Weston Area Health NHS Trust

February 2015

Section 1 Executive Summary

January and February have been a challenging period across the organisation, this has in the main been due to the prolonged period of Norovirus within the Trust which has caused the closure of a number of wards for periods since September 2014. The Director of Infection, Prevention & Control has been closely involved in the decision making during these outbreaks, ensuring the Trust meets, or goes beyond, national guidance in re-opening affected areas.

These outbreaks have unavoidably caused a reduction in discharges and difficulties with patient flow, as a result during January additional bed capacity was opened to assist in providing safe clinical care during a particular period of escalation in the New Year. Our staff have worked extremely hard during what has been a challenging few months and we thank them for their co-operation and dedication. Over the escalation periods the Trust have worked closely with partners across the health community and acknowledges the support provided by North Somerset CCG, North Somerset Community Partnership, North Somerset Council and the Hospice, who all worked flexibly to provide additional support during this time.

In January we welcomed eight new registered nurses to the Trust who have joined us from Italy as part of our European recruitment drive; these staff will be joined by seven further overseas nurses in March.

A project to refurbish the main theatres at the hospital was approved during January; this £2.2 million project will run over the current and next financial years and will bring the environment within the four main theatres to modern standards. Work to some areas has begun on site with the major construction work being completed from May to November 2015.

The Trust remains on track to deliver its savings plan during for 2014/15 and achievement of the quality CQUINS are forecast to be delivered at 97%. The Trust has also reported an improved financial position for this year with a reduction in the overall deficit of

£0.95 million.

1.0 Monitor Scorecard

1.1

1

1.2 Summary Scorecard

· Data Reported in arrears

Section 2 Quality & Patient Safety

· The number of complaints received in December and January equates to 2.8% of all inpatients over these months or 0.25% against all activity

· In December, the Department of Health confirmed that the Net Promoter score would no longer be used as the headline measure, and instead the percentage of respondents who would or wouldn’t recommend the service would be highlighted. During January the Emergency Department scored very favourably with 95% saying they would recommend the services.

· Confirmed outbreaks of Norovirus had a major operational impact on the Trust throughout December and the majority of January; this was compounded by the unprecedented demand on Trust services during this period.

· Additional beds were deployed in December and January for winter resilience planning and to re-provide beds closed due to Norovirus outbreaks. With an associated increase in temporary staff, quality and safety were more closely monitored to minimise any impact on patient experience and outcomes.

continues on falls prevention with an increase noted in August and September. Staff education regarding falls prevention remains an ongoing commitment and all nursing staff on wards where significant harm is a result of a fall will receive a letter of recommendations to follow. SWARM has been reinvigorated on Kewstoke ward, and the outcome is reflected in the reduction of patient falls in that area. As a result, Hutton and Uphill wards have been invited to complete SWARM documents

In September the Trust improved performance and achieved the national target of 95% with 97.2% of appropriate patients receiving a VTE risk assessment.

The management of complaints across the Trust has recently undergone a period of change brought into effect by the Director of Nursing to improve patient experience. The Trust is currently trialling a process where concerns are sent to the relevant area with a 48 hour resolution time.

2.1. Patient Story

An incident was reported by staff that a patient had become aggressive, paranoid and wishing to leave the ward. On leaving the ward staff followed the patient and requested that security attend the front of the hospital. In the car park opposite the hospital the patient took an aggressive stance towards the security guards. At this time staff were joined by a policeman who during the struggle, to restrain the patient for his own safety, used his taser. Further police assistance was requested and the patient was returned to the ward wearing handcuffs. The patient attempted to run to the internal door of Uphill ward where he was restrained on the floor by four policemen. Due to the nature of the incident the Trust reported the incident as a “Serious Incident Requiring Investigation”.

A complaint was also received from the patient’s wife raising concerns she had with the care the patient had received in Weston Area Healthcare Trust. The complaint details that the patient had an emergency operation to remove his bowel on the 24th November due to ulcerative colitis. Following surgery the patient was taken to recovery and not taken back to the ward until the afternoon of the 25th November. On visiting the patient the wife explains that he seemed quite pleased that the operation had been completed and was looking forward to being pain free.

The wife then explains that she received a call the next morning to inform her that her husband had become agitated and could she attend the ward. On arrival to the ward and waiting for the patient to be treated the wife was informed by staff that the patient was refusing treatment and could she help in making him co-operate. She was informed that this was her decision but staff would appreciate if she could help. The wife then details that when she saw her husband for the first time she was shocked as he was covered in blood and surrounded by so many people. She states that “how would you like to see your loved one surrounded by 2 Security Guards, 2 Police Officers, Doctors and 2 Nurses”.

The wife then explains that she was advised by a staff member that the events of the day were most probably caused by the withdrawal of the steroid medication her husband was taking. He had been prior to his hospital admission on a week’s course of steroid tablets (6 a day for a week) with a plan of reducing the dosage over 10 days. Since his admission he was also on steroids up until the operation.

The wife then details that the implications of the events have been enormous for the family and her husband now has to live with the fact that he went into hospital to sort his ulcerative colitis, which led to unexpected major surgery and an admission to a mental health ward. Her husband has not only got to recover from the physical aspects of bowel surgery but now has the added worries of mental health issues and he is very negative about having the operation reversed in 12 months especially if it means he will end up on a mental health ward. The wife concludes that “It has certainly been a most unpleasant and traumatic experience for him and one he will never forget unfortunately and neither will she”.

ACTION TAKEN

The incident/complaint has been thoroughly investigated through both the serious incident process and the complaints process. The Executive Medical Director and Director of Nursing are scheduled to meet with the wife at a being open meeting in March 2015. The implications for practice from this incident are that Irritable Bowel Disease patients needing surgery require joint care (Surgical and Medical) and the time prior to surgery should be used to gain a holistic view of the patient and this then transmitted to the Surgical Team to aid in post-operative management.

2.2 Registration with Care Quality Commission (CQC)

The Trust is compliant with all five of the CQC’s essential core standards of:

1. Treating people with respect and involving them in their care

2. Providing care, treatment and support the meets people’s needs

3. Caring for people safely and protecting them from harm

4. Staffing

5. Quality & suitability of management

The essential standards of quality and safety set by the CQC government body are central to our work as a Trust. The July 2014 Intelligent Monitoring Report, produced by the Care Quality Commission, places the Trust in priority banding 6 for inspection, with a banding of 1 being high priority for inspection and 6 being low priority for inspection, based on analysis of a number of quality and safety measures.

Quarterly monitoring of Trust compliance with CQC standards occurs via reporting to our Quality & Governance Committee.

The CQC inspection of the Trust, scheduled for 6th January 2015, has been postponed due to the closure of three wards at the Trust due to infection outbreak.  The CQC continued to hold their listening event on the 5th January 2015 and have provisionally advised a rescheduled visit date of 19th May 2015.

2.3 Nursing Metrics

The use of agency nurses increased in December 2014 and January 2015 due to the opening of an additional 20 beds on Cheddar Ward for winter capacity planning and the need to open further escalation beds on Stroke Unit and Ashcombe Unit.

The Registered Nurse and overall nursing numbers for Berrow, Uphill and Kewstoke Wards were less than the planned establishment to reflect lower nursing numbers required for a reduced number of patients on these wards due to Norovirus outbreaks.

There were a total of three Nurse staffing incidents reported through Datix in December 2014 and January 2015. One incident related to a period of high escalation for the Trust with two further patients requiring artificial ventilation in addition to the five patients already in ITU; this required the Critical Care Outreach Nurse to care for these patients. The two other incidents were reported for the Surgical Assessment Unit/Clinical Decision Unit on two separate days a week apart, with insufficient temporary staffing cover arranged for the ward. The Ward Sisters and Matrons are meeting daily to review deficits and reallocate staff to ensure patient safety. The Ward Sister of SAU/CDU has also worked clinically within the nursing numbers to ensure the safety of the ward during this period.

NHS England is defining methodology to RAG rate nursing metrics data on NHS Choices. Trusts will be assigned to a rating based on:

· Staff sickness rate (taken from Electronic Staff Record)

· The proportion of mandatory training completed (taken from the national staff survey)

· Completion of an appraisal in the last 12 months (taken from the national staff survey)

· Staff views on staffing (taken from the national staff survey)

· Patient views on staffing (taken from the national patient survey)

A draft composite indicator has been shared in confidence with NHS Trusts in February 2015 with publication on NHS Choices in spring 2015 (date yet to be announced).

Figure 1:

NB. Agency (WTE) and Statutory Mandatory Training Compliance as above encompass nurse staffing Trust-wide

Figure 2: December 2014

Figure 3: January 2015

2.4 Incident Reporting

Incident reporting systems and policies are integral to patient safety and enable the Trust to analyse the type, frequency and severity of incidents that occur. The Trust’s open and honest reporting demonstrates a commitment to our patients and their safety. The information arising from these reports is used to make active changes to improve our provision of quality care and to safeguard the wellbeing of our staff and patients.

