AGENDA - Poole Hospital NHS Foundation Trust: … 1 CoG Pack Sept. 2013.pdf · 3 Draft Minutes of Meeting held on 25 July 2013 CoG Sep 13 A CoG ... Elections for Governors would commence

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Poole�Hospital�NHS�Foundation�Trust

Council�of�Governors

Council�of�Governors�September

26�September�2013�-�17:30

Board�Room,�Poole�Hospital�BH15�2JB

AGENDA

1 Apologies�for�Absence

2 Declaration�of�Interests

3 Draft�Minutes�of�Meeting�held�on��25�July�2013CoG�Sep�13�A�CoG�Minutes�Jul�13�Part�1�Draft 6

4 Matters�Arising/Action�ListCoG�Sep�13�B�Actions 13

5 Chairman’s�Comments

6 FOR�APPROVAL

7 Proposed�2014�Meeting�datesOwner:�Chairman

CoG�Sep�13�C1�Meeting�Date�Schedule�cover�sheet 14CoG�Sep�13�C2�DRAFT�2014�diary 15

8 TO�RECEIVE

9 2012/13�Annual�Report�&�Accounts

9.1 Annual�Report�&�Accounts�(including�Audit�Opinion.Owner:�Chief�Executive/�Director�of�Finance/�External�Auditor

CoG�Sep�13�D�AR�and�A�Cover�Sheet 17

http://www.eshareuk.com

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9.2 Supporting�Information

9.3 Letter�&�Report:�The�Quality�AccountsOwner:�External�Auditor

CoG�Sep�13�E1�Cover�Sheet�Deloitte�LLP 18CoG�Sep�13�E2�PHFT�QA�Report�(FINAL) 19

9.4 Letter�on�the�Financial�AuditOwner:�External�Auditor

CoG�Sep�13�F1�Cover�Sheet�Deloitte�LLP 38CoG�Sep�13�F2�Poole�Report�to�the�Governors�2012-1 39

10 Annual�Complaints�ReportCoG�Sep�13�G1�Annual�Report�Cover�Sheet�13 54CoG�Sep�13�G2�Annual�Report�13 55

11 Report�from�NREC�Meeting�26/09/13Owner:�Chairman

12 FOR�INFORMATION/SCRUTINY

13 2013/14�Quality�Accounts�ContentOwner:�Director�of�Nursing�&�Patient�Services

14 Integrated�Trust�Performance�Report�Month�5Owner:�Chief�Executive

CoG�Sep�13�H�INTEGRATED�PERFORMANCE�REPORT�AUG�13� 62

15 Merger�UpdateOwner:�Chief�Executive

CoG�Sep�13�I1�Cover�Sheet��-�Part�1�-�Merger�Updat 122CoG�Sep�13�I2�Part�1�Board�of�Directors�Merger�Pro 123

16 Monitor’s�Risk�Assessment�Framework�(FTN�Briefing)Owner:�Company�Secretary

CoG�Sep�13�J1�Monitor�RAF 125CoG�Sep�13�J2�Monitor�Risk�Assessment�Framework�-� 126

17 FOR�REVIEW


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18 Register�of�InterestsOwner:�Chairman

CoG�Sep�13�K1�Register�of�Interests�Cover 129CoG�Sep�13�K2�Register�of�Interests 130

19 Reports�from�Reference�Groups:

20 Membership�Engagement�and�RecruitmentOwner:�Mrs�Yeoman

21 Future�Plans�&�PrioritiesOwner:�Mr�Purnell

22 Future�Agenda�ItemsCCG�Presentation�TBA�CMcall�SWASFT�Presentation�TBA�CB�

23 Motions�on�Notice

24 Urgent�Motions�or�Questions

25 Date�of�next�meeting:�16�January�2013

26 A�glossary�of�abbreviations�that�may�be�used�in�these�papers�will�be�foundat�the�back�of�this�document

27 AGENDA�–�PART�2

28 SECTION�A�(Chairman�&�Company�Secretary�to�withdraw�from�the�meeting)

29 Conduct�of�a�GovernorOwner:�DAC�Beachcroft

30 SECTION�B�(Chairman�&�Company�Secretary�to�return�to�the�meeting)

31 Part�2�Minutes�of�Meeting�held�on�25�July�2013

32 Draft�Minutes�from�Nominations,�Remuneration�and�Evaluations�Committeeheld�on�25�July�2013

33 FOR�APPROVAL


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34 Re-Appointment�of�Non-Executive�DirectorsOwner:�Chairman

35 FOR�INFORMATION/SCRUTINY

36 Strategic�Risk�ReportOwner:�Director�of�Nursing�&�Patient�Services

37 Merger�UpdateOwner:�Chief�Executive

38 Monitor�APRR�Feedback�and�MeetingOwner:�Chief�Executive

39 Monitor�Quarter�1�Monitoring�FeedbackOwner:�Chief�Executive

40 Close�of�MeetingOwner:�Chairman

Attendees


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IndexCoG�Sep�13�A�CoG�Minutes�Jul�13�Part�1�Draft.docx.............................................................. 6

CoG�Sep�13�B�Actions.docx................................................................................................... 13

CoG�Sep�13�C1�Meeting�Date�Schedule�cover�sheet.docx....................................................14

CoG�Sep�13�C2�DRAFT�2014�diary.xlsx.................................................................................15

CoG�Sep�13�D�AR�and�A�Cover�Sheet.doc............................................................................ 17

CoG�Sep�13�E1�Cover�Sheet�Deloitte�LLP.doc...................................................................... 18

CoG�Sep�13�E2�PHFT�QA�Report�(FINAL).ppt.......................................................................19

CoG�Sep�13�F1�Cover�Sheet�Deloitte�LLP.doc.......................................................................38

CoG�Sep�13�F2�Poole�Report�to�the�Governors�2012-13�(FINAL)�........................................ 39

CoG�Sep�13�G1�Annual�Report�Cover�Sheet�13.docx............................................................54

CoG�Sep�13�G2�Annual�Report�13.docx.................................................................................55

CoG�Sep�13�H�INTEGRATED�PERFORMANCE�REPORT�AUG�13�FINAL.doc....................62

CoG�Sep�13�I1�Cover�Sheet��-�Part�1�-�Merger�Update.docx................................................122

CoG�Sep�13�I2�Part�1�Board�of�Directors�Merger�Programme�Upd......................................123

CoG�Sep�13�J1�Monitor�RAF.docx........................................................................................125

CoG�Sep�13�J2�Monitor�Risk�Assessment�Framework�-�FTN�briefi......................................126

CoG�Sep�13�K1�Register�of�Interests�Cover.docx................................................................ 129

CoG�Sep�13�K2�Register�of�Interests.docx...........................................................................130

Glossary�of�abbreviations�Feb�13.docx.................................................................................132


1

A

COUNCIL OF GOVERNORS

The minutes of the meeting of the Council of Governors of Poole Hospital NHS Foundation Trust held on 25 July 2013 at 5.30 pm in Seminar Rooms 1 - 3, Poole Hospital.

Present: Mrs A Schofield Chairman Cllr. J Adams Bournemouth Borough Council AVM G Carleton Purbeck, East Dorset & Christchurch Mrs L Cherrett Clinical Staff Ms C Cherry Bournemouth University Mr A Creamer Poole Mrs V Duckenfield Poole Mr B Faith Poole Mrs R Gould Purbeck, East Dorset and Christchurch Mr G Hermsen Poole

Mrs B Hooper Purbeck, East Dorset and Christchurch Cllr. D Jones Dorset County Council

Canon J LLoyd Non-Clinical Staff Dr C McCall Dorset Clinical Commissioning Group Mrs I McLellan North Dorset, West Dorset, Weymouth

and Portland Mr B Newman Bournemouth

Mr J Pride Poole Mrs E Purcell Poole Mr T Purnell Bournemouth

Cllr. A Stribley Borough of Poole Mrs S Yeoman Poole

In attendance: Mr M Beswick Company Secretary

Mr C Bown Chief Executive Miss J Retigan Minute Taker

Mr G Spencer Senior Independent Director

The Chairman welcomed the Governors and members of the public and staff present to the meeting. It was noted that Ms Cherry was attending her first meeting of the Council of Governors as the nominated governor for Bournemouth University. The Chairman welcomed Ms Cherry and Cllr Jones, who had be re-appointed as the nominated governor for Dorset County Council, to the meeting. CoG 067/13 Apologies for Absence

Apologies for absence were received from Mr R King; Poole, Miss K Knudsen; Clinical Staff, and Mrs S Lowrey; Clinical Staff. The Council of Governors sent their best wishes for a speedy recovery to Mr King.

CoG�Sep�13�A�CoG�Minutes�Jul�1

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Overall�Page�6�of�135Page�1�of�7


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CoG 068/13 Declarations of Interest

It was noted that the Council of Governors could potentially have an interest in any item related to merger.

The Chairman and the Senior Independent Director noted their interest in item

7. CoG 069/13 Minutes of the Meeting held of the 25 April 2013 (Paper 1)

It was agree that the minutes would be changed to reflect that Cllr. Stribley had been awarded an MBE not an OBE, and the date of the next meeting would be corrected. Subject to the above amendments the minutes were agreed as an accurate record of the meeting.

CoG 070/13 Matters Arising (Paper 2)

043/13 – The Chairman reported that the figures had been checked in the Integrated Performance Report and corrected for subsequent reports.

050/13 – The Chairman noted that a presentation from the Ambulance

Service remained as an item for a future meeting but had been deferred due to other demands.

050/13 – The review of the Francis Report was on the programme for the

Annual Members meeting.

It was noted that all actions, unless subject to this agenda, had been executed.

CoG 071/13 Chairman’s Comments

The Chairman reported that as a result of the submission of the Annual Plan Monitor had reduced the Governance Rating for the Trust to red. The submission of the Annual Plan, alongside the decision to not pursue the working capital facility due to costs, had resulted in the Financial Risk Rating being assigned as 2. Following the unannounced visit of the Care Quality Commission (CQC) in May their final report had been received. The report was tabled and the Chairman noted that the Trust had fully met four of the five standards tested. A minor concern had been raised for the fifth standard and an action around the Serious Untoward Incident process was required, the Director of Nursing & Patient Services was leading this work. The report was discussed and Mr Bown noted that the quality and hard work of staff was reflected in the excellent comments. It was agreed that the appreciation of Governors would be included in feedback to staff. ACTION: CB Dr Dan Poulter, the Health Minister, had visited the MIU and RACE units on 9 May. The Chairman was pleased to report on the positive feedback received from this excellent visit. The Clinical Commissioning Group had held a Care and Compassion Day which had brought together colleagues from the Health and social care community from Dorset and beyond.


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The Mayor and Mayoress of Poole had attended the Volunteers cream tea and visited areas of the hospital. Following his visit the Mayor had issued a number of invitations to staff and volunteers to meet him in the Mayor’s Parlour. The Health Promoting Hospital event had taken place and the good turnout had included representatives from many different organisations. A letter had been received from Professor Michael Richards, the new Inspector of Hospitals, along with the request to share the letter with Governors, which had been done. It was noted that it was intended that all hospitals would be subject to a visit before March 2015 and a date for Poole was yet to be set. The Chairman reported that the Annual Members Meeting would take place on the 30 September at the Salvation Army, Poole. It was noted that with a change to tradition this would not follow a meeting of the Council of Governors and would take place during the day.

Elections for Governors would commence on 21 August 2013.

At the private meeting of the Council of Governors in April they had scrutinised a number of reports with a particular emphasis on the Annual Plan.

Upcoming Fundraising events were detailed, including the Bournemouth Festival of Running on 5-6 October, The Great Poole Bake Off taking place between 9 October and 6 November. Poole Africa Link would be holding a South Sudan Summer Sizzler on 16 August. Further details on these and other events would be available at the Fundraising Office. The report was NOTED.

CoG 072/13 2013/14 Remunerations and Allowances for Chairman and Non-Executives (Paper 3)

The Chairman presented the report. She noted that the Nomination,

Remuneration and Evaluation Committee recommended that the Council of Governors approved the proposal that there were no increases in the remuneration and allowances for the Chairman and Non-Executive Directors.

The Council of Governors thanked the Chairman and Non-Executive Directors

for their contribution to the hospital. The report was APPROVED. CoG 073/13 Report from NREC Meeting 25 July 2013

The Chairman reported that the main business of the meeting, which had preceded this, had been to consider the evaluation and appraisals of the Chairman and Non-Executive Directors and their remuneration and allowances. The report was NOTED.


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CoG 074/13 2012/13 Annual Council of Governors Assessment of Collective Performance (Paper 4)

The Chairman presented the report which had previously been circulated to the Council for their comment. The Chairman and Council of Governors thanked Anita Bonham for her contribution to the report. The report was RECEIVED.

CoG 075/13 Receive Annual Audit and Governance Report (Paper 5)

The Senior Independent Director presented the report as Deputy Chairman of the Audit & Governance Committee.

The Senior Independent Director noted that the committee scrutinised

processes and financial controls and the full terms of reference of the committee were included in the report.

The report and work of the committee were discussed and comments and

questions were taken. It was agreed that figures in App. 4, detailing the work of Internal Audit, would be checked for accuracy. ACTION: MB

The report was NOTED. CoG 076/13 Francis Report Summary Update Report (Paper 6) Mr Bown presented the report and detailed the work undertaken since the

publication of the Francis Report. A programme of listening events was underway and provided staff and stakeholders an opportunity to discuss the findings and raise any concerns. The Board had received several update reports on the Trust’s position and a gap analysis had been undertaken. Mr Bown detailed the priorities for action and noted that the Trust response to the Francis Report would be discussed at the August Board Seminar and further details would be provided at the next meeting of the Council of Governors. ACTION: MSm

The report was discussed and the national review of bureaucracy was noted.

Consideration was given to how the Trust encourages and deals with complaints. The Senior Independent Director reported that the Board had received the Annual Complaints Report at their July meeting and had considered the complaints process in depth. It was agreed this report would be submitted to the next meeting and, if possible, would be presented by the Medical Director. ACTION: RT/JR

The report was NOTED. CoG 077/13 Integrated Trust Performance Report Month 3 (Paper 7) Mr Bown presented the report and noted that financial performance remained

in line with plan and the forecast for the year remained on track at just over break even. Mr Bown confirmed that the Financial Risk Rating for the Trust had been downgraded to two. This was due to the decision to not renew the Working Capital Facility due to costs, and the forecast of a deficit for 2014/15 and 2015/16 in the Annual Plan.


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Mr Bown reported that clinical performance remained good and all Monitor targets had been delivered for the quarter. He noted that the Clostridium Difficile target remained challenging and there had been no cases of MRSA reported for the year to date.

The merger costs were discussed and Mr Bown noted that the Strategic

Health Authority had contributed £2m in 2012/13 to help facilitate the potential merger. A general discussion on finance and savings took place and the implications of a Trust reporting a deficit were detailed by Mr Bown. It was noted that the financial performance for the current year was supported by non-recurrent funds. Mr Carleton expressed strong concern over the limited size of the forecast end of year operating surplus of £200k bearing in mind this already took account of transitional funding from the Dorset CCG to support the Trust through to the proposed merger, and a transfer of £2m of donated income from Charitable Funds. It was also noted that significant savings had been achieved over the last four years from redesign work and external advisers had noted that potential to extract further costs savings was very limited.

The report was considered. It was noted that there appeared to be an error on

page two, relating to the number of Serious Untoward Incidents (SUI), where the cumulative position appeared to be seven rather than the report three, and this would be checked. ACTION: CB

Post meeting note: the reporting of SUIs has been checked. In each monthly

column the year to date position is recorded. The total year to date column is correct at three cases in total from April to June.

Dr McCall noted the increase in attendance at Emergency Departments

nationally. He noted the effort from staff at Poole Hospital to achieve the quarterly targets. Dr McCall reported that research indicated the increase was not solely attributable to out of hours service and was something that would need to be addressed as a whole health community issue.

Cllr. Adams asked about the effect of alcohol on attendees at the Emergency

Department. It was agreed a copy of the presentation given at the April Council of Governors meeting would be issued to Cllr. Adams. ACTION: CB

The report was NOTED. CoG 078/13 Merger Update (Paper 8) The Chairman reported that the position with merger had been discussed in

depth at the Informal Governors meeting. She noted the preliminary findings of the Competitions Commission (CC) and their initial assessment that the merger would cause a significant lessening of competition. The Chairman reported that the Trust position was that the positive impact on the quality of care for local residents outweighed the potential increase in harm created by the reduction of competition. Mr Bown reported that work to persuade the CC of this position was ongoing.

The letter to the CC from the Board of Directors was noted and it was agreed

that two paragraphs from the Council of Governors would be added to the letter. ACTION: CB/AS

The merger and the position of the CC were discussed. Cllr. Stribley reported

that Poole Borough Council had passed an urgent motion on the issue at their last council meeting and she agreed to share the detail of this with Cllr. Adams. ACTION: ASt


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Some Governors reported that they intended to write to the CC independently

and would copy the Chairman into their correspondence. The report was NOTED. CoG 079/13 Governor Development/Training Event (Paper 9) Mr Beswick presented the report and noted that following advice from

advisers a suggested event to cover the new responsibilities for Governors under the Health & Social Care Act 2012 and Monitor guidance had been put forward.

The report was discussed and the Council agreed that the Board of Directors

were welcome to join the event for part of the day. The Council of Governors SUPPORTED the proposed development/training

event. CoG 080/13 Reports from Reference Groups Membership Engagement and Recruitment Mrs Yeoman reported that a Membership Engagement and Recruitment

Group (MERG) meeting had taken place on 11 July and she thanked those Governors who regularly attended and the Chairman for their support. Mrs Yeoman noted that as of 30 June, eighty four new members had been recruited and this good work needed to continue to meet the target.

Mrs Yeoman detailed the ongoing work to attract young people and that it was

hoped information would be in schools for the new academic year. The report was NOTED.

Future Plans & Priorities

Mr Purnell reported that no meeting of the group had been undertaken as it had been agreed that the Annual Plan would be considered by the full Council of Governors. It was noted that the requirements for this group would be assessed when the position with the potential merger was clear. The report was NOTED. Research & Innovations Group (R&IG) Mr Creamer reported that since his nomination for Governor Representative on the Research & Innovations Group he had found the meetings interesting. He noted that National Institute for Health Research Clinical Research Network has issued a press release which praised Poole Hospital for increasing the number of studies they do locally, and helping to bring research opportunities to patients. The report was NOTED.

CoG 081/13 Report from Joint Governor Event 1 July 2013-08-01

The Chairman reported on the Joint Governor Event held at Saltern’s Hotel with the Council of Governors from the Royal Bournemouth & Christchurch


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Hospitals. It was noted that the event encompassed presentations on the Integrated Business Plan, the Big Ask and the organisational Development Programme for the proposed organisation. The Chairman reported that a further event had been held on 22 July to allow both Councils to receive information on the Provisional Findings of the CC. Discussion had included clinical services and the way forward. The report was NOTED.

CoG 082/13 Future Agenda Items

It was agreed that in was not appropriate to decide on a full programme of future business until more clarity on the future had been received.

CoG 083/13 Notices of Motion

No notices of motion were received.

CoG 084/13 Urgent Notices of Motion

No urgent notices of motion were received. CoG 085/13 Date of Next Meeting

26 September 2013 at 5.30 pm in the Board Room, Poole Hospital. The Chairman noted there would not be an Informal Governor Briefing in August.

CoG 086/13 Withdrawal of Press and Public

The Chairman asked any members of the public and representatives of the press to withdraw from the meeting.


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B POOLE HOSPITAL NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS ACTION LIST

26 September 2013

Minute No Meeting Date

Agenda Action Deadline Lead

046/13 25/04/2013 Part 1 Director, Governor Interaction Best Practice Guide for Directors

– to be revisited when decision on merger has been received

As

appropriate

Angela Schofield

050/13 25/04/2013 Part 1 Presentation from the Ambulance Service to be a future agenda

item

As

appropriate

Chris Bown

071/13 25/07/2013 Part 1 The appreciation of Governors to be included in feedback to

staff following CQC report, etc.

As

appropriate

Chris Bown

075/13 25/07/2013 Part 1 Figures in App. 4 of Annual A&G Report to be checked As

appropriate

Michael Beswick

076/13 25/07/2013 Part 1 Update on Trust position re Francis Report to next meeting September Martin Smits

076/13 25/07/2013 Part 1 Annual Complaints Report to be submitted to the next meeting

and, if possible, presented by the Medical Director.

September Robert Talbot/ Jill

Retigan

077/13 25/07/2013 Part 1 Copy of the presentation on Alcohol given at the April Council of

Governors meeting to be circulated

As

appropriate

Chris Bown

078/13 25/07/2013 Part 1 Two paragraphs from the Council of Governors would be added

to the letter to the CC from the Board.

As

appropriate

Angela Schofield /

Chris Bown

078/13 25/07/2013 Part 1 Urgent motion from Poole Borough Council to be shared with

Cllr. Adams

As

appropriate

Ann Stribley

CoG�Sep�13�B�Actions.docx

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Meeting Date: 26 September 2013

Agenda Item: 7 Paper No: C

Title:

2014 Proposed Meeting Dates Schedule

Purpose:

To receive the 2014 meeting dates schedule

Summary:

To provide the schedule of 2014 meeting dates of the Council of Governors and other events the Governors are invited to attend.

Recommendation:

The Council are asked to receive the report.

Prepared by:

The Company Secretary Function

Presented by:

MICHAEL BESWICK Company Secretary

CoG�Sep�13�C1�Meeting�Date�Sch

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BOARD OF DIRECTORS 2014 MEETING SCHEDULE

BoD Part 1 BoD Part 2 BoD Seminar BoD Dev A&G WC QSP FIC Spec A&G/FIC CF BoD/CoG Dev

29/01/14 29/01/14 29/01/14 08/01/14 27/01/14 27/01/149am 12.30pm 10.45am 2pm 10am 2pm

BR 1&2 BR 1&2 BR 1&2 BR 1 BR 2 BR 2

26/02/14 26/02/14 26/02/14 24/02/14 24/02/149am 12.30pm 10.45am 10am 2pm

BR 1&2 BR 1&2 BR 1&2 BR 1 BR 1

26/03/14 26/03/14 26/03/14 12/03/14 12/03/14 24/03/14 24/03/14 12/03/149am 12.30pm 10.45am 4pm 1pm 10am 2pm 3pm

BR 1&2 BR 1&2 BR 1&2 BR 1&2 BR 1 BR 1 BR 1 BR 1

23/04/14 23/04/14 23/04/14 22/04/14 22/04/149am 12.30pm 10.45am 10am 2pm

BR 1&2 BR 1&2 BR 1&2 BR 1 BR1

28/05/14 28/05/14 14/05/14 14/05/14 27/05/14 27/05/14 28/05/14 14/05/1410am 11.45am 4pm 1pm 10am 2pm 8.30am 3pm

BR 1&2 BR 1&2 BR 1&2 BR 1 BR 2 BR 2 BR1 BR 1

25/06/14 25/06/14 25/06/14 23/06/14 23/06/14 TBC9am 12.30pm 10.45am 10am 2pm 1/2 day PM

BR 1&2 BR 1&2 BR 1&2 BR 1 BR 2 TBC

30/07/14 30/07/14 30/07/14 28/07/14 28/07/149am 12.30pm 10.45am 10am 2pm

BR 1&2 BR 1&2 BR 1&2 BR 2 BR 2

27/08/14 27/08/1411.15am 9am

BR 1 BR 1

24/09/14 24/09/14 24/09/14 10/09/14 10/09/14 01/09/14 22/09/14 22/09/14 10/09/149am 12.30pm 10.45am 4pm 1pm 10am 10am 2pm 3pm

BR 1&2 BR 1&2 BR 1&2 BR 1&2 BR 1 BR 1 BR 1 BR 1 BR 1

29/10/14 29/10/14 29/10/14 27/10/14 27/10/149am 12.30pm 10.45am 10am 2pm

BR 1&2 BR 1&2 BR 1&2 BR 1 BR 2

26/11/14 26/11/14 26/11/14 12/11/14 12/11/14 24/11/14 24/11/14 12/11/149am 12.30pm 10.45am 4pm 1pm 10am 2pm 3pm

BR 1&2 BR 1&2 BR 1&2 BR 1&2 BR 1 Br 1 BR 2 BR 1

17/12/14 15/12/14 17/12/14

9-10.30am 2pm

Development AM &

xmas lunchBR 1&2 BR 1 BR 1&2

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Yellow highlight = school holidays

Red text TBCCoG�Sep�13�C2�DRAFT�2014�diary

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COUNCIL OF GOVERNORS' MEETING SCHEDULE 2014

BoD Gov Brief BoD/CoG Dev Pre Meet Brief NREC CoG CoG Dev Chair Mtg DC & LG Chair/CE with Staff Govs AMM

30/01/14 16/01/14 16/01/14 16/01/145pm 4pm Electronic 5.30pmBR 1 BR 1&2 N/A BR 1&2

27/02/14 27/02/145pm 4.15pmBR 1 Chair's Office

27/02/14 TBA5pm Late AMBR 1 CE Office

24/04/145pmBR 1

29/05/14 01/05/14 01/05/14 01/05/14 01/05/145pm 4pm 3.15pm 5.30pm 2.30pmBR 1 BR 1&2 BR 1&2 BR 1&2 Chair's Office

26/06/14 TBC TBC TBA5pm 1/2 day PM 1/2 day PM Late AMTBC TBC TBC CE Office

31/07/14 31/07/14 31/07/14 31/07/144pm 3.15pm 5.30pm 2.30pm

BR 1&2 BR 1&2 BR 1&2 Chair's Office

25/09/14 25/09/14 TBA 25/09/14TBC 4.15pm Late AM TBCBR 1 Chair's Office CE Office TBC

30/10/14 30/10/144pm 5.30pm

BR 1&2 BR 1&2

27/11/14 27/11/145pm 4.15pmBR 1 Chair's Office

17/12/14 17/12/14 TBADevelopment AM

& xmas lunch

Development AM

& xmas lunch Late AMBR 1&2 BR 1&2 CE Office

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Yellow highlight = school holidays

Red text = TBCCoG�Sep�13�C2�DRAFT�2014�diary

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Agenda Item: 9 Paper No: D

Title:

Annual Report and Accounts for the year to 31st March 2013

Purpose:

The Council of Governors to receive the Trust’s Annual Report and Accounts for the year ending 31 March 2013

Summary:

The Trust's Annual Report and Accounts for the year ending 31 March 2013 were presented to Parliament in July; they were then published on the Monitor website (and our own) and are to be received by the Council of Governors at its next (today’s) public meeting. And will be presented at the Annual Members meeting on 30 September 2013 As previously notified to Council The Annual Report and Accounts can be found here :

https://www.poole.nhs.uk/PDF/PHFT%20Annual%20Report%201213 %20final%20for%20web.pdf and a hard copy of the document will be available at the meeting. The accounts show that despite the financial challenges facing the sector the trust has achieved its key financial objectives:

Achieved an operating surplus of £1.3m before the impact of the

revaluation of the estate

Increased income from £195.7mm in 2012/13 to £202.4m in the current

year

Maintained a healthy liquidity position with cash balances of £15m at

the end of the year (last year £15.3m)

Invested £11.8m in the hospital and its equipment

Maintained a Monitor Financial Risk Rating of 3

However the trust continues to face significant financial challenges, in common with the rest of the NHS,. Over the next three years the trust will be required to improve financial performance by 4% to 5% per year, equivalent to approximately £10m each year.

