Part I (Open) Meeting of the Board of Directors Tuesday 29 … · 2019-10-25 · The Hillingdon Hospitals NHS Foundation Trust Part I (Open) Meeting of the Board of Directors Tuesday

The Hillingdon Hospitals NHS Foundation Trust

Part I (Open) Meeting of the Board of Directors

Tuesday 29 October 2019, 14.00 – 17.00

Furze Board Room, Hillingdon Hospital

AGENDA

Item Business Lead Format Indicative Timings

Business Matters

1 Welcome and Apologies for Absence Chair Verbal 14.00

2 Declarations of Interest Chair Verbal

3 Minutes of the meeting held on 25 September 2019 Chair Minutes

4 Matters Arising and Action Log Chair 5 Chair’s Report Chair Verbal 14.15 6 Chief Executive’s Report CEO Report 14.25

Quality & Performance

7 Patient Story CN/MD Verbal 14.40

8 Integrated Quality & Performance Report (Month 6, September 2019)

DoO Report

9 Hillingdon Improvement Plan MD Report 10 CARES + Report DoT Report

11 Infection & Prevention Control Annual Report, 2018/19 MD Report

Finance & Estates

12 Finance & Performance Committee Chair’s Report

Committee Chair Verbal 15.25

13 Finance Report (Month 6, September 2019) DoF Report

14 Estates Report DoE Verbal 15 NHSI Undertakings FD Report

Well-Led/Governance & Workforce

16 Audit & Risk Committee Chair’s Report

Committee Chair Verbal 16.15

17 BAF Summary Report DCEO Report

18 Annual Cycle of Business, 2019/20 TS Report

19 People Committee Chair’s Report

Committee Chair Verbal

20 Use of Seal TS Verbal Questions from the Public

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This item is an opportunity for members of the public to pose questions to the Board on matters that related to the Board agenda. Where possible, questions should be sent in advance to the Trust Secretary by Monday 21 October 2019, in order for the Board to ensure that relevant information is available to answer questions raised

Chair Verbal 16.45

Date of Next Meeting:

27 November 2019 (14.00 – 17.00) Board Room, Mount Vernon

Present:

Professor Lis Paice, Interim Chair Sarah Tedford, Chief Executive Linda Burke (NED) Dr Cathy Cale, Medical Director Janet Campbell (NED) Professor Soraya Dhillon (NED) Jenny Greenshields, Director of Finance Catherine Jervis (NED) Simon Morris, NED Jason Seez, Deputy CEO Tahir Ahmed, Director of Estates Terry Roberts, Director of People & OD Piers Young, Hospital Director

In Attendance:

Alan Hayes, Communications Officer Vanessa Saunders, Deputy Chief Nurse Vikas Sharma, Assistant Director (Information Governance) Chris Mann, Matron & Manager, Paediatrics Department Ian Brandon, GGI

Interim Trust Secretary: Michael Wood

Members of the Public:

Tony Ellis, Lead Governor Rosemary Jenkins, Public Governor Ahmet Moustafa, Public Governor M Bishop V Cook J Davis A Hays

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE BOARD OF DIRECTORS Part I, Open Meeting

Wednesday 25 September 2019

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A Khakoo Mr Singh A Thomas

1. Welcome and Apologies for Absence

1.1 The Chair welcomed all to the meeting, including Janet Campbell (NED). An apology for absence was received in respect of Richard Whittington, Deputy Chair/SID.

2. Declarations of Interest

2.1 There were no Declarations of Interest.

3. Minutes

3.1 The Minutes of the Part I (Open) meeting held on 31 July 2019 were approved as an accurate record of the meeting,

subject to it being noted that Dr Cathy Cale was the substantive Medical Director, not interim.

4. Matters Arising & Action Log

4.1 There were no matters arising from the Minutes. The Action Log was noted.

5. Chair’s Report

5.1 The Chair commented that her period as Interim Chair would end on 30 September and that she was delighted that Sir Amyas Morse had been appointed as the substantive Trust Chair from 1 October 2019.

5.2 The Board noted that the Chair had attended a series of meetings since the date of the last Board, including a meeting of London Chairs on 23 September where it was again recognised that Hillingdon Hospitals were high on the list for capital investment. The Chair further commented that she wished to see more dialogue and partnership working with social care, primary care networks and neighbouring Trusts moving forward.

6. Chief Executive’s Report

6.1 The Chief Executive reported the following matters:

• the Director of People was leading on Brexit preparations

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and was having regular meetings with the Centre in this regard;

• improved information for patients and staff was beingprepared in relation to major estates works for which £16.5mhad been received. It was hoped disruption could be kept tothe minimum wherever possible and a new decant ward wasplanned;

• the Trust was working on a detailed strategic outline case inrespect of a new hospital build;

• as part of the new Staff Survey, a series of open forum eventswould be held, to include Executive and NED members – theTrust wanted to receive as much information as possible byway of feedback;

• it was noted that Camilla Wiley (new Chief Nurse) would jointhe Trust on 21 October with Tina Benson (new ChiefOperating Officer) taking up post on 17 December.

7. QUALITY REPORTS

7.1 The Chair of the Quality & Safety Committee provided an overview of the Committee’s meetings held on 20 August and

19 September. Information relating to key metrics, including Infection Prevention Control, A&E and RTT was considered. A ‘deep dive’ presentation from Surgery was particularly informative for the Committee in respect of quality and risk issues, staffing being the primary risk. With regard to the care of elderly surgical patients, it was pleasing to note that the Trust was in the upper quartile nationally.

7.2 The Committee considered a new Consolidated Learning Report which was an essential part of an effective learning organisation, together with an update on progress in respect of the Trust’s Improvement Plan. With the appointment of the new Chief Nurse, there would be a renewed focus on quality walkabouts with the Executive and NEDs. The Committee also agreed its cycle of business for the year ahead.

Patient Story

7.3 The Board received a report from the Matron & Manager in Paediatrics in respect of an adolescent Cystic Fibrosis patient

and their experiences. The Chair thanked the Matron for her

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presentation.

Infection Prevention Control

7.4 Detailed consideration of the Annual Report on Infection Prevention Control, 2018/19 was deferred until the next meeting.

Hillingdon Improvement Plan

7.5 The Chief Executive provided the Board with an update on progress in respect of the Trust’s Improvement Plan. It was noted that a total of 13 work streams had now been established each led by a member of the Executive team, a key focus being on the ward accreditation programme which was to be extended to Mount Vernon. The Board learned that a detailed action plan was in place with regard to IPC, linked to ward accreditation. The monthly HIP Board included strong representation from external partners (CCG, CQC, Healthwatch) for assurance purposes.

7.6 The Chair of the Quality & Safety Committee commented that the Committee would be following up on CQC recommendations at its November meeting, to include evidence of actions taken. NEDs were cognisant of the previous CQC observation that the Trust was over-optimistic in addressing quality and safety issues. The Medical Director commented that staff were now far more prepared to speak up and to identify issues that needed to be addressed as part of a more open safety culture. This was welcomed by the Board.

Safer Nurse Staffing Report

7.7 The Deputy Chief Nurse presented the report to the Board for July 2019. It was commented that the Trust was reviewing its nurse recruitment to ensure that it have the best trained workforce possible, although it was accepted that there were currently a large number of HCAs. NEDs discussed the recent rise in patient falls and the need to maintain a careful balance of independence within a safe environment (ie not creating a dependency culture for patients).

7.8 The Director of People advised the Board that Apprentice Nurse Associate (ANAs) posts had been factored in to staffing plans, and the Trust was working closely with the RCN in this regard. The Chair of the People Committee commented that

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the Committee would be looking at job roles (including ANAs) at its January meeting.

The Board noted the report.

8. FINANCE & PERFORMANCE REPORTS

8.1 The Chair of the Finance & Performance Committee providedan overview of the Committee’s meetings held on 20 Augustand 18 September. It was noted that the Committee hadreviewed its Terms of Reference and had made a number ofproposed minor changes, including the requirement to meeton ten occasions during the year.

A key focus of the Committee had been theneed for the Trust to achieve its control target for Quarter 2,requiring some £1.2m in CIP savings. It was reported thatstrenuous efforts were being made on the part of theExecutive working closely with Divisions to deliver theseagreed savings.

8.2 The Committee was pleased to note that significant progress had been made on the BAF, members reviewing specific Finance and Performance risks in relation to this on-going work. As part of improved governance, a Capital Programme Group had been established, reporting to the Committee for assurance purposes. The Committee had also agreed its

annual cycle of business.

Integrated Performance Report

8.3 The Board considered the Integrated Performance Report for July 2019, as presented by the Hospital Director. The following key points were highlighted:

• the Trust was below its A&E trajectory for the monthand RTT performance remained challenging;

• the two-week wait for Cancer stood at 88.2% (cf 95%)and a recovery plan had been put in place to addressspecific specialty performance in this regard;

• the Trust had narrowly missed its 62 day treatmenttarget;

• with regard to those patients who remained inhospital over 7 days, the Trust was actively working

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with partners to improve this situation pre-winter, something NHSI had commented favourably upon as a best practice model.

8.4 The Medical Director reported on the increased instance of pressure ulcers, two of which had been Category 3 ulcers. The number of falls had slightly increased and the situation

was being reviewed. Metrics had improved in respect of medical safety and mortality levels were within accepted limits. It was noted that the Trust had no overdue Serious Incidents requiring investigation. The resolution of outstanding discharge summaries remained a key focus of concern.


Finance Report, August 2019 (Month 05)

8.5 The Director of Finance presented the Month 05 Finance Report to the Board. It was commented that currently the Trust was £1.5m behind plan and this situation needed to be urgently corrected before 30 September in order to secure £5m from NHSI/E.

8.6 It was noted that a great deal of work was being devoted to reducing agency spend across all staff groups. In the current year, a Cost Improvement Programme of £11.7m had already been agreed with Divisions and a further £2m in savings had been identified. Work was now taking place to identify savings in the next financial year.


Standing Financial Instructions/Scheme of Delegation

8.7 The Board approved the Trust’s revised Standing Financial Instructions (SFI) and Scheme of Delegation which had been the subject of detailed scrutiny by the Audit & Risk

Committee. Under Section 5 Health & Safety arrangements it was agreed that these would come under the new COO rather than the Chief Nurse. The Board noted that the new SFI were designed to improve local budget management and accountability which was urgently required.

The Director of Finance confirmed that the revised procedures would be subject to annual review.

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Audit & Risk Update

8.8 The Deputy Chair of the Audit & Risk Committee provided an update on the special meeting of the Committee held on 19 September specifically to discuss the BAF and the Corporate Risk Register. It was commented that the meeting had been facilitated by GGI and that a comprehensive set of documents had been considered related to operating procedures, risk

management and gap analysis.

Board Assurance Framework (BAF)

8.9 The Deputy CEO reported that following the July Board meeting, the Executive had been tasked with focusing on six

key areas related to strategic risks and gaps in control. It was commented that the Board’s assurance committees were working well, each having agreed a forward business plan and reviewed those sections of the BAF which were directly related to their responsibilities. The Board would consider a summary BAF report at its October meeting.

9. WELL-LED/GOVERNANCE MATTERS

9.1 The Chair of the People Committee provided an update on the inaugural meeting of the Committee held on 22 August. The Committee had devised an agenda for the year ahead, focusing on staff recruitment, retention, health and well-

being matters, and had agreed a series of ‘deep dives’, the first of which was to be centred on the Staff Survey.

9.2 The Director of People referred the Board to the workforce section within the monthly Integrated Performance Report, it being highlighted that the Trust was in the upper quartile nationally for statutory and mandatory training, although some areas (eg GDPR, IPC) required more focused attention. NEDs requested that they receive more advance notice in respect of their own training and development.


10. Use of Trust Seal

10.1 It was reported that the Trust Seal had been used on two occasions since the date of the last meeting, as included in the Board papers.

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11. Any Other Business

11.1 There was no other business.

12. Questions from Members of the Public

Q1: When would patients and Governors be invited again to join walkabouts?

The Chair of the Quality & Safety Committee commented that the new Chief Nurse would be undertaking a review of the current walkabout process.

Q2: To encourage more staff to participate in the Staff Survey, would the Trust consider providing greater access to computers?

The Director of People stated that PCs were made available to staff in Learning Zone 1. It was agreed that Staff Governors should be asked to promote the Survey amongst staff.

Q3: What was the Trust doing to prevent patient falls and pressure ulcers?

The Medical Director commented that all efforts were made to minimise falls, yet respecting patient independence. Likewise, pressure ulcers were taken very seriously by the Trust. Further staff training was planned in respect of both important patient safety matters.

Q4: How much was the Trust receiving for capital investment?

The Chief Executive advised that the Trust would receive £16.5m over the next two years from NHSI’s emergency fund, which was in addition to its normal capital allowance. Most of the money would be used to address major backlog maintenance issues (including pipe-works and the incinerator) and a detailed procurement exercise was being carried out.

Q5: The Trust spent £2m on external consultancy last year – why?

The Chief Executive advised that the Trust needed to contract for specialist, time-limited support from time to time to increase its capacity.

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Q6: Would it be possible to have the names of the patients who were involved in working with the Trust on groups and committees, so as to be able to contact them?

The Chair stated this information was not in the public domain.

Q7: What is the date of the next meeting?

The Chair advised that the next meeting would take place on Tuesday (rather than Wednesday) 29 October 2019.

Closing Remarks

The Chair thanked everyone for their contribution to the meeting which closed at 4.30pm.

On behalf of the Board and the Trust, the Chief Executive formally thanked Professor Paice for her work as Interim Chair and continued commitment to the Trust.

Thanks and good wishes were also extended to Piers Young, Hospital Director for his services to the Trust.

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Board of Directors Part I Action Log: 25 September 2019

Minute Ref. Meeting Date Item Action Lead Due Date Comments

7.4 September 2019 Infection Prevention & Control

The Annual IPC Report, 2018/19 to be considered at the next meeting MD October

2019

8.7 September 2019 Standing Financial Instructions

Amendment to Section 5 of the SFI: Health & Safety matters to be the responsibility of the COO and not the Chief Nurse DoF immediate

8.9 September 2019 Board Assurance Framework A Summary BAF Report to be considered at the next meeting DCEO Oct 2019

8.3 July 2019 Integrated Care Partnership Update report to be considered by Board later in the year. CEO Nov 2019

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Board of Directors

29 October 2019 Agenda Item: 6

Title Chief Executive’s Report

Report Author Sarah Tedford, CEO

Status of Report Public Private Internal

X ☐ ☐

Purpose of Report For Decision For Assurance For Information

☐ ☐ X

Summary To update the Board on key developments and action since the date of the last meeting.

Recommendations The Board is invited to note the report.

Links to Corporate Objectives ALL

Impact

Quality and Safety X

Legal X

Financial X

Human Resources X

Equality & Diversity X

Engagement and Communication X

Chief Executive’s Report to the Board of Directors: 29 October 2019

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Introduction We are moving into our busiest period and are beginning to feel not only the change in the weather, but the increasing pressures across the organisation. This is not unexpected and we continue to work with all our partners to ensure the best possible pathways of care for our patients. We are also undertaking the business planning cycle for next year, reviewing our meeting structure to reduce duplication and improve efficiency, whilst beginning to look at our Divisional management structure. Very importantly, we are ensuring a clear focus on the new build process, making sure that this moves at pace and is underpinned by a clinical strategy that is both fit for the future as well as sustainable. 1. Internal Matters

a) Paediatric Move

As a precautionary measure Paediatric Services have been re-located from Peter Pan and Wendy Wards following a specialist engineer’s report that was commissioned to review the paediatric building stock. Inpatient services have subsequently moved to a refurbished ward in the tower block and outpatient services have moved to the Tudor Centre. The decant of paediatrics has necessitated a temporary relocation of the discharge lounge and a more permanent reduction in adult inpatient beds on the Hillingdon site. Adult inpatient capacity has been created at Mount Vernon Hospital to mitigate against the reduction in beds at Hillingdon that may otherwise have impacted on patient flow. Adult outpatient services have also been affected, requiring a number of moves to allow paediatrics to be delivered from one location. Staff are currently working with local health partners with a view to relocating services to a community setting where it is appropriate to do so. The clinical divisions and support services have worked tirelessly to ensure minimal disruption for patients and their families with on-going delivery of all services during this period.

b) Financial Position and Business Planning

The Trust achieved a surplus in September of £0.4m which is £1.8m favourable to plan. Year to date the trust has a deficit of £9.9m which was £0.3m ahead of plan and so the Trust has been able to recognise £4.0m of non-recurrent PSF and FRF funding in Q2.

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Income at £22.1m was £1.5m up on plan for M06 and has reached £124.3m which is £0.4m ahead of plan year to date. The favourable variance in month was largely due to rephasing the income recognised from NWL Commissioners.

Pay was £0.27m lower than in August, giving a favourable variance of £0.1m in month. The year-to-date favourable position improved to £0.14m. Agency costs reduced by £0.15m to £0.76m compared to August, well below the NHSI ceiling of £0.91m.

Cost Improvement Programme

At month 6 YTD the Trust has achieved £1,568k of the planned £1,920k, a shortfall of £352k and the situation is being carefully monitored with Divisions.

c) Our People

Chief Nurse

Camilla Wiley has now taken up the post of Chief Nurse at the Trust. Camilla is a former Director of Nursing at the Royal National Orthopaedic Hospital and has joined us most recently from the Royal Free London. Camilla will be out in the organisation meeting staff during her induction period; she brings a wealth of both nursing and operational experience, and we are delighted to welcome her to the Trust.

OD Programme

The Trust’s organisation-wide Organisational Development (OD) Programme has now commenced. This is a key initiative to support and engage staff over the next 18 months and is crucial to building the skills and capability needed to support our improvement journey. PwC were selected as the external consultancy support for the Programme and have a strong track record of delivery. The PwC team are currently information gathering, including interviewing key stakeholders, a culture survey, and holding focus groups comprising staff from across the Trust. This information will be used to develop a bespoke Programme for our staff with a range of OD initiatives to further embed our values and build capability and skills

d) Council of Governors

The Council of Governors met on 10 October which was the first meeting chaired by our new Chair. The meeting was well-attended with a lot of Governor engagement. Governors are currently being consulted on minor changes to the Constitution which would allow time-limited extensions to Public Governor appointments in special circumstances. Public Governor elections will be held in the first quarter of next year.

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2. External Matters

a) Strategy

On the 30 September, the Department of Health and Social Care published ‘Health Infrastructure Plan - A new, strategic approach to improving our hospitals and health infrastructure’

The Plan details that six new large hospital builds are receiving funding to go ahead now (aiming to deliver by 2025), and 21 more schemes have the green light to go to the next stage of developing their plans (with the aim of being ready to deliver between 2025-2030).

We are one of the 21 schemes that have the green light to go to the next stage of developing our plan and we are working closely with our regulators and our local stakeholders in the development of our approach.

In the meantime, we have secured funding for a new 20-bedded ward. This will allow us to decant from the tower block and refurbish the wards there. In addition, we have submitted a bid for four 32-bedded modular wards which will provide alternative accommodation for patients who are currently being treated in our very oldest accommodation (Annexe wards).

Sarah Tedford Chief Executive

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Board of Directors


Title Integrated Quality and Performance Report

Report Authors

Vanessa Saunders, Deputy Chief Nurse Rachel Stanfield, Deputy Director of People and Organisational Development Melissa Mellett ,Director of Operational Performance Jay Dungeni, Deputy Chief Nurse

Report Sponsor Piers Young, Hospital Director

Status of Report Public Private Internal X ☐ ☐

Purpose of Report

For Decision

For Assurance

For Information

☐ ☐ X

Summary

In order to monitor its performance across of range of key indicators on a monthly basis, the Trust produces an Integrated Quality & Performance Report which is also reviewed by the Board’s main assurance committees.

Recommendations The Board is invited to note the report.

Links to Corporate Objectives ALL

Impact

Quality and Safety X Legal X

Financial X

Human Resources X


Engagement and Communication

X

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Cover Page

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Title Integrated Quality and Performance Report – September 2019

Report author

Vanessa Saunders, Deputy Chief Nurse

Rachel Stanfield, Deputy Director of People and Organisational Development

Melissa Mellett ,Director of Operational Performance

Jay Dungeni, Deputy Chief Nurse

Report sponsor Piers Young, Hospital Director


☒ ☐ ☐


☐ ☒ ☐

Summary This report provides oversight to the Trust Board on progress against the performance standards the Trust seeks to meet as

either national or local standards.

Recommendations The Board is invited to note the progress and assurance provided in the report.

Links to Corporate

Objectives

To improve the present A&E 4 hour standard; the 18 week Referral to Treatment performance; to meet the Cancer targets; to

complete the CQC action plan; to implement year 2 of Quality and Safety Improvement Strategy; to maintain finance and the

use of resources score of 3 in meeting the control total.

Impact

Quality and Safety To continue to provide the best level of patient care and safety in delivering core constitutional standards and implementing year 2 of Quality and Safety Improvement Strategy.

Legal

Financial

Human Resources To provide hospital services in the most efficient and effective manner

Equality and Diversity To provide and deliver services taking account of the requirements of diverse groups

Engagement and Communication To deliver nationally and locally set targets in terms of engagement, communication , listening and learning 18

Quality Summary

Summary: Key Issues Requiring discussion:

Discharge Summaries not issued - 2019/20 there continues to be a number of summaries not completed and overallhas seen an increase in the number not issued.

Patient falls – Rate of patient falls exceeded the trust target @ 5.0 per 1000 bed days against a target of 4.6. Zero fallswith fracture in September.

Hospital acquired pressure ulcers – 11 category 2 and zero category 3 or 4 pressure ulcers reported in September. 7.6% (5.7% for patient safety incidents) of incidents are overdue against a threshold of <10%. This indicator will

change from 1st November from 30 days to 14 days in line with the revised Incident Reporting Policy. Serious Incident performance in August was 88.8%. One Serious incident is overdue where the investigation is being

led by North West London Pathology. Infection Control:

o The Trust has reported one case of MRSA Bacteraemia on 27th September 2019, a Post Infection Review (PIR)meeting was held on 4th October 2019 initial findings are that this maybe an unavoidable case.

o C. diff - At the end of Q2. An improvement has been made with regards to the number of cases (three in Q2)totalling 13 against a mid-way position of 12 for the year.

Medication Safety – Target for medicines reconciliation rate and omitted doses met in August (September data notavailable).

Complaints performance in September was 93.9% against a target of 95%. Friend and Family Test requires improvement in particular A&E and Outpatients. Mortality:

o HSMR 12 months rolling and SHMI remains within expected limits and continues to be monitored closely by theMSG.

Action required: Review and discuss the quality and safety performance outlined in the report

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Discharge Summaries – Not Issued @ 7th October 2019

Actual 945 910↓

2019/20 YTD 2018/19

Lead: Nikki Jackson, Divisional Director for Women & Children

Threshold Executive: Cathy Cale – Medical Director

Analysis of data

For 2018/19 the data shows a slight reduction in the number of 2018/19 discharge summaries. The number reduced on 7th October as approximately 300 discharge summaries were issued. For 2019/20 there continues to be a number of summaries not completed and overall has seen an increase in the number not issued.

Actions taken, Have they worked? What is stopping actions progressing?

The Discharge Summary Task and Finish Group will no longer take place. A monthly Discharge Summary Improvement Group will now run, starting November 2019. This meeting will be chaired by Miss Nikki Jackson, Divisional Director for Women and Children. Targeted work in Divisions/Specialties is ongoing and includes: - Ensuring processes are corrected to ensure the patient leaves with their

completed discharge summary and this is issued correctly on EPRO (and othersystems).

- Continual review of backlog clearance and resolve issues.- Continue issuing of ward specific data extracted from the weekly compliance

report and is sent to relevant teams for prompt action. This has been successful

in some areas to promptly clear summaries and address data quality issues,

further work is required for other areas, which will take place with Divisions. The

current week has seen an increase in PAU summaries not issued.

- Work is taking place to identify system administrators and monitoring for nonEPRO discharge summaries.

