit remains at £6.737m, against its original plan of £4.600m. This position is due to the implementation of the system resilience improvement plan with its additional net costs,

unachievement of activity income with fines and penalties, and system pressures that the Trust has borne throughout the year. Achievement of £6.737m is also subject to CCG support of £1.967m, and negotiations around

this are ongoing.

Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in Clinical Business Units on CIP and budget delivery involving business managers have now been extended to Corporate

areas.

The Category A income position includes under performance and penalties against CCG PbR contracted activity of £1.225m (£0.228m activity and £0.997m penalties) plus delayed investments and cost per case services

that are over or under plan. These delays are offset by a corresponding balance in reserves of £425k (£97k IoW CCG, £328k NHSE).

Operating costs include considerable over spends in the Clinical Business Units. These relate to unachievement of CIP requirements, and additional costs in respect of operational pressures and black alert status which

are being addressed through contract discussions with commissioners, and formally requested financial support.

The current trajectory year end forecasts from Business Units are a deficit of £7.9m. With further opportunites and support from CCG, this can be reduced to £6.7m.

The current Full Year Plan budgets differ from the Base Budget Plan due to directorates movement of CIP targets between Pay, Non Pay and Income as savings plans are developed.

February 16

Page 31


Surplus

February 16

-1,600

-1,400

-1,200

-1,000

-800

-600

-400

-200

-

200

400


£0

00

s

Surplus / (Deficit) by Month

Plan

Actual

-9,000

-8,000

-7,000

-6,000

-5,000

-4,000

-3,000

-2,000

-1,000

-


£0

00

s

Cumulative Surplus / (Deficit) by Month

Plan

Actual

Page 32


Income



£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Surplus / (Deficit) 166,836 13,936 14,673 737 155,131 156,455 1,324 169,087 172,710 3,623


Income Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000sNHS Isle of Wight CCG 132,668 10,837 11,366 530 122,408 121,573 (835) 133,769 134,649 880 NHS England 11,142 986 965 (20) 9,472 9,554 82 10,228 10,342 115 Isle of Wight Council 1,748 463 476 13 3,883 3,946 63 4,346 4,406 59 Commissioning Support Unit 320 27 25 (2) 294 287 (7) 320 314 (6) Non Contractual Activity 1,575 64 64 0 1,477 1,352 (125) 1,575 1,450 (125) Southampton University Hospitals FT 105 9 5 (4) 96 70 (26) 105 77 (28) Capital to Revenue Transfer 0 0 0 0 607 607 0 607 607 Other income 8,686 1,552 1,771 220 17,500 19,066 1,566 18,743 20,866 2,122

TOTAL INCOME 156,244 13,936 14,673 737 155,131 156,455 1,324 169,087 172,710 3,623

The Trust planned income in February was £13.936m. The actual reported income is £14.673m in month, a favourable variance of £0.737m.

The cumulative income plan is £155.131m. The actual position is a cumulative income of £156.455m, a favourable variance of £1.324m.

This position includes £1.225m provision for estimated contract under performance and penalties (£0.228m activity and £0.997m penalties).

The NHS Isle of Wight CCG position year to date has an estimate of £1.225m for cumulative under performance and penalties against the PbR contract. This is sub divided as £1.600m on Elective and Outpatient activity

(£1.299m activity and £0.301m penalties), and £0.375m favourable variance on Non Elective activity (£1.070m over activity and £0.696m penalties).

There are also contract services that have yet to commence and cost per case services over and under plan (£97k), but is offset by a corresponding balance in revenue reserves.

The year end position assumes that income will exceed the plan due to formally requested support from the CCG in achieving the overall year end forecast position.

NHS England variance relates to

i) under performance against Non PbR excluded drugs (£328k), which is offset by a reduction in costs within Clinical Business Units.

ii) over performance against service contract at an estimated £411k to date.

IoW Council variance relates to over performance against the Sexual Health contract.

February 16

Page 33


Income

February 16

11,500

12,000

12,500

13,000

13,500

14,000

14,500

15,000

15,500


£0

00

s

Monthly Income

Plan

Actual

105,000

115,000

125,000

135,000

145,000

155,000

165,000

Nov Dec Jan Feb

£0

00

s

Cumulative income by month

Plan

Actual

Page 34


Cost Improvement Programme

February 16

The in month position for CIP is an achievement of £0.807m against a target of £0.733m, an over achievement of £0.074m.

Cumulatively there is an achievement of £5.884m with a target of £7.759m. This is an adverse variance of £1.875m.

The current year forecast is an achievement of £8.656m against a target of £8.500m, an over achievement of £0.156m. This has been achieved by moving Business Units under spending budgets to CIP achievements.

Although non recurrent, this has the effect of highlighting areas of underspend for review and scrutiny as potential recurrent CIP to carry forward into 2016/17.

Directorate

CIP Target

2015/16

£'000

Recurrent

achieved

forecast year

end

Non Recurrent

achieved

forecast year

end

CIP achieved

year end

forecast

£'000

Over / (Under)

Target

forecast

£'000Chief Operating Officer 160 0 0 0 (160)

Community and Mental Health 1,216 532 1,065 1,597 381

Ambulance & Community 908 202 48 249 (659)

Clinical Support 3,744 1,303 1,295 2,598 (1,145)

Surgery 1,105 70 123 193 (912)

Finance and Performance 250 281 1,914 2,195 1,945

Nursing and Workforce 219 67 307 374 155

Strategic and Commercial 706 325 829 1,154 448

Trust Administration 192 99 196 295 103

Grand Total 8,500 2,879 5,777 8,656 156

Directorate

CIP Target

year to date

£'000

Recurrent

achieved year

to date

Non Recurrent

achieved year

to date

CIP achieved

year to date

£'000

Over / (Under)

Target

year to date

£'000Chief Operating Officer 146 0 0 0 (146)

Community and Mental Health 1,110 487 1,065 1,552 442

Ambulance & Community 710 185 48 232 (477)

Clinical Support 3,541 1,096 233 1,329 (2,212)

Surgery 1,005 64 123 187 (819)

Finance and Performance 228 257 1,418 1,675 1,447

Nursing and Workforce 200 67 75 142 (58)

Strategic and Commercial 644 304 331 634 (10)

Trust Administration 175 99 33 132 (43)

Grand Total 7,759 2,559 3,325 5,884 (1,875)

Page 35


Cash

Plan

Year to date

Actual Variance Plan

Full Year

Forecast Variance£000s £000s £000s £000s £000s £000s

Cash Balance 3,361 1,145 (2,216) Cash Balance 1,890 1,715 (175)

Plan Year to date Variance Plan Full Year Variance£000s £000s £000s £000s £000s £000s