Figure 4 depicts the number of patient incidents reported each month, compared to previous years.

Figure 4:

Since August 2014 the reporting of incidents within the Trust has remained fairly stable, with the number of reported incidents fluctuating between 350 to 400 per month. There were a total of 718 patient incidents reported in December/January, 354 in December and 364 in January and the top 3 themes of incidents were pressure ulcers, falls and medication. There is an increase in incidents reported under a) Pressure Ulcers (both community and hospital acquired), 221 compared to 181 for October/November and b) Slips, trips and falls, 115 compared to 93 for October/November.

On closer inspection:

· The increase in the pressure ulcer reported incidents has been due to the number of community acquired pressure ulcers the Trust has reported. This has increased from a 142 in October/November to 174 in December /January.

· The increase in the number of falls has been due to there being more reported falls from a height, bed or chair (31 compared to 26) and suspected falls (11 compared to 6). On closer inspection the Stroke unit has reported 18 falls for December/January compared to 6 in October/November. On a positive note all of the incidents were reported with no or low harm.

A total of 218 pressure sores were reported in December and January (total number of community and hospital acquired), accounting for 31% of all patient incidents. The Trust reported 47 hospital acquired pressure sores, which is an increase of 8 from October/November. The Trust reported 7 hospital reported grade 3 and 4 pressure ulcers. All relevant external organisations were notified in December/January and a full investigation was commenced.

115 slips, trips, falls & collisions were reported in December and January, which is slightly up on the numbers reported in October and November (93). Kewstoke (18), Stroke unit (18), Harptree (13) and Uphill reported the highest number of falls incidents. 1 fall was reported as moderate harm due to the patient sustaining a fractured neck of femur (a full investigation was undertaken).

87 medication incidents were reported in December/January, slightly up from 75 in October/November. These errors included administration (meaning medication administered orally or intravenously) from a clinical area (such as ward areas), medication error during the prescription process and preparation of medicines/dispensing in pharmacy. Further review of incidents revealed no identified theme.

Further detail on actions to address falls, pressure ulcers and medication errors is outlined in the Harm Free Care Report.

2.4.1 Staff Incidents

The Trust Health and Safety Committee reviews incident trends and receives reports on incidents reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995. Figure 5 depicts the number of staff incidents reported each month, compared to previous years.

Figure 5:

There were 34 staff incidents reported in December and 47 incidents reported in January; a total of 81. Incidents reported involving abuse of staff has decreased again with 20 incidents reported in December/January. During December and January the Trust has seen an increase in reported staff incidents around adverse events that affect levels of staffing on the wards, an increase to 25 from 20 for October/November and Staff falls with an increase to 15 from 11 for October/November.

2.4.2 Serious Incidents (SIRIs)

A Serious Incident is defined in the http://www.england.nhs.uk/ourwork/patientsafety/ (2013) as an incident that occurred in relation to NHS-funded services and care resulting in: 

· Unexpected or avoidable death of one or more patients, staff, visitors, or members of the public.

· Serious harm to one or more patients, staff, visitors, or members of the public or when the outcome requires life saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm).

· A scenario that prevents or threatens to prevent a provider organisations ability to continue to deliver healthcare services, for example, acute or potential loss of personal/organisational information, damage to property, reputation or the environment, IT failure or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population.

· Allegations of abuse

· Adverse media coverage or public concern about the organisation or the wider NHS.

· One of the core set of Never Events

Figure 6 depicts the number of serious incidents reported by the Trust

Figure 6:

Resultant investigation reports are reviewed by the local Clinical Commissioning Group and, for the most serious cases, also reviewed by the NHS Trust Development Authority. Between the 1st December and 31st January 12 serious incidents.

The 12 investigations are classified as follows:

Category

Grade 1

Grade 2

Operational (e.g. unit closure)

2

0

Adverse media attention

0

0

Information Governance (e.g. loss of data)

0

0

Clinical Care of patient (e.g. pressure ulcer, delayed diagnosis, avoidable severe harm)

10

0

Safeguarding (e.g. allegation of abuse)

0

0

Avoidable severe harm to staff

0

0

2.5 Patient Feedback

2.5.1 Complaints

Complaints management is critical to ensuring the Trust not only responds to the complainant in a timely manner, but to ensure the learning from complaints is translated into action. Complaints data enables the Trust to determine if there are any trends in subject matter, location or personnel. Figure 7 portrays that the total number of complaints received in December 2014 and January 2015 as 39. The number of complaints received equates to 3.0% of all inpatients over this period or 0.29% against all activity. (This is against inpatient activity of 1,283, Emergency Department attendance of 3601, Outpatient Department attendance of 7,597 and Day case activity of 960).

Figure 7:

2014

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Complaints

16

22

38

15

27

23

23

20

5

15

12

16

PALS

111

114

107

102

91

100

97

140

166

140

111

107

Compliments

83

137

153

106

84

60

89

84

103

152

180

189

2015

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Complaints

23

PALS

101

Compliments

118*

*At the time of writing this report, there have been 118 compliments logged for January. The full figure will be available in next month’s report.

Figure 8:

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Jan

Complaint Response rates 2014

Planned Care

72%

40%

33%

38%

55%

69%

33%

89%

85%

100%

40%

75%

83%

Emergency

82%

63%

42%

25%

85%

100%

75%

92%

85%

66%

85%

66%

90%

Overall response rate

77%

50%

36%

37%

73%

88%

48%

82%

90%

80%

50%

73%

88%

Figure 9:

The number of days taken to resolve complaints that were closed in December and January

0 - 30

31 - 60

61 - 89

90 plus

Re-opened

Planned Care Division

7

2

0

0

1

Emergency Division

2

3

0

0

1

Facilities

2

0

0

0

0

The Trust aims to provide a full response to all complainants within 30 working days. The response time for complaints as shown in Figure 8 demonstrates the commitment of the Trust to resolve complaints in a timely manner. The response rate of 73% in December and 88% in January achieved by the Trust, met the 80% standard required in January only.

The Heads of Nursing regularly meets with the Team to discuss target dates. This enables the complaints team to keep complainants up to date and provide reasons should there be a delay to their response. There have been 5 cases that have taken longer than the Trust target of 30 days. In each case the complainant was kept informed of the delay.

There were 6 complaints linked to safety incidents in December and January. During this period the Trust has received 3 requests of further information relating to complaints already raised. One complainant has contacted the Trust to raise concern that the subject of a previous complaint has reoccurred. The concern relates to a Do Not Attempt Resuscitation instruction, this is currently being investigated by the Head of Nursing for the Emergency Division as a new complaint.

All complainants are offered the opportunity to meet with relevant staff should they wish. Five complaint resolution meetings were held during December and January resulting in satisfactory resolution for the complainant. Should complainants remain unsatisfied with the final response from the Trust, and all options for internal resolution have been exhausted, complainants are advised of the option to refer their complaint to the Complaints Ombudsman. One new complaint was referred to the Complaints Ombudsman in January.

Complaints Themes

Figure 10:

a) Medical treatment - was a significant theme for complaints in January however the number for December was significantly lower than the previous 8 months. 19 out of a total of 39 complaints mentioned medical treatment. It should be noted that 2 out of the 4 complaints received by the Orthopaedic team related to care in 2012 and 2013. Further concerns raised include:

· Patient did not feel that appropriate investigations were undertaken before discharge

· Full drug list was not taken on admission

· Undiagnosed fracture was discovered 3 weeks after admission

· Consultant dismissed patient in pain as being anxious

The Executive Medical Director has taken a proactive role in the management of complaints since coming into post in April 2014. With effect from 1st December more detailed information is being provided to doctors by the Complaints Team with the aim of enabling the doctors to provide a more patient focused and timely response.

b) Communication - The number of concerns raised linked to communication through December and January has remained consistent with the previous 2 months and remains high. 17 out of a total of 39 complaints mentioned communication. ED received the highest number of complaints linked to communication which is consistent with previous months.

The complaints Manager has delivered a session for Junior Doctors to discuss emerging themes and how best to resolve or prevent these complaints. The issues that Doctors have raised with the Complaints Manager are as follows; lack of space on wards for Doctors to work at a computer, on call Doctors asked to speak with relatives of patients of whom they may not know the background, nurses do not appear to be making appointments with Consultants to discuss concerns with families, no smart card reader in the Doctor’s mess. The issues are being reviewed by the Matron for Patient Safety and the Medical Education Coordinator for the Trust.

2.5.2 Patient Advice & Liaison Service

The total number of cases dealt with by the team in December and January was 208. The top 4 themes were Appointments, Care, Communication and Information.

Information was the highest theme across the Divisions with 52 out of 208 cases requiring information. Appointment was the highest theme within the Planned Care Division with 22 PALS cases. Lengthy wait remains the highest sub-theme and is consistent with previous months. Other sub-themes for Appointment are Cancelled by Hospital, Change Appointment and Texting.