Cancer and Clinical Support Services (CCSS) – The Division are working with specific Consultants to resolve any issues where the discharge summary is not completed at the time of patient discharge. Regular monitoring by the Dermatology Service

Indicator Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecYTD

19/20Target SPC Trend

Discharge summaries not issued

2019/20 (cumulative) 458 634 609 787 827 806 945 945

2018/19 (cumulative) 1919 1701 1402 1080 969 922 910 910

458

634 609

787 827 806

945

1919

1701

1402

1080 969 922 910

0

500

1000

1500

2000

2500

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May

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Jun

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Sep

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Oct

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Discharge Summaries - Not Issued Monthly Cummulative Trend

2019/20 2018/19

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Manager continues to take place to support the ongoing process. Medicine – A lead junior doctor has been identified to work improving compliance to clear the backlog and ensure the discharge summary is completed at patient discharge. Junior doctors are working on bank to clear the backlog. Surgery – Funding has been agreed for two foundation year doctors to clear the backlog, it was expected that the backlog would be cleared by the end of Sept, but due to sickness of one of the doctors, this has now been delayed. Paediatrics – Improved processes had been put in place for discharge summaries in PAU, the team are looking into the reasons for the increase in non- issue of discharge summaries. Gynaecology - since May 2019 Gynaecology are issuing over 95% of their discharge summaries to GPs within 24 hours. The department have an SHO rota/ admin co-ordinator who monitors discharge summaries with one of the secretaries and distributes any outstanding to be done by an appropriate team member.

What else needs to be done

When summaries are ‘ready’ issuing rights need to be agreed to not delayclearing the backlog

Reporting and monitoring processes to be set up for non EPRO dischargesummaries.

Continued weekly reporting

Requirement for Nervecentre to update PAS automatically as consultant ischanged.

Trajectory for improvement

The Discharge Summary Improvement Group will oversee continuous improvement and embedding of processes.

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Patient Falls **Rate per 1000 bed days # = fracture

No. incidents 58

Sept 19

No. incidents 344

YTD

Lead: Vanessa Saunders – Deputy Chief Nurse

Rate 5.0 Rate actual 4.6 Executive: Chief Nurse

Rate Threshold 4.6 Rate Threshold 4.6

Falls with # 0 Fall with # actual 4 Fall with # Threshold 10

Analysis of data

The overall rate of falls increased by 0.1 per 1000 bed days in September. Year-to-date rate isat threshold rate.

Increase is due to increased number of non-inpatient falls (increased from 4 in August to 6) inSeptember

Of the non-inpatient falls, 3 were in CDU. One patient reported he got his zimmer framecaught on a door frame, the other 2 were unwitnessed – both were mobile patients fit enoughto sit in chairs.

The number and rate of inpatient falls reduced in September.

The rate is within target range and continues below last published national average (6.6, RCP2015)

Performance is on track and in line with previous two years

No falls in September were recorded as resulting in fracture.


Case for dedicated Falls Prevention practitioner – scoping to be completed by December 2019




Patient falls

No. Inpatient falls 72 59 50 43 68 48 65 62 58 344 N/A Within control limit

Rate of inpatient falls (1000 bed days) 5.0 4.5 3.4 3.1 4.8 3.6 4.5 4.6 4.4 4.2 N/A

No. non-inpatient falls 8 10 7 11 3 4 5 4 6 33 N/A Within control limit

Rate of all patient falls (1000 bed days) 5.5 5.2 3.9 3.9 5.0 3.9 5.1 4.9 5.0 4.6 4.6

Falls with fracture 0 0 0 1 1 1 1 0 0.0 4 10

5.5 5.2

3.9 3.9

5.1

3.9

5.1 4.9 5.0

0

1

2

3

4

5

6

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

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9

Sep

-19

Rate of Patient Falls per 1000 bed days

Threshold Rate

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Risk of increased falls as “Get up, get dressed, keep moving” campaign progresses.

Falls Group to receive reports detailing number of falls categorised as near miss/ assisted falland to monitor trend in falls resulting in harm

Trust reporting methodology under review

Root Cause Analysis template and process for falls resulting in fracture currently under review


To continue to achieve Trust target

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Hospital Acquired Pressure Ulcers/Moisture Lesions **Rate per 1000 bed days

No. incidents 27

Sept 19

No. incidents 142

YTD

Lead: Vanessa Saunders – Deputy Chief Nurse

Category 3+ 0 Category 3+ 7 Executive: Chief Nurse

Rate Cat 2+ 0.8 Rate Cat 2+ 0.8

Rate Threshold <1 Rate Threshold <1.0

Analysis of data

The overall rate of category 2+ pressure ulcers decreased to within target rate inSeptember.

There were no new Category 3 &4 hospital acquired pressure ulcers reported inSeptember. Year-to-date incidence is higher than in previous years

There were 3 Unstageable pressure ulcers reported. Specific reporting for this Categorywas introduced from July therefore baseline is not fully established

There has been high variability in the reported rate for all categories each month thisyear. Contributing factors include:

o new categorisation methodology introduced by NHSI at the end of 2018o revised and extensive training programme throughout July 2019o staff turnover within Tissue Viability service


Interim in Tissue Viability Nurse has high clinical presence. Actively reviewing allcomplex (i.e. Category 3,4 and /unstageable lesions) to ensure appropriatemanagement plans in place

“Stop the Pressure” training campaign held throughout July raised awareness andunderstanding of categorisation; evidenced through increased reporting

Further study day taking place in October



Hospital Acquired Pressure Ulcers/Moisture Lesions

No. HPAU/Moisture Lesionsincidents 18 9 18 21 18 24 23 29 27 142 N/A Within control limit

Rate of HPAU/Moisture Lesions incidents (1000 bed

daysCat 2+)0.8 0.5 0.5 0.7 0.6 0.9 0.9 1.1 0.8 0.8 1

No. Category 2 pressure ulcers 11 8 9 10 8 12 8 22 11 71 N/A Within control limit

No. Category 3 & 4 pressure ulcers 1 0 0 0 0 1 4 2 0 7 N/A

No. Unstageable pressure ulcers 2 0 3 5 N/A

11

16

12

18 18

25

20 18 17

9

18

21

18

24 22

28

27

0

5

10

15

20

25

30

35

May

20

18

Jun

20

18

Jul 2

01

8

Au

g 2

018

Sep

20

18

Oct

201

8

No

v 2

01

8

Dec

20

18

Jan

20

19

Feb

20

19

Mar

20

19

Ap

r 2

019

May

20

19

Jun

20

19

Jul 2

01

9

Au

g 2

019

Sep

20

19

Hospital Acquired Pressure Ulcers and Moisture Lesions

Data MeanUCL LCL

24

Introduction of NWL formulary including preventative treatments – further workongoing with Procurement to ensure supplies available


Work with NWL to review application of NHSI 2018 categorisation guidance. This will beled by the Head of Safeguarding Adults

In partnership with governance team, strengthen root cause analysis model and tools tomaximise learning and practice development opportunities

Service review underway to ensure resourcing appropriate and robust. New workforcemodels being evaluated; options to be presented to Chief Nurse in November

Root Cause Analysis process being reviewed by Lead Nurse for Quality and ClinicalStandards, in partnership with Integrated Governance, to improve timeliness andquality of learning.

Deep dive into incidents and application of NHSI guidance to be presented at PatientSafety Committee and Quality and Safety Committee


Impact of changes to categorisation and continued training programmes have the potential to increase reported incidence

25

Patient Safety Incidents (PSI) **Rate per 1000 bed days

No. PSI incidents 584

Sept 19

No. PSI incidents 3137

YTD

Lead: Vikas Sharma – Assistant Director of Integrated Governance

PSI Reporting Rate 51 PSI Reporting Rate 44 Executive: Cathy Cale - Medical Director Chief Nurse PSI Reporting

Threshold >=35 PSI Reporting Threshold >=35

Overdue (all incidents)

FY 2018/2019 97

Overdue (all incidents)

FY 2019/2020 324 (10.7%)

YTD

Analysis of data

11 Patient safety incidents were graded as moderate and above harm in September 2019.

4 of the 11 incidents have been declared as Serious incidents and reported to StEIS.

5 of the 11 incidents are having internal investigations carried out.

2 of the 11 incidents require further information to confirm the level of harm, these are both Hospital acquired pressure ulcer incidents.

The NRLS Official Statistic Release published on 26th September 2019 shows an increase in the Trust incident reporting rate @43.1 incidents per 1000 bed days (previously 40.0) and no evidence of under reporting. Increased reporting over time may indicate an improved reporting culture.



Patient Safety Incidents

Patient Safety Incidents 591 520 493 482 483 513 556 519 584 3137 N/A Within control limit

Reporting rate of patient safety incidents (KH03) 47 45 39 39 39 44 47 44 51 44 >=35

No. patient safety incidents graded Moderate + 5 5 8 8 8 11 9 4 11 51 N/A Within control limit

Rate of patient safety incidents graded Moderate + 0.4 0.4 0.6 0.7 0.6 0.9 1.1 0.3 0.9 0.7 <3.5

26

Actions taken since, Have they worked? What is stopping actions progressing?

Overdue Incidents (Incidents reported before 31st March 2019 @ 4th October 2019

Open Incidents by Division Total

Medicine 38

Other/Corporate Services 7

CCSS 1

WC 3

Surgery 1

Grand Total 50

ED 6

Overdue Incidents FY 2019/2020 @ 4th October 2019

Open Incidents by Division Greater 30

days

% All incidents overdue

% Patient safety

incidents overdue

Medicine 156 8.48 6.68

WC 46 5.6 4.74

CCSS 26 6.58 4.56

Surgery 38 6.45 5.26

Other/Corporate Services 18 14.63 0.81

Grand Total 338 7.61 5.7

ED 48 7.55 5.6

The Medical Director cascaded expectations to Divisions at the February Patient Safety Committee, and set a threshold for overdue incidents at < 10%.

47 45

39 39 39 41 47

44

51

0

10

20

30

40

50

60Ja

n-1

9

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Reporting rate of Patient Safety Incidents

Reporting rate of patient safety incidents Threshold

27

All divisions are below the 10% threshold apart from corporate services we have however seen a substantial decrease in the corporate services indicator since July2019 where the overdue % was 46%. The Patient safety team and Governance systems teams continue to support the incident managers with their incidents, investigations and training needs to ensure that each division remains below 10% for open incidents.

Incident managers receive a bi-weekly email reminder from the Datix system alerting of any overdue incidents for action.

Monthly Divisional Governance reports provide visibility on overdue incident position by number, location and allocated manager.


Overdue Incidents

Divisions to continue monitoring and ensure accountability when this indicator is at risk.

Governance systems team and Patient safety team are continuing to work with the Ward Managers to ensure that the incident management can be shared within teams, instead of a single allocated manager per area (All areas already have multiple Datix trained incident managers).

This indicator is changing from 1st November In line with the revised incident reporting policy the threshold for incident closure will reduce from 30 days to 14 calendar days.


Overdue Incidents

The 30 day threshold for incident will be reduced to 14 calendar days with effect from 1st November 2019. This proposal was agreed and will mean this indicator is likely to show deterioration but will need to be taken into context and in line with this key change to the incident reporting and management process. Serious incidents 60 working days (no change) and internal investigations 30 working days (previously Duty of Candour Incident Investigations 45 working days) timelines for these incidents will not form part of this indicator and will follow their own timelines.

28

Serious Incidents and Never Events (NE)

No. SIs Incl. NE 6

Sept 19

No. SIs Incl. NE

36

YTD

Lead: Vikas Sharma – Assistant Director of Integrated Governance

NE 0 NE 0 Executive: Cathy Cale – Medical Director

Performance % 88.88% NE Threshold 0

Overdue SIs 0

SIs Declared by Category Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 YTD

Diagnostic incident including delay meeting SI criteria (including failure to act on test results) 1 1 1 4 0 9

Sub-optimal care of the deteriorating patient meeting SI criteria 1 3 1 0 1 7

Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus. neonate and infant) 1 1 1 0 2 6

Treatment delay meeting SI criteria 0 0 1 1 0 5

HCAI/Infection control incident meeting SI criteria 0 1 0 1 0 4

Slips/trips/falls meeting SI criteria 3 1 0 0 0 4

Pressure ulcer meeting SI criteria 0 1 0 0 1 2

Operation/treatment given without valid consent 0 1 0 0 0 1

Pending review (a category must be selected before incident is closed) 0 0 0 0 0 1

Analysis of data

6 Serious incidents were declared in September. 0 Never Events were reported. Performance Performance continues to show improvement, with 88.8% of serious incidents submitted on time with one breach where the investigation is being led by North West London Pathology. There is however more improvement required to improve compliance and to ensure timely implementation of actions and dissemination of learning.

Backlog/overdue SIs There is one overdue incident that was investigated by the Pathology Lead from North West London Pathology. The report has been drafted as is with the Divisional Director for sign off.

Themes The most common theme of SIs is in relation to sub-optimal care of the deteriorating patient. NHSI/E have also raised a concern regarding the no of SIs in relation to deteriorating patients, especially in ED. The patient safety team have supported a thematic review of SIs around deteriorating patients over the last 12 months the scope of investigation included



Serious Incidents and Never Events

SIs declared (reported to StEIS) 7 6 11 5 6 6 9 4 6 36 N/A

Never events 1 0 0 0 0 0 0 0 0 0 N/A

SI performance 60 60 67 67 67 50 60 83.3 88.8 69 N/A

29

Maternity/Obstetric incident meeting SI criteria: mother and baby (this include foetus. neonate and infant) 1 0 0 0 0 1

Grand Total 7 9 4 6 4 40

the numbers pre and post introduction of HObs and the new sepsis screening protocols, any hotspots, recommendations, actions and common themes. The report was presented at September’s PSC committee and will be presented at this month’s QSC. A thematic review of SIs relating to the failure to follow up on diagnostic results is also being scheduled, the scope of which is to look back at incidents over a three year period. The report is due to be presented at the November 2019 Patient Safety Committee.


Daily review of moderate and above incidents is now embedded into practicewithin the Patient Safety team. These are reviewed, cleansed and sent daily (withaudit trail) to the Chief Nurse and Medical Director to prompt early escalationand instigate action.

Email reminders and hotlist of SIs sent to investigating officers, Divisional leads,and line managers.

Weekly SI review meetings with Divisional leads

Weekly SI scope meeting with the Medical Director and Divisional Directors toagree the terms of reference for each case and confirm the duty of candourdetails.

Revised SI process agreed via May QSC

All serious incident action plans have been uploaded on the GiveMeDataelectronic database. First phase of reminders have been sent to action plansleads.

The revised SI process has been implemented.

Action plans from serious incidents have been uploaded onto GiveMeData andsent to leads for updates and evidence.

Two Learning summits to share learnings from serious incidents has been held.

Two HILHS newsletters have been produced and shared via email, commsbulletin and the intranet to share learnings from serious incidents

Backlog of serious incidents cleared.

Revised Incident and SI Policy to reflect and changes in process has been written

and is currently going through ratification.

0 0

33

0 0

25 22 25

67 60 60 67 67 67 50

60

83.3 88.8

0

10

20

30

40

50

60

70

80

90

100

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

SI Performance Improvement Trajectory %

Actual Performance min Performance max

30


Focus on improving the quality of reports first time.

Implement a structured and effective process of disseminating and sharing thelearning.

Implement a training programme to support the investigation of SIs


The aim is to achieve 100% compliance against the 60 working day timeframe oragreed extension.

31

MRSA No. 1 Sept 19

No. 1 YTD Lead: Glenda Shadford – Lead Nurse Infection, Prevention & Control

Threshold 0 Threshold 0 Executive: Cathy Cale - Medical Director

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

19/20 Target

(Unavoidable)

MRSA (trust attributed) 0 0 1 0 0 0 0 0 1 1 0

MRSA (Bacteraemia): The Trust has reported one case of MRSA Bacteraemia on 27th September 2019, a Post Infection Review (PIR) meeting was held on 4th October 2019 initial findings are that this maybe an unavoidable case.

Actions taken in the last month: September. Have they worked? What is stopping actions progressing?

Planning for securAcath training in progress

Visual Infusion Phlebitis (VIP) care plan pilot due for completion end of October.

Revised MRSA policy on agenda for October Trust Infection Prevention and Control Committee (TIPPC)o Once approved the IPCNs will embark on an awareness campaign in the Trust


Continue to implement the recommendations from NHSI/E IP&C report to generate improved assurance and management processes.

Pilot PICC care plan

VIP care plans training provision will be required and an agreement between IPC and practice development nurses to roll out across the Trust. This will improvecompliance and be in line with Epic 3 guidelines and improve patient safety.

Completion of ICnet upgrade to provide MRSA screening compliance data.

Review of visual infusion phlebitis pilot and plan way forward.


No MRSA Blood Stream Infections for the rest of the year.

32

Clostridium difficile Lapses in care 0

Sept 19

Lapses in care

6 YTD

Lead: Glenda Shadford – Lead Nurse Infection, Prevention & Control

Cases 1 Threshold 7 Executive: Cathy Cale - Medical Director

Indicator Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD 19/20 Target

C.diff cases 0 1 1 5 3 2 0 2 1 13 24

C. diff lapses in care 0 0 0 4 1 1 0 * * 6 7

* awaiting commissioner review

Analysis of data

Clostridium difficile (C.diff) cases: At the end of Q2. An improvement has been made with regards to the number of cases (three in Q2) totalling 13 against a mid-way position of 12 for the year.

C.diff Lapses in care (LIC): There have been no new lapses in care since the last report. Although this indicator is no longer in use for contract penalties it has beenmaintained as local quality indicator. The lapses in the previous months were due to poor antimicrobial prescribing, lack of antimicrobial documentation, delayed isolationand delayed sampling.

Actions taken since last month September. Have they worked? What is stopping actions progressing?

A number of actions have been taken since the significant increase in c. difficile cases in Q1. the Consultant Microbiologist and Infection Prevention and Control Team have:

Undertaken a C. difficile roadshow visiting wards and departments to explain and highlight the changes to the C. difficile policy and practice with regards to ‘what’s newand what’s changed’.

o More session required as some wards still showing a gap in knowledge

Weekly C. difficile/antimicrobial ward rounds are taking place reviewing all C difficile toxin and OPCR patients as well as readmitted previous positive cases.

C. difficile focus group will continue to be held monthly until performance improves.

Antimicrobial guidelines have been revised such as Over 65’s antimicrobial prescribing, Obstetrics and Gynaecology, Surgical prophylaxis guidelines and overarchingantimicrobial policy have all had consideration of themes identified in Root Cause Analysis investigations incorporated and were presented at HMMC on 12th Septemberfor ratification.

Capital projects and IP&C meet weekly in preparation for the ‘Smarten and Clean’ programme due to start once prefurb ward has been erected.

Lead IPC Nurse has worked with the Assistant Director of Facilities to review the current provision of cleaning (nursing, facilities and estates) to identify area that needmore provision due expanded hours of working throughout the Trust a supporting report has been prepared for board.


Continue to educate all staff groups on the significant changes to C. difficile policy.

Embed the RCA process and timeframes into practice of both medical and nursing staff to provide improved assurance and turnaround of investigations for learning tobe shared early.

33

‘Smarten and Clean’ recommendations to be accepted and supported by Trust board with funds made available to implement required improvements throughout theTrust.

Continue to educate and improve knowledge and practice with regards to ‘Enteric Isolation’ posters throughout the Trust.

Continue to work on implementing recommendations from NHSI/E Norovirus outbreak learning event.

Work with the IP&C Senior Programme manager to implement the recommendations from NHSI/E IP&C report to improve assurance and management processes.

Publish revised versions of Antimicrobial guidelines which have been revised such as Over 65’s antimicrobial prescribing, Obstetrics and Gynaecology, Surgicalprophylaxis guidelines and overarching antimicrobial policy .

IPCNs participated in a HCAI DCS (Health Care Associated Infection Data Capture system) Stakeholder forum Skype meeting on 11.09.2019. Moving forward the Trust isrequired to enter further data with regards to community attributed cases that have been inpatients at the Trust in the previous 4 and 12 weeks preceding the CDIbeing detected. If these cases have been prescribed antibiotics during the time the case maybe attributed back to the Trust.


No more lapses in care for the rest of the operational year.

34

E.coli Blood stream infections (BSIs) Infections2

Sept 19

Infections 13

YTD

Lead: Glenda Shadford – Lead Nurse Infection, Prevention & Control

Threshold N/A Threshold N/A Executive: Cathy Cale - Medical Director

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

19/20 Target

E.Coli 2 3 5 0 5 4 1 1 2* 13 N/A

Analysis of data

E.coli Blood stream infections (BSIs) – No threshold set however to reach a 50% reduction in gram-negative BSIs by 2020/21.

In 2019/20 to date (end of) the Trust had reported 13 cases of E.coli BSI this is equal to the same period at the end of September in 2018/19. *September data yet to be reconciled.

Actions taken since last month September, Have they worked? What is stopping actions progressing?

The IP&C team continue to work with both the Continence and Gram-negative BSI working groups, in devising a strategy to achieve this ambitious reduction and will continue to do so into 2019/20.

Capacity of Microbiologists continued to be stretched throughout September mainly due to the holiday period at times and vacancies where not always filled. Thetwo substantive microbiology consultants are often at capacity with regards to other clinical priorities preceding this.

IPCNs participated in a HCAI DCS (Health Care Associated Infection Data Capture system) Stakeholder forum to share best practise with other Trusts.

A further advert for a third Consultant Microbiologist was made without success to date.

Trust IPCNs continue to enter ALL GNBSI data of which most is CCG attributed (1/20 split in September).

IPCNs now all have access to Nervecentre and will be working towards utilising it more.


Revise the questionnaires being used to improve the quality of the results and interventions being implemented.

Complete pilot of monitoring of catheter bed days to identify opportunities for quality of care improvement.

Continue to work towards improving IV & PICC line care by improving the care plans and policies.

Consider Post Infection Reviews of all GNBSI infections (this will require significant input from the Microbiology Consultants who will have a vacant WTE post duringthe coming months and will be relying on Locums). To be entered onto IP&C work plan.

The Trust is to be represented at the North West London GNBSI Stakeholder Event on 11th October 2019.


Achieve a further 10% reduction from 2018/19.

35

Medication Safety No. Incidents 72

Sept 19

Lead: Andrew Caunce – Chief Pharmacist ** Reconciliation rate % 71

Reconciliation threshold >70

** Omitted dose % 14 Executive: Cathy Cale – Medical Director

Omitted dose threshold <18

** September data not available

Analysis of data

Omitted doses are attributable to no documentation on the drug chart or unavailablemedicines procedure not followed.


Assessment of how to access medication out of hours has been included in into the WardAccreditation Programme.

An action plan has been developed which details improvement interventions for theseindicators (Medicines Reconciliation rate and omitted doses) and is overseen by theMedication Safety Committee.

There is ongoing effort by the pharmacy team to reduce omitted doses; any identified

missed doses of medicines are highlighted to the nurse in charge.

Nurses are encouraged to review drug charts during every shift to ensure appropriate

documentation and no blanks in administration boxes. Ward managers/matrons are

encouraged to do spot checks on the ward to identify inappropriate documentation/missed

doses.

The Chief Pharmacist and Medication Safety Officer carry out weekly medicine compliancereviews on wards and spot check knowledge of staff regarding how to access medicines toprevent missed doses.



Medication Safety

No. medication incidents 60 52 63 53 65 73 100 58 72 421 N/A Within control limit

** % medicines reconciliation started within 24

hours of admission46 57 50.6 65.9 74.2 65.3 72 71 62.7 >70

** % omitted dose in the last 24 hours 28 18 22.2 20.7 17.6 24.3 21.5 14 20.8 <18

61 58

70

62 57

53 59

73 69

60 54

64

53

66

74

100

62

72

0

20

40

60

80

100

120

Ap

r 2

018

May

20

18

Jun

20

18

Jul 2

01

8

Au

g 2

018

Sep

20

18

Oct

201

8

No

v 2

01

8

Dec

20

18

Jan

20

19

Feb

20

19

Mar

20

19

Ap

r 2

019

May

20

19

Jun

20

19

Jul 2

01

9

Au

g 2

019

Sep

20

19

SPC: Medication Related Incidents

Data Mean UCL LCL

36

Targeted training to poor performing wards has been provided by the Medication SafetyOfficer to identify reasons for poor performance and where support can be provided.

Bulletin on how to obtain medication when pharmacy is closed has been displayed in allclinical rooms.

The link on intranet to access medicines out of hours has been refined to enable easieraccess to ‘THH drug stock holding on wards’.


