Isle of Wight NHS Trust Board NARU Update NARU Update ... July 2018.pdf · Isle of Wight NHS Trust Board Meeting in Public to be held on Thursday 5 July 2018 at 1.30pm -Conference

IW NHS Trust Board (Public) 5 July 2018 - Page | 1

NARU Update NARU Update

Agenda

AGENDA

No. Item Lead Purpose Enc/Verbal PROCEDURAL 1 Apologies Chair Receive Verbal 2 Confirmation that meeting is Quorate Chair Receive Verbal 3 Declarations of Interest Chair Receive Verbal 4 Minutes of previous meeting Chair Approve A 5 Matters Arising and Schedule of Actions Chair Receive B 6 Chair's Update Chair Receive C 7 Chief Executive's Update Maggie Oldham Receive D STRATEGY 8 Equality & Diversity Workforce Report 2017/8 –

incorporating the Public Sector Equality Duty Julie Pennycook Approve E

9 Gender Pay Gap Report 2018 Julie Pennycook Approve F 10 Interim Workforce Strategy 2018/19 Julie Pennycook Approve G 11 Recruitment & Retention Strategy Julie Pennycook Approve H 12 Risk Management Strategy 2018-2021 Suzanne Rostron Approve I 13 Local Care Board Update

Darren Cattell Assurance J

PERFORMANCE 14 Quality Performance Report Suzanne Rostron

Barbara Stuttle Alistair Flowerdew

Assurance K

15 National Report Under Pressure: Safely Managing increased demand in Emergency Departments

Nikki Turner Assurance L

16 Safe Staffing Report Barbara Stuttle Assurance M 17 Workforce & Organisational Development

Performance Report Julie Pennycook Assurance N

18 Financial Performance Report Darren Cattell Assurance O 19 Integrated Performance Reports: • Acute Services Nikki Turner Assurance P • Ambulance Services & Patient Transport

Services Bob Williams Assurance Q

• Community Services Barbara Stuttle Assurance R • Mental Health & Learning Disabilities

Services Lesley Stevens Assurance S

COMMITTEE ASSURANCE AND GOVERNANCE 20 Board Assurance Framework Suzanne Rostron Assurance T 21 Committee Reports from the meetings held on 4

July 2018: Chairs: Assurance Verbal

• Quality Committee Tim Peachey • Performance Committee Charles Rogers CLOSING MATTERS

Isle of Wight NHS Trust Board Meeting in Public Date: 5 July 2018 Time: 1.30pm – 4.00pm Venue: Conference Room – Level B Main Hospital (opposite Full Circle Restaurant), St. Mary’s Hospital, Newport, Isle of Wight PO30 5TG

IW NHS Trust Board (Public) 5 July 2018 - Page | 2

22 Issues to be covered in Private Chair Receive Verbal 23 Questions from the Public Chair Receive Verbal 24 The next meeting in Public of the IW NHS Trust

Board will be on: Date: Thursday 02 August 2018 Venue: Conference Room - Level B, St Mary's Hospital, Newport, IW PO30 5TG

Chair Receive Verbal

Following the conclusion of the agenda items in Part 1

of the Trust Board, the Board will now convene as Corporate Trustee

Board Convened as Corporate Trustee 25 Charitable Funds Committee report from the meeting

held on 4 July 2018:

Chair of CFC (Caroline Spicer)

Assurance Verbal

26 Charitable Funds Strategy Darren Cattell Approve U

Public and Staff Attendance Staff and members of the public are welcome to attend the meeting. Questions for the Board Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given. Issues to be Covered in Private The meeting may need to move into private session to discuss issues which are considered to be ‘commercial in confidence’ or business relating to issues concerning individual people (staff or patients). On this occasion the Chairman will ask the Board to resolve: 'That representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1(2), Public Bodies (Admission to Meetings) Act l960. Recording of Meeting This meeting will be recorded for the purposes of assisting in transcribing the minutes and actions from the meeting. Confirmation of Quoracy No business shall be transacted at a meeting of the Board of Directors unless one-third of the whole number is present including: The Chairman; one Executive Director; and two Non-Executive Directors. Apologies Received from

•

mailto:[email protected]

Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public

to be held on

Thursday 5 July 2018

at

1.30pm - Conference Room

Level B Main Hospital

(opposite Full Circle Restaurant)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

IOW NHS Trust Board Meeting Pt 1 7 June 2018 1

Minutes of the meeting of the Isle of Wight NHS Trust Board held in public at 1.30pm on Thursday 3 May 2018 in the Conference

Room, St Mary’s Hospital, Newport, IW PO30 5TG PRESENT: Voting Members: Vaughan Thomas Chair Darren Cattell Director of Finance, Estates and IM&T Alistair Flowerdew Medical Director Maggie Oldham Chief Executive (CEO) Tim Peachey Non-Executive Director Charles Rogers Non-Executive Director Frank Sims Deputy Chief Executive Officer Caroline Spicer Non-Executive Director Anne Stoneham Non-Executive Director Barbara Stuttle CBE Director of Nursing, Midwifery, AHPs &

Community Services Non-Voting Members:

Charles Godden Associate Non-Executive Director

Julie Pennycook Director of Human Resources & Organisational Development

Steve Parker Interim Medical Director (IMD) Suzanne Rostron Director of Quality Governance Lesley Stevens Director of Mental Health & Learning Disabilities

Services Nikki Turner Director of Acute Services Sara Weech Associate Non-Executive Director Bob Williams QAM Ambulance Advisor to the Board Attendees Claire Budden Board Secretary David Haycox Governance Advisor Daniel Robinson Corporate Business and Development Manager Alan Thorne NHSI Improvement Director Andy Hollebon Head of Communications & Engagement For item 18/T/102 Alison Toney Communications & Engagement Officer For item 18/T/102 Jo Henley Membership & Engagement Officer For item 18/T/111 Leisa Gardiner Freedom to Speak Up Guardian Observers: Pamela Ainslie Organisational Development Project Manager Vincent Grant Deputy Chair of Patient Council Caryl Morrison Healthwatch Cllr John Nicholson Councillor – IW Council Minuted by: Lynn Cave Board Governance Officer Members of Staff and Public in attendance:

There were no members of staff or members of the public present. A representative from the IW County Press and IW Radio attended

Minute No.

Chair’s Opening Remarks The Chair welcomed everyone to the meeting and especially the representatives

from the Patient Council, Healthwatch, IW Council and IW County Press.

Enc A


The Chair welcomed Claire Budden who was joining the Trust as Board Secretary and also Bob Williams who would be supporting the Ambulance Services. The Chair advised that confirmation had now been received from NHSI and was pleased to announce that Mr Alistair Flowerdew was joining the Trust as Medical Director; Dr Lesley Stevens had been appointed Director of Mental Health & Learning Disabilities Services; Darren Cattell had also been confirmed as Director of Finance, Estates and IM&T & Information. The Chair gave thanks to David Haycox who has been supporting the Trust as Governance Advisor since September 2017 and would be leaving at the end of June. He also thanked Steve Parker for all his work as Interim Medical Director since September 2018. He advised that Steve Parker had been instrumental in dealing with a range of complex issues during this time and confirmed that he would be returning to his surgical duties.

PROCEDURAL 18/T/094 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND

CONFIRMATION THAT THE MEETING IS QUORATE Apologies for absence were received from:

• Dr Robert Ghosh, Director of Clinical Improvement The Chair confirmed that the meeting was quorate. Declarations of interest were received from:

• Darren Cattell as Director of Wight Life Partnership • Charles Rogers as Director of Wight Life Partnership • Barbara Stuttle as Non-Executive Director of Basildon and Thurrock

University Hospitals NHS Foundation Trust • Sara Weech as Chair of the Earl Mountbatten Hospice • Tim Peachey as Deputy Chief Executive of Barts Health NHS Trust

18/T/095 MINUTES OF PREVIOUS MEETING Minutes of the meetings of the Isle of Wight NHS Trust Board held on 3 May 2018

were reviewed and approved with the following amendments:

a) 18/T/090 - P12 – Internal Audit & Counter Fraud - last sentence: After ‘next meeting’ add ‘together with regular updates to the Board’.

b) 18/T/084 P8 – Ist paragraph, 2nd sentence: Amend ‘He confirmed’ to read ‘He had requested’

c) Observers – P1: Alistair Flowerdew -remove Job Title

Resolution The Chair requested that the minutes of the meeting held on 3 May 2018 be Approved. Motion Proposed by Darren Cattell and Seconded by Anne Stoneham. The motion was carried unanimously.

18/T/096 MATTERS ARISING AND SCHEDULE OF ACTIONS a) Matters Arising:

There were no other matters arising.

b) Schedule of Actions: The Governance Advisor confirmed that a number of actions had been


completed since the previous meeting and that the remaining 3 actions were due in July.

Resolution The Isle of Wight NHS Trust Board received the Matters Arising and Schedule of Actions Update

18/T/097 CHAIR’S UPDATE The Chair presented his report which outlined his activities over the last month.

The Chair also advised that a programme of visiting speakers had been introduced to the Clinical Senate and gave thanks to the Wessex Academic Health Science Network for their support in arranging speakers. He confirmed that Keith Dewar, Prince Edward Island Canada (PEI) would be visiting the Trust and that it was a comparable size population and demographic to the Island. The Chair confirmed that the report from the CQC had been received and whilst the outcome was disappointing it was not unexpected but highlighted that the CQC had acknowledged there had been progress in a number of areas, including pockets of outstanding care and many examples of good care. He thanked all the Trust staff who had worked with the inspectors in a highly professional manner whilst maintaining their regular duties. He also thanked the Director of Nursing who had been available to the media and the public to answer any concerns or queries regarding the report. In addition, he thanked the stakeholders and members of the public who had supported the Trust during this period. He stressed that it was important to note that the Safety rating does not mean that care is unsafe but rather that it is not good enough. Resolution The Isle of Wight NHS Trust Board received the Chair’s Update.

18/T/098 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented the report and in addition expressed the Board’s

condolences to the two families of staff who had sadly passed away, and stated that they would both be missed. The Chief Executive also gave thanks and sincere appreciation to the 300 dedicated Volunteers who regularly support the Trust in many areas. She advised that an opportunity to showcase their work would be arranged for a future Board meeting. The Chief Executive read the following statement to the Board in response to the CQC report:

‘I would however like to spend some time talking about the CQC reports which were published yesterday. I would like to take the opportunity of this Board meeting in public to express to our community the sadness that I share with my colleague Board Directors that some of the services we provide were still rated as Inadequate by the CQC. I also know that all our staff want to see things continue to improve. I would also like to take this opportunity to apologise to any member of our community who feels they or their families have been adversely affected by


the care in these areas not being of the standard that we are striving to provide. We take our responsibility to provide good or outstanding care extremely seriously. Throughout the Board meeting today we will be able to discuss and demonstrate some improvements, and importantly where we are still having problems how we are tackling them. I would also like to encourage any member of the public who is anxious about using our services as a result of what they have heard in the news or read in the report that they should contact us through our Patient Advice and Liaison Service who can ensure that they are able to speak to the relevant clinician’s about their concerns. We will take those concerns very seriously and ensure we support people appropriately. Mary Cridge the CQC Head of Inspection said on the news yesterday that the CQC did not view our services as dramatically unsafe otherwise they would have taken steps to stop services being delivered. Mary also indicated that the Trust was sighted on all the issues and had plans in place to improve. I wanted to remind and put into context where we find ourselves. As you will know, in April 2017 the Isle of Wight NHS Trust was rated as ‘Inadequate’ by the Care Quality Commission (CQC) following an inspection of some but not all of our services. As a result of the CQCs concerns NHS Improvement placed the Trust in ‘special measures’. Since then all of our staff have been striving to improve the care and services we provide. In January and February this year the CQC revisited the Trust to conduct its first full inspection of our all of our services and yesterday, the CQC published its report. Overall, the CQC said it found – and I quote – “clear signs of recovery and improvement” since its last inspection and there was “growing momentum” at the Trust. The CQC acknowledged that the Trust’s recovery was, “starting from a very low base” and therefore “it was too early for the overall rating to change”. However, although the Trust remains rated as ‘Inadequate’ overall, the CQC identified a number of areas of progress in the report, including several examples of outstanding practice in both acute and ambulance services. I would like to express thanks and congratulate all those who have demonstrated improvements in their areas, we need to learn from what they have done and share the good work across the Trust. They are helping to raise the bar for the rest of our services. In the context of whether staff are caring, the CQC rated all four of the Trust’s services as ‘Good’ overall. It said: “Staff treated patients with kindness, respect and compassion, providing emotional support when needed”, involved patients and those close to them in decisions about care and treatment, and promoted privacy and dignity. There was also acknowledgment that the Trust is now more responsive,


with the rating improving from ‘Inadequate’ to ‘Requires Improvement’, and we saw an improvement in the overall rating for our ambulance services, which moved from ‘Inadequate’ to ‘Requires Improvement’. However, the fact remains that we have not improved our overall rating from ‘Inadequate’ and we are under no illusions that we still have a lot of hard work ahead of us to turn things around. We have always said that our improvement journey would not be an easy or a short one…and we were not expecting to have seen significant improvement at this stage. Turning things around will take time and a lot of hard work. The report provides us with a number of recommendations that will help us continue our improvement journey, and our aim remains to be rated as ‘Good’ by 2020. We must build on these small but important steps of progress by continuing at pace to deliver better care and services across the board. This will require continued commitment from everyone at the Trust, as well as continued support from our health and social care partners. As the CQC rightly concluded, we are in the early stages of our improvement journey and the potential for significant improvement is there. The wheels of improvement are turning and we now have the foundations in place to transform services for the communities that live and work on the Isle of Wight. It is now up to all of us to deliver this.’

The Chief Executive advised that with Board’s agreement she proposed that the Chair, Chief Executive and Medical Director sign the NHS Smoke Free Pledge on behalf of the Trust. Resolution The Isle of Wight NHS Trust Board received the Chief Executive’s Update. The Board also supported the signing of the NHS Smoke Free Pledge on behalf of the Trust

STRATEGY 18/T/099 EQUALITY AND DIVERSITY REPORT 2017/18 INCORPORATING THE PUBLIC

SECTOR EQUALITY DUTY The Director of Human Resources & Organisational Development confirmed that

the report had been seen at the Quality Committee, and outlined that equality, diversity and inclusion is essential for the Trust in achieving our vision and embedding our values into everything we do. She advised that the report is a national format which measures our progress to becoming an inclusive employer and outstanding service provider and provides an outline of our performance against our Equality Standard, before providing a demographic profile of our workforce and information to drive a more focused approach to identifying and tackling inequalities – Public Sector Equality Duty. The Director of Human Resources & Organisational Development outlined the next steps which included development of benchmarking against other similar Trusts, alignment to the Clinical Divisions, and a staff engagement programme to culturally embed the principals within the organisation. She noted that the report did unfortunately include a number of errors of


transposed figures. She confirmed that the following amendments should be read: • P14 – Table 3 – Employee Relations by Race - Sickness Absence should

read: White British 146, BAME 3.

The Improvement Director also queried if the Disciplinary totals within the same table were also transposed. The Director of Human Resources & Organisational Development advised that this was likely but she would verify following the meeting. The Board discussed the report and it was queried by Anne Stoneham, Non-Executive Director, whether there was any evidence of institutional barriers shown within the data. The Director of Human Resources & Organisational Development acknowledged that this was a valid question and that a deep dive analysis into the data would be undertaken to ensure that a clear understanding of any potential areas of concern and these would be reflected within the actions. She advised that the outcome of the staff survey would also be aligned to provide a comprehensive view. The Chief Executive welcomed the report and confirmed that it would be taken to the Local Care Board to review against the wider Island demographics. The Chair advised that the report would be received for assurance at this time to allow for validation to be undertaken. Action Validation of the data within Table 3 – Employee Relations by Race on p.14 of the report to be undertaken prior to submission.

Action by: DHROD Resolution The Isle of Wight NHS Trust Board received Equality and Diversity Report 2017/18 Incorporating the Public Sector Equality Duty

18/T/100 LOCAL CARE BOARD UPDATE The Chair advised that the Local Care Board is a collaboration between the Trust,

CCG and the IW Council, and which oversees the island wide plan for all services on the Island. The Director of Finance, Estates and IM&T & Information highlighted that the Trust has an important role within the group and as such it was important to identify clearing where within the plan the role of the Trust sits and what actions are required to fulfil this role. The Board discussed the report with additional information on key elements being provided by the Executive team. It was noted that there were a number of complex work-streams being undertaken and that progress had slowed as a result of changes to senior roles within the various organisations, but that now John Metcalfe, IW Council, had been confirmed as the Local Care Board Convenor it was anticipated that progress would move ahead at pace. The Director of Finance, Estates and IM&T confirmed that regular updates would be provided to the Board updating on progress and efforts to move the ‘RAG’ status to green, and that operationally this would be monitored by the Trust Leadership Committee. Resolution The Isle of Wight NHS Trust Board received the Local Care Board Update.


PERFORMANCE 18/T/101 QUALITY PERFORMANCE REPORT The Director of Quality Governance presented the report which included updates

on: • Quality Strategy Indicator Dashboard • Serious Incidents • Inquests • The National Inpatient Survey • Quality Strategy • CQC Reports • Nursing Clinical Standards • Safety Thermometer

The Board discussed the report with the Director of Quality Governance and Director of Nursing providing additional details as requested. Tim Peachey, Chair of Quality Committee confirmed that the report had been discussed. The Committee acknowledged that full assurance was not appropriate at this stage but it was seeking assurance that the Executives had oversight of the key issues and that these were identified and action plans implemented. The Committee would be reviewing more quantitative and trend data over future reports and was encouraged by progress being made. Resolution The Isle of Wight NHS Trust Board received the Quality Performance Report.

18/T/102 CQC FEEDBACK The Director of Quality Governance delivered a presentation on the CQC report

following the full comprehensive inspection across all services carried out between 25-27 January 2018 and the Well-led Inspection carried out between 20-22 February 2018. She outlined the ratings for the whole Trust across the CQC domains of Safe, Effective, Caring, Responsive and Well-led together with the overall rating. She also presented the combined ratings for the Acute, Community, Mental Health and Ambulance Divisions which make up the overall Trust ratings. It was noted that many services across the Trust had not been inspected in some years, as highlighted by the CQC in relation to Acute Services. The Director of Quality Governance highlighted the ratings for individual services within each Division and stressed that there were outstanding practice shown in some services with improvements made on previous ratings. The Directors of each of the divisions provided updates on progress and key issues within their areas. The Director of Quality Governance advised that the CQC summarised their findings as follows:

• Overall, little change with the exception of improvement in the ‘Responsive’ domain.

• ‘Caring’ consistently ‘Good’ • Deterioration seen in Acute Services, with many services not having been

inspected since 2014. • Improvements seen in Ambulance Services resulting in a positive rating

change from ‘inadequate’ to ‘requires improvement’ • Deterioration in Community Services, particularly for children and young

people.


• Improvements seen in Mental Health acute services with the Section 31 being lifted. Community mental health services remain ‘inadequate’; Mental Health Crisis also received a rating of ‘inadequate’ as did mental health wards for older people (largely Shackleton).

Key principles for improvement were identified as: • Staff engagement is essential • Service understanding and definition of ‘what good looks like’ • Shift in focus from completion of action plans to change in outcome. • Patient at the centre • ‘Inadequate’ ratings in the Safe domain are unacceptable – additional

support and oversight will be provided via the 10-week programme • Quality Strategy will be the main focus for improvement • Accountability will be at the right place

The Director of Quality Governance outlined the process for the 10 week programme which would be implemented to progress actions at pace and how it would align with the overall improvement plan. She also provided an overview of the regulations applied to each division. The Improvement Director commented that overall the assessments were fair and reflective of the changes which have been made. It demonstrated that the foundations for change were in place and that now evidence is required to show sustainability. He gave an example of another Trust whose journey through Special Measures had taken 3 years and cautioned that it was important to acknowledge that this report was just part of a longer journey which the Trust would be taking before it could come out of Special Measures. The Chair advised that the report would be discussed in detail over the coming months. He stated that the Board would be leading the drive to ensure excellence in all areas and professional standards and that it was the role of everyone in the Trust to help get the Trust to Good by 2020. Resolution The Isle of Wight NHS Trust Board received the CQC Feedback update.

18/T/103 SAFE STAFFING MONTHLY REPORT The Director of Nursing presented the report which provides an overview of

staffing levels; agency and bank fill rates and the work being undertaken for improved rostering practice using the Carter KPIs for rostering. She advised that the acute wards continued to use agency and bank staff to cover vacancies and sickness although the agency float had been reduced by 9.3 WTE which equated to 350 hours per week, and this was due to reduced patient acuity and dependency post winter pressures. She confirmed that the implementation of the ‘SafeCare’ tool was progressing over 12 wards who were now recording the current inpatient acuity and dependency three times a day to generate a ‘Care Hours per Patient per Day’ score which is measured against staffing available hours to ensure safe staffing levels are attained. Resolution The Isle of Wight NHS Trust Board received the Safe Staffing Monthly Report.

18/T/104 WORKFORCE & ORGANISATIONAL DEVELOPMENT PERFORMANCE REPORT

The Director of Human Resources & Organisational Development presented the


report which had been reviewed at the Performance Committee. She provided updates on the following:

• Agency & Bank Staff Usage • Recruitment • Sickness Absence • Mandatory Training • Data Security Awareness (Information Governance) Compliance • Physical Assaults data now available

She confirmed that the report would be developing to include trajectories and trend data. Charles Rogers, Chair of Performance Committee, confirmed that the Committee would be looking in future at detailed projections against the Operating Plan, and that it welcomed the progress on recruitment and retention. The Director of Human Resources & Organisational Development provided an overview of the plans recruitment and retention of staff which included additional support from the Kings Fund and NHS Elect who would be working with the senior management team over the next 18 months on a leadership development programme. Vincent Grant, Deputy Chair of Patient Council, highlighted the need for all staffing levels to have appropriate capabilities and skills. The Director of Human Resources & Organisational Development confirmed that this was the beginning of a wider programme of development which would disseminate throughout the staff base. Resolution The Isle of Wight NHS Trust Board received the Workforce & Organisational Development Performance Report.

18/T/105 FINANCIAL PERFORMANCE REPORT The Director of Finance, Estates and IM&T presented the report which had been

discussed at the Performance Committee. He outlined the month 1 financial performance which was showing a £0.5m adverse variation against the deficit plan which had been caused by under delivery against the phased CIP plan and the additional cost of winter bed capacity remaining open without agreed funding. Agency usage also contributed to the position. He confirmed that the Service & Financial Improvement Sub-Committee was monitoring the position closely against the Financial Recovery Plan. Charles Rogers, Chair of Performance Committee, advised that the Committee was disappointed to see an adverse variance so early in the new financial year although strong mitigation had been provided. Concern continued over the CIP target. Caroline Spicer, Non-Executive Director, stressed the need to develop additional plans over and above the £8m. She acknowledged the positive progress on recruitment but highlighted the need for the data to be triangulated across finance, workforce and clinical staffing to clearly show trends and gaps. It was confirmed that this was in development with the teams and would be included in future reporting. Resolution The Isle of Wight NHS Trust Board received the Financial Performance Report.

INTEGRATED PERFORMANCE REPORTS: 18/T/106 ACUTE SERVICES The Director of Acute Services presented the new report which covered the Acute

Services and included updates on:


• Emergency Care 4 hours Standard • Referral to Treatment Times • Cancer Urgent Referral to Treatment under 62 Days Standard • Patients waiting over 6 weeks for diagnostics

Charles Rogers, Chair of Performance Committee, confirmed that a detailed report had been discussed at the Performance Committee and noted that more detailed reporting would be developed to cover the complexities of the services covered by Acute Services. Resolution The Isle of Wight NHS Trust Board received the Acute Services Performance Report.

18/T/107 AMBULANCE SERVICES & PATIENT TRANSPORT SERVICES The Board Advisor for Ambulance Services presented the new report which

covered the Ambulance & Patient Transport Services and included updates on: • NHS111 Service • Ambulance Response on Scene - Category 1 • Ambulance Response on Scene – Category 2/3 • New Ambulance Response Programme

Resolution The Isle of Wight NHS Trust Board received the Ambulance Services & Patient Transport Services Performance Report.

18/T/108 COMMUNITY SERVICES The Director of Community Services presented the new report which covered the

Community Services and included updates on: • The provision of services through the locality model • Front Door Frailty Initiative • Referral to Treatment times • 0-19 Service Caseload Review

Resolution The Isle of Wight NHS Trust Board received the Community Services Performance Report.

18/T/109 MENTAL HEALTH & LEARNING DISABILITIES SERVICES The Director of Mental Health & Learning Disabilities Services presented the new

report which covered the Mental Health & Learning Disabilities Services and included updates on:

• 7 Day follow up for inpatients discharged from inpatient services • Referral to Treatment times • Key Performance Indicators for Mental Health

Resolution The Isle of Wight NHS Trust Board received the Mental Health & Learning Disabilities Services Performance Report.

COMMITTEE ASSURANCE AND GOVERNANCE 18/T/110 TERMS OF REFERENCE AND MEMBERSHIP FOR BOARD AND BOARD

COMMITTEES The Governance Advisor outlined that following the Trust Board Committees’

Terms of Reference and Membership approval by the Board in November 2017,


the Executive Director structure had been revised following proposals by the Chief Executive which were approved by the Board. As a result the updated Terms of Reference for the Board Committees reflect the required changes to membership to take account of the new Executive Director structure. Additionally, the Trust Board Committees Governance Pack had been updated to reflect the agreement for Integrated Improvement Framework Board to be closed. The Terms of Reference for the Trust Board have also been revised to reflect the new Executive Director membership. Resolution The Chair requested that the Terms of Reference and Membership for Board and Board Committees be Approved. Motion Proposed by Darren Cattell and Seconded by Anne Stoneham. The motion was carried unanimously.

18/T/111 FREEDOM TO SPEAK UP GUARDIAN QUARTERLY REPORT The Chair advised that this report is not considered by other Committees and

forums as it has direct report authority to the Board. The Freedom to Speak Up Guardian also has a direct link to both the Chair and Chief Executive to ensure that there are no barriers in place and to ensure that they are fully appraised of all concerns and issues raised through the Freedom to Speak Up Guardian. The Freedom to Speak Up Guardian presented the report which covered the period January – March 2018 (Quarter 4). She advised that she had directly received 20 concerns for Quarter 4 and a further 13 concerns were raised via the FTSU Advocates/Anti Bullying Advisors. She outlined how these concerns were spread across the various staff groups and the 4 categories. Of the 33 cases in the period 30 had been closed. The Freedom to Speak Up Guardian gave an overview of the lessons learnt from these cases and outlined the measures which were being implemented to address the concerns and to encourage staff to report their concerns. The Board discussed the report. Charles Rogers, Non-Executive Director, stated that the results were encouraging but queried whether the cases had been closed to the satisfaction of the staff member who raised the concern. The Freedom to Speak Up Guardian advised that a feedback form is provided but it is optional and the return rate is not 100% but work continued to further engage staff and provide more champions across all levels of staffing. Resolution The Isle of Wight NHS Trust Board received the Freedom To Speak Up Guardian Quarterly Report.

COMMITTEE REPORTS: 18/T/112 QUALITY COMMITTEE Tim Peachey, Chair of the Committee which covered the key points raised at the

last meeting held on 6 June 2018: The Committee agreed to recommend the following papers for approval by the Board:

1. NHS Resolution – IOW NHS Trust Progress against Clinical Negligence Scheme for Trust (CNST) Scheme - Maternity Safety Actions

2. Equality & Diversity Report 2017/18 incorporating the Public Sector Equality Duty

3. Learning Disability Strategy – Living well with a learning disability on the


Isle of Wight Assurance The Chair summarised the meeting and noted that at this stage of the Trust’s improvement journey, the Committee is not expecting to gain full assurance that Quality performance is satisfactory. The Committee was, however, seeking assurance that issues had been identified, plans have been made and actions are in train to drive improvement. The Committee expects to be assured that the Executive Directors can demonstrate that they are effectively dealing with the issues. In this respect the Committee had received significant assurance during this meeting. He stressed that the Committee would be requiring more quantitative and trended data regarding quality in future reports to demonstrate quality improvement across the whole organisation. The Committee welcomed the impending arrival of the new Quality Report Indicators which would provide an effective measure to demonstrate progress as well as highlight areas of concern. The Committee wanted to highlight to the board the very significant progress made on the comprehensive analysis of equality and inclusion data, which is being presented to the Board this month for the first time. Resolution The Isle of Wight NHS Trust Board received the Chair’s Report from the Quality Committee.

18/T/113 PERFORMANCE COMMITTEE

Charles Rogers, Chair of the Performance Committee, presented the report on the key points raised at the last meeting held on 6 June 2018

• ICT Programme: The Committee had received assurance that progress was being made with SystmOne rollout and integration between systems but there remain capacity and capability barriers.

• General Data Protection Regulations (GDPR): The Committee received assurance that the process was currently on track and that further work was planned.

• WAVE 4 Capital Bid: The Committee supported an expression of interest to be made for the next phase of national funding. This would be undertaken with partner organisations and would include a range of projects. The Board discussed the proposed expression of interest for WAVE 4 funding and supported the progression of the bid by the Executive team.

Resolution The Isle of Wight NHS Trust Board received the Chair’s Report from the Performance Committee, and supported the progression of the Expression of Interest for the WAVE4 Capital Bid for national funding.

18/T/114 ASSURANCE, RISK & COMPLIANCE COMMITTEE Anne Stoneham, Chair of the Assurance, Risk & Compliance Committee,

presented the report on the key points raised at the last meeting held on 6 June 2018


• Board Assurance Framework (BAF): The Committee received updated

BAF noting that this is an ongoing process but were assured at this stage. • Risk Management Strategy: The Committee supported approval of the

strategy for final approval at Board at July 2018 meeting. • Regulatory Compliance including CQC inspection feedback: The

Committee received an update around the Care Quality Commission (CQC) inspection. This will be looked at further in Board Seminar.

• Emergency Preparedness, Resilience and Response (EPRR): The Committee approved the direction of travel for EPRR.

Resolution The Isle of Wight NHS Trust Board received the Chair’s Report from the Assurance, Risk and Compliance Committee.

18/T/115 MENTAL HEALTH ACT COMMITTEE Charles Godden, Chair of the Mental Health Act Committee, presented the report

on the key points raised at the last meeting held on 6 June 2018.

• Mental Health Act Activity Data: The Committee received a detailed presentation on the level of activity undertaken against the Mental Health Act which included trend data. It was confirmed that this data would be further analysed to provide detailed reports which would be seen by the Committee and considered for presentation to the Board/Seminar at a future date.

• Community Mental Health Vacancies: The Committee were advised that 7 posts were vacant and 5 had now been recruited to.

• Mental Health Act Review Managers (MHARMs): The Committee were advised that there had been some delays and cancellations of reviews and that this would be monitored by the Committee in future. It was also confirmed that there were 6 MHARMs in place at present and all will need an annual appraisal later in 2018.

Resolution The Isle of Wight NHS Trust Board received the Chair’s Report from the Mental Health Act Committee.

CLOSING MATTERS 18/T/116 ISSUES TO BE COVERED IN PRIVATE The Chair advised that the following items would be covered in private:

• Board Development – Buddying Proposal • Control Total discussions with NHSI • NHS Resolution – Safer Maternity Actions • Employee Relations • Quality Report - Supplementary Appendices

18/T/117 QUESTIONS FROM THE PUBLIC None received

18/T/118 ANY OTHER BUSINESS There was no other business


DATE OF NEXT MEETINGS The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board to

be held in public is on Thursday 5 July 2018. The venue for this meeting will be the Conference Room – Level B Main Hospital – opposite Full Circle Restaurant, St Mary’s Hospital, Newport, IW PO30 5TG

The meeting closed at 4.15pm Signed………………………………….Chair - Vaughan Thomas Date:…………………………………….

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27/06/20181 of 1

ISLE OF WIGHT TRUST BOARD January 2018 - December 2018ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

KEY TO RAG STATUS Action overdueAction ProgressingAction complete

Name of Meeting

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update & Evidence of Completion Due Date Forecast Date

Progress RAG

Date Closed

Board in Public

01-Mar-18 18/T/036 TB/323 All Staffing Levels in Safe Staffing report

The Director of Nursing & Interim Medical Director to review the report to show all staffing levels across all business units and to include nursing, clinical and allied health professionals.

Barbara StuttleAlistair

Flowerdew

24/04/18 - Information to be obtained from HR and incorporated within future reports from Quarter 2. Nursing Review done and the Medicine and Allied Health Professionals will be undertaken over next 2 months.27/06/18 - All Nursing reviews now complete except MAU and Emergency Department.

05-Jul-18 02-Aug-18 Action Progressing

Board in Public

05-Apr-18 18/T/069 TB/337 Access to Specialist Treatment by Island Residents

A review of the data covering referrals for off island treatment to be undertaken in conjunction with the Local Care Board and the CCG

Alistair Flowerdew

27/06/18 - Process is ongoing at present - progress update to be provide at the next Board meeting

05-Jul-18 02-Aug-18 Action Progressing

Board in Public

03-May-18 18/T/080 TB/338 Nursing & Midwifery Six Monthly Staffing Review

Outstanding queries relating to the Nursing &Midwifery Six Monthly Staffing Review to beaddressed and presented to the ExecutiveManagement team for discussion prior toreturning to the Board for approval.

Barbara Stuttle 30/05/18 - Review is taking place and the revised paper will be submitted through the governance process.27/06/18 - Report coming to Trust Board in September 2018 post acuity and dependency studies July/August

05-Jul-18 06-Sep-18 Action Progressing

Board in Public

06-Jun-18 18/T/099 TB/339 Equality & Diversity Report 2017/18

Validation of the data within Table 3 – Employee Relations by Race on p.14 of the report to be undertaken prior to submission.

Julie Pennycook

27/06/18 - Amendments have been made and the revised report will be submitted to July Board. Acton closed

05-Jul-18 05-Jul-18 Action Closed 27-Jun-18

Agenda Item No 6 Meeting Trust Board in Public Meeting Date

5 July 2018

Title Chairs Report Sponsoring Executive Director

Vaughan Thomas, Chair

Author(s) Vaughan Thomas, Chair Report previously considered by inc date

N/A

Purpose of the report Information only X Assurance Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight X Link to CQC Well Led Domains Effective x Responsive X Caring Well-led X Safe Executive Summary Last Board meeting on 7 June 2018. During the month, I have conducted and participated in meetings with, advisors, stakeholders, staff, and partners of the Trust. These have included:

• Meetings/calls with NHSI including: o Fortnightly calls with Transactions and Sustainable Solutions Director o Chair Portsmouth Hospitals NHS Trust

• Meetings with partner organisations including:

o System redesign 'Question Time' style panel event 11 June 2018 o Chair/CEO meeting – Isle of Wight NHS Trust/Isle of Wight Council o Digital Health Supporting Transformational Change on the Isle of Wight – 13 June

2018 o Local Care Board 14 June 2018 o NHS Providers Dinner with the Care Quality Commission – Chief Executive, Sir David

Behan, CBE, Professor Ted Baker, Chief Inspector of Hospitals, Amy Key, Head of Engagement and Chris Hopson, CEO NHS Providers

o North East Locality Case Review Meeting o Clinical Excellence Senate – Speaker Marie Gabriel, East London NHS Foundation

Trust o Hampshire & Isle of Wight Chairs Meeting o Chair/CEO Meeting Isle of Wight NHS Trust/Isle of Wight CCG

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o Isle of Wight Quality Summit o Visit to Community Mental Health Service at Chantry House

• Meetings with Individuals including trust executives

o Anne Eden, CEO, NHS Improvement

Key outcomes from these activities are: - Further Clinical Excellence Senates planned with a range of speakers and topics During the course of the month ahead I shall continue the programme of meetings and visits. Key Recommendation The Board is recommended to receive the report

Trust Board Cover Sheet Page | 1

Agenda Item No 7 Meeting Trust Board in Public Meeting Date 5th July 2018

Title Chief Executive Officer’s Report - 30th May 2018 to 28th June 2018

Sponsoring Executive Director

Maggie Oldham, Chief Executive Officer

Author(s) Andy Hollebon, Head of Communications and Engagement

Report previously considered by inc date

N/A

Purpose of the report Information only X Assurance Review and discuss Agreement X Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary This report has been prepared by the Head of Communications & Engagement on my behalf. The report covers the period 30th May 2018 to 28th June 2018. The report is intended to provide information on activities and events and usually cover issues of national, regional and local importance that would not normally be covered by the other reports and agenda items. Detailed information about the business of the Trust appears in the performance reports. This report provides a summary of key successes and issues which have come to the attention of the Chief Executive. The report covers the following issues:

• Quality Summit • Ambulatory Emergency Care • Medina IoW parkrun marks NHS70 birthday • Getting to Good High Tea • Service of Celebration on 11th July • Intensive Care Unit • St. George’s School Visit • Building hospital services fit for the future • Capital bid to support acute services redesign • IW Festival • Physical and verbal assaults against staff • NHS Providers briefings and reports • Governance - Trust Leadership Committee

Key Recommendation The Board is asked to consider the following recommendations: • The Board is recommended to note the contents and receive the report..

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Chief Executive’s Report for the period to 30th May 2018 to 28th June 2018 My report this month covers a range of issues between 30th May 2018 to 28th June 2018 including items of national and regional importance, and local issues. More detailed information about the business of the Trust appears in the performance reports.

Quality Summit

I reported at the last Trust Board meeting on the publication on 6th June of the Care Quality Commission’s report of their full inspection of Trust services. We also had a presentation from Director of Quality Governance Suzanne Rostron on the detail of the report. We still have a lot to do and we certainly appear to have a growing momentum to achieve the improvements we require.

For the eight areas where we have an ‘Inadequate’ rating for ‘Safety’ we have now commenced 10 week action plans. These are designed to be deliberately short and very focused on the key findings the CQC gave us. They have either been started or are in the process of commencing. It has been really positive to work with the teams and see some really significant changes in a very short period of time.

Yesterday (Wednesday 27th June) we had our ‘Quality Summit’ and the display stands outlining improvements will remain up for a period so that as many people as possible can view the progress being made. I have written to all staff about issues around Communication and Basic Fundamental Care. All I ask of staff is that they do their job to the very best of their abilities, escalating either in person to managers or via the Trust’s Datix incident reporting system when things go wrong. Our problem seems to be that we don’t achieve consistency all the time and we need a renewed campaign to offer the same experience to all our patients.

Despite the negatives in the CQC report which we are addressing we also get an awful lot of positive responses from patients and their families; I can receive a complaint and compliment letter about the same team and area on the same day:

• I would like to communicate my great appreciation and thanks following the emergency care I received for a leg injury on 3rd June. I was treated by Dr A, ably supported by KE (who herself sewed up the wound very well), EN, and A, whose surname I have forgotten. All the team, and also the lady at reception, were courteous and extremely professional. Please convey my thanks to all involved. Your team and hospital are a great example of the NHS providing excellent emergency service.

• I would like to express my gratitude and how impressed I have been today visiting my father in Compton ward. The care, he and all the other patients received from Paul particularly was outstanding. They were treated with dignity, respect and it was clear he had formed excellent relationships with the patients. If it could in some way be recognised, I very much hope it can be

• I recently had a minor procedure in the Day a Surgery Unit on 17 May and I just wanted to let you know I felt looked after from start to finish by everyone who was involved in my care. All were professional, friendly and took the time to explain to me what was happening. For some people these procedures are frightening, however, the team were reassuring, caring and used appropriate humour throughout the day to help alleviate any fears I may have had. I work for the Trust and I know from personal experience how nice it is receive good feedback and a thank you. Although I thanked individuals on the day it is important that the team and their managers have a written compliment that highlights the care that I received. As we all know if you don't write it down it didn't happen!

• We were staying on the island to do a charity walk around. On Bank holiday Monday, 28 May, my partner Tom slipped in the bathroom of our cottage cutting his head and damaging his back. The paramedics who came to us were amazing. If possible please pass on our thanks to A&E and the two female crew members who came out too. We went on to complete 76 miles of the island. The care and attention, especially from the paramedics was second to none.

Matron Marcia Meaning speaks about the ‘Safe’ domain in

Medicine


Dr Bob Ghosh, Director of Clinical Improvement talks about Ambulatory Care at the Quality Summit.

Ambulatory Emergency Care

On 5th June we re-opened our Ambulatory Emergency Care (AEC) for medical conditions with the service running between the hours of 09:00- 19:00. Initially, it will be based within the Medical Assessment Unit but at a later date, will be incorporated within the urgent care re-design in the Emergency Department. The AEC consultant will be taking referrals from 10:00 – 18:00.

Ambulatory Emergency Care is an approach which results in a significant proportion of emergency adult patients being managed safely and efficiently on the same day avoiding admission to a hospital bed. This means that patients are assessed, diagnosed, treated and are able to go home the same day, without being admitted to hospital overnight.