Operating Surplus/(Deficit) (819) (4,559) (3,740) Operating Surplus/(Deficit) (1,001) (3,156) (2,155)Depreciation and Amortisation 5,965 5,625 (340) Depreciation and Amortisation 6,531 6,303 (228)Impairments and Reversals 0 0 0 Impairments and Reversals 0 0 0Gains /(Losses) on foreign exchange 0 0 0 Gains /(Losses) on foreign exchange 0 0 0Donated Assets - non-cash 0 0 0 Donated Assets - non-cash (70) (70) 0Government Granted Assets received, credited to revenue but non-cash 0 0 0 Government Granted Assets received, credited to revenue but non-cash 0 0 0PFI/Finance Lease Interest Paid 0 0 0 PFI/Finance Lease Interest Paid 0 0 0Interest Paid (24) (20) 4 Interest Paid (27) (32) (5)Dividend (Paid)/Refunded (1,813) (1,834) (21) Dividend (Paid)/Refunded (3,625) (3,646) (21)Release of PFI/Deferred Credit 0 0 0 Release of PFI/Deferred Credit 0 0 0Movement in Inventories 0 348 348 Movement in Inventories (228) 302 530Movement in Receivables 900 (4,969) (5,869) Movement in Receivables 1,000 (185) (1,185)Movement in Other Current Assets 0 0 0 Movement in Other Current Assets 0 0 0Movement in Trade and Other Payables 2,515 3,784 1,269 Movement in Trade and Other Payables 2,997 275 (2,722)Movement in Other Current Liabilities 0 0 0 Movement in Other Current Liabilities 0 0 0Provisions Utilised (185) (258) (73) Provisions Utilised (330) (270) 60Movement in Non Cash Provisions 0 (48) (48) Movement in Non Cash Provisions 0 (27) (27)Cashflow from Operating Activities 6,539 (1,931) (8,470) Cashflow from Operating Activities 5,247 (506) (5,753)Cashflow from Investing Activities Cashflow from Investing ActivitiesInterest Received 22 26 4 Interest Received 24 26 2Capital Expenditure - PPE (11,117) (7,309) 3,808 Capital Expenditure (11,244) (7,776) 3,468Capital Expenditure - Intangibles (794) (139) 655 Capital Expenditure - Intangibles (837) (446) 391Cashflow from Investing Activities (11,889) (7,419) 4,470 Cashflow from Investing Activities (12,057) (7,667) 4,390Cash Flows from Financing Activities (5,350) (9,350) 4,000 Cash Flows from Financing Activities (6,810) (8,173) (1,363)Revolving Working Capital Support Facility Accessed 0 0 0 Revolving Working Capital Support Facility Accessed 0 0 0Revolving Working Capital Support Facility Repaid 0 0 0 Revolving Working Capital Support Facility Repaid 0 0 0Capital Element of Finance Leases (88) (39) 49 Capital Element of Finance Leases (99) (39) (60)

0 0 00 0 0

Cashflow from Financing Activities (88) 1,696 1,784 Cashflow from Financing Activities (99) 1,089 (1,188)Net increase/decrease in cash (5,438) (7,654) 5,784 Net increase/decrease in cash (6,909) (7,084) (2,551)Opening Cash Balance 8,799 8,799 0 Opening Cash Balance 8,799 8,799 0Opening Balance Adjustment 0 0 0 Opening Balance Adjustment 0 0 0

8,799 8,799 08,799 8,799 0

0 0 0 0 0 0

Closing Cash Balance 3,361 1,145 (2,216) Closing Cash Balance 1,890 1,715 (175)

February 16

The cash balance of c£1.1m held at the end of February is c£2.2m less than planned. Primarily, this is because the increase in

the reported deficit of £3.7m is offset by the reduced cash spent on capital £4.5m (£7.4m against the original planned spend of

£11.9m). The variation in the cash balance can therefore be attributable to the net movement in other working capital. This

includes a fairly significant increase in receivables which primarily relates to additional CVs due from the IWCCG and which should

therefore return to a similar level as planned (c£7m) in March when cash payment is received.

The table above shows the forecast cash balance at 31st March 2016 as £1,715k and this will require careful monitoring

of cash in the last month of the year. This is now based on the latest estimate of all known cash related items in 2015/16

including the draw down of the £1.73m interim working capital support, the repayment to the IWCCG of the cash

advanced in October and November and the expected recovery for the under-performance in the acute SLA. The balance

also includes the additional Contract Variations now agreed with the CCG and receipt from the sale of Swanmore Road.

Pending the updated plan due to be submitted at the beginning of April, the cash forecast assumptions have yet to be

finalised and built into the forecast cash flow. The graph below is therefore based on the current best estimate and still

indicates that it may be necessary to apply for further revenue support sometime early in the new financial year.

Discussions about the Trust's furure cash requirements are ongoing with the TDA.

The cash balance held at the end of February is c£1.1m which is c£2.2m less than planned. The difference in the planned deficit to the actual figure at month 11 is c£3.7m. This is offset in cash terms by the underspend of £4.4m on capital expenditure and

the variance against the original budgeted depreciation charges of £340k. Other working capital movements of £4,296k account for the other reduction in the planned cash balance.

Restated Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the

Period

Restated Cash and Cash Equivalents (and Bank Overdraft) at Beginning of

the Period

Capital grants and other capital receipts (excluding donated/government

granted cash receipts)

Capital grants and other capital receipts (excluding donated/government granted

cash receipts)

Effect of Exchange Rate Changes in the Balance of Cash Held in Foreign

Currencies

Effect of Exchange Rate Changes in the Balance of Cash Held in Foreign

Currencies

Page 36


Cash

February 16

-25000000

-20000000

-15000000

-10000000

-5000000

0

5000000

10000000

15000000

20000000

25000000

Feb

-16

Mar

-16

Ap

r 1

6

May

16

Jun

16

Jul 1

6

Au

g 1

6

Sep

16

Oct

16

No

v 1

6

De

c 1

6

Jan

17

Feb

17

Mar

17

Ap

r 1

7

May

17

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Feb

18

£

Cash flow - Forecast to February 2018

Payroll

Capital

NON NHS expenditure

NHS expenditure

PDC expen

Interim Revolving Working Capital Support - RECEIVED

Recharges to IOW CCG

SLA with IOW CCG

Other income

Month end bank balance as per GL

Page 37


Statement of Financial Position

1st April 2015

Plan Actual Variance Notes Plan Forecast Variance Notes

£k £k £k £k £k £k £k

Property, Plant and Equipment 107,504 109,808 107,870 (1,938) Property, Plant and Equipment 114,042 115,196 1,154

Intangible Assets 3,495 2,534 2,404 (130) Intangible Assets 2,451 2,629 178

Investment Property 0 0 0 0 Investment Property 0 0 0

Other Financial Assets 0 0 0 0 Other Financial Assets 0 0 0

Trade and Other Receivables 340 224 174 (50) Trade and Other Receivables 150 200 50

Non Current Assets 111,339 112,566 110,448 (2,118) Non Current Assets 116,643 118,025 1,382