Electronic Prescribing and Medicines Administration (EPMA) - outcome of the bid to NHSIfor EPMA funding has been delayed.

Consistent spot checks by ward managers/matrons

Review of all drug charts before each shift change by nurses.


Aim for medicines reconciliation rate to increase to 80% by April 2020.

The trajectory for omitted doses is <12% by April 2020.

37

Complaints Performance % 93.9%

Sept 19

Performance % 71.7%

YTD

Lead: Lynne Simpson – Complaints Manager

Target 95% Target 95% Executive: Chief Nurse

Complaint theme (Top 5) 2019/20

Communication/ Information to Patients 16

Clinical Care Medical Staff 15

Clinical Care Nursing Staff 6

Attitude (Other Support Staff) 5

Appointments (OPD & A&E) 5

Analysis of data

Performance Receipt of a complaint has to be acknowledged within three working days. Complaints response performance is measured by the percentage of complaints answered within the timescale that has been agreed with the complainant; the target is set at 95%.

There were 27 new complaints received in September 2019

There were 33 complaints due for response in September 2019, an increase of 94% on theprevious month.

100% compliance was achieved for acknowledgement

93.9% compliance was achieved for response, with two complaints breaching.

One complaint was declared a serious incident in September 2019 and transferred to be managed by the governance team.

There were no re-opened complaints in September 2019.

Themes The two top themes in September 2019 were around clinical care from medical staff and Communication/Information to Patients.

Divisions develop an action plan for each complaint that is upheld or partially upheld. Themes are triangulated on a quarterly basis and presented to Experience and Engagement Group to guide priority actions.

Ombudsman investigations PHSO issued one draft report in September 2019, in which the provisional view is to uphold one

Patient experience

% Compliant performance 93 100 83 96.6 100 68.6 77.4 88.2 93.9 71.7 95

Reopened complaints 0 0 1 1 2 1 1 0 0 4 N/A

38

element around poor communication with the family of a dying patient. We also issued a Trust wide action plan on another case that was reported in July 2019. This was primarily to do with SALT referrals and management of medication for patients with swallowing difficulties. Clinical staff are to receive training by January 2020.

Actions taken since June TME, Have they worked? What is stopping actions progressing?

Two surgical complaints breached in September 2019, one by one working day, the other by four working days. Both of these breached because of late receipt of the investigation reports, which were then found to contain inadequate information.

The Complaints Management Unit continues to work closely with divisions to ensure that divisional responses are completed in good time and address all the issues identified in the complaint.

Complaints investigators are being asked to provide evidence of actions undertaken as a result of a complaint in order for the Complaints Management Unit to be able to gather the evidence to enable thematic review.

Give Me Data has now been set up to record actions arising from complaints; this is being piloted in CCSS before being rolled out to other divisions over the coming weeks.


Divisions to ensure they progress complaint investigations in line with the ComplaintsPolicy i.e. provide investigation reports by the due date to allow time for drafting, checkingand obtaining a signature. The reports need to be checked for quality before being sent tothe complaints team, as this will minimise delays. Actions that have been completedshould be evidenced.

Divisions to ensure there is a named lead for complaints at all times.

Improved action planning and sharing of learning from complaints

Implementation of the web version of Datix is required as a preferred solution to capture action plans arising from complaints.


Aim to achieve the Trust target every month.

39

PALS Contacts 127

Sept 19

Contacts 587

YTD

Lead: Sally Taylor – PALS Manager

Concerns 93 Concerns 583

Threshold N/A Threshold N/A Executive: Chief Nurse

PALS Top 5 Themes 2019/20

Appointments (OPD&A&E) 225

Communication/ Information to Patients 144

Admissions 51

Clinical Care Medical Staff 36

Information (Internal) 22

Analysis of data

In September 2019 PALS received 122 negative contacts an increase of 27 contacts compared to the same time period last year. Of those contacts the top two recorded subjects were “Appointments” and “Communication/Information to patients”. 42 were recorded for “Appointments” and 29 for “Communication/Information to patients”. This is almost an exact comparison to the same month for the last year where these two subjects were also the top two themes, with 21 contacts recorded for “Communication/Information to patients” and 30 contacts recorded for “Appointments”.

PALS work closely with relevant operational staff to answer patients concerns and seek resolution informally and promptly, where possible preventing a formal complaint from being logged. The positive impact of the service is demonstrated by the decreased number of formal complaints received in the Trust. The majority of PALS concerns are very individual and when resolved they do not require a change in practice.

PALS activity is reported to the Experience and Engagement Group, with data presented by top themes. Further narrative is provided with respect to specific theme or subject area under discussion, with case study examples. This is a well- attended group with representation from all divisions, public governors, and lay members which is held on a quarterly basis.



PALS concerns 89 114 80 80 102 83 103 93 122 583 N/A

40

Friends and Family Test Lead: Catherine Holly - Head of Patient and Public Engagement

Executive: Chief Nurse

Indicator Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD 19/20 Target

Patient experience

A&E

% Response rate 5 6 4 14 15 14 12 11 13 13 20

% Recommended 98 96 96 83 84 86 83 87 80 84 96

Inpatient

% Response rate 40 34 41 29 32 36 39 32 34 33 30

% Recommended 97 98 98 97 97 98 97 98 98 98 96

Maternity All

% Response rate 18 26 25 24 12 27 27 24 19 32 20

% Recommended 98 97 97 96 100 98 95 97 98 97 96

Outpatients

% Response rate 5 5 4 5 5 6 6 6 6 6 6

% Recommended 96 93 94 95 95 95 94 93 94 94 96

Analysis of data

Inpatients and Outpatients achieved their response target. A&E and Maternity failed to achieve their response target.

Admitted Care and Maternity Care achieved the 96% target for positive responses. Outpatient and A&E failed to achieve the 96% performance target.

A&E - despite introducing SMS texting the service is still not meeting its response target. 5966 text messages were sent out from the trust in September 2019. The response rate for MIU was 18.70%, an increase of 1.01% compared to August 2019. The A&E/Paediatric A&E response rate was 9.48%, an increase of 3.01% from August 2019.

80% of A&E patients recommended the service which is a decrease of 7% since August 2019.

Outpatients - has achieved the 6% response rate since June 2019 when the trust introduced SMS texting to Radiology patients. In September 2019 5717 patients who attended a radiology appointment received a text message asking about their experience. 633 patients responded to the SMS text message in September 2019 compared to 26 in September 2018.

Outpatient performance has not reached the 96% target since January 2019. 94% of outpatients recommended the outpatient service in September 2019. The Head of Patient and Public Engagement is meeting with the IT department to ascertain whether there is funding available to introduce SMS texting in other outpatient areas.

41

Actions taken since August, Have they worked? What is stopping actions progressing?

Introduction of SMS texting

A&E – The increase in response rate has resulted in the A&E and Minor Injuries Unit receiving a larger amount of qualitative feedback which will help managers tounderstand what is working well and what needs to be improved. Reports are provided to the senior managers in A&E and Minor Injuries for dissemination anddiscussion with departmental staff.

A&E – although 5966 SMS text messages were sent out in September, 889 electronic responses were returned (512 from MIU and 377 from A&E and PaediatricA&E). Although this is an increase from August 2019 it is not known why so many patients decide not to provide feedback after leaving the MIU or ED.

Outpatients – All radiology patients receive a text message within 48 hours of their appointment.

Each area has been asked to continue to offer paper surveys to patients as not all patients will have a mobile phone or wish to use technology to complete a survey.


There needs to be increased divisional ownership for the FFT process. Every month posters and patient comments are delivered to each ward and department bythe Patient Experience Team. FFT results should be discussed at each divisional governance meeting.

Frontline staff need to continue to offer the survey to all patients being discharged, with particular focus in ED and in community maternity clinics.

Ascertain whether SMS texting can be introduced to additional patients attending outpatients or community maternity clinics.

Changes to the FFT process from April 2020 - currently the FFT guidance states that a survey should be offered on or within 48 hours of discharge and so it is notpossible to send a text message after this timescale. National guidance is awaited on the proposed changes from April 2020 and so if the 48 hour rule is lifted itmay be possible to send a text message more than once.


A&E – increase overall response rate to 15% by December and 20% by March 2020.

42

Mortality Lead: Anita Maudsley – Business Manager to Medical Director

Executive: Cathy Cale – Medical Director

- Crude Mortality is reviewed monthly at theMortality Surveillance Group (MSG) and is asexpected. No further actions required at present.

- HSMR 12 data has not been updated by DrFoster, therefore data reported remains the sameas the last month.

- SHMI is within expected limits and continues tobe monitored closely by the MSG. Case notereviews are underway for the two areas wherethe Trust is an outlier in procedures (respiratoryand external resuscitation). Results are beingpresented at the MSG in October/November2019.

Action 1. Mortality figures continue to be reviewed atthe monthly Mortality Surveillance Group.

0.00%

1.00%

2.00%

3.00%

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

Chart 1: Crude Mortality Rate

2018/2019 2019/2020

0102030405060708090

100


Chart 2: Number of Deaths

2018/2019 2019/2020

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Chart 3: Rolling 12 Month HSMR (Aggregate)

RelativeRisk Benchmark

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Chart 4: Rolling 12 Month HSMR (Weekend Admissions)

RelativeRisk Benchmark

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1

Chart 5: SHMI

43

Executive Summary: Operational standards (1/2)

1

Commentary

• A&E performance increased in September but wasbelow trajectory by 1.7%, driven by significantlyabove plan demand in all Types, (4%) but in particularType 1.

• RTT performance was below trajectory in September(unvalidated) 79.9%, with the ongoing validationprogramme likely to put further pressure onperformance. The Total Waiting List grew by 2,273people in September. The Trust reported 43 patientswaiting longer than 52 weeks for the month.

• Q2 Cancer performance was non- compliant againstthe 2WW target. The Trust performance wascomplaint against the 62 day standard in July 19 butfailed in August 19. The unpublished September2WW performance standard is at risk of non-compliance.

• Diagnostics remained compliant in August andunvalidated September performance is above thestandard, however following the external review ofour reporting systems and diagnostic waiting lists theTrust is expecting to report non-compliance later thiscalendar year as changes are made to reports inOctober.

Summary of performance against constitutional standards

Note: 1Cancer validation takes c 1 month so current month reported position is unvalidated and likely to improve; Conditional formatting indicates achievement of monthly target/ trajectory Source: I-Reporter; Planning Submission

Standard Target Jul-19 Aug-19 Sep-19

A&E Performance (All

Types)

Target: 95%

Trajectory: 86.6%84.4% 83.8% 84.9%

RTT PerformanceTarget: 92%

Trajectory: 88.0%83.2% 81.2% 79.9%

RTT Total Waiting List 22,773 (Mar 18) 26,694 27,290 29,563

Cancer 2 Week Wait

Performance93% 91.8% 83.4% 88.4%

Cancer 62 Day Treatment

Performance85% 89.7% 81.7% 87.0%

Diagnostics Performance 99% 99.9% 99.8% 99.9%

44

A&E Performance Executive Summary: Operational

standards (2/2)

2

Commentary

• The Trust delivered 84.9% (All type) and 65% (Type 1) performance in September 19against our submitted all type trajectory of86.6%.

• In September 19, both total and Type 1attendances were above plan.

• 60 min ambulance handover performanceremained within trajectory but 30 minhandovers increased slightly in September,bring the Trust outside of trajectory.

• Challenges to flow saw stranded patientsworsen in September, with DTA delaysremaining high.

A&E Performance Overview

Note: Conditional formatting indicates achievement of monthly target/ trajectory Source: Informatics

Standard Plan: Sep-19 Jul-19 Aug-19 Sep-19

A&E Performance (All Types) 86.6% 84.4% 83.8% 84.9%

A&E Performance (Type 1) 68.4% 63.8% 61.5% 65.0%

A&E Attendances (All Types) 13,473 14,463 13,046 13,998

A&E Attendances (Type 1) 5,433 5,898 5,367 5,784

Ambulance Arrivals n/a 2,221 2,124 2,264

A&E Type 1 Admission Rate n/a 32.6% 33.5% 30.5%

A&E Decision To Admit

Delays - 4 hrsn/a 529 301 400

Stranded Patients 7+ Days n/a 185 175 198

DTOCs - Days Delayed n/a 251 277 n/a

Ambulance Handover 60 min

Delaysn/a 8 1 6

45

A&E Performance (1/7)

3

Commentary

• The Trust delivered 84.9% (All type) and 65 % (Type 1) performance in September against our submitted all type trajectory of 86.6%.

• Although below trajectory, type 1 performance improved against the previous month from 61.5% to 65%. This was across admitted and non-admitted flows

• Type 1 breaches (and within that non-

admitted Type 1) remain the greatest opportunity to improve performance further ahead of trajectory.

• A revised rapid improvement project supported by the CARES+ team, which reorganised the blue zone (see and treat at front door) took place throughout September which has shown an improved performance. Work throughout October will be to sustain this and improve the consistency of approach.

Performance – All

Source: I-Reporter; Planning Submission

81.3%

84.6% 83.9% 84.4% 83.8%84.9%

70%

75%

80%

85%

90%

95%

100%


2019/2020 2018/2019 Trajectory Standard

Performance – Type 1 Only

56.4%

64.6%62.5% 63.8%

61.5%65.0%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%


2019/2020 2018/2019 Trajectory

46

A&E Performance- Type 1 split (2/7)

4

Commentary

Admitted and non-admitted performance missed the monthly trajectory in September however both indicators showed an improvement on August figures.

Non-admitted accounts for c 65% of all Type 1 activity so is the major driver of Type 1 performance and thereby overall A&E performance. A revised rapid improvement project supported by the CARES+ team, which reorganised the blue zone (see and treat at front door) took place throughout September which has clearly shown an improved performance. Work throughout October will be to sustain this and improve the consistency of it’s application.

Performance – Type 1 Admitted

Source: ED Trajectory v3; Integrated EC Performance Pack

Performance – Type 1 Non Admitted

45.3%

52.0%

48.1%

39.0%40.8%

44.5%

30%

35%

40%

45%

50%

55%

60%

65%

70%


2019/2020 2018/2019 Trajectory

62.0%

71.4% 70.1%

74.4%70.8%

74.0%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%


2019/2020 2018/2019 Trajectory

47

A&E Performance - Daily Type 1 (3/7)

5

Commentary • Type 1 admitted and non-admitted

performance was variable across the month, with admitted performance deteriorating in the second half of the month.

Source: Informatics

Performance Type 1 Admitted (Sep-19)

0

10

20

30

40

50

60

70

80

90

0%

10%

20%

30%

40%

50%

60%

70%

80%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Att

end

an

ces

Per

form

an

ce

Attendances Performance Trajectory

Performance Type 1 Non Admitted (Sep-19)

0

20

40

60

80

100

120

140

160

180

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Att

end

an

ces

Per

form

an

ce

Attendances Performance Trajectory

48

A&E Attendances by Type (5/8)

6

Commentary • In September 19, total

attendances and Type 1 attendances were above plan.

• This change in acuity mix compared to plan provided further challenge to delivering the A&E trajectory.

• The Trust continues to work with the CCG and other local partners to review demand management options.

Source: Informatics; Plan Submission

Attendances – All Types

Attendances – Type 1 Only

10,000

10,500

11,000

11,500

12,000

12,500

13,000

13,500

14,000

14,500

15,000

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2017/2018 2018/2019 2019/2020

A&E Attendances (All Types) Trajectory

4,000

4,500

5,000

5,500

6,000

6,500

7,000

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2017/2018 2018/2019 2019/2020

A&E Attendances (Type 1) Trajectory

49

Ambulances Attendances (6/8)

7

Commentary • Total ambulance attendances rose in September to 2,264.

• 30 mins ambulance handover delays increased slightly to

141, bringing performance outside of the agreed trajectory and 60 min delays remained within trajectory with a total of 6 breaches for the month.

Source: I-reporter

2,092 2,057 2,016 2,048 2,0042,084

2,179 2,1912,301 2,346

2,125

2,313 2,283 2,272

2,1312,221

2,124

2,264

508 517451

330

449338 315

259 256 250 248 238 236156

103 12475

14162 89

29 42 6411 36 3 20 9 6 25 19 3 10 8 1 6

0

500

1,000

1,500

2,000

2,500

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

2018/2019 2019/2020

Ambulance Arrivals - Non-Blue Light Ambulance Arrivals - Blue Light Ambulance Handover 30 min Delays Ambulance Handover 60 min Delays

Actions taken since last meeting. Have they worked or is there a barrier to progress? What further actions are required? • Ongoing focus on front door improvements as part of ED improvement

plan • Development of OD programme • Rapid Improvement Event on “Blue Zone” to decrease delays to

first clinician assessment • Performance & accountability discussions at middle grade level

50

Decision to Admit (6/7)

8

Commentary

• Decision to admit (DTA) delays increased in September to the previous month, and remain high in particular in comparison to2018/19. This was partly driven by higher than plan (4%) in all type attendances.

Decision to Admit Delays (4-12 hours)

Source: i-Reporter

138

288

161

188

150

4426

13

71

193

435 428

370

292

334

529

301

400

0

100

200

300

400

500

600


2018/2019 2019/2020

51

Discharge Improvement (7/7)

9

Long and Extended Stay Patients

Source: i-Reporter

Weekly Delayed Transfers of Care (DTOCs)

50

60

70

80

90

100

110

150

160

170

180

190

200

210

220

21

+ D

ays

7+

Da

ys

Stranded Patients 7+ Days Stranded Patients 21+ Days

0

5

10

15

20

0

20

40

60

80

100

Spe

lls

Da

ys D

ela

yed

DTOCs - Days Delayed DTOCs - Spells

Commentary • September’s DTOC data is not available at the time of publishing this report • Challenges to ED performance and flow saw long and extended stay patient performance worsen in September • Work continues with external partners, (CCG and local authority) and across the wards to improve discharges. This is through refreshing

board rounds and improving the attendance, grip within the long length of stay ward reviews and divisional dedicated flow leads • Regular conference calls with external partners weekly have had exec escalation calls now added to help support unpicking barriers to

discharge and ensuring traction across the system with this work.

52

RTT Performance Overview (1/3) Commentary • Performance continues to deteriorate

as the true weekly capacity gap emerges following reporting changes and the completion of the validation programme.

• Further deterioration to the total incomplete waiting list position is expected as the next wave of the validation and operational queries are completed in November

• Clinical harm reviews completed show no patient has come to moderate or severe harm through waiting for appointments and treatment.

Source: Infomatics

18 Weeks Performance and Trajectory

Over 18 Weeks

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Phase one of the validation programme

has been completed as planned – some operational and clinical queries are still to be resolved.

• Phase two of validation has started and is on trajectory.

• RTT and activity recovery plans have been developed for orthopaedics and ophthalmology in particular and are being closely monitored weekly.

• Demand and capacity modelling training sessions commence in October with the Trust expecting to be able to articulate better recovery times in late November.

• Endoscopy insourcing and extra activity implemented in particular in pain management to help see and treat long waiting patients

10

87.5% 87.1%85.6%

83.2%81.2%

79.9%

60%

65%

70%

75%

80%

85%

90%

95%


2019/2020

RTT Performance Trajectory Standard

3,156 3,396 3,811 4,495 5,138 5,930

25,184 26,387 26,544 26,694 27,29029,563

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000


2019/2020

18 Week Waiters 18 Week Trajectory Total Waiting List Total Waiting List Trajectory

53

RTT Performance Overview (2/3) Commentary • Allergy remains the most challenged specialty

for the Trust but has a detailed recovery plan which is reviewed regular. It is not expected to return to compliance in 2018/19.

• Validation work have revealed further pressures for pain management, and gastro/endoscopy

Note: Table cut to reflect nationally reported dataset; June data unvalidated Source: Informatics

RTT Incomplete and PTL by Service

18+ Week Waiters by Service

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Detailed recovery plan for Allergy services

developed with support from commissioners.

• A head of patient access has been appointed internally to start work on improving the booking systems and processes across the Trust.

• The first and most significant part of the validation programme was completed by external validators and on schedule.

• Phase two has now commenced. • Recovery plans for the most challenged

specialties have been reviewed and revised. • Increased capacity for long waiting patients.

11

PTL Last

Period

PTL This

Period

RTT 52

Weeks

RTT 40

Weeks

RTT 18

WeeksMay-19 Jun-19 Jul-19 Aug-19 Sep-19

(110) Trauma & Orthopaedics 4,561 5,037 7 75 1,281 83.2% 81.3% 77.9% 76.0% 74.6%

(130) Ophthalmology 2,991 3,140 0 5 348 95.2% 94.9% 92.4% 90.8% 88.9%

(100) General Surgery 2,337 2,626 13 49 504 86.0% 83.8% 79.8% 78.9% 80.8%

Other 1,885 2,056 0 3 147 94.3% 93.2% 92.3% 92.2% 92.9%

(301) Gastroenterology 1,823 2,035 15 49 544 86.8% 84.2% 81.3% 75.6% 73.3%

(191) Pain Management 1,514 1,671 1 50 641 78.1% 74.3% 70.8% 65.6% 61.6%

(120) ENT 1,638 1,638 2 7 206 96.0% 95.4% 91.1% 89.6% 87.4%

(317) Allergy Service 1,566 1,544 1 97 744 58.7% 58.3% 55.2% 51.3% 51.8%

(330) Dermatology 1,312 1,427 2 16 287 77.3% 74.3% 75.6% 78.3% 79.9%

(400) Neurology 1,108 1,309 1 6 236 86.3% 84.2% 85.7% 85.3% 82.0%

(502) Gynaecology 1,272 1,307 0 0 162 91.7% 92.0% 91.7% 89.2% 87.6%

(420) Paediatrics 1,220 1,225 0 0 50 97.4% 97.3% 96.0% 97.1% 95.9%

(140) Oral Surgery 966 1,158 0 3 127 95.2% 95.3% 92.1% 92.1% 89.0%

(101) Urology 1,037 1,135 0 10 231 94.1% 92.0% 86.8% 81.8% 79.7%

(410) Rheumatology 762 847 2 10 217 84.9% 81.4% 78.1% 76.5% 74.4%

(320) Cardiology 597 669 0 4 67 94.2% 92.0% 91.9% 93.0% 90.0%

(340) Respiratory Medicine 421 433 0 2 39 97.5% 95.7% 94.5% 94.1% 91.0%

(257) Paediatric Dermatology 280 306 0 8 99 72.4% 75.2% 73.8% 65.7% 67.7%

Total 27,290 29,563 44 394 5,930 87.1% 85.6% 83.2% 81.2% 79.9%

(317) Allergy Service

(110) Trauma & Orthopaedics

(330) Dermatology

(100) General Surgery

(191) Pain Management

(301) Gastroenterology

Other

What further actions are required? What is the trajectory for improvement? • Detailed demand and capacity work commences

with support from NHSI in October with the Trust preparing to provide a recovery trajectory November/December.

• Support from CCG is required to manage demand appropriately and to identify resources to see and treat patients waiting more than 18 weeks for treatment.

54

Cancer Performance (1/2) Commentary • In Q1 and the start of Q2 the Trust did not

achieve the two week wait and performance and has remained below 93% since April 2019.

• The position was driven by non compliance across the following tumour groups; Breast, Lower GI, Urology & Skin).

• The tumour groups have highlighted receiving a high proportion of inappropriate referrals on the Cancer 2WW pathway. An audit of inappropriate referrals has been undertaken and the findings shared with the CCG to discuss with referring GP’s.

Note: Validation for Cancer lags 1 month so last reported period is unvalidated Source: NHS Digital Cancer Dataset (via internal Informatics team)

2 Week Wait Performance (all tumour sites)

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Capacity issues are being addressed in the

following tumour sites to improve the trajectory with detailed plans agreed with the clinical leads; Colorectal, Urology, Breast & Skin.

• Review of staffing levels and work force planning is underway. Successful recruitment of x1 Colorectal STT Nurse and x1 STT Nurse and B2 A&C post currently out to vacancy.

12

What further actions are required? What is the trajectory for improvement? • Tumour sites to revisit demand and capacity

review to ensure adequate capacity is available to accommodate suspected cancer referrals.