Trust staff, GPs and any other stakeholder may refer into the AEC Service by contacting the main St. Mary’s Hospital Switchboard. Further information on the service can be found at http://intranet.iow.nhs.uk/Home/Corporate/Patient-Flow/Patient-Journey/Ambulatory-care

Medina IOW parkrun marks NHS 70th birthday

Medina IOW parkrun was one of hundreds of ‘parkruns’ around the UK to host a special NHS birthday celebration event on Saturday 9th June. The initiative, known as ‘parkrun for the NHS,’ recognised the contribution of the NHS to the health of the Island and aimed to inspire people to take part in physical activity and volunteering. Medina IOW parkrun is a free 5k event that takes place every Saturday morning at 9am. It is open to walkers and runners of all ages and abilities and is coordinated entirely by volunteers from the local community including some of our staff.

Getting to Good High Tea

On 5th July – the actual 70th Birthday of the NHS - we are encouraging teams across the whole Trust to celebrate with a tea party – the Big 7T! As an early celebration Diversity & Equality Lead Sam Greatrex and Catering Manager Jo Sheppard organised a celebratory high tea for the individuals who put forward examples of great work taking place in the Trust and the individuals nominated by them. A number of staff benefited from a competition supported by IOW Tours for a 4 night / 5 day stay at Norton Grange Coastal Village. Further recognition was provided by IOW Tours at the High Tea when vouchers were presented to those who entered the competition but were runners up. We’re very grateful to Shirley Winn, managing director at IOW Tours for supporting the Trust.

Service of Celebration on 11th July

We're holding a multi-faith service of celebration on Wednesday 11th July 2018 at All Saints Church, Ryde. The service will start at about 6:00p.m. and last for about 45 minutes. Light refreshments will be available afterwards. The service is open to all serving and former NHS staff as well as Islanders who support the NHS. Please register your interest in attending at http://www.smartsurvey.co.uk/s/NHS70service/.

Intensive Care Unit

The Intensive Care Unit at St. Mary’s Hospital has moved back to its newly refurbished home on Level B. The unit has been redecorated throughout creating a bright, fresh environment for patients and staff to occupy. The flooring has been replaced and improvements have been made to the IT infrastructure and to the nurses’ station creating a much more spacious area for staff to work.

http://intranet.iow.nhs.uk/Home/Corporate/Patient-Flow/Patient-Journey/Ambulatory-care

http://iowtours.com/

https://www.warnerleisurehotels.co.uk/hotels/norton-grange-holiday-village

http://www.smartsurvey.co.uk/s/NHS70service/


Whilst the improvement work was carried out the entire intensive care unit moved out of the area and up to the coronary care unit in the north hospital which was a huge undertaking. But the teams worked together and made the move a seamless process with minimal disruption to patients and other hospital services. Well done to everyone involved.

St. George’s School Visit

I was pleased to welcome students from St. George’s School, Newport to St. Mary’s Hospital on 25th June. St George’s School is the only maintained secondary special school on the Isle of Wight for students with Severe and Complex Needs. They take students with a very broad range of needs including Severe Learning Disability, Moderate Learning Disability, Profound and Multiple Learning Disability, Autistic Spectrum Disorder. etc.. I hope that the visit has helped to make St. Mary’s a more friendly place for all the students should they need to visit us for healthcare.

Building hospital services fit for the future

We have been involved in a clinically led programme of work looking at how we might need to reconfigure the way we provide acute (hospital based) services in the future to tackle both current and future challenges. I and colleagues have attended a range of events over the last month about the acute services redesign programme. This included a dedicated staff session at St. Mary’s Hospital, a session hosted by Isle of Wight Radio and Isle of Wight County Press and broadcast live across the Island, and public drop in sessions at various venues.

I want to remind everyone that no decisions have been made at this stage; we are at least a year away from any final decisions which will follow a period of formal consultation and three-five years away from any potential changes being implemented.

It is important that we keep talking during this time though and I hope we can continue over the course of this year to have further opportunities to listen to your views to help us shape this important piece of work.

Capital bid to support acute services redesign

The guidance for refreshing NHS plans in 2018/19 asked all sustainability and transformation partnerships (STPs) to undertake a strategic, system-wide review of buildings and land (Estates) and develop a plan. The Hampshire and Isle of Wight sustainability and transformation partnership (STP) have submitted a local system bid of £48m to NHS Improvement/NHS England. The bid has been developed jointly by the Solent Acute Alliance (SAA) partners (Isle of Wight NHS Trust, University Hospital Southampton NHS Foundation Trust and Portsmouth Hospitals NHS Trust) in support of the delivery of the strategic ambitions set out in the Isle of Wight Acute Services Redesign (ASR) blueprint agreed in February 2018.

In summary, the bid enables the Island to reconfigure St Mary’s Hospital and other buildings that improves the estate and enables better streaming of patients between urgent and planned care. There will also be additional capacity put in place at Southampton Hospital and Queen Alexandra Hospital. A further focus is a major investment in modernising the digital systems on the island. A national announcement on the bids supported will be made in the autumn 2018.

IW Festival

I want to thank everyone who worked the Festival weekend. It was a very busy weekend due to the increasing acuity of the Island patients we care for. This was compounded by Norovirus on 3 wards. We know that D&V is circulating in the Community and we have asked everyone to be vigilant and ensure all the appropriate infection control measures are in place. I would like to thank all our staff including the Ambulance silver level officer in the Event Liaison Team (ELT), the Emergency Department (ED) Consultant Mr Robin Beal who undertook a morning clinic on site to prevent festival goer’s attendance at our ED, as well as the IRIS drug and alcohol team who were on site to provide advice to Festival participants and the Trust’s HR Team who were promoting working on the Island to festival goers.


Our involvement at the Festival takes various forms. We work with other agencies and Festival organisers to ensure that the Festival can take place safely and the impact on our services is minimised. The medical provision to the site was undertaken by Festimed as in previous years and each area (campsite, Strawberry Fields and the main arena) had a medical tent. The campsite cover started Thursday 1200 Hours and ran through until 1300 hours Monday.

Physical and verbal assaults against staff

Following several incidents involving physical and verbal abuse towards staff, primarily in ambulance and the emergency department we have made it known that the Trust has a ‘Zero tolerance’ approach towards violence, aggression and abuse; NHS staff should be able to do their job without fear of violence, abuse or harassment from patients, their relatives or friends.

In the majority of cases, people show appreciation towards NHS staff who care for them but unfortunately there is a minority of people who have been abusive or violent, in particular towards frontline staff.

Police assistance will always be requested when violent or abusive incidents occur towards Trust employees, we will pursue legal action and we will fully support staff who wish to bring private prosecutions against the perpetrators.

NHS Provider Briefings and reports

Over the last month NHS Providers, who represent almost all NHS Trusts and Foundation Trusts including Isle of Wight NHS Trust, provided briefings and reports on a range of topics as follows:

31-05-18 On the day briefing:Q4 finances and performance

12-06-18 On the day briefing: Health and Social Care Select Committee report - integrated care

18-06-18 On the day briefing: prime minister's speech on NHS funding commitment

26-06-28 Wholly owned subsidiaries in the NHS

26-06-18 The role of the Freedom to Speak Up Guardian

These briefings are available on the NHS Providers website at http://nhsproviders.org/resource-library/briefings

Governance - Trust Leadership Committee

The Trust Leadership Committee (TLC) comprises Executive Directors and Clinical Business Unit representatives and meets monthly. There are no items from the meeting held on 16th and 24th May 2018 to be reported to the Trust Board that are not already covered by agenda items. Maggie Oldham Chief Executive Officer 28th June 2018

http://nhsproviders.org/resource-library/briefings/on-the-day-briefingq4-finances-and-performance

http://nhsproviders.org/resource-library/briefings/on-the-day-briefing-health-and-social-care-select-committee-report-integrated-care

http://nhsproviders.org/resource-library/briefings/on-the-day-briefing-prime-ministers-speech-on-nhs-funding-commitment

http://nhsproviders.org/resource-library/briefings/wholly-owned-subsidiaries-in-the-nhs

http://nhsproviders.org/resource-library/briefings/the-role-of-the-freedom-to-speak-up-guardian

http://nhsproviders.org/resource-library/briefings

http://nhsproviders.org/resource-library/briefings

Page | 1

Agenda Item No 8 Meeting Trust Board in Public Meeting

Date 5 July 2018

Title Equality & Diversity Workforce Report 2017/8 – incorporating the Public Sector Equality Duty


Julie Pennycook – Director of Human Resources and Organisational Development

Author(s) Liz Nials – Senior HR Manager, Sam Greatrex – Equalities Lead Report previously considered by inc date

Quality Committee (6th June 2018) HR and OD Committee (6th June 2018)

Purpose of the report Information only Assurance Review and discuss Agreement Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective Responsive Caring X Well-led X Safe Executive Summary This is report was presented to Trust Board in June. This revised report has corrected the error that was highlighted on page 14. Key Recommendation The Trust Board is asked to consider the following recommendations

Approve the actions set out in the Equality and Diversity Report 2017/18

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EQUALITY AND DIVERSITY WORKFORCE REPORT

2017/18

Incorporating the Public Sector Equality Duty

Page 2 of 18

Contents

1. Introduction ................................................................................................................... 3

2. Diversity and Inclusion Report 2017/18 ......................................................................... 5

Section 1: Equality Standard ................................................................................................ 6

Section 2: Introduction of a Workforce Diversity Scorecard ................................................. 8

2.1. Introduction ................................................................................................................ 8

2.2. Workforce Diversity Scorecard ................................................................................... 9

2.3. Age ............................................................................................................................ 9

2.4. Disability ................................................................................................................... 11

2.5. Marriage and Civil Partnership ................................................................................. 13

2.5. Race......................................................................................................................... 13

2.6. Religion and Belief ................................................................................................... 16

2.7. Sex ........................................................................................................................... 17

2.8. Sexual Orientation ................................................................................................... 18

Section 3 Next steps 2018-19 ........................................................................................... 18

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1. Introduction

The Isle of Wight NHS Trust’s vision is “Patients come first in everything we do. We fully involve patients, staff and volunteers, carers and communities” this is underpinned by our values “We care….We are a team…..We innovate and improve.

The Trust Board understands that equality, diversity and inclusion are important in achieving our vision and embedding our organisational values in everything we do.

The Trust’s Equality Objective is “The Isle of Wight NHS Trust strives to demonstrate excellence against all goals set out in the NHS Equality Delivery System (EDS 2), by everyone recognising equality and integrating it into everything we do”. By end of March 2019 the Trust intends to review and re-define its Equality Objectives.

Protected Characteristic

Diversity Scorecard Analysis1

Age

100% workforce reporting to Age

The largest age group employed at Isle of Wight NHS Trust is 46-55 yrs.

The number of staff employed between the ages of 16-25 is 6.76%

Leavers are over-represented in the 16-25 age range

Disability

75% of our workforce data reporting to Disability

2.68% of the workforce have declared ‘yes’ when asked if they had a disability.

Of our future workforce, 4.70% of applications received and 5.50% of those appointed declared to having a disability

Marriage and Civil Partnership

97.65% workforce reporting to Marital and Civil Partnership Status

Race

95.05% workforce reporting to Race

85.98% of the workforce is White British

9.7% of the workforce is BAME

BAME staff fare less favourably to White British staff in recruitment and selection; employee relations (excluding sickness absence) and are under-represented from Band 6 and above.

Religion or Belief

69.32% of our workforce reporting to Religion or Belief

Sex

95.54% of our workforce reporting to Sex

74.14% of the total workforce is female

25.40% of the total workforce is male

Employment banding shows under-representation of women from Band 7 and above.

Employment banding shows under-representation of males in

1 Data source Electronic Staff Record and NHS Jobs as at 31

st December 2017

Page 4 of 18

Band 1, 3, 4, 5 and 6.

Sexual Orientation

71.05% workforce reporting to Sexual Orientation

59.98% of the workforce identify their sexual orientation as Heterosexual

1.04% of the workforce identify as Lesbian, Gay or Bisexual (LGB)

With our commitment to quality improvement, we have identified the following actions for further investigation and response.

1.1. Workforce Race Equality Standard (WRES)

85.98% of our workforce is White British and 9.7% Black, Asian and Minority Ethnic backgrounds (BAME).

Actions for further investigation:

Recruitment and Selection:

The proportion of applications received from people who identify as White is 79.60%, and the proportion of successful applicants is 88.20%.

The proportion of applications received from people who identify as Asian is 6.60%, and the proportion of successful applicants is 2.30%.

The proportion of applications received from people who identify as Black is 3.50%, and the proportion of successful applicants is 1.50%.

Employee Relations:

BAME staff are over-represented in being subject to Grievance; Bullying and Harassment and Disciplinary compared to White British staff.

BAME staff are under-represented in sickness absence.

Employment Banding:

BAME staff are under-represented at band 6 and above.

WRES

The Trust will continue to publish WRES data and review our WRES action plan ready for delivery in July 2018. We aim to demonstrate year on year improvements across all WRES metrics.

1.2. Sex

74.14% of our workforce is Female and 25.40% is Male.

Actions for further investigation:

Employee Relations

We will seek to establish any trends between men and women who have been subject to Grievance, Bullying and Harassment and Disciplinary procedure.

Employment Banding

The Trust will report on the Gender Pay Gap on 31 March 2018

Female staff are under-represented from Band 7 and above

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1.3. EDS2

Completion of EDS2 summary reports across each Clinical Business Unit will be launched during 2018, pilot grading panels will be undertaken after the reports are generated.

EDS2 Grading Panels demonstrate our commitment to the public sector equality duty (PSED) we will deliver a strong engagement programme with our patients, families, carers, communities and staff. More specifically, we will engage and involve our patients and people and invite them to have the opportunity to scrutinise our equality performance. This will be based on the completed EDS2 summary reports. Involvement of the voluntary and community sector is crucial to our engagement.

1.4. Equality and Diversity Programmes, Frameworks and Initiatives

The Trust will closely monitor its response to the Accessible Information Standard; Disability Equality Standard and Time for Change. We will also respond positively to Equality, Diversity and Human Rights Week and key equality and human rights events.

2. Diversity and Inclusion Report 2017/18

We are delighted to introduce our Equality and Diversity Annual Report 2017/18. It gives us the baseline from which we will measure our progress to become an outstanding service provider and an inclusive employer of choice.

This report aims to demonstrate due regard to promote equality of opportunity, foster good relations and eliminate unlawful discrimination. The report provides a demographic profile of our current workforce and information to drive a more focussed approach to identifying and tackling inequality.

The Isle of Wight NHS Trust monitors its workforce against the following protected characteristics:

• Age • Disability • Gender Reassignment • Marriage and Civil Partnership • Pregnancy and Maternity • Race • Religious and/or Belief • Sex • Sexual Orientation

This report will be presented in three sections.

Section 1 Will introduce our Equality Standard, a nationally awarded framework to integrate equality, diversity and inclusion in everything we do. This includes a rapid assessment of key actions to enable the Trust to respond positively to our legal, regulatory and commissioner requirements to equality and diversity.

Section 2 Presents our response to the Public Sector Equality Duty (PSED) which contains our workforce diversity information.

Section 3 Will present our ‘Next Steps’

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Section 1: Equality Standard The Trust has adopted the Equality Delivery System (EDS2), a national framework developed by NHS England. In response to the requirements of the EDS2, the Trust’s new equality and diversity strategic ‘Equality Standard’ and this report outlines the progress we have made as at 31st May 2018.

The aim of our Equality Standard is to:

respond positively to the legal, regulatory and commissioner requirements for equality, diversity and human rights;

meet the requirements of the EDS2, Gender Pay Reporting and WRES (NHS England);

embed an evidence based equality and diversity strategy with clear governance and reporting structures;

to embed equality and diversity into everything we do. These aims have been identified from an appraisal of local and national policies and legislative drivers including the requirements on Trusts to meet the regulatory framework of the CQC well-led domain and other inspection systems that encompass equality and diversity functions.

The summary report below outlines our response in meeting our obligations for equality, diversity and inclusion.

Section 1. Equality Standard Performance Report

Organisational Values Equality Objectives

We Care..

We are part of a team..

We innovate and improve..

The Equality Standard will champion the values of the organisation at every opportunity and in everything we do. The values are an integral part of defining our culture and being recognised as an inclusive employer of choice. Our equality objectives include:

Excellent Patient Care

Work with others to keep improving our services

A positive experience for patients, service users and staff

Skilled and capable staff

Cost effective, sustainable services

Equality Standard Actions

Idenfity Executive Lead/s for equality and diversity

The Trust has identified an executive lead for equality and diversity and has responsibility to champion and be accountable for the Equality Standard. The identified executive leads are:

The Director of Workforce, Organisational Development and Communication is the nominated executive lead for equality and diversity.

Diversity and Inclusion is being championed by our Associate Directors of Nursing; one of whom is the clinical lead for the HR and OD “Getting to Good” work stream.

The Deputy Director Medical Director will also champion diversity and inclusion focussing on the medical workforce.

Co-design and launch an equality and diversity strategy

This 2018 strategy embraces the national requirements of the EDS2, Gender Pay and WRES.

Equality Impact Leads (EIL) will be identified across our Clinical Business Units to oversee the implementation of the

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Equality Standard. VOX POP Diversity Champions will be identified to drive the standard at a local level.

A review will take place in September 2018 to prepare actions in response to the findings of the Equal Pay Gap Reporting; Accessible Information Standard and Disability Equality Standard.

Establish governance and reporting arrangements for equality and diversity

HR data is collated across all protected characteristics of the workforce and is reported against employee relations including recruitment and selection and retention throughout the staff journey (employee life cycle). This data is an integral part of our diversity performance and is published annually in response to the Public Sector Equality Duty (PSED). The Trust will complete the EDS2 across each clinical area of the organisation and report annually against the WRES. The Trust positively supports the completion of Equality Analysis on all new policies and those that are being reviewed. The Trust has identified the following committees to monitor and report the performance of equality and diversity:

Equality Impact Group

HR and OD Sub-Committee

Performance Committee

Quality Governance Committee

Trust Board

Patient Experience Group

Delivery of equality and diversity training

The Trust is establishing a multi methods approach to delivering equality and diversity. This includes:

Organisational Induction

E-Learning

VOX POP staff engagement events

Diversity Moments is a series of 10 equality and diversity learning topics that are aimed to be presented at a mainstream business meeting at each clinical division and corporate function. The benefit of Diversity Moments is that it (i) raises operational understanding of equality and diversity; and (ii) demonstrates evidence of mainstreaming equality and diversity across the organisation.

Workforce engagement for equality and diversity

The Trust will establish staff network groups with equality and diversity an integral part of their function. A number of engagement events are delivered throughout the year which focuses upon the key objectives and outcomes of the EDS2, WRES and NHS Staff Survey

Diversity calendar of events to celebrate diversity and inclusion and embed equality for all.

VOX POP – Diversity Champions

Health and Wellbeing Champions

Patient Experience Champions

Identify risk and assurance

Active management of the Trusts statutory obligations through the delivery of the Equality Delivery System (EDS2) and Workforce Race Equality Standard (WRES). The Trust Board has recognized that its diversity and inclusion is an area of high risk for the organisation. An action plan has been developed to address the Board’s concerns. The Risk Register will be

Page 8 of 18

used to monitor progress to ensure the risk to the organisation is significantly reduced by March 2019.

Legal implications

The Trust has quality, safety and operational obligations related to Equality and Diversity, both for patients and staff.

Equality Act 2010

Human Rights Act 1998

Regulatory and commissioner requirements

CQC Domains

NHSI

SC13 – NHS Standard Contract

Section 2: Introduction of a Workforce Diversity Scorecard

2.1. Introduction

Supporting individual differences helps every member of staff reach their own potential and contributes to the delivery of the Trust’s vision and values. To do this we need to have an in-depth understanding of the effect of our workplace cultures, policies, practices and procedures on our workforce and people who use our services.

Collating and analysing data on our staff by protected characteristics (Workforce Diversity Scorecard) provides a good starting point to develop this understanding. It provides us with an evidence base to identify any differences in outcomes for groups protected by the Equality Act 2010.

We have published this report because, under the Equality Act 2010, we have a duty to "publish information relating to persons who share a relevant protected characteristic who are its employees." 2

We also have a duty to "publish information relating to persons who share a relevant protected characteristic who are other persons affected by its policies and practices."3

The public sector equality duty, which came into force on 5 April 2011, was created by the Equality Act 2010 in order to harmonise the race, disability and gender equality duties and extend protection to the new protected characteristics of age, sex, gender re-assignment, pregnancy and maternity, religion or belief and sexual orientation. There is now a requirement for public bodies to publish:

equality objectives, at least every four years

equality information to demonstrate their compliance with the equality duty at least annually.

2 Equality Act 2010 (Specific Duties) Regulations [2011] para 2(4)a.

3 Equality Act 2010 (Specific Duties) Regulations [2011] para 2(4)b.

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2.2. Workforce Diversity Scorecard

This data is based on staff employed at Isle of Wight NHS Trust as at 31 December 2017.

Staff In Post as at 31.12.17

Sum of Headcount

Sum of FTE

Total

3579

2713

The Equality Standard was launched in 2014 as a positive response to meet the requirements of the EDS2. A work programme was designed and implemented to improve workforce equality monitoring across all protected characteristics of the workforce. 2.3. Age

Isle of Wight NHS Trust has 100% workforce reporting to Age

The largest age group employed at Isle of Wight NHS Trust is 46-55 (30.32%)

The number of staff employed between the ages of 16-25 is 6.76%

Table 1. Workforce by Age

Age Group Sum of Headcount Percentage of Total

16-25 242 6.76%

26-35 657 18.36%

36-45 773 21.06%

46-55 1085 30.32%

56-65 719 20.09%

66 and above 103 2.88%

Grand Total 3579 100.00%

Table 2. Recruitment and Selection by Age

Age Band (NHS JOBS)

Total Applicants %

Total Shortlisted %

Total Appointed %

Under 20 137 1.70% 59 1.80% 7 1.50

20-24 1004 12.60% 349 10.90% 48 10.10

25-29 1337 16.70% 461 14.30% 72 15.20

30-34 892 11.20% 344 10.70% 64 13.50

35-39 755 9.40% 286 8.90% 41 8.70%

40-44 873 10.90% 397 12.40% 56 11.80%

45-49 1007 12.60% 446 13.90 60 12.70%

50-54 976 12.20% 419 13% 58 12.30%

55-59 669 8.40% 307 9.60% 49 10.40%

60-64 298 3.70% 126 3.90% 16 3.40%

65-69 28 0.40% 9 0.30 2 0.40%

70+ 16 0.20 10 0.30 0 0%

Undisclosed 1 0% 0 0% 0 0%

Total

100%

100%

Page 10 of 18

Table 3. Leavers by Age

Age Group

Total Sum of

Headcount

Percentage of

Total

Leavers as a % of

total workforce

16-25 242 6.76% 1.8%(65)

26-35 657 18.36% 3.8%(139)

36-45 773 21.06% 2.5%(90)

46-55 1085 30.32% 3.0%(109)

56-65 719 20.09% 4.3%(156)

66 and above 103 2.88% 1.0%(36)


2.3.1. Actions for further analysis and response (2018/19)

Our workforce information by age tells us:

we have an ageing workforce

The impact of age on recruitment and selection show a slight under-representation in appointments from 16-39 and a slight over-representation from 40-70+. However, this does require further analysis including a statistical significance test.

Leavers are over-represented in the 16-25 age range

A key action is to undertake further analysis to identify the involvement of age groups in employee relations and employment banding.

Key issues to consider about the ageing workforce (NHS Employers)

Research has shown that many older workers report feeling undervalued and not respected by managers and their co-workers.

Managing a multi-generational team where more staff are older will require managers and organisations to adopt a more flexible approach to work organisation, task management and rotas/shifts.

Organisations need to be prepared for the fact that, just like the communities they serve, their workforce will experience ill health, impairment and disabilities. Retaining staff with these lived experiences can be beneficial to organisations as their understanding can enhance patient care.

Flexible working, including different or set work patterns, has been proven in recruitment and retention strategies.

Attracting, retaining and developing a millennial workforce is a priority action for our equality and diversity plan. We have already started to ‘re-brand’ the Trust as an a “great place to work”. Recruitment and Retention Ideas generated at a Workforce Summit in April 2018 will feed to the revised HR and OD strategy.

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2.4. Disability

Isle of Wight NHS has 75% workforce reporting to Disability

2.68% of the workforce have declared ‘yes’ to disability.

Recruitment and Selection for people who have declared ‘Yes’ to disability is positive in regard to application received and appointed.

Table 1. Workforce by Disability

Disability Sum of Headcount Percentage of Total

No 1728 48.30%

Not Declared 1039 29%

Prefer Not To Answer 3 0.1%

Undefined 715 20%

Yes 94 2.68%

Grand Total 3579 100%

Table 2. Recruitment and Selection by Disability

Disabled Total

Applicants % Total

Shortlisted % Total

Appointed % No Not

Declared 7476 93.50% 2986 92.90% 442 93.40%

Undefined 141 1.80% 54 1.70% 5 1.10%

Yes 375 4.70% 173 5.40% 26 5.50%

Total

100%

100%

100%

Table 3. Employee Relations by Disability

Diversity Scorecard Employees who have reported they

have a disability

Employees who have not reported a disability

Workforce (3579)

Grievance

2 35

Bullying and Harassment

0 4

Disciplinary

2 52

Sickness Absence

3 146

Leavers 1 598

Page 12 of 18

Table 4. Employment Banding by Disability

Diversity Scorecard Headcount with a disability

Workforce (3579)

Band 1 and 2 22

Band 3

13

Band 4 9

Band 5 28

Band 6 30

Band 7 6

Band 8a to 8d 3

Band 9 0

Medical workforce from FY1 to Consultant

2


The Trust will raise the importance of workforce and patient equality monitoring.

Further analysis will be undertaken to identify the involvement of staff declaring ‘yes’ to disability and being subject to a grievance.

Staff who declare ‘yes’ to disability are under-represented at Band 8a and above.

The Trust anticipates the proposed Disability Equality Standard (DES) will be a challenge; we have a good foundation to work from. We have been recognised as a Mindful Employer, supporting staff with mental health problems. The Trust has recently been recognised as a champion for patients and staff with a disability by achieving the Disability Confident Leader accreditation and shows people with a disability, we are committed to improving the experiences of patients and staff.

Page 13 of 18

2.5. Marriage and Civil Partnership

The Isle of Wight NHS Trust has 97.65% workforce reporting to Marital and Civil Partnership Status

Table 1. Workforce by Marriage and Civil Partnership

Marital Status Sum of Headcount Percentage of Total

Civil Partnership 41 1.13%

Divorced 308 8.46%

Legally Separated 72 1.98%

Married 1983 54.45%

NULL 25 0.69%

Single 1114 30.59%

Unknown 61 1.67%

Widowed 38 1.04%



The Trust will investigate the impact of marital and civil partnership status on recruitment and selection; employee relations and employment banding.

The Equality Act 2010 says an employer must not discriminate against you because you’re married or in a civil partnership. Further work will be undertaken to identify how services are responding to the needs of people who are married or in a civil partnership in the design, delivery and evaluation of services..

2.5. Race

Isle of Wight NHS Trust has 95.05% workforce reporting to Race

85.98% of the workforce is White British

9.7% of the workforce is BAME

Table 1. Workforce by Race

Race

Sum of

Headcount

Percentage of

Total Workforce

A White - British 2924 81.70%

B White - Irish 27 0.80%

C White - Any other White background 126 3.50%

D Mixed - White & Black Caribbean 7 0.20%

E Mixed - White & Black African 4 0.10%

F Mixed - White & Asian 8 0.20%

G Mixed - Any other mixed background 21 0.60%

H Asian or Asian British - Indian 41 1.10%

J Asian or Asian British - Pakistani 8 0.20%

K Asian or Asian British - Bangladeshi 2 0.10%

Page 14 of 18

L Asian or Asian British - Any other Asian

background 125 3.50%

M Black or Black British - Caribbean 5 0.10%

N Black or Black British - African 20 0.60%

P Black or Black British - Any other Black

background 5 0.10%

R Chinese 6 0.20%

S Any Other Ethnic Group 51 1.40%

Undefined 15 0.40%

Z Not Stated 182 5.10%


Table 2. Recruitment and Selection by Race

Ethnic Origin

Total Applicants %

Total Shortlisted %

Total Appointed %

Asian 530 6.60% 145 4.50% 11 2.30%

Black 282 3.50% 94 2.90% 7 1.50%

Mixed 109 1.50% 20 1.10% 3 0.60%

Other 137 1.70% 37 1.20% 1 0.20

Unknown/ Not Stated 147 1.80% 79 2.50% 22 4.70%

White 6362 79.60% 2680 83.40% 417 88.20%

Total 7567 100.00% 3055 100.00% 461 100.00%

Table 3. Employee Relations by Race

Diversity Scorecard

White British

BAME (including White Irish and

White Other Background)

BAME (excluding White Irish and White Other Background)

Workforce (3579)

Grievance

33 5

Bullying and Harassment

0 4

Disciplinary

52 2

Sickness Absence

146 3

Leavers 462 137 109

Page 15 of 18

Table 4. Employment Banding by Race

Diversity Scorecard

White British BAME (excluding White Irish and White Other

Background)

Workforce (3579)

Clinical %

Non-Clinical %

Clinical %

Non-Clinical %

Band 1 0

Band 2 86.8 84.7 6.9 7.3

Band 3

92.1 93.7 0.8

Band 4 93.3 96.1 2.6 1.2

Band 5 73.1 97.5 20.7 0

Band 6 92.3 100 4.1 0

Band 7 90 91.5 5 4.3

Band 8a 98.4 100 0 0

Band 8b 94.1 93.3 0 0

Band 8c 100 100 0 0

Band 8d 50 87.5 0 0

Band 9 0 0 0 0

Medical Workforce

117 0 85 0

N.B variances are attributed to staff who do not wish to disclose their ethnicity


Our workforce race equality performance must improve. We will identify key actions

contained within a WRES action plan that will be underpinned by engagement at all levels of the organisation.

We will design and deliver a strong staff engagement programme that aims to (i) understand the experience of BAME people within our organisation; and (ii) undertake a review of BAME recruitment and selection, involvement of BAME in employee relations and identifying any potential barriers to career development and progression.

The Trust has identified that BAME are significantly under-represented at Band 6 and above with the exception of non-clinical band 8d.

Page 16 of 18

2.6. Religion and Belief

Isle of Wight NHS Trust has 69.35 % workforce reporting to Religion or Belief

41.83% of the workforce identifies their religion/belief with Christianity

Table 1. Workforce by Religion or Belief

Religion and/or Belief Sum of Headcount Percentage of Total

Atheism 330 9.22%

Buddhism 12 034%

Christianity 1497 41.83%

Hinduism 19 0.53%

I do not wish to disclose 1097 30.65%

Islam 22 0.61%

Jainism 1 0.03%

Judaism 1 0.03%

Other 271 7.57%

Sikhism 1 0.03%

Undefined 328 9.16%


Table 2. Recruitment and Selection by Religion or Belief

Religious Belief

Total Applicants %

Total Shortlisted %

Total Appointed %

Atheism 1347 16.90% 561 17.50% 91 19.20

Buddhism 51 0.60% 15 0.50% 0 0%

Christianity 4036 50.50% 1689 52.60% 261 55.20%

Hinduism 131 1.60% 36 1.10% 5 1.10%

I do not with to disclose religion/ belief

947 11.80% 407 12.70% 60 12.70%

Islam 285 3.60% 60 1.90% 1 0.20%

Jainism 1 0% 1 0% 0 0%

Judaism 2 0.10% 2 0.10% 0 0%

Other 1184 14.80% 439 13.70% 55 11.60

Sikhism 8 0.10% 3 0.10% 0 0%

Total 7992 100.00% 3213 100.00% 473 100.00%


The Trust will investigate the impact of religion or belief status on employee relations and employment banding. This will be incorporated and analysed for statistical significance within the WRES action plan.

Initial analysis of recruitment and selection data does show a negative impact in applications received to appointments for the following categories: Hinduism; Islam; Jainism; Sikhism and Other.

Page 17 of 18

2.7. Sex

Isle of Wight NHS Trust has 100% workforce reporting to Sex

74.30% of the total workforce is female

25.70% of the total workforce is male

Isle of Wight NHS Trust monitors the representation of Women on Board and will respond positively to the requirements contained with Equal Pay Gap Reporting (31 March 2018)

Table 1. Workforce by Sex

Sex Sum of Headcount Percentage of Total

Female 2658 74.30%

Male 921 25.70%


Table 2. Recruitment and Selection by Sex

Sex Total

Applicants % Total

Shortlisted % Total

Appointed % Male 1954 24.40% 735 22.90% 99 20.90%

Female 6004 75.10% 2456 76.40% 367 77.60%

Undisclosed 34 0.40 22 0.70% 7 1.50%

Total 7992 100% 3213 100 473 100%

Table 3. Employee Relations by Sex

Diversity Scorecard Female Male

Leavers

427 169


We will investigate the involvement of males subject to a disciplinary. We will triangulate with Race to identify any trends in data sets.

We are unable to provide a breakdown of employee relation cases by pay band/grade. This report will be developed during 2018.

Page 18 of 18

2.8. Sexual Orientation

Isle of Wight NHS Trust has 62.23% workforce reporting to Sexual Orientation

61.62% of the workforce identify their sexual orientation as Heterosexual

1.01% of the workforce identify as Lesbian, Gay or Bisexual (LGB)

Table1. Workforce by Sexual Orientation

Sexual Orientation Sum of Headcount Percentage of Total

Bisexual 6 0.17%

Gay 19 0.53%

Heterosexual 2191 61.61%

I do not wish to disclose my

sexual orientation 1023 28.58%

Lesbian 11 0.31%

Undefined 329 9.19%

Transgender 0 0


Table 2. Recruitment and Selection by Sexual Orientation

Sexual Orientation

Total Applicants

% Total

Shortlisted %

Total Appointed

%

Bisexual 80 1% 18 0.60% 1 0.20%

Gay 77 1% 31 1% 5 1.10%

Heterosexual 7294 91.30% 2932 91.30% 428 90.50%

I do not wish to disclose sexual orientation

497 6.20% 208 6.50% 37 7.80%

Lesbian 44 0.60% 24 0.70% 2 0.40%

Total 7992 100.00% 3213 100.00% 473 100.00%


1. The Trust will investigate the impact of sexual orientation status on recruitment and

selection; employee relations and employment banding.

Section 3 Next steps 2018-19

1. The Trust will undertake a full analysis of workforce data by protected characteristics and

address gaps in reporting as specified in the report.

2. The Trust will respond positively to workforce equality requirements such as Gender Pay Gap reporting; Disability Equality Standard; Accessible Information Standard; Workforce Race Equality Standard (WRES) and Equality Delivery System (EDS2).

3. The Trust will publish EDS2 Summary reports completed by our clinical divisions

4. The Trust will pilot a programme of EDS2 Grading Panels (April- August 2018) with a full launch (September 2018-March 2019).

Page | 1


Date 5 July 2018

Title Gender Pay Gap Report 2018 Sponsoring Executive Director

Julie Pennycook – Director of Human Resources and Organisational Development

Author(s) Liz Nials – Senior HR Manager, Sam Greatrex – Equalities Lead Report previously considered by inc date

Joint Local Negotiating Committee (17th May) Partnership Forum (discussion only (5th June) Performance Committee (4th July)

Purpose of the report Information only Assurance Review and discuss Agreement Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective Responsive Caring X Well-led X Safe Executive Summary The Gender Pay Regulations required employers that have more than 250 employees to publish and report on gender pay differences. The data presented in this report is for the whole organisation and shows that men are paid 19% more than women. Over the next 12 months we intend to analysis this data to establish if there is any pay differences between men and women by professional group. Key Recommendation The Board is recommended to approve the actions set out in the Gender Pay Gap Report 2018

Enc F

Page 1 of 7

Gender Pay Report

2018

Prepared in accordance with the Equalities Act 2010

(Gender Pay Gap Information) Regulations 2017

May 2018

Page 2 of 7

EQUALITIES ACT 2010 (Gender Pay Gap Information) Regulations 2017

1. Introduction

Gender pay gap reports are an important milestone as we develop the evidence base on pay equality. The Isle of Wight NHS Trust is committed to promoting equality for all staff and we view Gender pay gap reporting as an invaluable tool to understand our workforce and consider the best strategies for improvement.

2. Gender pay gap reporting legal obligation

There are two sets of regulations which place mandatory gender pay gap reporting obligations on all employers. The regulations that apply to NHS organisations are:

• From 31 March 2017 any public sector organisation that has 250 or more employees must publish and report specific figures about their gender pay gap.

• The gender pay gap is the difference between the average earnings of men and women, expressed relative to men’s earnings. For example, ‘women earn 15% less than men per hour’.

Employers must both:

• publish their gender pay gap data and a written statement on their public-facing website.

• report their data to government online - using the gender pay gap reporting service.

This obligation is governed under the statutory provision found in The Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017.

3. What is the Difference between gender pay gap and Equal pay?

The gender pay gap differs from equal pay:

• Equal pay deals with the pay differences between men and women who carry out the same jobs, similar jobs or work of equal value. It is unlawful to pay people unequally because they are a man or a woman.

• The gender pay gap shows the differences in the average pay between men and women. If a workplace has a particularly high gender pay gap, this can indicate there may a number of issues to deal with, and the individual calculations may help to identify what those issues are. In some cases, the gender pay gap may include unlawful inequality in pay but this is not necessarily the case.

https://www.gov.uk/guidance/gender-pay-gap-reporting-what-employers-must-publish

https://www.gov.uk/report-gender-pay-gap-data

Page 3 of 7

3.1 Gender pay reporting and gender identity As a large employer with a diverse workforce the Isle of Wight NHS Trust is sensitive to how an employee chooses to self-identify in terms of their gender. The regulations do not define the terms ‘male’ and ‘female’ and the requirement to report gender pay should not result in employees being singled out and questioned about their gender. The data provided for this report has been taken from the Trust’s employee record and uses data provided to us by our employees. In cases where the employee does not self-identify as either gender, an employer may omit the individual from the calculations. 4. ‘Gender Pay Gap – Data and Analysis’ In order for the Isle of Wight NHS Trust to comply with their obligation two types of averages have been calculated:

• A mean average which involves adding up all of the salaries of everyone the Trust employs and dividing the result by the number of staff we employ.

• A median is an average which involves listing all of the numbers in numerical order. If there is an odd number of results, the median average is the middle number. If there is an even number of results, the median will be the mean of the two central numbers.

Looking at the data in this way gives the Trust an overall picture of the pay gap between men and women. Table 1 Gender Pay Gap Summary as at 31st March 2017

The overall pay difference is at 19% higher for men than women within the Trust.

Gender Avg. Hourly Rate Median Hourly Rate Male 18.27 14.06 Female 14.78 13.45 Difference 3.48 0.61 Pay Gap % 19.07 4.32

Page 4 of 7

Key points • The median hourly rate of pay is calculated from a specific pay period, in this case it is

March 2017. The median rate is calculated by selecting the average hourly rate at the mid-point for each gender group.

4.1 The averages are separated into quartile bands: This calculation requires the Isle of Wight NHS Trust to show the proportions of male and female full-pay relevant employees in four quartile pay bands, which is done by dividing the workforce into four equal parts. These quartile pay bands are established when making the calculation, so any other pay banding used in a workplace must not be used The Isle of Wight NHS Trust employed approximately a workforce ratio of one third male and two thirds female in quarters 1 and 4 whereas in quarters 2 and 3 the ratio was nearer one fifth male and four fifths female.

Graph 1 Gender Pay by Quartiles as at 31st March 2017

1 2 3 4Male % 28.84 20.00 20.44 31.29Female % 71.16 80.00 79.56 68.71

0.0020.0040.0060.0080.00

100.00120.00

Perc

enta

ge

Quartiles

Female % Male %

Page 5 of 7

Key Points:

• In order to create the quartile information all staff are sorted by their hourly rate of pay, this list is then split into 4 equal parts (where possible).

• The highest variances for the quartiles when compared to the overall Trust value are in the lower, middle lower and middle upper all at similar values.

• There is a higher proportion of female staff in the lower quartile; included in this quartile are admin & ancillary staff groups that have a higher proportion of female staff which is reflected in the calculation.

• The upper quartile has a lower difference with just under 68% of the workforce female staff.

4.2 Gender Pay Gap – Bonus

This indicator applies to our medical workforce who receive a Clinical Excellence Award (CEA) which, for the purpose of Gender Pay Reporting is classified as bonus pay. CEA’s are awarded as a result of recognition of excellent practice over and above contractual requirements. Applications are scored independently by a multi-disciplinary panel to eliminate the risk of gender bias.

The Trust appreciates that this group has a significantly different gender split when compared to the Trust as a whole. Of our medical workforce, 0.38% of females receive an CEA award, compared with 3.86% of men.

Table 4 Gender Pay Gap – Summary of Bonuses as at 31st March 2017

Gender Avg. Pay Median Pay Male £13,092.45 £11,934.30 Female £8,639.42 £8,033.79 Difference 4,453.03 3,900.52 Pay Gap % 34.01 32.68

Graph 2 Gender Pay Gap – Summary of Bonuses as at 31st March 2017

£0.00£5,000.00

£10,000.00£15,000.00£20,000.00

£25,000.00

£30,000.00

malefemale

Median pay

Avg. Pay

Page 6 of 7

Key Points:

• This calculation expresses the number of staff receiving bonus pay as a percentage of the total number of staff in each gender group.