Recommendation:

The Council of Governors is requested to receive the annual accounts for the year to 31st March 2013

Prepared by:

Paul Turner DoF Karen Hollocks Head of Communications

Presented by:

Chris Bown CE Paul D Turner, DoF Martin Smits DoNPS Matthew Hepenstal External Auditor

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https://www.poole.nhs.uk/PDF/PHFT%20Annual%20Report%201213%20%20final%20for%20web.pdf

https://www.poole.nhs.uk/PDF/PHFT%20Annual%20Report%201213%20%20final%20for%20web.pdf




Agenda Item: 9 Paper No: E

Title:

Deloitte LLP Letter and Report on the Quality Accounts

Purpose:

To present the Council of Governors with a letter and a report on the Quality Accounts from the external auditors, Deloitte LLP.

Summary:

Attached is a document setting out the report to the Council of Governors of Poole Hospital NHS Foundation Trust (PHFT) from Deloitte LLP, on their external assurance review of the 2012/13 Quality Report. The report covers the principal matters that have arisen from the review. The report is confidential and prepared solely for the purpose set out in the engagement letter dated 7 March 2013

Recommendation:

The Council of Governors are asked to note the report

Prepared by:

Presented by:

MATTHEW HEPENSTAL Deloitte LLP

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© 2013 Deloitte LLP. Private and confidential.

Poole Hospital NHS Foundation Trust Findings and Recommendations from the 2012/13 NHS Quality Report External Assurance Review

May 2013

CoG�Sep�13�E2�PHFT�QA�Report�(

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27 May 2013

Ladies and Gentlemen

We have pleasure in setting out in this document our report to the Council of Governors of Poole Hospital NHS Foundation Trust (PHFT) on our

external assurance review of the 2012/13 Quality Report. This report covers the principal matters that have arisen from our review.

We take responsibility for this report which is prepared on the basis of the limitations set out below. The matters raised in this report are only those

which came to our attention during the course of our work and are not necessarily a comprehensive statement of all the deficiencies that may exist

or all improvements that might be made. Any recommendations made for improvements should be assessed by you for their full impact before

they are implemented.

This report is confidential and prepared solely for the purpose set out in our engagement letter dated 7 March 2013.

Sue Barratt

Senior Statutory Auditor

The Council of Governors

Poole Hospital NHS Foundation Trust

Longfleet Lane

Poole

Dorset

BH15 2JD

Deloitte LLP

Mountbatten House

1 Grosvenor Square

Southampton SO15 2BZ

Tel: +44 (0) 23 8033 4124

Fax: +44 (0) 23 8033 0948

www.deloitte.co.uk

1

Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited ("DTTL"), a UK private company limited by guarantee, and its network of member firms, each of which is a legally separate and

independent entity. Please see www.deloitte.co.uk/about for a detailed description of the legal structure of DTTL and its member firms.

Deloitte LLP is the United Kingdom member firm of DTTL.

© 2013 Deloitte LLP. All rights reserved.

Deloitte LLP is a limited liability partnership registered in England and Wales with registered number OC303675 and its registered office at 2 New Street Square, London EC4A 3BZ, United Kingdom.


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Contents

1. Executive summary

2. Our approach and scope

3. Our review of the content and consistency of the Quality Report

4. Our testing of the Trust’s performance indicators

5. Our recommendations for improvement

6. Use of this report

Appendix 1: Draft Independent Assurance Report

Appendix 2: List of interviewees and documentation reviewed

Appendix 3: Details of the key performance indicators (KPIs) tested in our

work

We would like to take

this opportunity to

thank the Trust staff

with whom we

worked on this

assignment for their

assistance and co-

operation during the

course of our work

2 NHS Quality Report 2012/2013 – PHFT NHS FT

The contacts at Deloitte in connection with this report are: Sue Barratt Partner Tel: 0118 322 2219 [email protected] Matthew Hepenstal Director Tel: 02380 354215 [email protected]


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1. Executive summary

Status

We have substantially completed our work in connection with the Trust’s 2012/13 Quality Report including our audit testing in connection with the reported

KPIs. At the date of issuing this paper, we await a management response to one recommendation that we have made in connection with the cancer wait time

performance indicator. Other outstanding procedures include a final review of the Trust’s Quality Report.

The scope of our work is to support a “limited assurance” opinion, which is based upon procedures specified by Monitor in their Detailed Guidance for External

Assurance on Quality Reports. This includes testing and reporting on the two mandated performance indicators which were as follows:

• Clostridium Difficile; (C Difficile or C Diff) and

• The wait time between urgent GP referral and first treatment for all cancers.

We anticipate issuing a “clean” unmodified opinion in our public report. We will also issue a private report to Governors in connection with Patient Safety

Incidents. (this is not covered by our limited assurance opinion)

Overall

conclusion Page

Content

We have reviewed the contents of the Quality Report compared to the requirements of Monitor’s Annual Reporting Manual

(“ARM”). During the year, we have communicated regularly with the key personnel involved in preparing the Quality Report. No issues [3]

Consistency

We have reviewed the contents of the Quality Report for consistency with various specified information sources, such as Board

papers, the Trust’s complaints report, staff and patients surveys and Care Quality Commission reports.

No issues [3]

Data testing

We performed data testing of three different performance indicators and a description of the individual

performance indicator definition is provided in Appendix 3. Our work considered:

• The quality of the data supporting the indicator, compared to Monitor’s six dimensions of data quality.

• Whether the indicators have been reported in accordance with the ARM requirements.

C Difficile No issues [8]

62 day cancer wait

times

Some errors

noted [9]

Incidents resulting

in severe harm or

death

No Issues [10]

NHS Quality Report 2012/2013 – PHFT NHS FT 3 CoG�Sep�13�E2�PHFT�QA�Report�(

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External assurance requirements

As part of our review, we are required to provide assurance over the Quality Report, following procedures set out in Monitor’s Audit Code and detailed guidance

published each year. We are required to:

• Review the content of the Quality Report for compliance with the requirements set out in the Annual Reporting Manual 2012/13.

• Review the content of the Quality Report for consistency with various information sources specified in Monitor’s detailed guidance, such as Board papers, the

Trust’s complaints report, staff and patients surveys and Care Quality Commission reports.

• Perform sample testing of three indicators.

‒ For 2012/13, all Trusts are required to have testing performed on Incidents resulting in severe harm or death.

‒ The Trust also selected C Diff and cancer wait times as its publically reported indicators – the alternative was 28 day readmission rates (fuller details of

these indicators is provided in Appendix 3).

‒ The scope of testing includes an evaluation of the key processes and controls for managing and reporting the indicators; and sample testing of the data used

to calculate the indicator back to supporting documentation.

• Provide a signed limited assurance report, covering whether:

‒ Anything has come to our attention that leads us to believe that the Quality Report has not been prepared in line with the requirements set out in the ARM; or

is not consistent with the specified information sources; or

‒ There is evidence to suggest that the C Diff and 62 day cancer wait time indicators have not been reasonably stated in all material respects in accordance

with the ARM requirements.

• Provide this report to the Council of Governors, setting out our findings and recommendations for improvements for the indicators that we tested.

2. Our approach and scope

NHS Quality Report 2012/2013 – PHFT NHS FT 4

Form an opinion

Content and consistency work

Detailed data

testing

Identify

improvement areas

Performance indicators

Interviews Review content Document review

Interviews Identify potential

risk areas


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3. Our review of the content and consistency of the Quality Report The Quality Report meets regulatory requirements

Recommendations

We have no specific recommendations to make in connection with the preparation of the Quality Report.

5 NHS Quality Report 2012/2013 – PHFT NHS FT

Content of Quality Report We reviewed the content of the 2012/13 Quality Report against the content requirements set out in Monitor’s 2012/13 Annual Reporting Manual.

There have been some significant changes in the reporting requirements that were in place last year and our approach was to discuss with management and

agree how the requirements could be met. By working alongside management we have been able identify amendments needed and these have been agreed with

management. We are therefore satisfied that the updated version of the report will comply with the mandatory guidance issued by Monitor. We have made initial

comments and await an updated version following the Trust.

Statement of Directors Responsibilities Monitor require NHS FTs to sign a Statement of Directors’ Responsibilities in respect of the content of the quality report and the mandated indicators. The

guidance requires these to be published in the Quality Report.

As part of our review we have reviewed the Statement of Directors Responsibilities and confirmed that the Trust signed “Statement of Directors’ Responsibilities”

is an unamended version of the proforma provided by Monitor. The Trust plans to include a signed copy of this statement in the 2012/13 Quality Report.

Consistency of the Quality Report Monitor require Auditors to undertake a review of the content of the Quality report for consistency with the content of other sources of management information

specified by Monitor in its “Detailed Guidance for External Assurance on the Quality Reports”.

We reviewed the consistency of the Quality Report against this supporting information required by Monitor and did not identify any significant matters specified in

the supporting information which are not specified in the Quality Report. We also consider the implications for our report if we become aware of any apparent

misstatements or material inconsistencies with those documents (collectively the “documents”). Our responsibilities do not extend to any other information.

Stakeholder Engagement Monitor require Auditors to consider the processes which NHS FTs have undergone to engage with stakeholders.

The Trust does contact a range of different external organisation for comments and to involve them in the process. Our view is that the Trust has arrangements in

place that are reasonable to ensure that relevant and interested external groups are invited to participate in the overall process.


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4. Our review of the Trust’s performance indicators


Recommendations

The following pages show detailed findings for each of the Monitor mandated performance indicators against the six dimensions of data quality. The assessment

includes key strengths, perceived gaps and detailed recommendations that should be implemented. No recomendations were identified in the areas of C Difficile

and patient safety incoidents.

For the Cancer wait time performance indicator, our work did identify two errors where the relevant dates had been incorrectly recorded. One of these errors

originally concealed the fact that the 62 day target had been breached for the specific patient. We therefore extended our testing and have identified a

recommendation to improve the controls over date recording processes. The extended testing did not identify any further errors.

Our recommendation in connection with the cancer wait time performance indicator can be found, together with management response, in Section 5 of this report

on page 11.

Quality of Data

Monitor require Auditors to undertake detailed data testing on a sample basis of three mandated indicators. The indicators that we tested related to C Difficile, the

62 day maximum target from urgent referral to treatment for cancers and the number of patient safety incidents that led to severe harm or death.

Nothing has come to our attention that causes us believe that, for the year ended 31 March 2013, the indicators in the Quality Report subject to limited assurance

have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data

quality set out in the ‘Detailed Guidance for External Assurance on Quality Reports’.

A draft of our limited assurance opinion can be found in Appendix 1 and has been included within your 2012/13 Annual Report.

We have also undertaken detailed data testing of incidents resulting in severe harm or death, which has been mandated by Monitor for all FTs but is outside our

limited assurance opinion. It is anticipated that this indicator will be included in our limited assurance opinion as part of our 2013/14 Quality Report external

assurance.


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4. Our review of the Trust’s performance indicators Assessed against the Monitor six dimensions of data quality


C Difficile

62 day cancer wait

time from urgent

referral to

treatment

Incidents resulting

in severe harm or

death

Accuracy

Is data recorded correctly and is it in line with the methodology.

Validity

Has the data been produced in compliance with relevant requirements.

Reliability

Has data been collected using a stable process in a consistent manner over a period of

time.

Timeliness

Is data captured as close to the associated event as possible and available for use within a

reasonable time period.

Relevance

Does all data used generate the indicator meet eligability requirements as defined by

guidance.

Completeness

Is all relevant information, as specified in the methodology, included in the calculation.

Overall Conclusion Unqualified

Opinion

Unqualified

Opinion

No opinion

required

No issues

Requires improvement Significant improvement

required


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C Difficile The Trust did not meet its target in connection with the number of C Difficile cases in 2012/13.


• Our approach to this element of our work involved obtaining information from the Trust’s laboratory for the results of tests performed to establish the existence

of the bacteria and the toxin associated with C Difficile. It is important to note that the Trust also performs tests for many community based organisations such

as GP practices and therefore it is necessary to exclude positive results that should not be attributed to the Trust from the reported result.

• In addition, where a test proves C Difficile positive, but the patient has only very recently been admitted to the hospital, these should also be excluded as it is

likely that the patient was not infected in the hospital environment. Detailed rules exist therefore to ensure that these tests are not attributed to the Trust.

Approach

Results Recommendations

Strengths

• The Trust has a well established process for

testing samples and has an infection control team

to oversee this area.

Issues

• No issues were identified.

• No recommendations were identified for this

aspect of our work.

Reported Performance: 2012/13 Target was no more than 25 cases. Trust reported performance was 27 cases


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62 Day cancer wait times


• In 2012/13 , the Trust received approximately 750 urgent GP referrals in respect of different cancers. The Trust has a target of responding to at least 85% of

the referrals so that treatment commences within 62 days of the urgent referral. However, if the patient is not available and in certain specified situations, the

Trust is permitted to adjust the time elapsed. For example, if the patient has agreed not to attend an appointment so that a later appointment is required that is

after the 62 day target, the Trust may adjust for certain of these types of referral.

• Our approach included selecting a sample of items and testing to the underlying documentation and information.

• We have completed our audit testing of the data where we extended our testing to include additional items as errors were identified in our interim (see Issues

below). We were able to isolate the impact of the error and conclude it was not significant and accordingly expect to be able to issue an unmodified opinion

Approach


Strengths

• The Trust has a well established system where

locally prepared base data is subject to a range of

control procedures prior to submission to the

Department of Health.

Issues

• For most items included in our sample, we were

able to agree dates back to the underlying

documentation confirm the referral date and first

treatment date to the trust’s system. Our testing

did identify one error where the days recorded

proved to be incorrect and led to the case initially

being incorrectly recorded as a “pass” when in

fact the case had breached the 62 day target

period. This item was subsequently corrected by

the Trust and also required us to extend our

sample. In addition, one further error affecting an

adjusted item was identified but this had no

impact on the Trust’s reported performance in this

area. Accordingly there was no requirement to

extend our sample for this particular error.

• We identified two errors in connection with the

date recording and therefore recommend that

each month the date and the elapsed time period

from referral to first treatment should be subject

to checking.

Reported Performance: 2012/13 Target = 85% Trust reported performance 2012/13 = 88%

The Trust met its target of delivering first treatment phase within 62 days for more than 85% of urgent cancer referrals.


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Patient safety incidents resulting in severe harm or death


The Trust has developed an internal reporting system where incidents that either did cause, or could have caused, harm to a patient are notified to a central

team managed by the Trust’s Associate Director of Clinical Governance.

In total the Trust reported more than 7,000 incidents in 2012/13 of which 21 of these incidents were recorded as having resulted in severe harm.

We have agreed the data reported by the Trust in its 2012/13 Quality Report back to the Trust records. Our work does not cover the accuracy or the validity of

the data provided to the National Reporting and Learning Service (NRLS) ) as there is no regulatory requirement of the Trust to report on this basis and the

accuracy of this data cannot be verified. This indicator relies on clinical judgement to determine the correct classification of each incident. In addition, each

incident may also be subject to potentially lengthy investigation which may result in the classification subsequently being changed. We have not challenged the

clinical judgements made regarding the classification of each incident. In addition, although we have checked a sample of patient safety incidents excluded from

the severe harm indicator to confirm the exclusion is valid, we are only able to confirm that this exclusion is accurately recorded.

Approach


Strengths

• We note that the Trust has a well developed

system for ensuring that incidents that either did,

or potentially could have, led to patient harm are

recorded and the information passed quickly to

the Risk Management Team.

Issues

• The Trust follows national NPSA severity

definitions. The definitions surrounding actual

severe harm and death are reasonably clear.

However, the definitions surrounding those that

are beneath this threshold are less so.

• The Trust should continue to encourage reporting

of incidents so that it can monitor and react to

emerging patient safety issues.

The Trust reported performance of 21 severe harm incidents in 2012/13.


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5. Our recommendations for improvement

Draft NHS Quality Report 2012/2013 – PHFT NHS FT 11

Pg Issue & Impact

Priority

Rating

(H/M/L)

Recommendation Agreed Management response Responsible

Person

Time-

scale

9

We identified two errors

in connection with cancer

wait times, one that

initially resulted in an

item initially being

recorded as a pass when

it had actually breached

the 62 day deadline.

Med

Management should introduce a monthly

check to confirm the dates of referral and

date of first treatment are correct. Yes

We accept the need to check

that the date of referral and

first treatment are correct. A

review is currently underway

and a system will be

introduced in quarter 2 of

2013/14

Sue Whitney 30 Sept

2013

Key: High Medium Low


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6. Use of this report Scope of reporting on the Quality Report

Draft NHS Quality Report 2012/2013 – PHFT NHS FT 12

This report is confidential and prepared solely for the purpose set out in our engagement letter dated 7 March 2013. You should not, without our prior written

consent, refer to or use our name on this report for any other purpose, disclose them or refer to them in any prospectus or other document, or make them

available or communicate them to any other party. No other party is entitled to rely on our report for any purpose whatsoever and thus we accept no liability to

any other party who is shown or gains access to this report. We agree that a copy of our report may be provided to Monitor for their information in connection with

this purpose but, as made clear in our engagement letter dated 7 March 2013, only on the basis that we accept no duty, liability or responsibility to Monitor in

relation to our Deliverables.


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Appendices

Draft NHS Quality Report 2012/2013 - XXX NHS FT 13 CoG�Sep�13�E2�PHFT�QA�Report�(

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© 2013 Deloitte LLP. Private and confidential. NHS Quality Report 2012/2013 – PHFT NHS FT 14

Independent Auditor’s Report to the Council of Governors of Poole Hospital NHS Foundation Trust on the Quality Report

We have been engaged by the Council of Governors of Poole Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of

Poole Hospital NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the “Quality Report”) and certain performance indicators contained

therein.

This report, including the conclusion, has been prepared solely for the Council of Governors of Poole Hospital NHS Foundation Trust as a body, to assist the

Council of Governors in reporting Poole Hospital NHS Foundation Trust ’s quality agenda, performance and activities. We permit the disclosure of this report within

the Annual Report for the year ended 31 March 2013, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by

commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility

to anyone other than the Council of Governors as a body and Poole Hospital NHS Foundation Trust for our work or this report save where terms are expressly

agreed and with our prior consent in writing.

Scope and subject matter

The indicators for the year ended 31 March 2013 subject to limited assurance consist of the national priority indicators as mandated by Monitor are as follows:

• C Difficile; and

• 62 day cancer wait times from urgent referral until treatment.

We refer to these national priority indicators collectively as the “indicators”.

Respective responsibilities of the Directors and auditors

The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual

Reporting Manual issued by Monitor.

Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:

• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;

• the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports; and

• the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material

respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for

External Assurance on Quality Reports.

We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the

implications for our report if we become aware of any material omissions.

We read the other information contained in the Quality Report and consider whether it is materially inconsistent with the documents specified within the detailed

guidance. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents

(collectively the “documents”). Our responsibilities do not extend to any other information.

We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW)

Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.



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© 2013 Deloitte LLP. Private and confidential. NHS Quality Report 2012/2013 – PHFT NHS FT 15


Assurance work performed

We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – “Assurance

Engagements other than Audits or Reviews of Historical Financial Information” issued by the International Auditing and Assurance Standards Board (“ISAE 3000”).

Our limited assurance procedures included:

• Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators.

• Making enquiries of management.

• Testing key management controls.

• Analytical procedures.

• Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation.

• Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report.

• Reading the documents.

A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient

appropriate evidence are deliberately limited relative to a reasonable assurance engagement.

Limitations

Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the

methods used for determining such information.

The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can

result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature

and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the

Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual.

The scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Poole Hospital NHS

Foundation Trust.

Conclusion

Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2013:

• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;

• the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports; and

• the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation

Trust Annual Reporting Manual.

Deloitte LLP

Chartered Accountants

…May 2013


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Appendix 2: List of Interviewees and Documentation Reviewed


Interviewees Documentation Reviewed

As part of our work, we reviewed the following documentation:

• The Trust’s Quality Report for 2012/13

• The Trust’s Quality Report for 2011/12

• The Head of Internal Audit Opinion and Annual Report for

2012/13

• 2012/13 Board minutes and papers

• Complaints Report

• Stakeholder communications

• Latest national and local patient survey

• Latest national and local staff survey

• Annual Governance Statement

• Care Quality Commission’s quality and risk profiles

As part of our work, we interviewed several of the Trust staff

including:

• Martin Smits

• Sam Robinson

• Sue Budden

• Denise Richards

• Jaydee Swarbrick


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Appendix 3: Details of key performance indicators (KPIs)

tested in our work The Trust needed to select two indicators for audit testing from three that were identified by Monitor. The three identified indicators are

set out below and the Trust selected items 1 and 2 from the available indicators:

1. Clostridium Difficile - Clostridium Difficile, often referred to as C. Difficile (or C-diff), is a bacterium that is present naturally in the gut of around

two thirds of children and 3% of adults. C. Difficile does not cause any problems in healthy people but some antibiotics that are used to treat

other health conditions can interfere and cause the C. Difficile bacteria to multiply and produce toxins. At this point, a person is said to be

infected with C. Difficile.

2. 62 day cancer - The NHS Cancer Plan set the goal that no patient should wait longer than two months (62 days) from a GP urgent referral for

suspected cancer to the beginning of treatment, except for good clinical reasons.

3. 28 day readmission - The percentage of patients readmitted to hospital with 28 days of discharge following their operation can indicate early

complications after discharge and how appropriate the original decision made to discharge was. Some emergency readmissions are to be

expected given the complex nature of the patients the Trust treats.

In addition, the Trust was required to obtain a private report in connection with Patient Safety Incidents and the definition is outlined below:

• Severe Harm/Death Patient Safety Incidents - Any Patient Safety Incident (PSI) that appears to have resulted in permanent harm to one or

more persons receiving NHS funded care. Permanent harm directly related to the incident and not to the natural course of the patient’s illness or

underlying condition is defined as a permanent lessening of bodily functions, sensory, motor physiologic or intellectual, including removal of the

wrong limb or organ or brain damage


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Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited (“DTTL”), a UK private company limited by guarantee, and its network of member firms, each of which

is a legally separate and independent entity. Please see www.deloitte.co.uk/about for a detailed description of the legal structure of DTTL and its member firms.



Deloitte LLP is a limited liability partnership registered in England and Wales with registered number OC303675 and its registered office at 2 New Street Square, London

EC4A 3BZ, United Kingdom. Tel: +44 (0) 20 7936 3000 Fax: +44 (0) 20 7583 1198.

Member of Deloitte Touche Tohmatsu Limited

18 Draft NHS Quality Report 2012/2013 - XXX NHS FT CoG�Sep�13�E2�PHFT�QA�Report�(

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Agenda Item: 9 Paper No: F

Title:

Deloitte LLP Letter and Report on the Financial Audit

Purpose:

To present the Council of Governors with a report on the audit of the Trust’s 2012/13 financial statements from the external auditors, Deloitte LLP.

Summary:

Please see report attached.