• All areas requested to review eRS polling ranges. Continue to provide extra clinics to accommodate demand

736

906810 855 809 799

913845 802 775 798

915 937 950 944

11631057

998

0

200

400

600

800

1,000

1,200

1,400

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%


2018/2019 2019/2020

Tota

l See

n

Per

form

an

ce

Total Seen Performance Target

2 Week Wait Performance by Tumour Site

Jun-19 Jul-19 Aug-19 Sep-19 Jun-19 Jul-19 Aug-19 Sep-19

Suspected skin cancers 197 218 233 220 94.9% 94.0% 88.0% 86.4%

Suspected lower gastrointestinal cancers 200 234 217 188 82.0% 83.3% 80.7% 75.0%

Suspected breast cancer 140 246 223 177 90.7% 93.5% 74.0% 97.7%

Suspected gynaecological cancers 101 114 85 98 97.0% 95.6% 96.5% 98.0%

Suspected urological cancers (excluding testicular) 95 76 66 82 74.7% 94.7% 51.5% 82.9%

Suspected head and neck cancers 93 125 102 77 96.8% 93.6% 99.0% 87.0%

Suspected upper gastrointestinal cancers 57 79 68 71 82.5% 88.6% 92.7% 93.0%

Suspected haematological malignancies excluding acute leukaemia13 14 13 29 100.0% 100.0% 100.0% 96.6%

Suspected lung cancer 23 40 36 28 95.7% 97.5% 88.9% 96.4%

Suspected brain or central nervous system tumours 8 7 6 17 100.0% 100.0% 100.0% 88.2%

Suspected children's cancer 11 9 3 7 100.0% 100.0% 100.0% 100.0%

Suspected testicular cancer 6 1 5 4 100.0% 0.0% 40.0% 100.0%

Suspected sarcomas 0 0 0 0 - - - -

Other suspected cancer 0 0 0 0 - - - -

Total 944 1,163 1,057 998 89.4% 91.8% 83.4% 88.4%

Total Seen Performance

55

Cancer Performance (2/2) Commentary • The Trust failed to meet the 62 day cancer

performance target in Aug 19 and is undertaking targeted work to recover its position in Q3.

• There is on going work streams with NWLJV to improve reporting turnaround times to facilitate continuing improvement in 62 day cancer performance. New dedicated histopathologist for THH has joined in September.

• Targeted work is ongoing with tumour sites to streamline patient pathways.

Note: Validation for Cancer lags 1 month so last reported period is unvalidated Source: NHS Digital Cancer Dataset (via internal Informatics team)

62 Day Performance (all tumour sites)

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Diagnostic backlogs and reporting times

being reviewed and addressed. • Work ongoing to implement Straight to

Test pathways in specific tumour sites • Breast symptomatic and suspected

cancer data validated corrected on an ongoing basis until electronic solution agreed.

13

What further actions are required? What is the trajectory for improvement? • Address polling range - where possible poll

to 7 days to support earlier diagnosis. • Review IPT and timelines of transfer.

62 Day Performance by Tumour Site

47

60

41

52

4541

5247

32

50

34

4650

38

55 54

47

58

0

10

20

30

40

50

60

70

60%

65%

70%

75%

80%

85%

90%

95%

100%


2018/2019 2019/2020

Tota

l See

n

Per

form

an

ce

Total Seen Performance Target


Skin 12 12 9 29 91.7% 100.0% 88.9% 93.1%

Urological (Excluding Testicular) 17 23.5 11 13 76.5% 87.2% 81.8% 84.6%

Breast 11 3 8 6.5 81.8% 100.0% 87.5% 92.3%

Gynaecological 2 3.5 4 3.5 75.0% 71.4% 87.5% 100.0%

Haematological (Excluding Acute Leukaemia) 0 4 4 3 - 75.0% 75.0% 33.3%

Lower Gastrointestinal 8 4 6 1 87.5% 100.0% 66.7% 100.0%

Upper Gastrointestinal 2 0 2.5 1 100.0% - 80.0% 0.0%

Head and Neck 0.5 1 1 0.5 100.0% 100.0% 50.0% 100.0%

Lung 1 2.5 1 0 100.0% 80.0% 100.0% -

Sarcoma 0 0 0 0 - - - -

Brain/Central Nervous System 0 0 0 0 - - - -

Testicular 0 0 0 0 - - - -

Head & Neck 0 0 0 0 - - - -

Other 0 0 0 0 - - - -

Total 54.5 53.5 46.5 57.5 84.4% 89.7% 81.7% 87.0%

Total Seen Performance

56

Diagnostics Performance (DMO1 Standards)

Commentary • Consistent performance of DM01

over the last 7 months, however following the external review of our reporting systems and diagnostic waiting lists the Trust is expecting to report non-compliance later this calendar year as changes are made to reports in October.

Note: Most recently reported month is non validated Source: Informatics Team

Diagnostics Performance against DMO1 Standard

14

Performance by Modality

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Extra capacity has been made

available in ultrasound. Currently working a 7 day service.

• Cystoscopy have managed to achieve 100% this month due to workforce availability.

What further actions are required? What is the trajectory for improvement? • Continued weekly monitoring of 6

weeks performance for all modalities and report of any notifiable deviation in performance


Audiology - Audiology Assessments 329 293 291 279 100.0% 100.0% 100.0% 100.0%

Barium Enema 0 2 1 1 - 100.0% 100.0% 100.0%

Cardiology - echocardiography 3 2 5 3 100.0% 100.0% 100.0% 100.0%

Colonoscopy 248 242 216 233 100.0% 100.0% 100.0% 99.1%

Computed Tomography 315 291 315 424 100.0% 100.0% 100.0% 100.0%

Cystoscopy 61 78 77 76 100.0% 91.0% 89.6% 100.0%

Flexi Sigmoidoscopy 61 76 45 52 100.0% 100.0% 100.0% 96.2%

Gastroscopy 244 286 215 274 100.0% 100.0% 100.0% 98.9%

Magnetic Resonance Imaging 563 571 520 634 100.0% 100.0% 100.0% 100.0%

Non-obstetric ultrasound 2776 2770 2131 2736 100.0% 100.0% 100.0% 100.0%

Total 4600 4611 3816 4712 100.0% 99.9% 99.8% 99.9%

Total Waiting List Performance99.4% 98.9%99.8% 99.9% 99.3% 99.8% 99.7%

84.1% 83.7%

88.5%

97.4%

100.0%99.9%100.0%100.0%99.9% 99.8% 99.9%

75%

80%

85%

90%

95%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2018/2019 2019/2020

Diagnostics Performance Target

57

People & OD Executive Summary: Well Led

1

Commentary • Medical appraisals is at the highest level of the

year with 6 outstanding/expired. • StaM has increased to 92.96% (+0.61%) with only

two subjects under target; DSP at 91.90% and IPC L.2 at 87.93%.

• PDR continues to increase to 97.3% with 66 outstanding (Sept). This is just 0.3% lower than the same time last year.

• Sickness absence has increased to the highest level this year 4.37% (+0.43%) as both short and long-term sickness increased.

• Substantive vacancies have reduced by -0.85% to 12.43% due to an increase in staff numbers.

• Time to recruit average times to recruit have increased by +0.6 average working days to 30.5 following lengthy recruitments in W&Cs pushing the average to over 40 working days.

• Voluntary turnover has increased to over 14% at 14.12% (+0.45%).

• Agency spend has reduced by -£150k to just under £760k as medical spend reduced by almost -£140k to £203k.

• Bank spend has reduced to the lowest level of the year at £921.5k (-£216k).

People & OD Overview

Workforce Metric Target Jul-19 Aug-19 Sep-19

Medical Appraisals 90% 96.51% 91.32% 98.15%

Statutory/Mandatory Training 90% 93.55% 92.35% 92.96%

PDR Compliance 95% 95.46% 95.63% 97.30%

Sickness Absence 3% 3.96% 3.94% 4.37%

Substantive Vacancies 11% 12.35% 13.28% 12.43%

Time to Recruit 33 working days 28.7 29.9 30.5

Voluntary Turnover 11% 14.19% 13.67% 14.12%

Agency Spend n/a £847,251 £909,643 £759,584

Bank Spend n/a £992,728 £1,137,511 £921,522

58

Divisional Heatmap

The divisional heatmap collates a selection of key Workforce and Financial metrics, applies an appropriate score based on performance (lower score = higher performance), and colours each metric and score on a scale. This is presented as an overview of division-level

performance and can help infer correlation between metrics.

• Medicine – Overall lowest performing division in September due to relatively low StaM compliance particularly amongst medical staff, 41 outstanding PDRs at the end of Sept, and high vacancies could be increasing temporary staffing.

• Women’s & Children’s – Comparatively good StaM/PDR compliance and the lowest use of temporary staffing due to low vacancy rates, yet turnover is high and retaining new staff with less that a year’s services is low which could be affecting sickness rates.

• Corporate – High sickness both in-month and YTD appears not to have affected the other metrics. • Surgery – Similar performance to Corporate, but with a slightly more stable workforce. However StaM requires attention. • CCSS – Highest performing of the divisions yet despite vacancies remaining within target, voluntary turnover is high, which could be

affecting agency as short-term cover is required.

Workforce Metrics Financial Metrics

Division StaM

% PDR %

Sickness In-Month

Sickness YTD

Vol. Turnover %

Stability %

Vacancy FTE

Vacancy %

Staff in Post

Agency % of

paybill

Temporary Staffing

% of paybill Score

Medicine Division 90.34% 93.40% 3.39% 3.63% 14.18% 91.0% 163.12 15.55% 886.11 6.97% 16.40% 0.62

Women's & Children's Division 92.42% 98.71% 4.29% 4.27% 15.27% 87.1% 42.05 9.13% 418.54 2.48% 7.49% 0.55

Corporate 95.24% 98.72% 6.29% 5.21% 12.46% 88.8% 85.68 11.44% 663.11 3.35% 9.95% 0.53

Surgery Division 93.24% 97.12% 4.13% 3.85% 11.90% 89.0% 80.99 12.32% 576.57 3.48% 9.28% 0.53

Clinical Support Services Division 96.68% 99.60% 3.98% 3.22% 17.24% 89.0% 67.25 10.94% 547.71 7.35% 12.18% 0.50

Grand Total 92.96% 97.30% 4.37% 4.03% 14.12% 88.8% 467.75 12.43% 3092.04 4.99% 11.77%

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Statutory/Mandatory Training Compliance (Analysis)

• StaM compliance for September increased by +0.61% to 92.96%, the third highest compliance level of the year. This alsoplaces the Trust in second highest quartile overall using 18/19 Model Hospital data.

• Both Data Security & Protection (DSP) and Infection Prevention Control Level 2 (IPC2) continue to be under target at 91.9%(DSP) and 87.93% (IPC2) respectively.

• Having seen compliance improvements over the summer, Temporary Staffing compliance has fallen below target at 89.42%(-1.89%) particularly in the medical bank.

• Medicine division has seen improvement on compliance by over 2% to 90.47%, but 5 subjects remain under target.• The remaining divisions are all over the target 90%; W&Cs 93.72%, Surgery 93.73%, Corporate 95.14% and CCSS 96.78%.

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Statutory/Mandatory Training Compliance (Actions)

• Medicine, non-compliant medics being restricted from bank work via Patchwork, arranging additional bespoke face-to-face training sessions for hotspot courses; letters to non-compliant medics from the Clinical Lead; arranging training sessions to be held in monthly team meetings; and giving protected time on a rotational basis to focus on hotspot courses.

• Surgery, compliance is reported at surgical wards’ regular KPI meeting; there is agreement to update the Study Leave form

(medics) to include direct question on whether StaM is compliant before approval is given. • W&Cs, bespoke sessions with SMEs; hotspot report presented at monthly divisional meetings with escalation to AND/ADO. • CCSS, divisional PA actively chasing non-compliance; reminders of network access removal for DSP non-compliance. • Estates & Facilities, divisional PA continuing to chase non-compliant staff; review of Safeguarding levels with SME.

Course Clinical Support Services

Division Medicine Division Surgery Division

Women's & Children's Division Corporate Services

Temporary Staffing

Grand Total

Adult Basic Life Support Level 1 [Once Only], 80% target 99.62% 100.00% 98.80% 100.00% 100.00% 99.32% 99.76%

Adult Basic Life Support Level 2 [1 Year], 80% target 90.38% 81.97% 88.02% 87.62% 79.79% 80.87% 84.91%

Blood & Blood [2 Years], 80% target 95.49% 90.87% 94.28% 93.12% 91.26% 88.53% 91.80%

Conflict Resolution [3 Years], 80% target 98.42% 93.51% 96.77% 94.87% 96.96% 93.69% 95.62%

Data Security & Protection [1 Year], 95% target 97.46% 90.21% 93.20% 94.20% 94.47% 82.56% 91.90%

Equality & Diversity [3 Years], 80% target 98.57% 94.17% 97.79% 96.65% 97.10% 95.02% 96.39%

Fire Safety Level 1 [1 Year], 80% target 95.27% 76.36% 84.31% 88.07% 89.18% 66.33% 83.96%

Fire Safety Level 2 [1 Year], 80% target 92.39% 84.27% 90.44% 92.35% 81.13% 85.57% 88.17%

Health, Safety & Welfare [3 Years], 80% target 98.57% 94.39% 96.60% 94.64% 97.65% 93.19% 95.85%

Infection Control Level 1 [3 Years], 90% target 99.36% 97.56% 100.00% 100.00% 96.70% 95.00% 97.31%

Infection Control Level 2 [1 Year], 90% target 91.58% 88.42% 91.57% 89.59% 92.59% 77.89% 87.93%

Moving & Handling Level 1 [3 Years], 80% target 98.73% 79.34% 94.29% 80.68% 96.99% 87.54% 92.12%

Moving & Handling Level 2 [2 Years], 80% target 97.50% 91.98% 85.36% 93.89% 88.04% 91.49% 91.41%

Safeguarding Adults Level 1 [3 Years], 90% target 98.57% 92.30% 95.41% 95.76% 96.40% 94.35% 95.26%

Safeguarding Adults Level 2 [3 Years], 90% target 96.61% 91.54% 95.28% 95.18% 92.29% 93.07% 93.79%

Safeguarding Children Level 1 [3 Years], 90% target 97.94% 93.07% 96.26% 96.43% 93.77% 94.52% 95.08%



Safeguarding Children Level 4 [3 Years], 90% target #DIV/0! #DIV/0! #DIV/0! 100.00% #DIV/0! #DIV/0! 100.00%

Grand Total 96.78% 90.47% 93.73% 93.72% 95.14% 89.42% 92.96%

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Time to Recruit (non-medical)

• Time to recruit increased to 30.5 average working days, however this remains within the 33-day target and is fourth fastest time of the year. This also places the Trust in the top quartile, top 10 overall and second of STP peers using 18/19 Model Hospital data.

• September saw an increase in activity as 35 internal and 46 external applicants were recruited; at 81 applicants this was the highest number of recruits this year.

• Only W&Cs division breached the target at 34 days following 3 lengthy recruitments (x2 in Paediatrics and x2 in Women’s Services) average over 40 days.

• Average divisional times; CCSS 31.44, Medicine, 31.33, Corporate 28.25 and Surgery 25.5 days.

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Voluntary Turnover

Actions

• Medicine, review of bespokerecruitment campaigns and a skillsreview of ward managers to offerrecruitment/interview sessions ifrequired.

• W&Cs, “You Said, We Did”

posters in response to Staff Surveyoutcomes have been finalised anddisplayed across the division, andregular meetings continue with ouroverseas recruitment provider tounblock recruitment flow.

• Surgery, review of Trustredeployment process to retainstaff at risk and medicalredeployment. Leadership teamposters to be displayed in keyareas.

• CCSS, reviewing use of overseasrecruitment for RadiologyConsultants and OTs from SouthAfrica. Plans to focus onalternative roles, e.g. B4 AssistantPractitioners in Radiology.

• Estates, structure/developmentpathways for Capital DevelopmentTeam & Facilities, staff openforum (9th Oct).

Analysis

• Following a run of reductions, voluntary turnover has increased to 14.12% (+0.45%) forSeptember.

• The graph above highlights (orange “F”) a special cause for concern since February and

this is expected to continue for future months (orange “H”).

• Reduction were seen in Surgery at 11.9% (-0.13%) and Corporate at 12.46% (-0.42%)only. Increases were seen in CCSS 17.24% (+1.73%), W&Cs 15.27% (+1.29%) andMedicine 14.18% (+0.24%). 63

Substantive Vacancies

Actions:

• Medicine, Recruitment & Retention plan within wards; updating adverts and gathering of insight from the student nurse experience.

• CCSS, opportunistic recruitment (process to over-recruit) has been completed in Pharmacy and Clinical Records.

• Surgery, development of an induction pack for new starters to improve the on-boarding process.

• W&Cs, monthly triumvirate “walkabouts” in maternity wards.

Completion of Post-Natal ward external review.

• Estates, reviewing the structure and progression opportunities with estates management.

• Facilities, monthly KPI meetings incorporate vacancy and turnover discussions.

• September saw a reduction in vacancies by -0.85% to 12.43% as staff in post numbers increased by almost 40fte; Scientific/Tech +5.7fte, clinical support (inc. HCAs) +8.7fte, estates & ancillary +3.5fte, medical & dental +11.4fte, N&M +11fte and students +4fte.

• All areas experienced a reduction in vacancy rates except for Surgery division following a slight reduction in staff numbers (1fte) and an increase in establishment (+9.4fte):

– Medicine, 15.55% (-1.55%) with 163.12fte vacancies – CCSS, 10.94% (-1.12%) with 67.25fte vacancies – W&Cs, 9.13% (-0.9%) with 42.05fte vacancies – Corporate, 1.44% (-0.77%) with 85.68 fte vacancies

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Sickness Absence

Actions:

• Medicine, HRC prioritising ongoing management of cases via regular 1:1s with managers with a particular focus on hotspots. HRC/ADON meeting all ward managers monthly for 15 min slots to discuss sickness, fortnightly in ED.

• Surgery, bespoke sickness absence session for sisters in Theatres has been delivered. Development of process map for record and managing medical sickness.

• CCSS, weekly discussion at DTM and PAR meetings with Execs.

• W&Cs, sickness absence training for doctors. Health & Wellbeing plan rolled out in Paediatrics and being developed for Community Midwives. Managing sickness training delivered as part of Maternity and Labour Ward away days. Bespoke ‘Return to Work’ training

for short-term hotspot areas.

• September has seen an increase in sickness across both short-term 1.60% (+0.36%) and long-term 2.77% (+0.08%) bringing the overall total to 4.37% (+0.43%), 3944 fte days and an estimated salary cost of over £361k.

• Current sickness rates puts the Trust in the second highest quartile and higher than STP peers using the latest Model Hospital data (Jun 19).

• Divisions with increases were: Corporate at 6.29% (+1.56%) 1242 days, Surgery at 4.13% (+0.51%) 689.5 days, and CCSS at 3.98% (0.8%) 636.5 days. Reductions were seen in Medicine at 3.39% (-0.48%) 864.5 days and W&Cs at 4.29% (-0.62%) 511.4 days.

• Long-term sickness reasons continue to be Anxiety/stress/depression, musculoskeletal and gastrointestinal, with short-term reasons as gastro, cold/cough/flu and headache/migraine.

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Agency Spend

Actions:

• HRBPs working closer with Temporary Staff Manager to tackle hotspot areas for high agency use/spend.

• Managers reminded that the notice period for Band 5 staff increased to 6-weeks from June 2016.

• September agency spend reduced by -£150k to £759,584 as medical agency spend reduced to the lowest level of the year at £203,040 (-£137k).

• Contributing to the spend reduction, the Medicine division reduced by -£210k to £321,970 with Nursing agency spend contributing to £271.3k of the overall figure with AMU spending £130.8k and A&E spending £104.4k on agency nursing.

• All other division experienced spending increases: – CCSS, £170,805 (+£32.3k)) – Surgery, £115,288 (+£10.3k) – Corporate, £99,050 (+£3.5k) – W&Cs, £52,470 (+£13.8k)

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Bank Spend

Actions:

• Safer staffing meetings to monitor publication of roster within agree 6-week timescale to help improve bank bookings.

• Director of Estates & Facilities have oversight of vacant shift requests to ascertain whether other options can be used to fill.

• September bank spend reduced by -£216k to £921,522, the lowest level of the year. • At 54% the Trust is in the top quartile and ahead of most STP peers for proportion of

substantive staff who are also on the bank (18/19 Model Hospital). • Nursing bank spend was under £400k at £397,671 for the first time since Dec 18. Support pay

also decreased back under £300k at £269,277. • All clinical division reduced spend with Corporate increasing to £179,336 (+£2.9k):

– Medicine, £392,915 (-£114,277) – Surgery, £146,145 (-£65,280) – W&Cs, £98,924 (-£34.7k) – CCSS, £104,203 (-£4.6k)

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PDR and Medical Appraisal Compliance

• Highest compliance level of the year; 98.15% following a lot of work by the medical revalidation team.

• 6 outstanding medical appraisals: – Surgery 97.4% (3 outstanding) – CCSS 93.6% (2 outstanding) – Medicine 99.2% (1 outstanding) – W&Cs 100% – Corporate 100% • Divisional Directors continued to be provided with

the names of expired appraisals.

• PDR for September was 97.30%, -0.3% less than the same time last year. The Trust ended last year with the third highest PDR compliance overall and ahead of all STP peers (18/19 Model Hospital).

• 66 appraisals still outstanding. Over half remain within the Medicine division, particularly A&E where hardcopy PDR forms need to be input into iDevelop.

• CCSS have reduced to 99.6% compliance as x3 staff returned from maternity leave. These have been completed and iDevelop will be updated.

• The L&OD have been getting feedback on the system/process to prepare for next year.

0.65%

14.01%

85.48% 95.46% 95.63% 97.30%

0%10%20%30%40%50%60%70%80%90%

100%


PDR compliance %

2018-19 2019-20 Target (95%)

86.69% 84.64% 96.77% 96.51%

91.32% 98.15%

0%

20%

40%

60%

80%

100%

120%


Medical Appraisals compliance %

2018-19 (Cumulative) 2019-20 (Rolling-Year) Target (90%)68

Board of Directors


Title Hillingdon Improvement Plan Update

Report author Antoinette Flynn - Assistant Director of Programme Management Fran Davies - Interim Quality Improvement Director

Report sponsor Jason Seez - Deputy Chief Executive

Status of Report Public Private Internal ☒


☒ ☒

Summary

Overview: The Hillingdon Improvement Board continues to meet fortnightly chaired by the Chief Executive. Alternate meetings have external representation from NHs England/Improvement, CCG, Healthwatch and patients. CQC have been invited but so far have not attended in person. The Plan comprises 13 workstreams and related actions, as follows: Safety Culture; Governance (Corporate & Clinical); Deteriorating Patient (inc Sepsis); Emergency Department; Transitional Care; Safe Care; Safeguarding; Medicines Management; End of Life Care and Mortality; Data Quality; Hospital at Night; Medical Devices and Operational Standards and National Quality Requirements. A report monitoring the progress in delivery of actions against the planned milestone delivery dates is contained in Appendix 1.

Recommendations The Board is invited to note the content of this progress report.

Links to Corporate Objectives

The Hillingdon Improvement Plan supports delivery of the following corporate objectives: Quality - We will deliver good care every day Workforce - We want empowered, committed people with the right skills and attitude Performance - We will deliver the right care at the right time for our patients Money – We will live within our means. Well Led - We will empower our people to deliver Partnership - We will develop sustainable models of care centred around our patient

Impact

Quality and Safety X

Legal

Financial

Human Resources

Equality and Diversity

Engagement and communication x

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Sustainability

Hillingdon Improvement Board 7 October 2019

September Progress Report for the Hillingdon Improvement Plan

1.0 Progress to date/Highlights The Improvement Plan is currently on track to deliver the thirteen workstreams; actions are continually being reviewed and consolidated as the work to achieve milestones is progressing.