• Only certain medical staff receive pay that is classified as bonus pay. This group has a significantly different gender split when compared to the Trust as a whole.

• The percentage variance for the median bonus is 33%. While this seems high, the staff

group identified in this section only has 45 staff eligible 35 male and 10 female. The pay elements that are used in this calculation are awarded as a result of recognition of excellent practice over and above contractual requirements and have no gender bias. As such, the relevance of this indicator is less significant for our organisation.

• The average hourly rate of pay is calculated from a specific pay period, in this case it is

March 2017. The hourly rate is calculated for each employee based on 'ordinary pay' which includes basic pay, allowances and shift premium pay.

In conclusion although the difference between men and women’s pay is fairly low the significant issue is that of the proportion of men to women working for the Trust illustrates that women are seemingly working in the lower quartiles and men at the higher end of the highest quartile. We believe this is a similar position to many other NHS Trusts but it will need further exploration to understand how to improve the gap.

5. Action plan

The Isle of Wight NHS Trust is committed to reducing any unjustified gap in pay between men and women. In the first year of reporting the Isle of Wight NHS Trust will consider improvement under two main headings – (1) family responsibilities and (2) occupational trends. The reason for choosing theses is based on academic research into gender pay gap which has found both factors as prevalent in understanding gender pay gaps1.

5.1 The data contained in this first Gender Pay Gap Report, is at an organisation level. During 2018/19 the Trust will undertake a detailed analysis of the data so the Trust Board can be assured that gender pay gaps are identified by staff group and are being addressed.

Research suggests that the 5 key work areas where women are employed are Cleaning, Catering, caring roles, cashiers and clerical work. It would be advantageous to break our statistics down to compare whether the demographic of the Trust is in line with the general census if this is the case

What we will do:

• Undertake a detailed analysis of the data by professional group; once gathered • Identify any career and development training trends.

1 European Commission Expert Group and Employment ,’ Gender Segregation in the labour market, Root causes, implications and policy responses in the EU’[2009]: Hook J et el,’ Reproducing Occupational inequality, Motherhood and occupational segregation [2016] Social politics v23 p329

Page 7 of 7

• Investigate the viability of a career development course in line with high performing leader from band 6 as this will in turn allow for a larger proportion of already settled staff to move up the bands and less transience within the work place

5.2 Retention of staff is a significant challenge for the Trust. The statistics illustrate that whilst 75% of our workforce is female, they are earning less than men. One reason for this could be that women are leaving the Trust earlier than men; women who return from maternity leave tend to return on fewer hours. Therefore females are not remaining in the Trust employment long-term in order to benefit from the annual pay increments.

What we will do:

• We will undertake some targeted exit interview with women who have left or are leaving the Trust.

5.4 Family responsibilities

Statistics have shown within private sector organisations that the ratio of women returning to work after maternity leave is significantly low. It has found the reason for such a decline is due to new priorities within their life which are difficult to reconcile.

What we will do:

• We will explore piloting a life coaching course for both pregnant women and post pregnancy women in order to offer a positive setting to return to work.

• Other positive considerations would be to actively promote through our communications

team and induction.

• We will review our flexible working policy and support line managers to consider a more flexible way of using their workforce, if it means retaining people.

• Child care salary sacrifice scheme we will work with our on-site Day Nursery to explore

staff discounts and discussing extended hours to allow for parents to drop children off before their shift starts with the nursery providers would generate an appeal to work within the Trust.

6. Board Level Approval

I confirm that the information contained in this report is accurate.

Authorised on behalf of the Isle of Wight NHS Trust Board

Signed:

Julie Pennycook, Director of Human Resource and Organisational Development 14th May 2018

Page | 1


5 July 2018

Title Interim Workforce Strategy 2018/19 Sponsoring Executive Director

Julie Pennycook, Director of HR & OD

Author(s) Jeff Crawshaw, Interim HR Management Consultant Report previously considered by inc date

Trust Leadership Committee 20 June 2018 Quality Committee 4 July 2018

Purpose of the report Information only Assurance Review and discuss Agreement Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary This strategy is an essential building block of the Trust’s commitment to improve in everything we do ‘Getting to Good’ but has, deliberately, a short horizon. The Trust will develop a new clinical strategy in 2018 and the workforce strategy will be refreshed to reflect changes in the organization, scope and delivery of care. We anticipate much of this strategy will remain unchanged, but it is important that the workforce strategy fully supports the clinical realities and ambitions of the Trust and its Commissioner. This strategy is designed to address our challenges, build on our successes and provide outstanding HR & OD services. To achieve “A Great Place to Work” we will focus on the following priorities: • Well Led – Culture and Leadership development • Developing our Leaders • Equality and Diversity • Recruiting and Retaining a Motivated Workforce • Staff Engagement • Training and Development • Health and Wellbeing • Living Within our Means

Key Recommendation The Board is recommended to consider and approve the Interim Workforce Strategy 2018/19

Enc G

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An Interim Workforce Strategy

2018/19

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Foreword from the Chair and Chief Executive We are pleased to present the interim Workforce Strategy for 2018 to 2019 for the Isle of Wight NHS Trust. The NHS faces huge workforce challenges and as a Trust providing services to an island population we are faced with some unique circumstances which offer both additional challenges and, at the same time, opportunities. To meet these challenges and seize opportunities we recognise that we must do more to improve the recruitment and retention of the very best people – people with right skills and values - to care and treat our local population. This interim strategy describes how we will confront these challenges, embrace the opportunities and work tirelessly to create an environment in which our staff can, confidently, realise their potential and give the very best care possible to our patients and clients. This strategy is an essential building block of the Trust’s commitment to improve in everything we do ‘Getting to Good’ but has, deliberately, a short horizon. The Trust will develop a new clinical strategy in 2018 and the workforce strategy will be refreshed to reflect changes in the organisation, scope and delivery of care. We anticipate much of this strategy will remain unchanged, but it is important that the workforce strategy fully supports the clinical realities and ambitions of the Trust and its Commissioner. As a Trust in special measures we know we have lot to do and we need to achieve change quickly. Working alongside our dedicated staff the new Board will do everything it can to achieve our ambition of being one of the very best employers in the NHS. Vaughan Thomas – Chairman Maggie Oldham – Chief Executive

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1. Introduction The Isle of Wight NHS Trust is the only integrated acute, community, mental health and ambulance health care provider in England. Established in April 2012, the Trust employs a workforce of some 3200 staff (2700 full time equivalent) and spends over £125 million a year on the workforce. Around 75% of the workforce are female, 8% from black and ethnic minorities and 40% over the age of 50. Our Workforce

The Trust has, during the last few years, faced considerable leadership turmoil and reputational harm and, as a result, is struggling to recruit and retain staff in a fiercely competitive national environment. Our loyal workforce continues to give unselfishly to maintain services. We are proud of what they do and, through this strategy, promise to do everything we can to rebuild trust and our reputation, strengthen staffing levels and improve the safety, effectiveness and efficiency of our services. The CQC findings alongside the publication of the 2017 Staff Opinion Survey results tell us what we need to do:

• Lead with integrity and compassion • Value and engage with our staff • Eliminate poor behaviours and hold people to account • Develop our staff and empower them to act

Our aim is to be in the top 20% of the best NHS employers and to have the best possible reputation locally, and beyond. We want our staff to have the right tools and support to flourish.

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Underpinning this strategy is a decision to refocus our HR function so it is better placed to meet the needs of our managers and staff. We will reflect the new organisational structure (built around the four clinical services – acute, ambulance, community and mental health) and priorities with the introduction of HR Business Partners and an improved central support function aimed at improving the support we can give to staff and managers. We also commit to strengthen inclusion. We will, through our dedicated equality and diversity lead, engage with our staff, wider community and partners in developing a progressive approach to inclusion and act to address shortcomings in employment practices and in our service provision. This strategy is designed to address our challenges, build on our successes and provide outstanding HR and OD services. To achieve “A Great Place to Work” we will focus on the following:

• Well Led – Culture and Leadership • Developing our Leaders • Equality and Diversity • Recruiting and Retaining a Motivated Workforce • Staff Engagement • Training and Development • Health and Wellbeing • Living Within Our Means

2. The National Picture The Trust operates in a national system where pay, workforce planning and professional standards and regulation are determined by a variety of NHS bodies. The Trust will continue to operate within this national framework and support national and regional initiatives aimed at improving workforce supply. 3. Consultation and engagement with stakeholders We continue to work closely with our Trade Union representatives through our Social Partnership Forum and seek regular feedback from our staff through the annual staff survey and our quarterly pulse surveys. We have, as part of our culture and leadership initiative, also begun to hold workshops with our staff to better understand their needs and how we can improve the employment opportunities that the Isle of Wight NHS Trust has to offer. Much of the feedback from these sources has been used to shape this strategy.

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Well Led – Culture and Leadership What do we want to achieve? We want staff to be well led, valued and supported, to be proud to work for the IOW NHS Trust and recommend it to others as a place to work and live. Why is this important to us? The leadership, engagement and the working environment is crucial to attracting and retaining a motivated workforce and creating a reputation that attracts others to the Trust. How will we achieve this? • Through our culture and leadership improvement programme creating a working

environment where staff feel safe, supported and well led. • Ensuring our senior leaders are always accessible and responsive to staff at all levels. • Promoting good behaviours, setting standards and tackling poor performance head on. • Offering development and training for leaders and managers to equip them with the

skills and understanding to make our ambition a reality. • Ensuring there is a clear accountability framework, expectations are clear and staff are

held to account. • Working with staff advisors and staff representatives to give staff a voice. How will we know if we have succeeded? Improvements in key staff survey result in 2019 ↑Improvement in overall staff engagement. ↑Increase in the number of staff recommending the organisation as a place to work. ↑Percentage of staff appraised in the last 12 months. ↑Proportion of staff indicating they receive recognition and are valued by managers and the organisation. ↑Percentage of staff reporting good communication between senior management and staff.

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Developing our Leaders What do we want to achieve? Managers and Leaders from all professional backgrounds who are equipped with the behaviours, skills and knowledge needed to perform effectively. Why is this important to us? As an employer of over 3000 staff providing a vital public service of we need managers and leaders who can inspire people, operate effectively in a high profile and often challenging environment and above all, through compassionate leadership, bring out the very best in our staff. How will we achieve this? • Through our Culture and Leadership Development programme talking to our staff about

how we can best create an environment where staff feel valued, supported and safe. • Providing dedicated development programmes based on organisational needs for our

managers and leaders at all levels: Board, Executive, Clinical leader, Senior Manager and Middle & Junior manager.

• Ensuring our programmes are based on local needs and draw on best practice from across the NHS.

• Establishing a talent programme for those who aspire to leadership roles. This will include developing a transparent approach to succession planning and supporting those with clinical backgrounds who are looking to develop their leadership skills and roles.

How will we know if we have succeeded? Programmes launched and evaluated. ↑ Increase in the number of staff recommending the organisation as a place to work. ↑ Proportion of staff indicating they receive recognition and are valued by managers and the organisation. ↑ Percentage of staff reporting good communication between senior management and staff. Talent management and succession planning programmes launched.

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Equality and Diversity What do we want to achieve? We aim to be recognised as a national leader for the delivery of equality and diversity and our aims are set out in our Equality and Diversity Strategy. Why is this important to us? Promoting equality, diversity and human rights is closely related to the pursuit of quality and actions to address and reduce gaps in health inequalities. A quality service is one that recognises the needs and circumstances of each patient, carer, community and staff member, and ensures that services are accessible, appropriate and effective for all, and that workplaces are free from discrimination where staff can thrive and deliver. How will we achieve this? • Establishing an Equality Steering Committee to provide support, advice, assurance to

the Trust Board and the wider organisations. • Developing and embedding a culture of promoting Equality and Diversity and

eliminating unlawful discrimination. • Meeting our duties and responsibilities under Equality, Diversity and Human Rights

legislation and codes of practice, including NHS, commissioners and regulatory requirements.

• Promoting, recognising valuing the diverse nature of communities and staff groups within the Trust.

• Mainstreaming equality and diversity in everything we do. How will we know if we have succeeded? ↑ Improvement in the annual staff survey: • Staff Engagement score • Violence, bullying and harassment • Health and wellbeing • Staff motivation • Staff reporting they are able to contribute to improvements at work ↑ Response rate and results to the quarterly Friends and Family Test for staff. Diversity Scorecard to include workforce demographic profile and employee relations performance, including recruitment and retention levels. Effective support for new staff and understanding why people leave. Taking the temperature through observations, walk-arounds , peer reviews and ‘back to the floor’ by senior leaders. Benchmarking our data such as Workforce Race Equality Standard and Gender Pay Gap data with other NHS Trusts (locally and nationally).

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Recruiting and Retaining a Motivated Workforce What do we want to achieve? We want to be one of the very best NHS employers where new staff feel welcome and all staff feel supported and valued. Why is this important to us? NHS employers operate in a fiercely competitive environment with most clinical professions facing national shortages. Promoting the island as a great place to live and work and retaining highly skilled, experienced and healthy workforce will enable us to provide high quality safe care. We want to be recognised as an enlightened employer that meets the aspirations and needs of our diverse workforce, offers development and career opportunities for all and, for those with carer responsibilities, employment choices which allow them to balance work and domestic needs. We also want to promote a work/life balance that promotes health lifestyles, so our staff set an example for our wider community. How will we achieve this? Recruitment: • Investing in marketing the Trust and Island as a great place to work and live and

promoting jobs through profile-raising material, social media, recruitment events and campaigns.

• Investing in new technology and systems to ensure our recruitment processes are agile, safe and secure new staff in the shortest time.

• Appointing a nurse lead to work alongside HR and ward sisters to improve the coordination and management of nursing and medical vacancies respectively.

• Actively pursuing an international recruitment drive for 100 nurses in 2018. • Examining the case for financial incentives to attract new employees and help

ease their travel and living costs. Retention: • Ensuring all staff receive a comprehensive induction on the day they join the

Trust and receive additional support in their first few months. • Consulting staff on new workforce policies and practices that create a positive

and supportive working environment. • Supporting career aspirations through a personal development plan which

guarantees an annual appraisal and time off for training and development. • Providing facilities and support that promotes a healthy lifestyle and good health

and wellbeing. • Demonstrating Executive engagement with staff through weekly meetings, ‘back

to the floor’ initiatives and shadowing opportunities.

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How will we know if we have succeeded? High quality promotional material, highly visible presence at recruitment events and use of social media to connect with and recruit health professionals. ↑ Aspiring to match the best (shortest) NHS ‘time to hire’ performance. 100 international nurses joining the Trust in 2019. ↓ Reduction in the number of vacancies. All new staff attend induction on first day or employment and all staff have time off during the year for development and training. ↑ All staff are appraised. New workforce policies reflecting the needs of staff and best practice. ↓ Reduction in turnover rates in key areas. ↓ Reduction in sickness absence rates. ↑ Improvement in overall staff engagement. ↑ Increase in the number of staff recommending the organisation as a place to work.

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Staff Engagement What do we want to achieve? A workforce that feels valued, involved and recognised for the vital work that it does. Why is this important to us? Involving staff in our plans and decisions and communicating clearly with them will help improve staff morale, enhance our reputation as an employer and help us meet the needs of our community especially during periods of difficulty and change. How will we achieve this? • Through our Social Partnership Forum working closely with staff representatives

involving them in our plans and decisions. • Creating opportunities for staff to meet and talk to the Board and other senior leaders

and hear first-hand about and comment on our plans and decisions. • Ensuring staff are actively involved in plans when they affect them. • Recognising and rewarding staff for the work they do through our staff recognition

scheme. • Ensuring staff engagement is the responsibility of all leaders and managers – not just

HR. How will we know if we have succeeded? Improvements in key staff survey result in 2019 ↑ Improvement in overall staff engagement. ↑ Increase in the number of staff recommending the organisation as a place to work. ↑ Percentage of staff appraised in the last 12 months. ↑ Proportion of staff indicating they receive recognition and are valued by managers and the organisation. ↑ Percentage of staff reporting good communication between senior management and staff. ↑ Staff reporting they are able to contribute to improvements at work. ↓ Reduction in turnover rates in key areas. ↓ Reduction in sickness absence rates. ↑ Response rate and results to the quarterly Friends and Family Test for staff. Taking the temperature through observations, walk-arounds, peer reviews and ‘back to the floor’ by senior leaders.

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Training and Development What do we want to achieve? A competent and confident workforce with the skills and behaviours to meet the needs of our patients and community. Why is this important to us? Healthcare is a dynamic environment with rapid and constant changes in treatment, technology and practice. Our workforce must be equipped with the skills and behaviours to meet these changes as well as showing compassion in meeting the needs and expectations of our patients. We want to be recognised as an employer committed to developing our staff so they can realise their potential. How will we achieve this? • Offering structured and guaranteed learning and development opportunities for all

staff. • Recognising the diversity of our workforce offer a modern and flexible approach to

development. • Ensuring all our staff have an annual appraisal which is of a high quality and relevant to

the role and working environment. • Ensuring all staff undertake their annual mandatory training. • Offering coaching and mentoring to those in a new or changing role and ensure learners

have appropriate mentoring and clinical supervision to help them make the most of their clinical placements.

• Providing high quality placements and supervision for those in training with us. • Developing a strong ‘team’ ethos. How will we know if we have succeeded? An annual Trust wide development programme based on organisational priorities and staff training needs. All new staff attend induction on first day of employment. Training and development can be accessed through a variety of media. ↑All staff are appraised. ↑All staff undertake their annual mandatory training. All staff have a personal development plan and all staff have time off during the year for development and training. ↑ Improvement in the Staff survey score ‘Quality of non-mandatory training, learning or development’. ↑ Improvement in the feedback from our trainees. ↑ Improvement in the Staff survey score ‘Effective Team Working’.

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Health and Wellbeing What do we want to achieve? A healthy and safe workforce and a reduction in sickness absence. Why is this important to us? Many of our staff work in services that can often be challenging. All of our staff require training in the use of equipment, procedures and techniques to work effectively and safely. Staff need to be able to easily turn to help and advice when most needed. We also want a workforce that is healthy and to provide working environment and lifestyle support that will reduce the risk of illness and absence. How will we achieve this? • Providing access to occupational health services. • Providing essential training so staff can work effectively and safely. • Providing positive working environment and accessible support targeted at specific

health issues such as stress through a mental health support worker and muscular skeletal injury through access to physiotherapy.

• Promoting healthy lifestyle such as healthy eating, regular exercise and stop smoking help.

• Promoting winter flu jabs and good hygiene to prevent infection and illness. How will we know if we have succeeded? ↓ Reduction in absence from work. ↓ Reduction in reported cases of and absence due to injury at work, stress, muscular skeletal injury and influenza. ↑ Improvement in the Staff survey score ‘feeling unwell due to work related stress’. ↑ Improvement in the Staff survey score ‘Organisation and management interested in health and wellbeing’. Availability of specialist advisers e.g. ‘Speaking Up’ guardian and Bullying and Harassment advisers. Availability of healthy food and promotion of healthy lifestyles.

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Living Within Our Means What do we want to achieve? An overall reduction in our workforce expenditure so we are able to live within our means. Why is this important to us? The Trust faces significant financial difficulties. We are spending beyond our means and during 2017/18 spent nearly £2million a month more than we received. We must now look at every aspect of our work, every department and every pound we spend and reduce costs wherever possible. Our priority must be safeguarding patient services. How will we achieve this? • Ensuring pay reflects prevailing market rates and that there is a clear link between

reward and performance. • Reviewing how all our non-clinical services are organised and run. We will set ambitious

but achievable cost reduction targets whilst maintaining essential activities. • Exploring the opportunities for making better use of technology and eliminating

duplication and bureaucracy to reduce costs. This includes making the fullest use of e- rostering for nursing staff.

• Seeking to recruit more permanent staff and encourage agency workers to join the Trust to reduce the reliance on high cost agency workers

• Reviewing the management of our temporary staffing suppliers to ensure we have secured competitive pay rates and fees.

• Working closely with our staff representatives to minimise the impact that these changes may have on our substantive and temporary workers.

How will we know if we have succeeded? ↓ Reduction in temporary staffing expenditure ↓ Reduction in corporate services pay expenditure A fair and transparent pay policy, increments, merit pay and other reward which are linked to performance. 4. Implementation and monitoring Executive and operational leads for the strategic intentions are set out in Table 1 below. The HR and OD Sub-Committee will be the Board Committee with responsibility for seeking assurance on the funding and delivery of the Workforce Strategy. The Social Partnership Forum will also play a key role in advising on and monitoring progress with the Workforce Strategy.

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Following planned organisational change each service (Acute, Ambulance, Community and Mental Health) will have their own Boards to monitor their elements of the strategy. During Quarter 2 2018/19, baseline data and cost estimates will be obtained for each priority to enable the Board to allocate funding and agree milestones. The ultimate success of the Strategy will be demonstrated by:

• Being in the top 20% of Trusts in national staff survey results • Reduction in vacancies • Lower than NHS average turnover rate for staff • Lower than NHS average rate for sickness absence • Reductions in temporary workforce spend • Being rated as a minimum of ‘Good’ by the CQC in 2020

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TABLE 1 Well Led Priority Executive lead Operational lead Monitoring

committee Culture and Environment

Director of HR and OD

Assistant Director for OD Senior Managers

HR & OD Sub-Committee Quality Committee Social Partnership Forum

Executive engagement Director of HR and OD

Business and Development Manager

Standards Director of HR and OD


Management development


Assistant Director for OD

Accountability framework

Director of Finance Deputy Director of Finance

Working with staff advisors and representatives


Deputy Director of HR

Developing our Leaders Culture and Leadership Development programme




Development Programmes



Talent and Succession planning programmes



Equality and Diversity Equality Steering Committee


E&D lead Equality Steering Committee HR & OD Sub-Committee Quality Committee Social Partnership Forum

Creating the right Culture


E&D lead

Meeting statutory duties


E&D lead

Recruiting and Retaining a Motivated Workforce Marketing and promotion




New technology/recruitment systems



Nurse lead Director of HR and OD

Deputy Director of Nursing

International recruitment

Director of Nursing Deputy Director of Nursing

Financial incentives Director of Finance Deputy Director of

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HR Comprehensive induction



Workforce policy and Practice



Personal Development Plans



Health and Wellbeing Director of HR and OD

Deputy Director of HR Senior Managers



Staff Engagement Staff side/Social Partnership Forum engagement




Board and senior leaders visibility and accessibility



Staff recognition Director of HR and OD


Training and Development Structured and guaranteed learning and development




Flexible learning Director of HR and OD


Appraisal Director of HR and OD


Mandatory training Director of HR and OD


Coaching and mentoring



Trainee supervision Director of HR and OD


Team working Director of HR and OD


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Health and Wellbeing Reduction in absence from work


Senior Managers HR & OD Sub-Committee Quality Committee Social Partnership Forum

Reduction in main cases of ill health



Availability of specialist advisers



Availability of healthy lifestyle options and advice



Living Within Our Means Pay policy Director of HR and

OD Deputy Director of HR


Non-clinical services Director of HR and OD

PMO

Technology Director of Finance IMT Lead Senior Managers

Permanent staffing Director of HR and OD


Staff representatives Director of HR and OD


Version Draft for consultation

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5 July 2018

Title Recruitment & Retention Strategy Sponsoring Executive Director


Author(s) Jeff Crawshaw, Interim HR Management Consultant Report previously considered by inc date

Trust Leadership Committee 20 June 2018 Quality Committee 4 July 2018

Purpose of the report Information only Assurance Review and discuss Agreement Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary This strategy, which draws heavily on the Workforce Strategy, is an essential building block to help us realise our ambition to be a sustainable health organization, the preferred choice for employment on the Island and be an attractive proposition for health professionals on the mainland and from overseas. Our aim is to be in the top 20% of the best NHS employers and have the best possible reputation locally, and beyond. This strategy sets out the steps we are taking to create this environment and do everything we can to attract and retain staff in our local health service. Our priorities have been shaped by our staff and our recent experiences recruiting and retaining staff. Our priorities for 2018-20121 are: • Leading the Workforce – Our Culture and Leadership • Planning and Redesigning the Workforce • Working with our Partners • Attracting the Best • Retaining Staff • Engaging with Staff

Enc H

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Key Recommendation The Board is recommended to consider and approve the strategy as the direction for Recruitment and Retention 2018-2021.

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Recruitment and

Retention Strategy

2018-2021

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Foreword from the Chair and Chief Executive We are pleased to present the Recruitment and Retention Strategy for 2018 to 2021 for the Isle of Wight NHS Trust. The NHS faces huge workforce challenges with national shortages in most professions, many trained staff leaving the NHS prematurely and limitations on international recruitment. As a Trust providing services to an island population we are faced with some unique circumstances which offer both additional challenges and, at the same time, opportunities. To meet these challenges and seize opportunities we recognise that we must be ambitious in our efforts to create a reputation and an environment that encourages the very best people – people with right skills and values - to join and remain with the Trust. We have learned from past decisions, are determined to embrace the best NHS practice and above all create a compelling offer which attracts and retains those commitment to providing the very best health care to our local population. This Recruitment and Retention strategy has been shaped by our staff and reflects a shared ambition. We make no apology for placing well lead - culture and leadership at the top of our priorities. Staff must feel valued and supported and can only give their very best if we create the right environment for them to flourish. This strategy is aimed at promoting the Isle of Wight as a great place to work and live, securing the workforce we need to provide first class health care to our local population and achieving our commitment of ‘Getting to Good’. Vaughan Thomas – Chairman Maggie Oldham – Chief Executive

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1. Introduction The Trust employs a workforce of some 3200 staff (2700 full time equivalent) and spends £125 million a year on the workforce. Around 75% of the workforce are female, some 8% from black and ethnic minorities and some 40% over the age of 50. Our Workforce

This strategy, which draws heavily on the Workforce Strategy, is an essential building block to help us realise our ambition to be a sustainable health organisation, the preferred choice for employment on the Island and be an attractive proposition for health professionals on the mainland and from overseas. Our aim is to be in the top 20% of the best NHS employers and have the best possible reputation locally, and beyond. We want our staff have the right tools and support to flourish. This strategy sets out the steps we are taking to create this environment and do everything we can to attract and retain staff in our local health service. 2. Our Recruitment and Retention Priorities Our priorities have been shaped by our staff and our recent experiences recruiting and retaining staff. Each year NHS staff have the opportunity to give feedback to their employer on their experiences at work. The survey provides individual Trust feedback on over 30 key aspects of working life. The survey is conducted each Autumn and the results published in March. The results are an important pointer to organisational health and, for this strategy, will be key measures of success.

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The IOW NHS Trust results have highlighted significant problems which have a major impact on reputation and retention. This strategy alongside other initiatives aims to address the underlying causes and improve the experiences of staff. Our priorities for 2018-2021 are:

• Leading the Workforce – Our Culture and Leadership • Planning and Redesigning the Workforce • Working with our Partners • Attracting the Best • Retaining Staff • Engaging with Staff

3. The National Picture The Trust operates in a national system where pay, workforce planning and professional standards and regulation are determined by a variety of NHS bodies. The Trust will continue to operate within this national framework and support national and regional initiatives aimed at improving workforce supply. 4. Consultation and engagement with stakeholders We continue to work closely with our Trade Union representatives through our Social Partnership Forum and seek regular feedback from our staff through the annual staff survey and our quarterly pulse surveys. We have, as part of our culture and leadership initiative, also begun to hold workshops with our staff to better understand their needs and how we can improve the employment opportunities that the Isle of Wight NHS Trust has to offer. We have also talked to staff and collected their ideas about how we can improve working life and make the IOW an attractive career option for health professionals. Some 120 wide ranging ideas have been put forward and all the themes and many of the suggestions are reflected in this strategy.

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Leading the Workforce – Culture and Leadership What do we want to achieve? We want staff to be well led, valued and supported, to be proud to work with the Isle of Wight NHS Trust and recommend it to others as a place to work and live. Why is this important to us? The leadership, engagement and the working environment is crucial to attracting and retaining a motivated workforce and creating a reputation that attracts others to the Trust. How will we achieve this? • Through our culture and leadership improvement programme creating a working

environment where staff feel safe, supported and well led. • Ensuring our senior leaders are always accessible and responsive to staff at all levels. • Promoting good behaviours, setting standards and tackling poor performance head on. • Offering development and training for leaders and managers to equip them with the

skills and understanding to make our ambition a reality. • Ensuring there is a clear accountability framework, expectations are clear and staff are

held to account. • Working with staff advisors and staff representatives to give staff a voice. How will we know if we have succeeded? Improvements in key staff survey result in 2019 ↑Improvement in overall staff engagement. ↑Increase in the number of staff recommending the organisation as a place to work. ↑Percentage of staff appraised in the last 12 months. ↑Proportion of staff indicating they receive recognition and are valued by managers and the organisation. ↑Percentage of staff reporting good communication between senior management and staff.

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Planning and Redesigning the Workforce What do we want to achieve? We want effective annual workforce planning that provides the Trust and Health Education England the information needed to commission the training we need and, where appropriate, to explore the opportunity to introduce new roles reflecting the needs of our patients. Why is this important to us? Health Education England have responsibility for NHS workforce planning and for commissioning training. Ensuring the Trust and HEE have accurate data on our needs will assist with local and regional workforce supply and skills development. Recognising there are national shortages in many key areas we need to be creative about how we train staff and explore the opportunity for new roles to help enhance our local health professions. How will we achieve this? • Through our annual business planning processes establishing the skills and roles needed

to maintain and improve services. • Introducing new and enhanced roles, new approaches to training staff locally and

career pathways for bands 1 – 4. • Working closely with HEE to ensure our needs are understood and reflected in

commissioning intentions. • Introduction of new training routes and new roles such Registered Nurse Apprentices

and Nursing Associates. • Making better use of workforce data to improve reporting and planning. How will we know if we have succeeded? Production of timely workforce plans that reflect Trust staffing needs and financial resources. HEE training commissions reflecting Trust needs. Production of weekly and monthly workforce reports that supports informed Trust planning and investment decisions. Introduction of new and enhanced roles, new approaches to training and career development.

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Working with our Partners What do we want to achieve? We want effective collaboration with our health partners will help us maintain a stable regional workforce environment, train for the skills we need and learn from each other. Why is this important to us? We are increasingly working with our neighbouring Trusts in Hampshire. As an active partner with the Hampshire and Isle of Wight sustainability and transformation plan workforce collaboration programme we must attract, develop and retain staff within Hampshire & Isle of Wight area. How will we achieve this? • Being an active partner within the Hampshire and Isle of Wight health and social care

system and supporting the aspirations of the Sustainability and Transformation Plan. • With our health partners exploring ways to improve the recruitment, retention and

movement of staff in the Hampshire and Isle of Wight health and social care system. • Offer joint appointments with neighbouring Trusts to make IOW roles more attractive. How will we know if we have succeeded? Active and equal participation in the workforce STP Introducing joint initiatives with neighbouring NHS Trust and other health partners e.g. joint appointments, movement of staff between organisations and incentives to attract health professionals in to the area.

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Attracting the Best What do we want to achieve? We want to be the best employer. Our recruitment processes - from advertising roles to new staff starting their induction – must help us bring in staff as quickly as possible. We want new staff to feel welcome and supported. Why is this important to us? NHS employers operate in a fiercely competitive environment with most clinical professions facing national shortages. Promoting the island as a place to live and work and having efficient recruitment systems will ensure we secure quickly and avoid losing, those with the skills and values we need to provide services of a high quality. Supporting new staff will help them settle in to their new roles and show the Trust is a good long-term career option. How will we achieve this? • Investing in marketing the Trust as a great place to live and work and promote

jobs through profile-raising material, social media, recruitment events and campaigns.

• Investing in new technology and systems to ensure our recruitment processes are agile, safe and secure new staff in the shortest time.

• Appointing a nurse lead to work alongside HR and ward sisters to improve the coordination and management of nursing and medical vacancies respectively.

• Actively pursuing an international recruitment drive for 100 nurses in 2018. • Examining the case for financial incentives to attract new employees and help

ease their travel and living costs. How will we know if we have succeeded? High quality promotional material, highly visible presence at recruitment events and use of social media to connect with and recruit health professionals. ↑ Aspiring to match the best (shortest) NHS ‘time to hire’ performance. 100 international nurses joining the Trust in 2019. ↓ Reduction in the number of vacancies.

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Retaining Staff What do we want to achieve? We want to create a great place to work and reduce staff turnover. Why is this important to us? Retaining highly skilled, experienced and healthy workforce will enable us to provide high quality safe care. Losing staff creates gaps in services and new staff are costly to temporarily cover, recruit and train. We want to be recognised as an enlightened employer that meets the aspirations and needs of our diverse workforce, offers development and career opportunities for all and, for those with carer responsibilities, employment choices which allow them to balance work and domestic needs. We also want to promote a work/life balance that promotes health lifestyles, so our staff set an example for our wider community. How will we achieve this? • Ensuring all staff receive a comprehensive induction on the day they join the

Trust and receive additional support in their first few months. • Consulting staff on new workforce policies and practices that create a positive

and supportive working environment. • Supporting career aspirations through a personal development plan which

guarantees an annual appraisal and time off for training and development. • Providing facilities and support that promotes a healthy lifestyle and good health

and wellbeing. • Demonstrating Executive engagement with staff through weekly meetings, ‘back

to the floor’ initiatives and shadowing opportunities. How will we know if we have succeeded? All new staff attend induction on first day or employment and all staff have time off during the year for development and training. ↑All staff are appraised. New workforce policies reflecting the needs of staff and best practice. ↓ Reduction in turnover rates. ↓ Reduction in sickness absence rates. ↑Improvement in overall staff engagement. ↑Increase in the number of staff recommending the organisation as a place to work.

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Engaging With Staff What do we want to achieve? A workforce that feels valued, involved and recognised for the vital work that it does. Why is this important to us? Involving staff in our plans and decisions and communicating clearly with them will help improve staff morale, enhance our reputation as an employer and help us meet the needs of our community especially during periods of difficulty and change. How will we achieve this? • Through our Social Partnership Forum working closely with staff representatives

involving them in our plans and decisions. • Creating opportunities for staff to meet and talk to the Board and other senior leaders

and hear first-hand about and comment on our plans and decisions. • Ensuring staff are actively involved in plans when they affect them. • Recognising and rewarding staff for the work they do through our staff recognition

scheme. • Ensuring staff engagement is the responsibility of all leaders and managers – not just

HR. How will we know if we have succeeded? Improvements in key staff survey result in 2019 ↑ Improvement in overall staff engagement. ↑ Increase in the number of staff recommending the organisation as a place to work. ↑ Percentage of staff appraised in the last 12 months. ↑ Proportion of staff indicating they receive recognition and are valued by managers and the organisation. ↑ Percentage of staff reporting good communication between senior management and staff. ↑ Staff reporting they are able to contribute to improvements at work. ↓ Reduction in turnover rates in key areas. ↓ Reduction in sickness absence rates. ↑ Response rate and results to the quarterly Friends and Family Test for staff. Taking the temperature through observations, walk-arounds, peer reviews and ‘back to the floor’ by senior leaders.

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5. Our Temporary Workforce

The increase in vacancies and staffing establishments has resulted in a greater reliance on temporary workers. Temporary staff play a vital part in the provision of services to our community. Bank and agency workers have always been part of NHS life. Many have considerable years of experience in health care and help us, often at short notice, meet gaps in services or peaks in service demand. These workers are also subject to the same training and employment checks and whilst we aim to reduce our reliance on agency workers in favour of bank staff, they will, rightly, continue to be a key part of our workforce for the foreseeable future. Our bank workers can expect the same opportunities as our permeant staff. 6. Supporting Activities This document focusses on the key strategic priorities. These will be underpinned with a range of other tactical measures aimed at further improving recruitment and retention. We recognise we must do more to widen participation – attracting people from a range of economic, social and academic backgrounds and those from communities that are often hard to reach. We must promote apprenticeships and look at pathways to help staff move from bands 1 – 4 into professional training and roles. 7. Implementation and monitoring Executive and operational leads for the strategic intentions are set out in Table 1 below. The HR and OD Committee will be the Board Committee with responsibility for seeking assurance on the funding and delivery of the Recruitment and Retention Strategy. Following planned organisational change each service (Acute, Ambulance, Community and Mental Health) will have their own Boards to monitor their elements of the strategy. During Quarter 2 2018/19, baseline data and cost estimates will be obtained for each priority to enable the Board to allocate funding and agree milestones. The ultimate success of the Strategy will be demonstrated by:

• Being in the top 20% of Trusts in national staff survey results • Reduction in vacancies • Lower than NHS average turnover rate for staff • Lower than NHS average rate for sickness absence • Reductions in temporary workforce spend • Being rated as a minimum of ‘Good’ by the CQC

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TABLE 1 Leading the Workforce Priority Executive lead Operational lead Monitoring

committee Culture and Environment






Standards Director of HR and OD


Management development


Assistant Director of OD

Working with staff advisors and representatives



Planning and Redesigning the Workforce Business Planning Process




New roles Director of HR and OD


HEE Director of HR and OD


Workforce data and reporting



Working with our Partners STP Director of HR and

OD Deputy Director of HR


Joint Appointments Director of HR and OD

Deputy Director of HR Senior managers

Recruiting the Best Marketing and promotion




New technology/recruitment systems



Nurse lead Director of HR and OD

Deputy Director of Nursing

International recruitment

Director of Nursing Deputy Director of Nursing

Financial incentives Director of Finance Deputy Director of HR

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Retaining Staff Comprehensive induction




Workforce policy and Practice



Personal Development Plans



Health and Wellbeing Director of HR and OD

Deputy Director of HR Senior Managers



Engaging With Staff Staff side/Social Partnership Forum engagement




Board and senior leaders visibility and accessibility



Staff recognition Director of HR and OD


Version Draft for consultation

Page | 1

Agenda Item No 12 Meeting Trust Board in

Public Meeting Date

5 July 2018

Title Risk Management Strategy 2018-2021 Sponsoring Executive Director Suzanne Rostron, Director of Quality Governance Author(s) Suzanne Rostron, Director of Quality Governance Report previously considered by inc date

Assurance, Risk and Compliance Committee, June 2018 Operational Risk Sub-Committee, April 2018

Purpose of the report Information only Assurance Review and discuss Agreement Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective Responsive Caring Well-led X Safe Executive Summary Members of the Board will have been aware of the need for the Trust to take a fresh approach to risk management, both at Board and Committee levels and generally at all levels across all clinical and corporate services throughout the Trust. During the past few months a new Risk Management Policy has been developed and approved. This is now being used to instill and embed improvements to the approach to risks management consistently. In the meantime, a Risk Management Strategy has been developed, setting out the approach to the use of risk management tools and techniques for the Trust in order that risk management becomes a key vehicle for supporting the strategic and business planning of the Trust as well as a platform for supporting the operational management of each clinical service on a day to day basis. The Risk Management Strategy attached to this report has been considered through the Assurance, Risk and Compliance Committee and the Operational Risk Sub-Committee, with input from all divisions and corporate functions incorporated. Key Recommendation The Trust Board is asked to consider the following recommendations

To agree and approve the Risk Management Strategy.

Enc I

Risk Management Strategy

2018-2021

Contents

1. Purpose of the Document 2. Overview 3. Scope of the Strategy 4. Purpose and Vision 5. Risk Management Strategic Objectives 6. Risk Priorities 7. Responsibilities 8. Oversight of Risk 9. Implementation of the Risk Management Strategy 10. Monitoring the implementation of this Strategy 11. Associated Strategies, Policies and Procedures

1. Purpose of the Document This document sets out the strategic direction for risk management for the Isle of Wight NHS Trust for the next three years. It has been developed to comply with legal and statutory requirements, assist in compliance with national standards, promote proactive risk management and to improve the safety and quality of patient care.

2. Overview Risk Management is the process by which an organisation identifies risks, assesses their relative importance, determines the appropriate risk control mechanism and most importantly, ensures that the agreed action is taken. The Trust has a legal requirement to give assurance that risks in the organisation are identified and appropriately managed.

The Risk Management Strategy confirms the organisational framework for the management of risk within Isle of Wight NHS Trust. Management of risk is an integral part of the management process and is an iterative process of continual improvement. Risks at Isle of Wight NHS Trust are managed at two levels; strategic risks and operational risks. Strategic risks can be considered as: Those business risks that, if realised, would fundamentally affect the way in which the organisation exists or conducts its business. These risks may have a detrimental effect on the organisations Annual Business Plan and thus achievement of its key business objectives. This risk realisation could lead to material failure, loss or lost opportunity. Strategic risks are detailed in the Trust’s Board Assurance Framework (BAF) and mapped against the Trust’s strategic aims. Each of the Board Committees is responsible for managing the strategic risks aligned to them, with oversight at the Assurance Risk and Compliance Committee and ownership at Trust Board level. Operational risks can be considered as: The risks associated with the key business processes at specialty and clinical business unit level. The issues arising from these will be considered at specialty and clinical business unit level in the first instance, and then escalated to the Operational Risk Sub-Committee and the Assurance Risk and Compliance Committee if required, (i.e. if the risk is rated 15 or above or the Operational Risk Sub-Committee observe trends). This approach will ensure effective use of key business processes, streamlining information and risks towards the Trusts Strategic aims. All risks are categorised using the same matrix and framework. This can be found at Appendix 1. Further details and guidance are available within the Risk Management Policy. 3. Scope of the Strategy The Risk Management Strategy is applicable to all members of staff within the organisation, including members of the Trust Board, Clinical Directors, General Managers, all Medical Staff, all Nursing and Midwifery Staff, all Allied Health Professionals and all non-clinical staff.