Inventories 2,303 1,728 1,954 226 Inventories 1,500 2,000 500

Trade and Other Receivables 7,604 6,948 12,755 5,807 Trade and Other Receivables 6,930 7,925 995

Other Financial Assets 0 0 0 0 Other Financial Assets 0 0 0

Other Current Assets 0 0 0 0 Other Current Assets 0 0 0

Cash and Cash Equivalents 8,799 3,361 1,145 (2,216) Cash and Cash Equivalents 1,890 1,715 (175)

Sub Total Current Assets 18,706 12,037 15,854 3,817 Sub Total Current Assets 10,320 11,640 1,320

Non-Current Assets Held For Sale 0 0 497 497 Non-Current Assets Held For Sale 0 0 0

Current Assets 18,706 12,037 16,351 4,314 Current Assets 10,320 11,640 1,320

Trade and Other Payables (18,694) (19,628) (21,413) (1,785) Trade and Other Payables (17,993) (16,842) 1,151

Other Liabilities 0 0 0 0 Other Liabilities 0 0 0

Provisions (643) (334) (257) 77 Provisions (448) (266) 182

Borrowings (incl. Working Capital Support Facility) 0 0 0 0 Borrowings (incl. Working Capital Support Facility) 0 0 0

Other Financial Liabilities 0 0 0 0 Other Financial Liabilities 0 0 0

Liabilities arising from PFIs / Finance Leases 0 (19) (8) 11 Liabilities arising from PFIs / Finance Leases 0 (102) (102)

DH Working Capital Loan - FT Liquidity 0 0 0 0 DH Working Capital Loan - FT Liquidity 0 0 0

DH Revenue Support Loan (Including RWCSF) 0 0 (1,735) (1,735) DH Revenue Support Loan (Including RWCSF) 0 (1,735) (1,735)

DH Capital Loan 0 0 0 0 DH Capital Loan 0 0 0

Current Liabilities (19,337) (19,981) (23,413) (3,432) Current Liabilities (18,441) (18,945) (504)

Trade and Other Payables 0 0 0 0 Trade and Other Payables 0 0 0

Other Liabilities 0 0 0 0 Other Liabilities 0 0 0

Provisions 0 0 (80) (80) Provisions 0 (80) (80)

Borrowings 0 0 0 0 Borrowings 0 0 0

Other Financial Liabilities 0 0 0 0 Other Financial Liabilities 0 0 0

Liabilities arising from PFIs/Finance Leases 0 (933) (739) 194 Liabilities arising from PFIs/Finance Leases (933) (637) 296

DH Working Capital Loan - FT Liquidity 0 0 0 0 DH Working Capital Loan - FT Liquidity 0 0 0

DH Working Capital Loan - Revenue Support 0 0 0 0 DH Working Capital Loan - Revenue Support 0 0 0

DH Capital Loan 0 0 0 0 DH Capital Loan 0 0 0

Non-Current Liabilities 0 (933) (819) 114 Non-Current Liabilities (933) (717) 216

TOTAL ASSETS EMPLOYED 110,708 103,689 102,567 (1,122) TOTAL ASSETS EMPLOYED 107,589 110,003 2,414

FINANCED BY: FINANCED BY:

Public Dividend Capital 6,762 6,762 6,762 0 Public Dividend Capital 6,762 6,155 (607)

Retained Earnings Reserve 69,520 63,038 61,883 (1,155) Retained Earnings Reserve 62,406 62,995 589

Revaluation Reserve 34,426 33,889 33,922 33 Revaluation Reserve 38,421 40,853 2,432

Other Reserves 0 0 0 0 Other Reserves 0 0 0

TOTAL TAXPAYERS EQUITY 110,708 103,689 102,567 (1,122) TOTAL TAXPAYERS EQUITY 107,589 110,003 2,414

February 15

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in asset values, as well as other movements in working capital.

Year to Date Full Year

The reduced asset values of c£1.9m are attributable to the less than planned spend on capital items up to the end of

February. The movement in working capital, mainly the increase in receivables offset by the increase in payables, is more

than the planned level at month 11. As previously reported this is mainly because the plan was based on figures before the

final outturn for 2014/15 were confirmed. Assets Held for Sale relates to the properties in Swanmore Road, the sale of

which is due to be completed on 15th March. The receivables figure includes the £607k cap-to-rev transfer pending the

transaction being actioned by the DH in March and c£2m regarding outstanding CVs yet to be paid by the IWCCG.

Payables include significant accruals relating to winter resilience costs and Revolving Working Capital loan received in

month is included as an outstanding liability.

The planned asset values included an estimated price increase of 5% and this has now been updated in line

with the latest information received from the DV during their initial review of the estate and therefore forecast

values show a slight increase over plan. The revenue support loan of £1,735k is now included and liabilities are

based on the best available current information. Provisions have been split between current and non-currents,

based on the estimated timing of cash outflow. The PDC included in Taxpayers Equity has been reduced by the

£607k capital to revenue transfer.

Page 38


Capital

Year to Date Year End Forecast

Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

Strategic Capital 4,234 3,350 884 Strategic Capital 4,233 3,362 871

Operational Capital 3,776 2,378 1,398 Operational Capital 3,947 3,669 278

Total 8,010 5,727 2,283 Total 8,180 7,031 1,149

Strategic Capital Operational Capital Full Year

Plan Actual Variance Plan Forecast Plan Actual Variance Plan Forecast

Source of Funds £k £k £k £k £k Source of Funds £k £k £k £k £k

Strategic Funds C/F 0

External Funding 0 Initial Capital Resource Limit (based on Depn) 5,783 5,783 0 6,134 6,134

Finance Lease (MRI) 1,057 778 0 1,057 778

Capital Investment Loans 0 Capital to Revenue Transfer 0 0 0 0 (607)

Operational Capital 0 0 0 4,234 4,234 6,840 6,561 0 7,191 6,305

Donated Capital 0 Property Sales 750 526

0 0 0 4,234 4,234 Donated Funds 70 0 70 70 70

Other 169 0 169 169 169

Transfer to Strategic Capital (4,234) (4,234) 0 (4,233) (4,233)

2,845 2,327 239 3,947 2,837

Application of Funds Plan Actual Variance Plan ForecastVariance Risk Application of Funds Plan Actual Variance Plan ForecastVariance Risk

Strategic Capital Schemes £k £k £k £k £k £k Rating Operational Schemes £k £k £k £k £k £k Rating

MAU Extension 588 649 61 588 588 0 G Estates Schemes 491 515 (24) 534 767 (233) G

Ward Reconfiguration Level C 103 0 103 103 0 103 R IM&T RRP 500 155 345 500 273 227 G

Endoscopy Relocation 2,774 2,701 73 2,774 2,774 0 G MRI Upgrade - Finance Lease 1,057 778 279 1,057 778 279 G

Carbon Energy Fund 769 0 769 769 0 769 A Equipment RRP 882 623 259 882 987 (105) G