Recommendation:

The Council of Governors are asked to note the report

Prepared by:

Presented by:

MATTHEW HEPENSTAL Deloitte LLP

CoG�Sep�13�F1�Cover�Sheet�Delo

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September 2013

Poole Hospital NHS Foundation Trust

External audit report to the Council of

Governors on the audit of the Trust’s

2012/13 financial statements

CoG�Sep�13�F2�Poole�Report�to�

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Contents

Executive summary 1

1. Our approach 3

2. The focus of our work 4

3. Analysis of audit fees 6

4. Responsibility statement 7

Appendix 1: Briefing on Audit Matters 8


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External audit report to the Council of Governors 1

Executive summary

Introduction

We were delighted to be appointed as the Trust’s external auditor by you, the Poole

Hospital NHS Foundation Trust (“the Trust”) Council of Governors, in October 2012.

We have now completed our first year as the Trust’s external auditor. This report to you

summarises the findings of our audit of the Trust’s 2012/13 signed financial statements

and is not an update to our audit report issued on 29 May 2013.

We also performed certain procedures in respect of the Trust’s 2012/13 Quality Report

and, in accordance with guidance published by Monitor, our findings from that work are

set out in a separate report to you.

We have issued a clean or unqualified opinion on the Trust’s 2012/13 financial

statements

We provided detailed reports, on both our audit of the Trust’s financial statements and our

work on the Trust’s Quality report, to the Trust’s Audit and Governance Committee and

Board in May 2013 and signed our audit opinion on the Trust’s financial statements. Our

opinion on the financial statements was as follows:

In our opinion the financial statements:

give a true and fair view of the state of the Trust’s affairs as at 31 March 2013

and of its income and expenditure for the year then ended;

have been properly prepared in accordance with the accounting policies directed

by Monitor – Independent Regulator of NHS Foundation Trusts; and

have been prepared in accordance with the requirements of the National Health

Service Act 2006.


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Executive summary (continued)

Our audit report includes a clean ‘report by exception’

As well as providing an opinion on the Trust’s financial statements, in accordance with

Monitor’s Code of Audit Practice (“the Code”) we are also required to perform other

procedures and sign a ‘report by exception’ on certain other matters. In respect of this

requirement, we included the following statement in our audit report on the Trust’s

financial statements:

We have nothing to report in respect of the following matters where the Audit Code for

NHS Foundation Trusts requires us to report to you if, in our opinion:

the Annual Governance Statement does not meet the disclosure requirements set

out in the NHS Foundation Trust Annual Reporting Manual, is misleading or

inconsistent with information of which we are aware from our audit. We are not

required to consider, nor have we considered, whether the Annual Governance

Statement addresses all risks and controls or that risks are satisfactorily addressed

by internal controls;

proper practices have not been observed in the compilation of the financial

statements; or

the NHS foundation trust has not made proper arrangements for securing

economy, efficiency and effectiveness in its use of resources.


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1. Our approach

Procedures for auditing the Trust’s financial statements

In summary, the audit of the Trust’s financial statements included:

developing an understanding of the Trust, including its systems, processes, risks,

challenges and opportunities and then using this understanding to focus audit

procedures on areas where we consider there to be a higher risk of misstatement

in the Trust’s financial statements;

interviewing members of the Trust’s management team and reviewing

documentation to test the design and implementation of the Trust’s internal

controls in certain key areas relevant to the financial statements; and

performing sample tests on balances in the Trust’s financial statements to

supporting documentary evidence, as well as other analytical procedures, to test

the validity, accuracy and completeness of those balances.

We have included further details of our audit approach in Appendix 1.


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2. The focus of our work

Our focus on items in the financial statements which had a higher risk of misstatement

When auditing the Trust’s financial statements, we focused our work on significant balances and

on those areas where we considered there to be a higher risk of misstatement. We refer to these

areas as significant audit risks. We assessed the significant audit risks of the Trust in our

transition and planning procedures and provided a detailed audit planning document to the

Trust’s Audit and Governance Committee in January 2013. This document set out the significant

audit risk areas for the Trust, together with our planned approach to addressing those risks.

We have provided a summary of each of the significant audit risks in the table below.

We did not identify any audit adjustments greater than our planning materiality level. Based on

our procedures, we concluded that the Trust’s financial statements were not materially misstated

and did not identify material issues in any of the significant audit risk areas we had identified. We

have made some recommendations for the improvement of the Trust’s policies, procedures and

internal controls throughout the year. However, we do not consider these recommendations to

reflect any material weakness in the Trust’s control environment and the Trust has been

committed to the implementation of our recommendations.

Significant audit risk Description of risk

Going Concern

In assessing the validity of the going concern assumption as the basis for preparing the Trust’s 2012/13 accounts, the Trust is required to consider all available information about the future in reaching its conclusion. To help inform the Trust’s assessment the Trust’s Director of Finance prepared a paper for the members of the Audit and Governance Committee outlining why the Trust would continue to be a going concern for at least 12 months beyond the date of signing the accounts.

We assessed and challenged the content of this paper and agreed that the going concern basis was valid for the 2012/13 accounts. Of particular note is the Trust’s forecast surplus for 2013/14 and a forecast cash balance of more than £10 million at 31 March 2014. Looking forward, it is evident that this assessment must continue to be updated to assess the validity of the going concern basis for accounts prepared in future years.

We concluded that the assumptions used by management were reasonable and that appropriate disclosure had been made in the Trust’s Annual Report and Accounts.

Property valuations and the treatment of fixed asset additions

The Trust used an external Valuer to perform a desk-top valuation of its estate in 2012/13. The valuation of assets is based on a number of assumptions and judgements made by the Trust and its Valuer. We identify this as a significant audit risk because, given the size of the Trust’s estate, small changes or errors in assumptions could have a significant impact on the asset balance shown in the Trust’s financial statements.

We concluded that the Trust’s accounting treatment for this area had been reasonable.

Recognition and provisioning of revenue and receivables

The Trust’s 2012/13 income was generated predominantly from contracts with PCTs. In addition, there were various other sources of income from a range of patient-based and non-patient based activities including private patients, car parking and education and training. The Trust also recognised £2.5 million of charitable income derived largely from the donation of funds in connection with the new MRI Scanner and the oncology management IT system.

At 31 March 2013 the Trust’s financial statements showed that it was owed £6.8m from other NHS bodies. Typically, Trusts do not expect to receive the full amount of


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Significant audit risk Description of risk

debt they are owed and therefore estimate a provision against that debt in the financial statements. At 31 March 2013 the Trust estimated a provision of £0.5m against this debt. This estimate is based on management judgements and assumptions. As auditors we focus our attention on estimates like this because, due to their nature, they are more susceptible to management bias.

We concluded that the Trust’s accounting for these areas had been reasonable.

Provision for redundancies

The level and recognition of provisions for board or other redundancies is an area of risk as a result of the judgment applied to the calculations and the sensitivity of the resulting disclosures. A provision of £1.26m has been recognised in the accounts arising from the status of the proposed merger.

We concluded that the accounting treatment for this area had been appropriate.

Transfer of ledger to a third party service provider

From 1 April 2012 the finance ledger has been operated by ELFS, a third party service provider. This fundamental change in underlying responsibility and controls represented a risk in the first year of operation both in relation to the ledger transfer and the impacts on the underlying financial controls.

We note that the Trust management is working with ELFS to formalise roles and we recommend that these are formalised in the Trust’s laid down procedures. We did not, however, identify any issues during the course of our audit with the quality of working papers provided either ELFS or Trust management.

Management override of controls

As auditor we are required to assume on all audits that there is a risk that management may override control procedures. To address this risk we focus our attention on the key accounting estimates made by management, such as provisions for amounts owed to the Trust and valuations, as well as looking at the effectiveness of other controls such as those around input of entries to the Trust’s accounting system.

We did not identify any instances of management override of controls.


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3. Analysis of audit fees

The professional fees earned by Deloitte in the period from 1 April 2012 to 31

March 2013 were in accordance with our contract as follows:

Current year

£

Work carried out under the Monitor Audit Code

Financial statement audit 42,975

Whole of Government Accounts 3,000

Quality Accounts work 13,000

58,975

Audit related services

Audit of the Trust’s charity 4,200

Total audit services 63,175

Non-audit services

None nil

Total non-audit services nil

Total fees 63,175


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4. Responsibility statement

This report should be read in conjunction with the "Briefing on audit matters" included as an appendix to this

report. This report sets out matters of interest which came to our attention during the audit. Our audit was not

designed to identify all matters that may be relevant to the Trust and this report is not necessarily a

comprehensive statement of all deficiencies which may exist in internal control or of all improvements which

may be made.

This report has been prepared for the Council of Governors and we therefore accept responsibility to you alone

for its contents. We accept no duty, responsibility or liability to any other parties, since this report has not been

prepared, and is not intended, for any other purpose. Except where required by law or regulation, it should not

be made available to any other parties without our prior written consent.

Deloitte LLP

Chartered Accountants

Southampton

10 September 2013


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Appendix 1: Briefing on audit matters

Published for those charged with governance

This document is intended to assist those charged with governance to understand

the major aspects of our audit approach, including explaining the key concepts

behind the Deloitte Audit methodology including audit objectives and materiality.

Further, it describes the safeguards developed by Deloitte to counter threats to our

independence and objectivity.

This document will only be reissued if significant changes to any of those matters

highlighted above occur.

We will usually communicate our audit planning information and the findings from

the audit separately. Where we issue separate reports these should be read in

conjunction with this "Briefing on audit matters".

Approach and scope of the audit

Primary audit

objectives

We conduct our audit in accordance with International Standards on Auditing (UK &

Ireland) as adopted by the UK Auditing Practices Board (“APB”). Our statutory audit

objectives are:

to express an opinion in true and fair view terms to the members on the

financial statements;

to express an opinion as to whether the accounts have been properly prepared

in accordance with the relevant Financial Reporting Manual;

for certain disclosures relating to directors’ remuneration to form an opinion as

to whether they are made in accordance with the relevant Financial Reporting

Manual; and

to express an opinion as to whether the directors’ report, including the business

review, is consistent with the financial statements.

Other reporting

objectives

Our reporting objectives are to:

present significant reporting findings to those charged with governance. This

will highlight key judgements, important accounting policies and estimates and

the application of new reporting requirements, as well as significant control

observations; and

provide timely and constructive letters of recommendation to management.

This will include key business process improvements and significant controls

weaknesses identified during our audit.

Materiality The concept of materiality is fundamental to the preparation of the financial

statements and the audit process and applies not only to monetary misstatements

but also to disclosure requirements and adherence to appropriate accounting

principles and statutory requirements.


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(continued)

Approach and scope of the audit (continued)

Materiality (continued) “Materiality" is defined in the International Accounting Standards Board's

"Framework for the Preparation and Presentation of Financial Statements" in the

following terms:

"Information is material if its omission or misstatement could influence the economic

decisions of users taken on the basis of the financial statements. Materiality

depends on the size of the item or error judged in the particular circumstances of its

omission or misstatement. Thus, materiality provides a threshold or cut-off point

rather than being a primary qualitative characteristic which information must have if

it is to be useful."

We determine materiality based on professional judgment in the context of our

knowledge of the audited entity, including consideration of factors such as

shareholder expectations, industry developments, financial stability and reporting

requirements for the financial statements.

We determine materiality to:

determine the nature, timing and extent of audit procedures; and

evaluate the effect of misstatements.

The extent of our procedures is not based on materiality alone but also the quality of

systems and controls in preventing material misstatement in the financial

statements, and the level at which known and likely misstatements are tolerated by

you in the preparation of the financial statements.

Uncorrected

misstatements

In accordance with International Standards on Auditing (UK and Ireland) (“ISAs (UK

and Ireland)”) we will communicate to you all uncorrected misstatements (including

disclosure deficiencies) identified during our audit, other than those which we

believe are clearly trivial.

ISAs (UK and Ireland) do not place numeric limits on the meaning of ‘clearly trivial’.

The Audit Engagement Partner, management and those charged with governance

will agree an appropriate limit for 'clearly trivial'. In our report we will report all

individual identified uncorrected misstatements in excess of this limit and other

identified errors in aggregate.

We will consider identified misstatements in qualitative as well as quantitative terms.


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(continued)

Approach and scope of the audit (continued)

Audit methodology Our audit methodology takes into account the changing requirements of auditing

standards and adopts a risk based approach. We utilise technology in an efficient

way to provide maximum value to members and create value for management and

the Board whilst minimising a “box ticking” approach.

Our audit methodology is designed to give directors and members the confidence

that they deserve.

For controls considered to be ‘relevant to the audit’ we evaluate the design of the

controls and determine whether they have been implemented (“D & I”). The controls

that are determined to be relevant to the audit will include those:

where we plan to obtain assurance through the testing of operating

effectiveness;

relating to identified risks (including the risk of fraud in revenue recognition,

unless rebutted and the risk of management override of controls);

where we consider we are unable to obtain sufficient audit assurance through

substantive procedures alone; and

to enable us to identify and assess the risks of material misstatement of the

financial statements and design and perform further audit procedures

Other requirements of

International Standards

on Auditing (UK and

Ireland)

ISAs (UK and Ireland) require we communicate the following additional matters:

ISA (UK & Ireland) Matter

ISQC 1 Quality control for firms that perform audits and review of financial statements,

and other assurance and related services engagements

240 The auditor’s responsibilities to consider fraud in an audit of financial statements

250 Consideration of laws and regulations in an audit of financial statements

265 Communicating deficiencies in internal control to those charged with governance

and management

450 Evaluation of misstatements identified during the audit

505 External confirmations

510 Initial audit engagements – opening balances

550 Related parties

560 Subsequent events

570 Going concern

600 Special considerations – audits of group financial statements (including the work

of component auditors)

705 Modifications to the opinion in the independent auditor’s report

706 Emphasis of matter paragraphs and other matter paragraphs in the independent

auditor’s report

710 Comparative information – corresponding figures and comparative financial

statements

720 Section A: The auditor’s responsibilities related to other information in

documents containing audited financial statements


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(continued)

Independence policies and procedures

Important safeguards and procedures have been developed by Deloitte to

counter threats or perceived threats to our objectivity, which include the items

set out below.

Safeguards and

procedures

Every opinion (not just statutory audit opinions) issued by Deloitte is subject to

technical review by a member of our independent Professional Standards

Review unit.

Where appropriate, review and challenge takes place of key decisions by the

Second Partner and by the Independent Review Partner, which goes beyond

ISAs (UK and Ireland), and ensures the objectivity of our judgement is

maintained.

We report annually to those charged with governance our assessment of

objectivity and independence. This report includes a summary of non-audit

services provided together with fees receivable.

There is formal consideration and review of the appropriateness of continuing

the audit engagement before accepting reappointment.

Periodic rotation takes place of the audit engagement partner, the independent

review partner and key partners involved in the audit in accordance with our

policies and professional and regulatory requirements.

In accordance with the Revised Ethical Standards issued by the APB, there is

an assessment of the level of threat to objectivity and potential safeguards to

combat these threats prior to acceptance of any non-audit engagement. This

would include particular focus on threats arising from self-interest, self-review,

management, advocacy, over-familiarity and intimidation.

In the UK, statutory oversight and regulation of auditors is carried out by the

Professional Oversight Board (POB) which is an operating body of the

Financial Reporting Council. The Firm’s policies and procedures are subject to

external monitoring by both the Audit Inspection Unit (AIU), which is a division

of POB, and the ICAEW’s Quality Assurance Department (QAD). The AIU is

charged with monitoring the quality of audits of economically significant entities

and the QAD with monitoring statutory compliance of audits for all other

entities. Both report to the ICAEW’s Audit Registration Committee. The AIU

also reports to POB and can inform the Financial Reporting Review Panel of

concerns it has with the accounts of individual companies.


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(continued)

Independence policies and procedures (continued)

Independence policies Our detailed ethical policies’ standards and independence policies are issued to all

partners and employees who are required to confirm their compliance annually. We

are also required to comply with the policies of other relevant professional and

regulatory bodies.

Amongst other things, these policies:

state that no Deloitte partner (or any closely-related person) is allowed to hold a

financial interest in any of our UK audited entities;

require that professional staff may not work on assignments if they (or any

closely-related person) have a financial interest in the audited entity or a party

to the transaction or if they have a beneficial interest in a trust holding a

financial position in the audited entity;

state that no person in a position to influence the conduct and outcome of the

audit (or any closely related persons) should enter into business relationships

with UK audited entities or their affiliates;

prohibit any professional employee from obtaining gifts from audited entities

unless the value is clearly insignificant; and

provide safeguards against potential conflicts of interest.

Remuneration and

evaluation policies

Partners are evaluated on roles and responsibilities they take within the firm

including their technical ability and their ability to manage risk.

APB Revised Ethical

Standards

The Auditing Practices Board (APB) has issued five ethical standards for auditors

that apply a ‘threats’ and ‘safeguards’ approach.

The five standards cover:

maintaining integrity, objectivity and independence;

financial, business, employment and personal relationships between auditors

and their audited entities;

long association of audit partners and other audit team members with audit

engagements;

audit fees, remuneration and evaluation of the audit team, litigation between

auditors and their audited entities, and gifts and hospitality received from

audited entities; and

non-audit services provided to audited entities.

Our policies and procedures comply with these standards.


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Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited (“DTTL”), a UK private company limited by guarantee, and its network of

member firms, each of which is a legally separate and independent entity. Please see www.deloitte.co.uk/about for a detailed description of

the legal structure of DTTL and its member firms.



Deloitte LLP is a limited liability partnership registered in England and Wales with registered number OC303675 and its registered office at 2

New Street Square, London EC4A 3BZ, United Kingdom. Tel: +44 (0) 20 7936 3000 Fax: +44 (0) 20 7583 1198.

Member of Deloitte Touche Tohmatsu Limited


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COUNCIL OF GOVERNORS – COVER SHEET

Meeting Date: 26 September 2013 Agenda Item: 10 Paper No: G

Title:

Complaints Annual Report 2012/2013

Purpose:

The Statutory Instrument 2009 No 309 NHS England, Social Care, England, the Local Authority Social Services and NHS Complaints (England) Regulations 2009” requires an annual report which must cover a number of key areas and is available to any person on request.

Summary:

The report covers the number of complaints, how many complaints have been referred to the Parliamentary and Health Service Ombudsman and the actions taken to improve matters as a consequence of complaints made as per the Statutory Instrument Para 18 (1).

Recommendation:

For information

Prepared by:

CARRIE STONE Legal Services Manager

Presented by:

ROBERT TALBOT Medical Director

This report is relevant to: (Please tick relevant box)

Assurance Framework

Risk Register I/D No.

Healthcare Standards: Please specify which standard

Financial implications YES / NO

Monitor compliance

Human Resources implications YES / NO

Internal monitoring

Yes Legal implications YES

CoG�Sep�13�G1�Annual�Report�Co

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POOLE HOSPITAL NHS FOUNDATION TRUST

COMPLAINTS ANNUAL REPORT

1st April 2012 to 31st March 2013

Briefing Paper for the Council of Governors

1 INTRODUCTION 1.1 The Statutory Instrument 2009 No 309 “NHS England, Social Care, England – the Local Authority Social Services and NHS Complaints (England) Regulations 2009” requires that Trust Boards must receive quarterly reports on complaints in order to monitor arrangements under the Regulations and use the information collected to identify trends and consider any lessons that feed into service improvement. The key areas to be covered in the annual report include the number of complaints received in total, the outcome, an analysis of the nature of the complaints, how many complaints have been referred to the Parliamentary and Health Service Ombudsman and the action taken to improve matters as a consequence of complaints being made. Reports must avoid any possible breach of patient confidentiality. 2 THE MANAGEMENT OF COMPLAINTS

2.1 The Trust’s Complaints Policy was amended and approved by the Trust Board in May 2009 following the publication of the revised complaints arrangements as set out in the 2009 Regulations. Guidance for the Investigation of Complaints, Claims and Incidents is available to staff and a guide “How to handle a complaint/concern” assists staff in dealing with patients’ complaints and concerns at ward and departmental level. Training is provided to all newly appointed registered nurses and Foundation Years 1 and 2 medical staff on the complaints policy and how to deal with difficult situations. The Trust employs a senior manager charged with managing the complaints procedure. The Medical Director is the Executive Director with responsibility for leading and overseeing the Complaints Policy, ensuring that processes are robust, lessons are learned and the impact for patients and the Trust mitigated. The Local Resolution stage of all investigations is scrutinised by the Chief Executive and letters of response are signed by the Chief Executive, in line with the requirements of the Statutory Regulations and the Trust’s Complaints Policy. The Trust’s Chairman receives copies of all complaints and responses. A leaflet entitled “How to make complaints, comments and suggestions – a guide for patients”, is available on all wards and departments and the Trust’s web-site provides information on how to access the complaints procedure. 3 NUMBER OF COMPLAINTS RECEIVED 3.1 The number of formal complaints received by the Trust for the year ending 31st March 2013 was 472. For the same period last year the total number received was 430. This equates to one complaint in every 737 admissions, Emergency Department attendances and Outpatient appointments. For the previous year, 1:791 patients/carers complained about an aspect of their hospital experience.

CoG�Sep�13�G2�Annual�Report�13

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3.2 The following graph illustrates the trend over the past eleven years, by financial year:

3.3 When reviewing the trend in terms of the number of complaints received by

the Trust over the last eleven years, the average number received annually is 400. For the previous year, the average was 392.

3.4 The NHSLA standards highlight the importance of ensuring that patients, relatives and carers have clear access to register formal complaints. The Trust’s “complaints leaflet” was redistributed to all wards and departments earlier in the year, together with the “Being Open” leaflet. The Trust accepts complaints in a variety of different formats, although letters remain the most common form of contact. The table below illustrates the methods by which patients and/or their relatives complain: there has been an increase in email contact from the previous year, from 22% to 27% and decrease in complaints received by letter, from 59% to 49%.

4 NATURE OF COMPLAINTS RECEIVED 4.1 Complaints relating to professional and clinical care, staff attitude,

communication problems and discharge and transfer arrangements are the most common cause of complaint. There has been a slight rise in complaints relating to clinical care from 38% to 41%. Looking at the trend over the previous 11 years for those complaints involving clinical care, this year falls

0

100

200

300

400

500

02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13

Complaints received April 02 - March 13

Received via E-mail 27%

Received via Letter

49%

Received in Person

3%

Received via the

telephone 21%

Method


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within the range. In terms of outcome, 36% were not upheld, 31% were upheld partially, 24% were upheld in their entirety, 6% of complainants received reimbursement for lost or damaged property, 3% of complainants withdrew their complaints and 1% resulted in disciplinary action being taken. The common themes arising from complaints are described in the quarterly reports to the Board of Directors and the Patient Safety and Quality Committee.

4.2 The following table illustrates the nature of complaints received across the

Trust. The incidence of the top 3 categories has changed since the previous year, with admission, discharge and transfer arrangements appearing in the “top 3” for the first time. Complaints concerning the attitude of staff are more prevalent in terms of numbers:

Category of Complaint Total

All aspects of clinical treatment 195

Attitude of staff 83

Admissions, discharge and transfer arrangements 48

Communication/information to patients (written and oral) 48

Patients' property and expenses 42

Appointments, delay/cancellation (out-patient) 26

Appointments, delay/cancellation (in-patient) 8

Hotel services (including food) 5

Patients' privacy and dignity 4

HA/PCG commissioning (including waiting lists) 4

Others 4

Aids and appliances, equipment, premises (including access) 2

Patients' status, discrimination (eg racial, gender, age) 1

Policy and commercial decisions of trusts 1

PCT commissioning (including waiting lists) 1

Totals: 472 4.3 This table illustrates where, by Division, complaints about clinical care have been received. Comparison with the previous year indicates a change in the profile with a greater number involving the Medical and Surgical Divisions:

Division Total

Medical Division 87

Surgical Division 68

MCD Division 39

Operations 1

Totals: 195 5 STAFF ATTITUDE


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5.1 Turning to complaints about staff attitude towards patients and their relatives, 18% of all complaints received raised concerns about this issue. This reflects a small increase of 3% in complaints of this nature from the previous financial year. Complaints of this nature are raised in the quarterly reports to the Board of Directors and the Patient Safety and Quality Committee. Action points are directed to all the Divisions and relevant Directorates. Customer care and communication training has been provided for individual members of staff. The Complaints, Claims, Incidents and PALS Review Group monitors complaints of this nature to review emerging trends and to monitor the impact of action plans and the highlighting of attitude in the Legal Services Department’s publication “Snapshots”. In terms of outcome, 44% were not upheld, 32% were upheld partially, 19% were upheld in their entirety, 3% were withdrawn by the complainant and 2% were referred for disciplinary investigation. A higher percentage was not upheld than has been seen in the previous two financial years.