Highlights since the last report include: HI 3 Deteriorating Patient (including Sepsis) World Sepsis Day 13 September saw the launch of the sepsis training programme aim for 600 staff in 60 days and the launch of the sepsis dashboard. The dashboard will support management of sepsis by flagging late or missed sepsis screening or actions, allowing managers to identify poor compliance trends and address poor performance. HI 9 EoL & Mortality The workstream has reviewed the improvement plan and via the change control process has updated the plan to include actions from their local work plan including a training programme to support staff to deliver end of life care; increased use of Coordinate My Care which share care plans with external partners; and adoption of the Comfort Care Symbol. Ward accreditation Baseline ward accreditation across all wards was completed in September, all 18 wards were graded as white which indicates improvements are required across all wards; the tool is not sufficiently sensitive to provide nuanced grading which is being addressed with input from IT. Ward accreditation is a rolling programme of performance assurance under the directorship of the Chief Nurse, a separate report on the findings of the programme will be taken to TME on 17 September. 2.0 Current position A progress tracker for all actions within the HIP is contained in Appendix 1. The workstreams with the highest slippage of actions completed are HI 2 and HI 6. HI 2 Governance (Corporate and Clinical) Board Assurance Framework, SFIs & schemes of delegation approved at July QSC, awaiting Board approval in October. The workstream and associated milestone delivery dates are being reviewed once Board approved received, with likely completion in February. HI 6 Safe Care Significant slippage in delivery however the Medical Director (SRO) undertook a review of the workstream & presented a recovery plan to HIP Board on 29 August. Remedial actions planned through September and October with a plan to re-present progress to HIP Board 31 October. Substantive appointment to the IP&C Team means that focus in October will allow a number of actions in the plan to close; including policy update, compliance assurance, training needs analysis, thematic reviews and analysis to inform ward or departmental support requirements. A review of the Clinical Records Committee has identified a requirement to update the terms of reference and the membership of the group, to ensure our move to electronic records is adequately understood and managed trust-

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wide. That policy, standard operating procedures and practice support clear standards of documentation, and ensures all healthcare professionals understand their responsibilities with regard to paper and electronic records. 3.0 CQC compliance

Following the previous Hillingdon CQC report in July 2018 the trust, with its partners from Hillingdon CCG, North West London CCG Conglomeration and NHS England and NHS Improvement (NHS E/I) established an Evidence Assurance Group. The aim of the group is to review performance against the CQC action plan and to validate evidence.

Whilst all the outstanding actions and deadlines have been integrated into the HIP and monitored via HIP Board the Evidence Assurance Group focuses on the specific Must do and Should do actions from the CQC report and incorporate visits to the pertinent site where appropriate to ensure the improvements are in place and the evidence is validated.

The meeting occurs monthly and the Group review the progress to date. Currently the status of the actions is as detailed in the table below:

Type Number Transitioned into HIP Reasonable assurance Limited assurance Outstanding Must do 14 5 5 2 2 Should do 64 13 28 6 17 Requirement notice 19 7 8 3 1 Total 97 25 41 11 20

The 20 items still outstanding for review by the Evidence Assurance Group, 8 items will be reviewed on Thursday 10 October with the remainder timetabled for review by 31 December.

The intention is that the Group will continue regular monthly meetings until all actions are reviewed and achieve a rating of reasonable assurance when they transition into the Improvement Plan for on-going monitoring and assurance. Outcomes from the meeting will be reported to the Hillingdon Improvement Board to ensure triangulation with the HIP.

4.0 CQC Preparedness

The CQC Oversight Group convened its first meeting on 13 September; the members of the CQC Oversight Group are responsible for overseeing the Trust’s preparations for the forthcoming CQC inspection, and as part of that the Use of Resources assessment and for overseeing plans for the how the actual clinical services inspection, the well led element and the post inspection process will be managed.

• Formal sign off-of CQC preparations. • Overseeing the peer service reviews. • Overseeing the collation of information and evidence for the PIR and Use of Resources assessment. • Overseeing the practice interviews of Board members and Trust senior leaders. • Oversee the production of a briefing pack for Board members and Trust senior leaders. • Overseeing the production of a timetable of visits and preparations for accommodating and communicating

with the inspection teams at both hospital sites. • To provide assurance to Trust Board on the preparedness for the CQC Inspection. • To support resolution of issues escalated to the CQC Oversight Group. • To oversee the production of a communications and engagement plan and to ensure it is effective, so that

staff are fully engaged and prepared for the forthcoming CQC inspection and Use of Resources Assessment. • To support our people in the preparation, throughout the inspection and assessment and post inspection

processes, and in the management plan for any actions arising from the recommendations included in the report.

The CQC Oversight Group is accountable to the Hillingdon Improvement Plan Board, progress updates will be provided to TME, QSC and Trust Board via the monthly HIP Board reports.

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4.0 Summary

Focus needs to continue to deliver the improvements through October, November and December to ensure the plan is delivers to the agreed timescales, and that the Trust delivers the identified required improvements to patient care. Whilst the Trust has started preparation for the CQC Inspection, date unknown but likely Q4 2019-20, it important that staff recognise the improvements delivered are not just in preparation for the inspection but that a culture of sustained and continuous improvement needs to embed in individuals, teams, departments and across the Trust to ensure we deliver the best possible care to patients and the people of Hillingdon.

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Appendix 1

Workstream Key Milestones - Due DateDelivery against milestone

Forecast delivery against milestone

On track to deliver

(Y/N)

Milestone Achieved

Milestone Assured

Comments, risks & issues

1.1. Lessons learnt from incidents & complaints - September 2019 G G Y Not due Not due SI process agreed at May QSC1.2 Cares+ QI Programme - May 2019 G G Y Y Y Programme in place1.3 Delivery of Cares+ programmes - November 2021 G G Y Not due Not due On track1.4 Exchange Cares+ Programme - June 2021 A A Y Not due Not due Action needs review, as the national exchange programme not proceeding1.5 OD Staff Programme - September 2020 G G Y Not due Not due Provided appointed & on site, delivery launch & roll out plan1.6 Effective audit processes - October 2019 G G Y Not due Not due Presentation to September PSC1.7 Patient experience methodology - December 2019 A A Y Not due Not due Work in progress, outcome & timescales will be reviewed, no issues flagged at present2.1 Board Assurance Framework - September 2019 G G N Not due Not due Working with GGI recommendations2.2 Board, committees & sub-committees roles & responsibilities - April 2019 R R N N N Slipped to July for GGI report & recommendations2.3 Policies & documents are current & available to use - April 2019 A A N N N SFIs & scheme of delegation going to July Audit & Risk Committee2.4 Framework for corporate & clinical governance - July 2019 R R Y N N All policies mapped to committees 2.5 Incident management systems & processes - June 2019 G G Y Y N SI process agreed at May QSC, policy to PSC July2.6 SI management systems & processes - April 2019 G G Y Y N Backlog monitored against weekly SI meeting2.7 Risk management systems - July 2019 R R N N N Working with GGI to determine systems & processes2.8 Datix system that supports revised policies & processes - June 2019 G G Y Y N Dashboard development via GiveMeData2.9 Risk & incident management training - March 2020 G G Y Y Y Learning Sis incorporated into Lesson Learnt Patient Safety, HiHLS 24 July2.10 Duty of Candour resource hub on Intranet - March 2020 G G Y Not due Not due Training materials collated, page under development2.11 Duty of Candour policy - September 2019 R R N N N Working with GGI to determine systems & processes2.12 Duty of Candour training - March 2020 G G Y Not due Not due On track2.13 Datix system that supports DoC - September 2019 G G Y Not due Not due Training materials recieved & delivered2.14 DoC performance reported in divisional performance reviews- September 2019 G G Y Not due Not due Performance reportintg to commence in July2.15 Governance Team structure - October 2019 G G Y Not due Not due On track2.16 Governance, assurance & performance framework in place - September 2019 R R N N N Working with GGI to determine systems & processes2.17 Refresh Trust QIA process - October 2019 G G Y Not due Not due On track3.1 Sepsis management process - April 2019 G G Y Y N In place via hObs or paper Sepsis Screening Tool. MIU last place for hObs to be launched3.2 Sepsis Policy - April 2019 G G Y Y Y Policy in place3.3 Sepsis training - June 2019 R R N N N TNA complete - training package agreed with OD

3.4 Monitoring process to embed accountability & compliance - July 2019 G G Y N NDashboard data being shared with individual wards. Governance and Nursing Meeting reporting being agreed. Trajectory for improvement being agreed

3.5 Response from teams to late/missed sepsis screens &/or actions - Sept 2019 G G Y Not due Not dueDashboard is identifying areas for improvement including sepsis screening data - team working with wards to drive improvements

3.6 Patient information complies with NICE guidance - September 2019 G G Y Not due Not due Patient Information under review by Deteriorating Patient Group3.7 Structure obs & screening for sepsis - December 2019 G G Y Not due Not due hObs in use across the organisation except MIU which is being progressed.3.8 Sepsis treatment within 1 hour - September 2019 G G Y Not due Not due Dashboard provides data on sepsis treatment within 1 hour. Monitoring as per 3.4

3.9 Neonates inclusion into sepsis processes - September 2019 G G Y Not due Not duePaediatric guideline in place (covers 0-16 year olds). Guideline referenced in the sepsis policy. Audit presented at Deteriorating Patient & Sepsis Group.

3.10 Rescreening protocol for sepsis - May 2019 G G Y Y Y Policy updated to clarify re-screening, policy published3.11 Efficient rescreening process in place - June 2019 G G Y Y Y As above3.12 Identified deteriorating patient/sepsis link - December 2019 G G Y Not due Not due Lead Sepsis Nurse in post, work progressing with wards to improve processes3.13 Robust process in place for managing deteriorating patient - December 2019 G G Y Not due Not due In progress3.14 TEP will be in place - March 2020 G G Y Not due Not due Resus Committee and key stakeholders are reviewing implementation of ReSpect and alternatives4.1 Assurance & monitoring of ED improvement plan - May 2019 G G Y Y Y Complete - agendas & action logs available4.2 Reduction in Ambulance handover delays - July 2019 G G Y Y N On track4.3 Safe & effective Ambulatory Emergency Care (AEC) service - July 2019 G G Y Y N On track4.4 Appropriate patient streaming - May 2019 G G Y Y N Criteria & data required4.5 Effective ED triage service - May 2019 G G Y Y N In place4.6 Deliver an effective fractured neck of femur pathway - August 2019 G G Y Y N In place4.7 Deliver an effective direct access stroke care pathway - July 2019 G G Y Y N In place4.8 Improved paedatric ambulatory care pathways - March 2020 G G Y Not due Not due On track4.9 Achieve 4 hour transit time trajectory - model & infrastructure - October 2019 A A Y Not due Not due Not meeting trajectory, remedial actions identified however need to address significant obstacles 4.10 Achieve 'Intercollegiate Committee Standards CYP in ED - May 2019 G G Y Y N Complete - assurance evidence required4.11 ED meets the Royal College Emergency Medicine recommended 16 hours per day - April 2019 G G Y Y N In place4.12 Identify & appropriately assess vulnerable patients in ED - March 2020 G G Y Not due Not due On track4.13 ED patients receive safe care - March 2020 G G Y Not due Not due On track4.14 Development of a safety culture - December 2019 G G Y Not due Not due On track5.1 Seamless transition to adult services - September 2019 G G Y Not due Not due CSL leading on transition & CCG funded 8 week pilot for a transitional care nurse

5.2 Identified transition services - September 2019 G A N Not due Not duePilot pathway complete, need to review plan & timescales for all pathways. CYP Board to review & sign-off prior to upload to HIP

5.3 Patient centred care - December 2019 G G Y Not due Not due Age specific feedback currently being collected5.4 Robust mental health care provision - December 2019 A A Y Not due Not due TNA required for staff supporting CYP with MH needs6.1 Proactive care consistently across the Trust - July 2019 R R N N N Proactive care currenty cntinues in line with existing model pending revison. Discussed at August Care 6.2 Safety Huddles embedded across the Trust - December 2019 A G Y Not due Not due A decision required if the Safety Huddles should form part of the Board Round.6.3 Consistent handover process embedded across the Trust - July 2019 R R N N N Planned rollout across all staff groups & wards by November

6.4 Effective & safe trust-wide NG management - September 2019 R R N N N

NGT guidleines and competencies in place; training for nursing staff provided by Nurse Education team. Enteral feeding guidelines and associated nursing care plans currently being updated by dietetics and Medical Matron.

6.5 Safe administration of oxygen & air trust-wide - September 2019 A A N Not due Not dueThe hospital prescription chart has been updated to meet updated BTS standards. Pharmacy undertaking a clinical audit on the revised chart.

6.6 IPCC appropriate compliance with Hygiene Code (2015) - June 2019 R R N N NIP&C action plan to be included in HIP - new IP&C lead in post has made good progress to-date & planned further focussed action in October

6.7 Processes to support 7 day services - March 2020 G G Y Not due Not due NHSI/E Board Assurance Framework self-assessment to monitor compliance due in November6.8 Safe & appropriate conscious sedation use - June 2019 R R N N N Confirming clinical audit requirements

6.9 Safe & appropriate NIV use - June 2019 R R N N N

Appropriate training to nurses provided. CCOT under review with consideration as to whether NIV support can be included within this remit - CCOT Nurse Consultant in post from November. A review of SJRs, incidents, outcome from respiratory procedures outlier audit will take place to determine we are effectively mitigating NIV risk.

6.10 Principles of NATSSIps & LOCSSIPs are embedded trust-wide - December 2019 G G Y Not due Not due A centralised management system is being introduced6.11 Compliance with WHO checklist - June 2019 G G Y Y N On track6.12 Right patient, right place with timely discharge - December 2019 G G Y Not due Not due On track6.13 Audited compliance with Trust clinical records standards - December 2019 A A Y Not due Not due Review of Clinical Records Committee function and Chair to be taken forward7.1 Adherence to restraint & management of violence & aggression policy - December 2019 G G Y Not due Not due On track - TNA complete, training programme to be developed with TIA7.2 Embedded compliance with Intimate Examinations & Chaperon policy - December 2019 G G Y Not due Not due On track - Policy drafted, currently out for consultation7.3 Compliant with Lampard Review & Bradbury Report recommendations - December 2019 G G Y Not due Not due On track7.4 Seamless pathways for LD patients tranistioning to adult services - December 2019 A A N Not due Not due Recruitment to LD nurse in progress7.5 Compliant with Child Protection Information Sharing - July 2019 G G Y Y N CP-IS in place across ED & Maternity7.6 Embedded appropriate trust-wide assessments MCA, DoLS & LD - June 2019 G G Y Y N Compliance below baseline, Safeguarding Team undertaking a review

8.1 Improve security, storage & safe handling - August 2019 R G Y Not due Not dueAll actions in the plan complete however the ward accreditation process highlights the cultural behaviour shift has not been sustained

8.2 Improve safty (reconciliation, reduce omitted doses) - August 2019 G G Y Not due Not due On track9.1 Support learning from Deaths & EoL care - June 2019 G G Y Y Y Policy published & uplaoed to DIMS 12 August 20199.2 Conforming to HSMR & SHMI standards - August 2019 G G Y Y N Reported at Board Committees & part of Quality & Safety Report9.3 Accurate coding & documentation - December 2019 A G Y Not due Not due External audit to confirm 9.4 Process support understanding causes of mortality - December 2019 G G Y Not due Not due Remains on track

10.1 Core data quality improvement - September 2019 G G Y Not due Not due On schedule will report at DQISG

10.2 Single repository for information - September 2019 G G Y Y N Reporting functions aligned to Management, Committee & Board reports

10.3 Implement data quality e.g. kite mark - September 2019 G G Y Not due Not due On track

11.1 Effective Hospital at Night service defined leadership - June 2019 G G Y Y N Board meeting dates agreed

11.2 Corporate & clinical governance for Hospital at Night Service - January 2020 G G Y Not due Not due Policy in place, roster process review required

11.3 Revised Hospital at Night model in place - September 2019 R G Y N N Policy & SOP signed off - training & launch of new model 15 October

12.1 Embedded compliance with Medical Devices Management policy - March 2020 G G Y Not due Not due Gap analysis in process

12.2 Medical Devices Group delivery against ToR - July 2019 G G Y Y N In places & minuted since Nov 2017

12.3 Trust-wide departmental processes to demonstrate compliance - March 2020 G G Y Not due Not due TNA completed & action leads identified13.1 Complaince with RTT standard - March 2020 A A N Not due Not due Trajectory will be reviewed following completion of the MBI validation project13.2 Zero RTT 52 week wait - March 2020 A A Y Not due Not due Working with MBI to identify, validate & treat 52 week breach patients in-month13.3 Compliance with diagnostic standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.4 Compliance with ED wait time standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.5 Compliance with Cancer wait time standards - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.6 Zero mixed sex breaches - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.7 Compliance with rebooking standard hospital non-clinical cancellations of surgery March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.8 Zero methicillin-resitant staphylococcus aureus - ongoing G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.9 Minimal C-diff rates - ongoing G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.10 Ambulance handover 15 mins & <30 mins - see HI 4 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.11 Ambulance handover 15 mins & <60 mins - see HI 4 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.12 Zero >12 hour waits in ED - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.13 No operations cancelled for a second time - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.14 Complaince with VTE assessment standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.15 Compliance with Notifiable Safety Incident Regulation 20 - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.16 Compliance with first episode psychosis or ARMS standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.17 Full implementation of an e-Prescribing system - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.18 Compliance with emergency presentation & sepsis screening standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards13.19 Compliance with inpatient sepsis screening standard - March 2020 G G Y Not due Not due Refer to Integrated performance report for progress with constitutional standards

Draft HIP Board Report September 2019

HI 1: Safety CultureSRO: Medical DirectorPlanned milestone completion: December 2019

HI 2 a/b: GovernanceSRO: Deputy CEOPlanned milestone completion: September 2019

HI 3 Deteriorating Patient (including Sepsis)SRO: Chief NursePlanned milestone completion: March 2020

HI 5 Transitional CareSRO: Medical DirectorPlanned milestone completion: December 2019

HI 4 Emergency DepartmentSRO: COOPlanned milestone completion: March 2020

HI 6 Safe CareSRO: Medical DirectorPlanned milestone completion: March 2020

HI 13 Operational StandardsSRO; COOPlanned milestone completion: March 2020

HI 7 SafeguardingSRO: Chief NursePlanned milestone completion: December 2019

HI 8 Medicines ManagementSRO: Medical DirectorPlanned milestone completion: August 2019

HI 9 EoL & MortalitySRO: Medical DirectorPlanned milestone completion: December 2019

HI 10 Data QualitySRO: Director of FinancePlanned milestone completion : September 2019

HI 11 Hospital at NightSRO: COOPlanned milestone completion: January 2020

HI 12 Medical DevicesSRO COOPlanned milestone completion: March 2020

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Board of Directors 29 October 2019 Agenda Item: 10

Title CARES+ Transformation Report

Report author James Ross, Director of Transformation Report sponsor Jason Seez, Deputy CEO


Purpose of Report

For Decision

For Assurance

For Information

☐ X ☐

Summary

This is a regular monitoring report for the Transformation Programme, covering progress against Improvement Practice, Emergency Care, Outpatient and Theatres.

Recommendations The Board is invited to note the Report.


ALL

Impact

Quality and Safety X Legal X

Financial X

Human Resources X



X

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1. Improvement Practice update October 2019

Practice Coach Training

Table 1: September 2019 training session provision

Training Type Attendees Comments Lean Basics x2 23 Training sessions provided at both THH & MVH Module 4 x1 3

30 Practice coach participants have completed all five modules, and 35 have completed modules 1-4.

Uptake of training is reflected in Figures 1 and 2 which show the participant numbers by division, and overall progress to date.

There has only been a minor increase in uptake of Module 5 (Lean Basics) since the last report following active canvassing to promote session availability. The remaining training dates have been recirculated to a targeted group; overall there are 21 practice coaches who have not yet booked training.

Four further Lean Basics sessions are planned for all staff between now and the end of November via iDevelop, including 2 sessions at Mount Vernon Hospital. The team are aiming to train 150 staff through this awareness session, and 103 will be trained (based on current bookings) during this time period, with capacity to train a further 96 staff. Attendance has been driven by Corporate areas (55%), with only 25% bookings coming from the clinical divisions. The team will review their marketing approach for these divisions, and provide an update in next month’s report. Attendance has been enhanced by direct communications through Executive line management structures and regular communications in the Bulletin, as well as ongoing individual contact with teams and services.

Practice Coach Improvement projects

All four Practice Coaches in the CARES+ team were certified in September following completion of their improvement projects. Focused support is being provided to a targeted group to achieve the certification requirements during October and November, as outlined in the table below:

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Division/ Area Target PCs to meet Certification Requirement October November

CCSS 2 1 Corporate 4 1 Executives - 4 Medicine 3 - Surgery - 3 Womens & Childrens - 1 Kata

Two members of the CARESplus team attended a three day workshop in September planning the next stage of kata deployment in the NHS. The workshop included highly insightful input from health organisations in the United States who have been implementing kata in the healthcare environment for in excess of five years, and was led by a kata sensei, Beth Carrington from Kata Matters. There was significant learning in this event, and a paper will be taken to the next guiding board to identify how THH can take advantage of the enhanced understanding of kata deployment gained through the event. The CARES+ team are continuing to develop their skills as learners.

Event Planning

The team are providing intensive post event support to Pre-Operative Assessment, Lister and Flow teams, following their recent participation in their respective Rapid Improvement Events. Each team is requiring a range of input, enabling them to build on the improvements initiated and identified during their event weeks.

Guiding Board

The fourth improvement practice guiding board has been held. The Board were provided with an update on current activity, progress with training, and advised on the development of the practice coach programme.

Report Outs

Report Outs continue to take place, with a wide range of presenters now making contact with the team to share improvement projects they have undertaken. All clinical divisions have now presented,

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with CCSS and Corporate doing so most frequently. Targeted communications have been used to encourage report out presentations from currently under-represented divisions.

Partnership working

Four members of the Trust attended the Kaizen Open Day at East Surrey Hospital on the 26th September, providing positive feedback on their experiences.

The team have taken part in additional kata training provided by NHS Improvement with the Vital Signs partnerships. Following a successful internal NHSI review in early August, a planning session for next year was held last month with all sites represented. The NHSI team are developing a summary and outline of the 19/20 programme priorities which will be shared at Guiding Board once available.

NHSI provided all Vital Signs partners places at the 2019 Lean Healthcare Summit, and 3 staff attended. This two day event provided opportunity to learn and share with other organisations working with improvement methodologies and all participants found the summit very informative.

2. Emergency Care Improvement

The Emergency Care improvement programme continues, tracked weekly at the A&E programme board, chaired by the chief executive.

Metrics

Figure 5: Metrics for ED Programme

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Quartile Commentary Delivery The organisation did not meet the trajectory for September, achieving

84.9% against a trajectory of 86.6% Cost The financial value of the programme relates to the bed closure

programme. The expected value of this programme is £1.4m. The current achievement of savings ascribed to bed closures is on track.

Quality The number of patients in hospital for more than 21 days is showing a sustained reduction, but is not yet achieving the target.

People The programme is yet to have a visible impact on patient experience, as measured by the Friends and Family test metric. The friends and family metric is only available one month in arrears.

Progress Highlights

The revised model of care for the blue zone continues to supported towards sustainability. The department is maintaining a process of continuous improvement, and introducing new amendments to the model as issues become evident. The metrics indicate that the change should be continued, and therefore the programme to deliver and sustain the improvement is continuing to ensure sustained performance.

The referral algorithm for the assessment floor has been signed off and implemented, with the aim of simplifying the patient pathway into ambulatory care. The work group is addressing the issue of the number of follow-up appointments booked, and the pathway for discharge from the service. Recruitment is ongoing and a number of the overseas recruited doctors have arrived and begun their work.

The stranded and super-stranded patient review process has also been expanded, with a division between the acute and rehabilitation wards to provide increased clarity and focus, and a deep dive work plan is in progress to explore the issues affecting patients staying between 7 and 14 days.

The Lister ward Rapid Improvement Event (RIE) provided focussed insight into issues around communication for discharge planning – this has enabled the Integrated Discharge Team to start work on visual management approach to have a Trust wide improvement of Discharge communication.

Next steps

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Additional focus will continue on the assessment floor pathways, and there will be continued work on criteria led discharge, clinical engagement with stranded patient review, and the system wide review of discharge to assess pathways.

The focus on organisational development support to the emergency department and the ongoing support to the Blue Zone revised process will continue.

Winter planning is underway, and the winter plan will be produced by the end of October.

There will be additional divisional input into the long length of stay review process. There is a clinical site management and discharge team rapid improvement event being planned for November.