ICU/CCU 0 0 0 0 0 0 G Estates Staff Capitalisation 165 148 17 180 180 0 G

Contingency/Unallocated 555 0 555 555 169 386 G

Donated Assets 0 0 0 70 70 0 G

PARIS Implementation 126 42 84 169 84 85 G

Other (Non RRP, Equipment) 0 117 (117) 0 361 (361) G

4,234 3,350 884 4,233 3,362 871 3,776 2,378 1,398 3,947 3,669 278

NB - Please note the Year to Date and Full Year Plan figures are as per FIMS Return and not Capital Plan

February 16

Year to Date Full Year

The initial source of funds for 2015/16 was £8.18m, this included expected property sales of £750k which were delayed from 2014/15. The sale of Swanmore Road properties is expected to be completed on 15th March and the cash received will

contribute to the £607k capital to revenue transfer shown in the figures below. The variation of £1,149k in forecast spend against plan is mainly because Gables will not be sold within this financial year, the reduction in the actual MRI finance lease cost

of £279k (£1,057k plan less £778k actual) and the agreed capital to revenue transfer of £607k.

Strategic Capital schemes includes the larger capital projects.

The MAU Extension and the Endoscopy Relocation scheme have now been completed. The ICU/CCU project

from 2014/15 remains on hold and in Assets Under Construction in 2015/16, no further expenditure on this

project has been agreed as yet. The Ward Reconfiguration of Level C is still on hold with an expectation that

this scheme will form part of the capital programme in 2016/17. Similarly the phasing of the spend of the

funding for the Carbon Energy Fund project has also been changed and will now commence in 2016/17.

These two account for the variance in the actual spend compared to plan relating to Strategic Capital projects.

Slippage on several operational capital schemes e.g. the replacement ambulance contribute to the year to

date underspend.

Operational Capital - Projects from 2014/15 carried forward into 2015/16 are the Ambulance CAD Upgrade (Equipment RRP) and the

Sevenacres AntiClimb Roofing Installation (Estates Scheme), the latter of which is now complete.

The Upgrade to the MRI (Equipment RRP) has now been completed. Following the finalisation of the lease the MRI has been added to

the Trust's asset register at £778k, the net present value of the lease payments over the seven year lease term. This has produced a

variance against the plan of £1.057m of £249k which is not available for cash spend as this was an increase to our CRL at the start of the

financial year and so the CRL has been adjusted to reflect this variance.

The agreed capital to revenue transfer of £607k has been actioned and therefore the Trust's CRL reduced accordingly. The asscociated

cash transactions with the DH expected to occur during March.

With the exception of £169k still to be allocated in March, as at 29th February all other capital resources have been committed.

Year to Date Full Year Year to Date

Page 39


Governance Risk Rating

With effect from the September report, the GRR has been realigned to match the Risk Assessment Framework as required by 'Monitor'.

See 'Notes' for further detail of each of the below indicators

Ref Indicator Sub SectionsThresh-

old

Weight-

ing

Q1

2015/16

Q2

2015/16

Q3

2015/16Jan Feb Mar

Q4

2015/16Notes

1 90% 1.0 No No No No No No


3 92% 1.0 Yes No No No No No


Urgent GP referral for suspected cancer 85%

NHS Cancer Screening Service referral 90%

surgery 94%anti-cancer drug treatments 98%

radiotherapy 94%

7 96% 1.0 Yes Yes Yes Yes Yes Yes

All urgent referrals (cancer suspected) 93%For symptomatic breast patients (cancer

not initially suspected) 93%

Receiving follow-up contact within seven days of discharge 95%

Having formal review within 12 months 95%

10 95% 1.0 No No No Yes No No


Red 1 calls 75% 1.0 No No No No No No

Red 2 calls 75% 1.0 No No Yes Yes No No

13 95% 1.0 No No Yes Yes No No

14Early intervention in Psychosis (EIP): People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral

50% 1.0 - - - - - -

People with common mental health conditions referred to the IAPT programme

will be treated within 6 weeks of referral75% 1.0 No No No No Yes No

People with common mental health conditions referred to the IAPT programme

will be treated within 18 weeks of referral95% 1.0 Yes Yes Yes Yes Yes Yes

Is the Trust below the de minimus 12 Yes No No No No No

Is the Trust below the YTD ceiling 1 No No No No No No

17 ≤7.5% 1.0 No No No No No No


19 50% 1.0 Yes Yes Yes Yes Yes

20 N/A 1.0 Yes Yes Yes Yes Yes Yes

Referral to treatment information 50%Referral information 50%

Treatment activity information 50%

TOTAL 11.0 12.0 12.0 11.0 11.0 0.0 14.0

R R R R R R R

Out

com

es

16

21

Acc

ess

9 Care Programme Approach (CPA) patients, comprising:

8

Meeting commitment to serve new psychosis cases by early intervention teams

All cancers: 62-day wait for first treatment from:

Improving access to psychological therapies (IAPT)

6

Admissions to inpatients services had access to Crisis Resolution/Home Treatment teams

All cancers: 31-day wait from diagnosis to first treatment

Cancer: two week wait from referral to date first seen, comprising:

All cancers: 31-day wait for second or subsequent treatment, comprising:

1.0

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

Clostridium difficile – meeting the C. difficile objective

12

Minimising mental health delayed transfers of care

Mental health data completeness: identifiers

Mental health data completeness: outcomes for patients on CPA

1.0

15

Category A call – emergency response within 8 minutes, comprising:

Category A call – ambulance vehicle arrives within 19 minutes

Data completeness: community services, comprising:

No

No

No

Yes Yes

Yes Yes

Yes

No

YesNo

Yes

No

Yes Yes

No Yes

1.0 Yes

1.0 Yes Yes

1.0

No YesNo

No

No

February

Yes

No

GOVERNANCE RISK RATINGSInsert YES (target met in month), NO (not met in month) or N/A (as appropriate)