5.2 The following tables illustrate where, by division/directorate and staff type, complaints of this nature have arisen:

Staff Type Total

Consultant 18

Staff Nurse 16

Registrar 13

Administrative/Trust Staff 7

Radiographer 6

Health Care Assistant 5

Associate Specialist 3

Physiotherapist 3

Midwife 2

Nurse Practitioner 2

Clinical Assistant 1

F1 1

Medical Laboratory Assistant 1

Other 1

F2 1

Sister 1

Technical Staff 1

Totals: 82

6 ACTIONS ARISING FROM COMPLAINTS AND LESSONS LEARNED 6.1 Summaries of a selection of complaints where action has been taken or

lessons learned following investigation are reported on a quarterly basis to the Board of Directors, Patient Safety and Quality Committee, Complaints,Claims, PALS and Incident Review Group and the Risk Management and Safety Group. Divisions are expected to provide updates on actions taken. The use of the checklist for all formal complaints, which is completed by the lead investigator(s) identifies the root cause(s) of the complaint and also confirms what action has been taken and to whom the

Division/Directorate Total

Medical Division 34

Surgical Division 24

MCD Division 22

Finance, IT and Estates 1

Operations 1

Totals: 82


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information is disseminated and discussed. Where appropriate, lessons learned in one division are notified to all divisions through the Complaints, Claims, PALS and Incident Review Group.

6.2 The following table illustrates outcomes at the conclusion of complaints investigations:

Outcomes at conclusion of complaint investigation

Total

Advice/warnings given to staff 223

No change recommended/necessary 210

Organisational change or review 19

Procedural/guideline alteration/production 11

Training/educational requirement identified 5

Remedial work, alteration to building/grounds 3

Human Resource Issues 1

Totals: 472

6.3 With regard to the 210 complaints where no changes were recommended or

necessary, 169 of these complaints were not upheld: of the remainder 12 were withdrawn and 28 received reimbursement or personal apologies.

6.4 Evidence of learning from complaints include:

Clinical Director reminded radiology of correct protocolling for particular type of CT scan.

Manufacturer of sweat test equipment provided additional training and support to nursing staff.

Matrons for Medicine and Children’s Services liaising to ensure that adults with autism in transition period are managed appropriately.

Review of clinic resulting in information now being forwarded to reception staff and radiotherapy nurse now checking waiting area to keep patients informed.

Leaflet written to accompany Anticoagulation Yellow book clarifying communication and referral process and consultant ensuring that doctors have a clear understanding of process of referral.

Detailed flow chart developed to assist staff when caring for patients following a TVT procedure.

Process now in place whereby appropriately trained staff in Outpatients can undertake FNA’s to reduce patient delays

Staff reminded of the importance of establishing GP details are accurate when patients attend physiotherapy appointments

Eligibility criteria for TBSI patients redefined by PCT

Staff reminded of importance of checking patients prior to discharge for cannulae in situ

Complainant’s views on disabled facilities to be taken into account during survey.

Review of discharge criteria when breastfeeding not established

Guidelines for bowel management and education session commenced on Lulworth Ward


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Importance of medicines reconciliation on the patient’s arrival to the ward or as soon as possible thereafter reinforced to junior medical staff.

System implemented in Children’s Unit to ensure that test results are checked and communicated to parents in a timely manner.

Review of discharge process in care of the elderly to ensure improvements in communication with relatives and carers.

Ward staff reminded of correct fitting of Jura walkers and the provision of advice to patients regarding their use.

Email sent by Infection Prevention and Control with regard to the disposal of soiled clothing

Staff reminded of the uniform policy and the use of mobile phones

Junior medical staff reminded that must check EPR before contacting patients

Antibiotic guidance in Dermatology Department reviewed and amended

Review of threshold for lockdown on Portland Ward initiated in view of patient who absconded from the ward

Practice with regard to transporting soup across the dome entrance area changed

Pathway for back pain reviewed and reinforced

EPU information leaflet amended and sent to patient for comment 7 REQUESTS TO THE HEALTH SERVICE OMBUDSMAN 7.1 The Statutory Instrument 2009 No 309 “NHS England, Social Care, England -

the Local Authority Social Services and NHS Complaints (England) Regulations 2009”, requires that the number of complaints referred to the Health Service Ombudsman is specified. In 2012/2013, 5 complainants referred their complaints, which equates to 1:94 complaints received. For the previous year the ratio was 1:53. Until April 2009, requests were made to the Health Care Commission for independent review, the Ombudsman being the third stage. The amendments to the regulations changed this process, streamlining it to a two stage process of Local Resolution and then the Ombudsman. The 5 requests have been reported in more detail in the quarterly complaints reports to the Board. In all 5 cases the Ombudsman decided not to investigate the complaints.

8 RESPONSE TIMES 8.1 The guidance on response times at the Local Resolution stage allows three

working days to acknowledge complaints. Letters of acknowledgement were sent to all complainants, 99% of which were within 3 days, which is an improvement of 1% over the previous year. The NHS Complaints Procedure no longer stipulates a time-scale within which the organisation must provide a substantive response. However, the Trust continues to aim for 85% responses within 25 days. For this financial year, 86% of all complaints received were replied to within that time-scale.

9 OUTCOMES 9.1 In terms of outcome, the vast majority of complainants want an acknowledgement of their concerns, to know why it happened, to receive a meaningful apology where shortcomings are identified, to be made aware of changes in practice arising from the investigation and for someone to be held accountable for what went wrong. Very few complainants start out wanting financial recompense. The Trust follows a policy of “Being Open” and


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apologises in those instances where complaints are upheld or partially upheld. 9.2 The table below illustrates the outcome of investigations:

Outcome Total

Complaint not upheld 169

Complaint upheld partially 146

Complaint upheld 114

Ex-gratia/reimbursement payments made 28

Complaint withdrawn 12

Referral to disciplinary procedure 3

Totals: 472

9.3 28 patients were offered reimbursement for loss of or damage to property or

out of pocket expenses. To date, 22 patients have received payments, totalling £4,378.

9.4 14 patients who sought explanations regarding the outcome of treatment

subsequently instructed solicitors to investigate the potential for a successful claim.

9.5 Since the second quarter of 2011/2012, the Legal Services Manager has also reported to the Board of Directors and the Patient Safety and Quality Committee the number of complainants who have contacted the Trust after the Local Resolution letter has been sent. The following table illustrates the nature of the contact made:

Nature of response Total

Seeking legal advice 3

Further questions 8

Clarification 2

Disputes investigation findings 8

Thank you to Legal Services Manager 21

The BOARD is asked to APPROVE this report. Carrie Stone Robert Talbot Legal Services Manager Medical Director May 2013


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1

INTEGRATED PERFORMANCE REPORT – COVER SHEET Meeting Date: 28th November 2012

Agenda Item: 14 Paper No: H

Title: Integrated Performance Report

Purpose:

To report on performance against key indicators for the Trust in August 2013.

Summary:

Financial Performance

The Trust has achieved a surplus of £50k in August bringing the cumulative surplus for the five months to £211k compared to plan of £98k. The overall Financial Risk Rating (‘FRR’) has fallen to 2 but the new, draft ‘Continuity of Service Rating’ remains at 4.

The Trust has delivered savings of £1.8m in the first 5 months, £0.2m ahead of plan and expects to achieve the full target of £4.3m for the year. However it is likely that around 28% of the CIP target will be delivered non-recurrently.

The Trust’s cash balance remains broadly in line with plan: £12.5m against plan of £12.6m. However the Trust is now unlikely to achieve its plan year position of £11.3m. Clinical Performance & Quality

The Monitor A&E metric (95% within 4 hours) was achieved in August (95.62%), quarter 2 year to

date 95.97%.

There were no C-Diff cases identified in August, the year to date total is four which is within the

planned level for the year of 19.

The MRSA year to date total for 2013-14 remains zero.

All cancer standards have been confirmed as achieved in July, the most recent period available.

RTT standards for admitted and non-admitted clock stops were met for August at aggregate and

Unify specialty level.

The 48 hour operating target (95%) was achieved in August for both general trauma patients and all

fractured Neck of Femur (NoF) targets. The 36 hour NoF target was not achieved in August.

There was one Endoscopy patient waiting in excess of the six week diagnostic target at the end of

August.

Stroke performance was achieved in August. The monthly delayed discharges snapshot for August was 2.40%. There were no Mixed Sex Accommodation (MSA) breaches in August

Recommendation:

For discussion and noting.

CoG�Sep�13�H�INTEGRATED�PERFOR

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2

Prepared by:

PAUL TURNER Director of Finance / KATE THOMAS Performance Manager /SOPHIE JORDAN Operations & Performance Manager

Presented by:

PAUL TURNER Director of Finance MARY SHERRY Chief Operation Officer MARTIN SMITS Director of Nursing SARAH-JANE TAYLOR HR Director

This report is relevant to: (Please tick relevant box)

Assurance Framework

Risk Register I/D No.

Healthcare Standards: Please specify which standard

Financial implications YES

Monitor compliance

Human Resources implications YES

Internal monitoring

Legal implications NO


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3

Year End

Target /

LimitMar-12 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

current

or YTD

Actual

YTD

Target /

LimitForecast

Jan-00

PATIENT EXPERIENCE

meeting the C-Diff objective (ytd) 19 24 27 2 2 3 4 4 ↑ 4 19 1.0

meeting the MRSA objective (ytd) =<1 1 4 0 0 0 0 0 ↑ 0 =<1 1.0

MSA occurances 0 0 1 0 0 0 0 0 ↔ 0 0

MSA patients 0 0 5 0 0 0 0 0 ↔ 0 1

VTE (target 90% to Mar 2013, 95% from Apr 1203) 95% 93.00% 94.10% 95.40% 95.50% 96.20% 95.90% ↓ 95.40% 95%

CLINICAL QUALITY

Dr Foster Mortality relative risk rating (3 month rolling) 100% 78.0 101.0 96.2 not avail 95.1 ↓ 95.1 100%

All deaths - actual as % of expected (Dr Foster) 100% 88.8% 103.2% 105.2% 94.7% 92.8% ↑ 92.8% 100%

HSMR deaths - actual as % of expected (Dr Foster) 100% 94.3% 101.8% 105.1% 92.0% 92.4% ↑ 92.4% 100%

Number of SUIs reported within appropriate timeframe (ytd) 12 19 1 4 7 8 12 ↓ 12

Number of Serious Untoward Incidents (SUIs) for the year to date 12 20 1 4 7 8 12 ↓ 12

ACCESS AND TARGETS

Referral to waiting time (weeks) for admitted (95th centile) 23.0 21.3 17.1 17.7 17.0 17.1 17.1 17.6 ↓ 17.6 -

Referral to waiting time (weeks) for non-admitted (95th centile) 18.3 17.0 16.7 15.3 15.1 15.0 16.0 16.0 ↔ 16.0 -

Referral to treatment (18 weeks) for admitted 90% 92.5% 98.0% 96.8% 97.9% 97.7% 97.7% 96.9% ↓ 96.9% 90% 1.0

Referral to treatment (18 weeks) for non-admitted 95% 96.6% 97.2% 97.3% 98.4% 98.2% 97.9% 97.6% ↓ 97.6% 95% 1.0

Referral to waiting time (18 weeks) for incomplete pathways 92% 93.5% 97.5% 98.4% 98.7% 98.2% 97.5% 97.3% ↓ 97.3% 92% 1.0

Maximum 62 day wait from referral to treatment for all cancers 85%

90.1%

qtr 92.2%

87.4%

qtr 89.3%92.1% 85.7%

88.3%

qtr 88.6%86.0% ↓

86.0% 85%

62 day wait for 1st treatment - consultant screening service 90%

100%

qtr 98.2%

100%

qtr 100%94.4% 95.7%

93.9%

qtr 94.8%91.9% ↓ 91.9% 90%

31 day wait for 2nd or sub treatment : Anti cancer drug treat 98%

100%

qtr 100%

100%

qtr 100%100.0% 100.0%

100%

qtr 100%100.0% ↔

100.0% 98%

31 day wait for 2nd or sub treatment : Surgery 94%

97.9%

qtr 98.8%

100.0%

qtr 98.9%96.8% 96.0%

100.0%

qtr 97.6%99.2% ↓

99.2% 94%

31 day wait for 2nd or sub treatment : Radiotherapy 94%

99.3%

qtr 99.6%

100.0%

qtr 98.2%99.2% 97.2%

100.0%

qtr 98.8%98.5% ↓ 98.5% 94%

31 days wait diagnosis to start of 1st treatment: All cancers 96%

100%

qtr 98.8%

99.2%

qtr 99.3%100.0% 100.0%

100%

qtr 100%99.3% ↓ 99.3% 96% 0.5

2 week wait from urgent GP referral to 1st appt (susp cancer) 93%

95.8%

qtr 96.3%

97.3%

qtr 99.3%94.8% 97.4%

95.4%

qtr 95.9%95.7% ↑

95.7% 93%

2 week wait for Symptomatic Breast Patients 93%

100%

qtr 96.1%

88.7%

qtr 93.5%91.9% 98.0%

94.5%

qtr 94.7%94.7% ↑ 94.7% 93%

percentage of patients within the 4 hour target 95% 96.11%

93.28%

qtr 94.85% 92.51% 96.40%

97.14%

qtr 95.38% 96.30% 95.62%↓

95.62% 95%1.0

Total time in A+E (95th centile) =< 4 hours 3hrs 59 4hrs 29 5hrs 07 3hrs 59 3hrs 58 3hrs 59 4hrs 00 ↓ 4hrs 00 =< 4 hours

Time to initial asessement (95th centile) =< 15 mins 12 21 22 19 17 21 17 ↓ 17 =< 15 mins

Time to treatment decision (median) =< 60 mins 67 62 61 55 68 83 59 ↓ 59 =< 60 mins

Unplanned reattendance rate =< 5% 2.83% 2.50% 2.90% 2.62% 2.20% 3.00% 2.50% ↓ 2.50% =< 5%

Left without being seen =< 5% 3.35% 3.10% 3.30% 3.00% 3.40% 3.60% 2.90% ↓ 2.90% =< 5%

1.0

0.5

A&

E

TRUST PERFORMANCE SUMMARY

Year To Date

August 2013

Dire

ctio

n #

Monitor

targets &

weightings

2011-12

RT

T

2012-13 2013-14

cancer

1.0


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4

Year End

Target /

Limit

Mar-12 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

current

or YTD

Actual

YTD

Target /

Limit

Forecast

No waits more than 6 weeks for diagnostic investigations 0 27 0 0 0 0 1 1 ↔ 1 0

Elective Access - rebooking 0 1 1 5 0 0 1 0 ↑ 0 0

Patients who spend at least 90% of their time on a stroke unit 80% 68% 82% 81% 81% 81% 90% 88% ↓ 88% 80%

Higher risk TIA cases who are treated within 24 hours 60% 70.6% 43% 49% 60% 46% 73% 48% ↓ 48% 60%

Outpatient Access : ASIs at =< 4% 4% 8% 27% 16% 12% 22% 20% 19% ↑ 19% 4%

Screening to normal results within 14 days 90% 96.8% 90.0% 89.0% 97.0% 93.0% 97.0% 98.0% ↑ 98.0% 90%

Screening to assessment in 21 days - screening to 1st appt offer 90% 94.8% 97.0% 84.0% 94.0% 92.0% 96.0% 99.0% ↑ 99.0% 90%

Screening to assessment in 21 days - screening to attended appt 90% 92.2% 92.0% 78.0% 82.0% 87.0% 90.0% 95.0% ↑ 95.0% 90%

90% of eligible woman screened within 36 months 90% 99.2% 99.0% 99.2% 98.6% 98.6% 99.3% 96.8% ↓ 96.8% 90%

Delayed transfers of care to be maintained at a minimal level 3.5% 6.18% 2.44% 1.10% 3.24% 3.23% 2.90% 2.40% ↑ 2.40% 3.5%

Trauma inpatients (fit for surgery) receive treatment within 48 hrs 95% 96% 98% 97% 95% 96% 96% 95% ↓ 95.00% 95%

Hip fractures who are medically fit for surgery receive treatment within

36 hours95% - 96% 96% 97% 95% 96% 88% ↓ 88%

Hip fractures within 36 hours (NHFD) 90% - 74% 86% 90% 86% 87% 77% ↓ 77%

Hip fractures to receive treatment within 48 hrs 95% 96% 99% 99% 100% 99% 96% 97% ↑ 97% 95%

OPERATIONAL EFFICIENCY

Theatre Utilisation - Main 85% 87.0% 87.0% 87.0% 85.0% 88.0% 85.2% 87.7% ↑ 87.7% 85%

Theatre Utilisation - Day (target 85% to Mar 2013, 80% from Apr 2013) 80% 74.0% 74.0% 77.0% 78.0% 76.0% 76.1% 78.8% ↑ 78.8% 80%

Day Case Rates (basket of 25) 75% 83.5% 78.7% 79.1% 75.6% 80.7% ↓ 80.7% 75%

Bed Occupancy 95% 96% 98% 98% 96% 95% 95% 95% ↔ 95% 95%

WORKFORCE INDICATORS

Staff Turnover (Overall) <=11% 0.92% 1.05% 0.64% 1.00% 0.41% 0.77% 1.12% ↑ 3.94% <=11% 94.60%

Staff Turnover (Auxiliaries and HCAs) <= 13.5% 1.54% 0.62% 1.24% 1.86% 0.40% 0.59% 1.95% ↑ 6.04% <= 13.5% 14.50%

Absence <=3.5% 3.85% 3.57% 3.80% 3.42% 3.33% 3.09% 3.16% ↑ 3.58% <=3.5%

FINANCE & ACTIVITY

Cash balance 15.4 15.0 19.8 13.7 13.3 12.9 12.5 12.5 12.6 11.3

Income 195.10 19.00 16.90 17.00 17.30 17.20 85.80 85.8 85.20 205.1

Operating Expenditure -182.20 -18.00 -16.00 -16.10 -16.17 -16.20 -80.70 -80.7 -80.10 -192.9

EBITDA 12.30 0.80 0.80 0.80 0.95 0.80 4.20 4.2 4.20 9.7

EBITDA % 6.3% 4.4% 4.3% 4.8% 5.5% 4.8% 5.0% 0.1 5.0% 4.8%

Surplus/Deficit 1.00 -0.10 0.00 0.03 0.08 0.00 0.20 0.2 0.10 0.2

SLA over / (under) performance 0.8 0.3 0.28 0.28 -4.70 0.20 0.40 0.00 0.0

CIP 0.20 0.30 0.5 0.3 1.8 1.8 1.60 4.3

Financial Risk rating - current 3 3 3 2 2 2 2 2 2 2

Financial Risk rating - revised 3 4 4 4 4 4 4 4 4 4

2011-12

Dire

ctio

n #

Year To Date

Monitor

targets &

weightings

2012-13

# : Arrow direction indicates improvement ↑, deterioration ↓, or no change ↔ in performance since the previous month

2013-14

access

bre

ast s

cre

en


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5

INTEGRATED FINANCE AND PERFORMANCE REPORT

Month Five - August 2013

Key Issue

Executive Summary RAG Sch

Monitor Targets

All Monitor standards were met in month five.

RTT

The Trust achieved the targets for admitted clock stops (96.7% against

90% target) and non-admitted (97.6% against 95% target) clock stops, at

aggregate level in August. The incomplete pathways target was achieved,

(97.3% against 92% target). The board should note an anticipated

underperformance will occur in Neurology over Sept/Oct whilst a backlog

of patients are treated through new capacity. The Trajectory to be agreed

with the CCG and an updated position will be reported in the next Board

report.

Cancer

All monitor cancer standards have been confirmed as achieved in July,

the most recent period available.

Emergency Department

The Monitor A&E metric (95% within 4 hours) was achieved in August

(96.30%). Work is on-going to achieve quarter 2, against a background of

increased attendances, particularly in the evenings.

MRSA

The MRSA year to date total for 2013-14 is zero. The 2013/14 target is zero, and the Monitor de minimis limit is 6 cases.

CDiff

There were no C-Diff cases identified in August, and the year to date total

of four is currently within the planned level for the year of 19. This metric

potentially attracts a Monitor rating of 1.0 if failed for the quarter.

Risk Assessment Framework (RAF)

The current Compliance Framework used by Monitor will be replaced

by the Risk Assessment Framework with effect from 1st October, the

third quarter. There are several key changes that relate to

performance, these include the following:

o All cancer targets are now weighted as 1.0 o MRSA has been removed o The risk rating calculation is no longer a purely transparent

quantitative process in that a variety of reports (eg CQC) will also be taken into account in addition to weighting scores.

Mo

nito

r sco

rec

ard

G


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6

Clinical Quality

The Clinical Quality scorecard is comprised of five key indicators, none of which are part of the Monitor scorecard. For the most recent year to date position (June/ August 2013) there are red rated indicators relating to SUIs only.

Mortality

During the three month period ended June 2013, (the latest information available from the Dr Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 95.1, within the target of 100.

Mortality performance for June 2013 has been green rated as the overall number of deaths was less than the expected level calculated by Dr Foster.

The HSMR subset for June 2013 has been green rated as the overall number of deaths was less than the expected level calculated by Dr Foster.

An audit has now been undertaken the Mortality group will continue to ensure that;

o cases with a zero or very low co-morbidity rating are reviewed ; o deaths are reviewed by clinicians; o pneumonia remains under scrutiny.

Serious Untoward Incidents

o There were 4 SUIs identified in August, these were reported within the prescribed timescale.

C

linic

al Q

uality

Sco

rec

ard

Key Issue

Executive Summary RAG Sch

Patient Experience

The Patient Experience scorecard is comprised of six key indicators; three of these are part of the Monitor scorecard. For the most recent year to date position ( August 2013)

C-Diff

There were no C-Diff cases identified in August, and the year to date total

of four is currently within the planned level for the year of 19. This metric

potentially attracts a Monitor rating of 1.0 if failed for the quarter.

Action: DoN to review

MRSA

The MRSA year to date total for 2013-14 is zero. The 2013/14 target is zero, and the Monitor de minimis limit is 6 cases.

Action: Infection Control issues remain under continued scrutiny DoN/Infection Control.

Mixed Sex Accommodation (MSA)

There have been no occurrences of mixed sex accommodation (MSA) breaches in August. Venous Thromboembolism (VTE)

VTE performance for August was 95.9%, continuing to achieve the increased target of 95% for 2013/14.

Patie

nt E

xp

erie

nc

e S

co

recard

A

G


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7

Key Issue Executive Summary RAG Sch

Access and Targets

The Access and Targets scorecard is comprised of 22 key indicators.

RTT (Performance Report appended)

The Trust achieved the targets for admitted clock stops (96.7% against

90% target) and non-admitted (97.6% against 95% target) clock stops, at

aggregate level in August. The incomplete pathways target was achieved,

(97.3% against 92% target).

At Unify specialty level, all specialities achieved the admitted, and the

non-admitted targets for August.

Operationally the Trust continues to pursue the achievement of RTT

targets at specialty level for each and every specialty.

Cancer

All monitor cancer standards have been confirmed as achieved in July, the most recent period available.

Emergency Department: 4 hour target (Performance Report appended)

The Monitor A&E metric (95% within 4 hours) was achieved in August

(96.30%). Work is on-going to achieve quarter 2, against a background of

increased attendances.

Diagnostic Access (Performance Report appended)

There was one Endoscopy patient waiting in excess of the six week

diagnostic target at the end of August, the patient was unable to attend an

earlier appointment due to commitments as a carer.

The percentage of all 15 key diagnostic tests waiting 6+ weeks has

exceeded the 1% PCT contract target due to an increase in radiology

demand. This situation is being reviewed and will be reported back at the

next Board meeting.

The department has been running additional lists in order to keep pace

with demand, which has been exacerbated by reduced capacity due to on-

going issues with the endoscopy washers.

Breast Screening (Performance Report appended)

All four reported breast screening targets were achieved in August.

Delayed Transfers of Care (Operations Summary appended)

The percentage of patients formally delayed on the last Thursday of

August (DH reporting methodology) was 2.40 %.

The focus continues on the reduction of informal delays and all other

internal delays in order to further improve inpatient pathways.

48 hours standard for #NoF and Trauma (Performance Report appended)

The 48 hour operating target (95%) was achieved in August for general trauma patients (96%) and for fractured NoF patients (95%). The 36 hours local target of 95% was not achieved (88%).

Stroke (Performance Report Appended)

Stroke performance was achieved in August, with 88% of patients

spending 90% of their stay on a stroke ward, against a target of 80%.

Acce

ss a

nd

Targ

ets

Sco

recard

A-G


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8

This performance should be noted in context of a high number of

presentations and a significant number of complex

ASI (Appointment Slot Issues)

Despite an improvement on July’s position, ASIs continued to exceed the

10% local target during August (19%). The deterioration in performance

has been due to both demand and capacity.

Actions continue to reduce the level of ASI, targeted at specialty level in

the coming months.

Efficiency The Efficiency scorecard is comprised of four key indicators; none of these are part of the Monitor scorecard. For the most recent year to date position (April/ July 2013) there is one red rated indicator:

Theatre Utilisation (Performance Report Appended)

Main theatre utilisation (88%) attained the 85% target in August.

Day theatre utilisation did not achieve 80% target (79%).

Both metrics have improved since last month. Bed Occupancy

Average bed occupancy in August was 95%, against the internal target of 95%. Daycase Rate

The day case rate for June was 80.7%, achieving the 75% target.

Effic

ien

cy S

co

reca

rd

Workforce Indicators

The Workforce Indicator Scorecard (Appended) comprises of eight key measures of HR performance, three of which are RAG rated.