3. Outpatient Transformation

The system-wide outpatient transformation board has developed a clear programme structure, incorporating four major work streams. These are:

• North West London wide outpatient transformation programme – 13 specialties in three phases

• Efficiency programme – This programme has several facets, looking at improved clinic utilisation, reduced cancellations, reduced DNAs, and improved communication

• Hillingdon system wide outpatient improvement – working as a system through Hillingdon Health and Care Partners to revise clinical pathways, increase the use of virtual and non-face to face delivery of outpatient services, and to decrease the number of follow-up appointments through increased use of advice and guidance and additional information for patients

• Service transformation in specific specialties, though revised service delivery and commissioning models – initially focussed on Ophthalmology, Musculo-skeletal, Pain and Dermatology.

Metrics

Figure 6: Metrics for the Outpatient Transformation Programme

Quartile Commentary Delivery September has seen the in the new to follow up ratio return back toward

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June / July levels, slightly above target. Cost The programme value as assessed by PA Consulting is currently at £1.15m.

Progress against delivery of this value is currently off track Quality The number of clinic cancellations remains below last year’s average

(14.2%). September performance has moved back toward the target of 8% (top quartile performance)

People The programme is yet to have a visible impact on patient experience, as measured by the Friends and Family test metric. The friends and family metric is only available one month in arrears.

Progress Highlights

The NWL Outpatient Transformation programme began with five specialties in phase one. These specialties are all now live with their new guidelines. A further four specialties (phase 2) are nearing completion, and four further specialties are at the clinical workgroup stage. The NWL Outpatient Transformation programme is in the process of finalising Quality, Delivery and Financial KPIs, and these will be reported when confirmed.

The focus specialties for the internal and system wide transformation have been agreed, with the first three specialties being Gastroenterology, Gynaecology and Dermatology. This work will focus on Post triage pathway re-design – working with clinical teams to review current pathways and identify where a) there are inefficiencies and b) where alternative models of delivery can be utilised (i.e. virtual clinics, patient initiated follow-ups)

Next Steps

Work continues on the efficiency programme, with additional support from PA Consulting. October will see the go-live of the e-vetting system, allowing improved triage and management of consultant to consultant referrals.

The organisation is working to establish resource in Urology and Neurology to introduce triage for these NWL wave 2 specialities, where consultant staffing gaps are creating challenges in implementation of the new pathways.

An outpatient dashboard has been designed and agreed, and will go live shortly to track progress of the improvement programme.

4. Theatres Transformation

The theatres transformation programme continues, focussing in September on reducing DNAs, continued reinforcement of the 6, 4, 2 booking system, reviewing scheduling to ensure maximum appropriate use of lists, ensuring robust annual leave management and 42 week activity, reducing on the day and short notice cancellations, and considering best use of Mount Vernon site, including moving potential service(s) to that site.

Metrics

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Quartile Commentary Delivery The utilisation percentage is within normal variation. Target is top quartile

performance. Some specialties have lower rates, however, and will be a focus for improvement

Cost The programme value as assessed by PA Consulting is currently at £0.8m. Further opportunities are being sought. M6 delivery is at £32k. Delivery of the total value is currently off track.

Quality The number of cases cancelled on the day due to DNA has reduced substantially with the new process in place.

People The people focus of the programme is on staff experience / morale. The team will be developing a staff morale metric.

Progress Highlights

A significant focus in the past month has been on the reduction of DNAs. All elective patients were to be contacted a week prior to their operation taking place to confirm their attendance and answer any questions they had about their upcoming operation – this task was performed by a HCA on weekends.

The outcomes of this work have been:

• Reduction in number of cancellations within 7 days of their operations due to patient DNA / request to reschedule in total by 29.3 a month (YTD)

• Reduction in number of cancellations on the day due to patient DNA / request to reschedule by 10.3 a month (YTD)

The reduction in DANS has enabled additional patients to be scheduled into lists, and reduced wasted theatre time at a value of >£45,000 ytd..

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Next Steps

An over-arching theatres control room will be developed, allowing visual management of waiting lists, and ensuring the most efficient flow of patients from outpatient decision to operate, through pre-operative assessment and theatre scheduling, to surgery, recovery and (if required) in patient care.

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Board of Directors 29 October 2019

Agenda Item: 11

Title Annual Infection Prevention & Control Report, 2018/19

Report Author Glenda Shadford, Lead Nurse Infection Prevention and Control Dr Stella Barnass, Infection Prevention and Control Doctor

Report Sponsor Chief Nurse


Purpose of Report For Decision

For Assurance

For Information

☐ X ☐

Summary

The Annual Report discusses the Infection Prevention and Control Team (IPCT) service, delivered in challenging clinical environment, and including response to infection incidents, antibiotic surveillance information and infection prevention and control audits. The aims of the IPCT are to prevent and control healthcare-associated infections (HCAI) and to be compliant with the Health and Social Care Act 2008 and Department of Health and Social Care (DHSC) directives and guidance in relation to infection prevention and control.

Recommendation The Board is invited to note the report. Links to Corporate Objectives

Quality - We will deliver good care every day

Impact

Quality and Safety X Legal

Financial

Human Resources

Equality & Diversity


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Infection Prevention and Control Annual Report

1 April 2018 – 31 March 2019

Reviewing period: April 2018 – March 2019

Lead Author/s Glenda Shadford, Lead Nurse Infection Prevention and Control Dr Stella Barnass, Infection Prevention and Control Doctor

Approved by Infection Prevention and Control Committee

Approved by Chair July 2019

Received by Quality and Safety Committee

September 2019

Executive Sponsor Professor Siobhan Gregory Interim Chief Nurse

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Table of Contents

Section Page

1 Executive Summary 5

2 Organisational Structure and Governance

2.1 Infection Prevention and Control Team 2.2 Infection Control Committee and Internal reporting Arrangements 2.3 Reports to the Executive Team and Trust Board 2.4 Risk Management 2.5 Infection Prevention and Control Resources 2.6 Infection Prevention and Control Policy

5

6 6 6 7 7 7

3 Healthcare Associated Infections Action Plan April 2017 – March 2018 7

4 Mandatory Surveillance and Reporting

4.1 Meticillin Resistant Staphylococcus aureus Blood Stream Infection 4.2 Post Infection Review of Meticillin Resistant Staphylococcus aureus

Blood Stream Infection Cases 4.3 Meticillin Sensitive Staphylococcus aureus Blood Stream Infection 4.4 Gram negative bacteria Blood Stream Infection

4.4.1 Escherichia coli Blood Stream Infection 4.4.2 Klebsiella spp Blood Stream Infection 4.4.3 Pseudomonas aeruginosa Blood Stream Infection

4.5 Clostridium difficile Infection

7

8 8

9 9 9

10 11 11

5 Strategic Executive information System (STEIS) Reports 12

6 Infection Prevention and Control Incidents

6.1 Norovirus 6.2 Group A Streptococcal Infection in Maternity 6.3 Extended Spectrum Beta-Lactamase (ESBL)-producing coliform isolates 6.4 Single case of MRSA carriage in a baby on the Neonatal Unit 6.5 Suspected Middle Eastern Respiratory Syndrome – Corona Virus (MERS-CoV) case 6.6 Case of open Pulmonary Tuberculosis

12

12 13 13

13 13

13

7 Audit, Monitoring and Surveillance

7.1 Meticillin Resistant Staphylococcus aureus Screening 7.2 Hand Hygiene 7.3 Surgical Site infection 7.4 Orthopaedic Surveillance 7.5 Infection in Critical Care Quality Improvement Programme (ICCQIP) 7.6 Environmental audits

13

14 15 15 15 16 16 16

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Contributions gratefully received from: Ramiz Amin – Antimicrobial Pharmacist Dr Kathy Bamford – Consultant Microbiologist Jay Dungeni – Deputy Chief Nurse and Deputy Director of Infection Prevention and Control Wadzanai Hatitye – Infection Prevention and Control Administrator Chris Knight – Capital Projects Manager Saghir Siraj – Occupational Health Advisor Steve Wedgwood – Assistant Director of Facilities Mark Williams – Head of Estates Operations

7.7 Carbapenemase Producing Enterobacteriaceae (CPE)

8 Education and Training 16

9 Antimicrobial Stewardship 18

10 Infection Prevention and Control Link Staff 19

11 Care Quality Commission Inspection and Report – Outcome 8 20

12 Cleanliness and Infection Prevention and Control

12.1 PLACE 12.2 Sterile services

20

21 22

13 Occupational Health

13.1 Needle stick Incidents and Prevention of Needle stick Injuries 13.2 Staff Flu Vaccination – Winter 2018/19 13.3. Staff Diarrhoea and Vomiting

22

22 22 23

14 Redesigning Environments and New Builds 23

15 Water Quality Monitoring 23

16 Ventilation 24

17 Working with the Patients and the Public 24

18 NHS Improvement (NHSI) Visits 25

19 Changes to Pathology Services 25

20 Central and North West London NHS Foundation Trust 25

21 Priorities for The Year Ahead 25

Appendix A Infection Prevention and Control Team

27

Appendix B List of Infection Prevention and Control Policies

28

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Foreword I am pleased to present this report on the Trust’s performance from 1st April 2018 to 31st March 2018 with regards to infection prevention and control. The report discusses the Infection Prevention and Control Team (IPCT) service, delivered in challenging clinical environment, and including response to infection incidents, antibiotic surveillance information and infection prevention and control audits. The aims of the IPCT are to prevent and control healthcare-associated infections (HCAI) and to be compliant with the Health and Social Care Act 2008 and Department of Health and Social Care (DHSC) directives and guidance in relation to infection prevention and control. The Infection Prevention and Control Work Plan was the overarching document that ensured that the work undertaken by the team over the year continued to focus on goals relating to these standards and that progress is constantly measured and reported. The Trust continues to show good performance in maintaining a low incidence of Meticillin Resistant Staphylococcus aureus (MRSA) blood stream infection with two cases attributed to the Trust this year. The Clostridium difficile Infection (CDI) trajectory of seven or less avoidable cases was met; ending the year with a total of four avoidable cases attributed to the Trust. However, despite the good progress made in regard to achieving our infection targets, on commencing the role of Interim Chief Nurse in May 2019 I raised concerns around IPC. Whilst this report relates to the 2018/19 operational year, the Trust recognises that the concerns identified were in some cases long standing and related to areas including – general cleaning, differences in what results show and experience on the ground, lack of robust governance around IPC activity and feedback and in some cases, poor IPC practice by our staff. The Trust engaged with experts from NHS England and Improvement and the Hillingdon Clinical Commissioning Group to undertake a review of the assurance and improvement arrangements within IPC. An improvement action plan is now in place with progress being made throughout 2019/20 and it forms part of the key improvement priorities for the Trust. The Trust continues to face challenges related to an increase in demand for care, high bed occupancy and a physical environment requiring refurbishment and repair. Much work has been undertaken to address these issues, and the Trust continues to work within and report in line with the National Specification for Cleanliness in the NHS (2007). Achieving the required standard in the Nurse Technical Cleaning audits has been a particular challenge and an increased focus has been required to improve compliance during this current year. Awareness and engagement of all staff is vital if infection prevention and control is to remain a top priority for the Trust. The recommendations and proposed actions in this report highlight the high profile of IPC in the Trust. They also address many of the issues identified in the external review and reflect the Trusts ambition to provide the best healthcare possible for our population. Communication and interaction with all designations of staff demonstrates that both clinical and non-clinical staff are engaged with the Trust’s aims to maintain low levels of HCAI and committed to improving IPC.

Professor Siobhan Gregory Interim Chief Nurse

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1. Executive Summary

The Trust has a statutory responsibility to be compliant with the Health and Social Care Act 2008 (DH, 2010). A requirement of this Act is for the Board of Directors to receive an annual report from the Director of Infection Prevention and Control (DIPC). This report details Infection Prevention and Control activity from April 2018 to March 2019, with an assessment of performance against national targets for the year. Key Points:

• There were two Trust-apportioned Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia cases reported against the national zero tolerance. Learning points from the Post Infection Review (PIR) were addressed. Following updated guidance on the MRSA PIR process issued by NHS Improvement, the Trust is no longer required to carry out a PIR process but continues to carry out formal local reviews of MRSA bacteraemia cases.

• There were five Trust-apportioned Methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia cases, three fewer cases than those reported for 2017/18.

• There were 16 Trust-apportioned Clostridium difficile cases, four of which were classed as a ‘lapse in care’ against a ceiling target of seven.

• There were 35 Trust-apportioned E. coli bacteraemias, three more than the number of cases reported for 2017/18.

• Following the implementation of modified admission MRSA screening guidance for NHS (2014) the MRSA screening compliance for the year was 67 % (measured Dec - Mar).

• There were two outbreaks of diarrhoea and vomiting between November 2018 and February 2019 affecting 21 patients and 10 staff on two wards, in which norovirus was confirmed.

• The Trust continued to participate in the Public Health England mandatory orthopaedic surgical site infection surveillance system (SSISS) reporting on total hip replacement (THR) and repair of fractures of the neck of femur (NoF). The results of the surveillance have not yet been released.

• The Care Quality Commission (CQC) inspected the Trust during 6 – 9 March 2018. The inspectors’ findings were received after the IPC Annual Report for 2017/18 was produced, and are therefore included in this year’s Annual Report. The CQC Report recommended the Trust needed to improve Infection Prevention and Control Practice by addressing environmental issues, cleanliness, and hand hygiene and bare below the elbows compliance. Hand hygiene and bare below the elbows have been addressed during the year 2018/19; compliance was 94% for hand hygiene and 98% for bare below the elbows.

• The Learning and Development department switched the e-learning from WIRED to iDevelop leading to an improved, more accurate reflection of training compliance. As of 31st March 2019, 97% of non-clinical staff had completed Level 1 mandatory infection prevention and control training, up from 92% last year, and 89% of clinical staff had completed Level 2 mandatory infection prevention and control training, up from 79% last year, although the annual compliance objective of 90% was narrowly missed for Level 2.

2. Organisational Structure and Governance

The DIPC is both an Executive member of the Board and also the Chief Nurse. The Trust has three Consultant Microbiologists, one of whom holds the position of Infection Prevention and Control Doctor and they continue to provide specialist advice and microbiology support on a 24-

88

hour basis. The specialist nursing team and antimicrobial pharmacist are available during office hours Monday to Friday. 2.1 Infection Prevention & Control Team The Infection Prevention & Control Team (IPCT) establishment is: Director of Patient Experience and Nursing who is the DIPC Consultant Microbiologist / Infection and Prevention and Control Doctor Consultant Microbiologist / Laboratory Lead Consultant Microbiologist / Antimicrobial Stewardship Lead 1.0 Whole time equivalent (WTE) Infection Prevention & Control Lead Nurse 2.0 WTE Senior Infection Prevention and Control Nurses 1.0 WTE Infection Prevention and Control Nurse 1.0 WTE Antimicrobial Pharmacist 1.0 WTE Infection Prevention and Control Administrator / Coordinator Please see Appendix A for full details of staff in post and vacancies during the year. 2.2 The Infection Control Committee and Internal Reporting Arrangements The Infection Control Committee (ICC)1 reports an overview of the Trust’s infection prevention and control agenda, policies and progress throughout the year to the Regulation and Compliance Committee (RCC) which, in turn, reports to the Quality and Safety Committee. ICC is a key forum for the development and performance management of the infection prevention and control agenda across the organisation. The membership of the Committee is multi-disciplinary and includes representation from all Divisions and senior management. The Committee is chaired by the Director of Infection Prevention and Control (DIPC) or deputy, and meets every quarter. The Committee also has representatives from external bodies such as the local Public Health England (PHE) Health Protection Unit, Hillingdon Clinical Commissioning Group (CCG) and a patient representative. The DIPC provides a monthly report to the Board. Infection prevention and control reporting includes performance against national objectives as well as progress on local Trust initiatives. Infection Prevention and Control (IPC) is also discussed monthly at the Divisional Review meetings chaired by a panel of the executive team. These are based on divisional dashboards which include data on HCAI, overall IPC performance and compliance with antimicrobial prescribing. 2.3 Reports to the Executive Team and Trust Board The IPCT provide a range of measures to the Trust Board on a monthly basis which includes cleaning scores, infection prevention and control audit results, restricted antimicrobial prescribing compliance, MRSA screening and other initiatives. Infection prevention and control performance is also commented on in the monthly Integrated Quality and Performance Report so that feedback on Post Infection Reviews (PIR) or Root Cause Analysis (RCA) is provided directly to the Trust Board with any necessary actions.

1 The Infection Control Committee has been renamed the Trust Infection Prevention and Control Committee for 2019/20 for consistency with the other elements of Infection Prevention and Control work.

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2.4 Risk Management Infection prevention and control risks are assessed in line with the Trust’s Risk Management Strategy and Policy. The process starts with the systematic identification of risks via structured risk assessments. Identified risks are documented on risk registers. These risks are analysed in order to determine their risk score using a risk scoring matrix and assigning a local or corporate management level dependent on their relative importance and mitigating actions required. A target risk score and target mitigation date is assigned to ensure that risks are controlled in a timely manner and to an acceptable level of risk. Risk control measures are identified and implemented via action plans to achieve the target level of risk. Local risks are managed by the area in which they are found whilst corporate level risks are managed at progressively higher levels within the organisation. Achieving control of the higher scoring risks is given priority over lower scoring risks. The ICC maintains oversight of IPC risks to drive the progression of risk mitigation and, where necessary, to escalate if risks are not being mitigated in a timely manner. 2.5 Infection Prevention and Control Resources The IPCT continues to have a budget that is predominantly allocated to staff pay. The Team does however continue to work closely with the Procurement Department to ensure the Trust purchases quality products that are fit for purpose and deliver value for money. 2.6 Infection Prevention and Control Policy On the Document Information Management System (DiMS) there are 21 policies and 6 clinical guidelines assigned to Infection Prevention and Control, which are reviewed every three years or in light of new best practice or guidance. In 2018/2019 eight policies were reviewed with amendments made to the Cleaning Policy, Food Handling Policy, Visual Infusion Phlebitis (VIP) Score Policy, Hand Hygiene Policy, Care and Management of Patients in Hospital with Diarrhoea and Gastroenteritis Policy, Animals and Pets in Hospital, Laundry Sorting Policy and the Outbreak Policy (Food Poisoning and Communicable Disease). All policies are on the approved Trust template and are approved at the ICC then ratified at the RCC upon revision. See Appendix B. 3. Infection Prevention and Control Work Plan 2018 to 2019 The Infection Prevention and Control Work Plan, which incorporates all of the Department of Health (DH), Health and Social Care Act 2008, is completed, to ensure all elements of the Care Act are being monitored, and planned reviews are completed quarterly. 4. Mandatory Surveillance and Reporting Since April 2017 the Trust reports patient level mandatory surveillance data on the following organisms on a monthly basis via the PHE Healthcare Associated Infections Data Capture System (HCAIDCS):

• Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia • Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia • Escherichia coli (E. coli) bacteraemia

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• Clostridium difficile infection (CDI) • Klebsiella bacteraemia • Pseudomonas bacteraemia

4.1 Meticillin Resistant Staphylococcus aureus (MRSA) Blood Stream Infections In 2018/19 the Trust objective for Meticillin-Resistant Staphylococcus aureus (MRSA) - Blood Stream Infection (BSI) remained zero tolerance. However, two MRSA positive blood cultures were reported, the first in Q3, and the second in Q4. Table 1: 2018/19 Quarterly MRSA Blood Stream Infection

2018- 2019 Q1 Q2 Q3 Q4 Total MRSA BSI - THH 0 0 1 1 2 MRSA BSI - CCG 1 1 2 1 5

Figure 1: Number of MRSA BSI patients reported for the Trust and the CCG 4.2 Post Infection Review of MRSA BSI cases As per DHSC guidance, a Post Infection Review (PIR) was undertaken for both MRSA BSI cases. The first case occurred on a medical ward. A review of the case identified that the patient was not screened for MRSA on admission, when transferred from another hospital, hand hygiene compliance was sub-standard, and Visual Infusion Phlebitis (VIP) scores2 were not recorded on three occasions. The PIR was reviewed by the Clinical Commissioning Group (CCG) and attributed to the Trust.

2 The VIP score is used to record signs of inflammation and infection related to intravascular devices (cannulae), and prompts removal of the device if clinically indicated.

0

5

10

15

20

25

No.

of P

atie

nts

Year

MRSA Blood Stream Infections 2006 - 2019

THHCCG

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The second case occurred on a different medical ward and the PIR identified that VIP scores were not recorded daily according to policy. The PIR was reviewed by the Clinical Commissioning Group (CCG) and attributed to the Trust. Sadly the patient passed away and MRSA septicaemia was recorded on Part 1a of the death certificate therefore investigated as a Serious Incident. Learning points from both cases were disseminated to clinical staff. 4.3 Meticillin Sensitive Staphylococcus aureus (MSSA) Blood Stream Infections There are no national set objectives for MSSA blood stream infections. In 2018/19 mandatory reporting of blood stream infections has continued. There is currently no PIR process for these cases however the Consultant Microbiologists / Infection Prevention and Control Doctor discuss any identified cases with the patients’ Consultants. All cases were found to be unavoidable with other contributing factors attributed as the cause. The Trust reported fewer MSSA BSI cases in 2018/19 (five cases) when compared to 2017/18 (eight cases); the number fluctuates due to the nature of the organism. Table 2: 2018/19 Quarterly MSSA Blood Stream Infection

2018 - 2019 Q1 Q2 Q3 Q4 MSSA BSI - THH 3 0 1 1 MSSA BSI - CCG 6 11 3 4

Figure 2: Number of MSSA BSI patients reported for the Trust and the CCG 4.4 Gram Negative Bacteria Blood Stream Infections 4.4.1 Escherichia coli (E. coli) blood stream infections NHS Improvement set an ambition to reduce Gram Negative Bloodstream Infections (GNBSI) by 50% by March 2021, based on the local 2016 baseline. As part of this NHS Trusts are required to report cases of bloodstream infections caused by Pseudomonas aeruginosa and Klebsiella spp. in addition to E. coli bacteraemia reporting already in place. The revised reporting is expected to enable improved monitoring of trends and inform the improvement work being undertaken in response to the increasing concern over this type of BSI.

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25

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35

40

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

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The Trust created a GNBSI Working Group, which has been undertaking work across the acute and community health sectors to identify the causes of GNBSIs. The main focus of the group is to work towards reducing GNBSI cases by examining all aspects of care relating to prevention of the source of GNBSIs, including urinary tract infections, chest infections and hepatobiliary infections. Areas of focus for the group’s work includes making informed changes to the care of indwelling devices, antibiotic use and the education of staff. The group also has the responsibility of overseeing the development and implementation of the Hillingdon GNBSIs reduction programme. The preliminary work of the group was presented as a poster at the 11th Healthcare Infection Society International Conference in Liverpool in November 2018 and feedback from the Conference was used to inform new initiatives for the Working Group. The Working Group is represented at the NW London Clinical Commissioning Groups’ Gram-negative Bloodstream Infections Steering Group, which provides a forum to share best practice. To date, the Trust and the CCG have not been able to demonstrate a reduction in GNBSIs, although without intervention numbers would be expected to increase each year. It is recognised that the reduction of GNBSIs is challenging, since they are mainly acquired in the community and often involve the patient’s endogenous flora. In 2018/19, the year-end totals were 35 Trust-attributed and 186 CCG cases, representing a year-on-year increase of 3 and 16 cases respectively. Table 3: 2018/19 Quarterly E. coli Blood Stream Infection

2018 - 2019 Q1 Q2 Q3 Q4 E. coli - Trust 9 7 9 10 E. coli - CCG 58 45 46 37

Figure 3: Number of E. coli BSI patients reported for the Trust and the CCG 4.4.2 Klebsiella spp. blood stream infections Numbers of Klebsiella spp. BSI infections remain low and are fewer than in the previous year. There were seven and 25 cases of Klebsiella spp. BSI reported for the Trust and CCG respectively in 2018/19, compared with 12 and 35 cases respectively in 2017/18.