The Strategy is also applicable to staff contracted to provide services to the Trust, both on and offsite. It applies to all honorary contract holders and to all workers of other organisations visiting the Trust sites in the course of their employment or studies.

4. Purpose and Vision Awareness of, and responsibility for, risk issues must be linked explicitly to key objectives in order to build a sustainable risk management culture. There must be delegated responsibility for risks at every level in the organisation. This is crucial to embedding risk management into the organisation and its culture, with risk management seen as an intrinsic part of the way the organisation works. The Trust is committed to the management of risk in order to: • Monitor continuously and seek to improve the quality of care provided in

partnership with patients, carers, staff and the public. • Provide a safe environment for the benefit of patients, staff and visitors by

reducing and, where possible, eliminating the risk of loss/harm. • Protect its assets and reputation. The Trust is committed to mitigating those risks within its control and preparing contingencies for risks beyond its control. As the Trust seeks to manage risks according to the appetite for those risks, it recognises the need to balance the costs and benefits of measures to reduce risk levels. In order to succeed, risk management must be embedded at all levels within the Trust. To this end, the following components are critical: • Clear and effective governance arrangements • Strong, respected and impactful leadership with accountability • Explicit strategic objectives • Appropriate resource allocation • Integrated planning arrangements • Effective stakeholder involvement • Education and training strategies • Recognising the value of innovation that all staff can contribute to the overall

management of risk • A system of risk identification, recording and action planning (Risk Register) • Learning lessons and changing practice both within the divisions / health groups

and organisation wide • Sharing lessons to learn with the wider health community • Promotion of a fair and open culture: The Trust supports a fair blame culture and

individuals are supported through any investigation and in learning and development afterwards. It is recognised that exceptional cases may arise where there is clear evidence of wilful or gross neglect, contravening the Trust’s policies and procedures and/or professional codes of conduct, or where there is repeated evidence of poor performance despite intervention/support. In these exceptional cases, the Trust will invoke its disciplinary policies

5. Risk Management Strategic Objectives This strategy aims to support the Trust in achieving its Strategic Objectives, which are:

Risk Management Strategic Objectives This Risk Management Strategy has been developed to support the delivery of the Isle of Wight NHS Trust’s Strategic Objectives. The Risk Management Strategy priorities are: • To ensure that risks that could prevent objectives being achieved are proactively

identified, quantified and managed to an acceptable level and in doing so provide a robust risk management framework with appropriate reporting arrangements and individual responsibilities clearly identified.

• For all strategic risks to be managed in line with the Trust Board’s risk appetite. • To improve organisational risk maturity, at all levels of the Trust.

6. Risk Priorities 6.1 To ensure that risks which could prevent objectives being achieved are identified proactively, quantified and managed to an acceptable level, and in doing so provide a robust risk management framework with appropriate reporting arrangements and individual responsibilities clearly identified. Current Position • Risks are not discussed in detail, via the risk register, at any level of the

organisation. • The risks that are relevant to services are not all recorded on the risk register. • Services have not historically had support with their risk registers; there is no

check and challenge of the content. • The quality of risk registers is variable across the organisation; some registers

are limited to Health and Safety risks and do not identify all residual risks to the service

• Risk descriptions do not always identify the condition, cause and consequence of the risk

• Inconsistency in risk ratings with risk ratings not always applied using the matrix in the Risk Management Policy

• Poor identification of controls and gaps in controls • Ineffective action plans with some risks being >3 years old and little challenge

applied at risk reviews • Target risk rating not always appropriate or achievable. Planned Position • All key risks should be identified, assessed and managed in accordance with the

Risk Management Policy • Risk descriptions should clearly articulate the condition, cause and consequence

of the risk • All risks, when entered onto the DATIX risk management system, should have

clearly detailed existing controls in place. • The action plan to achieve the ‘target risk’ for operational risks should be

uploaded to DATIX at the time of entering the risk • All high risks (≥15) should have a review date of no longer than 1 month from the

time of entry. • All moderate risks (8-14) should have a review date of no longer than 3 months. • All low risks (<8) should have a review date of no longer than 6 months. • The Board Assurance Framework should be monitored at every meeting of the

Assurance Risk and Compliance Committee and no less than 4 times per year by the Trust Board.

Key Milestones for 2018/19 • Develop a Risk Management intranet page with simple risk guidance for all staff

(June 2018) • Hold a training event for the Quality Managers (May 2018) • Quality Managers to work with the Clinical Business Units to review all existing

risks in line with the guidance (June to September 2018) • All Clinical Business Unit governance meetings to consider whether all key risks

are captured on their risk registers, including clinical, financial, operational and

staffing risks. This should be facilitated by sharing the strategic objectives and Board Assurance Framework (July to September 2018)

• Review dates for all high risks to be set for no longer than 1 month (June 2018) • Review dates for all moderate risks to be set for no longer than 3 months (June

2018) • Review dates for all low risks to be set for no longer than 6 months (June 2018) • Continue to deliver the Risk Management Workshop training • To review the Risk Management Strategy priorities and agree milestones for

2019/20 (February 2019) 6.2 For all strategic risks (Board Assurance Framework) to be managed in line with the Trust Board’s risk appetite. Current Position • Strategic objectives have risks to achievement identified • The Board members are familiar with the strategic risks and how these risks are

being managed • Systems and processes for management of the Board Assurance Framework are

in the early stages • Risk appetite not agreed or understood for each risk • Limited sources of assurance applied • Risk register not linked fully due to lack of confidence in risk registers • There is no simple overview to determine what actions have been taken and how

this has impacted on the risk ratings Planned Position • A comprehensive Board Assurance Framework that demonstrates the end of

financial year target position, how the Trust will reach it and progress throughout the year

• Board Committee management of assigned strategic risks • A minimum of 80% of strategic risks achieving the target risk rating at the end of

each financial year by the end of the Strategy • Board determined risk appetite for each strategic risk at the beginning of each

financial year • Summary reports presented to the Board and Board Committees that clearly

demonstrate the progression, or otherwise, of the risk • Sources of assurance that are regularly challenged by the Audit Committee Key Milestones for 2018/19 • Executive Director risk owners to agree process for reviewing their risks (April

2018) • Board approval of the Board Assurance Framework for 2018/19 (May 2018) • Risk appetite definitions to be agreed and applied to each strategic risk (May

2018) • All strategic risks to have a realistic target risk score (May 2018) • Actions for all strategic risks to be clearly articulated (June to August 2018) • Summary report for the Board Assurance Framework to be developed (June

2018) • Assurance workshop for Board members (June 2018)

• Approach for Audit Committee scrutiny of existing sources of assurance to be developed and agreed (August 2018)

• Review of Board Assurance Framework alongside the development of the Bi-annual Plan to determine the strategic risks for 2019/20 (February 2019)

• To review the Risk Management Strategy priorities and agree milestones for 2019/20 (February 2019)

• A minimum of 60% of target risk ratings to be achieved (March 2019) 6.3 To improve organisational risk maturity, at all levels of the Trust Current Position • No measure of risk maturity has been undertaken Planned Position • Annual risk maturity reviews undertaken demonstrating year on year

improvement Key Milestones for 2018/19 • Agree on a recognised tool for use within the Trust to measure risk maturity

(August 2018) • Undertake a baseline assessment at Trust-wide level to determine risk maturity

level (December 2018) • Based on the findings, agree the risk maturity level that the Trust will aim to

achieve by the end of this strategy (February 2019) • Develop the tool to be used to assess risk maturity at Clinical Business Unit level

(October 2018) • Agree a schedule for clinical business units risk maturity assessments for

2019/20 (January 2019) • To review the Risk Management Strategy priorities and agree milestones for

2019/20 (February 2019)

7. Responsibilities All staff have a responsibility for risk management, however, the following provides an overview of those with specific responsibilities in accordance with the Risk Management Policy. Chief Executive is responsible for: • reviewing the strategic objectives of the Trust with the Board • ensuring that the Trust has a Risk Management Policy in place and that it is

delivered Executive Directors are responsible for: • ensuring delivery of the strategic objectives • identification, control, monitoring and reporting of the risks which may threaten

achievement of strategic objectives • maintaining accurate and up to date risk registers, relevant to their objectives and

report through the Board Assurance Framework

Quality Governance Department is responsible for: • development and review of the Risk Management Policy • provision of education, support and expertise in relation to Risk Management • provision of education and training on the Risk Management Policy • provision of training of Datix Risk Management system • facilitating the reporting of appropriate risks to the Board, Committees and

Operational Risk Sub-Committee • facilitating the provision of a Board Assurance Framework to the Board and

Committees • monitoring and reporting compliance with the Risk Management Policy • facilitating the reporting of appropriate risks to specialist corporate groups Clinical Directors, Heads of Operations and Heads of Nursing and Quality (or equivalent for non-clinical business units) are responsible for: • leading and overseeing implementation of the Risk Management Policy at

business unit Level which includes the effective identification, control, monitoring and reporting of the risks which may threaten achievement of business unit objectives

• facilitating the reporting and where necessary, escalation of appropriate risks to the Operational Risk Sub-Committee from the business unit

• maintaining accurate and up to date risk registers, relevant to their business unit / service objectives

Quality Managers (or equivalent for non-clinical business units) are responsible for: • facilitating implementation of the Risk Management Policy at business unit Level

which includes the effective identification, control, monitoring and reporting of the risks which may threaten achievement of business unit objectives, in accordance with the procedure set out within this policy

• monitoring and reporting compliance with the Risk Management Policy at business unit level, as directed by the Quality Governance Department

‘Risk Owners’ including all Departmental / Ward / Service Managers are responsible for: • identification, control, monitoring and reporting of the risks which may threaten

achievement of business unit objectives, in accordance with the procedure set out within this policy

• maintaining accurate and up to date risk registers, relevant to business unit objectives

Chairs of Specialist Sub-Committees (e.g. Information Governance Sub-Committee) are responsible for: • identification, management and oversight of risks relevant to their specialist

subject, ensuring appropriate action is taken • reporting to the relevant Committee • reporting, where appropriate, to the Operational Risk Sub-Committee Chairs of Specialist Groups (e.g. Infection Prevention Control Group) are responsible for: • identification, management and oversight of risks relevant to their specialist

subject, ensuring appropriate action is taken • reporting to the relevant Sub-Committee

8. Oversight of Risk Risks are overseen at various levels throughout the Trust. The table below sets out the levels at which risks must be reported and overseen:

Level of Escalation / Oversight

Level / Types of Risk

Role and Purpose of Oversight

Style of Report

CO

RPO

RA

TE O

VER

SIG

HT

Board Risks identified against Strategic Objectives

• Scrutiny of the risks identified and holding responsible persons to account for the action being taken.

• Assurance from the Audit Committee that the process is working effectively

Board Assurance Framework (BAF)

Assurance, Risk and Compliance Committee / Performance Committee / Quality Committee

Risks identified against Strategic Objectives – relevant to their area of focus

Scrutiny of the risks identified and holding responsible persons to account for the action being taken.


Audit Committee

Risks identified against Strategic Objectives

Assurance from the Assurance, Risk and Compliance Committee, Quality Committee and Performance Committee that the process is working effectively


Performance Management Reviews

• Top Business Unit Risks

• New risks • Risks

increases • Risks for

escalation

Scrutiny of the risks identified and holding responsible persons to account for the action being taken.

Business Unit Performance Management Review Presentation

Trust Leadership Committee

A summary of risks considered by the Operational Risk Sub-Committee

Assurance that the Operational Risk Sub-Committee is fulfilling its Terms of Reference.

Output Summary Report from Operational Risk Sub-Committee

Operational Risk Sub-Committee

All risks scoring 12 or above from Business

• Scrutiny, challenge of risks scoring 12 or above.

Risk Oversight Report (taken from Risk

Unit Risk Registers

• Referral to and assurance from key specialist corporate groups as appropriate.

Registers)

Specialist Groups

All ‘corporate’ risks relevant to their area of specialism.

Identification, management and oversight of risks relevant to their specialist subject, ensuring appropriate action is taken.

Corporate Risk Register

DIV

ISIO

NA

L O

VER

SIG

HT

Business Unit Boards

All risks scoring 8 or above

• Challenge, review and monitoring of all risks scoring 8 or above.

• Escalation of risks to Operational Risk Sub-Committee.

Risk Register

Business Unit Governance Group

All risks

• Scrutiny, challenge, review and monitoring of all Divisional risks

• Escalation of risks to Business Unit Board

Risk Register

Operational Groups All relevant risks

• Scrutiny, challenge, review and monitoring of all Operational risks

Risk Register

9. Implementation of the Risk Management Strategy The implementation of this strategy will be achieved through:

• The identification of all significant risks to the achievement of the annual plan. Mitigating action will also be identified and an action plan recorded;

• The recording and on-going review of those risks and associated action plans on the Trust’s risk register to ensure they are managed and appropriate • Continuous development and review of governance arrangements and efficacy in

all Clinical Business Units and corporate directorates within the Trust; • On-going assessment of risk using a common methodology in all Clinical

Business Units and corporate directorates to identify, control and minimise risks; • The regular review of all identified and recorded risks to ensure they are

managed and valid; • Providing a comprehensive programme of risk management training and support

to senior managers to enable them to manage risk as part of normal line management responsibilities;

• Providing risk management awareness sessions and various training packages to ensure all staff are aware of their responsibilities for risk management systems and processes;

• Using Root Cause Analysis tools to undertake investigations, identify contributory factors and root causes;

• Ensuring that systems are in place to allow organisational learning from both individual incidents, risk, complaints, PALS and claims and trends from aggregated data for any of these sources;

• Improving performance against the Information Governance Toolkit • Continuing to implement the recommendations from Central Alerts Safety

Broadcasting System; • Ensuring that lessons learned from all of the above are shared and disseminated

Trust-wide to promote organisational development.

10. Monitoring the Implementation of this Strategy The outcomes below will demonstrate achievement of this strategy, and as such will be monitored during the implementation of this strategy: • The Trust’s progress against its strategic objectives; • A Well-Led rating of ‘good’ from the CQC by 2020; • Assurance from internal and external audit reports that the Trust’s risk

management systems are being implemented. • Improved risk maturity rating at all levels of the organisation (from 2019/20) The monitoring of compliance with this strategy will be undertaken through: • A quarterly risk management report to the Operational Risk Sub-Committee – this

will include monitoring the effective management of risks within the directorates and escalation processes;

• A six monthly Risk Management Strategy Indicator report to the Assurance Risk and Compliance Committee

• Areas for improvement identified within the above report will be monitored by the Assurance, Risk and Compliance Committee in the first instance via its action tracking list and escalated to the Trust Board if required

11. Associated Strategies, Policies and Procedures

• Risk Management Policy • Incident Management Policy • Health & Safety Policy

Appendix 1: Risk Matrix and Framework The use of the following tables is fully explained within the Risk Management Policy.

Impact Domains

Impact Score and Examples of Descriptions 1 2 3 4 5

Negligible Minor Moderate Major Catastrophic Impact on the safety of patients, staff or public (physical / psychological harm)

Minimal injury requiring no/minimal intervention or treatment.

No time off work

Minor injury or illness, requiring minor intervention

Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention

Requiring time off work for 4-14 days

Increase in length of hospital stay by 4-15 days

RIDDOR/agency reportable incident

An event which impacts on a small number of patients

Major injury leading to long-term incapacity/disability

Requiring time off work for >14 days

Increase in length of hospital stay by >15 days

Mismanagement of patient care with long-term effects

Incident leading to death

Multiple permanent injuries or irreversible health effects

An event which impacts on a large number of patients

Quality / Equality / Complaints / Audit

Peripheral element of treatment or service suboptimal

Informal complaint/inquiry

Overall treatment or service suboptimal

Formal complaint (stage 1)

Local resolution

Single failure to meet internal standards

Minor implications for patient safety if unresolved

Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness

Formal complaint (stage 2) complaint

Local resolution (with potential to go to independent review)

Repeated failure to meet internal standards

Major patient safety implications if findings are not acted on

Non-compliance with national standards with significant risk to patients if unresolved

Multiple complaints/ independent review

Low performance rating

Critical report

Totally unacceptable level or quality of treatment/service

Gross failure of patient safety if findings not acted on

Inquest/ombudsman inquiry

Gross failure to meet national standards

Human Resources / Organisational Development / Staffing / Competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective/ service due to lack of staff

Unsafe staffing level or competence (>1 day)

Low staff morale

Poor staff attendance for mandatory/key training

Uncertain delivery of key objective/service due to lack of staff

Unsafe staffing level or competence (>5 days)

Loss of key staff

Very low staff morale

No staff attending mandatory/ key training

Non-delivery of key objective/service due to lack of staff

Ongoing unsafe staffing levels or competence

Loss of several key staff

No staff attending mandatory training /key training on an ongoing basis

Statutory Duty / Inspections

No or minimal impact or breech of guidance/ statutory duty

Breech of statutory legislation

Reduced performance rating if unresolved

Single breech in statutory duty

Challenging external recommendations/ improvement notice

Enforcement action

Multiple breeches in statutory duty

Improvement notices

Low performance rating

Critical report

Multiple breeches in statutory duty

Prosecution

Complete systems change required

Zero performance rating

Severely critical report

Adverse Publicity / Reputation

Rumours

Potential for public concern

Local media coverage – short-term reduction in public confidence

Elements of public expectation not being met

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House)

Total loss of public confidence

Business Objectives / Projects

Insignificant cost increase/ schedule slippage

<5 per cent over project budget

Schedule slippage

5–10 per cent over project budget

Schedule slippage

Non-compliance with national 10–25 per cent over project budget

Schedule slippage

Key objectives not met

Incident leading >25 per cent over project budget

Schedule slippage

Key objectives not met

Finance including Claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget

Claim less than £10,000

Loss of 0.25–0.5 per cent of budget

Claim(s) between £10,000 and £100,000

Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget

Claim(s) between £100,000 and £1 million

Purchasers failing to pay on time

Non-delivery of key objective/ Loss of >1 per cent of budget

Failure to meet specification/ slippage

Loss of contract / payment by results

Claim(s) >£1 million

Service / Business

Loss/interruption of >1 hour

Minimal or no impact

Loss/interruption of >8 hours

Minor impact on

Loss/interruption of >1 day

Moderate impact on environment

Loss/interruption of >1 week

Major impact on

Permanent loss of service or facility

Catastrophic impact on

Interruption / Environmental Impact

on the environment

No impact on other services

environment

Impact on other services within the Division

Impact on services within other Divisions

environment

Impact on all Divisions

environment

Impact on services external to the Trust

Information Security / Data Protection

Potential breach of confidentiality with less than 5 people affected

Encrypted files

Serious potential breach of confidentiality with 6 – 20 people affected Unencrypted clinical records lost

Serious breach of confidentiality with 21 – 100 people affected

Inadequately protected PCs, laptops and remote device

Serious breach of confidentiality with 101 – 1000 people affected

Particularly sensitive details (i.e. sexual health)

Serious breach of confidentiality with over 1001 people affected

Potential for ID theft

Impact Score

1 2 3 4 5

Like

lihoo

d Sc

ore

1 1 2 3 4 5 2 2 4 6 8 10 3 3 6 9 12 15 4 4 8 12 16 20 5 5 10 15 20 25

Risk Score

1 – 3 Low 4 – 6 Moderate

8 – 12 High 15 – 25 Extreme

Page | 1


Date 05 July 2018

Title Local Care Plan Report – May 2018 Sponsoring Executive Director

Darren Cattell – Director of Finance, Estates and IM&T

Author(s) Nicola Longson – Programme Director, Isle of Wight Local Care System Rachael Knight – Programme Governance Manager


Operational Delivery Group – 23 May 2018 Local Care Board – 14 June 2018 Trust Leadership Group – 20 June 2018

Purpose of the report Information only X Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight x Link to CQC Domains Effective Responsive Caring Well-led Safe Executive Summary

The Local Care Plan Programme Summary Report provides an overview of key progress and risks/issues against the six initiatives within the Local Care Plan.

The overall Programme status is currently RED, indicating that key milestones are behind schedule and there are significant issues to delivering agreed outcomes. The Black/Red/Amber/Green rating of each initiative is broken down on page 2. Further development of programme reporting is underway to ensure delivery of impact is reported alongside delivery of key milestones.

The key messages from Local Care Board meeting on 10 May 2018 are detailed as Appendix A. Key Recommendation The Trust Board is asked to consider the following recommendations:

• To receive the update on the Local Care Plan Programme and to receive limited assurance on the status of the Programme.

Enc J

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Headline Status (delivery of key milestones) Red RAG status criteria

LCP Initiative Milestone RAG Impact Update Headline Issues

Acute Service Redesign Amber Currently N/A

Business Intelligence role urgently required to analyse McKinsey’s data. Until this activity data is ready the Solent Acute Alliance will not go forward with these projects. September 2018 milestones relating to signed off project documentation will not be achieved unless issue resolved.

Co-ordinated Access Red Tier 3 KPI’s drafted, awaiting sign-off by Task & Finish Group for inclusion in quad next report

Milestones for Enhanced Hub project are falling behind schedule – there is a lack of engagement/attendance at project huddles by key members of project team, resulting in a lack of assurance that tasks are being completed.

ODG ACTION 183: Discussed issues around non-attendance of Co-ordinated Access meetings/huddles by IWC staff. NT to forward to CT details of all meetings where IWC staff are expected to attend. CT will then follow this up with staff involved to improve attendance levels.

Community Service Redesign Red

Tier 3 KPI’s in development, awaiting sign-off by Task & Finish Group for inclusion in next quad report

Programme experiencing significant delays in meeting milestone deadlines. Mitigating actions are in place, such as development and implementation of 30/60/90 day plans to stabilise the Integrated Localities at pace, which include revised deadlines. Change request reflecting revised plans to come to next ODG meeting.

B Multiple key milestones are significantly behind schedule. Sponsor identified significant risk to outcomes being achieved

R Key milestones behind schedule (30+ days) /significant issues to delivering agreed outcomes A Key milestones within 30 days of schedule/ work underway to address delays

G Key milestones completed/project on schedule

Page | 3

Hospital to Home Red

• Delay data now available, data quality improvements ongoing

• Discharges before midday – not consistently hitting target of 33%

• LOS + 21 days (superstranded) is steadily reducing

• LOS <21 days still unstable

Continued implementation of the SAFER Bundle, Trusted Assessors, Patient Pathways implementation & Discharge to Assess Pathways has not been achievable within the Hospital to Home delivery dates and it is now proposed to be incorporated into the Trust’s Unplanned Flow CIP programme.

Mental Health Transformation Amber

Tier 3 KPI’s identified in quad report, awaiting agreement with staff and service users

Challenge to previously agreed business cases (Shackleton & Woodlands) by external adviser (NHSI) requires pause and review prior to implementation – potential change in direction is impacting delivery of milestones.

Transforming Learning Disabilities Care

Amber Tier 3 KPI’s identified in quad report, awaiting sign off by Task & Finish Group

Delay in decision on how to manage Bluebell Meadow and deregistration is impacting milestones for independent/supported living. IW Council to update project team on date they will receive legal advice/make decision. Tenants to continue to be identified.

Key progress in reporting period ! Risks/issues for escalation

Acute Service Redesign: • ASR Steering Group, 10th April 2018 – Confirmed bid for STP funding

for the ASR resource required to deliver the programme and ENT review.

• SAA/IW PMO Workshop 12th April 2018 – Agreed ownership and planned out the next steps within each workstream.

• ASR Communications meeting, 11th April 2018 – Agreed work plan for the remaining time of Robertson Foster external communication consultants.

• SAA Medical Directors meeting, 16th April 2018 – Agreed funding and resourcing for the future reconfiguration plans for ASR

• Communications meeting with CCG & IW Council, 16th April 2018 –

Acute Service Redesign: • RISK: The current clinical lead for programme – The ASR Clinical Lead not

appointed as Medical Director, therefore new Medical Director will take on the leadership of ASR; this could potentially slow down process whilst new MD develops knowledge, understanding and relationships across the System in regards to staff and public engagement. Mitigation – existing Clinical Lead working on ASR until June 2018. No other commitments have been made past this point.

• ISSUE: Media handling and communications –A more sustainable approach and capacity for handling of the overall staff and public communications and engagement plan from 1st March is urgently required. Current external communications consultant only extended until June 2018. ODG ACTION:

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IW Council Communications Lead to draft paper for LCB looking at capacity and resource across IWC, IW Trust & IW CCG.

• Health & Wellbeing Board ASR update, 26th April 2018 – Update provided by John Metcalfe regarding patient travel improvement task & finish group.

Co-ordinated Access:

• Implementation of New Integrated Urgent Care Pathway - Lead IUC pharmacist identified and linked to project, progress has been hindered by pharmacy staffing issues

• Redesigned Urgent Care Floor - Estate works progressing, due to be completed in mid-May. Director of Clinical Improvement has initiated an operational group for ambulatory and emergency care and service is expected to go live mid-May. Community Service Re-design: Co-ordinated Care Management

• Medium term accommodation for West and Central core staff identified – Parklands in Cowes.

• Working arrangements with Earl Mountbatten Hospice agreed as part of case review meetings

• Further TEC rollout in the community – 15 homes in total now • Integrated Locality leadership identified and workforce identified

(Circ. 121 staff members) • All Localities Leadership Group set up, 3 x Localities Huddles set up • 30/60/90 day milestones identified to stabilise localities at pace

New care model commissioning arrangements • Alliance Heads of Agreement signed

Hospital from Home:

• The Roadshow on 19/04/18 was a great success. Over 170 people attended the event and we received very good feedback from both the people who attended and exhibitors.

Escalated to ODG to ensure prioritised and issue properly mitigated and escalated to LCB if required.

• ISSUE: Digital Maturity project needs to progress at a quicker pace to enable the IT changes that will be identified in clinical pathways as part of the Workforce & Resilience 14 workstreams. Mitigation - Digital (IT) group have been asked to prioritise in line with the workstream project timelines.

• ISSUE: Resourcing – There is a need for a Business Intelligence role to analyse McKinsey’s data and map the activity figures to the number of transfers for Emergency & Elective Surgery & Urology. Until this activity data is ready the SAA will not go forward with these projects. A resource funding paper has been written to ask for STP resource, shared with the SAA. ODG ACTION: Escalated to ODG to ensure prioritised and issue properly mitigated and escalated to LCB if required.

Co-ordinated Access:

• RISK: Potential duplication of project activity in internal Trust flow programme - Elements of the urgent care floor project are also included under the remit of the Unplanned Flow programme which could result in an uncoordinated activity and duplication of effort. Mitigation - Project Manager and Exec Sponsor are working with flow project lead to agree governance arrangements.

• RISK: 111 software system update - delay to update is impacting on GP appointment booking pilot. Mitigation - initial preparation work by Trust 111 Service Support Officer and Tower House surgery to be completed so that pilot can go ahead as soon as updated.

• RISK: Integration dependant on telephony interoperability - Organisations have highlighted full integration of telephone systems needed to be able to work together to make the enhanced Hub viable. Mitigation - Operational Project Support Officer working with organisational IT teams to identify detailed requirements. Formal escalation to Digital Group may be required if solution not in place by next month.

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• Patient Navigation Team has reverted back to 5 days a week rota post PDSA cycle of 7 day working. This is to improve support at peak demands of the service.

• ECIP PDSA & SAFER staff training held on 11/04/18, beneficial to all attendees. Actions & recommendations will be taken forward as part of the newly formed SAFER Action Group.

• Review to action Project close down evaluation reports carried out on 13/04/18. Evaluation reports to be complete and distributed within the first 2 weeks of May 18. Relevant projects to be closed: • Patient Navigation Team • SHREWD System • Discharge Pathways • Patient Admission

• Any next steps for these projects, along with development of the SAFER Bundle, Patient Pathways & D2A Pathways are proposed to be incorporated into the developing Unplanned Flow CIP programme.

Mental Health Transformation:

• Claire Murdoch, National Director for Mental Health for NHSE met with the MH Steering Group to discuss progress with the plans.

• Creating a New Vision for Improved Mental Health - MH Blueprint wider stakeholder engagement ongoing – visits to GP Practice and Locality meetings, Parish Council leads and Service user forums. Feedback also sought at all transformation workshops with staff, partners, people who use the services and carers.

• Development of model to meet intensity of needs of people using services -Mood and Anxiety pathways workshops held on the 30th April

• Transforming Needs-led Community Provision & Strengthening Individual and Community Support - Gap analysis commenced following the outcome from the Community Mental Health Services (CMHS) workshop; Review completed of Mental Health day provision, employment support and self-help (as one element)

Community Service Re-design:

• RISK: GP Data Sharing – the Population Health Management/Risk Stratification

tool (IPA) is available for the CCG/Localities to use. If GP practices do not sign the Data Sharing Agreement to share data to populate the tool, this will impact the population health profile required for CSR Modelling, population health management through the Alliance contract, and for operational care planning, management and delivery within Localities. ODG ACTION: ODG to identify lead to engage with Primary Care on putting Data Sharing Agreement in place.

• ISSUE: Limited communications resource to support with CSR communications - risking engagement and understanding within communities and across staff groups. Resources allocated through IOW NHS Trust are not sufficient for the communication requirements of the programme (capacity). ODG ACTION: Requesting further escalation from ODG to LCB to ensure prioritised and issue properly mitigated.

Hospital to Home:

• No risks or issues identified for escalation to Operational Delivery Group.

ODG ACTION 184: NL to share CSR T&F Group process for identifying which issues/risks to escalate to ODG via quad report.

ODG ACTION 185: FS queried whether internal comms to ILS teams can be done by managers rather than seeking additional communications resource. Group agreed the challenge whilst recognising communication support is required for development of toolkit to support wider communications than staff groups. NL to feedback to CSR T&F Group. 04/06/18 - NL – Fed back to group and work continuing on communications.

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• Transforming Needs Led Acute Provision - Workshop held on 16th April for Single Point of Access, Crisis and Serenity to begin to determine future position within the new framework

• Transforming Dementia and Older Persons Mental Health - Older Person’s Mental Health and Dementia workshop held

• Reprovision of Rehabilitation and Reablement Services - Scoping opportunity underway for step-down independent support living unit to support the independent living model

Transforming Learning Disabilities:

• Co-produce Commissioning Strategy - Launch event for Commissioning Strategy held on the 30th April, to launch action plan and strategy. Over 200 people attended including service providers, family and carers and people with a learning disability; First Execs meeting held with the Learning Disability Partnership Group. This will be a regular 6 monthly meeting.

• Develop a diverse and quality assured market place - 18 people have registered interest in becoming Shared Lives Carers.

• Move from Residential or Hospital Provision to Supported and Independent Living - Carisbrooke House remains on track for handover on the 27th July.

Mental Health Transformation: • ISSUE: Challenge to previously agreed business cases (Shackleton & Woodlands)

by external adviser (NHSI) requires pause and review prior to implementation – potential change in direction is impacting delivery of milestones. Mitigation - meetings to be held with the CCG and new MH Director as soon as post holder in place and has had chance to review existing business cases

• ISSUE: Focus on short-term solutions to address CQC and other demands are prioritised over long-term transformational work - delaying delivery of LCP Mental Health transformation milestones. Mitigation - Resources managed through Trust MH Senior Leadership Team.

ODG ACTION 186: Group discussed the issue of short-term solutions to address CQC demands prioritised over transformational work. CT queried if outputs from CQC work are leading to any changes within scope of transformation work? GB to liaise with Suzanne Rostron - any changes to timelines as result of the CQC priorities to be presented as change requests to ODG. • ISSUE: Lack of continuity within the Trust Leadership – impacting delivery of LCP

Mental Health transformation and lack of senior support to address issues/barriers to delivery. Mitigation - Weekly meetings between MH Senior leadership team and Trust Executive colleagues.

Transforming Learning Disabilities:

• ISSUE: Delay in decision on how to manage Bluebell Meadow and deregistration is impacting milestones for independent/supported living. Mitigation - Senior level in the council need to update project team on date they will receive legal advice and make decision. Tenants to continue to be identified.

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LCP Enablers Headline Issues

Finance

• RISK: ASR assurance is currently set for October. There is a significant amount of work which will need to take place if this can be met. The system needs to consider whether the timescale is achievable.

• RISK: The progression of CSR modelling in a timeframe to demonstrate that it supports ASR is challenging. We need to keep the scope and scale tight initially in order to start to develop a model.

• ISSUE: Logic modelling has demonstrated that the Local Care Plans don’t currently have quantifiable outcomes to evidence why we are pursuing them. We need to discuss how we resolve this and drive this forward

• RISK: The development of a Systemwide FRP and justification for an Island premium will be resource intensive and require significant shared and open-book working.

• ISSUE: There is no further central funding for initiatives. The system needs to consider how further resource requests will be funded.

ODG ACTION 187: DC to confirm if issues identified within report are for escalation or matters the Finance Group are looking to address. If issues are to be escalated, identification of mitigation already in place needs to be documented.

Workforce

• RISK: Leadership capacity to support system wide work. Mitigation: To be discussed at next system workforce group. ODG ACTION 188: JP relayed that capacity issues identified relate to 'do'ers' as opposed to leadership. CT identified resource within Integrated Commissioning team to link in with Workforce Group. JS to advise JP of contact details of team member representative of independent sector. • RISK: Support with workforce planning and modelling Local Care Plan initiatives. Mitigation: STP to support with workforce planning and

modelling Local Care Plan. • RISK: System workforce delivery plan in place. Mitigation: Workshop held inviting local care plan initiatives for members of the system

workforce group to gain clarity around the requirements of each initiative in order to develop plans.

Estates

• RISK: PE programme may not meet the short/medium term requirements of the LCP programmes – mitigated through revised TOR and meeting format from March 2018

• RISK: OPE Project interdependencies, particularly Fire Service review in relation to Pyle Street development • RISK: Ability to identify further funding to develop Pyle Street to SOC and OBC • RISK: Blue-light hub and South Wight hub projects now progressing well but are at risk of further delays due to lack of partner

engagement/feedback on service requirements to inform feasibility/options appraisal work.

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Quality

• ISSUE: System capacity and demands on members is impacting the ability to meet regularly as a group. Mitigation: ODG approved proposal to combine Quality Group functions with those of existing CCG Quality and Patient Safety Committee (QPSC). This proposal has since been approved by the Trust Quality Committee so is now having terms of reference developed in readiness for the inaugural meeting in July 2018.

Digital

• System direction of travel for Technology Enabled Care (TEC) required following Joint Seminar in April 2018. ODG ACTION: ODG to discuss and agree next step.

• ISSUE: Organisation / system capacity to deliver programme including Digital Maturity project • ISSUE: Funding for development and implementation not yet identified • RISK: Integration of systems which need to be ‘fixed first’ • RISK: Impact of capital / revenue funding models to be reviewed and assessed • RISK: Process for joint review of LCP / system wide PIAs not yet agreed / operational –IG leads currently to review only those projects

where their own organisation is directly involved

Communication & Engagement No update received

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APPENDIX A Key messages from Local Care Board 10 May 2018:

1. The group reviewed the core principles of working together as an Integrated Care System, acknowledging some of the issues that sovereignty can bring when all organisations have their own governance arrangements to navigate in addition to system-wide structures. A number of examples where decisions taken by the Board were not fully implemented across the system were discussed. It was agreed that the formation of a Risk & Issues Log would provide the mechanism to address such issues going forward and ensure all decisions are implemented/barriers overcome.

2. LCB continued to focus on the development of ‘Place Based Care’ and the associated

timetable for the future commissioning arrangements for the Island. Gillian Baker will now lead a dedicated working group with representation from Public Health, NHS Trust, Primary Care, Housing sector, Voluntary sector and the Community Safety Partnership, initially to determine which activities and responsibilities should be undertaken on Island or jointly with mainland partners.

3. The group agreed the final allocations for 2018/19 funding to support the

transformational Local Care Plan with additional funding made available to the Enabling Groups, specifically Workforce and Business Intelligence.

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5 July 2018

Title Quality Report Sponsoring Executive Director

Barbara Stuttle CBE, Interim Director of Nursing Suzanne Rostron, Director of Quality Governance Alistair Flowerdew Medical Director

Author(s) Suzanne Rostron, Director of Quality Governance Quality Governance Team PIDS team


This paper has not been considered at any other Committee but provides highlights from reports received at the Quality Committee and its Sub-Committees.

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary Key areas of activity to note this month include: • Quality Strategy Indicator Dashboard is now in place. • There is an increase (16 on last month) Serious Incidents • To date Q1 there have been a total of 34 inquests involving the Trust • The National Inpatient Survey published on the 18 June 2018 shows we are on a par with

other acute Trusts. • Quality Summit held 27 June 2018 • Ten week ‘Safe’ programmes commenced in 3 areas Key Recommendation The Committee is asked to consider the following recommendations:

• Decide if sufficient assurance has been received in relation to the issues raised in the Quality Report

Enc K

1 Trust Board Quality report July 2018 V2

Quality Report

Trust Board July 2018

1. Purpose of the paper

To inform the Board of any quality improvements, concerns or risks and advise of actions being taken.

2. Background

The ‘Quality Report’ has started evolving to reflect the appropriate amount of information at each level of the Quality Committee structure. The Sub-Committees receive more detailed information and interrogate thematic and trend analysis. The extent of this will improve as the process is embedded.

The Quality Committee receives escalation and assurance reports and will investigate issues to seek assurance on behalf of the Trust Board. This report provides an overview of key issues or achievements and seeks approval when necessary.

3. Quality Report

The reporting mechanisms have now been established for both the Quality Strategy Dashboard and Quality Dashboard. These are enclosed at Appendix 1 and were included on the Quality Committee Agenda. A verbal update can be provided on this discussion and assurances received.

A number of areas where targets are yet to be set, due to requiring baseline data were discussed along with the areas where indicators are yet to be added. These include the risk management indicators, which will be taken from the Strategy submitted for approval today and the clear link with the CQC regulatory requirements outlined in the report last month to the Assurance Risk and Compliance Committee. Now that the programme has been set, all new Quality Strategy Indicators at Divisional level can be added and reported to the Divisional Quality Committees.

The exception reports that are included in the Quality Strategy Dashboard elements are also available for the Quality Dashboard. These will be discussed at the Quality Committee with any matters agreed for escalation presented to the Trust Board.

Duty of Candour is one of the early concerns from this data. The way that this information is captured has been changed, which now provides a much more accurate picture of the evidence available to support compliance. Compliance, in terms of understanding and awareness, was not raised by the CQC in its inspection findings as a concern. However, we are committed to ensuring that Duty of Candour is applied fully for all cases where we cause harm to patients (rated moderate or above).


4. Serious Incidents

4.1 New incidents reported 18 serious incidents were declared to the Isle of Wight Clinical Commissioning Group (CCG) during May 2018.

In June, up to 18 June 2018, 13 incidents had been declared.

A detailed summary of the incidents reported and immediate actions taken is included in the private board papers. The final number of incidents each month is subject to change due to the change in our policy of declaring serious incidents at the earliest opportunity and requesting de-escalation should the investigation indicate this is appropriate.

4.2 Immediate actions taken The 18 incidents reported in May all had an initial review via 72-hour report; immediate actions were identified to mitigate risk. These included:

Integrated working with mainland hospital

Formal conduct process managed via Medical Director

Reminder re WHO checklist

Reminder to staff re correct procedure for checking tube position

Deteriorating patient ward based competency pack issued

With immediate effect, handover to wards must be given by nurse providing the care, not the co-ordinator

All patients must receive a set of observations prior to transfer, will be audited by Head of Nursing & Quality and Matron

All patients admitted to Appley ward with History of substance misuse to have their medications stored in the Omnicell

Consultant and team reminded of importance of doctor-to-doctor handover when there is concern about a patient on transfer

Concerns over getting timely advice from tertiary centres escalated to medical director

New workshop have been organised to implement a dual diagnosis pathway

Service contracts checked for theatre equipment

Departmental Diabetic guideline to be reviewed - Guidelines for management of Type 1 diabetic patients that are not receiving steroids or are Nil by mouth need to be clearer to staff.