Staff Turnover (overall) at 1.12%, (3.94% year to date) rated green

Staff Turnover (Auxiliaries and HCA) at 1.95%, (year to date 6.04%) amber rated

Staff sickness at 3.16%, (3.58% year to date) rated green

A-G

A


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9

Finance & Activity

The Trust has achieved a surplus of £50k in August bringing the cumulative surplus for the 5 months to £211k compared to plan of £98k. The financial performance in the first 5 months of 2013/14 represents continued effective financial control but the forecast balanced financial position is increasingly dependent on non-recurring elements and on non-cash elements such as donated income. A detailed forecast for the year, directorate by directorate, has confirmed that the Trust is still projected to achieve the planned surplus of £0.2m. However the detailed forecast has confirmed that the Trust has a number of cost pressures which are currently being offset by non-recurring savings / underspends including the following:

£2.5m charitable income compared to sustainable level of approximately £1m

£3.3m ‘transitional’ funding which, although recurring, isn’t at present supported by activity / services

‘Vacancy’ factor of £2.8m which may become more difficult to sustain

High levels of agency and locum costs (£4m p.a.) currently off-set by other underspends on pay

Cost pressures in ED supported by non-recurring income and non-recurring underspends in other directorates

The overall Financial Risk Rating (‘FRR’) has fallen to 2 but the new, draft

‘Continuity of Service Rating’ remains at 4.

The Trust has delivered savings of £1.8m in the first 5 months, £0.2m ahead

of plan and expects to achieve the full target of £4.3m for the year. However it

is likely that around 28% of the CIP target will be delivered non-recurrently.

The Trust has spent £2.1m (17%) of its annual capital expenditure and

committed a further £4.7m bringing the total to £6.8m, 54% of the total

programme. It is likely that The Trust will need to commit additional capital

funds in year to address key priorities Recommendations will be made via the

Finance and Investment Committee in October.

The Trust’s cash balance remains broadly in line with plan: £12.5m against

plan of £12.6m. However the Trust is now unlikely to achieve its plan year

position of £11.3m. Revised forecast is dependent upon BoD decisions on

capital expenditure but even if capital expenditure is maintained in line with

plan the year cash balance will fall to approximately £9m (see relevant section

of report)

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10

Operations Summary August 2013

(For the period of 1st to 31st August 2013)

Note: This report summarises various operational aspects year to date. The performance

information relates to actual activity rather than a comparison against contract.

SUMMARY

1 ACTIVITY 1.1 There is no significant in month variance to the non-elective admissions year to date.

1.2 Attendances in the Emergency Department have marginally increased by 1.3% in August

2013 compared to the same period last year, this is a decrease on the previous months

activity.

1.3 Elective activity continues to steadily increase, with 5.2% more elective admissions and the

day case rate increasing by 1.0%.

1.4 The number of Maternity Ante Natal Day Assessment (ANDA) admissions year to date has

stabilised in comparison with the previous year due to ANDA activity being fully repatriated

back to PHFT.

1.5 Paediatric non-elective admissions have decreased in month by 6.1% YTD.

1.6 The variance in Trust activity (YTD) is summarised below

Activity Year to Date

Previous year

to date 12/13

Year to date

13/14

Variance

Adult Non Elective Admissions (Spells)

(Inc emergency & transfers excl maternity)

9,984 9,949 -0.4%

Child Non Elective Admissions (Spells)

(Excl maternity and Incl. children under 16)

3,158 2,967 -6.1%

Maternity Admissions (Spells)

4,795 4,895 +2.0%

Emergency Dept Attendances

25,823 26,160 +1.3%

Elective Inpatient Spells (all ages)

1,698 1,787 + 5.2%

Day Cases (all ages), including regular day attenders

11,660 11,783 +1.0%


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11

1.7 The table below shows a comparison of non-elective admission figures by specialty from

April 2012 to date.

Data Source: Kate Thomas

1.8 The graph below shows a decrease in new outpatient activity in August by 13% compared

to the previous month, this corresponds with an overall yearly trend. However, a 6% rise in

new appointment attendances can be seen YTD compared to 12/13

4000

4500

5000

5500

6000

6500

7000

7500

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

New Outpatient Attendances

New Outpatient Attend13/14




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12

Data source: Operations Monthly Report

2 LENGTH OF STAY

2.1 Adult Non Elective average Length of Stay (LOS) for August 2013 was 5.16 days. This is a

decrease on the previous month of 0.3 days.

2.2 The graph below shows the average adult non elective LOS from April 11 to date

5.00

6.00

7.00


Non-Elective: Adult

Non-Elective - Adult13/14




2.3 The table below shows LoS by Directorate from January 2012 to date. The majority of

areas have seen a reduction in LoS, however there are still a number of outlying services.

(The Medical and Elderly medicine statistics include assessment unit activity).

Grand Total

Jan Feb Mar Apr May Jun Jul Aug Sep Oc t Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Elderly Medicine 7.2 7.6 7.8 7.0 7.0 7.3 7.6 7.4 7.5 7.3 7.7 7.1 8.0 7.8 7.3 7.3 8.0 7.3 8.1 7.5 7.8

Gynaecology 1.6 1.9 1.9 1.6 1.9 1.9 1.8 1.7 1.6 1.9 1.7 2.2 2.0 1.4 1.5 1.4 1.8 2.1 2.0 2.1 1.8

Medical 2.9 3.2 2.8 3.2 2.7 2.8 2.9 3.1 2.9 3.1 3.3 2.8 3.0 2.9 2.5 3.2 3.0 3.1 2.8 2.8 2.7

Obstetrics and Well Babies 1.1 1.2 1.2 1.1 1.2 1.2 1.2 1.4 1.4 1.3 1.2 1.4 1.3 1.3 1.2 1.2 1.3 1.4 1.1 1.3 1.2

Oncology 5.8 5.6 5.6 7.0 7.4 6.0 7.0 7.4 4.5 4.8 5.3 5.9 6.3 6.0 6.1 5.1 5.1 5.5 5.7 6.5 6.1

Paediatric 1.7 1.9 1.8 2.4 1.8 2.0 2.0 2.0 2.1 2.1 1.3 1.4 2.0 1.9 1.7 1.3 1.6 1.8 2.2 2.0 1.9

Specialist Medical Services 16.7 14.2 16.8 19.1 18.5 9.3 14.1 9.6 14.7 12.8 15.9 22.7 15.9 13.3 16.9 17.8 33.4 8.0 12.4 11.6 13.6

Surgery 2.4 2.5 2.4 2.6 2.7 2.7 2.3 2.6 2.5 2.5 2.9 2.9 2.5 2.8 2.8 2.6 2.6 2.5 2.8 2.5 2.6

Trauma & Orthopaedics 7.0 6.1 6.3 6.6 5.5 5.9 6.1 6.1 6.2 7.2 7.0 7.0 8.0 7.9 7.3 7.3 6.5 6.2 6.1 5.6 6.4

Grand Total 3.1 3.1 3.0 3.2 3.0 3.0 3.0 3.3 3.0 3.2 3.2 3.1 3.4 3.2 3.1 3.2 3.3 3.0 3.1 3.0 3.1

2012 2013

Data Source: Information Team – C Stewart

2.4 The percentage of time the Trust is in a red bed state is a clear indication of how

pressurised the whole system is. The Hospital was in a red bed state for 48% of the time

during August 2013.


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13

3 DELAYED TRANSFERS OF CARE

3.1 The percentage of patients formally delayed on the last Thursday of August 2013 (DH reporting methodology) was 2.4%, 0.9% under Trust target. This is an improvement on the 2.9% recorded in July. The total number of bed days lost in month (552) a decrease on last month, July (598) and June (453) (Estimated Angio data)

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%


% Delayed Transfers of Care From Acute Beds including Paediatrics

Yr13/14

Yr12/13

Yr11/12

3.2 Delays during August were due to: Angiography/Angioplasty at RBCHFT (Not available),

Community Hospitals (25%), Social Services (24%), Intermediate Care (12%), Self-Funding

patients (23%), and the CHC assessment process (16%). Actions continue to be

progressed on a continuous basis to improve delays overall and tackle the main causes of

delays

3.3 The total number of bed days lost during August (552) showed a similar performance from partner agencies compared to July (598).

0

250

500

750

1000

1250

1500


Total Bed Days Lost

TOTAL Delays13/14

TOTAL Delays12/13

TOTAL Delays11/12


3.4 The number of bed days lost due to self-funding patients in August was 88 bed days

compared to 30 in June and 124 in July. The number has decreased in month, which may

be contributed by the introduction of a dedicated self-funding social worker starting in

month to support Poole locality patients.


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14

0

50

100

150

200

250

300

350


Number of Bed Days lost due to awaiting Self-Funding (data started Aug-09)

Self-Funding13/14

Self-Funding12/13

Self-Funding11/12


3.5 The number of patients delayed waiting for a community hospital has maintained the

performance of an average of 3 patients per day. The Discharge Team continue to validate

of delays with the Community Hospital Matron weekly and daily communications with

hospital leads to ensure speedier transfer of patients.

0

250

500

750

1000

1250


Number of Bed Days lost due to awaiting transfer to Community Hospitals

Community Hospitals13/14




3.6 The number of patients delayed as a result of the Continuing Health Care (CHC)

assessment process has decreased with 63 bed days lost in August, therefore decreasing

to an average of 2 delays per day. The ward teams continue to find the administration

element of CHC process a challenge to manage in a busy ward environment. The data

overleaf also includes the Funding out of Hospital (FoH) statistics.


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15

0

50

100

150

200

250


Number of Bed Days lost due to awaiting CHC (data started Aug-09)

CHC: Bed Days 13/14

CHC: Bed Days 12/13

CHC: Bed Days 11/12


3.7 Delays for intermediate care were 44 in August, maintaining the performance since April

2013. There are concerns that capacity may be challenging for the Intermediate Care

teams in future months, this is monitored on a daily basis by the Operations Team.

0

50

100

150

200

250

300

350


Number of Bed Days lost due to awaiting Intermediate Care (data started Mar-11)

Intermediate Care13/14




3.8 93 beds days were lost to patients formally delayed due to social services during the

snapshot period in August, an improvement on the July performance (116 days). Local

authority teams continue to be challenged by unprecedented absence and a lack of access

to complex packages of care.


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16

0

100

200

300

400


Number of Bed Days lost due to awaiting Social Services (Section5)

Social Services 13/14




3.9 Delays for patients awaiting transfer for cardiac intervention/imaging (Angio wait) are

unavailable this month, however there have been a number of patients who have waited

longer that the agreed waiting time of 5 days. This has been escalated via the appropriate

operational channels.

3.10 The table below demonstrates variance in the total number of bed days lost due to formal

delays compared to the same period in the last financial year. There is an obvious

improvement on the position reported in 12/13

Bed Days Lost Previous YTD 12/13 YTD 13/14 Variance

Overall Bed Days Lost 3526 2514 -40%

Community Hospitals 935 527 -77%

Social Services 428 314 -36%

Continuing Healthcare 692 283 -144%

Housing 102 0 -100%

Self-Funding 538 308 -75%

Intermediate Care 83 198 +58%

Angios TBC TBC TBC


3.11 The Discharge Support Team record all patient delays, which includes reimbursable

(Formal) delays and informal where partners may be provided with time to assess a patient

before it becomes a formal issue. The graph below shows that on any given day there are

a large number of patients informally delayed within the Trust who could be supported by


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17

social and health care teams outside of an acute setting, The main focus for the operations

team in 2013/2014 is to work with partner agencies and in house teams to reduce the

number of informal delays, a trust wide project ‘Improving Delays’ has been initiated to

support this work.

0

10

20

30

40

50

60

Formal Delays Informal Delays

4 CANCELLATIONS

4.1 All waiting list cancellations

4.1.1 The number of Elective admissions cancelled as a percentage of all elective admissions

has decreased to 12.9% which is an improvement on the previous month (17.2%) and is

consistent with the same period in 2012/13.

4.1.2 The graph below shows the % of elective admissions cancelled as a % of all elective

admissions

10%

20%

30%

40%


Elective Admissions Cancelled as % of All Elective Admissions

% Elective Cancellations13/14



Data source: Operations Report


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18

4.2 Waiting list cancellations within 1 day of the TCI (To Come In) date

4.2.1 Elective admissions cancelled within a day of their TCI date (subset of the total in the

previous paragraph) has decreased in month by 2.6%

4.2.2 The graph below shows the % of elective admissions cancelled within 1 day of TCI

0

20

40

60

80

100

120

140

160

180

200


%

month

Elective Admissions cancelled within 1 day of TCI

Electivecancellations(above) <= 1 day13/14



Data Source: Information Team – Operations Report

4.3 Cancelled operations

4.3.1 The graph below shows the cumulative position for cancelled operations on the day of

admission or operation. The trend is following previous years data.

0

50

100

150

200

250

300

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

Monthly cumulative position for cancelled operations

cancelled ops 2010/11




Data Source: Information Team – K Thomas


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19

4.3.2 The graph below shows monthly numbers of cancelled operations on the day of admission

or operation, split by cause.

0

5

10

15

20

25

30

35

40

Ap

r-1

0M

ay

-10

Jun

-10

Jul-

10

Au

g-1

0S

ep

-10

Oct-

10

No

v-1

0D

ec-1

0Ja

n-1

1F

eb

-11

Ma

r-1

1A

pr-

11

Ma

y-1

1Ju

n-1

1Ju

l-1

1A

ug

-11

Se

p-1

1O

ct-

11

No

v-1

1D

ec-1

1Ja

n-1

2F

eb

-12

Ma

r-1

2A

pr-

12

Ma

y-1

2Ju

n-1

2Ju

l-1

2A

ug

-12

Se

p-1

2O

ct-

12

No

v-1

2D

ec-1

2Ja

n-1

3F

eb

-13

Ma

r-1

3A

pr-

13

Ma

y-1

3Ju

n-1

3Ju

l-1

3A

ug

-13

Cancelled operations per month split by cause

other

no bed

staff sickness

no theatre time

list cancelled

Data Source: Information Team – K Thomas

5 READMISSIONS

5.1 The readmission rate is calculated by dividing the number of discharges that were followed

by an emergency readmission within 30 days by total number of discharges (excluding

deaths).

5.2 The table below shows the readmission rates by specialty from July 2012 to date.

Discharging specialty of original

admission Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

ACCIDENT AND EMERGENCY 11.7% 8.3% 6.8% 5.4% 3.3% 5.1% 5.8% 9.7% 8.6% 4.7% 8.6% 7.4% 5.6%

ACUTE INTERNAL MEDICINE 8.2% 8.4% 7.1% 11.6% 9.3% 9.5% 8.1% 8.8% 11.2% 10.9% 12.0% 8.5% 11.7%

CARDIOLOGY 14.7% 7.7% 13.1% 7.7% 9.5% 4.9% 8.8% 8.0% 6.6% 7.6% 5.4% 1.6% 9.6%

CLINICAL ONCOLOGY 1.4% 0.3% 1.5% 0.0% 0.8% 0.8% 0.0% 0.0% 0.6% 1.2% 0.6% 0.4% 0.6%

DERMATOLOGY 0.0% 0.9% 0.9% 1.0% 0.0% 0.5% 0.7% 1.2% 0.4% 0.3% 1.5% 0.8% 1.0%

EAR, NOSE AND THROAT 3.5% 1.2% 1.8% 3.4% 3.0% 2.1% 6.9% 5.4% 3.3% 2.0% 2.8% 2.7% 5.9%

GASTROENTEROLOGY 3.0% 1.5% 2.1% 3.8% 3.5% 0.0% 1.1% 3.6% 4.4% 2.4% 7.1% 0.0% 9.1%

GENERAL MEDICINE 9.9% 9.9% 6.7% 7.8% 7.5% 9.8% 10.5% 7.8% 8.8% 6.9% 7.7% 10.3% 8.8%

GENERAL SURGERY 7.4% 5.0% 7.3% 5.8% 5.0% 5.5% 4.9% 5.5% 5.3% 4.6% 6.6% 4.2% 5.3%

GERIATRIC MEDICINE 14.7% 13.8% 14.4% 13.6% 15.2% 15.5% 15.1% 13.0% 14.5% 15.1% 14.7% 14.1% 11.6%

GYNAECOLOGY 9.0% 4.1% 3.3% 5.8% 5.4% 6.4% 3.1% 4.7% 3.9% 6.7% 2.7% 5.2% 4.9%

HAEMATOLOGY (CLINICAL) 0.8% 0.5% 1.3% 1.6% 0.8% 1.0% 2.0% 0.8% 1.5% 0.4% 0.7% 0.9% 1.0%

Max Fax & Oral Surgery 0.5% 0.6% 3.4% 1.0% 1.6% 2.2% 2.4% 1.9% 1.7% 2.5% 0.5% 1.2% 1.5%

MEDICAL ONCOLOGY 0.0% 0.0% 0.0% 0.0% 0.6% 2.7% 0.6% 1.2% 0.5% 1.1% 1.6% 3.6% 2.7%

NEUROLOGY 4.0% 0.0% 0.0% 0.0% 5.4% 2.0% 2.3% 3.9% 4.4% 2.2% 0.0% 2.1% 3.8%

OBSTETRICS 0.0% 0.0% 0.0% 0.1% 0.0% 0.1% 0.1% 0.1% 0.1% 0.0% 0.4% 0.5% 0.1%

PAEDIATRICS 3.2% 3.4% 3.7% 3.6% 3.6% 4.0% 3.5% 3.8% 4.3% 5.5% 6.9% 4.1% 4.0%

RHEUMATOLOGY 0.8% 1.6% 2.3% 2.0% 1.2% 0.7% 1.3% 2.2% 1.8% 2.2% 0.7% 0.0% 0.0%

TRAUMA AND ORTHOPAEDICS 5.3% 6.5% 4.1% 6.4% 5.9% 5.8% 5.8% 5.6% 6.0% 6.2% 4.6% 4.4% 4.7%

Grand Total 4.6% 4.1% 4.0% 4.2% 4.1% 4.5% 4.3% 4.1% 4.4% 4.3% 4.5% 4.0% 4.1%

Month of Discharge of Original Admiss ion


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20

5.3 There are significant readmission rates in July (>10%) within Acute Internal Medicine

(11.7%) and Geriatric Medicine (11.6%). This is being monitored closely by the Directorate

teams to ensure safe discharging is in place.

Prepared by:

Sophie Jordan

Operations and Performance Manager

September 2013


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21

Quality Indicator Dashboard

AUGUST 2013

All target/thresholds are marked as a dotted black line.


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22


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23

Prepared by:

Sophie Jordan/Matt Braithwaite

Operations and Performance Manager/Information Analyst

September 2013


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24

PERFORMANCE REPORT – AUGUST 2013

Referral to Treatment (RTT)

Summary of Risk: The NHS Operating Framework 2012-13 RTT operational standards are:

- Non-admitted target: 95% of RTT periods where patients received their first definitive treatment in an outpatient (non-admitted) setting must be completed within 18 weeks of referral.

- Admitted target: 90% of RTT periods where the patient needs to be admitted (as an inpatient or day case) for their first definitive treatment must be completed within 18 weeks of referral.

- Incomplete target: 92% of patients who have not yet started treatment should have been waiting no more than 18 weeks (patients who have had a clock start but have not had a clock stop).

Within the PHFT contract with the PCT, it is expected that each of the main specialties achieves all three targets at specialty level. All remaining ‘sub-specialties’ are grouped together into a category ‘X01’; this category must be achieved at aggregated level.

Current position: The Trust RTT position at the end of August 2013:

- Non-admitted target: 97.6% (Target: 95.0%) - Admitted target: 96.9% (Target: 90.0%) - Incomplete target: 97.3% (Target: 92.0%)

At Unify specialty level, all specialties passed both the admitted and non-admitted targets for August 2013. The ‘X01’ aggregate level was also passed for both admitted and non-admitted.

Within the ‘X01’ category for admitted, all four specialties within this category within this category achieved the target.

Within the ‘X01’ category for non-admitted, whilst this passed the aggregate target at 99.4%, within the category Paediatric Cardiology breached the non-admitted target with a performance of 94.7%. This is based on 18 out of 19 patients being treated within target. This is an in-month non-reportable speciality as it falls within the ‘X01’ category and is below the de minimis limit of 20 clock stops in month.

At the Trust Weekly Performance meeting, monitoring at patient level continues of all patients waiting over 26 weeks for treatment, and the reasons for the pathway delays.

Actions for September 2013: A number of specialties require significant pro-active monitoring and management to ensure the achievement of the targets at specialty level.

At time of writing this report, the Trust is performing well at aggregate and specialty level, however it is still very early in the month to make definitive predictions regarding the month end position.

The Performance Team has identified the following specialties as having challenges to meeting the non-admitted targets during September 2013. Surgical Division: Ophthalmology (Non-admitted): Due to an influx of paediatric referrals to the service the ophthalmology service is experiencing capacity pressures. The Directorate Manager is in discussion with RBCH to resolve their capacity issues. Three additional optometrist sessions have now been agreed with RBCH. Additionally, work is in place to agree further joint ophthalmologist/optometrist sessions to improve the management of patients within target. Despite


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25

this work, it is anticipated that the specialty will breach the non-admitted target in September due to the number of patients waiting over 18 weeks in the weeks preceding the additional activity. The CCG are aware of the challenges within the specialty and the likely specialty breach in September.

General Surgery (Non-admitted): At 11.09.2013, the non-admitted performance of this speciality is 98.1% (51 out of 52 patients treated within 18 weeks) however there are a further nine patients due to attend in September who are over 18 weeks. These patients are primarily patients requiring specialist pelvic floor treatment. Whilst challenging, it is not envisaged that there is a risk of not achieving the non-admitted RTT target in September. It is intended that this will be achieved through the close management of the specialty, and the overall denominator being increased (bringing patients forward from October) to allow for the additional breaches.

Medical Division: General Medicine (Non-admitted): Work continues with the medical secretaries within the specialty to ensure that all RTT clocks are being stopped correctly. Whilst challenging, it is not envisaged that there is a risk of not achieving the non-admitted RTT target in September.

Neurology (Non-admitted): All patients are continuously reviewed to ensure that their pathway is completed in the best possible timeframe. The new Consultant Neurologist (7.5PA/week) commenced in post on 31.07.2013 and it is intended that this appointment will alleviate the pressures within the department. Unfortunately due to clinician sickness in the team, this has not been realised in the short term.

It is anticipated that the specialty will breach the non-admitted target in September (and possibly October) due to the number of patients waiting over 18 weeks in the weeks preceding the appointment of the new Consultant. It is anticipated that the performance in September will be approximately 90%, with 12 breaches. The CCG have been informed of the continuing impact on the target of increased referral rates; the CCG is also aware of the speciality ‘backlog’ and sickness within the speciality which has further reduced capacity.

Pressures regarding waiting times for CT/MRI scans and the time taken to receive the CT scan report continue to be challenging; this is being managed in conjunction with the radiology department.

Rheumatology (Non-admitted): At 11.09.2013, the non-admitted performance of this speciality is 98.0% (48 out of 49 patients treated within 18 weeks) however there are a further eight patients due to attend in September who are over 18 weeks. The impact of reduced Specialist Registrar capacity and the recent departure of one Consultant (replacement Locum Consultant commences in post 14.10.2013) have resulted in reduced outpatient clinic capacity, which is presenting overall capacity challenges for the specialty. This impact is being closely managed by the Directorate Manager to ensure the RTT non-admitted target for September is achieved.

MCD Division: Gynaecology (Admitted and non-admitted): Elective and non-elective gynaecology capacity continues to be challenging during high periods of annual leave; the target, however, is on track to be delivered for September.

With effect from 01.09.2013 the outpatients department will test patients who require urodynamic tests for urinary tract infections to ensure patients are fit and able to undergo the required examinations rather than be deferred, on arrival for tests, due to the presence of infection. This will reduce the number of patients re-referred for urodynamic tests and help reduce pressure on the urodynamic diagnostic pathway. Will effect from 01.10.2013 this addition to the pathway will take place at the gynaecology peripheral clinics of Wimborne, Swanage and Blandford Hospitals. Following a meeting on 01.08.2013, the emergency gynaecology pathway has been reviewed and will be forwarded to the Emergency Department for implementation, following Consultant sign off. This follows the continued work by the Gynaecology specialty to support the Emergency Department with their operational pressures.


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26

Prepared by: Suzie Hawkins Trust RTT Lead September 2013


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27

Cancer Waiting Times JULY 2013: Poole Hospital NHS Foundation Trust – Summary report

The following convention is used for indicating compliance with the performance standards:

Indicates that the target was not achieved in the month

Data are taken from the Open Exeter national database for Cancer Waiting Times.