020406080

100120140160180200

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

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Escherichia coli Blood Stream Infections 2011 - 2019

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Table 4 2018/19 Quarterly Klebsiella spp. Blood Stream Infection 2018 - 2019 Q1 Q2 Q3 Q4

Klebsiella spp. - Trust 2 4 1 0 Klebsiella spp. - CCG 5 7 10 3

4.4.3 Pseudomonas aeruginosa blood stream infections Numbers of Pseudomonas aeruginosa BSI infections remain low and are fewer than in the previous year. There were six and 12 cases of Pseudomonas aeruginosa BSI reported for the Trust and CCG respectively in 2018/19, compared with six and 12 cases respectively in 2017/18. Table 5: 2018/19 Quarterly Pseudomonas aeruginosa Blood Stream Infection

2018 - 2019 Q1 Q2 Q3 Q4 Ps. aeruginosa - Trust 2 2 2 0 Ps. aeruginosa - CCG 2 3 3 3

4.5 Clostridium difficile Infection (CDI) The surveillance of CDI is a mandatory requirement and all positive CDI tests from all patients over the age of two are reported on the HAIDCS. The Trust’s threshold for CDI cases with lapses in care for 2018/19 was seven, one less than 2017/18. NHS Improvement published updated guidance on sanction implementation and notification of changes to case attribution definitions from April 2018. CDIs identified 48 hours after admission are attributed to the Trust. There were 16 cases reported by year end, three less than in 2017/18. A Root Cause Analysis (RCA) is undertaken with the clinical team for all Clostridium difficile toxin positive cases identified after 48 hours of admission to the Trust. The outcome of the RCA is then presented to the Clinical Commissioning Group (CCG) for review and discussion, with a final agreement to establish if there were any lapses in care and if the infection was potentially avoidable. The CCG concluded that there were four cases with lapses in care (two in Q2 in relation to delayed sampling and cross infection with the same ribotyping, and two in Q4 in relation to delayed sampling and poor antimicrobial prescribing), two more than in 2017/18. However, the Trust remained within the threshold of seven lapses in care for the year. Of the 16 cases identified after 48 hours of admission to the Trust, there were three cases on the same medical ward in July 2018. A Period of Increased Incidence (PII) was declared. Two of the three cases were found to have lapses in care (included in the figures above). Weekly audits were carried out and bespoke training was given to staff within the department. These include hand hygiene and environment audits, and areas of non-compliance were followed up by the IPC team and the Matron responsible for the area. The findings of the RCAs and CCG’s reviews are incorporated into an action plan for the Clinical and IPC Teams; the findings are also disseminated to other clinicians, to share learning and reduce the likelihood of recurrence. Table 6: 2018/19 Quarterly Clostridium difficile Infection

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2018/2019 Q1 Q2 Q3 Q4 CDI – THH 5 7 2 2 CDI - CCG 8 9 2 7

Figure 4: Number of C. difficile toxin positive patients reported for the Trust and the CCG

5. Strategic Executive Information System (STEIS) reports The Trust follows national guidance for investigating HCAI associated deaths. Where MRSA or CDI are included on part 1a, 1b or 1c on a death certificate it is entered onto the Strategic Executive Information System (STEIS), a web based system for reporting serious incidents. On this basis in 2018/19 the second case of MRSA BSI was deemed a STEIS-reportable case. The Serious Incident investigation is still ongoing, and will be reported in the next Annual Report. 6. Infection Prevention and Control Incidents and outbreaks

6.1 Norovirus During 2018/19 there were two confirmed Norovirus outbreaks. a) One surgical ward was closed from 21 November – 3 December 2018. Six patients were affected. The main learning points were the need to improve availability of scrubs, and timely collection of specimens for laboratory testing. b) One medical ward was closed from 12 February to 22 February 2019 with 15 patients and 10 staff affected. In addition, one patient was found to have C. difficile infection. During the outbreak, appropriate infection control measures including training and raising awareness on prompt isolation, hand hygiene and enhanced cleaning were instigated. A review of the outbreak identified a number of actions that would facilitate management of future outbreaks, most of which are now in place, with the remainder added to the Work Plan for 2019/20:

• IPC Team to create a plan which gives instructions on what to do during an outbreak for Facilities, Cleaners, Nurses, Allied Health Professionals

• Education of staff on use of the stool chart and documentation

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• Use of a daily checklist for patient placement, communication with relatives, use of PPE, samples sent to the laboratory, hand hygiene, environment and cleaning, including terminal clean, equipment and linen.

No further wards were affected and the outbreak was contained in both cases. 6.2 Group A Streptococcal Infection in Maternity The IPC Team investigated fives cases (four patients including one mother/baby pair and one member of staff) of Group A Streptococcal (GAS) infection in the Maternity Unit. The last case occurred in December 2018, and the review included all cases in the previous seven months. Although each case was investigated at the time of occurrence, there was a need to try to establish whether they were linked and ensure that necessary actions had taken place. No links were found and the main learning action point was to liaise with the laboratory staff to ensure the recommendations in the national guidance for typing and storage of GAS isolates were implemented, to enable comparison of types for epidemiological assessment. 6.3 Extended Spectrum Beta-Lactamase (ESBL)-producing coliform isolates Following the anecdotal reporting of increased numbers ESBL-producing isolates on a surgical ward during December 2018 to February 2019, the cases were reviewed. Eight ESBL-producing coliforms were reported from urine samples and no indistinguishable isolates, based on the antibiogram susceptibilities, were found. This supports sporadic cases of ESBL colonisation, with no evidence to suggest cross infection. Isolates will now be saved prospectively so that they can be typed if indicated. Ongoing cleaning and environmental audits and hand hygiene audits are being performed in keeping with IPC requirements. 6.4 Single case of MRSA carriage in a baby on the Neonatal Unit In January 2019 routine screening revealed MRSA carriage in a baby who had been on the Neonatal Unit for over a week, and had previous negative swabs. Good practice (isolation, use of gloves and aprons, and thorough cleaning) was emphasised. Screening of the other babies and staff did not yield any other carriers. 6.5 Suspected Middle Eastern Respiratory Syndrome – Corona Virus (MERS-CoV) A patient was admitted in February 2019 with suspected MERS-CoV infection, which was not confirmed on laboratory testing. Following this, the MERS-CoV Pathway was updated to provide clarity, with a new system put in place at THH to transfer samples directly to the Reference Laboratory (necessitated by the partial move of the Microbiology Laboratory – see section 19), and specialist Ventilation systems for all the Trust Isolation Rooms were re-validated. 6.6 Case of open Pulmonary Tuberculosis A case of open pulmonary tuberculosis (TB) was identified on a medical ward in February 2019. Contact tracing was initiated for the patient and family contacts. The risks to staff were assessed and follow up reviews were undertaken by the Occupational Health Team. The lack of a side room on the Respiratory Ward continues to present difficulty in providing appropriate isolation; measures to resolve this difficulty are included in the Work Plan for 2019/20. 7. Audit & Monitoring The Trust undertakes paper based audits which are uploaded to an electronic database and are visible across the organisation. The IPC audit dashboard was launched in April 2016 and collates

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both IPC and ward audits, measuring hand hygiene, bare below the elbows, care bundles including urinary catheterisation and peripheral vascular lines, as well as patient and ward environment assessments (QQA). IPC audits in 2018/19 reported on the Trust Board (Monthly Measures table) included:

• MRSA screening (see 7.1) • Compliance with Hand Hygiene policy (monthly) • Compliance with Bare Below Elbows policy (monthly) • High Impact Intervention 1 Central Venous Catheter care (monthly) • High Impact intervention 2 Peripheral Line Care (quarterly) • High Impact Intervention 5 Ventilator Care (monthly) • High Impact Intervention 6 Urinary Catheter Care (quarterly) • High Impact Intervention 7 Clostridium Difficile care bundle (monthly) • Quick Question Assessment (monthly) • Aseptic Non Touch Technique Competency (quarterly)

Audits undertaken at local ward and department level for review by the Matron or Managerial Ward Rounds or for reporting on the Trust Board table are detailed below:

• Compliance with Isolation policy (annually) • Compliance with Restricted Antibiotic Prescribing policy (quarterly) • Compliance with Linen policy (annually) • Ward Manager Checklists (daily and weekly)

In addition the IPCNs undertake peer review audits and feedback results whilst providing training, and the Matrons undertake peer review audits of areas other than their own, with immediate feedback. The IPC Team has been working with the Governance Team to move five of these audits (Hand Hygiene Compliance, Isolation, Nursing Environmental Compliance Quick Question Assessment, Urinary Catheter Compliance and Peripheral IV Devices) to the GiveMeData system in Q1 2019/20, which enables electronic collection of audit data. Further work is ongoing to formalise how the results are made available to clinical staff. 7.1 Meticillin Resistant Staphylococcus aureus (MRSA) Screening Screening for MRSA carriage in patients and selected clinical areas is performed according to locally agreed criteria based upon assessment of the risks and consequences of transmission and infection, in line with DH guidance. Nasal and skin decolonisation is considered in certain categories of patients, as advised by the Consultant Microbiologists. The general principles of infection control are adopted for patients with MRSA, including patient isolation, and the appropriate cleaning and decontamination of clinical areas. With the Trust adopting the revised 2017 Department of Health Screening criteria, the screening compliance monitoring process on i-Reporter was no longer effective. IPCNs have been performing point prevalence audits of high risk areas on a monthly rolling programme, with feedback to the clinical teams. The Infection Prevention and Control Nurses (IPCNs) use ICNet (a clinical information system) to monitor known MRSA colonised patients and ensure they are screened and isolated appropriately. The IPCNs have also been providing education to ward staff in relation to the audit results and undertaking actions where alerts are raised. The audit is undertaken on random areas

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to ensure the revised policy is being met and the results vary from 65% to 82%. Areas with low compliance received a follow up visit and continue to be audited monthly until high levels of compliance are achieved. The IPCNs continue to educate and reinforce the importance of acknowledgment and action on PAS alert flags and at forums such as IPC link nurses and other nurse led forums. Bespoke training is also provided as needed. The upgrade of ICNet (due in 2019) is expected to introduce a more effective way of monitoring MRSA screening thereby providing stronger assurance to the Trust Board. 7.2 Hand Hygiene Good hand hygiene (HH) reduces the incidence of HCAI and is recognised as an essential aspect of infection prevention and control. The end of year audit results for HH compliance rate was 94% and compliance with Bare below the Elbows (BBE) was 98%. The Trust had a stand in the main entrance for Hand Hygiene Day (4th May 2018) to increase awareness among staff. The Trust has a zero-tolerance policy on compliance with this standard and the audit results continue to show that more work is required to achieve this. Hand hygiene and ‘Bare Below the Elbows’ continues to be part of the IPC training agenda with leaflets distributed to individuals who are observed to be non-compliant in practice, and escalation to disciplinary procedures if required. 7.3 Surgical Site Infection (SSI) In 2018/19, the Trust participated across both sites (Hillingdon Hospital and Mount Vernon Hospital) in Q4 with regard to Total Hip Replacements and Repair of Fractured Necks of Femur. In all previous years the Trust reported for all four quarters, but due to staff shortages this was not possible. However, the minimum PHE requirement, that is, for Trusts to report at least one quarter a year, was achieved. The Trust is committed to re-joining the surveillance programme in 2019/20 once the ICNet upgrade is complete. The process for SSI monitoring is manual with no dedicated resource to undertake this work within the Trust. The work to automate the process was delayed due to reduced staffing within the Team. However, the upgrade to ICNet will introduce functionality that automates and extends the monitoring to other surgical sites thereby providing stronger assurance on this important indicator. 7.4 Orthopaedic surveillance Surveillance of orthopaedic surgical site infection (SSI) is undertaken for both total hip replacements and repair of fractured neck of femur surgeries. Total hip replacements continue to be carried out across both hospital sites, with the majority of cases being undertaken at Mount Vernon Hospital. However patients with a Body Mass Index (BMI) over 40, ASA Score 3 or 4* or those who require ITU admission have their surgery undertaken at the Hillingdon site. (*The American Society of Anaesthesiologists (ASA) score is a subjective assessment of a patient's overall physical health that is based on five classes (1 to 5). The score ranges from 1 (healthy patient) to 5 (patient with severe systemic disease that is a constant threat to life). The data collected in Q4 is incomplete and not available for presentation. The data will be presented in the Annual Report for 2019-20.

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7.5 Infection in Critical Care Quality Improvement Programme (ICCQIP) The Trust participates in the National Infection in Critical Care Quality Improvement Programme (ICCQIP), supported by the IPC Team. Changes were made nationally to the ICCQIP reporting system in Q2. Due to the changes, the national team has not produced the Q2, Q3 and Q4 reports. However, review of the data at the time of data entry has shown that there were no themes or trends identified, as there were no line infections reported in ITU. 7.6 Environmental audits Environmental audits are conducted by the IPC Team for all clinical areas across both sites, with feedback within a week to Ward Managers and Matrons, who are required to review the audit results and to devise appropriate action plans, including requests for works required from the Estates Department. Any urgent findings are provided to the Ward Managers and Matrons on the day of the audit. The IPC Team continue to support this work. Reporting of progress is by exception and areas of concern via the ICC. The Nurse Cleaning Standards audit results reached the set target in all areas with Technical Domestic Cleaning for very high risk (VHR) and high risk (HR) areas totalling 99% and 97% respectively. Additionally, Technical Audit Nurse Cleaning reflected 98% and 97% at year end. The Cleaning Responsibilities group provides a regular forum for those directly involved in cleaning service planning, provision, monitoring and resourcing. IPCNs participate in ward cleaning audits whenever possible to provide peer review. Areas with a reduced compliance rate are visited by IPCNs to emphasise the importance of clean equipment and a clean environment in the healthcare setting and also to undertake spot checks with the Ward Manager to promote the sustainability of the actions. 7.7 Carbapenemase Producing Enterobacteriaceae (CPE) The IPC Team continue to monitor the presence of Carbapenemase Producing Enterobacteriaceae (CPE) in the Trust through screening of at-risk patients on admission, and onward screening of contacts as required. During 2018-19 11 admissions were found to be carrying CPE and were placed in isolation. The enzymes produced by the CPE bacteria were identified by the Reference Laboratory and no instances of cross infection occurred. Management of these patients remains challenging, as (unlike MRSA) the bacteria are carried in the patient’s intestine (gut) and there is no way to decolonise the patient. 8. Education and Training The Infection Prevention and Control Team (IPCT) continue to deliver IPC training to all members of staff across the organisation; this training varies from regular formal sessions to individual bespoke delivery at a ward or department level. The Core Skills Days training timetable for 2018/19 continued to offer two one-hour infection control training session per month at Hillingdon Hospital and one one-hour session every other month at Mount Vernon site. This was designed to offer an improved opportunity for staff to access training given the increased demand. The Trust has also increased the number of department bespoke infection control training sessions delivered through 'Study days' and ad hoc

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training. Even though the IPC Team provided all the sessions predicted to cover the predicted numbers of staff requiring training compliance was not met. E-learning for IP&C is also available to all staff and in 2018 new staff were expected to undertake e-learning as part of their Corporate Induction. The IPC Team will be working to revert to face-to-face training for the coming year due to the drop in compliance with good practice and feedback from staff who have only undertaken E-learning. Between April 2018 and March 2019, Level 1 infection control training compliance was 97% (improved from 92% in 2017/18) and Level 2 was 89% (again improved from 79% in 2017/18), although the annual compliance objective of 90% was narrowly missed for Level 2. The IPCNs continue to work with non-compliant staff and their managers to ensure training is undertaken within target dates. This is also reviewed and followed up by the DIPC or Deputy DIPC.

Figure 5: Infection Prevention and Control Training at Level 1 across all directorates 2018 – 2019

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Figure 6: Infection Prevention and Control Training at Level 2 across all directorates 2018 – 2019 9. Antimicrobial Stewardship Group

The World Health Organisation, when reporting on the escalating threat of antimicrobial resistance, warned that without urgent action we are heading for an era in which common infections, which have been treatable with antibiotics for decades, can kill once more. In some parts of the world this sadly is already a reality. Antimicrobial stewardship is a fast-growing field that aims to address this issue by managing our use of antibiotics to slow down or reduce the occurrence of antimicrobial resistance. These aims are ultimately achieved by improving antimicrobial prescribing through an organised antimicrobial management program. A Start Smart - Then Focus approach is recommended for all antibiotic prescriptions.

Each year the Trust undertakes a number of quality improvement initiatives under the Commissioning for Quality and Innovation (CQUIN) framework. This year the Trust took on the Reducing the impact of serious infections CQUIN which consists of targets for management of sepsis, antibiotic review and antibiotic consumption. In addition included within the medicines optimisation CQUIN, there was an antifungal stewardship section. The Antimicrobial Stewardship Group (ASG) members were closely involved in delivering and reporting on the above CQUINs.

During 2018/19 the Ward Pharmacists referred 2161 patients’ antimicrobial prescriptions to the Antibiotic Pharmacist / Consultant Microbiologist for further review (average 9 referrals per working day). The patients were referred for reasons that included review of prescriptions for restricted antibiotics, prolonged courses of antibiotics or unusual combination of antibiotics. The Trust compliance with restricted antibiotic use was consistently above the target of >90% (92% in May 2018, 93% in August 2018, and 91% in November 2018).

During the year there were national shortages of several antibiotics; through careful monitoring, and the use of alternative antibiotics and suppliers, the service continued to be provided without compromising patient care, and with cost savings. Spend on antimicrobials is part of the Antibiotic Pharmacist report for the ASG and monitored by the ASG at each quarterly meeting.

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The action plan for the Start Smart Then Focus gap analysis is reviewed at each of the ASG meetings and the ASG report is a standing agenda item at the Infection Control Committee.

This year we reviewed the antimicrobial section of the drug chart and the new drug chart was circulated in September 2018. It reflects the recommendations of local and national antimicrobial stewardship programmes and:

• Prompts staff to review antimicrobials at 24-72 hours post initiation. • Forces prescription review by day 7 and helps achieve the CQUIN target on reducing total

antibiotic consumption by reducing unnecessary lengthy prescriptions. • Improves documentation of the indication, the duration and the outcome of clinical review

at 24-72hrs. • Reduces unnecessary lengthy intravenous (IV) courses, as it prompts prescribers to

document the reason for continuing IV therapy. • Improves compliance with the Sepsis CQUIN antibiotic review, as it assists clear and

complete documentation of the review decision when treating sepsis and ultimately improves patient care.

The Antimicrobial Stewardship Group produced a written strategy and programme of work. It was agreed to establish an Antifungal Stewardship Group and a baseline audit of antifungal use was conducted in preparation. The Group approved the Emergency Department Neutropenic Sepsis Pathway and the Adult Teicoplanin Dosing and Monitoring Guidelines for Diabetic Foot Patients. The Group continued to review new drugs, reports of incidents, and new initiatives, such as those to improve compliance, reduce side effects and ultimately improve patient care.

10. Infection Control Link Staff The IPC Link Nurse Group consists mainly of qualified nurses, but there are also a few Allied Health Professionals and Healthcare Assistants with an interest in infection prevention and control. The IPC Link Staff support the areas that they work in by attending regular meetings that aim to update and inform staff about infection prevention and control practice in the Trust. But the meetings also provide updates on any national issues that may be relevant, with a view to cascading this information to ward or departments that they are based. Each clinical area has a named IPC Link person and in some departments and wards there are two members of staff who support each other in this role. During the last year monthly meetings were held and information that was shared was reinforced by the monthly information flyer ’Linked In!’ The following topics were covered in detail: April: VIP scoring, RCA update May: Convene catheter training, ANTT training, catheter passport update Jun: Carbapenemase Producing Enterobacteriaceae (CPE), hand hygiene refresher July: Risk alerts on PAS and cleaning August: CQC Report: hand hygiene and bare below the elbow September: Management of sharps October: MRSA screening November: Risk alerts on PAS December: Meeting cancelled due to Trust capacity issues January: MRSA screening audit & Side room management and Isolation February: Meeting cancelled due to Trust capacity issues March: GiveMeData – changes to audit process

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11. Care Quality Commission Inspection and Report – Outcome 8 The Care Quality Commission (CQC) inspected the Trust during 6 – 9 March 2018. The inspectors’ findings were received after the IPC Annual Report for 2017/18 was produced, and are therefore included in this year’s Annual Report. The CQC Report recommended the Trust needed to improve Infection Prevention and Control Practice by addressing environmental issues, cleanliness, and hand hygiene and bare below the elbows compliance. Environment issues have been long standing and have led to an ‘acceptance’ by staff. Staff are being empowered to reverse a culture of acceptance of poor standards and are encouraged to challenge poor standards and to take a critical view and to report environmental issues as soon as possible. The DIPC continues to conduct regular walkabouts with the IPC Nurses, and the Facilities and Estates Team; equipment decontamination and maintenance checks are a point of focus on the walkabouts and the findings are being addressed.

Inconsistent compliance with the Hand Hygiene and Bare Below the Elbows policy has continuously been addressed across the organisation. WHO guidelines on hand hygiene (5 Moments) continue to be reinforced in ICP training, bespoke training and all Divisional meetings. Where there is non-compliance staff are encouraged to challenge colleagues on the spot. The Trust holds ‘Themed Fridays’ and on 1st March 2019 IPC was the theme, with results being shared at all forums. The improvement actions also form part of the IPC Work Plan for 2019/20. 12. Cleanliness and Infection Prevention and Control A clean hospital environment is essential for the health and well-being of patients, staff and visitors. Ensuring all clinical and non-clinical areas are clean is a fundamental component in the delivery of effective healthcare, increasing confidence and offering assurance to all service users. Cleaning is not solely the responsibility of the Domestic Cleaning Team or nursing staff, but everyone has a contribution and responsibility for making and sustaining real improvements in the cleanliness of the Trust facilities. There is an ever-increasing profile on improving cleanliness in hospitals and this has become a key element of how each hospital’s performance is judged. Furthermore, cleanliness is believed to be a main contributor to patient perception of a hospital. Delivery of the Trust cleaning strategy will ensure that all patients, staff and members of the public can be confident that the service provided is safe, and that it is delivered in an environment that inspires confidence through excellent standards of cleanliness and estates maintenance. It must be noted however, the overall infrastructure of the hospital generally is outdated and requires continuous maintenance in relation to the majority of patient, public and staff facilities. The cleaning strategy meets the National Specifications for Cleanliness in the NHS 2007 (NSC). The NSC covers overall cleanliness which in practice at the Trust is delivered by a combination of the facilities and nursing services. The NSC focuses on the outcomes of cleaning rather than the method by which they are achieved, since the responsibility for day to day arrangements rests entirely with individual NHS Trusts providing:

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• a standard against which services can be benchmarked • an aid to establishing resource levels for cleaning • part of an ongoing performance management process • a framework for auditing • a useful support tool in improving patient and visitor satisfaction levels

The Quality Standard targets and results for 2018/2019, for each functional area across the Trust’s facilities are: Table 7: Infection Risk Categories including results for 2018/2019

Infection Control Risk Category

Domestic Cleaning

Nursing Cleaning

Trust Target (also NSC target)

Very High 99% 98% 98% High 96% 98% 95%

The cleaning infection control risk categories for each area which, in turn, drive the quality standard target and frequency of auditing have been calculated using up to date evidence on the functionality of the area. The Lead Nurse for Infection Prevention and Control and Assistant Director of Facilities review the infection control cleaning categorisation for all areas on a regular basis. This categorisation in turn drives the level of cleaning inputs required, frequency of auditing and quality target score. Environmental cleaning results have been monitored throughout the year at the ICC and at Trust Board level. There has been joint working with the nursing teams to support improvement. 12.1 Patient Led Assessments of the Care Environment (PLACE) The PLACE process has been aimed at revitalising the assessment of the patient environment process but also, more importantly, to ensure that there is a greater focus on patient involvement in the process. PLACE covers the domains of privacy, dignity and wellbeing, food, cleanliness, condition, maintenance and appearance of buildings and facilities, and dementia. PLACE focuses entirely on the care environment and does not stray into clinical care provision or staff behaviours. It extends only to areas accessible to patients and the public (for example, wards, departments and common areas) and does not include staff areas, operating theatres, main kitchens or laboratories. The key feature of PLACE is the central role of patients in carrying out the assessments. At least 50 per cent of the team must be patients, and local Healthwatch must be offered the opportunity to be involved. Recruiting and training patient assessors is carried out locally and there are criteria outlining who is eligible to become a patient assessor. The PLACE assessments took place at Hillingdon and Mount Vernon on seven days in April and May 2018. There were 17 patient assessors involved – including the Chief Executive of Healthwatch Hillingdon and the Chair of Trust Governors. For the first time the assessment teams also included a group of five youth assessors (aged 17 – 19 years old) from the Young Healthwatch Hillingdon initiative. There were also eight staff assessors involved covering Facilities, Estates and Infection Prevention and Control. Assessments were carried out across both sites in 12 wards, eight outpatient areas, A & E, Minor Injuries Unit, all internal public areas, all external areas and four ward food assessments. The scores for Cleanliness and Food & Hydration remained above the national average for the fifth year running. The scores for

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Condition, Maintenance & Appearance, Privacy, Dignity and Wellbeing, Dementia and Disability all showed improvements. The plan was developed by identifying areas where the most ‘Fail’ or ‘Qualified Pass’ scores were recorded by the assessors and grouping them under the relevant domain criteria. It focuses on those issues where the Trust can take action that directly impacts on and is likely to improve its score in future assessments. The PLACE Improvement Plan has been agreed by the PLACE Improvement Group, which has a membership that includes Nursing and Infection Prevention and Control, Facilities, Estates, Governors and Hillingdon Healthwatch. Progress on the plan will continue to be monitored by this group, which meets on a bi-monthly basis. 12.2 Sterile Services The sterile services contract with IHSS continues and is monitored by the Facilities team in partnership with clinical services. Performance remains high on equipment turnaround times and quality and the Facilities Manager, who oversees the contract, reports to the ICC on performance, developments and complaints. 13. Occupational Health

13.1 Needle stick Incidents and Prevention of Needle stick Injuries Occupational Health received 124 reports of needle stick and splash injury for 2018/2019, 9 more than the previous year. There are no particular patterns detected. An average of 100 sharps injuries has been consistently reported over the past 10 years, however this has to be balanced against an increase in both staffing numbers and patient activity, which if taken into consideration would show a drop in the overall rate of sharps injury occurrences. The majority of needle stick and splash injuries occur during the procedure before any safety feature can be activated and therefore this is difficult to address with safer needle devices, however it is being addressed through training. 13.2 Staff Flu Vaccination – Winter 2018/19 The 2018/19 staff flu vaccination campaign had a CQUIN target set by NHS England of a 75% uptake; this was a 5% increase on the target from the previous year. The Trust achieved the target, one of only 10 Trusts out of the 36 in London to do so.