See separate rule for A&E

Historic Data Current Data

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge

5 No


1.0

No

Page 40

Isle of Wight NHS Trust Board Performance Report 2015/16February

Glossary of Terms

Terms and abbreviations used in this performance report

Quality & Performance and General terms QCE Quality Clinical ExcellenceAmbulance category A Immediately life threatening calls requiring ambulance attendance RCA Route Cause AnalysisBAF Board Assurance Framework RTT Referral to Treatment TimeCAHMS Child & Adolescent Mental Health Services SUS Secondary Uses ServiceCBU Clinical Business Unit TIA Transient Ischaemic Attack (also known as 'mini-stroke')CDS Commissioning Data Sets TDA Trust Development AuthorityCDI Clostridium Difficile Infection (Policy - part 13 of Infection Control booklet) VTE Venous Thrombo-Embolism CQC Care Quality Commission YTD Year To Date - the cumulative total for the financial year so farCQUIN Commissioning for Quality & InnovationDNA Did Not AttendDIPC Director of Infection Prevention and ControlEMH Earl Mountbatten Hospice Workforce and Finance termsFNOF Fractured Neck of Femur CIP Cost Improvement ProgrammeGI Gastro-Intestinal CoSRR Continuity of Service Risk RatingGOVCOM Governance Compliance CYE Current Year EffectHCAI Health Care Acquired Infection (used with regard to MRSA etc) EBITDA Earnings Before Interest, Taxes, Depreciation, AmortisationHoNOS Health of the Nation Outcome Scales ESR Electronic Staff RosterHRG4 Healthcare Resource Grouping used in SUS FTE Full Time EquivalentHV Health Visitor HR Human Resources (department)IP In Patient (An admitted patient, overnight or daycase) I&E Income and ExpenditureJAC The specialist computerised prescription system used on the wards NCA Non Contact ActivityKLOE Key Line of Enquiry RRP Rolling Replacement ProgrammeKPI Key Performance Indicator PDC Public Dividend CapitalLOS Length of stay PPE Property, Plant & EquipmentMRI Magnetic Resonance Imaging R&D Research & DevelopmentMRSA Methicillin-resistant Staphylococcus Aureus (bacterium) SIP Staff in PostNG Nasogastric (tube from nose into stomach usually for feeding) SLA Service Level AgreementOP Out Patient (A patient attending for a scheduled appointment)OPARU Out Patient Appointments & Records UnitPAAU Pre-Assessment UnitPAS Patient Administration System - the main computer recording system usedPALS Patient Advice & Liaison Service now renamed but still dealing with complaints/concernsPATEXP Patient Experience PATSAF Patient SafetyPEO Patient Experience Officer - updated name for PALS officerPPIs Proton Pump Inhibitors (Pharmacy term)PIDS Performance Information Decision Support (team)Provisional Raw data not yet validated to remove permitted exclusions (such as patient choice to delay)

Page 41



ON 6th April 2016

Title Chief Operating Officers Report including Winter Resilience Plan


Shaun Stacey, Chief Operating Officer

Author(s) Sarah Hayward, Head of Performance

Purpose To receive the monthly update on delivery against the Winter Resilience Plan


Receive X Approve








Quality Governance Committee Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: None due to regular monthly update Executive Summary & Analysis:

The Trust’s Winter Resilience Programme is currently delivering interdependent system wide capacity and activity to improve patient flow for our non elective and elective patients to enable them to receive their treatment in the right place at the right time. This improved patient flow will also contribute to the achievement of key national performance standards including ambulance, emergency care and referral to treatment. Delivery of this Programme is monitored weekly against activity and financial plans both internally within the Trust and jointly through the System Resilience Group (SRG) structure. Three monthly updates have been previously provided to Trust Board in December 2015 and February and March 2016, and this report is the next update on progress for Trust Board’s information; a final report will be provided at May’s Board meeting.


The Board is recommended to receive this update for information.

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Attached Appendices & Background papers None For following sections – please indicate as appropriate:


Excellent patient care

Working with others to keep improving our services

A positive experience for patients, service users and staff Principal Risks (BAF)


Date: 30 March 2016 Completed by: Sarah Hayward, Head of Performance

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TRUST BOARD REPORT WINTER RESILIENCE MONTHLY UPDATE

March 2016 1. SITUATION

The Trust’s Winter Resilience Programme is currently delivering interdependent system wide capacity and activity to improve patient flow for our non elective and elective patients to enable them to receive their treatment in the right place at the right time. This improved patient flow will also contribute to the achievement of key national performance standards including ambulance, emergency care and referral to treatment. Delivery of this Programme is monitored weekly against activity and financial plans both internally within the Trust and jointly through the System Resilience Group (SRG) structure. Three monthly updates have been previously provided to Trust Board in December 2015 and February and March 2016, and this report is the next update on progress for Trust Board’s information; a final report will be provided at May’s Board meeting.

2. BACKGROUND

On 7 October 2015 the Trust Board approved the recommended preferred option to provide additional non elective and elective capacity required to deliver performance for the remainder of the year in emergency and elective care, whilst acknowledging a financial risk of £1.5m.

3. ASSESSMENT

Non Elective and Elective Capacity

The Winter Resilience Programme includes the following provision, with the current status reported against each: · acute medical capacity – Appley Ward opened in October 2015 providing 21 beds. 6

contingency beds opened following the Christmas and New Year period due to an increase in medical activity and these are still required. Actions in place to increase medical reviews and discharges to return to normal bed capacity levels continue and this is monitored within the daily patient flow meetings;

· reinstatement of non elective surgical capacity – Whippingham Ward has returned to its intended use, however, medical activity within this capacity has continued to be present, with the increase in January continuing and with contingency beds being opened. Increased reviews and discharges are also in place to reduce the contingency capacity required and return the ward to delivering its intended surgical activity;

· ringfencing elective capacity – both ring fenced elective wards continue to see non elective patients on the Wards; similarly, actions are in place to review these patients ensuring timely discharges to enable this capacity to be solely dedicated to elective activity going forward;

· opening step down medical capacity off site (including ‘safe haven beds’) – The average bed occupancy for Poppy Unit since 11 October 2015 to 29 March is 92%; further quality performance information is shown below; and,

· additional flexible capacity to enable unexpected events to be managed as required – identified contingency beds are currently in use.

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Progress against the above key objectives within the Winter Resilience Programme continues to be monitored regularly through the SRG structure and reported in the regular updates of the joint Isle of Wight System Resilience Improvement Plan 2015/2016. Longer term resilience post March 2016 has been being prioritised by the SRG to ensure appropriate and timely focus, alongside the elective and non elective capacity plans for 2016/17. As stated, quality performance information is available for Poppy Unit and some of this is provided here. This information is monitored within the Medicine Clinical Business Unit as well as reported weekly within the Winter Resilience reporting and discussed within the weekly SRG sub group meetings with the Clinical Commissioning Group (CCG). Poppy Unit – Daily bed occupancy as at 29 March 2016:

Alongside monitoring the quality performance information of Appley and Poppy Wards, patient satisfaction surveys continued to be undertaken in addition to the existing national Friends and Family Test to ensure further monitoring of patients’ experience during this period of concentrated elective activity. Unfortunately, the response rate has remained very low, however, the detail within is reassuring. This information is currently being shared with our clinical wards teams for review and agreeing actions in response for implementation. Patient Satisfaction Surveys – Elective Wards, week ending 24 March 2016

Delivery of the Winter Resilience Programme is detailed against the following key milestones and are monitored and discussed within the Trust’s Programme Governance Office

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framework, as well as the SRG’s weekly sub group meeting with the CCG. Progress against the key milestones is reported below. Winter Resilience Programme - Progress against key milestones as at 24 March 2016:

The Surgical Assessment Unit’s IT System requires investment to enable ward view of patients and this is currently awaiting Executive decision to inform the subsequent business case. The Medical outlier standard operating procedures (SOP) is to be completed by 30 April utilising best practice from other Trusts. With regards to the Oncology Bed Base, the Appley Ward location milestone is subject to alternative locations currently being discussed and will be resolved shortly.