The care of patients was another main theme for the Trust; 17 out of 208 cases. The subthemes for Care were evenly split between Nursing Care and Medical Care with 8 and 7 respectively. A PALS awareness session is now being delivered on the preceptorship training for newly qualified nurses.

As with formal complaints, communication was a significant theme over the past two months; 37 out of 208 cases. The cases highlighted communication concerns both with nursing and medical staff across varied areas with ED receiving the highest number of PALS related to Communication. The PALS department is working closely with the Matron and newly appointed ED Lead Consultant and to ensure they are made aware of all the concerns being raised.

An action plan has been developed by the Complaints Manager in partnership with Heads of Nursing to focus learning on the main themes identified from complaints and concerns; Medical Treatment, Communication and Communication linked to Medication. This action plan will be monitored by Heads of Nursing through the Divisional Governance process. The action plan will be updated and shared with the Quality and Governance Committee every three months.

2.5.3 Compliments

The number of compliments received in December was 189. At the time of writing this report January has received 118 compliments, though this figure is incomplete.

Wards are continuing to focus on gathering patient feedback and it is hoped that reviewing the exit cards weekly will encourage staff to make sure patients are given the opportunity to provide feedback before leaving the hospital. The Compliments formally recorded are received via email or letter. Figure 11 depicts three examples of compliments received by the Trust in December and January. Where appropriate each compliment receives a letter to thank the individual for taking time to comment.

Figure 11:

COMPLIMENTS

A thank you from the relative of a patient treated in the Endoscopy Suite

Throughout his 3-hour stay, the discomfort of the procedure was significantly eased by the wonderfully caring and professional staff. Waiting during the procedure, I was helped and supported by the reception staff.

Every time I met a member of staff in the hospital corridors, they took time to ask if I needed help, where I was going, etc.

We are both really impressed with Weston General Hospital, and would like to thank everyone who helped us today.

A thank you from a patient treated in AEC and Radiology

I would just like to thank all your teams at the hospital today; I needed to attend the AEC department. I first went to have a ultrasound were the whole team were very helpful and caring, I then had a bit if a wait in your very busy AEC department were everyone was very cheerful and attentive, everyone was working as hard as they could and a really nice touch was that a nurse noticed that there was a build up of people waiting for results etc, she went off and brought back a tea trolley and handed out teas and Christmas cake, and a few sandwiches for some older patients what a hero, I needed to go to x Ray and needed to be portered, again the porters and the girls in x Ray were all great, under such pressure as you are under at this time of year it's fantastic to see such a customer focused team. My thanks to you all keep up the great work.

A thank you from a recently bereaved relative

This extremely difficult time was made bearable by the outstanding care and support of the staff on the unit. Under very difficult circumstances with extra beds on the ward the staff offered care that was second to none. I am sorry but I can't remember the names but the without exception we were met with kindness and understanding, nothing was too much effort. He was kept comfortable and his dignity respected. The family were supported, given cups of tea and kindness which helped and relieved the pressure on us. Thank you from the bottom of my heart, Without the support of the night staff this difficult day would have been much harder. Your staff are amazing!

2.6 Patient Feedback

As a national requirement Weston Area Health NHS Trust is engaging in the delivery of the Friends and Family Test (FFT). This test has been implemented successfully across all areas. The Friends and Family Test is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. 

The FFT is offered to all patients at the point of discharge and when patients attend the Emergency Department.

In December, the Department of Health released a statement that confirmed the Net Promoter score would no longer be used as the headline measure, and instead the percentage of respondents who would or wouldn’t recommend the service would be highlighted. This is a positive move in more accurately reflecting patient and visitor’s experience.

Each Division and all wards receive a breakdown of the outcome of their survey results to ensure they can take relevant action to sustain improvements already made and proactively develop actions to deliver further improvement. Figure 12 provides a detailed report of December’s Friends & Family Test results, whilst Figure 13 shows January’s breakdown.

Figure 12:

Figure 13:

Emergency Care should be praised for an increase in the percentage of people who would recommend and a decrease in the percentage of people who wouldn’t recommend in January.

Both Acute Ward and Emergency Care are achieving the National CQUIN standard in maintaining or increasing response rates.

Monthly meetings are being set up to allow leads for Exit Cards from all areas to network and share ideas and best practice.

“Mobile boxes” exist in some areas but are being standardised to give a recognisable “brand” and greater visibility for FFT. Trust volunteers are helping with this.

2.7 Mortality Data

Mortality data remains overall within expected limits. Further details on mortality review and actions is included in the Harm Free Care report.

2.8 Infection Prevention and Control Performance

Clostridium Difficile

Weston Area Health NHS Trust has a local threshold of 17 hospital attributable cases of Clostridium difficile for the financial year 2014/15. Prevention of avoidable hospital attributed cases continues to be high on the agenda for the Infection Prevention and Control Team. To date there have been 18 cases of hospitable attributed Clostridium difficile reported; 5 of those cases have been associated with a lapse in care, for example, inappropriate antibiotic prescribing. The remaining 13 cases have been scrutinised and assessed as unavoidable.

One case of hospital attributable Clostridium difficile was reported in December and four in January. A root cause analysis meeting and thorough investigation into each case has been undertaken involving both the medical and nursing staff on the respective clinical areas. Three of the January cases were reported on the same day; all had been/were inpatients on Kewstoke ward. A period of increased incidence was declared at this time; subsequent ribotyping results showed no evidence of cross transmission or a link between cases.

MRSA/MSSA Bacteraemia

The Trust has a zero trajectory for MRSA bacteraemia and has reported two cases in the financial year 2014/15. No cases were reported in December 2014 or January 2015.

No cases of MSSA bacteraemia were reported in December 2014; one case was reported in January 2015. The Trust has reported a total of eight cases for 2014/2015 against our trajectory of three cases. A rapid improvement plan is being implemented to urgently address concerns around cannula care, standard infection control precautions and isolation practice. A programme of ward based training in Aseptic Non-Touch Technique (ANTT) with competency assessment is due to be launched. A policy to support this practice will be completed by the end of February 2015.

Outbreaks

Confirmed outbreaks of Norovirus had a major operational impact on the Trust throughout December and the majority of January; this was compounded by the unprecedented demand on Trust services during this period.

There were seven confirmed outbreaks of Norovirus in December and one in January. The outbreaks were located in Harptree, Kewstoke (x2), Uphill (x2), Berrow (x2) and Cheddar wards. Analysis of these outbreaks has demonstrated that the Trust was operating within the national Norovirus prevention and management guidelines. A post-outbreak review has highlighted the following areas for further improvement:

· Quality of documentation

· Analysis of airflows in wards

· Closure of whole ward as opposed to bays

Ebola Virus Disease (EVD)

The EVD working group continues to meet twice a month and is responsible for ensuring that the Trust is as prepared as possible for a case of EVD. The Viral Haemorrhagic Fever policy has been updated as changes to guidance have been released by Public Health England. Operation Diamond - a planned exercise to test our preparedness in the Emergency Department was undertaken in December. The exercise proved very successful and generated some key learning to enable our processes to be improved. Further exercises are planned. The majority of staff within the Emergency Department have now had specific training in the donning and doffing of Personal Protective Equipment (PPE) at the level required for EVD cases.

2.9 Maternity

The maternity team achieved variable results in both its national targets for initiating breastfeeding in-hospital and mothers not smoking at the time of delivery in December and January. The Matron would highlight again that the data does not give a true picture of the achievements of the service, and has suggested that additional data including all women booked for antenatal care be considered.  

The referrals to the Stop Smoking Service have increased again following communication to staff from the Matron after the dip in November 2014.

The closure of the Birth Centre for 3 days, and the restricted beds for a further 7 days in January, as escalation due to intense service pressure, has impacted on the birth numbers and the availability of inpatient postnatal care. Three women are known to have been redirected for labour care, and there may be others who did not contact ABC in labour as they knew of the closure.

An unknown number of women were unable to be admitted to ABC for postnatal care and feeding support. This impacted on the bed availability for Maternity care at UHBristol, and staff with contracts across both Trusts were redeployed on 3 of the days. The Head of Midwifery estimates that there may have been up to 5 women per day who would have been able to be admitted to ABC for postnatal care from UHBristol.

The total births in 2015-16 to the end of January are 194. Projected births for the year are therefore 233, compared to 237 actual births in the year 2013-14. If the redirected women are taken into account the projected number would be almost identical to 2013-14. This is an improvement from previous years where there has been an ongoing reduction in births.  

The Matron plans to produce some additional patient information from the updated NICE Intrapartum Care guideline which supports uncomplicated women giving birth at freestanding midwife-led units.  

Maternity bookings for women living in the area covered by the service are comparable to last year, with 1499 bookings in 2013-14, and projected bookings for 2014-15 at 1520.