4.3 New incidents reported in June (up to 18.06.18)

Division Clinical Business Unit Number

reported SI type/subject

Acute Surgery, Women's & Children's Health

1 • Grade 3 pressure ulcer (Whippingham ward)

Medicine 3 • Safeguarding adult (Appley) • Interpretation of results (General

Medicine) • Medication issue (Gastroenterology)

Clinical Support, Cancer &

Diagnostics 2 • Issues with epidural (Anaesthetics)

• Delay in procedure (Theatres) Ambulance, Urgent Care &

Community 3 • Care of deteriorating patient (Emergency

Dept) • Care of deteriorating patient (MAU) • Unexpected death (Emergency Dept)

Community Ambulance, Urgent Care & Community

2 • Grade 4 pressure ulcer (D/Nursing) • Patient fall (community rehab)

Mental Health Mental Health & Learning Disabilities

2 • Delay in medication (Chantry House) • Self-harm, near miss (Osborne ward)

4.4 Ongoing Serious Incident Management

Of the 14 cases submitted to the IW CCG for closure in May, 36% were submitted ‘in-time’, which is a drop on last month. For year 2018/19 so far, the following is a list, by clinical business unit, of those cases that were submitted for closure in-time, out of time or subsequently downgrade requested by the Trust following submission of evidence that they no longer meet with SI framework criteria for reporting.

CLINICAL BUSINESS UNIT Number out of time Number in-time Numbers downgraded (of totals

on left) Surgery, Women's, Children's

5 2 3

Medicine 5 2 3 Clinical, Cancer & Diagnostics

4 4 3

Ambulance, Urgent Care, Community

7 8 6

Mental Health & Learning Disabilities

3 1 0


4.3 Serious Incident Performance Key Performance Indicators (KPI) against the SI process; chart below demonstrates the KPI status across all CBUs, and June is subject to adjustment.

The stats below demonstrate the KPI of reporting an SI within 2 working days, by area

The stats below demonstrate the KPI of completing a 72-hour report within 3 working days, by area

As of 18 June 2018, there are a total of 96 current cases being managed through the SI process; 40 are overdue for submission to the CCG. Of those overdue, 1 was subject to non-closure by the CCG and further information was requested. Those overdue cases are listed below, by clinical business unit.

Criteria being measured May-18 Jun-18New SIs reported in month 18 14SI reported in 2 working days (of awareness) 13 7% in 2 working days 72% 50%72-hour report completed in 3 working days 12 5% in 3 working days 67% 36%How many reports included (adequate) immediate actions 10 4

Division Reported within 2 working days

Apr-18 May-18 Jun-18

Trajectory % 80% 80% 85%

Acute 60% 73% 44%Ambulance 0% - -Mental Health 100% 67% 50%Community 100% - 67%

Division 72 hour report within 3 working days

Apr-18 May-18 Jun-18

Trajectory % 60% 60% 65%Acute 40% 67% 33%Ambulance 100% - -Mental Health 0% 67% 0%Community 100% - 67%

CLINICAL BUSINESS UNIT Number OVERDUE Surgery, Women's, Children's 4 Medicine 13 Clinical, Cancer & Diagnostics 1 Ambulance, Urgent Care, Community

15

Mental Health & Learning Disabilities

7

Corporate services 0


The oldest case should have been completed in November 2017 but is overdue because it is being investigated by an external investigator. The final report has been received by the external investigator and is currently with a senior manager for completion of setting of action plan prior to submission to CCG. The Quality Governance team plan to do a “look back” exercise to review those serious incidents where downgrade has been made, with a view to identifying if we could have known earlier that the incident did not meet the SI criteria, or what other information would have been required to make this decision and could we have obtained this information from elsewhere. Of the 42 cases submitted for closure since April, 15 (33%) required a downgrade, as further information determined that the incident did not meet the SI criteria under the national framework.

5. Inquests

There were 17 inquests heard in May and a further 2 in June at the time of writing. Further inquest information is provided in the private Board Quality Report. Quarter 1 claims data will be provided to the next meeting of the Board.

6. Adult Inpatient Survey 2017 As reported to the last meeting of the Trust Board, the National Patient Experience Survey has now been published. A copy is attached at Appendix 2. The Patient Experience Sub-Committee is monitoring actions taken in response to the survey as part of the ‘Learning from Experience’ Quality Strategy priority. Assurance reports will be provided to the Quality Committee.

7. Quality Strategy

One of the main focuses during Quarter 1 has been engaging with the clinical divisions (Acute, Ambulance, Community and Mental Health) to determine their quality strategy priorities. These were on track to be presented at the Quality Summit, 27 June, at the time of writing this report. The priorities are scheduled to be written into mini quality strategies for presentation to the Division Quality Committees and approval at the Division Boards during July 2018. Once finalised, the quality strategy dashboard will be amended for each Division. This data, along with the Trust-wide dashboard, will be made available via the ‘getting to good’ website.

8. CQC Improvement Programme

As the Board are aware, in response to the ‘inadequate’ ratings in the Safe domain, the 10 week Safe improvement programme has commenced. At the time of writing, this had started in Medicine, Surgery and Mental Health with dates set for the Emergency Department and Community Services for Children. End of Life is being picked up in both the Medicine and Surgery programme. Gynaecology is included in the Surgery programme. Early responses have been positive. Staff report feeling engaged and there are many examples of actions taken since January, in addition to more recent changes. A Quality Summit was held on the 27th June 2018 to share our approach and present some of the excellent work and improvements that have our clinical teams have implemented since the inspection in January 2018. A verbal update will be provided on feedback from the event, which had not taken place at the time of writing.


9. Recommendations

The Board is asked to consider the following recommendations:

• Decide if sufficient assurance has been received in relation to the issues raised in this report.

Suzanne Rostron Barbara Stuttle CBE Mr Alistair Flowerdew Director of Quality Governance Interim Director of Nursing Medical Director June 2018 June 2018 June 2018

Patient survey report 2017

Survey of adult inpatients 2017Isle of Wight NHS Trust

137 trusts sampled additional months because of small patient throughputs.

NHS Patient Survey ProgrammeSurvey of adult inpatients 2017The Care Quality CommissionThe Care Quality Commission is the independent regulator of health and adult social care inEngland. We make sure health and social care services provide people with safe, effective,compassionate, high-quality care, and we encourage care services to improve. Our role is toregister care providers, and to monitor, inspect and rate services. If a service needs to improve, wetake action to make sure this happens. We speak with an independent voice, publishing regionaland national views of the major quality issues in health and social care.

Survey of adult inpatients 2017To improve the quality of services that the NHS delivers, it is important to understand what peoplethink about their care and treatment. One way of doing this is by asking people who have recentlyused health services to tell us about their experiences.

The fifteenth survey of adult inpatients involved 148 acute and specialist NHS trusts acrossEngland. Responses were received from 72,778 people, a response rate of 41%. Patients wereeligible for the survey if they were aged 16 years or older, had spent at least one night in hospitaland were not admitted to maternity or psychiatric units. Trusts sampled patients discharged duringJuly 20171. Trusts counted back from the last day of July 2017, including every consecutivedischarge, until they had selected 1250 patients (or, for a small number of specialist trusts whocould not reach the required sample size, until they had reached 1st January 2017). Fieldwork tookplace between September 2017 and January 2018.

Surveys of adult inpatients were also carried out in 2002 and annually from 2004 to 2016. They arepart of a wider programme of NHS patient surveys, which cover a range of topics includingemergency departments, children's inpatient and day-cases, maternity services and communitymental health services. To find out more about our programme and for the results from previoussurveys, please see the links contained in the further information section.

The Care Quality Commission will use the results from this survey in our regulation, monitoring andinspection of NHS acute trusts in England. We will use data from the survey in our system of CQCInsight, which provides inspectors with an assessment of performance in areas of care within anNHS trust that need to be followed up. Survey data will also be use to support CQC inspections.NHS England will use the results to check progress and improvement against the objectives set outin the NHS mandate, and the Department of Health and Social Care will hold them to account forthe outcomes they achieve. NHS Improvement will use the results to guide its work to improve thequality of care provided by NHS Trusts and Foundation Trusts.

Interpreting the reportThis report shows how a trust scored for each question in the survey, compared with the range ofresults from all other trusts that took part. It uses an analysis technique called the 'expected range'to determine if your trust is performing 'about the same', 'better' or 'worse' compared with othertrusts. For more information, please see the 'methodology' section below. This approach is designedto help understand the performance of individual trusts, and to identify areas for improvement.

A 'section' score is also provided, labelled S1-S11 in the 'section scores'. The scores for eachquestion are grouped according to the sections of the questionnaire, for example, 'the hospital andward', 'doctors', 'nurses' and so forth.

This report shows the same data as published on the CQC website(http://www.cqc.org.uk/surveys/inpatient). The CQC website displays the data in a simplified way,identifying whether a trust performed 'better', 'worse' or 'about the same' as the majority of othertrusts for each question and section.

2

http://www.cqc.org.uk/surveys/inpatient

StandardisationTrusts have differing profiles of people who use their services. For example, one trust may havemore male inpatients than another trust. This can potentially affect the results because people tendto answer questions in different ways, depending on certain characteristics. For example, olderrespondents tend to report more positive experiences than younger respondents, and women tendto report less positive experiences than men. This could potentially lead to a trust's resultsappearing better or worse than if they had a slightly different profile of people.

To account for this, we standardise the data. Results have been standardised by the age, sex andmethod of admission (emergency or elective) of respondents to ensure that no trust will appearbetter or worse than another because of its respondent profile. This helps to ensure that each trust'sage-sex-admission type profile reflects the national age-sex-admission type distribution (based onall of the respondents to the survey). Standardisation therefore enables a more accuratecomparison of results from trusts with different population profiles. In most cases this will not have alarge impact on trust results; it does, however, make comparisons between trusts as fair aspossible.

ScoringFor each question in the survey, the individual (standardised) responses are converted into scoreson a scale from 0 to 10. A score of 10 represents the best possible response and a score of zero theworst. The higher the score for each question, the better the trust is performing.

It is not appropriate to score all questions in the questionnaire as not all of the questions assess thetrusts. For example, they may be descriptive questions such as Q1 asking respondents if theirinpatient stay was planned in advance or an emergency; or they may be 'routing questions'designed to filter out respondents to whom following questions do not apply. An example of arouting question would be Q44 "During your stay in hospital, did you have an operation orprocedure?" For full details of the scoring please see the technical document (see furtherinformation section).

GraphsThe graphs in this report show how the score for the trust compares to the range of scores achievedby all trusts taking part in the survey. The black diamond shows the score for your trust. The graphis divided into three sections:

• If your trust's score lies in the grey section of the graph, its result is 'about the same' as mostother trusts in the survey

• If your trust's score lies in the orange section of the graph, its result is 'worse' compared withmost other trusts in the survey.

• If your trust's score lies in the green section of the graph, its result is 'better' compared withmost other trusts in the survey.

The text to the right of the graph states whether the score for your trust is 'better' or 'worse'compared with most other trusts in the survey. If there is no text the score is 'about the same'.These groupings are based on a rigorous statistical analysis of the data, as described in thefollowing 'methodology' section.

MethodologyThe 'about the same,' 'better' and 'worse' categories are based on an analysis technique called the'expected range' which determines the range within which the trust's score could fall withoutdiffering significantly from the average, taking into account the number of respondents for each trustand the scores for all other trusts. If the trust's performance is outside of this range, it means that itperforms significantly above/below what would be expected. If it is within this range, we say that itsperformance is 'about the same'. This means that where a trust is performing 'better' or 'worse' thanthe majority of other trusts, it is very unlikely to have occurred by chance.

In some cases there will be no orange and/or no green area in the graph. This happens when theexpected range for your trust is so broad it encompasses either the highest possible score for alltrusts (no green section) or the lowest possible score for all trusts (no orange section). This could bebecause there were few respondents and / or a lot of variation in their answers.

3

Please note that if fewer than 30 respondents have answered a question, no score will be displayedfor this question (or the corresponding section). This is because the uncertainty around the result istoo great. A technical document providing more detail about the methodology and the scoringapplied to each question is available on the CQC website (see further information section).

TablesAt the end of the report you will find tables containing the data used to create the graphs. Thesetables also show the response rate for your trust and background information about the people thatresponded.

Scores from last year's survey are also displayed. The column called 'change from 2016' usesarrows to indicate whether the score for this year shows a statistically significant increase (uparrow), a statistically significant decrease (down arrow) or has shown no statistically significantchange (no arrow) compared with 2016. A statistically significant difference means that the changein the results is very unlikely to have occurred by chance. Significance is tested using a two-samplet-test.

Where a result for 2016 is not shown, this is because the question was either new this year, or thequestion wording and/or the response categories have been changed. It is therefore not possible tocompare the results as we do not know if any change is caused by alterations in the surveyinstrument, or variation in a trust's performance. Comparisons are also not able to be shown if atrust has merged with other trusts since the 2016 survey, or if a trust committed a sampling error in2016. Please note that comparative data are not shown for sections as the questions contained ineach section can change year on year.

Notes on specific questionsPlease note that a variety of acute trusts take part in this survey and not all questions are applicableto every trust. The section below details modifications to certain questions, in some cases this willapply to all trusts, in other cases only to some trusts.

All trustsQ36: Two new response options, “I was not given any information about my treatment or condition”and “Don’t know/ can’t remember”, were added to question 36 (“How much information about yourcondition or treatment was given to you?”). As a result data is no longer comparable to the samequestion in 2016.

Q50 and Q51: The information collected by Q50 “On the day you left hospital, was your dischargedelayed for any reason?” and Q51 “What was the main reason for the delay?” are presentedtogether to show whether a patient's discharge was delayed by reasons attributable to the hospital.The combined question in this report is labelled as Q51 and is worded as: “Discharge delayed dueto wait for medicines/to see doctor/for ambulance.”

Q52: Information from Q50 and Q51 has been used to score Q52 “How long was the delay?” Thisassesses the length of a delay to discharge for reasons attributable to the hospital.

Q53 and Q56: Respondents who answered Q53 “Where did you go after leaving hospital?” as “Iwas transferred to another hospital” were not scored for question Q56 (“Before you left hospital,were you given any written or printed information about what you should or should not do afterleaving hospital?”). This decision was taken as there is not a requirement for hospital transfers.

Trusts with female patients onlyQ11: If your trust offers services to women only, a trust score for Q11 “While in hospital, did youever share a sleeping area, for example a room or bay, with patients of the opposite sex?” is notshown.

Trusts with no A&E DepartmentQ3 and Q4: The results to these questions are not shown for trusts that do not have an A&Edepartment.

4

Questions added and removed for 2017The following questions are new for 2017 and will therefore have no comparative results:

Q11: “While in hospital, did you ever share a sleeping area, for example a room or bay, with patientsof the opposite sex?"

Q13: “Did the hospital staff explain the reasons for being moved in a way you could understand?”

Q22: “During your time in hospital, did you get enough to drink?

Q31: “Did you have confidence and trust in any other clinical staff treating you (e.g.physiotherapists, speech therapists, psychologists)?

Q43: “If you needed attention, were you able to get a member of staff to help you within areasonable time?”

Q63: “Did the doctors or nurses give your family, friends or carers all the information they needed tohelp care for you?”

Q71: “Did you feel well looked after by the non-clinical hospital staff (e.g. cleaners, porters, cateringstaff)?”

The following questions were removed from the 2017 questionnaire (2016 numbering):

Q13: “After you moved to another ward (or wards), did you ever share a sleeping area, for examplea room or bay, with patients of the opposite sex?”

Q14: “While staying in hospital, did you ever use the same bathroom or shower area as patients ofthe opposite sex?”

Q18: “How clean were the toilets and bathrooms that you used in hospital?”

Q19: “Did you feel threatened during your stay in hospital by other patients or visitors?”

Q44: “How many minutes after you used the call button did it usually take before you got the helpyou needed?”

Q46: “Beforehand, did a member of staff explain the risks and benefits of the operation or procedurein a way you could understand?”

Q47: “Beforehand, did a member of staff explain what would be done during the operation orprocedure?”

Q50: “Before the operation or procedure, were you given an anaesthetic or medication to put you tosleep or control your pain?”

Q51: “Before the operation or procedure, did the anaesthetist or another member of staff explainhow he or she would put you to sleep or control your pain in a way you could understand?”

Q73: “During your time in hospital did you feel well looked after by hospital staff?”

For more information on questionnaire redevelopment and the rationale behind adding or removingindividual questions please refer to the Survey Development Report, available here:http://www.nhssurveys.org/survey/2008

5

http://www.nhssurveys.org/survey/2008

Further informationThe full national results are on the CQC website, together with an A to Z list to view the results foreach trust (alongside the technical document outlining the methodology and the scoring applied toeach question):http://www.cqc.org.uk/inpatientsurvey

The results for the adult inpatient surveys from 2002 to 2016 can be found at:http://www.nhssurveys.org/surveys/425

Full details of the methodology of the survey can be found at:http://www.nhssurveys.org/surveys/1084

More information on the programme of NHS patient surveys is available at:http://www.cqc.org.uk/content/surveys

More information about how CQC monitors hospitals is available on the CQC website at:http://www.cqc.org.uk/what-we-do/how-we-use-information/monitoring-nhs-acute-hospitals

6

http://www.cqc.org.uk/inpatientsurvey

http://www.nhssurveys.org/surveys/425

http://www.nhssurveys.org/surveys/1084

http://www.cqc.org.uk/content/surveys

http://www.cqc.org.uk/what-we-do/how-we-use-information/monitoring-nhs-acute-hospitals

Section scoresS1. The Accident & Emergency Department(answered by emergency patients only)

S2. Waiting list or planned admissions(answered by those referred to hospital)

S3. Waiting to get to a bed on a ward

S4. The hospital and ward

S5. Doctors

S6. Nurses

S7. Your care & treatment

S8. Operations & procedures (answered bypatients who had an operation or procedure)

S9. Leaving hospital

S10. Overall views of care and services

S11. Overall experience


Best performing trusts

About the same

Worst performing trusts

'Better/Worse' Only displayed when this trust is better/worse thanmost other trustsThis trust's score (NB: Not shown where there arefewer than 30 respondents)

7

The Accident & Emergency Department (answered by emergency patients only)Q3. While you were in the A&E Department, howmuch information about your condition ortreatment was given to you?

Q4. Were you given enough privacy when beingexamined or treated in the A&E Department?

Waiting list or planned admissions (answered by those referred to hospital)

Q6. How do you feel about the length of timeyou were on the waiting list?

Q7. Was your admission date changed by thehospital?

Q8. Had the hospital specialist been given allnecessary information about your condition/illnessfrom the person who referred you?

Waiting to get to a bed on a wardQ9. From the time you arrived at the hospital, didyou feel that you had to wait a long time to get to abed on a ward?



About the same



8

The hospital and ward

Q11. Did you ever share a sleeping area withpatients of the opposite sex?

Q13. Did the hospital staff explain the reasonsfor being moved in a way you couldunderstand?

Q14. Were you ever bothered by noise at nightfrom other patients?

Q15. Were you ever bothered by noise at nightfrom hospital staff?

Q16. In your opinion, how clean was thehospital room or ward that you were in?

Q17. Did you get enough help from staff to washor keep yourself clean?

Q18. If you brought your own medication with youto hospital, were you able to take it when youneeded to?

Q19. How would you rate the hospital food?

Q20. Were you offered a choice of food?

Q21. Did you get enough help from staff to eatyour meals?

Q22. During your time in hospital, did you getenough to drink?

Q71. Did you feel well looked after by thenon-clinical hospital staff?

DoctorsQ23. When you had important questions to ask adoctor, did you get answers that you couldunderstand?

Q24. Did you have confidence and trust in thedoctors treating you?

Q25. Did doctors talk in front of you as if youweren't there?



About the same



9

NursesQ26. When you had important questions to ask anurse, did you get answers that you couldunderstand?

Q27. Did you have confidence and trust in thenurses treating you?

Q28. Did nurses talk in front of you as if youweren't there?

Q29. In your opinion, were there enough nurseson duty to care for you in hospital?

Q30. Did you know which nurse was in charge oflooking after you? (this would have been a differentperson after each shift change)



About the same



10

Your care & treatment

Q31. Did you have confidence and trust in anyother clinical staff treating you?

Q32. In your opinion, did the members of staffcaring for you work well together?

Q33. Did a member of staff say one thing andanother say something different?

Q34. Were you involved as much as you wantedto be in decisions about your care andtreatment?

Q35. Did you have confidence in the decisionsmade about your condition or treatment?

Q36. How much information about yourcondition or treatment was given to you? Worse

Q37. Did you find someone on the hospital staffto talk to about your worries and fears?

Q38. Do you feel you got enough emotionalsupport from hospital staff during your stay?

Q39. Were you given enough privacy whendiscussing your condition or treatment?

Q40. Were you given enough privacy whenbeing examined or treated?

Q42. Do you think the hospital staff dideverything they could to help control your pain?

Q43. If you needed attention, were you able to geta member of staff to help you within a reasonabletime?

Operations & procedures (answered by patients who had an operation or procedure)Q45. Did a member of staff answer your questionsabout the operation or procedure in a way youcould understand?

Q46. Were you told how you could expect tofeel after you had the operation or procedure?

Q47. Afterwards, did a member of staff explainhow the operation or procedure had gone in a wayyou could understand?



About the same



11

Leaving hospital

Q48. Did you feel you were involved indecisions about your discharge from hospital?

Q49. Were you given enough notice about whenyou were going to be discharged?

Q51. Discharge delayed due to wait formedicines/to see doctor/for ambulance.

Q52. How long was the delay?

Q54. Did you get enough support from health orsocial care professionals to help you recover andmanage your condition?

Q55. When you left hospital, did you know whatwould happen next with your care?

Q56. Were you given any written or printedinformation about what you should or should notdo after leaving hospital?

Q57. Did a member of staff explain the purpose ofthe medicines you were to take at home in a wayyou could understand?

Q58. Did a member of staff tell you aboutmedication side effects to watch for when youwent home?

Q59. Were you told how to take your medicationin a way you could understand?

Q60. Were you given clear written or printedinformation about your medicines?

Q61. Did a member of staff tell you about anydanger signals you should watch for after you wenthome?

Q62. Did hospital staff take your family or homesituation into account when planning yourdischarge?

Q63. Did the doctors or nurses give your family orsomeone close to you all the information theyneeded to care for you?

Q64. Did hospital staff tell you who to contact if youwere worried about your condition or treatmentafter you left hospital?

Worse



About the same



12

Q65. Did hospital staff discuss with you whetheradditional equipment or adaptations were neededin your home?

Q66. Did hospital staff discuss with you whetheryou may need any further health or social careservices after leaving hospital?

Overall views of care and services

Q67. Overall, did you feel you were treated withrespect and dignity while you were in the hospital?

Q69. During your hospital stay, were you everasked to give your views on the quality of yourcare?

Q70. Did you see, or were you given, anyinformation explaining how to complain to thehospital about the care you received?

Overall experience

Q68. Overall...

I had a very poorexperience

I had a very goodexperience



About the same



13

The Accident & Emergency Department (answered by emergency patients only)S1 Section score 8.5 7.5 9.2

Q3 While you were in the A&E Department, how much informationabout your condition or treatment was given to you?

8.1 7.4 9.1 343 8.3

Q4 Were you given enough privacy when being examined or treatedin the A&E Department?

8.9 7.5 9.5 372 8.9

Waiting list or planned admissions (answered by those referred to hospital)S2 Section score 8.6 8.2 9.7

Q6 How do you feel about the length of time you were on the waitinglist?

7.7 6.3 9.7 174 8.1

Q7 Was your admission date changed by the hospital? 9.0 8.1 9.9 176 8.8

Q8 Had the hospital specialist been given all necessary informationabout your condition/illness from the person who referred you?

9.2 8.3 9.6 166 9.0

Waiting to get to a bed on a wardS3 Section score 7.4 5.8 9.7

Q9 From the time you arrived at the hospital, did you feel that you hadto wait a long time to get to a bed on a ward?

7.4 5.8 9.7 579 7.2


or Indicates where 2017 score is significantly higher or lower than 2016 score(NB: No arrow reflects no statistically significant change)Where no score is displayed, no 2016 data is available.

14

The hospital and wardS4 Section score 8.0 7.3 8.9

Q11 Did you ever share a sleeping area with patients of the oppositesex?

9.5 7.5 9.8 583

Q13 Did the hospital staff explain the reasons for being moved in a wayyou could understand?

6.7 5.2 8.9 128

Q14 Were you ever bothered by noise at night from other patients? 6.3 4.8 8.4 580 6.2

Q15 Were you ever bothered by noise at night from hospital staff? 8.2 7.1 9.1 581 7.8

Q16 In your opinion, how clean was the hospital room or ward that youwere in?

9.1 8.3 9.7 588 9.1

Q17 Did you get enough help from staff to wash or keep yourselfclean?

8.1 7.0 9.3 397 8.2

Q18 If you brought your own medication with you to hospital, were youable to take it when you needed to?

7.0 5.7 8.7 346 6.7

Q19 How would you rate the hospital food? 6.0 4.7 8.0 555 5.7

Q20 Were you offered a choice of food? 8.7 7.8 9.7 573 8.8

Q21 Did you get enough help from staff to eat your meals? 7.7 5.3 9.4 131 7.6

Q22 During your time in hospital, did you get enough to drink? 9.4 8.9 9.9 562

Q71 Did you feel well looked after by the non-clinical hospital staff? 9.3 8.2 9.7 514

DoctorsS5 Section score 8.5 8.1 9.5

Q23 When you had important questions to ask a doctor, did you getanswers that you could understand?

8.0 7.6 9.2 492 8.1

Q24 Did you have confidence and trust in the doctors treating you? 8.8 8.5 9.8 578 8.8

Q25 Did doctors talk in front of you as if you weren't there? 8.7 7.9 9.6 577 8.7



15

NursesS6 Section score 7.9 7.2 9.2

Q26 When you had important questions to ask a nurse, did you getanswers that you could understand?

8.3 7.3 9.3 500 8.4

Q27 Did you have confidence and trust in the nurses treating you? 8.9 8.0 9.6 578 8.9

Q28 Did nurses talk in front of you as if you weren't there? 8.9 8.0 9.6 577 9.1

Q29 In your opinion, were there enough nurses on duty to care for youin hospital?

7.4 6.5 9.1 576 7.6

Q30 Did you know which nurse was in charge of looking after you? (thiswould have been a different person after each shift change)

5.9 5.4 8.7 578 5.4



16

Your care & treatmentS7 Section score 8.0 7.5 9.0

Q31 Did you have confidence and trust in any other clinical stafftreating you?

8.3 7.8 9.6 354

Q32 In your opinion, did the members of staff caring for you work welltogether?

8.6 8.0 9.5 537 8.9

Q33 Did a member of staff say one thing and another say somethingdifferent?

8.1 7.3 9.0 578 8.2

Q34 Were you involved as much as you wanted to be in decisionsabout your care and treatment?

7.2 6.6 8.5 577 7.0

Q35 Did you have confidence in the decisions made about yourcondition or treatment?

8.2 7.7 9.4 580 8.0

Q36 How much information about your condition or treatment wasgiven to you?

8.5 8.3 9.6 550

Q37 Did you find someone on the hospital staff to talk to about yourworries and fears?

5.3 4.3 7.7 328 5.5

Q38 Do you feel you got enough emotional support from hospital staffduring your stay?

7.1 6.1 8.6 352 7.1

Q39 Were you given enough privacy when discussing your condition ortreatment?

8.6 8.0 9.4 574 8.6

Q40 Were you given enough privacy when being examined or treated? 9.6 9.1 9.8 581 9.5

Q42 Do you think the hospital staff did everything they could to helpcontrol your pain?

8.2 7.4 9.2 364 8.1

Q43 If you needed attention, were you able to get a member of staff tohelp you within a reasonable time?

8.0 6.7 9.1 526

Operations & procedures (answered by patients who had an operation or procedure)S8 Section score 8.1 7.6 9.0

Q45 Did a member of staff answer your questions about the operationor procedure in a way you could understand?

8.9 8.6 9.5 290 8.9

Q46 Were you told how you could expect to feel after you had theoperation or procedure?

7.3 6.8 8.7 311 7.1

Q47 Afterwards, did a member of staff explain how the operation orprocedure had gone in a way you could understand?

8.0 7.0 8.9 312 8.0



17

Leaving hospitalS9 Section score - 6.3 8.4

Q48 Did you feel you were involved in decisions about your dischargefrom hospital?

6.6 6.1 8.5 556 6.6

Q49 Were you given enough notice about when you were going to bedischarged?

6.9 6.3 8.5 575 6.5

Q51 Discharge delayed due to wait for medicines/to see doctor/forambulance.

6.1 5.0 8.7 538 6.5

Q52 How long was the delay? 7.4 6.4 9.2 535 7.9

Q54 Did you get enough support from health or social careprofessionals to help you recover and manage your condition?

6.4 5.3 8.0 305 6.6

Q55 When you left hospital, did you know what would happen next withyour care?

- 6.1 8.4

Q56 Were you given any written or printed information about what youshould or should not do after leaving hospital?

5.8 5.6 9.3 549

Q57 Did a member of staff explain the purpose of the medicines youwere to take at home in a way you could understand?

8.0 7.6 9.6 393 8.2

Q58 Did a member of staff tell you about medication side effects towatch for when you went home?

4.5 3.7 7.6 351 4.8

Q59 Were you told how to take your medication in a way you couldunderstand?

8.2 7.5 9.7 348 8.1

Q60 Were you given clear written or printed information about yourmedicines?

7.8 6.9 9.4 385 7.9

Q61 Did a member of staff tell you about any danger signals you shouldwatch for after you went home?

- 4.3 8.3

Q62 Did hospital staff take your family or home situation into accountwhen planning your discharge?

7.0 6.1 8.3 377 7.1

Q63 Did the doctors or nurses give your family or someone close to youall the information they needed to care for you?

5.9 5.3 7.9 376

Q64 Did hospital staff tell you who to contact if you were worried aboutyour condition or treatment after you left hospital?

6.9 6.5 9.8 515 7.5

Q65 Did hospital staff discuss with you whether additional equipment oradaptations were needed in your home?

8.4 6.6 9.3 204 8.3

Q66 Did hospital staff discuss with you whether you may need anyfurther health or social care services after leaving hospital?

8.3 7.2 9.2 312 8.1



18

Overall views of care and servicesS10 Section score 4.5 3.8 6.0

Q67 Overall, did you feel you were treated with respect and dignitywhile you were in the hospital?

8.9 8.5 9.7 576 9.0

Q69 During your hospital stay, were you ever asked to give your viewson the quality of your care?

1.9 0.7 3.6 492 1.8

Q70 Did you see, or were you given, any information explaining how tocomplain to the hospital about the care you received?

2.6 1.4 5.1 433 2.7

Overall experienceS11 Section score 8.1 7.5 9.2

Q68 Overall... 8.1 7.5 9.2 553 8.0



19


Background informationThe sample This trust All trustsNumber of respondents 596 72778

Response Rate (percentage) 50 41

Demographic characteristics This trust All trustsGender (percentage) (%) (%)

Male 45 47

Female 55 53

Age group (percentage) (%) (%)

Aged 16-35 3 5

Aged 36-50 5 8

Aged 51-65 16 23

Aged 66 and older 76 64

Ethnic group (percentage) (%) (%)

White 94 90

Multiple ethnic group 0 1

Asian or Asian British 0 3

Black or Black British 0 1

Arab or other ethnic group 0 0

Not known 6 5

Religion (percentage) (%) (%)

No religion 20 16

Buddhist 1 0

Christian 75 77

Hindu 0 1

Jewish 0 0

Muslim 0 2

Sikh 0 0

Other religion 2 1

Prefer not to say 2 2

Sexual orientation (percentage) (%) (%)

Heterosexual/straight 95 94

Gay/lesbian 1 1

Bisexual 0 0

Other 1 1

Prefer not to say 4 4

20

Page│ 1 of 6


5 July 2018

Title Under Pressure: Safely Managing increased demand in Emergency Departments (ED) report


Nikki Turner, Director Acute Services

Author(s) Michaela Morris – Operational Manager ED and MAU Report previously considered by inc date

None

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary The Isle of Wight NHS along with the majority of organisations providing Acute Care faced significant pressures during the 2017 / 2018 Winter. The CQC have subsequently published a review of national best practice within the National Report Under Pressure: Safely Managing increased demand in Emergency Departments (ED) report. This report identifies key learning and best practice from providers to ensure that lessons are learnt and improvements made prior to entering the 2018 / 2019 winter. Key Recommendation The Trust Board is asked to consider the following recommendations:

Agree that the areas of good practice contained within the report are being or will be delivered by the Unplanned Flow Programme work that has now commenced. That actions and progress will be monitored at the fortnightly Service and Financial Improvement Sub Committee.

Enc L

Page│ 2 of 6

National Report Under Pressure: Safely Managing increased demand in Emergency Departments

1. Situation 1.1. The Isle of Wight NHS along with the majority of organisations providing Acute Care faced

significant pressures during the 2017 / 2018 Winter. The CQC have subsequently published a review of national best practice within the National Report Under Pressure: Safely Managing increased demand in Emergency Departments (ED) report. This report identifies key learning and best practice from providers to ensure that lessons are learnt and improvements made prior to entering the 2018 / 2019 winter.

2. Background 2.1. Data for the 2017 / 2018 winter indicates an overall reduction in demand; however, this was

directly contributable to the changes in Walk in Centre provision. In contrast, the attendance for ED has grown by 6.4% as depicted within Figure 1.

Figure 1 – Total Attendance Figures

Urgent Care Activity (1st Nov'17 - 31st Mar'18)

15/16 16/17 17/1816/17 - 15/16

17/18 - 16/17

Total Attendances 26,861 22,718 17,971 (15.4%) (20.9%)

ED Attendances 16,156 16,202 17,245 0.3% 6.4%

Walk In Centre 10,705 6,516 3,175 (39.1%) (51.3%)

Breaches 3,389 3,573 3,638 5.4% 1.8%

% Non-Admitted 31.3% 32.4% 37.6% 1.1% 5.1%

ECS Performance 87.4% 84.3% 79.8% (3.1%) (4.5%)

2.2. Although the number of patients over 75 who attend ED has remained consistent in recent

years the number of patients who require admission via ED has increased exponentially during the winter of 17 / 18 as detailed within Figure 2.

Page│ 3 of 6

Figure 2 – Total Admissions

Urgent Care Activity (1st Nov'17 - 31st Mar'18)

15/16 16/17 17/1816/17 - 15/16

17/18 - 16/17

ED Attendances 16,156 16,202 17,245 0.3% 6.4%

Admissions 3,883 3,901 4,586 0.5% 17.6%

% ED Attendances 24.0% 24.1% 26.6% 0.0% 2.5%

Age 75+ 3,768 3,976 4,183 5.5% 5.2%

% ED Attendances 23.3% 24.5% 24.3% 1.2% (0.3%)

Age 75+ Adm 1,129 1,243 2,063 10.1% 66.0%

% 75 + Att 30.0% 31.3% 49.3% 1.3% 18.1% 2.3. This higher acuity of patients presenting and therefore greater demand on beds, led to a

failure to achieve both the national emergency care standard (4 hour target) and also our revised local trajectory.

3. Assessment 3.1. The organisational Winter Plan for 2017/18 minimised the occurrences of contingency beds /

areas being opened when compared to the previous year. The de-escalation of contingency areas was also managed well and during the period achieved a much improved recovery time of 3.5 days on average.

3.2. The Trust has and continues to make progress towards implementation and delivery of the areas of good practice as identified within the CQC report. These are being implemented via the following workstreams which are overseen by the Unplanned Flow Programme.

3.3. Appendix 1 provides a breakdown of the areas of identified good practice and the current

status on implementation or whether these areas now need to be included within the scope of the workstream. There has been significant work within recent weeks to develop governance structures to ensure delivery of the milestones contained within each workstream, which in turn will improve flow, quality and patient experience.

4. Recommendation 4.1. It is recommended that the Trust Board gain assurance that the areas of good practice

contained within the report are being or will be delivered by the Unplanned Flow Programme which reports in to the Service and Financial Improvement Sub-Committee.

Workstream Operational Lead Nursing Lead Medical Lead Urgent Care Floor Michaela Morris Kathryn Taylor Mr Robin Beal SAFER Simon Paul Judy Dyos Dr Mark Connaughton Ops Room / Site Coordination Lynne Barker Judy Dyos

Acute Frailty Emma Pugh

Caroline Robertson Dr Sarah Gladdish

Page | 4 of 6

Appendix One Areas of Good Practice from CQC Report Current IOW NHS Status Extended access to community services during the week and at weekends to reduce unscheduled attendance at emergency departments. Continuity of care improves people’s experience, person-centred care of complex conditions, and could reduce unnecessary hospital admissions.

To be included within the urgent care floor workstream.

GP referrals for hospital care should go straight to an appropriate assessment area for specialty review. They should not be channelled through the emergency department

All medical referrals for advice and potential admission are taken by an Acute Physician. Both the surgical and paediatric assessment units form part of the urgent care floor improvement plan.

Processes and pathways out of hospital for frequent attenders A multi professional High Intensity User Group now meets monthly. Frailty pathways for the elderly should be established so that frail patients can bypass the emergency department. Ipswich Hospital and Homerton University Hospital have addressed this, for example with the Frailty Assessment Base at Ipswich Hospital. This has led to fewer patients over 75 being admitted into hospital since its introduction.

The Trust is working with the frailty network to embed frailty assessments. Assessments are already being undertaken pre hospital and within ED. Although this is not currently reducing ED attendance, pathways are being developed to reduce this.

Early follow-up clinics following discharge after medical or surgical procedures, to make sure that patients receive appropriate follow-up care, can help preventing people defaulting to attending the emergency department if they are experiencing problems.

Inter professionals standards ensure that patients who have been recently discharged are accepted immediately by the discharging team for care when they attend ED. Availability of follow up clinics is currently limited.

Extra specialist outpatient clinics, such as rapid access, hot clinics and ambulatory care appointments, can help to prevent avoidable admission to emergency departments

Medical Ambulatory Service is operational and moves to designated space with emergency department by the end of June.

Integrated patient information systems that link primary medical services, community services and acute hospital services.

The Emergency Department will have access to System One by the end of July 2018. This will allow access to primary, palliative and community care records.

Page | 5 of 6

Capacity and capability Areas of Good Practice Current IOW NHS Status Trained and skilled clinical team in place at the front door to include utilisation of different skill sets such as advanced nurse practitioners, paramedics, phlebotomists and offering CESR (Certificate of Eligibility for Specialist Registration) programmes

Short, medium and long term staffing review for both medical and nursing staff underway. Competencies for nurses and emergency departments’ assistants in development.

Defined professional standards for emergency departments and the specialty services that support them to include timeframe for review once referral has been received.

Internal professional standards in place with Executive approval. System in development to monitor compliance against them

Agreed clinical standards and recognised clinical pathways for critically ill patients,

Some pathways in place however these need review and agreement by both ED and the relevant specialties.

Improved patient flow, supported by a system that makes sure that staff are always aware of key operational information:

Emergency department dashboard now used to provide “real time” data relating to operational pressures within the emergency department.

The trust must manage crowding in the emergency department as a high-risk Organisation wide Full Capacity Policy in development to include escalation triggers and whole organisation response. Review of Emergency Department Escalation procedure to be undertaken once full capacity procedure has been updated.

Trusts should monitor the total length of stay of all patients in the emergency department and set and manage appropriate internal targets rather than focusing purely on delays after a decision to admit.

Internal quality standards to be developed to include no patient to be within ED for longer than 12 hours from time of arrival not from decision to admit.

Output Effective patient flow through ambulatory care. Medical Ambulatory Service is operational and moves to designated

space with emergency department by the end of June. Closer multi-specialty team working. How emergency departments and specialty teams work together is key to improving patient flow and avoiding admission. This includes, for example, the use of validated risk stratification tools to inform clinical decisions about hospital admissions for patients with medical emergencies.

To be included within the Urgent Care Floor Workstream

Early discharge planning that starts at the moment the decision to admit the patient is made, particularly for medical patients.

To be included within the SAFER workstream

Page | 6 of 6

Provision of sufficient specialty beds for patients with more complex needs – for example, mental health, isolation, end of life care, respiratory, monitored and critical care.

To be included within the

Areas of Good Practice Current IOW NHS Status Improved bed management/inpatient capacity. Make sure that patients are not placed in any bed, but are given an appropriate bed for their needs and that they are available when patients need them. The goal of bed management is to move patients efficiently throughout the system. The practical steps that help to improve bed management are:

To be included within the operational room / site coordination workstream

Earlier discharge of patients during the day, not late in the afternoon. This requires taking a proactive approach to discharge. This includes regular ward rounds by the consultants, discharge checklists that identify which patients can be discharged, and making decisions about discharge the night before. These steps can help to make beds available earlier in the day (before midday), and in turn help to improve patient flow through the hospital.


Management of hospital bed occupancy. Hospitals running at over 95% bed occupancy cannot manage patient flow effectively. There needs to be an effective and proactive system response when hospital bed-occupancy is higher that the recommended level.

To be included within the operational room / site coordination workstream

Multidisciplinary team approach to reviewing patients in hospital to reduce the length of stay, including on weekends and bank holidays. This is especially important in extended holiday periods such as the Christmas and New Year break, since a surge in demand is to be expected immediately after.


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5 July 2018

Title Safe Staffing Report for the Period May 2018 Sponsoring Executive Director

Barbara Stuttle, Director of Nursing

Author(s) Emily Mullan Clinical Lead for eRostering and SafeCare Report previously considered by inc date

Quality Committee – 4 July 2018

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality

Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive Caring Well-led Safe X Executive Summary

This report provides an overview of staffing levels and gives details of issues that have arisen and points of note.