Non Elective Activity

Ambulance - Ambulance performance had been achieving against the three key national targets (Red 1 and Red 2, both within 8mins, and 19mins) however since January 2016 it has been dependent on patient flow within the Accident & Emergency Department, and is subject to frailty in the low volume call numbers. The Ambulance Service continues to be focused on achieving all targets and continues to grow its first responder community scheme to enable sufficient resources going forward to meet this challenge. The Service will continue to closely monitor the figures in line with performance on a daily basis and additional resources will be applied to each day where need is identified to ensure we meet the standards required.

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Ambulance Service 3 Main Performance Targets – as at week ending 27 March 2016

The above performance has been strongly influenced by the escalation to black alert at both system and hospital level over 8 days during March 2016. This was managed jointly with our system partners and as per the required actions within the Trust’s Escalation plan. This achieved an improved position, however, it was difficult to sustain this with the Easter weekend also falling in month and the demands such a holiday period brings. This was anticipated and significantly mitigated with the system wide Easter Plan in place.

Emergency Care 4hr Standard – Performance against the Emergency Care 4hr Standard (ECS) showed an initial improvement following the implementation of the Winter Resilience Programme in November 2015, however, not to the level planned, nor was it sustained due to a number of different reasons, as previously reported to Trust Board. In particular, performance in March was also impacted heavily by black alert as discussed above. It is forecast that improved performance will be achieved through the implementation of the ED action plan, in particular the implementation of the ambulatory care model, and will have a positive impact on improved patient flow and an improvement in related performance (Ambulance, 4 & 12hr ECS breaches, improved length of stay and discharges). However, it continues to be subject to patient flow within the hospital and into the community and, as part of the performance monitoring may require further revision.

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Emergency Care 4hr Standard – Actual vs. Trajectory as at 20 March 2016:

Elective Activity The Trust Plan to deliver elective admitted activity, following the Summer period where this

was very limited due to system wide pressures, commenced on 19 October 2015. The Plan aimed to treat the increasing backlog of patients who had been waiting longer than 18weeks for their operation by the end of March 2016. The impact of this inpatient and day case activity is measured by our performance against the ‘admitted’ part of the national ‘incomplete’ standard; the ‘non admitted’ part measures the outpatient part of the patient’s pathway. The information graph below shows our performance for non-admitted patients against our recovery trajectory as at week ending 27 March 2016. The non-admitted incomplete is 94.6% against a trajectory of 98.2%, impacted by current under delivery within the gastroenterology specialty; discussions are currently being held and actions developed to address this position and outcomes will be shared within the SRG structure.

Non Admitted Incomplete Performance against Revised Trajectory as at w/e 27 March 2016

The next graph below shows our performance for admitted patients against recovery trajectory as at 27 March 2016; the admitted incomplete is 72.5%, against trajectory of

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78.0%. The following table shows the breakdown of those percentages as waiting list sizes at specialty level. Admitted Incomplete Performance against Revised Trajectory as at w/e 27 March 2016

Total incomplete performance is 88.9% as at week ending 27 March 2016 against a trajectory of 92.61%.

Treatment provided at specialty level within the Trust Plan and the assumed income from this activity is shown below, split out into inpatient and day case activity. Whilst this performance is below Trust plan activity levels, it is good progress for our patients to be able to treated through the ring fencing of the elective capacity.

Delivering Admitted Activity Trust Plan (19/10/15 - 20/03/16)

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As with non elective activity, the above elective activity was impacted significantly with black alert during March leading to the cancellation of routine operations, whilst maintaining a focus on cancer and urgent operations. GP Referrals – The Trust has seen a varying reduction at specialty level in GP referrals as illustrated in the below tables; this will continue to be closely monitored during the year.

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Work continues with the Clinical Commissioning Group to ensure that patient choice is available to all and that it is correctly and appropriately informed with clear waiting times information, alongside clear quality outcome information. Cancer 62day target – Below is the cancer performance position as at 27 March 2016; February’s performance is subject to national validation and reporting by tertiary providers who the Trust delivers a joint pathway with and any subsequent breaches incurred. Urgent and suspected cancer activity has increased in Urology and, combined with the clinician vacancy issues, has continued to impact upon this specialty’s contribution to the Trust’s ability to achieve the cancer 62day target. Cancer Performance against national targets as at 27 March 2016

Financial Plan Contract variations for the additional winter resilience support have now been issued for the financial year.

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The costs pressures associated with the cost of contingency beds which have been opened throughout the financial year due to bed pressures are unsupported by the CCG (approx. £801k Oct to Mar forecast and £269k for April to Sept). Poppy Unit After 25 weeks, the variance against approved spend is £9k underspent, with a breakeven forecast at 31st March 2016. This current position does not take into account the use of contingency beds or the potential 17 patients in Acute beds at the start of the project when Poppy first opened at 13 beds (approx. £138k). Appley Ward The position is reflecting an underspend in 25 weeks and forecast outturn. However, the contingency bed costs have not been taken into account against this spend, and when combined they result in a forecast overspend of £151k. Theatres The project is currently £322k underspent against the plan in 25 weeks, with a forecast of £620k underspent at the end of the financial year, based upon the same trajectory.

Demand & Capacity Planning and Trajectories 2016/17 As part of both national and the Trust’s own business planning cycle, work is being finalised on the demand and capacity plans for 2016/17 and this will be included in the Operating Plan 2016/17 which the Trust Board is receiving under separate cover.

4. RECOMMENDATION

The Board is asked to receive this update for information. 30 March 2016


ON 6 APRIL 2016

Title Non Consolidation of Charitable Funds 2015/16 Accounts


Chris Palmer, Executive Director of Financial & Human Resources

Author(s) Katie Parrott, Senior Financial Accountant

Purpose To approve decision NOT to consolidate Charitable Fund accounts in 2015-16 Trust accounts.