2.10 Venous Thrombo-Embolism (VTE)

VTE risk assessment compliance is achieving the required standard. Further information on VTE prevention and management is outlined in the Harm Free Care report.

Section 3 Operational Performance

3.1 Executive Summary Headlines

· Performance against the four hour ED target has fallen to 91.8% during January 2015, with a year to date position of 92.9%

· Delays in ambulance handovers have increased significantly

· Length of stay has increased to 3.0 days

· All eight cancer targets were achieved in December for the first time in over twelve months (reported in arrears)

· The 18 week referral to treatment and 6 week diagnostic targets remain consistent in achievement

3.2 Operational Performance

The following sections detail the Trust performance against a number of key indicators. The report is divided into:

· Clinical Indicators

· Clinical Pathways

· Emergency Access

· Elective Access

· Patient Flow

3.3 Clinical Indicators3.3.1 Emergency Readmissions

An emergency readmission is defined as an unplanned readmission within an identified time of leaving the hospital. The ideal readmission rate is zero however this is not always possible as patients can have multiple co-morbidities or long-term conditions which require frequent medical attention.

Monitoring emergency readmission rates is important to the Trust as it can help to prevent or reduce unplanned readmissions to hospital.

The Trust monitors emergency readmissions within 14 days and 30 days. As illustrated in Figure 14, performance of readmissions within 14 and 30 days continued to improve in December and January, and the Trust have noted the lowest readmission percentages in twelve months, over the last quarter.

Figure 14:

Trust Action:

To provide additional assurance that emergency readmissions are not related to the original episode of care, the Emergency & Urgent Care Division are undertaking regular audits of the readmissions to provide assurance that patients are not being readmitted as a result of the Trusts treatment and care.

3.3.2 Average Length of Stay

The average length of stay (ALOS) refers to the average number of days that patients spend in hospital. The Trust strives to have a length of stay below the Trust target as it demonstrates proactive planning of the whole process of care, as well as active discharge planning. In December and January the average LOS increased to 3.0 days which reflects the higher acuity levels of patients.

Figure 15:

The Trust also monitors the percentage of patients with a length of stay (LOS) over 10 days. The programme of work to improve patient pathways and the level of care alongside the focus on the Green to Go list has enabled the Trust to work to a reduction plan in the percentage of patients with a LOS over 10 days.

Figure 16:

Trust Action:

In addition to the work streams already underway as part of the Trust’s business plan, the operational teams are focussing on optimising the ward board rounds. A ward board round takes place twice during the day and is where the multi-disciplinary clinical teams review each of the patient in detail using the rounding tool. This will ensure that throughout the patients stay all necessary actions are undertaken on time and in line with the clinical pathway for the patient. Each ward has also been allocated a senior manager to support the teams to deliver and unblock any difficulties that arise.

Daily monitoring of delays to discharge takes place at ward level with any barriers to a timely discharge being escalated through the divisions. It is important that work to reduce length of stay is linked with feedback from patient complaints and surveys; therefore a discharge work stream is being established which will be responsible for both progressing timeliness and quality of discharge.

3.4 Clinical Pathways

This section sets out performance indicators related to key clinical pathways, including cancer and stroke.

3.4.1 Cancer Services

The Trust strives to achieve the national cancer waiting times as they are important to patients clinical outcomes, are a measure of how the Trust is responding to demands for services, and highlights where there are delays in the system. In December the Trust achieved all of the eight national cancer targets for the first time in over twelve months.

3.4.2 Cancer Two Week Wait

The two week wait target was achieved in both November and December with a score of 97.9% and 98% respectively. This was matched by the Breast Symptomatic two week wait target, which also achieved above 93% for November and met the quarter three target.

3.4.3 Day Target

The Trust achieved all three of the 31 day targets in November and December and achieved Quarter Three, demonstrating the Trusts ability to effectively treat patients once diagnosed with cancer.

3.4.4 Day Target

The Trust achieved the 62 days standard for December and in fact, Quarter three, which is a significant improvement for the Trust. The Trust did not meet the 62 Day Upgrade standard during the same period. The 62 Day standards are fragile owing to the numbers of complex pathways to neighbouring tertiary centres however the Trust continues to work with these centres to achieve the targets. The Trust is pleased to note that the 62 Day Upgrade standard was met in December.

Trust Action:

Daily monitoring of performance by the MDT Coordinator and cancer team leader.

Weekly monitoring at the Waiting List Forward Planning meeting.

Close liaison with tertiary centres to streamline patient pathways to ensure timely referral and treatment.

Work with primary care to develop information to be provided to patients to improve the availability of patients for appointment.

3.4.5 Stroke

The Trust achieved the stroke target of patients diagnosed with a stroke spending 90% of their time on the Stroke Unit in December and January (Figure 17).

The Trust continues to focus on patient flow and bedding patients in the most appropriate place.

Figure 17:

Trust Action:

The patient flow team have been instructed to create and keep a stroke hot bed for both sex’s available at all times. This will ensure that patients diagnosed with a Stroke or TIA in the Emergency Department can be transferred straight to the unit to start their care and treatment.

Use of the hot bed during times of escalation and/or outbreak must be with Executive approval only.

During January, there was an unprecedented number of Stroke patients admitted. In order to best care for these patients, six additional beds were opened on the Stroke Unit.

3.5 Emergency Access

3.5.1 Emergency Department (ED) Performance

The NHS constitution set the national standard wherein 95% of all patients attending NHS Emergency Department’s spend a maximum of four hours in the department before being discharged, referred/transferred to other services or admitted to the hospital and transferred to an inpatient bed. The target was not achieved in December (90.41%) or in January (91.83%) as illustrated in Figure 18. This as a result of two key factors:

1. Outbreaks of Norovirus and increased length of stays causing issues with patient flow throughout the Trust.

2. Throughout December and January the Trust has been experiencing not only an increase in activity out of hours but a pattern of activity arriving together causing peaks, which put significant pressure on the Emergency Department. This activity is a mixture of both walk-in patients and ambulance arrivals.

Figure 18:

Trust Action:

· The Trust has undertaken a detailed review of internal and external performance and activity data to understand the causes behind the sudden drop in performance. The review has been shared with key staff internal and external to the Trust to support the development and implementation of the necessary actions to bring about positive change.

· North Somerset CCG has increased the daily calls from three to five days per week to ensure that performance across the health and social care system is reviewed in detail to ensure all capacity is maximised to manage patients the most effective and caring manner.

· Trust has increased the number of site meetings throughout the day and increased the seniority of attendance, particularly when the Trust is in red escalation to ensure appropriate actions are taken and barriers escalated both internally and externally.

· A programme of work within the Emergency Department to bring about closer working with colleagues in Acute Medicine to support the department together with the introduction of Rapid Assessment and Treatment.

· Opening hours of the Ambulatory Emergency Centre have been extended to help assist with peaks in demand.

· Additional senior nurse cover has been put in place over the weekends to ensure more senior support.

3.6 Elective Access

This section reviews the key elective access targets to understand the effectiveness and the quality of care throughout the elective care pathways.

3.6.1 Referral to Treatment (RTT)

The NHS constitution states that patients have the legal right to start their NHS consultant-led treatment within a maximum of 18 weeks from referral, unless the patient chooses to wait longer or it is clinically appropriate to wait longer. For the months of October and November the following sub-sections will review the Trust performance against the three national 18 week targets.

3.6.2 Referral to Treatment (RTT) Admitted

The Trust achieved the admitted 18 week target in December and January at 95.57% and 95.51%.

Figure 19:

Trust Action:

The Trust continues to undertake weekly waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed by the Divisional Manager of Planned Care, Access Manager and Theatre Manager with the Director of Operations in attendance.

3.6.3 Referral to Treatment (RTT) Non-Admitted

The Trust continued to achieve the non-admitted target in December and January as illustrated in Figure 20.

Figure 20:

Trust Action:

The Trust will continue to undertake waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed on a weekly basis.

As a result of some patient cancellations during January due to a lack of beds, additional theatre sessions will be organised to ensure delivery into the new financial year.

3.6.4 Referral to Treatment (RTT) Incomplete

The 92% target was achieved for December and January as illustrated in Figure 21. This was expected according to plan. The Trust has undertaken a rigorous validation of its waiting list supported by a team from the Trust Development Authority, this has driven new algorithms to be put in place to ensure the current validated waiting list position maintains at a manageable level on an ongoing basis.

Figure 21:

Trust Action:

The Trust will continue to undertake waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed on a weekly basis.

3.6.5 Choose and Book

The Trust achieved the 96% National target for Choose and Book slots in December and January. This is depicted in Figure 22.

Figure 22:

Trust Action:

Work is ongoing to continue to maintain the 96% requirement now it has been achieved and met for the last two months by:

Review of capacity and demand required, particularly as we have experienced a continued increase in two week wait referrals resulting in choose and book slots being used to provide additional urgent appointments

Work with neighbouring Trusts who provide some visiting services where capacity fails to match demand leading to no slots being available for patients.