• Daily staffing huddles take place at 09:00 in the ops room utilising SafeCare and professionaljudgement to ensure that staffing for the next 24hrs is risk assessed. Temporary andsubstantive staff are redeployed as required to ensure staffing levels are as safe as possibleacross the wards. A daily staffing report is emailed out to all Ward Sisters, Matron’s, Heads ofNursing and Temporary Staffing outlining the daily staffing position, including any areas forconcern and actions for the next 24hrs.

• The monthly average fill rates for day shifts (Registered Nurses) in May showed three wardsrated as red (less than 90% fill rate); two four (90-94.9% fill rate), six green (95-101% fill rate)and seven purple (above 102%). For night shifts, two wards were red and amber, elevengreen and five purple.

• Further details (including Healthcare Assistant fill rates) are contained within the body of thisreport.

• Sickness across almost all areas has remained high and there are only three wards with lessthan 3% sickness in May; compared with two wards in March. Mandatory training attendanceremains compromised only 3 wards meeting 85% compliance.

• RN vacancies currently remain high but there have been positive responses to current

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recruitment. • A three year strategy for managing workforce is being developed and establishment meetings

have been held to review current staffing and identify opportunities to realign Registered Nurse care hours to Healthcare Assistant care hours in line with staffing recommendations.

• The SafeCare project is now live, with acuity and dependency data being entered three times a day on 12 wards. The current challenge with this is in embedding it into everyday practice however there has been increased activity with training and usage in June.

• NHSI commenced phase 2 of supporting effective rostering and this work is ongoing. • A decision has been made to disband the agency float on 30th June. • Weekly Roster meetings have been established with the Assoiciate Director of Nursing, Matrons,

Sisters and eRostering Team in order to monitor and review adherence to the policy and process for rostering. This includes reviewing a series of KPIs as recommended in The Carter Review (2016)

All Staffing Levels in Safe Staffing report. – All Nursing reviews now complete except MAU and Emergency Department. Nursing & Midwifery Six Monthly Staffing Review – Report coming to Trust Board in September 2018 post acuity and dependency studies July/August Key Recommendation The Board is asked to receive this report.

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Safe Staffing Levels Report June 2018

1. Overview

Nurse staffing levels are monitored daily at the 09:00 staffing huddle by Managers of the Day,

Matrons, Ward Sisters and the Clinical lead for e-Rostering using SafeCare. Staffing is risk

assessed and agency and substantive staff are redeployed as required to ensure staffing levels

are as safe as possible across the wards. A daily staffing report is emailed out to all Ward

Sisters, Matron’s, Heads of Nursing and Temporary Staffing outlining the daily staffing position,

including any areas for concern and actions for the next 24hrs. Any emergency staffing issues

occurring are managed by Ward Managers, Matrons and Temporary Staffing using SafeCare to

review staffing levels and redeploy staff as appropriate.

See Appendix A - Unify average fill rate data for each ward and quality and safety indicators.

1.1 Total Hours Planned Total hours planned is our planned staffing levels to deliver care for each area. This is based on

our current establishment and rota templates. Following the establishment review rota templates

are currently being revised to reflect the new establishments. Due to advanced rostering these

rosters will not be worked until September and therefore reported on in November.

1.2 Enhanced Care (1 to 1 care) A number of patients require specialist nursing care, i.e. for those patients with dementia. In

these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required

the ward may show as being over 100% fill rate as additional shifts will have been added to the

template. 1 to 1 requirement is managed in this way as it is challenging to predict when enhanced

care will be required.

1.3 Security Shifts due to building work

Due to necessary building work within the mental health units additional staff are currently

employed on every shift to safeguard patient safety this has increased the establishment fill rate.

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1.4 Acuity and Dependency Monitoring (SafeCare) Recording daily acuity and dependency has commenced via the implementation of the SafeCare

tool. Twelve wards are currently live recording the current inpatients acuity and dependency three

times a day to generate a Care Hours per Patient per Day score. This score along with

professional judgement is measured against available staffing hours to ensure safe staffing

levels.

1.5 CHPPD (Care Hours Per Patient Day) is a measure which shows on average how many hours of care

time each patient receives on a ward /department during a 24 hour period - this will vary across

wards and departments based on the specialty and type of care required. Both Registered

Nurses and HCA staff care hours are include in the calculation. This data is included in the safe

staffing report and is benchmarked online via The Model Hospital allowing comparison to Trust of

similar makeup to Isle of Wight NHS Trust

2 Monthly Data 2.1 The monthly average day shift fill rate of registered staff for May shows three ward areas had red

ratings (less than 90% fill rate), four had amber (90-94.9% fill rate), six achieved green (95-102%)

and seven achieved purple (above 102%) . The three areas that were rated red: ITU and CCU

due to planned restricted capacity during relocation due to building works. The Stroke Unit due to

above average sick leave.

2.2 The monthly average night shift fill rate of registered staff for May shows two ward areas had red

ratings (less than 90% fill rate), two had amber (90-94.9% fill rate), eleven achieved green (95-

102%) and five achieved purple (above 102%). The two areas that were rated red. Appley rated

red due to unfilled vacancies and high level of sickness with the ability to flex staff between

Colwell and Appley and CCU due to reduced patient capacity.

2.3 The monthly average day shift fill rate of HCA staff for May shows seven ward areas had red

ratings (less than 90% fill rate), four had amber (90-94.9% fill rate), four achieved green (95-

102%) and five achieved purple (above 102%). The seven areas that were rated red: Shackleton,

Osborne, Maternity, NICU, Appley, ITU and CCU due to unfilled vacancies and sickness.

2.4 The monthly average night shift fill rate of HCA staff for May shows one ward area had red

ratings (less than 90% fill rate), five had amber (90-94.9% fill rate), three achieved green (95-

102%) and nine achieved purple (above 102%). The one area that was rated red: ITU due to

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roster template and establishment differences which will be rectified in September with the

revised establishments.

2.5 Long lines of agency nurses continue to be booked for Mental Health Wards, Medical Wards,

Surgical Wards and Medical Assessment Unit during May. This has enabled vacancies to be

filled in a planned way, so that whilst vacancy rate is high, wards are not depleted to an unsafe

position. Agency nurse requests are scrutinised at Executive level and are also reviewed on a

daily and weekly basis to ensure that wards maintain safe staffing levels without being

overstaffed.

2.6 Sickness rates have remained high across almost all areas. There are three wards rated green

for sickness in May (less than 3%) in April there were two wards rated green. The biggest

reported loss of 1044 hours in May due to sickness is reported as anxiety/ stress/ depression/

psychiatric illness.

2.7 There has been a slight decrease of Mandatory Training attendance with three wards rated

green (above 85%) in May compared to four in April. Ward Managers continue to be challenged

in being able to ensure staff can achieve not only mandatory training but also additional training

for competencies and improving practice, or for quality improvement initiatives.

2.8 There have been two reported staffing incidents for May. The theme of these incidents being

reduced staffing due to short notice sickness. In both incidents substantive staff were redeployed

from their own ward area to cover the ward with compromised staffing this ensured that staffing

risk was minimised.

2.9 There has been an increase in patients being admitted in a confused state requiring 1:1 care this

may be an indication to the increase of reported falls.

2.10 Vacancy rates at the time of reporting remain high however there have been positive responses

to current recruitment. With applications from student nurses gaining their registered nurse

qualification in September. There have also been job offers to two midwives following a

successful recruitment day and a further two registered nurse job offers to two nurses relocating

to the Island.

See Appendix B- Current Vacancy Rates

2.11 In May the Trust CHPPD indicates we have provided over five care hours per patient per day

across all areas this may be a result of patient acuity and dependency. Some areas showed

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extremely high CHPPD levels, these are predominantly specialist areas where higher staffing

levels are mandated.

3 Summary of actions in progress

3.1 Two SBARS went to TLC in June 2018 requesting support and investment to undertake

international recrutimnet for 100 further RN in a staged apptrach and the second SBAR

requested support and investment for the nursing associate role and the regsistered nurse

apprenticeship role suported via current RN vacancies.

3.2 The 6 monthly staffing report will come to Trust Board in September 2018 after a full acuity and

dependency study has been completed in relavant areas.

3.3 Establishment meetings have been held with with the Director of Nursing, Interim Deputy

Director of Nursing, Finance Lead, Head of Nursing, Matron and Ward Sister. These meetings

reviewed current establishments and identify the opportunity to realign RN care hours to HCA

hours in line with staffing recommendations. The new acute wards and paediatric ward

establishments were approved at Trust Leadership Committee on 16/05/18 these have now been

changed on the roster template. Due to advanced rostering these rosters will not be worked until

September and therefore reported on in November.

3.4 Weekly Roster meetings have been established Assoiciate Director of Nursing, Matrons, Sisters

and eRostering Team in order to monitor and review adherence to the policy and process for

rostering. This includes reviewing a series of Key Performance Indicators (KPIs) as

recommended in The Carter Review (2016) these KPI’s include;

KPI 1 Headroom and usage of annual leave, study leave, sickness, maternity leave and other

leave

The overall total unavailability is set across the trust at 22%. The total headroom for May was

25.46% which may be indicated due to high sickness.

Trust 26 units (29.4.18 - 4 weeks) Previous period This period total % < 4 month trend

% Total unavailabil ity 21.70% 25.46%

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KPI 2 6 week roster approval rates

KPI 3 Lost contracted hours not used per month (unused hours)

On the 1st April 2018 all nursing unused hours were zeroed following a decision by the

Executive Team. All ward areas have received a directive to ensure a tight control of any

unused hours

Trust 26 units (29.4.18 - 4 weeks) Previous period This period total % < 4 month trend

% Unused hours 4.26% 2.88%

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KPI 4 Additional shifts and reasons for booking

The main reason for additional shift allocation is for increased service demand and capacity

this is due to the recording of last minute 1:1 staffing to safeguard patients. Ongoing work

remains to ensure that the appropriate request is recorded on Healthroster.

Additional Duty Reason Count of Additional Duty Reason1:1 Close Supervision 92Created by Shared Pattern 2FromPattern 190High Acuity 60Increase in Service Capacity 160Increase Service Demand 292Patient Escort Duty 14Safe Care 37Secondment 3Sickness (Long-Term) 50Sickness (Short-Term) 15Staff Request 45Training 24Unknown 3Using up staff hours 49Grand Total 1036

KPI 5 Working restrictions

There is an ongoing project in data collection to ensure meaningful reporting of this metric

KPI 6 Auto-roster percentages enabled

Work has commenced in ensuring shift patterns are EU working time directive compliant in

order to allow healthroster system to safely auto-roster.

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KPI 7 Number of bank requests to the total bank hours worked

Due to unavailability of last minute bank supply and cancelations there were 514 unfilled

hours in May which represents 26% of total bank shifts requested.

KPI 8 Number of bank requests on weekend and night duties

The number of Bank shifts requested is reduced on Sundays as per policy however is at it’s

highest on Saturday.

Total Bank Hours Requested 1974 Total Bank Hours Filled 1460 Total Bank Hours Unfilled 514

Total Bank Night Requested 497 Monday 56 Tuesday 70 Wednesday 78 Thursday 73 Friday 73 Saturday 84 Sunday 63

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3.5 The SafeCare project is now live with acuity and dependency data being entered three times

a day on Appley, Colwell, Luccombe, CCU, Afton, The Stoke Unit, Compton and Children’s

Ward, St Helen’s, Alverstone, Mottistone and Whippingham. With plans to go live with ITU,

MAU and NICU once appropriate acuity and dependency tools have been identified. There

remain multiple gaps on SafeCare data entry therefore the data is not currently operational.

This is being managed and challenged at the weekly ward sister and Matron rostering

meeting.

Current Challenges – embedding the three times a day acuity and dependence data

gathering (census periods) into everyday working practice. The SNCT tool is now licenced

through Imperial Innovations applications have been made for a licence.

Current Actions – education, weekly roster meetings, one to one support for ward managers

and ward walks

3.6 NHSi commenced Phase 2 of supporting effective eRostering this work is ongoing. Further

meetings have taken place in June 2018.

3.7 A senior Nurse has been working with Human Resources and nursing to support effective

use of temporary staffing and reduce agency use across inpatient services.

3.8 Agency float has been reduced by 9.3wte (350 hours) week commencing 28/05/18. This is a

Safe Staffing decision due to reduced patient acuity and dependency post winter pressures.

The agency float will be cancelled as of 1st July as ward areas have covered with long line

agency. Going forward agency requests will be on actual gaps on the rota ( shift by shift

requirement) rather than block booking.

Barbara Stuttle Interim Executive Director of Nursing Prepared by: Emily Mullan Clinical Lead for eRostering and SafeCare

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Appendix A - Unify average fill rate data for each ward and quality and safety indicators.

May-18

SHACKLETON 100.9% 69.5% 103.3% 104.3% 193 6.2 9.0 15.2 12.7% 75% 0 0 0SEAGROVE 110.9% 114.9% 100.1% 143.5% 187 11.1 11.5 22.6 2.3% 77% 0 0 0OSBORNE 96.9% 88.5% 93.3% 107.1% 424 5.0 3.9 8.9 3.6% 81% 0 0 2

AFTON 106.1% 90.6% 99.9% 93.1% 245 8.0 5.4 13.4 6.4% 92% 1 0 0WOODLANDS 97.1% 92.5% 98.8% 94.1% 253 6.7 2.9 9.5 10.0% 78% 0 0 0

ALVERSTONE 103.3% 91.5% 100.3% 130.4% 303 5.5 3.0 8.4 16.6% 76% 1 3 1 2LUCCOMBE 112.3% 149.4% 98.4% 166.0% 688 3.5 4.2 7.7 3.9% 62% 1 2 0 1

MOTTISTONE 101.7% 103.0% 100.0% 263 6.2 1.6 7.8 3.0% 84% 0 1 0 1ST HELENS 107.6% 98.8% 101.6% 103.2% 366 4.7 3.2 7.9 1.8% 86% 1 0 0 1

WHIPPINGHAM 93.4% 142.9% 113.3% 95.6% 767 2.7 1.9 7.9 4.5% 78% 6 2 0 0PAEDIATRIC WARD 97.6% 96.2% 93.5% 93.5% 187 13.6 3.7 17.3 4.1% 80% 0 0

MATERNITY 98.2% 83.9% 106.7% 99.4% 194 16.2 9.0 25.2 4.1% 70% 0 1NEONATAL

INTENSIVE CARE 137.6% 81.7% 96.1% 100.4% 54 42.3 12.8 55.1 5.3% 77% 0 1

MEDICAL ASSESSMENT UNIT 110.0% 97.2% 132.1% 92.8% 634 6.0 3.5 9.4 4.9% 87% 3 1 0 1

STROKE 81.1% 103.0% 98.0% 122.5% 656 4.2 3.4 7.5 9.2% 79% 1 2 0 2COMPTON 90.6% 92.9% 152.3% 97.8% 900 3.0 2.7 5.8 13.3% 74% 0 0 0 3COLWELL 92.2% 97.1% 101.1% 122.2% 846 3.5 2.6 6.2 6.6% 77% 1 0 0 1APPLEY 91.3% 89.0% 88.2% 94.1% 841 3.2 2.6 5.8 10.6% 75% 5 1 0 2

INTENSIVE CARE 88.4% 82.9% 97.5% 67.7% 135 37.0 2.5 39.4 6.2% 84% 0 3 0 3CORONARY CARE 73.5% 57.8% 79.2% 103.1% 272 11.1 2.6 13.8 7% 81% 1 1 1 1

95% - 102% fill rate 90% - 94.9% fill rate as per as per 0 0<90% fill rate >102% fill rate quality quality 2 2

dashboarddashbaord >2 >2

Care Staff Overall Sickness Mandatory

TrainingWard nameReported

Medication Errors

Falls with any

harm

Pressure Ulcers (new

reported)

Day Night Care Hours Per Patient Day (CHPPD)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Cumulative count over the month of patients

at 23:59 each day

Registered midwives/

nurses

Reported Staffing

Incidents

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Appendix B- Current Vacancy Rates

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Date 05 July 2018

Title Workforce Performance Report June 2018 Sponsoring Executive Director


Author(s) Mark Elmore – Deputy Director HR Report previously considered by inc date

Performance Committee June 2018

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective X Responsive X Caring Well-led X Safe Executive Summary Headlines from this report are:

• Total FTE staffing level is under budgeted establishment by 108 FTE, although costs are higher than budget due to use of agency.

• With clinical colleagues, we are attending a recruitment event on Saturday 30th June 2018 in London, this will focus on opportunities to recruit Nurses.

• Following a recruitment fair in London we held a follow up welcome day at Trust on 02 June 2018. From this event we had the following outcomes:

• 1 x MAU/ED Nurse offer • 2 x Student midwives offered preceptorship posts • 5 x Appointments to the Staff Bank – MH/LD nurses

• Agency usage has exceeded the NHSI ceiling due in the main to medical and nursing resources required to cover for vacancies and higher acuity and additional activity.

• Trust sickness absence rate: 4.13% in month (increase from April sickness of 4.64%). Top reasons for absence: Anxiety, Stress & Depression remains the highest % reason for sickness absence in May, representing almost a third of sickness absence at the Trust. Back Problems and Other Musculoskeletal Problems both showing a reduction over the past 6 months.

• Staff Turnover has decreased to 9.24% (rolling 12 months)

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• Following the introduction of a Physiotherapy referral service for staff by Occupational Health, we have seen a decrease in staff absent from work with MSK related issues over the past 6 months

• Mandatory Training compliance has remained at 80% against a target of 85%. • Data Security Awareness (Information Governance) compliance has decreased at 85% • Physical Assaults information is provided to PIDS and is available to the Board through their

reports, supplied from Corporate Governance Department. • An Appraisal Improvement project will be launched week beginning the 25 June 2018. Current

Appraisal rate 57% Key Recommendation The Board is asked to receive the report.

WORKFORCE PERFORMANCE REPORT

1. Workforce Information

Month 2 Summary

Actual Funded Establishment Vacancies

Staff In Post (FTE) 2702 3037 335 Temporary staff (FTE) 227

Total 2929 108

The Trust employs 3112 (headcount) substantive full and part time staff, some 400 bank workers with additional support provided by 300 volunteers. The decrease in FTE & headcount is representative of usual turnover levels from a number of Flexi-retirees at the time of the report, coupled with the Admin & Clerical recruitment freeze, resulting in lower levels of starters.

Tables 1 & 2 show that whilst staffing levels are under budgeted establishment, costs are in excess due to the high cost of agency and in particular medical staffing. Action is underway to recruit more substantive staff and offer long term agency doctors employment with the Trust.

2. Recruitment and Retention

The nursing workforce has remained largely stable during the last 12 months but we know we must do more to retain staff and promote the Isle of Wight as a great place to work and live. Following a recruitment fair in London we held a follow up welcome day at Trust on 02 June 2018. From this event we had the following outcomes:

• 1 x MAU/ED Nurse offer • 2 x Student midwives offered preceptorship posts • 5 x Appointments to the Staff Bank – MH/LD nurses

With clinical colleagues, we are attending a recruitment event on Saturday 30th June 2018 in London, this will focus on opportunities to recruit Nurses.

Our social media has been launched with dedicated Isle of Wight job sites through Facebook, LinkedIn and Instagram to promote and advertise jobs. This has been a successful source of nursing staff previously. In terms of international recruitment, a proposal has been submitted and is awaiting board approval.

We also recognise the need to improve how we manage recruitment and temporary supply and now that we have a Nurse Manager working directly with the HR and the wards to review every aspect of our management of nurse staffing rosters, vacancies

and temporary workers. The deep dives into each ward are proving very successful and now that the new establishments have been uploaded we are able to proceed at pace to recruit to the large volumes of HCA posts that have been created.

Table 1 shows the changes in funded establishment, substantive staffing and temporary staffing over the past 18 months. Table 2 shows monthly budget vs pay costs for the past 18 months.

Table 1

Table 2

3. Agency Information Continued Agency usage in month was predominantly to cover medical posts and continued cover for nursing vacancies. Medical and nursing usage in month remains high in MH/LD. There is significant work being carried out to convert agency workers to substantive and/or bank. Outcomes of revised Workforce Controls has resulted in changing the skill mix of agency floats in nursing and will result in a saving of c£1m to the Trust in the current financial year – 2018/19. The outcomes of the establishment reviews have now been uploaded onto the rostering system and take effect from the 1st June 2018 and the remaining floats will be stopped from 1st July 2018. The tender presentations for Master Vendor for the provision of nurses have now taken place and procurement is managing the award of the contract. Once a supplier has been awarded the go live date will be confirmed.

Agency Use: Breakdown of agency staff groups actual spend:

Table3

Highest users of Medical Agency staff continue to be General Medicine and Psychiatry Adult. Highest users of non-Medical Agency staff continue to be Mental Health & Acute Nursing.

Agency Use: Breakdown of agency staff groups FTE and cost:

Staff Group

Monthly Hours

Monthly Cost £000 Weekly FTE

Consultant 1878 £217k 11.74 Specialist Registrar 612 £57k 3.8 Core Trainee/ST1&2 (formally SHO) 1117 £71k 6.98

Nursing 11,320 £505k 77.59 TOTAL 14927 £850k 100.11

4. Compliance with NHSi Agency Ceiling

*agency data provided by Finance

5. Sickness

Trust sickness absence rate: 4.13% in month (decrease from April sickness of 4.64%). Top reasons for absence: Anxiety, Stress & Depression remains the highest % reason for sickness absence in May, representing almost a third of sickness absence at the Trust. Back Problems and Other Musculoskeletal Problems both showing a reduction over the past 6 months. Following the introduction of a Physiotherapy referral service for staff by Occupational Health, we have seen a decrease in staff absent from work with MSK related issues, albeit with a spike in May. This is highlighted in Table 6.

Table 5

Table 6

6. Staff turnover

Rolling 12 month (June 17 – May 18) % turnover has decreased at month 2, to 9.24%.

Improvement related to Physiotherapy referral service

7. Education, Training, Leadership and OD Activity Report June 2018

Statutory & Mandatory Training

Statutory Mandatory Training Compliance – Substantive and Bank Staff

Analysis:

• Current Trust position (04/06/18) is 80%. This has remained the same as last month.

• We have, however seen an overall increase of 3% in activity since last month.

• Conflict Resolution has improved by 3% and MCA and Prevent have each increased by 2% since last month. Infection Prevention & Control has increased by 1%.

• Information Governance, Manual Handling and Resuscitation have decreased by 1%

• All 5 other courses have held compliance from last month • DNA percentage for all training has decreased by 2% on last month; bringing

total DNA’s to 17% and therefore 7% above the 10% tolerance.

Update:

From the 4th June 2018 the Education, Training and Development Team are embarking on a 90 day project to further improve the provision of Mandatory Training and increase the overall Trust compliance percentages. We aim that at the end of the project all staff will have an accurate and concise list of Mandatory Training (MT) for their role.

Appraisals

Current position is 57%. This is a 2% decrease on last month.

An Appraisal Improvement project will be launched week beginning the 25 June 2018.

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Date 5 July 2018

Title Financial Performance Report – Month 2 (2018/19) Sponsoring Executive Director

Darren Cattell – Director of Finance, Estates and IM&T

Author(s) Gary Edgson – Deputy Director of Finance Report previously considered by inc date

Performance Committee – 4 July 2018

Purpose of the report Information only Assurance x Review and discuss Agreement

To receive the Month 2 Trust performance against the 2018/19 financial plan and note the immediate actions to correct financial performance proposed by the Executive

Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight Link to CQC Domains Effective Responsive Caring Well-led X Safe Executive Summary The key points from the Month 2 financial performance against plan are: Income & Expenditure

• The Trust’s in month financial position is a deficit of £2.2m • £0.5m in month adverse variance against deficit plan • Run rate position off plan due to:

a) under delivery against the phased CIP plan (£124k) b) the cost of Winter bed capacity remaining open without an agreed funding source (£182k)

c) cost pressures to deliver ED Service (£170k) • £4.3m actual deficit year to date (£1.0m off plan)

Agency

• NHSI agency control total ceiling for 2018/19 £4.6m • Actual agency spend to date £2.2m. Adverse against phased ceiling to date by £1.4m • Reduced agency spend in May, although still significantly above plan

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Year-end forecast and financial recovery plan • A revised planned deficit of £17.149m was submitted to NHSI on 20 June as agreed by the Board • CCG Contract income is not finalised and income assumptions remain a risk for Acute services • There is currently an outstanding issue of £1.4m on the CCG Contract for Community Services. The year to date position (£0.2m) and year end forecast assume that this income will be received

Progress to date against financial recovery plan

• Budgets have been signed off for all clinical business units in line with the Board approved deficit plan

• Plans are in place to deliver a cost improvement programme of £8m as supported by KPMG and Moorhouse

• Trust budgetary performance is relatively strong, the key variances are CIP and bed capacity remaining open without an agreed funding source.

The Executive has agreed a number of further financial control actions through the Service and Financial Improvement Sub Committee. Specific Actions

1. Finance to concentrate on forecasting full year outturn and longer term planning 2. ALL additional Quality investments require TLC approval where outside of budget 3. Actively encourage the use of Bank and in all but the most exceptional circumstances ban non

clinical overtime 4. ALL posts and changes to pay require approval by the Exceptional Pay Panel 5. Continue Grip and Control non pay controls supported by Procurement 6. Continue negotiations with CCG to resolve income levels and specific funding issues 7. Utilise contract database to enhance both income and expenditure controls 8. Agency reduction plans being developed as part of the Temporary spend work stream in the

Workforce CIP Further assurance for the Board

1. 2018/19 CBU detailed Budget sign-off took place in early June 2018 2. Service and Financial Improvement Sub Committee meeting every two weeks with Finance

Performance Reviews meeting (PRM) every two weeks to drive CIP planning and delivery and accountability for corrective actions

3. As part of the finance PRMs, CBU leads have agreed non recurrent underspends to count towards non recurrent CIP delivery in mitigation of current CIP shortfall

4. Focused corrective action plans for overspending services are also being produced at CBU level as part of the finance PRMs for example ED.

5. The Director of Acute Services has produced a urgent Winter Bed capacity closure plan which has been supported by the Executive, this capacity is expected to close at the end of June 2018.

6. Assurance reviews of our financial plan and CIP plans have been undertaken with NHSI Capital Planning Update • Initial CRL for 2018/19 based on Depreciation is £6.6m • Request to be made to NHSI to spend the underspend from 2017/18 of £0.8m • Major Projects expected for 2018/19 include:- • Back Up Generators £0.6m

Page | 3

• Ambulance CAD £0.6m • Ophthalmology Satellite Unit £0.6m • Paediatric Assessment Unit £0.6m • EIP Team Relocation £0.3m • Education Extension £0.3m • A&E Streaming Project £0.2m • Defibrillators £0.5m • Mental Health Refurb (CQC) £0.2m • IM&T New Schemes £0.3m • Other £0.6m • CBU Prioritisation £1.8m Cash update

• Loan funding for 2018/19 is being requested in line with the deficit plan • Loans of £1.6m for April, £1.762m for May and £1.845m for June have been secured • A request for £1.725m for July has been made • The Trust in unable to borrow more funds than our agreed deficit plan. The longer we

overspend the larger the risk that we do not have sufficient cash to pay our suppliers on time

Use of Resources Rating The Trust’s Use of Resources Rating is still a score of 4 (1 being best and 4 being worst) due to our financial performance. Key Recommendation The Board is asked to consider the following recommendations:

1. To receive the Month 2 Trust performance against the 2018/19 financial plan and note the immediate actions to correct financial performance proposed by the Executive

1

INCOME & EXPENDITURE - SUMMARY

YEARPlan Actual Variance Plan Actual Variance Plan

£000s £000s £000s £000s £000s £000s £000sIncome 13,943 14,616 673 27,867 28,670 803 168,811 Pay (10,977) (11,346) (368) (21,801) (22,849) (1,048) (133,823) Non Pay (3,902) (4,677) (775) (7,775) (8,541) (767) (43,537) EBITDA (936) (1,406) (470) (1,709) (2,721) (1,011) (8,549) Capital Charges (545) (562) (17) (1,111) (1,114) (3) (6,670) Public Dividend Capital (199) (199) (0) (398) (398) 0 (2,389) Interest Receivable/(Payable) (81) (81) 1 (163) (160) 2 (995) Bank Charges (0) 0 0 (1) 0 1 (4) RETAINED SURPLUS / (DEFICIT) (1,761) (2,248) (487) (3,382) (4,393) (1,011) (18,607) Receipt of Charitable Donations for Asset Acquisition 0 0 0 0 0 0 (50) Depreciation - Donated Assets 11 11 0 22 22 0 131 CQUIN Risk reserve adjustment 0 0 0 0 0 0 0 REVISED RETAINED SURPLUS / (DEFICIT) (1,750) (2,237) (487) (3,360) (4,371) (1,011) (18,526)

IN MONTH YEAR TO DATE

-2,134-2,237

-2,500

-2,000

-1,500

-1,000

-500

0Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

£'00

0

Trust Deficit Run Rate

Actual run rate Plan

To date the Trust is reporting a deficit of £4.3m against a deficit plan to date of £3.3m, a negative variance of £1m. The in-month position is a deficit of £2.2m. Trust budgetary performance is relatively strong, the key variances are CIP and bed capacity remaining open without an agreed funding source. To achieve a year end deficit of £18.6m will require an average in month run rate of £1.5m deficit each month. Achievement of the year end Board approved deficit of £18.5m, is dependent on agreeing the 2018/19 contract with the CCG at the value of £134.2m and delivery of £8m CIP. .

2

AGENCY EXPENDITURE

Agency expenditure in month is £1.03m. Agency costs have reduced in May due to reduction in MH medics and reliance on nurse agency floats. The year to date expenditure represents 9.6% of the total Trust expenditure on pay. For comparison, agency expenditure in 2017/18 was 8.3% of total pay. As part of the Financial Recovery Performance enhanced pay controls are already in place which will reduce agency expenditure:

• Exceptional Pay Panel – at least weekly • Finance and HR sign off on change forms • Interims & consultancies reviewed • E Rostering “Safe Care” reporting system

training held • Unused hours data review • E Rostering Clinical Lead now in place • Recruiting bank Healthcare assistants weekly • Reduction in agency rates

(200)

0

200

400

600

800

1,000

1,200

1,400

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

£'00

0

Monthly Agency spend and NHSI ceiling

Medical Nursing Clinical Administration Other TOTAL NHSI CEILING

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual - cumulative 2016/17 682 1,506 1,924 2,763 3,255 4,136 4,623 5,055 5,681 6,312 6,957 7,611Actual - cumulative 2017/18 535 1,253 2,176 3,024 3,939 5,084 5,928 6,879 7,870 8,807 9,963 10,887Actual - cumulative 2018/19 1,157 2,188NHSI Ceiling 383 766 1,149 1,532 1,915 2,298 2,681 3,064 3,447 3,830 4,212 4,594

0

2,000

4,000

6,000

8,000

10,000

12,000

£'00

0

Cumulative Agency spend

Actual - cumulative 2016/17 Actual - cumulative 2017/18 Actual - cumulative 2018/19 NHSI Ceiling

8,000

8,500

9,000

9,500

10,000

10,500

11,000

11,500

12,000

£'00

0

Total pay spend by month

Substantive Bank & Locum Agency

3

COST IMPROVEMENT PROGRAMME (CIP)

Plans are in place to deliver a cost improvement programme of £8m. Service and Financial Improvement Sub Committee meeting every two weeks with Finance Performance Reviews meeting (FPRM) every two weeks to drive CIP planning and delivery and accountability for corrective actions .

333 333

0

209

0

50

100

150

200

250

300

350

April May

£'00

0

CIP position

Plan

Actual

4

CASH

Actual Actual ActualMonth 1 YTD YTD VAR

£m £m £mCash Balance 01.04.18 6.0 6.0 0.0

Income and Expenditure Surplus / (Deficit) -2.1 -4.4 -2.2Depreciation 0.6 1.1 0.6Interest Payable 0.1 0.2 0.1PDC Dividend 0.2 0.4 0.2Other non-cash items 0.0 0.0 0.0Operating Surplus / (Deficit) -1.3 -2.7 -1.4

Change in Stock 0.0 -0.1 -0.1Change in Debtors -1.3 -0.6 0.8Change in Creditors & Other Liabilities 3.1 2.8 -0.3Change in Provisions 0.0 0.0 0.0Net Change in Working Capital 1.8 2.1 0.3

Capital Spend -3.0 -3.4 -0.4Interest Paid / Received 0.0 0.0 0.0PDC Dividend Paid 0.0 0.0 0.0Other -0.1 0.0 0.0Investing Activities -3.1 -3.5 -0.4

Working Capital Loans 1.6 3.4 1.8Loan/Finance Lease Repayments 0.0 0.0 0.0Cash Balance 31.5.18 5.0 5.2 0.2

The cash balance held at the end of May is £5.2m which is a £0.2m positive movement on last month.

Month 2 YTD Cash Movements

- The Month 2 I&E Cumulative Deficit is £4.4m which £1m worse than plan

- Within the I&E deficit, Depreciation (£1.1m) does not impact cash. The charges for Interest Payable (£0.2m) and PDC Dividend (£0.4m) are added back and the amounts actually paid for these expenses shown lower down for presentational purposes. This generates a YTD cash "Operating Deficit" of £2.7m

- The movement in working capital movements in month is due to an decrease in Debtors (Accrued Income) and an increase in Creditors due to pressures on cash

- Capital Spend is payment of creditors from 2017/18

- The Trust has borrowed £1.8m of Uncommitted Loans in month. These borrowings are subject to interest at 1.5% and with interest at 3.5% on previous year borrowings will represent costs in 2017/18 of £1.0m

5

CAPITAL

Our initial CRL is based on forecast depreciation of £6.561m and £50k Expected Charitable Donations. We are also going to apply to NHS Improvement to use the £788k underspend from 2017/18. Therefore capital funds of £7.4m are anticipated for 2018/19. As at Month 2 we have spent £460k Major Projects planned for 2018/19 are as follows:-

• Back Up Generators £0.6m • Ambulance CAD £0.6m • Ophthalmology Satellite Unit £0.6m • Paediatric Assessment Unit £0.6m • EIP Team Relocation £0.3m • Education Extension £0.3m • A&E Streaming Project £0.2m • Defibrillators £0.5m • Mental Health Refurb (CQC) £0.2m • Others £2.7m

2018/19 Capital programme plan and expenditure

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Actual Forecast

£

Other

IM&T

Equipment

QIP

Estates Schemes

Service Developments

6

USE OF RESOURCES RATING

Basis of scoring mechanism

The Trusts Use of Resources Rating as at 31 May is a score of 4, as set out below. This is against a score of 1 being best and 4 being worst.

Agenda Item No 19 MeetingMeeting Date

Title


Author(s)Report previously considered by inc date

X

XXX

X

X XX XX

Effective ResponsiveCaring Well-ledSafeExecutive Summary

The Trust has revised its performance trajectories for 2018/19 for each of its key national targets based on the 2017/18 outturn, 2018/19 year to date position and in alignment with NHSI guidance.

Emergency Care Standard: The Trust achieved the Emergency Care Standard trajectory of 88% for May 2018 (national target is 95%). The requirement in quarter 1 is to sustain this performance against the trajectory as it increases during the year with the aim of achieving 90% in September 2018.

62 Day Cancer: The Trust has provisionally under-performed in May 2018 at 64.8% against the 62 Day Cancer 68.1% trajectory for the month; the final performance is subject to actual tertiary centre treatments / breaches for upload in early June. For May, there are currently 46 treatments identified with 16.5 breaches; 85% target under-performance at tumour site level is as follows: - Colorectal: 0% (0.5 breaches / 0.5 treatments)- Gynaecology: 42.86% (2 breaches / 3.5 treatments)- Haematology: 33.33% (2 breaches / 3 treatments)- Lung: 75% (0.5 breaches / 2 treatments)- Upper GI: 60% (1 breach / 2.5 treatments)- Urology: 46.15% (10.5 breaches / 19.5 treatments)This is a worsening of performance compared to the previous month, whilst focus remains to reduce the number of long waiting patients and ensure treatment is timely both locally and at tertiary providers.

Actions to improve performance include:- Increase number of Cancer Nurse Specialists and pathway trackers (Qtr1)- Improved breach & Clinical Harm Review process (Jul18)- Forecasting & modelling activity with NHSI (Qtr2)- Improve local performance through increased diagnostic capacity (Qtr2)- Work with tertiary providers to reduce diagnostic waits (Qtr2)- Progress Cancer & Diagnostics ‘Business As Usual’ Project (Mar19)

The impact of these actions will be the recovery of performance against revised trajectory and continued reduction of patients waiting over 62days and 104days, ensuring timely treatment.

Referral to Treatment: The Trust performed at 85.2% against the Referral to Treatment (RTT) 85.5% trajectory for May 2018 (the national target is 92%), sustaining the previous month's performance of around the same level. The requirement in quarter one is to have fully mobilised delivery of the 2018/19 planned activity levels, however, this has been affected by the impact of medical patients continuing to occupy surgical wards.

Diagnostics: The Trust performed in May 2018 at 97.5% against the diagnostic trajectory of 96% (national target is 99%) requiring patients receive their diagnostic test within 6 weeks of being referred; the trajectory is lower than the target due to planned reduction in capacity in May and June and reverts to 99% from quarter 2.

The governance process for managing the performance of these national targets includes daily and weekly monitoring within the Clinical Business Units through to their leadership forums and the Weekly Patient Access Group (where appropriate), and onto the monthly Divisional Performance Reviews, the Acute Services Performance Committee and the Acute Services Divisional Board.

Key RecommendationThe Board is asked to consider the following recommendations:- To note the current performance position of the Acute Services.

Link to CQC Domains

Reason for submission to Trust Board in Private only (please indicate below)

Commercial Confidentiality Staff Confidentiality

Patient Confidentiality Other Exceptional Circumstance

Link to Trust Strategic ObjectivesProvide safe, effective, caring and responsive services – ‘Good’ by 2020Ensure efficient use of resourcesAchieve NHS constitutional patient access standardsAchieve excellence in employment, education and developmentLead strategic change on the Isle of Wight

Trust Board Approval is required

Trust Board in Public 05/07/2018

Performance Report - Acute Services

Nikki Turner, Director of Acute Services

Sarah Hayward, Head of Operational Performance

Performance Committee - 4th July 18

Purpose of the reportInformation only AssuranceReview and discuss Agreement

Enc P

Isle of Wight NHS Trust Board Performance Report 20 18/19

Index

Acute Services 3-14 Acute - Balance Scorecard…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………3 A&E Performance - Emergency Care 4 Hours Standard…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..4 Cancer Performance - Cancer Urgent Referral to Treatment <62 days………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..5 RTT Performance - Referral to Treatment Times………………………………………………………………………………………………………………………………………………………………….. 6 Diagnostics Performance - Patients Waiting >6 weeks for Diagnostics………………………………………………………………………………………………………………………………………… 7 Benchmarking of Key National Performance Indicators - Summary Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..8 Benchmarking of Key National Performance Indicators - IW Performance Compared To Other 'Small Acute Trusts'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..9 Benchmarking of Key National Performance Indicators - IW Performance Compared To Other Trusts in the 'Wessex Area'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….10

11

May 18

Glossary of Terms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Page 2

Isle of Wight NHS Trust Board Performance Report 20 18/19May 18

Acute Balanced Scorecard - Aligned to Our Goals

Excellent Patient Care AreaAnnual Target

YTDMonth Trend

A positive experience for patients, service users and staff

AreaAnnual Target

YTDMonth Trend

Cost effective, sustainable services

Area In month planAnnual Target

YTDMonth Trend

Patients that develop a grade 4 pressure ulcer AS3 (80%

reduction on 15/16)

0 May-18 0 � Emergency Care 4 hour Standards M 95% 88% May-18 85% � RTT % of incomplete pathways within 18 weeks - IoW CCG AS 89.6% 85% May-18 �

Patients that develop an ungraded pressure ulcer AS 2 May-18 3 � Emergency Care 4 hour Standards MTrajectory

88.0%88% May-18 85% � RTT % of incomplete pathways within 18 weeks - NHS England AS 92% 87% May-18 �

VTE (Assessment for risk of) AS >95% 99.5% May-18 98.0% �Number of patients who have waited over 12 hours in A&E from decision to admit to admission

M 0 0 May-18 0 �� Zero tolerance RTT waits over 52 weeks (Incomplete Return) AS 0 0 May-18 0 0 ��

MRSA (confirmed MRSA bacteraemia) AS 0 0 May-18 0 �� All Cancelled Operations on/after day of admission AS 42 May-18 81 � RTT Incomplete Trust Combined ASTrajectory

85.5%85% May-18

C.Diff(confirmed Clostridium Difficile infection - stretched target)

AS 7 2 May-18 5 �

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting

AS 0 0 May-18 0 �� No. Patients waiting > 6 weeks for diagnostics AS <8 48 May-18 <100 87 �

Clinical Incidents (Major) resulting in harm(all reported, actual & potential, includes falls & PU G4)

AS 10 2 May-18 2 � Patient Satisfaction (Friends & Family test - Total response rate) AS 0% May-18 0% � % Patients waiting > 6 weeks for diagnostics AS <1% 97.5% May-18 <1% 97.7% �

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by investigation)

AS 0 May-18 2 � Patient Satisfaction (Friends & Family test - A&E response rate) AS 0% May-18 0% � % Patients waiting > 6 weeks for diagnostics ASTrajectory

96.0%97.5% May-18

Falls - resulting in significant injury AS 5 0 May-18 0 �� Mixed Sex Accommodation Breaches AS 0 2 May-18 16 � Theatre utilisation AS 83% 79% May-18 83% 78% �

Symptomatic Breast Referrals Seen <2 weeks* AS 93% 89.7% May-18 88.6% � Formal Complaints AS 22 May-18 55 � Variable Hours (£000) (Trust Wide) TW £198 Finance Data May-18 £198 'Finance Data

Cancer patients seen <14 days after urgent GP referral* AS 93% 95.7% May-18 96.3% � Compliments received AS N/A N/A May-18 162 � Staff absences - Acute AS 3.5% 4.05% May-18

Cancer Patients receiving subsequent Chemo/Drug <31 days* AS 98% 100.0% May-18 100.0% �� Appraisal Monitoring CCD 100.0% 66.00% May-18

Cancer Patients receiving subsequent surgery <31 days* AS 94% 100.0% May-18 100.0% �� Skilled and capable staff AreaIn month

planYear to

date planYTD Appraisal Monitoring SWC 100.0% 69.00% May-18

Cancer diagnosis to treatment <31 days* AS 96% 97.0% May-18 98.4% � Total Workforce (inc flexible working) (FTE's) AS 2,964.10 2,929.0 May-18 N/A N/A Appraisal Monitoring M 100.0% 50.00% May-18

Cancer Patients treated after screening referral <62 days* AS 90% 85.7% May-18 91.7% � Total workforce SIP (FTEs) AS 2,750.80 2,702.0 May-18 N/A N/A Mandatory Training* AS 85% 80.0% May-18 80.0%

Cancer Patients treated after consultant upgrade <62 days* ASNo measured

operational standard

100% May-18 100% �� Variable Hours (FTE) AS 213.3 227.0 May-18 453.0 Staff Turnover AS 5% 0.8% May-18 5% 0.8%

Cancer urgent referral to treatment <62 days* AS 85% 64.8% May-18 68.8% � Employee Relations Cases AS 0 25 May-18 154

Cancer urgent referral to treatment <62 days* ASTrajectory

68.1%64.8% May-18 � Theatre utilisation AS 183% 100% May-18 183% 500% �

Summary Hospital-level Mortality Indicator (SHMI)July-16 - June-17

AS 1 1.097Published Jan 2018 N/A � * Rolling year

Never events AS 0 0 May-18 0 ��Working with others to keep improving our services

AreaAnnual Target

YTD Month Trend

Stroke patients (90% of stay on Stroke Unit) M 80% 91% May-18 89% � Delayed Transfer of Care (lost bed days) - (Acute) AS N/A 74 May-18 214 �

High risk TIA fully investigated & treated within 24 hours (National 60%) M 60% 100% May-18 100% ��

*Cancer figures for April are provisional.