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

Cancer Access urgent referral to 1st OPA - 14 days 95.2 93.3 94.5 95.8 97 97.3 97.2 97.3 94.8 97.4 95.4 95.7

Symptomatic breast referral to 1st OPA - 14 days 87.1 97.7 98.7 94.2 97.8 97.8 94.4 88.7 91.9 98 94.5 94.7

Cancer Access first txs - 31 days 99.3 98.5 99.3 100 99.3 98.8 100 99.2 100 100 100 99.3

Cancer Access subsequent txs(anti cancer) - 31 days 100 100 100 100 100 100 100 100 100 100 100 100

Cancer Access subsequent txs(surgery) - 31 days 100 100 100 100 96 96.6 100 100 96.8 96 100 99.2

Cancer Access subsequent txs(radiotherapy) - 31

days 98.1 97.7 100 86.2 98.5 95.5 100 100 99.2 97.2 100 98.5

Cancer Access urgent referrals - 62 days 91.5 81.7 86.6 91.2 86.8 90.8 89.6 87.4 92.1 85.7 88.3 86

Cancer Access screening patients - 62 days 98.1 94.4 100 100 100 100 100 100 94.4 95.7 93.9 91.9

Cancer Access consultant upgrade - 62 days 87 100 100 100 100 100 100 100 100 86.7 100 90

14 days: Urgent GP referral to Date First Seen

Measure

Maximum 2 week wait from urgent GP referral for suspected cancer to first hospital assessment by 2000

Everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently and requesting an appointment by 2000

Target 93% or more

Source National Cancer Waiting Times Database (Open Exeter)

Time Period JULY 2013

Tumour Type Total

referrals

seen

during the

period

% meeting

standard

in Poole

Median

wait

National

%

meeting

standard

Suspected brain/central nervous system tumours 8 75 96

Suspected breast cancer 143 98.6 96.5

Suspected children's cancer 3 100 95.5

Suspected gynaecological cancer 49 98 96.1

Suspected haematological malignancies (excluding acute leukaemia) 2 100 97.7

Suspected head & neck cancer 110 95.5 95.8

Suspected lower gastrointestinal cancer 66 97 95

Suspected lung cancer 12 100 97.5

Suspected sarcoma 1 100 97.3

Suspected skin cancer 146 94.5 94.9

Suspected upper gastrointestinal cancer 40 95 94.5

Totals 580 96.2 95.7

Breach reasons

No. of patients Breach reasons

22 Patient choice


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28

14 days: All breast symptom referrals

Measure Maximum 2 week wait from referral of any patient with breast symptoms to first hospital assessment by DECEMBER 2010

Target 93% or more



Total referrals

seen during the

period

% meeting

standard at

Poole

Median

wait

National

% meeting

standard

Totals 58 94.8 7 94.7

Breach reasons


3 Patient choice

31 days: Decision to Treat to First Treatment

Measure Maximum 31 day wait from decision to treat to first treatment for all cancers by 2005

Target 96% or more



a) By tumour site

Tumour Type Patients

treated

following an

urgent

referral for

suspected

cancer

Total

treated

Treated on

or within

31 days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Brain/Central Nervous System 0 1 1 0 100 20 99.6

Breast 13 21 20 1 95.2 16 99..6

Gynaecological 10 14 14 0 100 13 97.5

Haematological 4 12 12 0 100 0 99.8

Head & Neck 4 7 7 0 100 13 9609

Lower Gastrointestinal 5 13 13 0 100 13 98.6

Lung 4 12 12 0 100 3 98.8

Other 0 2 2 0 100 3 99.7

Sarcoma 3 3 3 0 100 4 97.3

Skin 25 42 42 0 100 5 98.7

Upper Gastrointestinal 3 7 7 0 100 5 99

Urological 6 6 6 0 100 18 97.1

All Cancers 77 140 139 1 99.3 98.5


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29

b) By treatment type

Treatment Group Patients

treated

following an

urgent

referral for

suspected

cancer

Patients

treated

following

an urgent

referral for

breast

symptoms

Patients

treated

following

an urgent

referral

from an

NHS

Cancer

Screening

Service

Patients

treated

following

a referral

from

another

source or

urgency

Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Drug Treatments 12 0 0 12 24 24 0 100 3 99.9

Palliative Treatments 3 0 0 12 15 15 0 100 0 100

Radiotherapy Treatments 14 0 1 3 18 18 0 100 18 97.8

Surgery 48 0 8 27 83 82 1 98.8 13 97.7

All Treatments 77 0 9 54 140 139 1 99.3 98.5

Breach reasons


1 Patient booked outside of target due to lack of availability of surgeon’s lists. Patient was offered a date but declined – this was outside of the target and therefore no WTA could be made.

31 days: Second and Subsequent Treatments

Measure Maximum 1 month wait from ready to treat to treatment for all second and subsequent treatments (chemotherapy and surgery by December 2008, all other treatments DECEMBER 2010)

Target 98% - Anti Cancer drug treatments ; 94% - Surgery treatments ; 94% - Radiotherapy treatments



a) By tumour site

Tumour Type Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Brain/Central Nervous System 1 1 0 100 2 99.7

Breast 108 106 2 98.1 12 98.9

Gynaecological 12 12 0 100 8 99.2

Haematological 13 13 0 100 1 99.4

Head & Neck 12 12 0 100 18 98.2

Lower Gastrointestinal 16 16 0 100 14 99.1

Lung 22 22 0 100 7 99.3

Other 2 2 0 100 15 99.3

Sarcoma 1 1 0 100 4 97.8

Skin 12 12 0 100 18 98.4

Upper Gastrointestinal 10 10 0 100 9 98.8

Urological 48 48 0 100 2 97.9

All Cancers 257 255 2 99.2 98.8


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Treatment Group Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Drug Treatments 71 71 0 100 4 99.8

Other Treatments 3 3 0 100 14 97.8

Palliative Treatments 26 26 0 100 1 100

Radiotherapy Treatments 132 130 2 98.5 14 98.2

Surgery 25 25 0 100 19 97.8

All Treatments 257 255 2 99.2 98.8

Breach reasons


2 Patient choice

62 days: Urgent GP referral to First Treatment

Measure Maximum 62 day wait from urgent GP referral to first treatment for all cancers by 2005

Target 85% or more



a) By tumour site

Tumour Type Actual no.

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Breast 13 13 1 92.3 97.4

Gynaecological 10 7 0.5 92.9 83.6

Haematological 5 4 2.5 37.5 81.6

Head & Neck 4 3 0 100 72.9

Lower GI 5 5 1 80 78.6

Lung 4 3 0.5 83.3 79.7

Sarcoma 3 3 1 66.7 79.3

Skin 25 24 0 100 97

Upper Gastrointestinal 3 3 0 100 79.7

Urology 6 3 3 0 84.3

Total 78 68 9.5 86 86.8


Treatment Group Actual no.

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Drug Treatments 13 12 1.5 87.5 85.5

Palliative Treatments 3 3 1 66.7 91.5

Radiotherapy Treatments 14 9 4.5 50 59.5

Surgery 48 44 2.5 94.3 89.2

Totals 78 68 9.5 86 86.8


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31

Breach reasons

Tumour Type First Seen Trust

First Treatment Trust

Patient CWT Ref

Wait Days

Report

Breast RD3 RD3 7384231 98

Patient required MRI requested 24/04 scanned 14/05 recommend mastectomy. Patient opted for immediate reconstruction. Had several appointments to discuss options and time to decide before TCI date given of 04/07.

Gynaecological RDZ RD3 8186477 88

Patient had failed hysteroscopy - 2nd one done CAH shown - upgraded to Grade 1 cancer at MDT - for surgery - forgot to stop taking Warfarin on TCI date so surgery postponed by a further week.

Haematological (Excluding Acute Leukaemia)

RD3 RD3 8167741 65 H&N ref needed cardiac assessment to see if fit for biopsies.


RD3 RDZ 8070631 86 Patient originally thought to have Head and Neck Cancer. Haematology cancer found at histology. Referred for treatment from other Trust after target treatment date had passed

Lower Gastrointestinal RD3 RD3 7996529 118 Patient was initially thought to be low risk for cancer on clinical assessment diagnostic tests were undertaken as routine

Urological (Excluding Testicular)

RDZ RD3 7472503 318 CARP recd day 70 of pathway from referring Trust.


RDZ RD3 7841930 204

CARP received day 68 of pathway from referring Trust. For Brachytherapy. Pt undergoing cardiac investigations at referring Trust. Clinical referral sent to PGH day 107 of pathway. Brachy day 204 of pathway.


RDZ RD3 7913712 109 CARP received late in pathway (day 49). Clinical referral received day 54 of pathway. OPA 10/06 opted for brachy added to waiting list. Treated day 109 of pathway.


RDZ RD3 7919060 178 CARP received day 68 from referring Trust. Pt considering brachy. Slightly compromised flow rate. Put on waiting list and treated day 178 of pathway.


RDZ RD3 7919072 160 CARP received after 62 day target from referring trust


RDZ RD3 7919081 157 CARP received after 62 day target from referring trust


RD3 RD3 6635451 73 Originally H+N fast track diagnosed with lymphoma referred to haematology 1st OPA 03/06 - requires imaging prior to MDT discussion. No indication to treat watch and wait 08/07.

Lung RDZ RD3 8070254 96 Cross trust referral form received from referring trust on day 37 of pathway - referred for radiotherapy. however patient needed PET scan to determine if for radical or palliative radiotherapy.

Sarcoma RD3 RD3 8167777 73 Patient was referred to tertiary trust for diagnosis and possible treatment was referred back for pre-op radiotherapy 4 days before treatment target which was not enough time for planning.


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32

62 days: Suspected cancer patients detected through national screening programmes

Measure Maximum 2 month wait from referral from NHS Cancer Screening Programme to treatment by December 2008

Target 90% or more



a) Breast

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

RD3 RBD 9 4.5 0 100 43 97.1

RD3 RD3 6 6 1 83.3 56 97.1

RD3 RDZ 12 6 0.5 95.8 70 97.1

27 16.5 1.5 94.4 97.1Total b) Gynaecological - No patients

c) Lower Gastrointestinal

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

RD3 RD3 2 2 0 100 44 83.5

RDZ RD3 1 0.5 0.5 0 127 83.5

Total 3 2.5 0.5 80 83.5 ALL SCREENING PROGRAMMES

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

RD3 RBD 9 4.5 0 100 95

RD3 RD3 8 8 1 87.5 95

RD3 RDZ 1 0.5 0.5 0 95

RDZ RD3 12 6 0.5 95.8 95

Total 30 19 2 89.4 95

Breach reasons

Tumour Type First Seen Trust


Patient CWT Ref

Wait Days

Report

Breast RD3 RD3 8380068 83 Problem with machine so had to go to Dorchester for 2nd biopsy. Patient chose to be seen in Poole so OPA at other Trust cancelled. Patient discussed at MDT 11/06 but OPA at Poole booked 17/06. Patient preference for conservative surgery.

Breast RD3 RDZ 8070158 70 OTHER

Lower Gastrointestinal

RDZ RD3 7988173 127 Patient was also under investigation for likely renal cancer found on staging CT


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33

62 days: Suspected cancer patients not referred urgently and upgraded by Consultants

Measure Maximum 2 month wait from consultant upgrade of urgency of a referral to first treatment by December 2008

Target PCT target - 90%



Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Lower GI 4 0 100 96.3

Lung 0.5 0.5 50 90.4

Skin 0.5 0 100 99.4

Totals 5 0.5 90 94

Breach reasons

Tumour Type Consultant Upgrade Trust


Patient CWT Ref

Wait Days

Report

Lung RDZ RD3 8184648 71 No cross trust referral form received from referring trust .

62 days: Breast symptomatic referral (non cancer) to first treatment

Measure Maximum 2 month wait from breast symptomatic referral (non cancer) to first treatment

Target No standard set


Time Period JUNE 2013

None

Key of Trust Codes:

RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST

RAN ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

RBA TAUNTON AND SOMERSET NHS FOUNDATION TRUST

RBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST

RD3 POOLE HOSPITAL NHS FOUNDATION TRUST

RDZ THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST

RHM SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

RJZ KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST

RM1 NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

RNZ SALISBURY NHS FOUNDATION TRUST

RPY THE ROYAL MARSDEN NHS FOUNDATION TRUST

RVL BARNET & CHASE FARM HOSPITALS NHS TRUST

RWA HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST


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34

CWT Trends in performance

Prepared by: Anne Foulkes Business and Performance Manager (Medicine Division) September 2013


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35

PERFORMANCE EXCEPTION REPORT August end 2013

Emergency Department Professional Standards

The Risk: The 4-hour target for August was met (95.62%), which left Quarter Two performance as 95.95%.

The remaining professional standards are monitored on a weekly basis and reported to the Trust’s performance meeting. Whilst the standards do not carry Monitor weighting, they are a key gauge for quality within the department.

The performance for August and Quarter 2 to date is outlined below:-

Standard TargetPerformance for

June

Performance for

July

Performance for

August

Comparision with

previous month

Performance for Q2

13/14 to date

% of patients seen within 4

hours≤ 95% 97.14% 96.30% 95.62%

↓decreased by

0.68%95.95%

Total time in the department ≤ 240 minutes 238 239 240↑increased by 1

minute239

Clinician seen time ≤ 60 minutes 6883

59↓decreased by 24

minutes 70

Left without being seen <5% 3.39% 3.60% 2.90%↓decreased by

0.7%3.26%

Time to nurse assessment ≤ 15 minutes 1721 17

↓decreased by 4

minutes 17

Re-attendance rate (all) Between 1% & 5% 5.30%6.30% 6.10%

↓decreased by

0.2% 6.10%

Performance, as measured has decreased across the range of performance standards, especially in clinician seen time and initial triage assessment time. This was due to the increase in attendances (up 8% on the same month last year) and an unfavourable attendance pattern (spikes in late evening attendance). The department has recognised the trends in attendance and has made changes to staff rotas to ensure a high performance for the remainder of the quarter.

Current Position and Actions:

Medical staffing has been improved and will continue to improve in the short-term as new registrars

and junior doctors arrive. Work is still on-going to ensure that staff are in place at the most

appropriate times to ensure resilience in the event of unusually high attendances.

The chart below demonstrates the weekly performance trend against the 95% target for 4 hours:-


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36

Action:

An extra registrar and SHO have begun in the department. This allows for all except 6 registrar

dayshifts of the medical rota to be filled; without the use of locum. This will decrease spending

and increase performance, especially as trust doctors will be more familiar with the department.

Additional nurses recruited (vacancies filled – to start in September).

Extra ENPs, paid for Urgent Care Board money, have been recruited and will begin in October.

A new Consultant, Harry Adlington is in post.

Reinforcement of levels of escalation through to CMT by coordinator if a patient reaches 3

hours with no clear plan of action (either for admission or discharge).

Pathway for expected Orthopaedics patients have been refined and are working well.

Continued use of Red Cross service to support discharge for appropriate patients needing

extra support to return home.

Consultant of the day agreed - to ensure oversight of department and proactive management

of patients throughout the day.

In progress:-

Work to recruit a further consultant within establishment is underway.

Review of consultant job plans and rotas to provide maximum cover across the 24-hour period.

Further review of a number of clinical pathways to improve onward movement to assessment

wards or admission where necessary.

Working with commissioners and partners to identify “quick win” solutions to support admission

avoidance, flow and timely discharge.

Pathway for specific-category Gynaecology patients is on-going.

Prepared by: Martin Smith Matt Welch Matron/Directorate Manager Assistant Manager Emergency Services Emergency Services September 2013


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37

PERFORMANCE EXCEPTION REPORT – AUGUST 2013

Bowel Cancer Screening Programme: Non-achievement of diagnostic screening target – 93.98%

1. S

Prepared by:

Suzie Hawkins

Bowel Cancer Screening Programme Manager

September 2013

Diagnostic Test Waiting Times

Month (2013) Referred Within Target Outside Target Within Target %

January 67 67 0 100.00%

February 68 66 2 97.06%

March 70 69 1 98.57%

April 69 68 1 98.55%

May 79 78 1 98.73%

June 59 57 2 96.61%

July 72 71 1 98.61%

August 83 78 5 93.98%

September 16 16 0 100.00%

Total 816 793 23 97.18%

Target: 100% of patients are offered a diagnostic screening appointment within 14 days

1.1 It is recognised that there will occasionally be instances within the BCSP when it is not

possible to offer all programme participants a diagnostic screening test within 14 days.

1.2 During August 2013, the Dorset BCSP was not able to offer all patients a diagnostic

screening test within 14 days and the achievement of target was 93.98%

1.3 Five patients were not offered a screening colonoscopy within 14 days. Three patients

were offered a screening colonoscopy within 15 days; a further two were offered a screening

colonoscopy within 16 days.

1.4 The breaches occurred as a result of clinician annual leave taken during August. The

programme has eight screening colonoscopists working across three sites, who are either

surgeons or gastroenterologists. Their annual leave is tracked closely, and the administrator

highlights to the Programme Manager when more than three colonoscopists over three sites, or

two at a single site, are off on the same day. In these occasions, the Programme Manager works

with the endoscopy departments and clinicians to organise additional activity.

1.5 The screening colonoscopists at each site work well together to prevent clashes in annual

leave, and these breaches did not occur due to the number of clinicians off at once, but a few

weeks of reduced resources due to annual leave taken in succession. The clinicians work in large

teams across two specialties at three Trusts, and having ‘the perfect annual leave schedule’ to

ensure leave is even spaced across the year is just not possible.

1.6 The programme continued to meet (100%) of the target stating that all patients must be

offered a Specialist Screening Nurse Practitioner clinic appointment within 14 days of their

positive FOBt result.


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38


Diagnostic Access Times: Patients waiting in excess of six weeks

The Risk: There was one month end breach within the reporting period.

Current Position: There was one patient waiting six weeks and over at the end of August (one end of month breach in July) as shown in the graph below. There were 337 patients on the waiting list at the end of July (260 at the end of July) and over 99% of patients referred to the department are being seen within six weeks - with very few exceptions.

There was one patient waiting over six weeks at the end of August; the patient’s admission date was altered due to challenges with capacity stemming from the failure of the decontamination unit – unfortunately the re-book date offered was unacceptable to the patient due to child care arrangements, and she opted for a date outside the 6 week target.

There have been increasing pressures on the waiting lists during August due to on-going issues with the endoscopy washers; as a result, a number of patients have been cancelled in August, and rebooked within the 6 week target (except the patient referred to in the preceding paragraph). This has mainly affected OGD and flexible-sigmoidoscopies as the department was reluctant to cancel any colonoscopies.

Total loss of washer capacity on site has resulted in all scopes being washed in the Harbour, RBCH or Wimborne – this has stretched the reprocessing team, and caused delays on lists throughout the final weeks of August. The Department have managed extremely well in the short term – however a longer term solution is now required urgently.

To regain some lost capacity, the department has organised three additional lists during July and August to minimise the impact on the waiting list. The waiting list continues to be managed closely to ensure patients are prioritised appropriately.

Action: Continue to closely monitor the waiting list, with a particular focus on the cancelled patients

Prepared by:

David Tyrrell

Directorate Manager

September 2013


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39


Stroke: Target: ≥80% of patients should spend > 90% of their LOS on the Stroke Unit

The Risk: The Trust has achieved this target month by month in year.

Current Position:

In August there were 49 Stroke patients discharged during the month, with 88% (43) of patients spending > 90% of their LOS on the Stroke Unit (target ≥ 80%).

The following table indicates the number of live Stroke discharges and the % that achieved the target in the previous months.

August

The Trust has managed to maintain this target for the last 10 months.

August discharges were comparable to the same period last year, but we managed to keep more patients on the Stroke wards this year. Numbers remain high compared to previous months.

The Stroke pathway remained intact.

The team still has the support of ESD and the Red Cross, which have enabled safe, successful discharges for a number of clients. The number of patients discharged during July with ESD dropped slightly to 35%. (August figures not yet available).

The general acuity of patients remains high; there is a piece of work to be done in October to review ESD discharges and LoS on the recognised Stroke beds. This will take place after further reconfiguration to the ASU and Rockley to absorb Brownsea beds into the Stroke numbers allowing greater flex, pathway management and placing of more acute general DME patients on the top floor of the PAU.

Direct access increased to 90% (44 patients), a jump from July in both % and actual numbers. The team remain aware that clinical care elsewhere is appropriate prior to patients joining the Stroke pathway. These will continue to affect figures though these cases are reviewed upon validation, managed onwards and appropriately actioned. There were 5 cases of non-direct access via Ansty which we believe were all appropriate at the time. There will be no follow up on these patients.


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40

The service continues to escalate delays due to the arrangement of care packages, these issues are raised weekly with ward discharge coordinators meetings with our secondary and Local Authority colleagues.

CT scan access <24 hours for August was 96% (47 patients). This remains high, and maintenance of this target remains a result of greater communication between teams and input from colleagues in imaging and their continued ability to remain flexible in our requests for imaging during the patient pathway. Any delays/potential delays are discussed and raised at the earliest opportunity.

August saw a seasonal peak in overall TIA referrals (76), in pattern with the same time last year. The number classified as high risk rose in relation to this, at 42 as opposed to 34 July. We were able to see 48% of these patients within the required 24 hours compared to 73% in June.

0

10

20

30

40

50

60

70

80

90

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Feb

-14

Mar

-14

Total

High Risk

Seen <24

%

The CCG are working with the tri-part and SWAST to interrogate data provided for those patients who are referred more than 6 hours after their initial contact. This will allow us to put into place training and education around the importance of immediate referrals. There is a Stroke Service Delivery Group Meeting on 5th November where this will be discussed further.

Actions:

1. Reconfiguration of Stroke Unit and Brownsea ward.

2. Continue to review TIA pathway and service provision. Work with CCG to understand delays in

referral from Primary Care to SWAST for TIA clinics and provide education to referrers.

3. Ward & CMT processes reviewed to maintain direct access targets and keep capacity within

ASU for management of emergency admissions. Management of beds out of hours to be

reviewed.

4. Recruitment action plan continues to be updated and managed to support staffing on

ASU/Rockley and DME services.

5. Stroke Consultant post did not attract any applicants but the department is currently reviewing

how best to manage this.

6. LoS and capacity monitored at monthly Capacity Meetings and Monthly Stroke meeting

Prepared by: Barry Duell Directorate Manager (DME, Diabetes, Rheumatology, Neurology & Gastroenterology)

September 2013


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41

PERFORMANCE EXCEPTION REPORT – August 2013

Appointment Slot Issue (ASI): Trust performance for August was 19%

Summary: Provider to ensure that ‘sufficient appointment slots’ are made available on the Choose and Book system. Standard: <4% slot availability issues. The Trust risks fines for every week >10%.

Current Position: At end of August 2013, the Trust position was 19%.

Rheumatology: Polling at 12 weeks. 160 ASI.

Breast: Polling at 2 weeks. 35 ASI.

Urology: Polling at 10 weeks. 25 ASI.

Orthopaedic All: Polling at 6 weeks. 108 ASI.

Ophthalmology: Polling at 8 weeks. 25 ASI.

Colorectal: Polling at 7 weeks. 11 ASI.

Gastroenterology: Polling at 10 weeks. 10 ASI.

General Surgery: Polling at 6 weeks. 14 ASI.

Actions for June/July 2013:

Rheumatology

ASI concerns reported to DD & COO for discussion at CCG performance meetings. CCG remain appraised of continuing impact of increased referral rates on departmental capacity.

ESP cover continues for SpR post, sessions remain on choose and book.

Locum Consultant Dr Asim Kurshid starts in post on October 7th. Corporate induction booked, clinics are being opened from October 7th. Discussions will now commence regarding substantive post in department and a business case will be developed to support this.

SpR appointed as joint post between PHT and RBCH meaning that ESP cover will need to continue to retain current clinical capacity. SpR should commence in post in October 2013, still awaiting confirmation of this.

Dr’s Richards, Thompson & Rahmeh are providing additional of sessions and ward cover in Dr Westlake’s absence meaning limited loss of interventional lists.

Agreement to return routine pain referrals to their GP to be managed in the community. Rheumatology pathways and capacity may continue to be adversely affected by Pain Clinic referrals until the community service commences later this year.

Breast:

This service saw a similar number of ASI's in August as it did in July and again this was in part due to annual leave and in part due to the number and pattern of referrals.

Due to potential changes to medical staff job plan the capacity is being reviewed.


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42

Urology:

In spite of providing some additional capacity in September the number of ASI's continued to reach double figures in August and there has been no loss of routine capacity within the 10 week polling range over the relevant period as funded cover for leave is now provided within this specialty.

RBCH are experiencing similar pressures on new referrals within this service.

The review of demand and capacity is due for completion by the end of September.

Orthopaedic (all):

Paediatric Orthopaedics

Although there were still a number of ASI's in August the additional September clinic reported last time is now in place and the opening up of these slots has assisted in maintaining the earliest available routine appointment within the polling range of 9 weeks.

From September there will be two middle grade medical staff available who now have the relevant paediatric experience to support the one consultant covering this service. Whilst not funded to provide additional routine capacity it is intended that leave will be covered where possible to avoid some of the fluctuations in new patient slots that occur.

There have been no ASI's in the first week of September

Adult Orthopaedics

As previously reported, reducing ASI's in this specialty without increasing the polling range from 6 weeks remains a challenge.

Any additional medical staffing resource available is currently being used to cover the increase in demand in the fracture service and therefore the opportunities to increase capacity within the elective service are limited.

The updated review of demand and capacity in all aspects of elective and acute T&O is due for completion by the end of September.

Ophthalmology:

The August ASI's were due to lost capacity through leave due to be taken during late September.

Some capacity has now been provided by opening up slots originally frozen as part of the fire break initiative introduced to reduce the difficulties encountered in moving patients already booked when clinics are cancelled with less than 8 weeks notice.

There have been no ASI's within the first week of September.

Colorectal & General Surgery

It is unusual to have ASI's in any significant numbers within these services and the increase a has been primarily due to a reduced level of cover through the use of a locum consultant, who is slightly less experienced in some aspects of the service, to cover a consultant vacancy and the fact that the clinic slots for the newly appointed consultant due to start in October are only now being opened up to choose and book.

The situation will be monitored.