3.7 Patient Flow

To support the delivery of key operational targets, it is vital that the Trust has good patient flow. An important aspect of ensuring good patient flow is the level of discharges throughout the day and at the weekend.

3.7.1 Delayed Transfer of Care

A delayed transfer of care is defined as when a patient is ready for transfer from acute care, but is still occupying an acute bed. Patients can be delayed for the following reasons:

· Further assessment required before their discharge destination can be decided

· Lack of capacity in local nursing/residential homes

· They may require a specialist placement

· Patient or their family/carer needs more time to make a decision about a long-term placement

The Trust monitors performance daily against delayed transfers of care as high levels can have a big impact on the daily numbers of discharges, causing delays in allocating beds for emergency admissions or planned operations. Performance in December improved at 0.80% then dipped again during January (Figure 23). There is still considerable work to undertaken with partner organisations and the use of the ‘Green to Go’ list.

Figure 23:

Trust Action:

The Trust continues to work with health and social care partners in North Somerset to manage the ‘Green to Go’ list, and where gaps in services are discovered, work with the Clinical Commissioning Group to identify how future commissioning can be organised to close these gaps, providing higher quality joined up care between all partners.

Agencies and other care providers are invited in regularly to assess patients, particularly those who may have complex needs with a view to discharging as soon as possible.

Daily Green to Go meetings held with all North Somerset organisations represented physically or by conference call.

Daily Alamac calls, which includes senior representatives from across the health community, addresses the performance indicators on a daily basis with escalation of particularly challenging areas as necessary.

3.7.2 Bed Stock

The Trust has a usual funded bed base of 234. As part of the winter ORCP, this funded base was increased from October 2014 – to March 2015 and allows a further 20 inpatient beds, currently located on Cheddar ward. There have been six unfunded beds in use consistently on the Stroke Unit during January.

During January, the Trust experienced periods of reduced flow and declared internal black escalation – this was the pattern for many Trusts across the region and indeed the UK. During this period, fourteen maternity beds were made available to medical admissions. All fourteen beds were returned back to maternity services within a fortnight.

Section 4 Workforce

4.1 Executive Summary Headlines

· The temporary staffing cost in December was 11.85% of the total pay bill compared to 12.74% in January.

· Sickness rates were 4.30% in December and decreased to 4.26% in January.

· The appraisal rate increased to 86.61% in December and increased further in January to 88.11%.

· The training compliance rate increased to 83.51% in December and slightly decreased to 83.11% in January.

4.2 Workforce

Figure 24 below shows the pay expenditure for contracted staff, for agency staff.

Figure 24:

Figure 25 shows the temporary staffing usage as a month on month comparator. Cost of temporary staff continues to be high, with there being particular pressure across the Trust during December and January, which resulted in unplanned usage of extra capacity, therefore increasing the temporary staffing requirements.

As previously reported the planned induction and orientation for overseas nurses commenced on 12th January 2015, with 8 new appointments starting employment. Local and national recruitment is ongoing with short listing and interviews taking place weekly. Whilst the volume of applicants is not at the level we would like these appointments help to reduce the number of vacancies in the Trust and maintain an effective nursing workforce.

Some progress has been made with medical recruitment with NHS appointments being made to two Consultant posts one in Upper GI and another in Gynaecology. However posts in Gastroenterology, Radiology and Community Paediatrics continue to be difficult to recruit to.

4.2.1Sickness

Sickness remains high although in December and January the sickness rates were lower when compared to the same two months last year. During January particularly short tern sickness has increased which is the main contributor to the Trust sickness, with high sickness in a small number of areas which impacts staffing in these operational areas.

Figure 26:

* Trust target ≤ 3.0%

4.2.2 Statutory/Mandatory Training

The training compliance rate increased to 83.51% in December and slightly decreased to 83.11% in January. Formal action is being taken against staff who remain non compliant with training.

4.2.3 Appraisal

The appraisal compliance rate was 86.61% in December and increased further in January to 88.11%. Appraisal compliance continues to be closely monitored, to ensure compliance is maintained and improved further.

4.2.4 Industrial Action

As part of the ongoing trade dispute between a number of NHS Unions and the government over a demand for fair pay for NHS workers employed under agenda for change terms and conditions. The Trade Unions followed the necessary procedures to ballot their members on two questions, these questions were:

· Are you prepared to take part in a strike?

· Are you prepared to take part in industrial actions short of strike?

Upon completion of these ballots the following Unions provided notice of their intention to take industrial action on 29th January 2015, followed by a period of discontinuous industrial action in the form of industrial action short of strike. The Unions involved included:

· Unite

· Unison

· Royal College of Midwifes

· Society of Radiographers

· GMB

Communications regarding the proposed action was shared with staff and managers, and the necessary contingency plans were put in place, although the projected impact on the Trust was minimal, which is consistent with the impact of previous industrial action taken by Trade Unions.

The evening before the strike, the Trade Unions cancelled the planned industrial action following a pay proposal by Jeremy Hunt (Secretary of State for Health). Details of these proposals are outlined below; however NHS Employers are currently working on how these may be implemented in practice.

· Abolition of the bottom point of AfC and increasing pay point 2 to £15,100. This means an increase of 5.6% for staff on point 1 and 3.1% for staff on pay point 2

· 1% consolidated pay rise for all staff up to point 42 from April 2015.

· A further consolidated pay rise of an additional £200 for staff on pay points 3-8. This means staff on these pay points will receive an increase between 2.1% and 2.3%

· An increment freeze in 2015/16 for staff on pay point 34 and above for one year only.

· Urgent talks to take place with a view to the proposed redundancy changes being implemented from 1 April 2015, including a floor for calculation of redundancy payments of £23,000 and a ceiling for calculation of £80,000 with an end to employer top up for early retirement on grounds of redundancy.

Staff have been informed of the proposals over pay and will be provided with further information as soon as the Trust is provided with further details.

4.2.5 Overseas Recruitment (Nursing)

Nurse recruitment is an ongoing challenge to ensure that the Trust sustains a stable and effective workforce by maintaining a low number of vacancies, therefore reducing the requirement for temporary workers.

Over the past year the Trust has recruited 22 nurses from overseas and plans to carry out a further overseas recruitment campaign in March. The Trust has made arrangements to hold a recruitment event in Spain, with the aim of recruiting up to 35 nurses. Whilst this is the intention, the European recruitment market is very competitive with many Trusts competing in the same area.

4.2.6 Library Services

Healthcare Library and Knowledge Services provide knowledge and evidence to support the delivery of excellent healthcare and the NHS Library Quality Assurance Framework England enables the robust quality assessment of healthcare library and knowledge services.

Weston’s Library Services have recently obtained a score of 98.94% against national quality standards and coupled with an award from Health Education England recognising good practice in introducing a ‘Roving Librarian’ service, the team are to be congratulated for their hard work and innovation.

4.2.7 Leadership Qualifications

The Trust has been notified that 13 of its managers have recently passed the Mary Seacole Postgraduate Certificate in Leadership offered through the NHS Leadership Academy. We are pleased to announce that of the 13 passes, 6 passed with merit. An award ceremony is being arranged through the Leadership Academy.

4.2.8 Apprenticeships

The Trust is keen to support the development of its Bands 1-4 workforce with 11 non-clinical staff recently signed up to complete an Apprenticeship with Weston College in either Business Administration, Customer Service or Team Leading. In addition, 9 clinical staff are in the process of registering for a Level 2 or 3 Diploma in Health and Social Care again delivered in conjunction with Weston College.

Section 5 - Finance Report

5.1 Executive Summary Headlines

· The financial position at Month 10 is that the Trust is reporting a year to-date deficit of £2,980k which is an improvement of £792k compared to the plan.

· Overall income is £1,369k over plan at the end of January.

· Overall expenditure is £585k over plan at the end of January.

· The Trusts plan for the year is a deficit budget of £4.95m. The Trust is forecasting the delivery of a £950k improvement from the planned position which would result in the deficit being reduced to £4m.

5.1.1 Statement of Comprehensive Income Position to Date

The financial position at Month 10 is that the Trust is reporting a £2,980k deficit which is an improvement of £792k from the plan.

Revenue from patient activity is £581k over plan for the 10 months to the end of January 2015. Other sources of income are £788k over plan.

Overall expenditure for pay, non pay and depreciation is £586k over plan for the 10 months to the end of January. Pay and non pay expenditure is £1,354k over plan and this is offset by £769k of reserves.

The Trust’s Service Improvement Programme (SIP) is below target by £418k with a year to date achievement of £3,238k against the target of £3,656k.

The adjusted run rate for expenditure has decreased by £162k in January when compared with the December level.

5.1.2 Statement of Comprehensive Income Position in Month

Income from patient care activity is £10k more than plan whilst other sources of income generated £211k more than plan.