Notes

Delivering or exceeding Target � Key to Area Code

Underachieving Target �� AS = Acute Services

Failing Target � SWC = Surgery, Women's and Children's Health

M = Medicine

CCD - Clinical Support, Cancer and Diagnostics

Improvement on previous month

No change to previous month

Deterioration on previous month

Actual Performance

Actual Performance

Actual Performance

Actual Performance Actual Performance

Page 3


Emergency Care 4 hours Standard (ECS)

Commentary: Analysis:

Analysis:

May 18


Issue:The Trust achieved the Emergency Care Standard trajectory of 88% for May 2018 (national target is 95%). The requirement in quarter 1 is to sustain this performance against the trajectory as it increases during the year with the aim of achieving 90% in September 2018.

Actions:- Improved management of ambulatory cases & commencement of GP advice & guidance (May18)- Complete estates works (Jun18)- Increased usage of community rehab capacity & reduced LOS (Jun18)- 90% bed occupancy achieved & changes in discharge practices (Aug18)- Sustain DTOCs performance and flex medical bed capacity (Nov 18)- Unplanned Flow Project (Mar19)

Impact:The impact of these improvement actions will be quantified as to their contribution towards a sustainable recovery against the current position whilst needing to accommodate the planned reduction of medical bed capacity as we approach the Summer period, thereby, contributing to an improved performance against this target.

Governance:As with other urgent care service delivery, hourly and daily monitoring takes place, informing Clinical Business Unit leadership meetings, the monthly Performance Reviews, Acute Services Performance Committee and Acute Services Board.

Emergency Care 4 hours Standard

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Jun

17

Jul

17

Au

g 1

7

Se

p 1

7

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Fe

b 1

8

Ma

r 1

8

Ap

r 1

8

Ma

y 1

8

Target not achieved Target achieved Target Trajectory

Page 4



Analysis:

May 18

Cancer urgent referral to treatment <62 days


Issue:The Trust has provisionally under-performed in May 2018 at 64.8% against the 62 Day Cancer 68.1% trajectory for the month; the final performance is subject to actual tertiary centre treatments / breaches for upload in early June. For May, there are currently 46 treatments identified with 16.5 breaches; 85% target under-performance at tumour site level is as follows: - Colorectal: 0% (0.5 breaches / 0.5 treatments)- Gynaecology: 42.86% (2 breaches / 3.5 treatments)- Haematology: 33.33% (2 breaches / 3 treatments)- Lung: 75% (0.5 breaches / 2 treatments)- Upper GI: 60% (1 breach / 2.5 treatments)- Urolgy: 46.15% (10.5 breaches / 19.5 treatments)This is a worsening of performance compared to the previous month, whilst focus remains to reduce the number of long waiting patients and ensure treatment is timely both locally and at tertiary providers.

Actions:- Increase number of Cancer Nurse Specialists and pathway trackers (Qtr1)- Improved breach & Clinical Harm Review process (Jul18)- Forecasting & modelling activity with NHSI (Qtr2)- Improve local performance through increased diagnostic capacity (Qtr2)- Work with tertiary providers to reduce diagnostic waits (Qtr2)- Progress Cancer & Diagnostics Business As Usual Project (Mar19)

Impact: Recovery of performance against revised trajectory and continued reduction of patients waiting over 62days and 104days, ensuring timely treatment.

Governance:Daily oversight of tumour site level waiting lists continues with the Clinical Business Units, feeding into the weekly Trustwide Patient Access Group, the monthly Performance Reviews, Acute Services Performance Committee and Acute Services Board.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Jun

-17

Jul-

17

Au

g-1

7

Se

p-1

7

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Fe

b-1

8

Ma

r-1

8

Ap

r-1

8

Ma

y-1

8

Cancer urgent referral to treatment <62 days

Target achieved Target not achieved Target Trajectory

Page 5


Referral to Treatment Times

Analysis:

May 18

Commentary: The Trust has revised its performance trajectories for 2018/19 for each of its key national targets based on the 2017/18 outturn, 2018/19 year to date position and in alignment with NHSI guidance.

Issue:The Trust performed at 85.2% against the Referral to Treatment (RTT) 85.5% trajectory for May 2018 (the national target is 92%), sustaining the previous month's performance of around the same level. The requirement in quarter one is to have fully mobilised delivery of the 2018/19 planned activity levels, however, this has been affected by the impact of medical patients continuing to occupy surgical wards.

Actions:- Reduced LOS (Jun18)- Progress Theatres utilisations project (end date Oct18), Outpatient utilisation project (end date Jan19) and Unplanned patient flow project (end date Mar19)- Utilised STP footprint capacity as required (Mar19)- Delivering the 2018/19 elective activity plan (Mar19)

Impact:Undertaking inpatient activity will improve patient experience, reduce waiting times for elective procedures and recover the current under-performance as we commence 2018/19. Delivery of outpatient efficiencies will improve the non-admitted element of this performance target thereby, offsetting the current under-performance of the admitted element.

Governance:Daily oversight of the elective activity is undertaken by the Clinical Business Units, feeding into weekly RTT specialty meetings and the Trustwide Patient Access Group, the monthly Performance Reviews, Acute Services Performance Committee and Acute Services Board.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Jun

17

Jul

17

Au

g 1

7

Se

p 1

7

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Fe

b 1

8

Ma

r 1

8

Ap

r 1

8

Ma

y 1

8

RTT Incomplete IoW CCG

Target achieved Target not achieved

Target Trajectory

0.0%

50.0%

100.0%

150.0%

Jun

17

Jul

17

Au

g 1

7

Se

p 1

7

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Fe

b 1

8

Ma

r 1

8

Ap

r 1

8

Ma

y 1

8

RTT Incomplete NHS England

Target achieved Target not achieved

Target Trajectory

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Jun

17

Jul

17

Au

g 1

7

Se

p 1

7

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Fe

b 1

8

Ma

r 1

8

Ap

r 1

8

Ma

y 1

8

RTT Incomplete IOW NHS Trust

Target achieved Target not achieved Target Trajectory

Page 6


Patients waiting > 6 weeks for diagnostics


May 18

Patients waiting > 6 weeks for diagnosticsIssue:The Trust performed in May 2018 at 97.5% against the diagnostic trajectory of 96% (national target is 99%) requiring patients receive their diagnostic test within 6 weeks of being referred; the trajectory is lower than the target due to planned reduction in capacity in May and June and reverts to 99% from quarter 2.

Actions:- Increase diagnostic imaging capacity required (MR & CT PbR Business Case submitted (Jul18) and reporting capacity (Sep18)- Increase nurse endoscopy capacity (Sep18 & Apr19) - recruitment completed with offer made- Progress Cancer & Diagnostics Business As Usual Project (Mar19)

Impact:Delivery of the recovery actions with realistic actions and timescales will enable a manageable waiting list size to be achieved, which, in turn will enable performance against the diagnostics target for all tests.

Governance:Delivery will be monitored by the Clinical Business Unit, Trustwide Patient Access Group, the monthly Performance Reviews, Acute Services Performance Committee and Acute Services Board.

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18

Target not achieved Target achieved Target Trajectory

Page 7


Benchmarking of Key National Performance Indicators: Summary ReportMay 18

Best Worst Eng

Emergency Care 4 hour Standards 95% 100% 70% 88.5% 82.4% 133 / 161 Red Qtr 4 17/18

RTT:% of admitted patients who waited 18 weeks or less 90% 100% 0% 86.9% 67.6% 155 / 161 Red Apr-18

RTT: % of non-admitted patients who waited 18 weeks or less 95% 100% 33% 95.4% 95.7% 119 / 186 Amber Red Apr-18

RTT % of incomplete pathways within 18 weeks 92% 100% 0% 87.1% 84.1% 152 / 184 Red Apr-18

%. Patients waiting > 6 weeks for diagnostic 1% 0% 22% 2.6% 2.1% 129 / 175 Amber Red Apr-18

Cancer patients seen <14 days after urgent GP referral 93% 100% 68% 94.5% 96.9% 29 / 149 Green Qtr 4 17/18

Cancer diagnosis to treatment <31 days 96% 100% 85% 96.4% 95.5% 120 / 153 Red Qtr 4 17/18

Cancer urgent referral to treatment <62 days 85% 100% 56% 83.0% 81.1% 108 / 152 Amber Red Qtr 4 17/18

Symptomatic Breast Referrals Seen <2 weeks 93% 100% 51% 92.3% 93.3% 79 / 129 Amber Red Qtr 4 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 100% 77% 94.5% 96.7% 81 / 148 Amber Red Qtr 4 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100% 89% 99.0% 100.0% 1 / 130 Green Qtr 4 17/18

Cancer Patients treated after screening referral <62 days 90% 100% 0% 90.7% 88.9% 79 / 135 Amber Red Qtr 4 17/18

Key: Better than National Target = Green Top Quartile = Green

Worse than National Target = Red Median Range Better than Average = Amber Green

Median Range Worse than Average = Amber Red

Bottom Quartile Red

Data PeriodIW RankNational

Target

National Performance IW

PerformanceIW Status

Page 8


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other 'Small Acute Trusts'May 18

Other Small Acute Trusts

Emergency Care 4 hour Standards 95% 82.4%21

87.6%15

98.1%2

98.7%1

82.7%20

84.7%18

91.7%10

NA 94.1%6

92.3%9

81.3%24

96.0%3

93.2%7

90.3%13

NA 85.0%17

90.5%12

NA 94.9%4

86.7%16

81.3%23

82.8%19

89.2%14

90.7%11

81.8%22

93.1%8

NA 94.3%5

Qtr 4 17/18

RTT % of incomplete pathways within 18 weeks 92% 84.1%19

90.1%14

92.1%9

87.7%16

93.0%4

NA 89.5%15

NA 90.3%13

92.7%6

80.2%21

84.2%18

95.1%2

93.2%3

NA 90.4%12

91.0%11

NA 92.9%5

84.7%17

N/A 83.1%20

92.3%8

92.4%7

78.4%22

92.0%10

NA 96.0%1

Apr-18

%. Patients waiting > 6 weeks for diagnostic 1% 2.1%17

0.2%5

0.7%13

12.6%23

0.3%7

22.4%24

0.6%11

NA 2.5%18

6.7%20

7.0%21

1.8%16

0.0%1

0.1%4

NA 0.3%8

8.6%22

NA 0.5%9

4.6%19

0.6%12

0.0%1

0.0%1

0.5%10

0.9%15

0.8%14

NA 0.2%6

Apr-18

Cancer patients seen <14 days after urgent GP referral 93% 96.9%5

94.0%25

96.1%14

92.2%28

95.6%21

91.7%30

94.3%23

NA 96.5%11

96.5%12

97.2%3

95.8%19

89.4%31

95.7%20

NA 96.6%9

97.0%4

NANA

96.9%7

96.2%13

92.9%27

98.3%1

96.5%10

96.0%15

95.9%18

94.3%23

NA 95.9%17

Qtr 4 17/18

Cancer diagnosis to treatment <31 days 96% 95.5%19

93.7%21

97.1%16

96.3%18

100.0%1

97.3%15

93.4%23

NA 99.2%9

100.0%1

97.5%13

98.0%10

100.0%1

97.7%12

NA 100.0%1

97.4%14

NA 95.5%20

100.0%1

93.4%22

97.0%17

100.0%1

100.0%1

97.9%11

84.8%24

NA 100.0%1

Qtr 4 17/18

Cancer urgent referral to treatment <62 days 85% 81.1%19

73.9%24

85.3%15

79.5%21

92.1%2

76.4%23

83.4%18

NA 90.6%4

90.4%6

80.7%20

89.0%8

91.4%3

90.5%5

NA 84.7%16

85.7%14

NA 85.9%13

88.4%10

87.9%11

86.1%12

92.9%1

88.8%9

89.4%7

83.5%17

NANA

79.4%22

Qtr 4 17/18

Breast Cancer Referrals Seen <2 weeks 93% 93.3%15

95.1%12

98.8%4

90.9%19

51.2%23

91.7%18

92.0%17

NA 89.4%21

95.2%11

97.0%7

95.9%8

NA 95.8%9

NA 92.4%16

98.8%5

NA 99.5%2

90.6%20

72.0%22

99.7%1

94.8%14

95.0%13

99.1%3

97.9%6

NA 95.3%10

Qtr 4 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 96.7%16

92.9%22

94.1%19

97.1%15

100.0%1

100.0%1

94.4%18

NA 96.6%17

100.0%1

93.3%21

100.0%1

100.0%1

100.0%1

NA 100.0%1

85.2%24

NA 100.0%1

100.0%1

90.9%23

94.1%19

100.0%1

100.0%1

100.0%1

100.0%1

NA 100.0%1

Qtr 4 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100.0%1

90.9%20

100.0%1

98.0%18

NA 95.7%19

100.0%1

NA 98.8%17

100.0%1

99.1%16

100.0%1

100.0%1

100.0%1

NA 100.0%1

100.0%1

NA 100.0%1

100.0%1

NA 100.0%NA

NA 100.0%1

100.0%1

100.0%1

NA NA Qtr 4 17/18

Cancer Patients treated after screening referral <62 days 90% 88.9%15

81.8%19

80.0%NA

100.0%1

100.0%1

66.7%23

90.3%14

NA 100.0%1

85.0%17

94.4%12

81.5%20

100.0%1

91.0%13

NA 95.1%11

79.2%22

NA 98.3%8

100.0%1

95.7%10

88.2%16

50.0%24

83.7%18

96.0%9

100.0%1

NA 100.0%1

Qtr 4 17/18

National

TargetData PeriodRLQ RLTRJD RJFRFF RFW RGR RJC RQQRNZRNQRN7RMPIW RBD RBT RBZ RC1RA3 RA4 RQXRJNRC3 RCD RCF RCX RD8 RE9

Page 9


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other Trusts in the 'Wessex Area'May 18

Emergency Care 4 hour Standards 95% 82.4%8

NA 98.7%2

85.2%6

NA 91.9%3

87.4%5

84.3%7

89.5%4

99.5%1

Qtr 4 17/18

RTT % of incomplete pathways within 18 weeks 92% 84.1%10

99.6%1

87.7%7

88.0%6

94.7%2

88.8%5

86.5%8

85.9%9

90.5%4

94.5%3

Apr-18

%. Patients waiting > 6 weeks for diagnostic 1% 2.1%6

0.0%1

12.6%10

0.9%5

0.0%1

0.3%4

3.1%8

2.2%7

3.4%9

0.0%1

Apr-18

Cancer patients seen <14 days after urgent GP referral* 93% 96.9%5

NA 92.2%28

98.2%2

NA 96.0%16

93.9%26

95.6%22

96.8%8

NA Qtr 4 17/18

Cancer diagnosis to treatment <31 days* 96% 95.5%6

NA 96.3%5

97.9%3

NA 96.8%4

89.6%7

99.0%2

99.2%1

NA Qtr 4 17/18

Cancer urgent referral to treatment <62 days* 85% 81.1%5

NA 79.5%6

87.6%2

NA 89.1%1

78.7%7

83.9%4

85.3%3

NA Qtr 4 17/18

Breast Cancer Referrals Seen <2 weeks* 93% 93.3%5

NA 90.9%6

98.3%2

NA 100.0%1

81.4%7

95.1%4

95.9%3

NA Qtr 4 17/18

Cancer Patients receiving subsequent surgery <31 days* 94% 96.7%4

NA 97.1%2

97.1%2

NA 95.7%6

86.7%7

98.0%1

96.5%5

NA Qtr 4 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days* 98% 100.0%1

NA 98.0%7

100.0%1

NA 100.0%1

100.0%1

99.1%6

100.0%1

NA Qtr 4 17/18

Cancer Patients treated after screening referral <62 days* 90% 88.9%7

NA 100.0%1

98.6%3

NA 93.3%5

89.3%6

94.0%4

100.0%1

NA Qtr 4 17/18

Key: Better than National Target = Green R1F Isle Of Wight NHS Trust

Worse than National Target = Red R1C Solent NHS Trust

RBD Dorset County Hospital NHS Foundation Trust

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RD3 Poole Hospital NHS Foundation Trust

out of the 10 other trusts in the Wessex area RDY Dorset Healthcare University NHS Foundation Trust

RDZ The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust

RHM University Hospital Southampton NHS Foundation Trust

RHU Portsmouth Hospitals NHS Trust

RN5 Hampshire Hospitals NHS Foundation Trust

RW1 Southern Health NHS Foundation Trust

RDYNational

TargetIW R1C RBD RD3 Data PeriodRDZ RHM RHU RN5 RW1

Page 10

Isle of Wight NHS Trust Board Performance Report 20 17/18May 18Glossary of Terms

Terms and abbreviations used in this performance re port

Quality & Performance and General terms QCE Quality Clinical ExcellenceAmbulance category A Immediately life threatening calls requiring ambulance attendance RCA Route Cause AnalysisBAF Board Assurance Framework RTT Referral to Treatment TimeCAHMS Child & Adolescent Mental Health Services SUS Secondary Uses ServiceCBU Clinical Business Unit TIA Transient Ischaemic Attack (also known as 'mini-stroke')CDS Commissioning Data Sets TDA Trust Development AuthorityCDI Clostridium Difficile Infection (Policy - part 13 of Infection Control booklet) VTE Venous Thrombo-Embolism CQC Care Quality Commission YTD Year To Date - the cumulative total for the financial year so farCQUIN Commissioning for Quality & InnovationDFI Dr Foster IntelligenceDNA Did Not AttendDIPC Director of Infection Prevention and ControlEMH Earl Mountbatten Hospice Workforce and Finance termsFNOF Fractured Neck of Femur CIP Cost Improvement ProgrammeGI Gastro-Intestinal CoSRR Continuity of Service Risk RatingGOVCOM Governance Compliance CYE Current Year EffectHCAI Health Care Acquired Infection (used with regard to MRSA etc) EBITDA Earnings Before Interest, Taxes, Depreciation, AmortisationHoNOS Health of the Nation Outcome Scales ESR Electronic Staff RosterHRG4 Healthcare Resource Grouping used in SUS FTE Full Time EquivalentHV Health Visitor HR Human Resources (department)IP In Patient (An admitted patient, overnight or daycase) I&E Income and ExpenditureJAC The specialist computerised prescription system used on the wards NCA Non Contact ActivityKLOE Key Line of Enquiry RRP Rolling Replacement ProgrammeKPI Key Performance Indicator PDC Public Dividend CapitalLOS Length of stay PPE Property, Plant & EquipmentMRI Magnetic Resonance Imaging R&D Research & DevelopmentMRSA Methicillin-resistant Staphylococcus Aureus (bacterium) SIP Staff in PostNG Nasogastric (tube from nose into stomach usually for feeding) SLA Service Level AgreementOP Out Patient (A patient attending for a scheduled appointment)OPARU Out Patient Appointments & Records UnitPAAU Pre-Assessment UnitPAS Patient Administration System - the main computer recording system usedPALS Patient Advice & Liaison Service now renamed but still dealing with complaints/concernsPATEXP Patient Experience PATSAF Patient SafetyPEO Patient Experience Officer - updated name for PALS officerPPIs Proton Pump Inhibitors (Pharmacy term)PIDS Performance Information Decision Support (team)Provisional Raw data not yet validated to remove permitted exclusions (such as patient choice to delay)

Page 11

Agenda Item No 19 MeetingMeeting Date

Title


Author(s)Report previously considered by inc date

X

XXX

X

X XX XX

Executive Summary Position:Proxy reporting of new Ambulance Response Programme national targets commenced and being submitted nationally; April's position is shown here.

Action:Priority actions continue alongside the implementation of reporting against the new Ambulance targets are: - review of governance and leadership requirements;- review of current transfer and discharge process; - further development of a fully integrated call handling hub - evaluation of service requirements to determine requirements to meet standards on a daily basis - review of hub and operational processes to deliver ARP sustainably; and, - implementation of new CAD.

Impact:Performance information, as it develops, will inform the trajectory for delivery against the new ARP standards; it is forecast it will remain at baseline for quarter 1 with an increase upwards to meet the core standards by September.

Governance:The performance of the Service is being monitored and managed throughout the Trust, however, the Ambulance Service is currently reviewing its governance structures in line with the new Trust Executive stuctures.

Key RecommendationThe Board is asked to consider the following recommendations:- To note the current performance position of the ambulance service

Effective ResponsiveCaring Well-ledSafe

Provide safe, effective, caring and responsive services – ‘Good’ by 2020Ensure efficient use of resourcesAchieve NHS constitutional patient access standardsAchieve excellence in employment, education and developmentLead strategic change on the Isle of WightLink to CQC Domains




Link to Trust Strategic Objectives

Purpose of the reportInformation only AssuranceReview and discuss AgreementTrust Board Approval is required


Performance Report - Ambulance Services & Patient Transport Services

Bob Williams, Advisor to the Trust Board - Ambulance

Victoria White, Head of Operations - Ambulance

Performance Committee - 4th July

Enc Q

Isle of Wight NHS Trust Board Performance Report 2018/19

Index

Ambulance Services & Patient Transport Services 3-4 Ambulance - Performance Summary……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..3 Ambulance Performance - New Ambulance Response Programme…………………………………………………………………………………………………………………………………………………. 4

May 18

Page 2


Performance Summary - Ambulance

Target Actual Target Actual Target Actual Target Actual

MRSA (confirmed MRSA bacteraemia) May-18 0 0 0 0 Mixed Sex Accommodation Breaches May-18 0 0 0 0

C.Diff (confirmed Clostridium Difficile infection - stretched target) May-18 0 0 No. of Complaints May-18 7 20

Clinical Incidents (Major) resulting in harm (all reported, actual & potential,

includes falls & PU G4)May-18 1 0 3 0 No. of Concerns May-18 16 24

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by

investigation)May-18 0 2 No. of Compliments May-18 N/A 0

Falls - resulting in significant injury May-18 0 0 Emergency Care 4 hour Standards May-18 95% 88.0% 95% 85.4%

Never Events May-18 0 0 0 0Number of patients who have waited over 12 hours in A&E from decision to admit

to admissionMay-18 0 0 0 0

Pressure Ulcers - Grade 1 May-18 0 2 Ambulance response on scene by category - Category 1 - Mean May-18 00:16:31 0% -

Pressure Ulcers - Grade 2 May-18 2 3 Ambulance response on scene by category - Category 1 - 90th centile May-18 00:18:41 0% -

Pressure Ulcers - Grade 3 May-18 0 1 Ambulance response on scene by category - Category 2 - Mean May-18 00:14:01 0% -

Pressure Ulcers - Grade 4 May-18 0 0 Number of Ambulance Handover Delays over 1 hours May-18 4 4

Pressure Ulcers - Ungradable May-18 0 0 No. of Reported SIRIs * May-18 3 6

Physical Assaults against staff May-18 2 6

Verbal abuse/threats against staff May-18 4 7


Appraisals May-18 49.0%

Plan Actual Plan Actual Target Actual Target Actual

Total SLA Value Apr-18 Not Available Not Available Not Available Not Available % Sickness Absenteeism May-18 5.5% 4.12% 4.80%

Ambulance time to answer call (in seconds) - median May-18 1 1 - -

Ambulance time to answer call (in seconds) - 95th percentile May-18 5 21 - -

Ambulance time to answer call (in seconds) - 99th percentile May-18 14 78 - -

NHS 111 Call abandoned rate May-18 5% 2.1% 5% 1.8%

NHS 111 All calls to be answered within 60 seconds of the end of the introductory

message May-18 95% 96.0% 95% 95.9%

NHS 111 Where disposition indicates need to pass call to Clinical Advisor this should

be achieved by ‘Warm Transfer’ May-18 95% 90.5% 95% 91.5%

NHS 111 Where the above is not achieved callers should be called back within 10

mins May-18 100% 40.7% 100% 37.9%

*12 hour breaches are now included in Siri figures **The Acute Service Level Agreement performance reports a month behind, therefore figures are from April 2018.

YTD

YTD

Income**Latest

data

In Month YTD Cost effective, sustainable services Latest

data

In Month

YTD

Working with others to keep improving our services

Latest

data

In Month YTD Skilled and capable staff Latest

data

In Month

May 18

Balanced Scorecard - Ambulance

Excellent Patient CareLatest

data

In Month YTD A positive experience for patients, service users and staff

Latest

data

In Month

Key Headlines:Priority actions continue alongside the implementation of reporting against the new Ambulance targets are:

- review of governance and leadership requirements;

- review of current transfer and discharge process;

- further development of a fully integrated call handling hub

- review of hub and operational processes to deliver ARP sustainably; and,

- implementation of new CAD.

- evaluation of service requirements to determine requirements to meet standards on a daily basis

Service has reviewed staff survey results and is currently forming an action plan to address further improvements

Page 3


New Ambulance Response Programme


Analysis:

May 18

Position:Proxy reporting of new Ambulance Response Programme national targets commenced and being submitted nationally; May's position is shown here.

Action:Priority actions continue alongside the implementation of reporting against the new Ambulance targets are: - end to end review of all CAT1incidents- weekly review and validation of all Cat 1- Cat4 and call handling outliers - continued development of a fully integrated call handling hub - Education sessions for ambulance performance support officers re ARP- review of hub and operational processes to deliver ARP sustainably; and, - implementation of new CAD.

Impact:Performance information, as it develops, will inform the trajectory for delivery against the new ARP standards; it is forecast it will remain at baseline for quarter 1 with an increase upwards to meet the core standards by September.

Governance:The performance of the Service is being monitored and managed throughout the Trust, however, the Ambulance Service has reviewied and now implemented its new governance structures in line with the new Trust Executive stuctures.

Page 4

Page | 1


Date 5 July 2018

Title Community Services Performance Report Sponsoring Executive Director

Barbara Stuttle, Director of Nursing, Midwifery, AHPs & Community Services

Author(s) Charlise Cuthbert, Operations Managers – Community Services Report previously considered by inc date

Performance Committee – 4 July 2018

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight X Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary Summary of Progress The following summarises areas of progress across the Community Division since the last report

• Revised leadership is in place and future community structure is being developed. • Quality, Performance and Finance indicator sets are being developed and first meetings of

community oversight group set for July. • Action plans have been developed and implementation is underway for the areas highlighted

in recent CQC review. • Community Nursing teams are using System One. • 30/60/90 days plans have been developed and are being implemented to drive 3 Localities

and multi-disciplinary working across Health and Care. • Work underway through community service redesign programme to identify the impact of

planned in year changes to community services. • Integrated Community Care Alliance agreement in place across all partner organisations

(Trust, IOW Council and Age UK) and new approach to monitoring and assurance is being implemented.

• Community dashboard is in development in conjunction with PIDs.

Enc R

Page | 2

Community Dashboard The community dashboard details activity under the following areas:

• Referrals • Activity • DNAs • Caseloads • Waiting Lists

These areas are split into nursing and AHP services to demonstrate the current demand on Community services. The dashboard highlights that referrals to Community services has increased, and as such caseload monitoring is imperative to not only patient safety but staff wellbeing. Performance information for Community Nursing will continue to develop as the new System develops and is fully embedded within the teams. Referral data is demonstrating an increase in patients referred with diabetes, which is reflected in an increase to podiatry, community nursing and dietetics. There is also an increase in acuity of patients and a shift from task based visits to holistic care planning which will demonstrate a reduction in follow up activity. Orthotics continue to decrease the waiting list, however once all productive works have been completed it is anticipated that there will be a 12% gap between capacity and demand (based on current referral trends). Sexual Health services continue to meet their key performance indicators for access. Key Recommendation The Board is asked to consider the following recommendations:

To note the current performance position of the Community Services


Index

Community Services 3 Community - Dashboard…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..3

May 18

Page 2

3

Agenda Item No 19 MeetingMeeting

Date

Title

Sponsoring Executive

Director

Author(s)

Report previously

considered by inc date

X

X

X

X

X

X X

X X

X

Trust Board Approval is required


Performance Report - Mental Health & Learning Disabilities Services

Dr Lesley Stevens Director of Mental Health and Learning Disabilities

John Doherty, Head of Mental Health and Learning Disabilities

Performance Committee - 4th July 18

Purpose of the report

Information only Assurance

Review and discuss Agreement

Link to CQC Domains




Link to Trust Strategic Objectives

Provide safe, effective, caring and responsive services – ‘Good’ by 2020

Ensure efficient use of resources

Achieve NHS constitutional patient access standards

Achieve excellence in employment, education and development

Lead strategic change on the Isle of Wight

Effective Responsive

Caring Well-led

Safe

Executive Summary

• Mental Health and Learning Disabilities Division (MH & LD) is establishing a new governance structure, this

will be agreed at the first divisional board on 10th July 2018 and commence from August 2018

• A new MH&LD dashboard is being developed that will support the governance structure and extend to team

level performance boards. Consequently please note the dashboard in this report is in development.

• Two operations managers have started in June in CMHS and Older People’s services and the new

Rehabilitation and IRIS operations manager is due to start in July.

Summary Of Performance:

• Effective:

o The Data for CPA is under development, this data is being validated in conjunction with the CPA Quality

Improvement work which includes caseload supervision

o There were 4 breaches for Gatekeeping by CRHT in May, due to CRHT not being involved in Mental Health

Act and Mental Capacity Act admissions

• Well Led

o Staff engagement survey for MH&LD launched to benchmark and inform work plan for next 12 months

o Caseload management recording is low, new team level dashboard being created which will improve data

quality.

• Safe

o New HR Officer assigned to MH&LD to support recruitment drive. Team leader posts being recruited to which

will reduce vacancies due to secondments, CMHS has recruited new staff and phasing the caseload handover

with agency.

• Responsive

o IAPT access rate 20% in May which is below the local target of 23%, this is due to workforce capacity.

National drive to increase to 25% by 2020, discussions being had with commissioners regarding capacity and

funding.

o MH & LD RTT task and finish group commenced on 26/06/18 to improve waiting times.

Finance:

• Year to date M2 is overspent by £78k due to Liaison Psychiatry £55k (funding to be recharged from Corporate

M3) plus agency covering vacancies.

• Agency anticipated to reduce following recruitment in CRHT, CMHS and the Medical budget and agency

premium expected to be on plan in line with the CIP target.

Operational Risks:

• IRIS: Alcohol Detox Team in business continuity due to vacancies and difficulties in recruitment.

o Mitigation: Business continuity planned to continue to end of July 2018. Weekly oversight meetings with PHE

commissioners. Recruitment underway with some success, but key gaps in clinical leadership. Working with

commissioners to review model of care in order to increase resilience.

• Early Intervention in Psychosis team in business continuity due to high levels of staff sickness.

o Mitigation: In Business continuity planned to continue to end of July 2018, agency nurse started and 0.5 band

7 nurse temporarily redeployed. Nurse led clinic being implemented.

Key Recommendation

The Board is asked to consider the following recommendations:

- To note the current performance position of the Mental Health & Learning Disabilities Service

Enc S


Index

Mental Health 3

Mental Health - Performance Summary……………………………………………………………………………………………………………………………………………………………………………… 3

May 18

Page 2


Performance Summary - Mental Health and Learning Disabilities


% of people on CPA with an updated risk assessment

completed within the last 12 monthsMay-18 100% 88% 100% 88% No. of Reported SIRIs * May-18 3 4

CMHS: % of CPA patients having formal review within last 12

months May-18 Not Available Not Available

Clinical Incidents (Major) resulting in harm

(all reported, actual & potential, includes falls & PU G4)May-18 1 0 3 0

CMHS: % of caseload on CPA May-18 50% 23% 23%Clinical Incidents (Catastrophic) resulting in harm

(actual only - as confirmed by investigation)May-18 0 1

CMHS: % of people over expected cluster time May-18 7% Number of Restraints May-18 Report being built

Number of people followed up within 7 days of inpatient

careMay-18 validation ongoing Number of Seclusions May-18 Report being built

% of admission gatekept by CRHT (incl MHA assesments) May-18 95% 79% 83% Vacancies May-18 54

% of IRIS KPI's met Q1 2018/19 next month next month

Readmission rates within 90 days May-18 Not set 8% Not set 8.7%

CaringLatest

data

Number of complaints May-18 3 7.00

Clinical supervision May-18 Not Available Not Available Number of compliments May-18Not

Available

Not

Available

Mandatory training compliance May-18 80% 80% 80% 81% Friends and Family Test data May-18 3017 5969

ResponsiveLatest

data

Target Actual Target Actual

Staff surveys Jul-18 IAPT Access May-18 23% 20% 22%

Appraisal % May-18 55%EIP: Psychosis treatement with a NICE approved Care Package

within 2 weeksMay-18 50% 100% 50% 100%

Caseload management supervision May-18 22% 41%CAMHS: % of children and young people under 18 estimated with

a diagnosable mental health condition accessing May-18

In

Development

In

Development

Sickness levels May-18 5% 4% 6%CAMHS: Proportion of CYP with Eating Disorder (routine) that wait

4 weks or less from referral to NICE approved pathwayMay-18

In

Development

In

Development

CAMHS: Proportion of CYP with Eating disorders (urgent) that wait

1 week or less from referral to NICE approved pathwayMay-18

In

Development

In

Development

Risk Register info May-18 12 19 RTT within 18 weeks (all services) May-18 92% 89%

Inpatients: Bed Occupancy, May-18 93% 92%

Inpatients: Out of area placements for non specialist adult acute

careMay-18 0 1

Finance Latest dataNumber of patients in A&E waiting for a mental health assessment

for 4 hours or more May-18 6 9

May-18

*12 hour breaches are now included in Siri figures **The Acute Service Level Agreement performance reports a month behind, therefore figures are from April 2018.

May 18

Balanced Scorecard - Mental Health and Learning Disabilities

Effective Latest dataIn Month YTD

SafeLatest

data

In Month YTD

The number of people with LD and/ or ASD who are in

inpatient care for mental and/or behavioural health needs

placed off Island

May-18 8 10 8

In Month

Target Actual

YTD

Target Actual

Well Led Latest data In Month YTDIn Month

Target Actual

YTD

Target Actual

Scoring 15+ Scoring 12+

Key Headlines: Sickness levels had been improving but have increased again in April. The service will undertake a piece of work to understand the detail and trends. The 7-day follow-up target was achieved in March but unfortunately the CBU has been unable to consistenly achieve this target in year resulting a year end position lower than the required target. The CBU will discuss issues and improvement plans for this indicator at the next Leadership Meeting. The CBU is working with PIDS to develope new reports for reporting against the CPA formal review within 12 months indicator. Data validation is to be undertaken and when complete the report be backdated to October 17. RTT performance has dipped below target this month due to a number of long waits in the Single Point of Access for Adult MH Services, these waits are currently being validated. The CBU is aware of capacity issues within the Single Point of Access and work is ongoing to review Consultant Job Plans across the community service to create additional capacity for new patient assessments in the longer term. A new In-patient Consultant Psychiatrist has taken up post and will be providing additional capacity in Single Point of Access in the short term whilst completing the qualifications necessary for the in-patient role.

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Page 1 of 4


Date 5 July 2018

Title Board Assurance Framework Sponsoring Executive Director

Suzanne Rostron, Director of Quality Governance

Author(s) Claire Budden, Board Secretary Report previously considered by inc date

Board Workshop, 7 June 2018 Performance Committee, 4 July 2018 Quality Committee, 4 July 2018

Purpose of the report Information only Assurance X Review and discuss Agreement X Trust Board Approval is required X Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Well Led Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary This report provides the Board with details of the Board Assurance Framework for 2018/19 and the current position as at the end of quarter 1. It builds upon the outputs of the Board Workshop held on 7 June 2018. The report will be supplemented with any verbal feedback from the Performance Committee and Quality Committee meetings held on 4 July 2018. Key Recommendation The Board is recommended to:

• Support and approve the proposed minor changes to the wording of the strategic objectives for 2018/19;

• Consider the proposed strategic risks for each strategic objective and agree that those are the relevant strategic risks for the Trust for 2018/19;

• Consider the proposed inherent, current and target risk scores for each of the strategic risks; • Consider the proposed risk appetite for each strategic risk and agree that the risk appetites

accord with the views of the Board; and • Consider and agree with the details (controls, assurances, gaps and actions) provided for each

strategic risk. • Receive and approve the Board Assurance Framework for 2018/19

Enc T

Page 2 of 4

BOARD ASSURANCE FRAMEWORK

1. INTRODUCTION

Since December 2017 the Board has received and supported a refreshed Board Assurance Framework (BAF) which was fully in place for quarters 3 and 4 for 2017/18. In June 2018 the Board held a workshop that considered the strategic objectives for 2018/19 and the strategic risks for each of those strategic objectives. It also gave consideration to the risk appetite and inherent, current and target, risk scores for each of those strategic risks. Since the workshop the Board Secretary and Governance Advisor have worked with each of the Executive Directors to build upon the outputs of the workshop, with the output of a Board Assurance Framework for 2018/19 and a current position for the end of quarter 1 as detailed at Appendix A.

2. CORPORATE RISKS

As advised to the Board in May a review of the Trust’s operational risks scoring 12 or above at the end of 2017/18 identified the beneficial impact training to CBUs had made but identified that further work was required to complete a review of the risk registers with Divisions. During May and June a number of meetings took place with each of the four Divisions to further develop the content and quality of the Trust’s risk register and to strengthen the awareness of risk management linked to the Risk Management Policy. A full review of the Corporate Risk Register on a Divisional basis will take place at the next Operational Risk Sub-Committee using a standardised template to ensure consistency of approach on a Trust wide basis. In the meantime, this report includes an initial mapping of corporate risks reported to Operational Risk Sub-Committee in June to each of the strategic objectives / risks.