Gastroenterology:

ASI issues experienced during month due to the impact of annual leave. This is recognised and is not expected to continue into September.

Prepared by: Barry Duell/Yvonne Hunter/David Clark/Hannah Elton Directorate Managers - Medical & Surgical Divisions September 2013


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43

PERFORMANCE REPORT – TRAUMA – AUGUST 2013

Trauma Directorate- Waiting Times for Surgery: Fractured Neck of Femur within 36 hours of being clinically appropriate for surgery (CCG target 95%) Fractured Neck of Femur within 36 hours of admission (Best Practice Tariff Criteria – internal target 90%) Trauma Patients within 48 hours of being deemed fit for surgery (CCG target 95%)

The Risk: Fractured neck of femur patients August 2013 88% operated on within 36 hours of being deemed clinically appropriate for surgery. 77% operated on within 36 hours of admission. All trauma patients August 2013 95% within 48 hours of being fit for surgery. Although the previously reported increase in capacity and improved management of the NOF pathway has made a significant improvement in the performance against these quality access targets overall, the risk has remained that in the busy summer months the available theatre capacity could still be insufficient when combined with the demand, the mix of patients and the pattern of admissions.

Current Position: Another busy month with a total of 432 trauma admissions overall, of which 361 were operated on (compared with 319 last month). There were 77 fractured neck of femur patients admitted in August. During the month there were five revision total hip replacement procedures performed and four primary total hip replacements for fractured neck of femur. All four fractured neck of femur patients waiting for THR’s breached the 36 hour target due to surgeon availability. Of the 18 fractured neck of femur patients that breached the target of 36 hours from admission, eight were unfit upon admission (but did attend theatre within 36 hours of being fit), two breached because of other trauma cases taking priority, four breached because of insufficient theatre capacity over the extremely busy Bank Holiday weekend and the remaining four were the patients awaiting a THR. August was the most challenging month for some time and this is reflected in the poor performance against the relevant targets, in particular in relation to the NOF’s. The service was in escalation four times during the month, at one point for 10 days. Over the Bank Holiday weekend a total of 11 NOF’s were admitted along with many other patients, some of whom required urgent surgery. Surgeon availability for the more specialist surgery was at times affected by a combination of annual leave, paternity leave and a resignation.

Patients not fit pre-op &

needed optimising

Other trauma

cases taking

priority/ran out

of time

Insufficient

theatre capacity

Awaited

specialist

surgeon for

THR

Other factors

8 2 4 4 0


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44

73 73 67 77 90

56 62 70 80 67

82 79 77

0

50

100

150

200

250

300

350

400

450

500

0%

20%

40%

60%

80%

100%

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

% o

pera

ted

wit

hin

36h

rs o

f ad

mis

sio

n

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

% Patients Operated on within 36hrs 58% 75% 93% 88% 84% 88% 90% 74% 86% 90% 86% 87% 77%

Number of NOF's admitted 73 73 67 77 90 56 62 70 80 67 82 79 77

Number of trauma admissions 488 407 427 403 378 355 316 363 388 425 432 433 432

% Patients Operated on within 36hrs Number of NOF's admitted Number of trauma admissions

Actions:

To continue with all the current practices around prioritising fractured neck of femur patients,

breach avoidance/breach management for individual patients and highlighting crucial patients and

their breach times to surgeons and to theatres.

To continue to undertake review of each breach in detail and highlight any changes required as a

result.

To continue with the Middle Grade training programme for total hip replacement surgery, in order

to improve surgeon availability to undertake this procedure. Whilst waiting times have reduced

undertaking THR’s within 36 hours remains a challenge at busy times.

To continue the on-going review of trauma demand vs theatre capacity during the busy summer

months to inform future decisions re provision of theatre capacity.

Clinical Director and Directorate Manager to re review peak time annual leave allocation and

impact at sub-specialty level.

0

10

20

30

40

50

60

70

80

90

100

Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13 Aug-13

Perc

enta

ge o

f pat

ient

to th

eatre

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Trauma 48 hrs from adm 91 91 91 97 91 95 98 96 93 98 96 94 95 93 96 97 95 97 96 98 97 96 96 92 91

NOF 36 hrs from adm 51 46 55 77 72 77 76 73 69 80 68 52 58 75 93 88 84 93 90 74 86 90 86 87 77

NOF 36 hrs from fit 66 62 66 93 79 92 86 79 77 92 68 70 63 81 99 97 96 95 97 96 96 97 95 96 87

Percentage of Patients to Theatre August 2011 - August 2013

Trauma 48 hrs from adm NOF 36 hrs from adm NOF 36 hrs from fit


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45

0

5

10

15

20

25

30

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13 Aug-13

Num

ber o

f pat

ient

s Bre

achi

ng

Month

NOFs - Treatment Times for Patients Breaching the 36 hour Target: August 2011 - August 2013

36-48 hours 2-3 days 3-4 days > 4 days

0

2

4

6

8

10

12

14

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13 Aug-13

Num

ber o

f Pat

ients

Brea

ched

Month

Non NOFs: Treament times for Patients Breaching the 48 Hour Target: August 2011 - August 2013

2-3 days 3-4 days 4-5 days >5 days

0

10

20

30

40

50

60

70

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13 Aug-13

Num

ber o

f Bre

ache

s

Month

Total Breaches August 2011 - August 2013

NOFs

Non NOFs

Combined

Prepared by:

Yvonne Hunter

Directorate Manager –Trauma & Orthopaedics

September 2013


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46

PERFORMANCE REPORT

Theatre services- Critical Care Directorate – August 2013

The Risk: Day Theatres is not reaching the 80% target

Current Position:

Booked Utilisation

85%

Expected Utilisation

80%

Actual Utilisation

79%

Losses on day of surgery

6%

Current Position: Previous calculations have shown that best achievement for Day Theatres ranges between 80 and 82%. This is based on the number of patients that is reasonable to put on each session which range from 2 patients to 6 patients. Based on these levels of activity it is impossible for every list to achieve 85% as any list with three patients or more is already unable to achieve the target. Working on the potential operating time available for each list based on the number of cases utilisation would be expected: 2 patients excluding team brief and turnaround time – 92% 3 patients - 89% 4 patients – 85% 5 patients – 82% 6 patients – 79% Based on the above matrix utilisation available for August 2013 was 85% Day Theatre reached 79% utilisation for August 2013 which is 3% increase in utilisation compared to July 2013

Graph 1 shows the total utilisation in Day Theatres. Utilisation in ENT (73%) decreased by 7% and OMF uitilsation (70%) remained the same as last month. OMF had a reduced cancellation rate by just over 1% and had cancellations on the day being unfit and DNAs which totalled 1.8%. Gynae utilisation increased this month by 2% the was due to patients not being cancelled due to procedure not being required.


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47

71

77

82

7876 76

74

7778

76 76

79

65

70

75

80

85

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

% o

f o

pe

rati

ng

tim

e

Day Theatre Utilisation rolling annual activity

Target utilisation Utilisation

Graph 2 shows the number of patients that were booked for total sessions and the number of completed patient episodes. The patient cancellations for this month were 1.2% which is within the agreed acceptable level of 2%.

43

5

50

2

48

2

25

7

46

5

42

1

41

7 43

9 45

8

37

3

52

9

41

3

40

5

49

6

46

8

24

4

37

8 41

8 45

9

43

2 47

1

35

9

49

9

43

4

0

100

200

300

400

500

600


Nu

mb

er

of

pat

ien

ts

Day Theatres patient activity 2012/13 2011/12

Graph 3 shows the percentage of time lost across total sessions in Day Theatres as indicated by the reasons on the chart. Cases booked prior to any time lost amounted to an estimated 85% utilisation. Time lost on day of surgey equated to 6% (14 hours) of this 0.9% (2 hours) was lost to patients being unfit for surgery on admission; 0.9% (2 hours) was lost to patients DNAs or cancellations on the day of surgery and 0% (0 hours) lost to patients who did not require surgery on the day of surgery (Gynae). All of these areas are a reduction on July rates.


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48

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%


Time lost on day of surgeryPatient unfitCancellations/DNAsProcedure - less timeTrauma - no patients waitingPatient declined surgeryOperation no longer requiredsession under booked

Actions:

The 3% increase in utilisation this month is encouraging but theatres needs to maintain the actions

put in place in July and monitor progress to minimise slippage.

Prepared by:

Vivian Stevens

Head of Theatres Services

September 2013


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49

APPENDIX 1 STAFF EXPERIENCE SCORECARD

Standard Description TargetMonitoring

periodApr-13 May-13 Jun-13 Jul-13 Aug-13 Comment

Staff Turnover

(Overall)

Overall avoidable staff turnover under

11% (average rate of 0.91% per month)

<=11% Monthly 0.64%

1.00%

(1.64%

Cumulative)

9.84%

projected

0.41%

(2.05%

cumulative)

8.20%

projected

0.77%

(2.82%

cumulative)

8.46%

projected

1.12%

(3.94%

cumulative)

9.46%

projected

Avoidable' staff turnover in M5 was 1.12% (39 leavers) compared with 0.90% in the same month last

year. In order to achieve the year end target of <=11% a monthly average turnover rate of 0.92% is

required. Although August's rate was above this average, the current year to date rate is well within the

level required to achieve the target. The year end avoidable turnover rate projects to 9.46%.

Staff Turnover

(Auxiliaries and

HCAs)

Overall avoidable staff turnover in

Auxiliaries/ HCAs under 13.5% (average

rate of 1.12% per month).

<=

13.5%Monthly 1.24%

1.86%

(3.10%

Cumulative)

18.60%

projected

0.40%

(3.50%

cumulative)

14.00%

projected

0.59%

(4.09%

cumulative)

12.27%

projected

1.95%

(6.04%

cumulative)

14.50%

projected

The Auxiliary turnover rate in M5 was 1.95% (10 leavers), the same as in M5 in 2012. This is a

significantly higher rate than has been experienced in the past several months. The cumulative rate in

the year to date is 6.04% (projecting to a year end rate of 14.5%) compared with 6.73% (16.15%

projected) at the same stage in 2012. However, it is normal in quarter 2 to experience the highest

number of Auxiliary leavers as many leave to start professional training courses. The year end target for

this staff group is <=13.5% target.

As previously noted, Auxiliary/HCA turnover is a significant problem nationally and much has been done

in the Trust to support this staff group in terms of recruitment, training and development, with the

support of senior nursing staff and management. Work is on-going with the Education Directorate to

devise and roll out a HCA development programme to support this staff group and aid with retention.

This has been agreed and is a feature of the 2013-14 commitments in the Trust's Annual Plan.

Sickness

Absence

Sickness absence rate <= 3.5%. (By

31st March 2013).

First figure is rate for the month,

second is cumulative rate for year to

date.

<=3.5% Monthly

3.82%

(3.82%

cumulative

ytd)

3.18%

(3.50%

cumulative

ytd)

3.34%

(3.45%

cumulative

ytd)

3.41%

(3.44%

cumulative

ytd)

3.16%

(3.38%

cumulative

ytd)

The first cut M5 sickness rate of 3.16% is the second lowest August rate recorded since 2007 when the

Trust started using the Electronic Staff Record. The year to August rate of 3.38% is the third lowest.

The July rate has been revised upwards. This is due to relatively early running of the first cut of the data

to meet reporting schedules, The year to date rate of 3.38% is within the Trust's target of <=3.5%.

Sickness related staff salary costs in the year at M5 were £1.24 million compared with £1.25 million at

the same stage last year, even though pay has increased due to the ending of the national pay freeze in

April. This makes the comparative year on year figure even better.

In the inter-organisation comparator group of 49 Trusts in the south and south west (data from the NHS

Information Centre). Poole was 15th in the latest 12 month data comparison (June 2012 - May 2013)

with a rate of 3.62%. The average sickness rate for the whole group was 4.14%, A more local

benchmark shows an average rate of 3.78%. Nine of the top 10 performing organisations were PCTs and

successor organisations.

Reporting for Month of August 2013

STAFF EXPERIENCE


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50

Standard Description TargetMonitoring

periodApr-13 May-13 Jun-13 Jul-13 Aug-13 Comment

Appraisal Appraisal Records On ESR

25% 29% 43% % 62%

Significant work has been undertaken by the HR Business Partners and Divisional Managers to ensure

that current appraisals are appropriately logged on the Electronic Staff Record. In areas where it has

been identified that appraisals need to be carried out, action plans have been devised to ensure

completion of the exercise. Assistance has been offered by HR to help load any backlogs of data

should managers have time constraints. It is anticipated that with the end of the summer holiday

season, the reported numbers will continue to rise steadily as some overdue appraisals are completed.

Establishment

compared with

Substantive Staff

in Post

WTE establisment and staff in post on

the final day of the month.

Monthly

3224 estab

3048 in post

Variance =

-176 wte

3224 estab

3046 in post

Variance =

-178 wte

3224 estab

3049 in post

Variance =

-175 wte

3219 estab

3061 in post

Variance =

-158 wte

3219 estab

3060 in post

Variance =

-159 wte

The variance between wte establishment staffing and wte staff in post on the last day of the month

increased marginally in M5 to 159 wte. This figure is consistent with the number of activities going

through the various stages of the recruitment process.

NB the change from month to month is not simply the result of staff in post, plus starters, minus

leavers, due to the fact that the most common day for staff to leave the Trust is the final day of the

month. Therefore these leavers are included both in the leaver figures and in staff in post.

Substantive

Starters

Headcount and WTE (excl junior

medical staff)57

(48.86 wte)

22

(18.48 wte)

58

(50.57 wte)

41

(34.31 wte)

52

(45.20 wte)

Significant recruitment activity continues across the Trust. All recruitment activities are vetted by the

Pay Spend Review Group, comprising Executive Directors, Divisional Directors and Matrons, which

meets weekly to consider all applications from managers to recruit to both vacant and new positions.

Substantive

Leavers

Headcount and WTE (excl junior

medical staff) 29

(24.46 wte)

42

(34.59 wte)

57

(52.98 wte)

35

(29.60 wte)

49

(43.68 wte)

Leaver numbers rose in August with 9 retirements and the start of the annual departures of staff going

on to further education, of whom there were 3. It is to be expected that more staff will leave in

September to start educational courses, (primarily nurse training) in particular Auxiliaries and HCAs.

Nursing Bank and

Agency Requests

Number of individual requests for

temporary nursing cover.Monthly

2685 shift

requests

2803 shift

requests

2960 shift

requests

2924 shifts

requested

3291 shifts

requested

Demand for temporary nurse staffing remains high and there was a 13% increase in August compared

to July, largely due to cover being required for annual leave. Active Bank worker/staff numbers for both

both qualified nurses and Auxiliaries/HCAs are the highest on record:

Nursing Bank and

Agency fill rate

Percentage of requested shifts filled by

the Nurses Bank (excl cancelled

requests).Monthly 85.32% 90.95% 87.64% 90.46% 87.39%

The fill rate for temporary nursing staff in August was 87.39% compared with 90.46% in July. This is in

the context of a 13% increase in shifts requested between the two months. Of the filled shifts in August

13.66% were from agencies, virtually unchanged from 13.80% in July. As anticipated, access to all

active bank staff in August was challenging due to the school holidays and staff being unavailable. This

situation will be remedied with the return to school in September. This remains consistent with the

national picture.


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51

DRAFT DOCUMENT

REF Indicator Indicator Definition 2013/14

TargetApr May Jun Jul Aug

1 Percentage of admitted patients starting treatment within a maximum of 18 weeks from referral 90% 96.8% 97.9% 97.7% 97.7% 96.9%

2Percentage of non-admitted patients starting treatment within a maximum of 18 weeks from

referral95% 97.3% 98.4% 98.2% 97.9% 97.6%

3Percentage of patients on incomplete non-emergency pathways (yet to start treatment) waiting

no more than 18 weeks from referral 92% 98.4% 98.7% 98.2% 97.5% 97.3%

4 Diagnostic test waiting times Percentage of patients waiting more than 6 weeks from referral for a diagnostic test. <1% <1% 0.1% <1% <1% 1.0%

5 A & E WaitsPercentage of A & E attendances where the patient was admitted, transferred or discharged

within 4hours of their arrival at an A&E department 95% 92.5% 96.4% 97.14%qtr 95.38% 96.3% 95.6%

6Percentage of patients referred urgently with suspected cancer by a GP waiting no more than

two weeks for first outpatient appointment.93% 94.8% 97.4%

95.4%

qtr 95.9%95.7%

7Percentage of patients referred urgently with breast symptoms (where cancer was not initially

suspected) waiting no more than two weeks for first outpatient appointment93% 91.9% 98.0%

94.5%

qtr 94.7%94.7%

8Percentage of patients waiting no more than one month (31-days) from diagnosis to first

definitive treatment for all cancers 96% 100.0% 100.0%

100%

qtr 100%99%

9Percentage of patients waiting no more than 31 days for subsequent treatment where that

treatment is surgery94% 96.8% 96.0%

100.0%

qtr 97.6%99%


treatment is an anti-cancer drug regimen98% 100.0% 100.0%

100%

qtr 100%100%


treatment is a course of radiotherapy94% 99.2% 97.2%

100.0%

qtr 98.8%99%

12Percentage of patients waiting no more than two months (62 days) from urgent GP referral to

first definitive treatment for cancer85% 92.1% 85.7%

88.3%

qtr 88.6%86%

13Percentage of patients waiting no more than 62 days from referral from an NHS screening

service to first definitive treatment for all cancers90% 94.4% 95.7%

93.9%

qtr 94.8%92%

14Percentage of patients waiting no more than 62 days for first definitive treatment following a

consultant’s decision to upgrade the priority of the patient (all cancers)90% 100.0% 86.7% 100.0% 94.0%

15 Mixed Sex Accommodation Sleeping Accommodation Breach <0 0 0 0 0 0

QUALITY AND PERFORMANCE INTEGRATED SCORECARED

Operational Standards


RTT waiting times for non-urgent

consultant-led treatment

Cancer waits – 2 week wait

(1 month lag)

Cancer waits – 31 days

(1 month lag)

Cancer waits – 62 days

(1 month lag)


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52

DRAFT DOCUMENT



16 Cancelled OperationsAll patients who have operations cancelled, on or after the day of admission (including the day

of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the

patient‟s treatment to be funded at the time and hospital of the patient‟s choice.

<0 5 0 0 1 0

17 RTT 52 week waits Zero tolerance RTT waits over 52 weeks <0 0 0 0 0 0

18 All handovers between ambulance and A & E must take place within 30 minutes<30

minutes

19 All handovers between ambulance and A & E must take place within 60 minutes<60

minutes

20 Trolley waits in A&E over 12 hours 0

21 Cancelled Urgent Operations No urgent operation should be cancelled for a second time 0

22 Published Formulary Failure to publish Formulary Yes Yes

23 Duty of Candour: Times used n/a 81 116 116 90 144

24Failure to notify the Relevant Person of a suspected or actual Reportable Patient Safety Incident

(as per Guidance)0 tbc

Operational Standards

Ambulance Handovers

Duty of Candour


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53

DRAFT DOCUMENT



25 Patient Early Warning Scores 95% of patients have observations completed as speci fied with their Care Plan 95% 93%

26

Number of hospita l deaths reviewed.Al l hospita l deaths reviewed to determine i f expected or

unexpected. Al l unexpected hospita l deaths (i .e. Service Users who were not expected to die at

time of admiss ion) have a Root Cause Analys is (RCA) and where appl icable are STEIS reported.

Al l patients admitted fol lowing a s troke who subsequently die in hospita l have a RCA.

n/a

27 Summary Hospita l Morta l i ty Index (SHIMI)

28 Hospita l Standardised Morta l i ty rates (HSMR) 96.2 not available 95.1

29Percentage of admitted patients whose deaths were included in the SHMI and whose

treatment included pal l iative care (Qual i ty Account s tandard).

30 Meningococcal septicaemiaChi ldren and Young people who have had bacteria l meningitis or meningococcal septicaemia

have a fol low up appointment with a consultant paediatrician i thin 6 weeks of discharge.

(NICE qual i ty s tandard)

100%

31 Improve Breastfeeding ini tiation at 48 hours 80% 80% 75%

32 Improve or Mainta in smoking at del ivery rates to 13% 13% 13.80% 13%

3390% of women see a midwife or a maternity healthcare profess ional for health and socia l care

assessment of needs , ri sk and choices by 12 weeks and 6 days of pregnancy.90% 90.40% 98%

34 VTEReport of local audits of the percentage of patients risk assessed for venous

thromboembolism who receive the appropriate prophylaxis100% 100% 99%

35 Number of confirmed cardio-pulmonary arrest calls to the Emergency Department n/a 0 2

36 Number of confirmed cardio-pulmonary arrest calls to all other areas of the Trust n/a 9 9

37 WHO Checklist Compliance with WHO surgical site Checlist 100% 66% n/a n/a n/a n/a

Domain 1: Preventing People from Dying Prematurely

Maternity

68%

Cardiac Arrest

12%

Mortality Rates


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54

DRAFT DOCUMENT



38Improving care for people with

Learning Disability

90% of service users with a flag on the PAS as having a learning disabi l i ty receive enhanced

assessment of care needs upon emergency admiss ion to hospita l . Provider must have system

in place to identi fy and flag whether Service Users have Learning Disabi l i ties and to what

extent these may require adjustments to care (with Service User consent).

95%

39100% assessed and managed by s troke nurs ing s taff and at least one member of the specia l i s t

rehabi l i tation team within 24 hours of admiss ion.100%

40 100% assessed by a l l relevant member of the specia l i s t rehabi l i tation team within 72 hours . 100%

4190% of patients admitted directly to specia l i s t acute s troke unit within 4 hours of arriva l at

hospita l . 90%

42 100% assessed for thrombolys is 100%

43 100% receive thrombolys is i f cl inica l ly indicated. 100%

44 100% with documented multidiscipl inary goals . 100%

45Care plans for Long Term

conditionsPercentage of pateints with long term conditions offered a personal ised care plan 100%

Domain 2: Enhancing Quality of Life for People with Long-term Conditions

Stroke Services

REF



4690% of cl inica l ly appropriate patients with #NOF operated on with 36 hours of admiss ion.

Tra jectory to achieve 95%

cons is tently by Q4 to be agreed by end of Q1.