Pay and non pay expenditure, including savings delivery, is £194k under plan for the month of January. This includes a one-off £256k benefit from a balance sheet review which was undertaken in month.

The Trust’s Service Improvement Programme (SIP) delivered £569k in January against a plan of £419k and is now £418k below target for the year to date an improvement of £150k compared with December.

5.1.3 Cash

The cash plan for 2014/15 is to hold a balance of £532k at 31st March 2015. The cash balance of £6,085k, as at 31st January, is £5,553k higher than the planned position of £532k.

The anticipated income and payment profiles have been forecast and updated until the end of the year on the cash flow which results in an increased yearend cash balance of £1,482k.

5.1.4 External Financing Limit

The Trust’s External Financing Limit will be achieved through the management of cash and working balances along with the planned level of Public Dividend Capital.

5.1.5 Capital Resource Limit

The capital resource limit is £3,858k and in addition to this the Trust is due to receive £124k matched funding from the NHS Safer Hospital, Safer Wards Technology Fund for the implementation of a new Order Communications system. Therefore the Trust’s anticipated forecast capital resource and spend on capital projects is £3,982k at 31st March 2015.

As at the 31st January the programme has delivered capital expenditure of £920k and this low level of spend significantly affects the cash balances reported in 5.1.3. The Trust will operate within its Capital Resource Limit and continued capital programme management will enable this to be achieved.

5.1.6 Capital Cost Absorption rate

The Trust’s Capital Cost Absorption (CCA) rate is fixed at 3.5% and this will be calculated based on 3.5% of actual balance sheet values at the end of the financial year.

5.1.7 Better Payment Practice Code (BPPC)

The Trust’s overall performance as at 31st January is 97.2% on the BPPC.

5.1.8 Forecast outturn

The Trust is forecasting the delivery of a financial position which reduces the deficit by £950k from the plan of £4,950k to £4,000k.

The current financial forecast outturn includes an overspend against pay budgets for the Medical and Nursing categories and a non pay overspend on drugs. The income has been forecast based on current referral patterns and activity levels. There are also significant favourable variances forecast against each of the sources of other operating income.

5.1.9 Risk to delivery of financial forecast against plan

The major financial risks are the delivery of the £4.5m savings programme, the management of Medical staffing to minimise locum agency expenditure, the higher than planned use of agency nursing staff, and the delivery of NHS service income in line with forecasts and with minimal contract penalties.

Financial Dashboards 2014/15: Month 10

5.2 The Income and Expenditure Position of the Trust

5.2.1 The financial position at Month 10 is a deficit of £2,980k, which is an improvement on the plan which is a deficit of £3,772k.

5.3 Expenditure

5.3.1 The main points are:

· The position is that overall the Trust has overspent the expenditure budgets by £1,354k which includes under delivery of Savings (SIP) of £418k. This has been offset with £769k from reserves.

· Pay expenditure is higher than budgeted with an overspend of £705k. The staff category with the highest overspend at the end of January was Nursing (£697k) followed by Medical Staff (£242k). These overspends were offset by underspends in the following categories Admin and Clerical (£262k), AHP’s (£215k) and Biomedical Scientists (£123k).

· Non pay expenditure is £649k over budget at the end of January, including the underachievement of savings. This is an improvement of £257k compared with December. There are overspends on Linen & Laundry (£118k), Medical & Surgical Equipment (£114k), Internal recharges (£108k), and NHS recharges (£63k) offset by underspends on Drugs (£214k), Blood Products (£92k), Training (£90k) and Catering (£59k).

· Bank and agency expenditure on Nursing increased in January with agency expenditure increasing to £236k from £228k in December, this included £97k expenditure on winter resilience projects. Bank expenditure increased from £174k in December to £239k in January, £84k of the expenditure was for winter projects.

· In recent months the Trust has had a significant number of Medical staff vacancies which has led to an increase in the use of Agency locums to cover the Trusts services; however some of these vacancies have now been filled. In November the Trust also increased its medical cover as part of the Operational Resilience and Capacity Planning (ORCP) Programme which has resulted in further Locum Medical Staffing being requested. In January £205k was spent, down from £226k in December. In January £66k of the expenditure was attributable to the ORCP project work. Some of this locum expenditure is offset by the medical staff vacancy savings of £129k.

5.3.2 At Month 10 the main points for the Divisional and Corporate performance

are as follows:

· The Emergency Division has overspent by £428k year to date, of which £8k was in month 10. Of this, Pay expenditure is overspent by £508k whilst Non Pay is underspent by £147k. There is SIP under delivery of £88k. The Pay overspend is mainly due to Medical Staffing (£382k), Uphill (£169k), ED (£118k), and Kewstoke (£82k), offset by an underspend on Pathology (£122k). The Non Pay underspend is due to a saving on drugs (£141k), Pharmacy (£40k) & Blood (£39k) offset by an overspend on Pathology (£129k).

· The Planned care Division has overspent by £1,054k year to date, an increase of £24k in January. The pay overspend is £301k whilst non pay is overspent by a further £268k. The divisional income is £216k above the planned level. The SIP underachievement is £701k. The pay overspend is in Theatres (£235k), Hutton (£142k) and SAU (£112k), offset by underspends in Planned Care Management (£88k), Hospital at Night (£43k), Medical Secretaries (£34k), Access Team (£33k) and Radiography (£25k). The non pay overspend is mainly on Theatres (£253k) with additional overspends in Radiology (£56k), Endoscopy (£25k) and ITU (£43k), offset by underspends on Radiography (£124k), PPU (£70k), Drugs (£23k), Blood (£19k) and GUM (£17k).

· The Estates and Facilities Division has underspent by £23k at the end of month 10 which is an improvement of £39k. The non pay is underspent by £2k which includes underspends against Residences (£19k) and Catering (£12k), offset by overspends on HSSU (£16k), Linen & Laundry (£11k) and Housekeeping (£10k).

· The Corporate Departments have underspent by £455k year to date.

Reserves have been deployed to cover spend where there are agreed allocations such as the cover of Medical agency premiums and agreed waiting list initiatives. Further monies have been made available to support the additional capacity for the Operational Resilience and Capacity Planning (ORCP) Programme.

5.3.3 The Trust’s expenditure run-rate information has been rebased to neutralise the effect on both expenditure and budgets for variations in monthly NICE funded drugs expenditure which has no overall impact on the Trust’s net financial position. There have also been some amendments for one-off exceptional items which include the impact of any work undertaken as part of the RTT project and the Operational Resilience and Capacity Planning Programme. The Trust’s expenditure run rate is shown in the table below compared to the adjusted expenditure level for each month.

The budgeted adjusted run rate for January is £7.664m. The adjusted expenditure run rate has decreased in January by £162k, from £7.933m in December 2014 to £7.771m in January 2015.

The main decreases in spend were Non Pay expenditure where Medical & Surgical Equipment reduced by (£88k), Clinical Supplies (£18k) and Estates Expenditure (£30k) offset by increases in Pay expenditure including Nursing (£71k) and Ancillary Staff (£14k).

5. 4 Savings Plans (SIP)

5.4.1 The Trust has a savings requirement of £4.5m for the year which represents 4.45% of expenditure budgets. Savings plans have delivered £3,238k against the profiled plan of £3,656k for the ten months, an under-delivery of £418k. Of the SIP savings delivered £2,027k is from recurrent schemes and £1,211k from non-recurrent schemes. In month the Trust delivered £569k against the £419k required, an overachievement of £150k in month. The Trust’s performance against its monthly SIP savings requirement is shown below along with the monthly phased plan.

The Trust will continue to take actions to ensure that the savings plans are implemented, with mitigating action taken where needed, to maximise the delivery of savings. Progress of individual schemes is reviewed at the monthly Business Plan Delivery Steering Group Meetings.

5.5 Activity and Income

5.5.1 Overall patient activity income is assessed at £581k over plan at the end of January 2015.

· Income related to North Somerset CCG contract is £189k over plan.

· Income related to the NHS Somerset contract is £84k over plan

· Other CCG patient care activities is £91k over plan

· The Specialist services contract is £310k over plan

· Local authorities is £15k over plan

· Private patients’ income is £111k under plan.

The actual activity for RTT catch up work is included in the respective elective day cases, inpatients, etc. in month 10 there has been an adjustment between Commissioners’ relating to Drugs which has accounted for the reduction in Specialist services and an increase in North Somerset CCG.

Significant volume variations in performance are shown in the table below:

5.5.2 The following table shows the overall activity for the period ended 31st January 2015:

5.6 CQUINS

5.6.1 The latest assessment of CQUINs is that the Trust is on target to receive most of the potential income, except for the Dementia (Find Assess Investigate and Refer) scheme. This will be monitored on a monthly basis.