Receive Approve X





Audit and Corporate Risk Committee 09/02/16 Approved

Charitable Funds Committee 15/03/16 Approved Finance, Investment, Information & Workforce Committee


Quality Governance Committee Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: Executive Summary & Analysis: Consolidation of charitable funds was required for the first time in the 2013/14 accounts. The decision whether to consolidate or not is based on materiality and on this basis, it was agreed last year not to consolidate Charitable Funds within the 2014-15 IOW NHS Trust Annual Accounts. Materiality is assessed annually and will vary depending on the NHS organisation’s accounts as well as the NHS Charity’s accounts. It will encompass both qualitative and quantitative aspects. This will often be a percentage (1 or 2%) of income, expenditure, assets or liabilities. Materiality will need to be considered on an ongoing basis, for example recognising that a successful campaign or legacy could change the financial position of the charity significantly from one year to the next. At 31 March 2015 IOW NHS Trust Charitable Funds had income of £162k, expenditure of £274k with a closing balance of £649k. Year to date figures for 2015-16 consist of income of £356k, expenditure of £328k with a closing balance of £677k and this is not expected to change significantly between now and the year end. Based on 1% of the Trust’s annual income of c£170m this does not result in a material figure. Although legacies are received on a reasonably regular basis, the maximum received to date is in the region of £200k which would still not affect materiality. Should much larger legacies be received in

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future years, the resulting position would be discussed with External Audit to agree if consolidation is required at that point. Based on this information both the Audit & Corporate Risk Committee and the Charitable Funds Committee have approved the decision not to consolidate the Charitable Fund Accounts into the Trust 2015/16 accounts.

Recommendation to the Board: The Board is recommended to approve the decision that Charitable Funds are not consolidated within the 2015-16 IOW NHS Trust Annual Accounts.

Attached Appendices & Background papers For following sections – please indicate as appropriate:


Goal: Cost effective, sustainable services Priority: Ensure value for money for each service Goal: Work with others to keep improving our services Priority: Make every service the best it can be. Goal: A positive experience for patients, service users and staff. Priority: Improve what people think of their care

Improve how staff feel about work Principal Risks (BAF) Finance


Compliance with Charity Commission & Department of Health Guidelines

Date: 29/03/16 Completed by: Katie Parrott, Senior Financial Accountant


PAPERS TO FOLLOW

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QGC MINUTES 29TH MARCH 16

PAPERS TO FOLLOW

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FIIWC MINUTES 29TH MARCH 16

Trust Board Convened as

Corporate Trustee for the following

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CHARITABLE FUNDS COMMITTEE

Minutes of the meeting of the Charitable Funds Committee held on the 15th March 2016 at 3.00 p.m. in the School of Health Sciences, St. Mary’s Hospital, Newport. PRESENT Nina Moorman Non Executive Director (Chair) Gary Edgson Deputy Director of Finance (DDF) Deputising for

the Executive Director of Financial & HR Dennis Ford Patient Council Representative Lesley Myland Friends of St. Mary’s Mark Price Company Secretary (CS) Deputising for the

Executive Director for Transformation & Integration

In Attendance Katie Parrott Senior Financial Accountant (SFA) Karrie Kennedy Financial Accountant Item 15/C015b Mark Elmore Deputy Director of Human Resources Item 15/C15b Donna Baker Head of Practice Education Item 15/C15c Mark Isaacson Hotel Services Manager Item 15/C15c/d Derek Bampton Community Infection Prevention Item 15/C15e Barbara Gove GMS IT Business Manager Item 15/C15f Jenny Honeyman Business Manager for Development & Training Minuted by Linda Mowle Corporate Governance Officer Min. No. Top Key Issues 16/C002 Quoracy: Meeting was not quorate. The Corporate Trustee to ratify all actions

and recommendations. 16/C003 Membership: Lesley Myland has replaced Vincent Thompson as the Friends

of St. Mary’s representative. 16/C007 Non Consolidation of Charitable Funds Annual Accounts: The Committee

agreed to recommend to the Trust Board that the 2015/16 Charitable Funds Accounts are not consolidated within the 2015/16 IOW NHS Trust Annual Accounts due to the level of materiality

16/C011; 16/C015

Approval of items over £15k: £56,266.72 from the Friends of St. Mary’s £25,541 – Funding for Apprenticeships & Work Experience: Future Careers Development Facilitator – provisionally approved £40,000 – Further Education Awards 2016/17 - approved

16/C001 APOLOGIES

Received from Katie Gray (Executive Director for Transformation & Integration), Jane Tabor (Non Executive Director), David King (Non Executive Director), Chris Palmer (Executive Director for Financial & Human Resources), Sarah Johnston (Deputy Director of Nursing) and Andy Hollebon (Head of Communications)

FOR PRESENTATION TO CORPORATE TRUSTEE ON 6 APRIL 2016

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Charitable Funds Committee 1 15 March 2016

16/C002 QUORACY The Chair confirmed that the meeting was not quorate. The Corporate Trustee to ratify all actions and recommendations. The minutes to be circulated to members for agreement.

16/C003 MEMBERSHIP The Chair, on behalf of the Committee, welcomed Lesley Myland to her first meeting of the Committee as the Friends of St. Mary’s representative and thanked Vincent Thompson for his input into the work of the Committee which was very much appreciated and wished him well for the future. The Committee also noted the resignation of Annie Hunter as Staff Representative (Fund Manager). The Chair, on behalf of the Committee, thanked Annie Hunter for her contribution to the work of the Committee.

16/C004 DECLARATIONS OF INTEREST Dennis Ford declared an interest in the bid for the Bioquell Machine as a relative of a member of staff. Mark Price and Mark Elmore declared an interest in the bid for funding for Apprenticeships and Work Experience (Future Careers Development Facilitator) as Chairman of the Island Innovation Trust and Deputy Chairman of the Governing Body of the Island Innovation Trust which runs Medina College, Carisbrooke College and the joint Sixth Form.

16/C005 MINUTES The minutes of the meeting held on the 15th December 2015 were agreed and signed by the Chair as a true record.

16/C006 MATTERS ARISING FROM PREVIOUS MEETINGS The Committee received the schedule of actions as follows: Min. No. 14/010 The Koan: Currently co-ordinating a date when the correct piece of equipment can be installed. Min. No. 14/053 Alignment of NICU and Barely Born Funds: Revised forecast date June 2016. Min. Nos. 14/071 & 15/C017 Friends of St. Mary’s Hospital Charity Lottery: Lesley Myland agreed to discuss the proposal with Andy Hollebon to ascertain the level of support for the Lottery and report back to the next meeting. Action: LM The Committee acknowledged the possibility that this action may not be taken forward and the action closed. Min. No. 15/C021 Charitable Funds Strategy 2014-2017/18 – Annual Plan: Revised forecast date June 2016. Action: DDF Min. No. Legacies Committed Funds – 5-6 Club & Long Service Awards: Agreed that an update be provided to the June 2016 meeting in order that the items are taken forward or closed. Action: CS/HCE Min. No. 15/C026 Staff Cultural Cook Book: No response had been received from Oliver Cramer to follow up email. Status – closed. Min. No. 15/C035 Guidance for Staff on Charitable and Fundraising Activities on IOW NHS Trust Premises: Revised forecast date June 2016. Min. No. 15/C041 Southampton Hospital Charity Leaflet: The feasibility of


hosting such events within the Trust – update to be provided to the June 2016 meeting. Action: SAC

16/C007 NON CONSOLIDATION OF CHARITABLE FUNDS ANNUAL ACCOUNTS The Committee agreed to recommend to the Trust Board that the 2015/16 Charitable Funds Accounts are not consolidated within the 2015/16 IOW NHS Trust Annual Accounts due to the level of materiality.