3. SUMMARY OF PROPOSED STRATEGIC OBJECTIVES AND STRATEGIC RISKS

At the Board Workshop in June 2018 consideration was given to the strategic risks and scores which have subsequently been further developed. Performance Committee and Quality Committee will have reviewed the respective strategic objectives and risks at their meetings on 4 July and verbal feedback will be provided as necessary. The strategic risk “Inability to achieve and maintain regulatory compliance” is overseen by Assurance, Risk and Compliance Committee. Although this Committee is not scheduled to meet until September, as the risk description and risk scores have not altered from those previously considered by the Committee in June, the Committee will be asked to receive the BAF retrospectively. The following table provides a summary of the proposed risk scores for the strategic risks for each of the strategic objectives:

Page 3 of 4

STRATEGIC OBJECTIVES AND STRATEGIC RISKS

INHERENT RISK SCORE CURRENT RISK SCORE AT Q1 TARGET RISK SCORE LEAD COMMITTEE EXECUTIVE LEAD Likelihoo

d Impact Score Likelihoo

d Impact Score Likelihoo

d Impact Score

STRATEGIC OBJECTIVE 01: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Inability to achieve and maintain regulatory compliance 4 4 16 4 4 16 3 4 12 Assurance, Risk

& Compliance Director of Quality

Governance Non-delivery of the outcomes of the Quality Strategy 4 4 16 3 4 12 2 4 8 Quality Director of Quality

Governance

Failure to deliver safe care 5 4 20 4 4 16 2 4 8 Quality Medical Director /

Director of Nursing / Director of Quality Gov

STRATEGIC OBJECTIVE 02: USE OF RESOURCES Expenditure incurred exceeds income by greater than agreed control total

4 5 20 4 5 20 3 5 15 Performance Director of Finance

STRATEGIC OBJECTIVE 03: PATIENT STANDARDS Failure to deliver patient standards of care including constitutional and contractual levels

4 4 16 4 4 16 3 4 12 Performance Divisional Directors

STRATEGIC OBJECTIVE 04: EXCELLENCE IN EMPLOYMENT Attract and recruit the right staff 4 5 20 4 5 20 3 4 12 Performance Director of Human

Resources & OD Develop and retain the right staff 4 5 20 4 5 20 3 4 12 Performance Director of Human

Resources & OD STRATEGIC OBJECTIVE 05: LEAD STRATEGIC CHANGE ON ISLE OF WIGHT Failure to drive cultural change; the future strategy for the provision of health services on Isle of Wight is not sufficiently being led by the Trust

4 4 16 4 4 16 2 4 8 Performance Deputy Chief Executive

Failure to set out and implement an analytics and digital technology strategy/plan

4 4 16 4 4 16 2 4 8 Performance Deputy Chief Executive

Failure to set out and implement an estates and facilities strategy/plan

4 4 16 4 4 16 2 3 6 Performance Director of Finance

Failure to comply with good IG and keep data safe 4 4 16 4 4 16 3 4 12 Performance Deputy Chief Executive

Page 4 of 4

4. SUMMARY OF PROPOSED RISK APPETITE FOR STRATEGIC RISKS

At the Board Workshop in June 2018 consideration was given to the risk appetite for each strategic risk and strategic objective. Conclusions were not finalised within the workshop and therefore the proposals below are the view of the respective lead Executive Directors.

STRATEGIC OBJECTIVES AND STRATEGIC RISKS

RISK APPETITE LEVELS Avoid Minimal Cautious Open Seek Mature

PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Inability to achieve and maintain regulatory compliance

Non-delivery of the outcomes of the Quality Strategy

Failure to deliver safe care USE OF RESOURCES

Expenditure incurred exceeds income by greater than agreed control total

PATIENT STANDARDS Failure to deliver patient standards of care including constitutional and contractual levels

EXCELLENCE IN EMPLOYMENT Attract and recruit the right staff

Develop and retain the right staff LEAD STRATEGIC CHANGE ON ISLE OF WIGHT

Failure to drive cultural change; the future strategy for the provision of health services on Isle of Wight is not sufficiently being led by the Trust

Failure to set out and implement an analytics and digital technology strategy/plan

Failure to set out and implement an estates and facilities strategy/plan

Failure to comply with good IG and keep data safe

Performance Committee and Quality Committee will consider risk appetite of their respective strategic objectives and strategic risks within their meetings and verbal feedback provided. Assurance, Risk and Compliance Committee is not scheduled to meet until September and therefore further consideration will be given to risk appetite in respect of “Inability to achieve and maintain regulatory compliance” at that time. A further Board Workshop regarding risk management with a specific focus on risk appetite and the impact upon target risk scoring will be scheduled to continue to develop the Board’s awareness of, and input to, this area.

5. RECOMMENDATIONS

• Support and approve the proposed minor changes to the wording of the strategic objectives for 2018/19; • Consider the proposed strategic risks for each strategic objective and agree that those are the relevant strategic

risks for the Trust for 2018/19; • Consider the proposed inherent, current and target risk scores for each of the strategic risks; • Consider the proposed risk appetite for each strategic risk and agree that the risk appetites accord with the views

of the Board; • Consider and agree with the details (controls, assurances, gaps and actions) provided for each strategic risk; and • Receive and approve the Board Assurance Framework for 2018/19.

BOARD ASSURANCE FRAMEWORK 2018/19 – Appendix A

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SO1: Objective: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020

Assurance Committee: ASSURANCE RISK AND COMPLIANCE COMMITTEE

Executive Lead: DIRECTOR OF QUALITY GOVERNANCE Operational Lead:

CQC Domain: ALL Enabling Strategy: QUALITY STRATEGY/ RISK MANAGEMENT STRATEGY Risks to objective Controls Gaps in controls Sources of

Assurance Assurance outcomes / gaps

Action plan Progress / Timescales

Principal risks: Condition: Inability to achieve and maintain regulatory compliance Cause: Lack of robust processes and management systems to provide evidence and assurance to regulatory agencies, poor understanding of minimum standards, ineffective governance, poor leadership. Consequence: Enforcement action, special measures, prosecution, financial penalties, reputational damage, loss of commissioner and patient confidence in provision of services

1. Governance structures

2. Clinical standards programme

3. 10 week ‘Safe’ programme

4. Executive walk rounds

5. Quality Impact Assessments for all service changes and CIPs that are considered

6. Professional standards

7. Trust policies and procedures

8. Quality Strategy and Risk Management Strategy

9. Board governance functioning effectively

10. Clinical audits/outcomes

11. Strengthened Divisional governance processes

12. Quality Committee and supporting arrangements in place

13. Registers for external agency visits and accreditations in place with mechanisms to identify and deliver regulatory requirements

14. IG Toolkit level 2/ Data Security & Protection Toolkit achieved for majority of requirements

1. Clinical Standards

programme in early stages 2. Lack of consistency or

co-ordination of Executive walk-rounds.

3. Inconsistent

challenge/accountability for maintaining professional standards.

4. Implementation of Quality Strategy – approved April 18

5. Embedding new

Divisional governance structures (commenced Q1 18/19)

6. Reporting of external

agency visits and accreditation requirements to be embedded at Divisional level

1. IG Toolkit level 2 IG

mandatory training not achieved

Management assurance:

1. Assurance, Risk and Compliance Committee

2. Performance Committee

3. Quality Committee

4. Safety Recovery Sub-Committee

5. Information Governance Sub-Committee

6. Operational Risk Sub-Committee

7. Divisional Boards

Gaps: 1. Safety Recovery

Sub-Committee to be established (commences 27/6/18)

2. Embedding Divisional Boards and supporting committees

1. To implement mock inspections and reviews across the Trust

2. Maintain Provider

information return with a quarterly review of data to identify any risks.

3. Embed new

governance structures at all levels of the organisation.

4. Provide training to

further develop functional risk registers

5. Implement a

process for formal recording of Executive walk rounds and any subsequent actions.

6. Continue to

develop the regulatory support from the Quality Governance Directorate

7. Ongoing

refinements of the PMO processes

8. Actions as detailed

within the Quality Strategy

9. 10 week

programme for key areas

To be completed to show development in Q2

Risks from Risk Register: As detailed at Appendix B

Metrics 1. Internal peer

review/mock inspection ratings

2. Improved regulatory standing

Outcomes: 1. Section 31

removed 2. Improved

regulatory position across the Trust

3. Progress on “Getting to Good” Independent / semi-

independent: 1. CQC 2. NHSI Oversight

meetings 3. QIPOG 4. CCG 5. Healthwatch

Inherent risk level (as at 1st April) Current risk level Target risk position by 31/3/19

Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score 4 4 16 4 4 16 3 4 12

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Assurance Committee: QUALITY COMMITTEE

Executive Lead: DIRECTOR OF QUALITY GOVERNANCE Operational Lead:

CQC Domain: ALL Enabling Strategy: QUALITY STRATEGY Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Non-delivery of the outcomes of the Quality Strategy. Cause: New strategy collating quality matters from across the Trust for consistent application and roll out Consequence: Failure to provide safe, effective, caring and responsive services.

1. Implementation plan for

the Quality Strategy – provider level

2. Divisional level Quality strategies and plans

1. Further development of

the implementation plan for the eight strands detailed in the Quality Strategy

2. Divisional priorities agreed at the end of Q1 – implementation yet to commence fully

Management assurance: 1. Quality

Committee 2. Safety Recovery

Sub-Committee 3. Divisional Quality

Committees 4. Patient Safety

Sub-Committee 5. Patient

Experience Sub-Committee

6. Clinical Effectiveness Sub-Committee



Sub-Committee to be established (27/6/18)


1. Quality Strategy work plan

2. Divisional level Quality Strategies & implementation plans

3. Continue to develop the support from the Quality Governance Directorate

4. Develop and implement engagement plan

5. Hold stakeholder

events (2-3) throughout the year


Risks from Risk Register:

As detailed at Appendix B

Metrics 1. As detailed in

each of the eight Quality Strategy strands

2. Complaints & compliments data

3. National Inpatient Survey

Outcomes: 1. Progress on

“Getting to Good” 2. Improved patient

experience 3. Improved clinical

outcomes (national audits, benchmarking)

Independent / semi-independent: 1. QIPOG 2. NHSI Oversight

Meetings 3. CCG 4. Healthwatch



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Assurance Committee: QUALITY COMMITTEE

Executive Lead: MEDICAL DIRECTOR/ DIRECTOR OF NURSING/ DIRECTOR OF QUALITY Operational Lead:

CQC Domain: SAFE / WELL LED Enabling Strategy: QUALITY STRATEGY Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Failure to deliver safe care Cause: multiple grounds of causality for failure to deliver safe care as identified in the 2018 CQC report indicating the Trust is inadequate on the safe domain across Community, Acute, Mental Health and Learning Disability services and requires improvement within Ambulance services. Consequence: Increased complication rate, poor clinical outcomes for patients, loss of commissioner and patient confidence in provision of services, reputational damage, continued regulatory intervention (special measures)

1. Clinical standards clearly

stated across the Trust’s services

2. Governance structures

3. Training programme (mandatory and non-mandatory)

4. Supervision and education

of clinical staff across all professions.

5. Clinical revalidation

6. Clinical Audit Programme including participation in relevant National Audit Programmes and reviews.

7. Mortality review process

8. Application of clinical pathways and guidelines.

9. R&D programme

10. Human factors training

11. 10 week safe programme

12. SI and Inquest processes and learning

13. Quality Strategy

1. Main themes

identified include: • Mandatory

training • Standard of

record keeping • WHO checklist • Staffing • Incident reporting

and learning • Environmental

risk assessments • Patient risk

assessment and escalation

• Systems and connectivity

• Safeguarding 2. Delivery of 10

week programmes across the Trust

Management assurance: 1. Quality

Committee 2. Safety Recovery

Sub-Committee 3. Operational Risk

Sub-Committee 4. Patient Safety

Sub-Committee 5. Patient

Experience Sub-Committee

6. Clinical Effectiveness Sub-Committee



Sub-Committee to be established


3. 10 week programme to be embedded

1. Application of 10

week programmes to address the main themes identified as gaps in control

2. Roll out of programme principles to other areas of the Trust not covered by the 10 week programme

3. Quality Strategy Implementation Plan


Risks from Risk Register: As detailed at Appendix B

Metrics 1. National Audits 2. Complication

Rates 3. Outlier alerts 4. HSMR/SMHI 5. NICE compliance 6. Internal peer

review/ mock inspection

Outcomes: 1. Progress on

“Getting to Good” 2. Improved patient

outcomes

Independent / semi-independent:

1. QIPOG 2. NHSI Oversight

Meetings 3. CCG 4. CQC 5. Healthwatch



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SO2: Objective: ENSURE EFFICIENT USE OF RESOURCES Assurance Committee: PERFORMANCE COMMITTEE

Executive Lead: DIRECTOR OF FINANCE Operational Lead: DEPUTY DIRECTOR OF FINANCE

CQC Domain: WELL LED Enabling Strategy: FINANCIAL RECOVERY PLAN Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Expenditure incurred exceeds income by greater than agreed control total Cause: Divisions and Corporate Departments do not deliver services within agreed budgets and do not achieve CIPs Block contract arrangements limit scope for payment Additional activity delivered may not result in increased income; due to levels of activity or coding issues Consequence: Impact on investment in quality Inability to meet regulatory requirements Reputational damage Impact upon recruitment Potential for financial special measures

1. Devolved and delegated budgets based on 2017/18 outturn in place with amendments for recurrent/non recurrent schemes

2. Improved financial

controls and governance in place

3. Some CIP schemes

agreed and further work ongoing

4. CIP process in place

through Service Improvement and Finance Sub committee

5. Financial Performance Review meetings in place with Divisions

6. Continuation of process

for expenditure reduction throughout the Trust

7. Substantive Director of Finance in place

8. External resource (KPMG and Moorhouse) consultancy arrangements in place to (a) support CIP plans (b) review of income maximisation and (c) develop contracting arrangements

9. Mechanisms for joint

working with other partners established and operating effectively with CCG and local authority

1. Ongoing development of accountability of Divisions – further improvements required

2. Cost reduction and

expenditure controls in place but with lack of consistent application within Divisions and corporate functions

3. Gap in identified CIP schemes and required level

4. Failure to include sufficient buffer on deliverability of CIP schemes

5. Limited measures in place for capacity restrictions

6. Limited planned

demand control measures in place

7. Plans to address commissioner QIPP targets

Management assurance: Key assurance mechanisms are: 1. Finance

Performance Reviews on a fortnightly basis

2. Consideration at Executive Management Team

3. Divisional, CBU, and Executive reports to Trust Leadership Committee

4. Reports to Service Improvement and Finance Sub-committee , Performance Committee and Trust Board

5. Internal Audit reports

6. Presentations and reviews with regulators at Oversight and QIPOG meetings

Gaps: 1. Under development

1. Increase accountability via monthly financial performance review meetings

2. Use scrutiny from

commercial partners and internal auditors to identify additional savings

3. Challenge CBUs on

the monthly finance reporting upwards from CBUs to Executive Directors

4. Identify real cost

reduction and expenditure controls with agreed timescales for delivery

5. Work with a

commercial partner to progress CIP schemes and identify other cost saving options


Risks from Risk Register: To be finalised 712 The Trust does not deliver the necessary improvements required in order to achieve removal from Special Measures 1215 Inadequate identification and implementation of Cost Improvement Programmes 1216 Inadequate achievement of Capital Resource Limit 699 Delivery of CIPs 1213 Failure to deliver the agreed Financial Plan 1214 Failure to plan effectively

Metrics 1. Run rate 2. I&E position 3. CIPs position 4. Activity

performance 5. Cash flow

Outcomes: 1. Reduced NHSI

regulation 2. Achieve Board

approved financial plan 3. Achieve NHSI

financial control total Independent / semi-

independent: 1. NHSI 2. CQC 3. Internal Audit 4. External Audit 5. Local Counter

Fraud Specialist



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SO3: Objective: PATIENT STANDARDS Assurance Committee: PERFORMANCE COMMITTEE

Executive Lead: DIVISIONAL DIRECTORS Operational Lead:

CQC Domain: RESPONSIVE Enabling Strategy: OPERATIONAL STRATEGY Risks to objective Controls Gaps in controls Sources of


Action plan Timescales

Principal risks: Conditions: Failure to deliver patient standards of care including constitutional and contractual levels

Causes: Flow, demand and capacity across each of (i) Acute, (ii) Ambulance, (iii) MH& LD, (iv) community services Wider issues of flow, demand and capacity across system partners including social care, 111, primary care etc. Lack of appropriately trained medical, nursing and allied healthcare staffing Instances of inappropriate use of system resources Service restrictions due to funding challenges

Consequence: Medically fit for discharge (MFFD) patients not progressing through the health and social care system ED breaching 4 hour targets Failure to achieve cancer standards RTT timelines not met

1. Integrated Trust provides the opportunity for collaborative working without organisational boundaries

2. Acute Services Redesign plan in draft and consultation underway

3. Identified focus for modernising community nursing and AHP delivery including greater self-care

4. Collaborative approach

to care planning with service users across mental health and learning disability services

5. Joint working between

CBUs and Divisions, to determine appropriate early access to diagnostics and best place of treatment for patients

6. Winter Plan including system winter plan

7. Workforce & OD and Recruitment & Retention strategies under development

8. Appropriate use of agency and locum staff

9. Local Care Board

10. Effective relationships with IW Council and CCG and primary care

1. Opportunities to maximise benefits of unified Trust not capitalised on.

2. Acute Service Redesign (ASR) model to be consulted, progressed and subsequently implemented

3. Consistent approach to promoting and educating users on self-management and collaboration to be developed

4. An Urgent Care Centres

model

5. Winter Plan has not been fully developed, costed and approved

6. Workforce &

Organisational development (OD) and Recruitment & Retention strategies to be finalised and approved

7. Inconsistency in

standards as a result of the utilisation of locum and agency staff

8. Plan for achievement of

Cancer targets requires further development


RTT targets requires further development


Emergency Department targets requires further development

11. Relationships with

primary care services require development

Management assurance:

1. Clinical Business

Unit reports to Acute Services Division

2. Divisional Board reports to Trust Leadership Committee

3. Consideration at

Executive Management Team

4. Directors of

Divisions reports to Performance Committee

5. Directors of

Divisions reports to Trust Board

6. Internal Audit

reports

7. Presentations and reviews with regulators at Oversight and QIPOG meetings

Gaps: 1. Divisional

governance structures to be fully functional and embedded

1. Support consultation, progression and subsequent implementation of the ASR

2. Develop an Urgent Care Centres model

3. Develop, cost and

seek approval of Winter Plan

4. Finalise and seek

approval of Workforce & OD and Recruitment and Retention strategies

5. Minimise use of

locum and agency staff in order to support the improvement in consistency in standards


seek approval of a plan for achievement of Cancer targets


seek approval of a plan for achievement of RTT targets


seek approval of a plan for achievement of Emergency Department targets

9. Relationship

development with system partners to support effective pathways and flow


Risks from Risk Register (score 15 and above): 1200 Implementation of Electronic ordering for GP's 1287 Unable to discharge all patients within 4hr Emergency Care Standards 1221 If unable to attract, recruit & retain sufficient staff of right quality/ skillset then the Trust will be unable to meet demand 1269 Insufficient staffing levels within IAPT M11 ED 4 hour target not met

Metrics: 1. Ambulance R1,

R2, 19min 2. A&E 4 hour

target 3. Cancer 62 day

target 4. RTT incomplete

target 5. DTOC system

performance

Outcomes: 1. Right place right

time for care 2. Timely access to

services with consistent flow through the health and social care system

Independent / semi-independent: 1. NHSI 2. CQC 3. Internal Audit 4. External agency

visits


Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score

4 4 16 4 4 16 3 4 12

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SO4: Objective: EXCELLENCE IN EMPLOYMENT Committee: PERFORMANCE COMMITTEE

Executive Lead: DIRECTOR OF HUMAN RESOURCES & ORGANISATIONAL DEVELOPMENT Operational Lead: DEPUTY DIRECTOR OF HR

CQC Domain: WELL LED Enabling Strategy: RECRUITMENT & RETENTION STRATEGY Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Attract and recruit the right staff Cause: Challenging recruitment picture across the NHS exacerbated by the Trust’s geographical location alongside a range of other issues Consequence: Failure to deliver high quality, safe patient care,

1. Produce weekly workforce information data and respond to trends

2. Effective and efficient recruitment processes rolled out

3. Appraisal policy, paperwork in place for all staff

4. Leadership Programme in place

5. Mandatory Training programme in place

6. Induction process for all new employees

7. Staff Recognition Programme in place

8. Visions & Values

9. Recruitment campaigns

1. Lack of finalised Recruitment and retention strategy

2. Lack of finalised Workforce and OD strategy

3. Development programme not fully in place

4. Not all new starters attending induction

5. Low compliance of Mandatory training

6. Releasing staff for

training

7. Not talent spotting / succession planning

8. Poor staff morale

9. Vision & values

Management assurance 1. HR & OD

Committee Mandatory Training Group

2. HR&OD Sub committee



Gaps: 1. Trajectory reporting

for workforce plan

1. Finalise the Recruitment and Retention strategy

2. Finalise the Workforce and OD strategy

3. Development programme to include;

• Kings Fund culture programme

• Published organisational standards

4. Leadership development programme for all managers underway

5. All staff attend induction on first day of employment

6. New policies reflecting the needs of staff developed and rolled out

7. Joint initiatives be

explored and introduced with external STP partners e.g. joint appointments, movement of staff between organisations and incentives to attract health professionals in to the area


Risks from Risk Register: 671 & 1221 If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skillset then it will be unable to meet demand 1343 Non-compliant with Public Sector Equality Duty 675 If the Trusts culture does not reflect our core values then we will be unable to deliver our vision, goals and priorities.

Metrics 1. Time to fill 2. Mandatory

Training Compliance 3. Appraisal

Monitoring 4. Sickness Data 5. Survey Results 6. Operating Plan

Outcomes: 1. Improved Staff

Survey results 2. Sickness absence

above target 3. Mandatory Training

above Target

Independent / semi-independent 1. NHSI 2. CQC 3. CCG



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SO4: Objective: EXCELLENCE IN EMPLOYMENT Committee: PERFORMANCE COMMITTEE

Executive Lead: DIRECTOR OF HUMAN RESOURCES & ORGANISATIONAL DEVELOPMENT Operational Lead: DEPUTY DIRECTOR OF HR

CQC Domain: WELL LED Enabling Strategy: WORKFORCE & OD STRATEGY Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Develop and retain the right staff Staff are not motivated, engaged or effective in delivery of the Trust’s vision, values and aims Cause: Poor staff morale, lack of clarity re objectives, lack of ability to influence, insufficient numbers of staff with appropriate skill mix. Stability of leadership team. Quality of appraisals. Poor communication. Consequence: Failure to deliver high quality, safe patient care,

1. Produce weekly workforce information data and respond to trends

2. Appraisal policy, paperwork in place for all staff

3. Leadership Programme in place

4. Mandatory Training programme in place

5. Induction process for all new employees

6. Whistleblowing Policy

7. Anti-Bullying Advisors in place

8. Freedom to speak up guardian process operating effectively with clear oversight

9. Staff Engagement Group in place

10. Staff Recognition Programme in place

11. OD & Workforce Policy

12. Clinical Supervision policy

13. Draft HR&OD Strategy

14. Visions & Values

15. Communications Strategy - meet your chief executive

1. Poor quality of appraisals

2. No clinical supervision

3. Low compliance of Mandatory training

4. Releasing staff for training

5. Not talent spotting / succession planning

6. Freedom to speak up guardian reporting

7. Poor staff morale

8. Vision & values

9. Lack of consistent communication at all levels

10. Lack of formal internal communications strategy

11. OD & Workforce

strategy not in place

12. Recruitment and Retention strategy not in place

Management assurance 1. Mandatory

Training Group

2. HR&OD Sub committee



5. Freedom to speak up guardian reports to Board

Gaps: 1. TBC

1. Finalise the Recruitment and retention strategy

2. Finalise the Workforce and OD strategy

3. Development programme to include; • Kings Fund culture

programme • Published

organisational standards

4. Leadership development programme for all managers underway

5. All staff attend induction on first day of employment

6. New policies reflecting the needs of staff developed and rolled out

7. Joint initiatives be

explored and introduced with external STP partners e.g. joint appointments, movement of staff between organisations and incentives to attract health professionals in to the area


Risks from Risk Register: 671 & 1221 If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skillset then it will be unable to meet demand 1343 Non-compliant with Public Sector Equality Duty 675 If the Trusts culture does not reflect our core values then we will be unable to deliver our vision, goals and priorities.

Metrics 1. Mandatory

Training Compliance 2. Appraisal

Monitoring 3. Sickness Data 4. Survey Results 5. Nursing/Medical

agency spend

Outcomes: 1. Improved Staff

Survey results 2. Reduced turnover

rate 3. Sickness absence

above target 4. Mandatory Training

above Target

Independent / semi-independent 1. NHSI 2. CQC 3. CCG



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SO5: Objective: LEAD STRATEGIC CHANGE ON ISLE OF WIGHT Committee: TRUST BOARD

Executive Lead: DEPUTY CHIEF EXECUTIVE Operational Lead: NONE

CQC Domain: WELL LED Enabling Strategy: TRUST OVERALL STRATEGY Risks to objective Controls Gaps in controls Sources of



Principal risks: Condition: Failure to drive cultural change; the future strategy for the provision of health services on Isle of Wight is not sufficiently being led by the Trust Cause: Lack of a Trust over-arching strategy and supporting clinical and other strategies Consequence: Failure to deliver a vision of effective, efficient, affordable high quality health services for the population of the Isle of Wight

1. Five new strategic

objectives initially proposed and agreed by the Board in November 2017 as part of Board Assurance Framework (BAF) and subsequently agreed by the Board as appropriate for 2018/19

2. Business Planning 2018/19 proposals considered by the Board leading to Business Plan and supporting Financial Plan Board approval

3. Development of the acute services redesign – option 4 recommended by CCG 1/2/18 and supported by the Trust’s Board

4. Local Care Board established with stated priorities

5. Creation of a community services redesign programme

6. Development of a blueprint for mental health & learning disabilities as new model for MH and progressing some tactical actions i.e.; relocation of early intervention in psychosis and community mental health

7. Solent Acute Alliance (SAA) to review how a range of services (pharmacy, spinal surgery, renal, vascular & back office) can be better coordinated between Southampton, Portsmouth and IoW

8. Creation of a pathology network across SAA and Hampshire and Dorset

1. No Isle of Wight Health

System Strategy in place that has been led by the Trust and supported by all stakeholder organisations

2. Current Trust strategy does not adequately meet the current and future needs of the organisation and does not fully or overtly address strategies for community, ambulance and mental health

3. Trust Strategy does not

fully derive options based on population need, prevalence and impact on pathways

4. Trust Strategy lacks clear delivery plan and staff and stakeholder engagement was limited

5. Trust Strategy does not

address the benefits of being an integrated Trust or whether these were currently being achieved

6. Supporting strategies not all in place approved by the Board

7. Lack of Trust

underpinning strategies including Estates & Facilities, IM&T, Workforce and Recruitment and Retention approved by the Board

8. System context is

complex and needs to take into account: the system-wide developments (listed under controls)

Management assurance 1. Consideration of

strategy at recent Board and Board Seminars

2. Plan agreed for the development of an overall strategy and underpinning supporting strategies

Gaps: 1. Specific gaps of

assurance to be outlined following the identification of specific assurance reports

2. Entry to special measures highlighted a lack of progress and drive to deliver – leadership

3. Financial position seriously deteriorated, highlighting the fragility of sub-scale services

The plan remains for the Trust to have a developed overall strategy between September 2018 and December 2018. Board has agreed the modular approach to the development of the strategy and the need for external support. A business case has been developed for external support and this has been submitted to NHSI. The Board to have evidence-based options on the overall organisational strategy and these to be worked up into an implementation road map with milestones, resources, engagement and the Board to confirm the level of appetite for change. This will cover all aspects of services the Trust is responsible for providing and which meets the current and future need of the Isle of Wight population, whilst delivering clinical and financial sustainability. To have answered a series of high-level questions that will shape the future, strategic position of service provided by the Trust (and partners), including: • Does the strategy

move the Trust to operational, clinical and financial sustainability?

• How will we exit special measures and get to good by 2020?

• What are the invest and disinvest criteria?

• Do we make, share or buy services and do we expand into new areas of health & social care, such as primary care, or withdraw from


Risks from Risk Register: 1212 The Trust does not deliver the necessary improvements required in order to achieve removal from Special Measures 1280 Trust planning does not meet current or future demand of IWAS 676 ICT 1089 The Trust Board is not sufficiently sighted on performance, risks and issues for the MH&LD CBU 1177 Cisco Prime Network Management 1356 Lack of clarity in relation to funding allocation for MH&LD services

Metrics 1. To be a clinically,

operationally and financially sustainable Trust

Outcomes: 1. Isle of Wight Health

System Strategy led by the Trust and supported by all stakeholder organisations

2. Trust Strategy approved by the Board

3. Trust supporting strategies including Clinical, Operational and Financial approved by the Board

4. Trust enabling

strategies including Estates & Facilities, IM&T, Human Resources and Organisational Development approved by the Board

Independent / semi-independent 1. Local Care Board

2. NHSI

3. CQC

4. Carnall Farrar

report

5. Internal Auditors

6. Other external advisors to the Trust

some aspects of current provision?

• What is the Trust’s position on a different organisational model?

To clearly describe the benefits of being an integrated Trust with supporting and enabling strategies



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Principal risks: Condition: Failure to set out and implement an analytics and digital technology strategy/plan Cause: Lack of a Trust ICT Strategy Consequence: Failure to deliver a vision of effective, efficient, affordable high quality health services for the population of the Isle of Wight

1. Increased Executive

Director and Trust Leadership Committee awareness

2. Trust-wide

workarounds in place to address gaps in IT provision caused by lack of strategic approach

3. ICT forums and

groups in place including regional groups external to the Trust via the STP

1. No Trust ICT Strategy

developed and approved by the Board

2. No Trust underpinning funded ICT plan developed and approved

3. No Trust Information Strategy developed and approved by the Board

4. No Trust

underpinning funded Information Plan developed and approved

5. Failure to articulate workplan

6. Lack of fully developed user group to support prioritisation and engagement

Management assurance 1. Performance

Committee

2. ICT Sub Committee

Gaps: 1. Supporting

internal groups and forums reporting to ICT Sub Committee and attended by representatives from each Division and Corporate Function

1. ICT Strategy to be

developed

2. ICT underpinning funded plan to be developed

3. Information Strategy

to be developed 4. Information

underpinning plan to be developed

5. User group to be

developed


Risks from Risk Register: 1212 The Trust does not deliver the necessary improvements required in order to achieve removal from Special Measures 76 ICT 1177 Cisco Prime Network Management

Metrics 1. No clinical risks

associated with ICT infrastructure / systems / information

Outcomes: 1. ICT Strategy

approved by Board 2. ICT underpinning

funded plan with agreed timescales

3. Independent / semi-independent 1. NHSE/I 2. CCG 3. STP 4. Local Care

Board 5. Internal Auditors

Inherent risk level (as at 1st April) Current risk level Target risk position by 31/3/19 Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score

4 4 16 4 4 16 2 4 8

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Principal risks: Condition: Failure to set out and implement an estates and facilities strategy / plan Cause: Lack of a Trust over-arching Estates and Facilities Strategies Consequence: Failure to deliver a vision of effective, efficient, affordable high quality health services for the population of the Isle of Wight

1. Increased Executive Director input

2. Trust-wide workarounds in place to address gaps in Estate provision caused by lack of strategic approach

3. Estate forums and groups in place including regional groups external to the Trust via the STP

4. Development of the acute services redesign – option 4 recommended by CCG 1/2/18 and supported by the Trust’s Board

5. Solent Acute Alliance (SAA) to review how a range of services (pharmacy, spinal surgery, renal, vascular & back office) can be better coordinated between Southampton, Portsmouth and IoW

1. No Estates and

Facilities Strategies developed and approved by the Board

2. No underpinning funded Estates and Facilities plans developed and approved

Management assurance 1. Performance

Committee

2. Estates and Facilities Sub Committee

Gaps: 1. Supporting

internal groups and forums reporting to Estates and Facilities Sub Committee and attended by representatives from each Division and Corporate Function

1. Estates and

Facilities Sub Committee to be established

2. Estates Strategy to be developed

3. Estates underpinning funded plan to be developed

4. Facilities Strategy to

be developed 5. Facilities

underpinning plan to be developed


Risks from Risk Register: 1212 The Trust does not deliver the necessary improvements required in order to achieve removal from Special Measures


associated with Estates and Facilities

Outcomes: 1. Estates and

Facilities Strategy approved by Board

2. Estates and Facilities underpinning funded plans with agreed timescales

Independent / semi-independent 1. NHSE/I 2. CCG 3. STP 4. Local Care

Board 5. internal Auditors

Inherent risk level(as at 1st April) Current risk level Target risk position by 31/3/19


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Principal risks: Condition: Failure to comply with good IG and keep data safe Cause: Lack of an IG Strategy and supporting IG plan Consequence: Failure to deliver a vision of effective, efficient, affordable high quality health services for the population of the Isle of Wight

1. IG Toolkit level 2/ Data

Security & Protection Toolkit achieved for majority of requirements

2. GDPR core requirements met

3. IG plan (and

underpinning GDPR plan) in place

2. IG Toolkit level 2 IG

mandatory training not achieved

3. No IG Strategy developed and approved by the Board

4. No underpinning fully-funded IG plan developed and consistently owned by all Divisions and Corporate Functions

5. Cyber security

concerns 6. Data security concerns

Management assurance 1. Assurance, Risk

and Compliance Committee

2. Information Governance Sub-Committee

3. Data Security

Audit

Gaps: 1. Consistent

attendance by all Divisions and Corporate Functions at IG Sub Committee

2. Additional external assurance from STP and IoW Digital Group to be developed

1. Achieve IG Toolkit

level 2 / Data Security & Protection Toolkit IG mandatory training for 2018/19

2. Develop IG Strategy developed and approved by the Board

3. Ensure IG plan is

revisited, fully-funded and consistently owned by all Divisions and Corporate Functions

4. Cyber security

issues addressed

5. Data security issues addressed

6. IG Improvement

Plan under development


Risks from Risk Register: 1212 The Trust does not deliver the necessary improvements required in order to achieve removal from Special Measures 676 ICT


associated with IG 2. No corporate

risks associated with IG

3. IAO identified %

Outcomes: 1. IG Strategy

approved by Board

2. IG Strategy underpinning funded plan with agreed timescales

3. Independent / semi-independent 1. internal Auditors 2. Information

Commissioners Office (ICO)

Inherent risk level(as at 1st April) Current risk level Target risk position by 31/3/19


Appendix B: Corporate Risk Register relating to Strategic Objective 1

M02 Unable to admit infected patients into single rooms 577 Patients within our care may develop ‘avoidable’ pressure ulcers 599 Diagnostic Imaging Department Facilities Inadequate 666 Pathology Information Management System 682 CQC inspections

1062 Capacity and Capability within the MH&LD CBU

1191 Insufficient psychological therapy in mental health services, resulting in excessive waiting times 1277 Un-reviewed Ophthalmology follow-up outpatient backlog

1294 Lack of standby outposts to enable effective dynamic deployment of staff 1304 Trained and sufficient Ambulance Service Strategic Commanders

1308 Lack of Suitable Transport for Ambulance Service Tactical Commanders to ensure an effective command structure

1326 Non-compliance of WHO Safety Check List 1332 GP Electronic ordering (ordercomms) for the Acute Trust to be implemented 1354 No funded CYP ASD service on the Island

1355 Insufficient staffing within the IRIS service to deliver a safe service to Adult Alcohol clients resulting in BCP arrangements

M01 Delays in completing discharges Summaries M04 No system one access M08 Safeguarding training out of date for significant numbers of staff M13 Noncompliance to infection control standards

549 Mixed economy of paper and electronic records and electronic patient record is not fit for purpose

623 Unsupported desktop environment

681 Without triangulation of incidents/complaints/claims lessons will not be learnt and effective decisions not taken

1073 Inadequate process around environment audits

1085 CQC - Conditions notice under section 31 of the Health and Social Care Act 2008 1101 Sustainability of microbiology service 1176 eCareLogic (EPR) Hardware Stack

1187 High risk to patients with airway issues if no anaesthetist is available with potential to lead to a catastrophic incident.

1188 Transfer of patients to mainland with Anaesthetist 1292 Lack of Paediatric Nursing cover within ED 1293 Failure to meet Ambulance Performance Standards 1311 Inadequate Staffing in Infection Prevention and Control Team

1329 Potential Harm to Patients and Trust Reputation from Operation of Hospital car Service 1359 labour suite ventilation fails to meet recommended standards

1365 Staffing Levels within MAU M05 Poor care or health and safety risk due to out of date mandatory training M07 Poor End of Life care M14 Poor documentation on inpatient wards 469 Unsupported electrical systems during power failure 716 Poor environment within Cellular Pathology and Blood Transfusion 933 No named oncology core member for the CUP MDT

1049 MRI capacity on Island

1274 Inadequate estates for Older persons Mental Health Services including Shackleton Afton and older persons CMHS

1285 No rolling replacement program for essential Ambulance equipment 1288 Non-compliance with EPRR Standards - ED Lock down 1290 Lack of Nursing Cover within ED

1291 Non Compliance against Standards for Children and Young People in Emergency Care Settings

1314 Negative impact for patients diagnosed with a Clostridium difficle (CDI) Healthcare Acquired Infection (HCAI

1344 The Trust is unable to guarantee time-appropriate transfer off island for patients who have urgent time-critical requirements

1345 Unreliable Fastext system - crews may not be notified in case of a Major Incident M10 Poor ward security

Trust Board Convened as

Corporate Trustee for the following

item

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Agenda Item No 26 Meeting Corporate Trustee Meeting Date

5 July 2018

Title Charitable Funds Strategy 2018 - 2021 Sponsoring Executive Director

Darren Cattell, Director of Finance, Estates and IM&T

Author(s) Katie Parrott, Senior Financial Accountant Report previously considered by inc date

Purpose of the report Information only Assurance Review and discuss Agreement X Trust Board Approval is required X Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources X Achieve NHS constitutional patient access standards X Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight X Link to CQC Domains Effective Responsive Caring Well-led X Safe Executive Summary The Strategy has been updated and linked to Trust objectives, following suggestions by the Charitable Funds Committee members. Key Recommendation The Corporate Trustees are recommended to approve the Charitable Funds Strategy

Enc U

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CHARITABLE FUNDS

CHARITABLE FUNDS STRATEGY 2018/19-2020/21

Isle of Wight NHS Trust Charitable Funds was registered with the Charity Commission with effect from the 1st April 2012 and is an umbrella charity with a Corporate Trustee, being the Board of IOW NHS Trust. There are approximately 50 funds comprised of restricted funds, numerous designated funds and a General fund resulting from donations, legacies, some research income together with actively raised funds for specific purposes. In order to ensure that the Charitable Funds are run efficiently and effectively, good governance principles and practice need to be established and implemented. The Trustees achieve good governance by following the principles of openness, integrity and accountability. The Charitable Funds are managed in line with the Trust’s Standing Financial Instructions (SFIs). The Charitable Funds Committee will work in partnership with staff, patients and the wider community to deliver this strategy. Charitable Funds are for any charitable purpose or purposes relating to the National Health Service and the objectives are to:

• Provide safe, effective, caring and responsive services through enhancing the environment and services provided by the IOW NHS Trust

• enhance the working lives of staff by supporting the Trust to achieve excellence in employment, education and development

• ensure the most effective, efficient and appropriate use of all available charitable funds • enhance and not substitute government funding of the core services of the NHS and so

aid strategic change on the Isle of Wight • maintain effective stewardship and use of the funds in accordance with the donors’

wishes. This includes careful consideration and scrutiny towards the purpose of any funds and the nature of fundraising activities to ensure they are aligned to our objectives and strategic direction.

Key Strategic Aim The Charitable Funds strategy will focus on ensuring utilisation of those funds in an effective and timely way. Objectives for the next three years are:

• To ensure that legacies and donations are maximised through Gift Aid and applied in accordance with the donors’ wishes, but in line with the charity objectives.

• To raise the profile of Charitable Funds through:- One significant campaign for something specific and tangible each year,

linked to the Trust Strategy More publicity inside the hospital and around the community to enable giving A digital presence and front page on the Trust’s web site Appointment of a fundraiser for 2019/20 onwards

• To promote, develop and implement an integrated approach with Fund Managers,

Friends of St. Mary’s and Healing Arts in order to focus effort and avoid duplication.

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• To ensure that there is an Investment/Reserve Policy which maximises income and capital growth while complying with the requirements of Acts of Parliament and Trustee responsibility to minimise risk.

Monitoring Reporting and monitoring arrangements of the Charitable Funds will be as follows:

• The Corporate Trustee will receive a verbal update of meetings at Trust Board meetings. Minutes will be made available if requested.

• Recommendations will be made to the Corporate Trustee to approve in line with SFIs. • An annual report and accounts will be submitted to the Charity Commission and

Corporate Trustee outlining achievements. • The Charitable Funds objectives will be reviewed annually and the Strategy bi-annually. • The Charitable Funds Committee will prepare an annual report, together with an

effectiveness review, for submission to the Audit Committee.

Corporate Trustee Approval: Strategy Review Date:

Documents

Isle of Wight NHS Trust Board NARU Update NARU Update ... July 2018.pdf · Isle of Wight NHS Trust Board Meeting in Public to be held on Thursday 5 July 2018 at 1.30pm -Conference