90% - 95% 96% 97% 95% 96% 88%

47Patient level data on hours :minutes taken to transfer patient to hospita l fol lowing diagnos is

of #NOF

48Annual Reported Health Gain PROMs for Groin hernia surgery, Varicose vein surgery, Hip replacement surgery and knee

replacement surgery. (Qual i ty Account scorecard)83% 83% 81% 57% 85%

49 Heart Failure 100% of people admitted to hospita l because of heart fa i lure are only discharged when stable

and receive a cl inica l assessment from a member of the multidiscipl inary heart fa i lure team

within 2 weeks of discharge. (National Heart fa i lure Audit)(National Heart fa i lure Audit)

100% 75%

Domain 3: Helping people to recover from episodes of ill health or following injury

Improved outcomes following

Fractured Neck of Femur

n/a


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55

DRAFT DOCUMENT



50 Innovation Health and Wealth 100% of the IHW Prequal i fication Cri teria are achieved and mainta ined 100%

519 Qual i ty s tatement to be ful ly completed by 31 March 2014 showing amber or green against

ELCQUA measures9

52 Percentage of Service Users supported to die in their preferred place. 95%92%Palliative

care only

53 99% of a l l patients to be seen within 26 weeks with effect from 1 October 2013 99%

54 100% of a l l patients to be seen within 35 weeks with effect from 1 July 2013 100%

55 Transfer to other providers99% of a l l patients to be transferred (i f required) to another provider within 6 weeks of referra l

with effect from 1 July 2013.99%

5699% of a l l ‘active’ patients across individual modal i ties are seen within 6 weeks (exception

where less than 20 tests are undertaken each month), with effect from 1 July 201399%

57100% of all ‘planned’ patients are seen within 6 weeks of their planned date, with effect from 1

April 2013100%

58Reduce Un-planned re-attendances at A&E within 7 days of original attendance to 5% by 1 July

20135% 2.90% 2.62% 2.20% 3.00% 2.50%

59 Reduce Left department without being seen rate to 5% by 1 July 2013 5% 3.33% 2.96% 3.39% 3.63% 2.90%

60Reduce Time to initial assessment - 95th centile to less than 15 minutes

TIME TO ASSESSMENT TRIAGE (MAJORS)<15 mins 22 19 17 21 17

61Reduce Time to treatment in department – median to less than 60 minutes

TIME TO BE SEEN BY CLINICIAN (MEDIAN)<60 mins 61 55 68 83 59

62 Cancelled elective admission Zero cancellations with a threshold of 0.7% of all elective admissions for non clincial reasons

either before or after admission 0.7%

63 Choose and book <4% Slot Avai labi l i ty Issues <4% 16% 12% 22% 20% 19%

64 Delayed Transfers of care Delayed Discharges to be <3.5% of occupied beds <3.5% 1.10% 3.24% 3.23% 2.90% 2.40%

End of Life care

Treatment within Emergency

Department

Access to appropriate services

within 18 weeks

Review of resources

underw ay to comply w ith

this requirement

Access diagnostic services within

6 weeks across all modalities

Domain 4: Ensuring that people have a positive experience of care


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56

DRAFT DOCUMENT



65Summary of compla ints , themes and improvement priori ties reported to Provider Board and

publ ished on Provider Webs ite.Yes tbc

66 Total number of Complaints 38 41 39 46

67 Total number of Complaints acknowledged within 3 working days 97% 100% 92% n/a

68 Mixed Sex Accommodation Breach 0

69 No of ambulance handover taking more than 15 minutes

70 No of minutes of handover above 15 minutes

71 Trolley waits in A&E above 4 hours

72 Trolley waits in A&E above 12 hours

73 Return to TheatreNumber of patients with an unplanned return to theatre during the same inpatient admission,

by procedure, by type and speciality. 2 3 3 7 2

74Patient satisfaction - Were you involved as much as you wanted to be in decisions about your

care and treatment?tbc n/a

75Patient satisfaction - Did you find someone on the hospital staff to talk about your worries and

fears?tbc n/a

76Patient satisfaction - Were you given enough privacy when discussing your condition or

treatment?tbc n/a

77Patient satisfaction - Before you left hospital, were you given any written or printed information

about what you should or should not do after leaving hospital?tbc n/a

78Patient satisfaction -Did a member of staff tell you about medication side effects to watch for

when you went home?tbc n/a

79 Patient Moves Number of patients moved 3 or more times with frequency distribution 34 33 37 45

80 Emergency Department ( Includes ED, RACE and Ansty) 3.20%

81 Inpatients 29.40%

82 Maternity Oct-13

83 % reported extremely likely to recommend to a family member 72.50%


Patients Satisfaction

Friends and Family Test

Summary of Complaints


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57

DRAFT DOCUMENT



84 95% of all admissions receive a MUST assessment within 24 hours of admission to hospital. 95% 62% n/a

85Number of patients screened for malnutrition (exception report on actions taken for those not

screened and those identified as at risk)

86 95% of nutritional screening on admission to hospital 85% n/a

8795% of high risk admissions have a completed pressure ulcer risk assessment within 6 hours

of admission. 95% 94%

88 Number of acquired pressure sores all grade 2+ 7 10

89 Number acquired in care, grade 3 and 4 2 0

90 Number admitted with pressur sore(s) all grade 52 55

9295% of all other Service Users to receive a risk assessment within 24 hours. Reduction

trajectory to be agreed by the end of Q2. Consequence of breach will only apply if trajectory

missed

95% 94%

Annual report prospectively detailing and confirming that rosters are in place that provides h e

required cover including Saturdays and Suanday and out of hours to include hours covered .100%

Annual retrospective report that details when there has been no cover which should be reported

as and when on an exception basis100%

Staff Levels publically availableAll actual nurse and skill mix staffing levels displayed prominently on each inpatient area on a

daily basis.95%

Number of falls 96 69

95% of high risk Service Users receive a risk assessment within 12 hours of admission 95% 94%

95% of all other Service Users receive a falls assessment within 24 hours of admission. 95% 93%

Patient falls resulting in a fracture or significant injury 2 1

Percentage of falls assessments completed within 24 hours of admission. see ref 97

Number of patients falling more than once 16

Percentage of Staff Trained in Safeguarding Children Level 1 74% 75% 73% 73%



Percentage of Staff Trained in Safeguarding Adults 74% 73% 71% 70%

Percentage of Staff Trained in MCA/DOLS 0 1 2 2

Number of DOLs applications made 0 1 2 2 1

Falls

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Nutrition

Pressure Ulcers

Consultant Cover

Safeguarding


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58

DRAFT DOCUMENT



MRSA Bactareamia 0 0 0 0 0

MRSA Screening

E.Coli (Cumulative) 6 3

MSSA (Cumulative) 2 3

Rates of Clostridium difficile (cumulative ytd figure each month) 2 2 3 4 4

Infection Control - Hand washing audit compliance 98% 99%

National Reporting and Learning System (% of low/no harm incidents) 95.14% 95.43% 95.80% 93.46% 94.41%

National Reporting and Learning System (% of severe harm incidents) 0.20% 0.60% 0.30% 0.40% 0.32%

Safety Alerts NPSA Safety Alerts - Number outstanding 0 0 0 0 0

Never Events Number of Never Events 1 0 0 0

Monthly summary report of all incidents requiring reporting 617 634 637 557 626

Number of Independent Investigations commissioned by provider tbc

Number of medication errors all harms 54 59

Number of medication errors relating to controlled drugs, all harm 9 12

Number of Serious Incidents Requiring Investigation (declared) 1 3 3 1 4

No of Serious Incidents reported within timescale 1 3 3 1 4

Sickness absence rate monthly% 3.86% 3.86 3.17 3.33 3.09 3.16

Staff turnover rate % 0.6% 0.64 1 0.41 0.77 1.12

Mandatory Training % 74% 74% 72% 72%

Appraisal % 29% 38% 43% tbc 63%

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Serious Incidents

NRLS

Workforce

Incidents

Medication

Infection Control


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59

DRAFT DOCUMENT




Inpatients

% reported extremely likely to recommend to a family member

% Harm Free Care 87.16% 89.09% 87.14% 87.31% 91.18%

Number of patients with harm free care 380 400 393 399 403

Number of patient eligible for survey 436 449 451 457 442

Number of patients surveyed 436 449 451 457 442

% of patients submitted 100% 100% 100% 100% 100%

Pressure ulcers - All % 8.94% 8.46% 7.76% 8.53% 4.98%

Pressure ulcers - New % 1.15% 0.89% 1.33% 1.31% 0.23%

% of patients aged 75+ admitted to ED with a LoS .72 hours who are asked the dementia case

finding question

% identified as potentially having dementa who are then appropriately assessed

% diagnostcally assessed who have a positive diagnosis and are then referred to specialist

services

Dementia training programme

Dementia support for carers - monthly audit of carer support

% risk assessment compliance 94.10% 95.40% 95.50% 96.20% 95.90%

% of all hospital associated thombosis with a completed RCA

COPD % of patients discharged with a completed COPD care bundle

Senior management representation on Urgent Care Steering Group

Audit of proactive and discharge planning to ensure people avoid crisis - TBC

% DNAR compliance

PROMS - Total Knee ReplacementNumber of patients listed (per quarter) with a score above and below 29 and the reasons for

listing any patients above 29

Friends and Family Test

Increased Response Rate - per month:

Safety Thermometer

Safety Thermometer - Pressure Ulcers

Dementia

VTE

Urgent Care Pathway

CQUIN SCHEME


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60


Top



COUNCIL OF GOVERNORS – COVER SHEET


Agenda Item: 15 Paper No: I

Title: Merger Update

Purpose: To provide the Council of Governors with an ongoing briefing on the merger programme and an update on progress

Summary:

Introduction The purpose of this paper is to provide the Council of Governors with an update on the merger programme. In particular, the Council of Governors is asked to note progress in the following areas:

the Competition Commission (CC) revised administrative timetable to complete the investigation

the CC’s written instructions following parties’ disclosure of breach of undertakings

key communication and engagement activities

Deborah Matthews Programme Director

Recommendation:

The Council of Governors is asked to note progress to date regarding the proposed merger project.

Prepared

by:

DEBORAH MATTHEWS Programme Director

Presented

by:

CHRIS BOWN Chief Executive DEBORAH MATTHEWS Programme Director

Assurance

Framework:

YES / No Risk

Register I/D

No:

Healthcare Standards:

Please specify which standard/

standards that apply;

CQC Standard (Please provide details:

Other; i.e /NHSLA/HSE etc Monitor compliance: YES NO

Human Resources implications YES NO Financial implications YES NO

Legal implications YES NO

Please ensure all boxes are completed in order to comply with national requirements

CoG�Sep�13�I1�Cover�Sheet��-�P

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MERGER PROGRAMME

Briefing Paper for the Council of Governors

26 September 2013

Introduction

The purpose of this paper is to provide the Council of Governors with a monthly update on

the merger programme.

The Competition Commission

Following the publication of the Competition Commission’s (CC) provisional findings on the proposed merger between Poole Hospital NHS Foundation Trust (PH) and The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (RBCH), both parties submitted a number of formal responses to the CC in August 2013 including a) a joint proposal for potential remedies and b) a re-statement of the benefits case. On 05 August 2013, the CC published a revised administrative timetable to allow more time to assess the customer benefits but indicating a further delay in the completion of the investigation by further 8 weeks (21 October 2013). Formal Party hearings were held on 07 August with questions focused on the relevant customer benefits (RCBs) and our proposed remedies. The parties responded to a number of post hearing questions in late August 2013. On 05 September 2013, the CC On 5 September, the CC held a public drop-in session at Parkstone Baptist Church Hall, Poole designed to gather the views of local people about the merger of Royal Bournemouth and Christchurch Hospitals and Poole Hospital. Following a breach of the undertakings reported by the Parties in July 2013, the Competition Commission (CC) issued directions on 04 September 2013, instructing that the FTs cease detailed integration planning meetings with immediate effect. We have reluctantly agreed to adhere to this stipulation. The practical effect of this new undertaking is to continue to prevent any and all effective preparation and planning for the merger. Inevitably this will delay the merger (if approved). With this in mind and following legal advice, we have taken the decision to stand down JPB, the Proposed Board and Joint Governor meetings until we have the Competition Commission’s (CC) final decision, currently scheduled for October 2013. The target deadline for completion of the investigation is now revised, with a deadline for 21 October 2013.

Merger reference made 08 January

Gathering of information, questionnaires issued January – February 2013

Publish statement of issues 28 January 2013

Site Visit 18 February 2013

Main party hearing (1) 23 April 2013

Deadline for all parties’ responses / submissions in advance of provisional findings

18 June 2013

Main party hearing (2)

11 June 2013

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Notify provisional findings and if required consider possible remedies

11 July 2013

Notify supplementary notice of possible remedies 12 July 2013

Final deadline for responses / submissions on remedies notice, including relevant customer benefits

26 July 2013

Hold response hearings 07 August 2013

Final deadline for responses / submissions on provisional findings

01August 2013

Final deadline for submissions on remedies before proposed provisional remedies decision

15 August 2013

Final deadline for all parties’ responses / submissions

17 September 2013

Publish final report October 2013

Statutory deadline 21 October 2013

Programme Governance and Controls

As a result of the CC provisional findings and remedies working paper, both parties will

review plans for the formal submission to Monitor.

Communications and Stakeholder Engagement

The Dorset wide listening exercise is drawing to an end. Around 6,000 questionnaires have

been received and a range of focus groups have been held. The Bournemouth University

Research Team will now collate the results for the final report in October.

A communications plan has been drafted in response to the Competition Commission’s final

decision. This has been circulated to both boards for comment and includes a joint

statement, a statement from each trust on the future, FAQs and an activities plan.

Deborah Matthews

Programme Director

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Agenda Item: 16 Paper No: J

Title:

Monitor Risk Assessment Framework (FTN Briefing)

Purpose:

To inform the Council of Governors of the Revised Monitor Risk Assurance Framework

Summary:

Monitor have issued the Risk Assurance Framework, which can be found here: http://www.monitor.gov.uk/raf Attached is the Foundation Trust Network’s (FTN) briefing on the subject.

Recommendation:

The Council is asked to note the new Risk Assurance Framework.

Prepared by:

JILL RETIGAN

Board & Council Admin. Presented by:


CoG�Sep�13�J1�Monitor�RAF.docx

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Monitor’s Risk Assessment Framework

1

CoG�Sep�13�J2�Monitor�Risk�Ass

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http://www.monitor-nhsft.gov.uk/home/news-events-publications/latest-press-releases/monitor-sets-out-new-approach-key-aspects-how-it

http://www.monitor.gov.uk/sites/default/files/publications/RAF_Consultation_Final_August2013.pdf

http://www.foundationtrustnetwork.org/resource-library/ftn-consultation-response-monitor-raf/



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Agenda Item: 18 Paper No: K

Title:

Register of Governors Interests

Purpose:

To present the updated Register of Interests for the Council of Governors.

Summary:

The annual review of the Council of Governor register of interest has been completed and presented for information. Should governors have any changes to the register at anytime they are to inform the Company Secretary function for noting at the next Council of Governor meeting.

Recommendation:

The Council of Governors are asked to note the register of interests.

Prepared by:

ANITA BONHAM Business Manager

Presented by:


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REGISTER OF COUNCIL OF GOVERNORS' INTERESTS

As at 3 September 2013, the following interests were declared by members of Poole Hospital NHS Foundation Trust’s Council of Governors:

John Adams Appointed governor for Bournemouth Borough Council

Councillor - Bournemouth Borough Council

Dorset Magistrate

Appointed Governor - Royal Bournemouth & Christchurch Hospitals NHS FT

Vice-Chairman of the Dorset Police and Crime Panel

Geoffrey Carleton Elected governor for Purbeck, East Dorset and Christchurch constituency

Nil

Lynn Cherrett Elected governor for clinical staff constituency

Daughter is an employee of Pricewaterhouse Cooper

Colette Cherry Appointed governor for Bournemouth University

Member of staff at Bournemouth University.

Mother is Assistant Registrar at Buckinghamshire w University in charge of nursing placements.

Andrew Creamer Elected governor for Poole constituency

Officer of Bournemouth Borough Council, working in adult social care

Vivien Duckenfield Elected governor for Poole constituency

Nil

Barry Faith Elected governor for Poole constituency

Director – Millennium Management Ltd

Sole Trader - Arlington Associates

Co-ordinator & Chairman, ARMA Dorset

Rosemary Gould Elected governor for Purbeck, East Dorset and Christchurch constituency

Nil

Geof Hermsen Elected governor for Poole constituency

Nil

Barbara Hooper Elected governor for Purbeck, East Dorset and Christchurch constituency

Nil

David Jones Appointed governor for Dorset County Council

Member of Dorset County Council

Member of Dorset Health Scrutiny Committee

Director and Chairman. Waterford Lodge (Christchurch)


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2

Richard King Elected governor for Poole constituency

Employee of South Western Ambulance Service NHS Foundation Trust

Wife is an employee of Poole Hospital

Kris Knudsen Elected governor for clinical staff constituency

Nil

Sylvia Lowrey Elected governor for clinical staff constituency

Nil

Jane LLoyd Elected governor for non- clinical staff constituency

Volunteer at Lewis-Manning Hospice

Trustee, Poole Africa Link

Dr Chris McCall NHS Dorset Clinical Commissioning Group (CCG)

Member of NHS Dorset CCG

Isabel McLellan Elected governor for North Dorset, West Dorset, Weymouth & Portland constituency

Nil

Brian Newman Elected governor for Bournemouth constituency

Nil

James Pride Elected governor for Poole constituency

Chairman - The Canford Cliffs Land Society Ltd (voluntary)

Wife is a consultant physician at Poole Hospital

Director – The New Yacht Company Ltd (RMYC)

Director – Sandbanks Boat Yard (RM) Ltd

Elizabeth Purcell Elected governor for Poole constituency

Chief Executive Officer – Lewis Manning Trust

Terence Purnell Elected governor for Bournemouth constituency

Professional relationships with Employers for carers and Focus Consulting

Ann Stribley MBE Appointed governor for Borough of Poole

President – Poole Volunteer Branch, British Heart Foundation

Member – Poole Council Unitary Authority

UK Delegate/Alternate Member – EU Committee of the Regions

Vice Chairman of the Dorset Fire Authority

Sandra Yeoman Elected governor for Poole constituency

Nil

MICHAEL BESWICK Company Secretary September 2013


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COMMONLY USED ABBREVIATIONS

ABBREVIATION EXPLANATION

18-week target Delivery of a maximum 18-week wait from GP referral to start of treatment (RTT)

A & E Accident and Emergency

A&GC Audit & Governance Committee

AfC Agenda for Change is the pay system for NHS staff implemented in 2004. A summary of the system is available on the Department of Health website

AHPs Allied Health Professionals – physiotherapists, occupational therapists, speech therapists and orthotists. Previously PAMs (Professions Allied to Medicine)

AIRS Adverse Incident Recording System – the Trust’s no-blame system for reporting all clinical and non-clinical adverse incidents and near misses

AQP Any Qualified Provider – this scheme means that, for some conditions, patients will be able to choose from a range of approved providers, such as hospitals or high street service providers.

ASI Appointment Slot Issue

ASU Acute Stroke Unit

c.difficile Clostridium difficile - the major cause of antibiotic-associated diarrhoea and colitis, an intestinal infection that mostly affects elderly patients with other underlying diseases.

CEA Clinical Excellence Awards - given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care

CHKS CHKS is a national independent provider of comparative performance and benchmarking healthcare data

CEPOD CEPOD (Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

CHC Continuing Healthcare

CIP Cost Improvement Plan

CMT Clinical Management Team

CoG The Council of Governors comprises:

14 public governors who are elected by members of their own constituency – Poole (8); Purbeck, East Dorset & Christchurch (3); Bournemouth (2); North Dorset, West Dorset , Weymouth & Portland (1);

4 staff governors who are elected by members of Trust staff – clinical (3); non-clinical (1);

6 appointed governors nominated by the Trust’s partner organisations – Bournemouth & Poole PCT (1); Dorset PCT (1); Dorset County Council (1); Poole Borough Council (1) Bournemouth Borough Council (1); Bournemouth University (1).

CQC The Care Quality Commission is the independent regulator of health and social care in England. The CQC regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations, and protects the rights of people detained under the Mental Health Act

CQUIN Commissioning for Quality and Innovation - the CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation. Its aim is to support the vision set out in High Quality Care for All of an NHS where quality is the organising principle. The framework was launched in April 2009 and helps ensure quality is part of the commissioner-provider discussion everywhere.

CRES Cost Releasing Efficiency Saving

CRT Clinical Record Tracking – a bar-code based system for recording the location of patients’ medical records.

Glossary�of�abbreviations�Feb�

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DATIX National software programme for Risk Management

DME Department of Medicine for the Elderly

Dr Foster Dr Foster Intelligence, a joint venture between the Department of Health’s Information Centre and a private sector company Dr Foster LLP. Dr Foster provides a range of health information to the public (online and via supplements in the national media) and makes NHS performance data available under licence to health sector organisations

DToC Delayed Transfer of Care

EBITDA Earnings Before Interest, Taxation, Depreciation and Amortisation

EBME Electrical, Biomedical Equipment

ENT Ear, Nose and Throat

ESR Electronic Staff Record - the national, integrated Human Resources (HR) and Payroll system used by all NHS organisations throughout England and Wales. The ESR has a bi-directional interface with NHS Pensions. Personal data for all staff will be transferred to a data warehouse. This will include contact details, salary information, HR records, trainings, qualification, occupational health and other records. It will also include sensitive information such as sickness record absence, disabilities, ethnic origin

EWTD European Working Time Directive - lays down minimum requirements in relation to working hours/rest periods/annual leave for all workers and working arrangements for night workers. The current limit is an average of 48 hours work per week.

FCE Finished Consultant Episode is a measurement which assigns a patient’s episode of care to a consultant

FFCE First Finished Consultant Episode identifies the first consultant episode of care during a patients hospital stay

FIC Finance & Investment Committee

Foundation Trust/FT

NHS foundation trusts are autonomous organisations, free from central Government control. They decide how to improve their services and can retain any surpluses they generate, or borrow money, to support these investments. They establish strong connections with their local communities; local people can become members and governors. These freedoms mean NHS foundation trusts can better shape their healthcare services around local needs and priorities. NHS foundation trusts remain providers of healthcare according to core NHS principles: free care, based on need and not ability to pay. Poole Hospital NHS Foundation Trust was authorised on 1 November 2007

FRP Financial Recovery Plan.

H@N Hospital at Night - the provision of multi disciplinary teams working in hospital Out of Hours who between them have the full range of skills and competencies to meet patients’ immediate needs

HDU High Dependency Unit, for patients requiring close monitoring and high levels of care but not life support

HR Human Resources

HRG Healthcare Resource Group – groupings of treatment episodes which are similar in resource use and in clinical response

HSE Health & Safety Executive

ICU or ITU Intensive Care Unit or Intensive Therapy Unit

I&E Income and Expenditure

IT or IM&T Information Technology or Information Management & Technology

KSF Knowledge & Skills Framework - identifies the knowledge and skills that individuals need to apply in their post. Used to provide a fair and objective framework on which to base review and development for all staff

LNC Local Negotiating Committee – the main management/medical staff forum


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LoS Length of Stay

LTFM Long Term Financial Model

MDT Multi-Disciplinary Team

Monitor The independent regulator of NHS Foundation Trusts. Monitor rigorously assesses applicants for NHS foundation trust status and subsequently monitors their activities to ensure that they comply with the requirements of their terms of authorisation. Monitor has powers to intervene in the running of a foundation trust in the event of failings in its healthcare standards or other aspects of its activities, which amount to a significant breach in the terms of its authorisation

Mortality rate The ratio of total deaths to total population in a specified community or area over a specified period of time. The death rate is often expressed as the number of deaths per 1,000 of the population per year.

MRSA Methicillin Resistant Staphylococcus Aureus – an antibiotic resistant infection commonly found on the skin and/or in the noses of healthy people. Although usually harmless at these sites, it may occasionally get into the body (eg through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or indwelling catheters) and cause infections. These infections may be mild (eg pimples or boils) or serious (eg infection of the bloodstream, bones or joints). An infection of the bloodstream is called a bacteraemia

MSC Medical Staff Committee

NCEPOD NCEPOD (National Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

NHSLA National Health Service Litigation Authority – the NHS clinical “insurance” scheme

NICE National Institute for Health & Clinical Excellence

NICU Neonatal Intensive Care Unit

NPfIT National Programme for Information Technology

NPSA National Patient Safety Agency

NSF National Service Framework - sets national standards and identifies key interventions for a defined service or care group. Also sets measurable goals within specified time frames.

NREC Nominations, Remuneration & Evaluations Committee - a sub-committee of the CoG responsible for the making recommendations to the CoG regarding the appointment, remuneration and performance review of the Chairman and non-executive directors

NVQ

National Vocational Qualification

OMF Oral Maxillo Facial

OFT Office of Fair Trading

PA/SPA Programmed Activities and Supporting Professional Activities. PAs identify medical staff clinical sessional commitments. SPAs are defined as “activities that underpin direct clinical care. This may include participation in training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities.”

PACS Picture Archiving and Communications System – the digital storage of x-rays

PALS Patient Advice and Liaison Service - provide information, advice and support to help patients, families and their carers

PBC Practice Based Commissioning – an initiative which enables clinicians and other front line staff to redesign services that better meet the needs of their patients

PbR Payment by Results - the funding system for the NHS in England. This pays a standard tariff for the treatment of different conditions. Not all hospital activity is funded by PbR and hospitals still have to negotiate “block funding” to cover these areas – eg. diagnostic and screening tests.


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PCT Primary Care Trust. The two local PCTs are now known as NHS Bournemouth & Poole and NHS Dorset.

PEAT Patient Environment Action Team - PEAT team Inspections are a national initiative coordinated by the Department of Health

PFI Private Finance Initiative

PEWS Poole Early Warning System – a system to identify and alert staff of the deteriorating patient based on scoring patient observations against a number of criteria. Patients causing ‘alarm’ are reviewed by the nurse in charge of the ward and an emergency call made to switchboard requesting attendance of a member of the patients medical team or on call team

PHFT Poole Hospital NHS Foundation Trust

PMETB Postgraduate Medical Education and Training Board

PMO Programme Management Office

PROM Patient Recorded Outcomes Measures

PTIP Post Transaction Implementation Plan

PYLL Potential Years of Life Lost

QIPP The Quality, Innovation, Productivity and Prevention Programme. This is about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients.

QSP Quality, Safety and Performance Committee

RBH Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

RCI/Reference costs

Reference Cost Index – reference costs are the average cost to the NHS of providing a defined service within a given financial year. The RCI compares the actual cost of activity with the same activity at national average costs - organisations with costs equal to the national average score 100 whilst an organisations with a score of 80 or 115 has costs 20% below/ or 15% above the national average. The RCI is used for benchmarking and as the basis of PbR

RTT Referral to Treatment. The current RTT Target is 18 weeks.

Self-funding patients

This relates to patients who are not eligible for funding of future long-term care due to personal assets over the agreed threshold of £23,250, therefore they are deemed to be responsible for funding their care themselves.

SHA Strategic Health Authority – NHS South West is one of the ten Strategic Health Authorities in England formed on 1 July 2006

SLA Service Level Agreement - a SLA is an agreement that sets out formally the relationship between service providers and customers for the supply of a service by one or another.

SLM Service Line Management

SLR Service Line Report

SMR Standardised Mortality rate – see Mortality Rate

SpR Specialist Registrar – medical staff grade below consultant

SPF Staff partnership Forum – the main management/ staff forum, previously known as the JCNC (Joint Negotiating & Consultation Committee)

SUI Serious Untoward Incident

TAL

NHS Direct provides The Appointments Line service as part of the Choose & Book system. Choose and Book is the electronic hospital appointments booking system. It allows people to make their first outpatient appointment online, at their GP practice, or by calling the Appointments Line (TAL). Patients can choose the place, date and time of the appointment to suit them.

VTE Venous Thromboembolism

WTE Whole Time Equivalent

Feb 2013


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Documents

AGENDA - Poole Hospital NHS Foundation Trust: … 1 CoG Pack Sept. 2013.pdf · 3 Draft Minutes of Meeting held on 25 July 2013 CoG Sep 13 A CoG ... Elections for Governors would commence