16/C008 HEALING ARTS The SFA updated the Committee on the Healing Arts Management Committee quarterly meeting held on the 21st January 2016, covering:

• Art Collection Activity • Capital % art schemes • Gardens maintenance • ‘Day by Day’ Older Persons and Artists Commission • Participative arts and arts on prescription • Exhibitions • National Alliance for Arts Health and Wellbeing

16/C009 FUND MANAGERS’ PROCEDURES The Committee received and agreed the updated Fund Managers’ Procedures and Summary Guidelines which incorporate new links to the intranet and the amended procedures for Infection Control, Medical Devices and Health & Safety approvals. Both documents have been uploaded to the Charitable Funds intranet page and emailed to Fund Managers. The Committee noted that these documents will be reviewed on an annual basis.

16/C010 FUND MANAGERS’ EXPENDITURE PLANS 2016/17 The SFA advised that at the beginning of the new financial year in April 2016 all Fund Managers will be asked to update their plans for 2016/17. Updated plans will be presented to the June 2016 meeting. Action: SFA

16/C011 BALANCES, INCOME AND EXPENDITURE The SFA reported on the current income, balances and expenditure for the period November 2015 to January 2016. The Committee noted that at the end of February 2016 the committed balance for the General Fund was £75,792.98. The donation of £56,266.72 from the Friends of St. Mary’s Hospital in respect of the 2015/16 bids was noted for approval by the Corporate Trustee.

Action: Chair 16/C012 ACKNOWLEDGEMENT LETTERS TO MAJOR DONORS

The SFA advised there had been no major donors since the last meeting. The Chair to continue signing acknowledgement letters.

16/C013 PAXMAN SCALP COOLERS – MAINTENANCE AGREEMENT 2016-2019 The SFA updated the Committee on the donation of £34k received in 2010 for the Chemotherapy Unit from ‘Walk the Walk’ charity for the purchase of Paxman scalp coolers/hair loss prevention systems including servicing and maintenance for 5 years. The Committee noted that the period has now expired and the charity has offered further funding of £6,867 to cover servicing, maintenance and training for the next 3 years (£2,289 per year). This would provide 2 training visits per


annum, an annual service on the 3 PSC-1 systems and any breakdown cover which may be required during this time. The formal ‘Deed of Gift’ agreement which both Chemotherapy and Finance will sign in order to proceed with the arrangement is awaited. The Committee confirmed its agreement to the further funding of £6,867 from ‘Walk the Walk’ Charity. The SFA to advise the Committee when the formal ‘Deed of Gift’ agreement has been signed. Action: SFA

16/C014 LEGACIES UPDATE The SFA presented the update on the status of unspent legacies as at 31st January 2016 and advised the Fund Managers for each of the 3 restricted legacies. With regard to the Fund Manager for Intensive Care, it was noted that Louise Webb retires at the end of March 2016. The Committee requested that the SFA follow up a replacement Fund Manager and advise the Committee accordingly. Action: SFA

16/C015 REQUESTS FOR CONSIDERATION The following bids from the General Fund were considered in accordance with the Charity Commission Guidelines and agreed that approved items were an enhancement for patients and staff: a) Cancer Research Projects: Deferred as additional information requested has not yet been submitted. b) Funding for Apprenticeships and Work Experience: Job Description for a Future Careers Development Facilitator submitted - £25,541 provisionally approved. It was recommended that HR pursue whether funding from My Life A Full Life and the CCG would be available, as the work of the post could be beneficial to primary/social care and the health sector as a whole. In the meantime, Charitable Funds will ensure the £25k is kept available whilst this line of enquiry is pursued. The bid to be re-assessed at June 2016 meeting.

Action: DDHR/SFA c) Bioquell Machine - £30,716: Not approved. It was considered that this item was part of ‘core services’ and as such should be from revenue/capital, and despite further information provided regarding consumables there was still concern around the additional costs to be incurred. d) Stop ‘n’ Wash Mobile Sinks:

• Reception - £3,300: not approved. It was felt that the unit for main reception would be too labour intensive to maintain, bearing in mind the amount of visitors to the hospital.

• Mobile Training based in Education Centre - £3,300: approved. e) Sostenuto Software for IT Department - £22,284: Not approved Although the Committee understood the benefits of implementation, it was felt that such a high cost could not be fully justified from Charitable Funds. f) Further Education Awards 2016/17 - £50,000: Approved £40,000 towards 90% funding individual fees for staff. If there is a shortfall, a bid to be presented to the June 2016 meeting. Lower amount approved based on funding available. Noted that there is also approximately £2,500 to be returned unspent from last year’s funding. g) Healing Arts:

• 2016/17 CAR Gardens Maintenance Contract - £4,962: Approved.


• Contract to re-create the ‘Incest & Child Abuse Survivors’ Commemorative Garden - £3,994: Not approved. Guy Eades to clarify further the importance of the project being carried out.

• Stroke Unit Garden - £1,750: Approved £875 being 50% with 50% from Stroke Unit Fund.

The total amount approved was £74,478, leaving a balance of £1,314.98 unspent in the General Fund. Bids previously agreed by e-mail: Careers Fair Funding - £6,223 approved 13/02/16 Waste Bins for Children’s Ward - £2,474.91 approved 50% funding of £4,949.82 with 50% from Children’s Ward Fund

16/C016 FEEDBACK ON FUNDING: GREEN INNOVATION FUND FOR TRANSPORT – END OF PROJECT REPORT The Committee received for information the End of Project Report prepared by Charles Joly, Environmental, Waste & Sustainability Manager. The Committee noted that in December 2015 a bid to the value of £2,938.80 was approved from the General Fund to upgrade bike shelter facilities at various locations around the St. Mary’s Hospital site. This also formed part of a grant bid to IOW Green Innovation Fund for Transport which brought the Trust further revenue to conduct a range of staff engagement activities during January 2016 on the theme of sustainable travel. The Committee acknowledged the success of the project. With regard to staff who do not have a car parking space, the Chair asked whether a ‘cash incentive’ could be made. The DDF to investigate and report back. Action: DDF The Chair to email Charles Joly to congratulate him on the successful outcome of the project. Action: Chair (Post meeting note:. The Chair emailed Charles Joly on the 16 March 2016)

16/C017 E-BULLETIN ITEMS The following items to be included in E-Bulletin in order to promote the work of Charitable Funds, funding for

• Further Education Awards 2016/17 • Stop ‘n’ Wash Mobile Sink • Gardens maintenance • Stroke Unit garden Action: SFA

16/C018 DATES OF 2016 MEETINGS Meetings to be held at 3.00 – 5.00 p.m. 21 June – Lesley Myland’s apologies 20 September 20 December

Signed: …………………………………………….. Dated: CHAIR


Documents

Trust Board Papers - iow.nhs.uk