5.7 Penalties

5.7.1 A provision of £227k for penalties for the period ending 31st January 2015 has been included for Referral to Treatment, Cancer access, waits and Ambulance handovers. The detailed assessment is shown in the table below. This will be updated as the validation of performance in these areas is finalised. It is expected that there will be no RTT penalties for July, August and September. It has been assumed in line with the CCG contract that the Emergency Department 4 & 12 hour penalty will be reinvested to help resolve the underlying performance issues and this has this has now been agreed with NSCCG.

Referral to Treatment penalty by specialty

5.8 Statement of Financial Position

5.8.1 The Trust’s main accounting statements are shown in the appendices of this report and see Appendix B for the Statement of Financial Position as at 31st January 2015.

Cash

5.8.2 The External Financing Limit will be achieved by in year management of cash and working balances. The cash balance of £6,085k, as at 31st January, is £5,553k higher than the planned position of £532k.

The difference between actual cash balance held £6,085k and the reported £4,978k on the Statement of Financial position relates to un-presented cheques and cash in transit as at 31st January 2015.

The forecast balance as at 31st March 2015 is £1,482k which will ensure that the Trust meets its requirement to remain within its External Financing Limit.

Debtors

5.8.3. The figures from the debtors system represent invoices raised for which cash has yet to be received. The total outstanding debt as at 31st January is £1,320k, which is divided between NHS £1,036k, Private Patients £102k and non NHS £182k. Debts over 250 days represent £62k which is 4.7% of the total debt.

Creditors

5.8.4 The measure for the better payment practice code is to pay all NHS and non-NHS trade creditors within 30 calendar days of receipt of goods or a valid invoice (whichever is later), unless other payment terms have been agreed. The compliance is for at least 95% of invoices to be paid (by the bank automated credit system or date and issue of a cheque) within thirty days, or within agreed contract terms. The year to date performance against the target is:

5.9 Capital Programme and Performance against Capital Resource Limit

5.9.1 The Trust will operate within its Capital Resource Limit and detailed capital programme management will enable the capital expenditure to be delivered within resources and the Trust’s cash plans for the year.

5.9.2As at 31st January 2015 there has been £920k of capital expenditure.

5.9.3The Capital Planning Committee continues to monitor the capital priorities and projects and the detail is included on Appendix D.

5.9.4 During February 2015 the Capital Planning Committee has approved further schemes in priority areas such as Estates Statutory Compliance and medical equipment to utilise available funding. Following the evaluation of the final tenders for the Theatre Refurbishment Project the total project cost for the revised scope is £2,218k which will be phased across three years as follows: 2014/15 £744k; 2015/16 £1,420k; 2016/17 £54k.

5.10 Foundation Trust Indicative Risk Rating

5.10.1 The Financial risk rating for the Trust, if operating as a Foundation Trust, as at the 31st January 2015 is a Level 1, and the liquidity ratio is 18.6 days which achieves a level 3.

5.10.2 The Continuity of Services risk metrics, if operating as a Foundation Trust, as at the 31st January 2015 is a Level 1.

5.10.3 The calculation for the Financial risk rating, after applying the over-riding rules, and for the Continuity of Services risk metrics, for the annual plan, year to date and forecast outturn for the Trust is a 1, which is a result of the Trust’s overall financial sustainability issues.

5.11 Recommendation

The Board is asked to note the Trust’s Month 10 financial performance for 2014/15 regarding the revenue, capital and cash positions.

Appendix A – Statement of Comprehensive Income – Accumulated Variances as at Month 10 – January 2015

Appendix B – Statement of Financial Position as at 31st January 2015

Appendix C - 12 Month statement of rolling cash flow

Appendix D - Capital Programme 31st January 2015

Staff Pay Bill

Contracted Staff Pay billJanFebMarAprMay JunJulAug SeptOctNovDecJan5165498452944948501250054984502550025015494650435040Agy/Bank/Locum Pay bill (000s)JanFebMarAprMay JunJulAug SeptOctNovDecJan651574620490511447550650728552600678736

Months

£000's

Bank and Agency Spend

Bank Nurses

61.49 WTE

76.10 WTE

81.33 WTE

53.20 WTE

47.67 WTE

48.56 WTE

47.34 WTE

51.33 WTE

78.97 WTE

47.57 WTE

39.31 WTE

49.38 WTE

61.50 WTE

48.56 WTE

81.33 WTE

JanFebMarApril MayJunJulAugSeptOctNovDecJan130.73499999999999154.92500000000001161.833123.43131.69129.5126.56141.22999999999999128.88000000000048121.01117.98119.05154.78Agency Nursing

15.30 WTE

31.32 WTE

41.41 WTE

17.17 WTE

22.13 WTE

6.54 WTE

17.60 WTE

27.87 WTE

29.23 WTE

29.66 WTE

29.88 WTE

33.60 WTE

31.44 WTE

6.54 WTE

41.41 WTE

JanFebMarApril MayJunJulAugSeptOctNovDecJan77.747000000000227144.798191.732105.69111.5844.67110.36180.47253.67198.73194.7159.52000000000001138.73999999999998Other AgencyJanFebMarApril MayJunJulAugSeptOctNovDecJan5.8745.8439999999999948.20000000000000118.530000000000001123.3419.4323.3917.889.050000000000000712.7713.926.69Medical Agency

10.66 WTE

5.81 WTE

3.19 WTE

13.63 WTE

13.78 WTE

12.65 WTE

11.98 WTE

15.68 WTE

13.76 WTE

12.49 WTE

9.63 WTE

8.14 WTE

8.55 WTE

12.65 WTE

7.19 WTE

JanFebMarApril MayJunJulAugSeptOctNovDecJan142.99116.10112253.58249.88000000000048250.23999999999998292.39304.3328.45223.45000000000007197.51159.88000000000048138.72Winter

17.21 WTE

13.94 WTE

12.10 WTE

10.43 WTE

21.82 WTE

24.33 WTE

JanFebMarApril MayJunJulAugSeptOctNovDecJan288.77099999999905149.721181.036000000088.06225.73277.98999999999899

Months

£000's

Sickness Absence Rates

Jan 13 - Jan 14JanFeb MarAprMayJunJulAugSepOctNovDecJan4.7600000000000003E-24.3400000000000001E-24.0000000000000022E-23.670000000000001E-23.0000000000000002E-23.1100000000000006E-23.1000000000000052E-23.4700000000000002E-24.0599999999999997E-23.7300000000000041E-23.9000000000000014E-24.3199999999999995E-24.3900000000000002E-2Jan 14 - Jan 15JanFeb MarAprMayJunJulAugSepOctNovDecJan4.3900000000000002E-24.3400000000000001E-24.1800000000000004E-23.9300000000000002E-24.2600000000000013E-23.8800000000000001E-24.5300000000000014E-24.36E-24.5200000000000004E-24.3900000000000002E-24.1199999999999987E-24.3000000000000003E-24.2600000000000013E-2Nat Avg Jan 14 - Oct 14JanFeb MarAprMayJunJulAugSepOctNovDecJan4.5300000000000014E-24.3800000000000013E-24.1199999999999987E-24.0400000000000012E-23.9300000000000002E-24.0300000000000023E-24.1700000000000001E-23.9000000000000014E-24.0700000000000014E-24.3299999999999998E-2

Level 1 Financial

IndicatorCalculation

Annual

Target

14/15

Plan /

TargetActual

Traffic

Light

Variance

from Target

Plan /

TargetActual

Traffic

Light

Variance

from Target

Plan /

TargetActual

Traffic

Light

Variance

from Target

Forecast

Outturn

Actual

Forecast

Outturn

Traffic Light

Financial duties

Cumulative

Bottom line

Statement of

Comprehensive

Income

Bottom line

Statement of

Comprehensive

Income against plan

Surplus/ (Deficit)

before impairments-4950

-2596-2596Green0-3254-3254Green0-3772-2980Green792-4000Green

In month

Bottom line

Statement of

Comprehensive

Income

Bottom line

Statement of

Comprehensive

Income against plan

Surplus/ (Deficit)

before impairments-4950

4545Green0-658-658Green0-518274Green792-510Green

Cumulative

Achievement of

External Financing

Limit

Cash available

against planned cash

available532

423385Green334318975312Green34155323456Green2924532Green

Cumulative

Achievement of

Capital Resource

Limit

Capital Expenditure

against plan3982

433433Green0619619Green0920920Green03982Green

Subsidiary duties

Cumulative

Capital cost

absorption rate3.50%

3.50%Green3.50%Green3.50%Green3.50%Green

Cumulative

Better Payment

Practice Code

Year to date

performance against

the prompt payment

policy for Combined

NHS & Non-NHS

suppliers (by number)

95.0%95.0%97.1%Green2.1%95.0%97.2%Green2.2%95.0%97.2%Green2.2%95.0%Green

January 2015December 2014November 2014

Annual

Plan

YTD

Plan

YTD

Actual

YTD

VarianceVariance

£,000£,000£,000£,000%

Day cases

8,0876,7147,1514376.5%

Elective Inpatients

5,7624,7655,2334689.8%

RTT income

2892890(289)

Non Elective Inpatients

26,92722,37122,053(318)-1.4%

Non Elective Excess Bed days

1,6161,3391,101(238)-17.8%

Emergency pathway reconfiguration

00501501

Excess Bed Days

7461218157257.4%

First Outpatients

5,4484,6044,290(314)-6.8%

Follow up Outpatients

5,0054,1954,129(66)-1.6%

Outpatient procedures

2,2051,8521,893412.2%

Unbundle OP radiodiagnostic

1,3901,1591,107(52)-4.5%

ED attendances

6,1825,1804,930(250)-4.8%

Critical Care

2,6082,1732,17300.0%

Rehabilitation

1,5771,3141,363493.7%

Children Services

2,6312,1922,19200.0%

Direct Access

3,1952,6622,8932318.7%

Maternity Services

2,5882,1562,221653.0%

NICE income

5,1654,2934,81452112.1%

Private patients

738609498(111)-18.2%

Other

3,4942,9262,93590.3%

Sub total

84,98170,85471,6958411.2%

Penalties

00(227)(227)

CQUINS

1,5401,2841,251(33)-2.6%

Total

86,52172,13872,7195810.8%

10 Months ending January 2015 Activity and Income Report

Significant over & under performance areas

Volume variances greater than 5% and more than 10 cases

Day casesElective inpatients

Over performingGeneral Medicine161%Breast Surgery27%

Paediatric67%Urology18%

Respiratory Medicine54%Gynaecology17%

General Surgery27%Colorectal14%

Colorectal14%Trauma & Orthopeadics5%

Gastroenterology13%

Under performingUpper GI Surgery-47%Upper GI Surgery-53%

Breast Surgery-31%

Urology-17%

Gynaecology-13%

Non Elective inpatientsOutpatient procedures

Over performingGynaecology85%Chemical Pathology314%

Urology15%Urology294%

Paediatrics22%General Medicine260%

General Surgery8%General Surgery207%

Upper GI Surgery119%

Colorectal Surgery118%

Haematology93%

Gynaecology57%

Respiratory medicine41%

Cardiology7%

Under performingGastroenterology-85%Dermatology-58%

Colorectal-67%Rheumatology-51%

Cardiology-61%Breast surgery-15%

Respiratory Medicine-49%Ophthalmology-5%

First Outpatient attendancesF/U Outpatient attendances

Over performingGeriatric Medicine161%ENT33%

General Surgery53%Ophthalmology32%

Ophthalmology20%Haematology19%

Urology11%General Surgery13%

Gastroenterology10%

General Medicine8%

Under performingDermatology-71%Anticoagulation-53%

Chemical Pathology-48%Dermatology-35%

General Medicine-41%Neurology-31%

Neurology-29%Upper GI Surgery-25%

Upper GI Surgery-22%Colorectal Surgery-25%

Respiratory medicine-20%Vascular surgery-24%

TIA-17%Palliative Medicine-21%

Paediatrics-17%Urology-17%

Trauma & Orthopeadics-17%GUM-14%

Diabetic medicine-13%Paediatrics-12%

Clinical oncology-13%Respiratory medicine-11%

Vascular surgery-12%

Colorectal Surgery-10%

Volumes including ACC

Annual

Activity

Plan

YTD

Activity

Plan

YTD

Activity

Actual

YTD

Activity

variance

Volume

Variance

%

Elective Day Cases13,21110,96811,3643963.6%

Elective Inpatients1,6351,3541,4591057.8%

Non-Elective Inpatients15,31912,75413,0462922.3%

First Outpatients36,77431,11028,749(2,361)-7.6%

Follow Up Outpatients57,14047,91046,537(1,373)-2.9%

Emergency department attendances56,37047,20644,307(2,899)-6.1%

10 Months ending January 2015 Activity and Income Report

Quarter 1Quarter 2Quarter 3JanuaryYTD

££££

RTT Estimate

18 weeks - Admitted£400 in respect of each excess breach above threshold1,2000001,200

18 weeks - Non Admitted£100 in respect of each excess breach above threshold 2,0000002,000

18 weeks - Incomplete£100 in respect of each excess breach above threshold1,3000001,300

RTT waits over 52 weeks£5000 per patient100%5,0000005,000

6 week Diagnostics£5000 per month99%00000

ED attendances within 4 hrs

£200 in respect of each excess breach above threshold

upto maximum of 8%

95%0107,200103,60035,100245,900

Trolley wait<12 hrs£1000 per event100%1,0000001,000

Ambulance handovers <15 minutes£200 per event100%4,00011,20020,0006,80042,000

Ambulance handovers <60 minutesAdditional £800 per event100%10,00034,00063,50021,000128,500

Percentage of Service Users referred urgently with suspected cancer by a GP waiting no more than two weeks for first

outpatient appointment

£200 in respect of each excess breach above threshold

93%00000

Percentage of Service Users referred urgently with breast symptoms (where cancer was not initially suspected) waiting no

more than two weeks for first outpatient appointment

£200 in respect of each excess breach above threshold

93%00000

Percentage of Service Users waiting no more than one month (31 days) from diagnosis to first definitive treatment for all

cancers

£1,000 in respect of each excess breach above threshold

96%00000

Percentage of Service Users waiting no more than 31 days for subsequent treatment where that treatment is surgery £1,000 in respect of each excess breach above threshold

94%00000

Percentage of Service Users waiting no more than 31 days for subsequent treatment where that treatment is an anti-cancer

drug regimen

£1,000 in respect of each excess breach above threshold

98%00000

Percentage of Service Users waiting no more than 31 days for subsequent treatment where the treatment is a course of

radiotherapy

£1,000 in respect of each excess breach above that

threshold 94%00000

Percentage of Service Users waiting no more than two months (62 days) from urgent GP referral to first definitive treatment

for cancer

£1,000 in respect of each excess breach above threshold

85%3,0007,00006,00016,000

Percentage of Service Users waiting no more than 62 days from referral from an NHS screening service to first definitive

treatment for all cancers

£1,000 in respect of each excess breach above threshold

90%00000

3,0007,00006,00016,000

Mixed sex accommodation breaches£250 per day per Service User affected

0%00000

VTEWhere the number of breaches in the month exceeds the

tolerance permitted by the threshold, £200 in respect of

95%360000360

MRSA

£10,000 in respect of each incidence in the relevant

month100%010,00010,00010,00030,000

C-Diff

£10,000 in respect of each excess breach above

threshold 00000

Total27,860169,400197,10078,900473,260

Reinvestment of ED Penalty0-107,200-103,600-35,100-245,900

Total062,20093,50043,800227,360

Quarter 1Quarter 2Quarter 3January

£££Total £

RTT

18 weeks - Admitted

£400 in respect of each excess breach above

threshold90%Urology6,4000006,400

Trauma & Orthopaedics9,6000009,600

General Surgery800000800

Reinvestment agreement-16,000000-16,000

18 weeks - Admitted£400 in respect of each excess breach above Total800000800

18 weeks - Non Admitted

£100 in respect of each excess breach above

threshold 95%Urology300000300

Neurology1,3000001,300

Reinvestment agreement-1,600000-1,600

Cardiology900000900

General Surgery200000200

Dermatology200000200

Gastroenterology300000300

ENT400000400

18 weeks - Non Admitted£100 in respect of each excess breach above Total2,0000002,000

18 weeks - Incomplete

£100 in respect of each excess breach above

threshold92%Urology7,7000007,700

Trauma & Orthopaedics18,50000018,500

Neurology3,4000003,400

Reinvestment agreement-29,600000-29,600

Ophthalmology100000100

General Medicine300000300

Gastroenterology300000300

General Surgery200000200

Respiratory medicine300000300

Rheumatology100000100

18 weeks - Incomplete£100 in respect of each excess breach above Total1,3000001,300

NumberValue

%%

Non-NHS97.698.1

NHS85.894.0

Combined97.296.9

Year to date 2014/15 - Month 10

WeightingPlan 2014/15

Monitor

Rating

Weighted

rating

Year to date

2014/15 -

Month

Monitor

Rating

Weighted

rating

Achievement of PlanEBITDA achieved10%216.850.501,108.950.50

Underlying performanceEBITDA margin25%0.810.252.120.50

Return on assets

excluding dividend20%(8.7)10.20(5.4)10.20

I&E Surplus20%(5.2)10.20(3.6)10.20

LiquidityLiquidity Ratio (days)25%13.120.5018.630.75

Monitor weighted criteria1.652.15

11

Key

Achievement of PlanEBITDA achieved (% of plan)

Underlying PerformanceEBITDA Margin (% underlying income)

Return on asset excluding dividend (%)

I&E Surplus Margin

Liquidity Ratio (days)

Continuity of Services Risk metrics

WeightingPlan 2014/15

Monitor