We carried out a survey on the Trust staff that declined to have the flu vaccine. The purpose was to identify the reasons for not having the vaccine in order to inform next year’s campaign. The four main reasons cited were: • I don’t believe the evidence that being vaccinated is beneficial • I’m concerned about possible side effects • I don’t think I‘ll get flu • I don’t like needles

These results have also been fed back to NHS England to inform next year’s campaign with a particular emphasis on providing strong evidence on effectiveness, in order to challenge and encourage uptake. Best practice from other Trusts will also inform initiatives for next year’s campaign.

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13.3 Staff Diarrhoea and Vomiting (D&V) Staff are mandated to report incidents of D&V to the Occupational Health Department. The staff are informed of the need to be away from work for 48 hours post their last episode and provide a stool sample for testing. During 2018/19 there were 133 staff reports of D&V. No pathogens were identified from the stool samples submitted. 14. Redesigning Environments and New Builds

The ICT continue to work closely with the capital projects team to ensure that proposed designs and new buildings are fit for purpose, meet the Health Technical Guidance and provide a safe and clean environment.

The capital works for 2018/19 included:

• Replacement of doors in Hillingdon Theatres • Planning for the new Interventional Scanner • Move of Private Patients Suite to Tudor Centre • Move of the Urgent Treatment Centre to the Private Patients Suite • Planning for decanting of Coronary Care Unit to Acute Medical Unit • Planning for decanting Intensive Care Unit to Coronary Care Unit • Planning for second phase of improving ventilation in the Intensive Care Unit, including the

Positive Pressure Ventilation Lobby (PPVL) Isolation Room • Reconfiguration and opening of A&E Blue Zone • Refurbishment of A&E Green Zone • Planning for the A&E Expansion project Phases Three & Four • Ambulatory Care Project • Reconfiguration of the Day Care Unit • Tudor/ Dermatology moves

15. Water Quality Monitoring The monitoring of water quality is undertaken via the Trust’s Water Quality Group (WQG) to advise, monitor and challenge the process of keeping all buildings compliant with current water systems legislation and guidance. The WQG receives test results and reports with regard to Legionella and Pseudomonas with membership consisting of the Director of Strategic Estate Development and Asset Management, Infection Prevention and Control Doctor, Infection Prevention and Control Lead Nurse, Assistant Director of Health & Safety, Head of Estates Operations and Estates staff (designated persons) with responsibility for water systems. The WQG reports to the Trusts Infection Control Committee, Director for Infection Prevention & Control (DIPC) and the Health and Safety Committee.

Due to concerns raised by the Trust’s WQG and in light of persistent high legionella counts being reported for both Hillingdon and Mount Vernon sites, an external Water Quality Audit Report was commissioned and identifies a number of remedial actions. The external company works closely with the Trust Authorising Engineer for Water to formulate remedial actions. During 2018/19, the following was completed:

• Hillingdon Hospital

o Installation of a Chlorine Dosing system in the tanks of the Tower Block to provide continual dosing in the cold and softened water systems.

o Re-instatement of the Softened Water Supply to the site at HH.

o Review of the Water Risk Assessments.

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• Mount Vernon Hospital:

o Re-instatement of the bore hole water supply with new Cold Water Storage Tank and booster system

o Rationalisation of the Clock Tower Cold Water system including removal of the old break tank.

o Review of the Water Risk assessments.

The Team continue to:

• Carry out sampling testing to the agreed Sampling Strategy for Legionella and Pseudomonas.

• Carry out remedial actions following positive results.

• Undertake remedial works following Authorising Engineer (AE) Report.

• Monthly Temperature monitoring

• Monthly Thermostatic Mixing Valve

• Use Point of Use (PoU) filters until there are clear readings

• Reduce Dead Legs

• Replace Missing Lagging

• Conduct detailed Survey of the pipework to prioritise the areas pipework replacement.

• Draw up plans for the phased replacement of pipework services in the Podium.

16. Ventilation

The Ventilation Group meets quarterly. The annual Ventilation audit takes place in April. Management and organisation of maintenance is good. Ongoing maintenance includes three-monthly filter changes in Theatres and Critical Care areas, and maintenance of the Planned Preventative Maintenance system. Specialist ventilation systems for the Isolation Rooms in ITU, AMU and the Paediatric Wards have been re-validated. Concerns remain about the staffing levels of competent persons at THH and the condition of the plant.

17. Working with the Patients and Public

The Fighting Infection Together Group (FIT) continues to meet quarterly. This group is a public group that was established back in 2006 to provide a formal mechanism by which patients are represented within the Trust and act as an internal reference group and provide the Infection Prevention and Control Team with an informed patient view on matters of interest to the Team and to patients.

FIT members come from a range of backgrounds and draw on their knowledge and experience as patients, carers, advocates or professionals working in a range of health-related fields (active or retired).

FIT members:

• Act as a critical friend on infection prevention and control issues that concern patients • Initiate constructive and robust challenges to decision making and policy development • Ensure policy development processes, information leaflets and related activities include

patients' perspective, interests and concerns

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• Help the IPCT understand how its decisions will affect patients and carers plus raise awareness of the needs of all patient groups.

18. NHS Improvement (NHSI) Visits

Following receipt of the report of the March 2018 CQC inspection, a deep dive into the IPC within the organisation was requested by the Chief Nurse / DIPC, as well as a review of assurance processes, in order to advise the Trust on strengthening IPC governance arrangements. The NHSI IPC Lead Nurse visited the Trust on two occasions: 14 November 2018 and 23 January 2019. The first visit reviewed the management arrangements, healthcare associated infections, training, audits, decontamination and water safety. The visit on 23 January 2019 was to review IPC practice in Wards and Departments. Areas of non-compliance or concerns raised have been incorporated into an action plan which has been shared and progress tracked. This forms part of an overarching NHSI action plan to incorporate all visits and findings, detailing actions taken and those required.

19. Changes to Pathology Services

As part of development to move to a hub-and-spoke configuration, aiming to modernise and improve the efficiency and quality of service, the Trust Pathology Laboratory has partially integrated its services with North West London Pathology (NWLP). The majority of the Microbiology culture work moved to the hub laboratory based at Charing Cross Hospital on 17 December 2018. Urine culture and serology work is carried out at the Hillingdon Hospital Laboratory. Full integration with NWLP is due to take place later in 2019 once Sunquest, the NWLP IT system is implemented for THH.

There have been some concerns regarding delayed reporting; incidents are notified to notify Laboratory Managers or the Consultant Microbiologists, and to report them using the DATIX system so that these can be investigated and addressed. The Consultant Microbiologists are full members of the Joint Governance Committee for the partnership with NWLP.

20. Central and North West London NHS Foundation Trust The contract for provision of the infection prevention and control service from CNWL for Hillingdon CCG came to an end at the end of September 2018. Hillingdon CCG is one of the very few in the country that does not have an IPC service, and at year end the CCG remains without cover. This in turn makes it difficult to provide seamless care for the prevention and management of infections across the whole health economy.

21. Priorities for the Year Ahead The Trust will have four main priorities for the coming year. We aim to strengthen our compliance with the Health & Social Care Act (2008). This will be attained through putting in place a programme to ensure we achieve compliance with Criterion 1

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of the Hygiene Code through the implementation of robust systems to manage and monitor the prevention of infection control. There will be a particular focus on the provision and maintenance of a clean and appropriate environment to facilitate the prevention of infections through collaborative working with the Estates and Facilities Department. The main priorities within this include the provision of decant facility to improve present structural environment enabling good standards of cleanliness; the re-instigation of the Trust Decontamination Committee and progressing the plans to improve the management of Water Systems at the Trust. We also set out to build on the programme to develop and embed the knowledge of our workforce in Infection Prevention and patient safety across all divisions and disciplines. In this priority we will focus on ensuring that robust training is in place to establish clearly defined divisional management responsibilities. This will support timely decision-making and analysis of information thereby adding to the culture of learning from excellence inherent in the Trust. Finally we will work to instil public confidence in the prevention and management of infection by improving the availability of information to patients, staff and visitors through up to date information systems, policies, guidelines and public information. This will build on the work previously undertaken to set up engagement and collaborative working with patient representatives. The Trust will also be making essential upgrades to the information system (ICNet) ensuring that we keep up with the advances in information technology to support the practitioners in carrying out their roles.

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22. Appendices Appendix A Infection Prevention and Control Team

Role Post Holder Dates Director of Patient Experience and Nursing, and DIPC

Mrs Jacqueline Walker 1 April 2018 – 31 March 2019

Deputy Director of Nursing and Integrated Governance and Deputy DIPC

Mr Jay Dungeni 1 April 2018 – 31 March 2019

Consultant Microbiologist / Infection and Prevention and Control Doctor/ Laboratory Lead1

Dr Arup Ghose

1 April – 18 November 2018

Consultant Microbiologist / Antimicrobial Stewardship Lead / Laboratory Lead1

Dr Prasanna Kumari 1 April – 18 November 2018

Consultant Microbiologist / Infection and Prevention and Control Doctor / Antimicrobial Stewardship Lead2

Dr Stella Barnass 17 December – 31 March 2019

Consultant Microbiologist / Laboratory Lead / Antimicrobial Stewardship Lead2

Dr Kathy Bamford 18 February – 31 March 2019

Locum Consultant Microbiologists

Dr Stella Barnass Dr Karen Fitzmaurice3 Dr Josephine Francis3 Dr Abdulrahman Kader

1 April – 31 May 2018 5 Nov 2018 – 31 March 2019 14 June 2018 – 31 March 2019 19 Nov 2018 – 31 March 2019

Infection Prevention & Control Lead Nurse

Mrs Glenda Shadford Ms Marjorie Gunvenzve4

1 April 2018 – 31 March 2019 16th May 2018 – 31 March 2019

Senior Infection Prevention and Control Nurses (2 WTE)

Ms Carmen Nagy Ms Jintana Loss Vacancy 1 Ms Kelly Marshall Vacancy 2

1 April – 10 August 2018 1 April – 3 September 2018 4 September 2018 – 7 March 2019 8 – 31 March 2019 11 August 2018 – 31 March 2019

Infection Prevention and Control Nurse

Ms Kelly Marshall 1 April 2018 – 17 March 2019

Antimicrobial Pharmacist Mr Ramiz Amin 1 April 2018 – 31 March 2019 IPC Administrator / Coordinator

Ms Kasia Kruczala Ms Wadzanai Hatitye

1 April – 7 September 2018 7 November 2018 – 31 March 2019

1 Laboratory Lead role shared 2 Antimicrobial Stewardship Lead role shared 3 Job share

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4 Acting Lead to cover Mrs Shadford’s parental leave from April 2018 to January 2019, and continuing to provide support to the IPC Team until year end

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Appendix B Infection Control Policies, Guidelines and Protocols Policy Policy

Number Animals & Pets in Hospital Policy 240 Aseptic Non-Touch Technique (ANTT) Policy 188 Care & Management of Patients in Hospital with Diarrhoea Policy 178 Central Venous Catheter (CVC) Insertion and Maintenance Policy 183 Clostridium Difficile (C diff) Associated Diarrhoea 179 Dealing with Suspected Cases of Viral Haemorrhagic Fever (VHF) Policy 180 Decontamination of Medical Devices Policy 169 Employment Health Screening (including food handlers and drivers) 245 Hand Washing Policy 177 Isolation Policy 170 Laundry Sorting (Transferred to Linen Manager in July 2016) 185 Meningitis including Meningococcal Septicaemia 175 MRSA Control (Methicillin-Resistant Staphylococcus aureus) 174 Outbreak (Food Poisoning or Communicable Disease) 167 Re-use of Single Use Items Supplied for Single Use Only (incorporated in Policy 169 Decontamination of Medical Devices Policy)

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Risks Associated with Infection Prevention and Control 165 Safe Handling & Removal of Infected Bodies 166 Scabies Policy 181 Standard (Universal) Infection Control Precautions 172 Surveillance Policy 171 The Prevention and Control of TB in Hospital Including Multi-Drug TB 176 Transmissible Spongiform Encephalopathies (TSE) Creutzfeldt Jacob Disease (CJD) 187 Urinary Catheter (Transferred to Urology Nurse Specialist in April 2016) 231 Varicella Zoster Virus (Chickenpox/Shingles) Policy 189 Visual Infusion Phlebitis (VIP) Score 173 Clinical Guideline Clinical

Guideline number

Blood Culture Protocol 325 Clostridium difficile Integrated Pathway 326 Suspected Middle Eastern Respiratory Syndrome (MERS): Accident and Emergency Pathway

899

High Consequence Infectious Diseases Pathway for the Emergency Department 970 Carbapenemase-producing Enterobacteriaceae - Patient Screening and Isolation Protocol

969

Nephrostomy Care; Pre-and Post-Insertion Guideline for Adults 973

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Board of Directors


Title Financial Performance Report - September 2019 Month 06

Report author Stephen Jones, Deputy Director of Finance

Report sponsor Jenny Greenshields, Director of Finance

Status of Report Public Private Internal ☒ ☐ ☐


For Assurance For Information

☐ ☒ ☐

Summary

This report provides oversight to the Trust Board, through the monthly Finance and Performance Committee, on progress against the financial targets of the Trust and the actions required to ensure the control total is met.



To improve the present A&E 4 hour standard; the 18 week Referral to Treatment; to meet Cancer target; to complete the CQC action plan; to implement year 2 of Quality and Safety Improvement Strategy; to maintain finance and the use of resources score of 3 in meeting the control total.

Impact

Quality and Safety Legal

Financial To maintain finance and the use of resources score of 3 in meeting the control total.

Human Resources Equality and Diversity


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FINANCIAL REPORT SEPTEMBER 2019 (MONTH 06)

1. EXECUTIVE SUMMARY

Table 1 Key Performance Indicators

This Month Last Month

Surplus/(Deficit) in month £0.37m (£1.68m)

Surplus/(Deficit) year-to-date (£9.86m) (£10.23m)

Variance from Plan in month £1.83m (£0.87m)

Variance from Plan year-to-date £0.3m (£0.66m)

Risk Rating 3 3

Agency Expenditure £0.76m £0.91m

Efficiency Savings £0.44m £0.43m

Cash Position at month end £4.1m £5.4m

Capital Expenditure £0.8m £0.5m Table 2 Trust Financial Position at Month 06

Annual Plan Actual Variance Plan Actual VariancePlan In Month In Month In Month to-date to-date to-date

£m £m £m £m £m £m £m

Operating IncomeNHS Clinical Income 208.03 16.97 18.40 1.43 102.54 103.25 0.72Drugs - PbR Excluded 12.84 1.07 1.22 0.15 6.42 6.39 (0.03)Non-NHS Clinical Income 3.37 0.28 0.25 (0.03) 1.68 1.29 (0.39)Other Operating Income 26.72 2.20 2.17 (0.03) 13.21 13.31 0.10

Total Operating Income 250.96 20.53 22.05 1.52 123.85 124.25 0.40

Operating Expenses

Employee Expenses (178.79) (15.32) (15.22) 0.10 (92.57) (92.43) 0.14

Drugs - PbR Excluded (12.64) (1.05) (0.90) 0.16 (6.32) (5.94) 0.37Drugs - In Tariff (5.32) (0.48) (0.54) (0.06) (2.90) (3.04) (0.14)Clinical Supplies and Services (25.10) (2.13) (2.26) (0.14) (12.83) (12.75) 0.08Other Operating Expenses (36.39) (3.06) (3.06) 0.00 (18.70) (19.87) (1.17)Total Non-Pay (79.45) (6.72) (6.76) (0.04) (40.75) (41.60) (0.85)

Total Operating Expenses (258.24) (22.04) (21.98) 0.07 (133.32) (134.03) (0.71)

EBITDA (7.28) (1.52) 0.07 1.59 (9.47) (9.79) (0.32)

Depreciation (9.42) (0.78) (0.76) 0.02 (4.71) (4.61) 0.11Interest Income/Expense (3.70) (0.31) (0.28) 0.03 (1.82) (1.72) 0.11PDC Dividend Expense (3.53) (0.29) (0.10) 0.20 (1.76) (1.57) 0.20

Surplus(Deficit) before Exceptionals (23.93) (2.90) (1.07) 1.83 (17.77) (17.68) 0.09

Financial Recovery Fund 14.81 0.99 0.99 0.00 5.18 5.18 0.00Provider Sustainability Funding 4.69 0.31 0.31 0.00 1.64 1.85 0.21Marginal Rate Emergency Tariff 1.58 0.13 0.13 0.00 0.79 0.79 0.00

Surplus(Deficit) after Exceptionals (2.86) (1.47) 0.37 1.83 (10.16) (9.86) 0.30

( ) variance indicates it is adverse

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Month 6 Summary

The trust achieved a surplus in September of £0.4m which is £1.8m favourable to plan. Year to date the trust has a deficit of £9.9m which was £0.3m ahead of plan and so the trust has been able to recognise £4.0m of non-recurrent PSF and FRF funding in Q2.

Income (see appendix 1) of £22.1m was £1.5m up on plan for M06 and has reached £124.3m which is £0.4m ahead of plan year to date. The favourable variance in month was largely due to rephasing the income recognised from NWL Commissioners to be in line with the contract which brought forward £0.9m of revenue. As this was a change in the timing of income recognition it will not have a full year effect.

Pay Pay was £0.27m lower than in August, giving a favourable variance of £0.1m in month. The year-to-date favourable position improved to £0.14m. Agency costs reduced by £0.15m to £0.76m compared to August, well below the NHSI ceiling of £0.91m. This was in part due to a review of accruals.

Pay costs in the Medicine Division showed a significant improvement this month, reducing by £0.3m compared to August. This reduction was against all three staff groups that were of concern - Medical Pay, Qualified Nursing Pay and HCA Pay. In particular, Medical pay has reduced by £0.2m and this reflects the impact of the overseas doctors who are now filling vacancies and also the review of accruals which has benefited the division.

Non-pay (see also appendix 3) Non-pay was £0.04m overspent in September, which is a significant improvement in the run-rate. Overall drugs are underspent, and in addition we are showing a favourable position on PbR Excluded Drugs income. Within Clinical Services there is an adverse variance of £0.14m as additional transition costs for the Pathology JV have been reflected in the position this month (£0.35m), although this has been partially mitigated by underspends elsewhere. In month Other Operating Expenses were on plan, having benefitted from the release of a year-end provision regarding energy costs, following resolution of the issue. Operating Expenses remain higher than plan year to date, largely due to recruitment expenses for overseas doctors, higher utility costs and ongoing support and consultancy across the Trust.

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2 Divisional Positions

Table 3 Breakdown of Financial Position by Division

Divisional performance Surgical activity remains behind plan at the end of month 6, however, the Division is developing a recovery plan to ensure that they deliver activity levels across planned care closer to the year-end plan. There is a risk that this activity will not be paid for under the current contacting arrangement with the NWL CCGs. Medical activity and income continues to over perform across emergency care with higher than expected levels of A&E attendances. Ambulatory care & Emergency activity is above plan on activity and income. Endoscopy & Cardiology continue to see increases in referrals and their activity levels have increased to cope with this level of demand. The Medicine Division has developed a workforce plan to bring the monthly Medical pay within the division back in line with plan. For Women and Children births in maternity are currently slightly behind plan which was expected as antenatal bookings are down and this is set to continue. Paediatric emergency activity is below plan but remains higher than the levels seen in 2018/19. Within Cancer & Clinical Support Services radiology direct access is significantly above plan as referrals for plain film and ultrasound have increased from Hillingdon CCG. Non pay is £1.0m above plan due to a combination of higher restructuring costs within the NWL Pathology JV (£0.5m) and outsourcing of activity from Radiology (£0.3m). Cost improvement plans to address the Radiology outsourcing cost pressures are in development.

Annual Plan Actual Variance Plan Actual Variance

Plan M6 M6 M6 To-Date To-Date To-Date

£m £m £m £m £m £m £m

Surgery Income 65.44 4.86 4.63 (0.23) 32.59 31.71 (0.89)Pay (38.35) (3.32) (3.35) (0.04) (19.79) (20.05) (0.26)Non-Pay (15.85) (1.34) (1.26) 0.08 (8.12) (7.86) 0.25Total 11.24 0.20 0.02 (0.18) 4.68 3.79 (0.89)

Medicine and Income 93.11 7.74 7.63 (0.10) 45.71 45.51 (0.20)Emergency Care Pay (54.39) (4.61) (4.62) (0.01) (27.71) (28.99) (1.28)

Non-Pay (20.65) (1.85) (1.98) (0.13) (10.74) (11.18) (0.43)Total 18.06 1.28 1.03 (0.24) 7.26 5.35 (1.91)

Women & Children Income 51.01 4.07 4.04 (0.03) 25.18 24.97 (0.20)Pay (24.98) (2.14) (2.13) 0.01 (12.88) (12.93) (0.05)Non-Pay (4.11) (0.36) (0.33) 0.03 (2.15) (2.09) 0.06Total 21.92 1.57 1.58 0.00 10.15 9.95 (0.20)

Cancer & Clinical Income 12.96 1.08 1.11 0.03 6.49 6.67 0.18Support Services Pay (26.75) (2.29) (2.39) (0.10) (13.76) (14.00) (0.25)

Non-Pay (2.39) (0.24) (0.73) (0.49) (1.44) (2.42) (0.99)Total (16.19) (1.44) (2.01) (0.56) (8.70) (9.76) (1.06)

Corporate Income 12.87 1.07 1.10 0.03 6.44 6.95 0.52Pay (31.37) (2.63) (2.58) 0.05 (15.93) (15.60) 0.33Non-Pay (29.65) (2.49) (2.67) (0.18) (15.06) (17.13) (2.06)Total (48.14) (4.05) (4.16) (0.11) (24.56) (25.77) (1.21)

Central Budgets Income 33.01 3.14 4.97 1.83 15.05 16.25 1.20Pay (3.44) (0.35) (0.15) 0.20 (2.50) (0.86) 1.64Non-Pay, Depn & Interest (20.87) (1.82) (0.93) 0.89 (11.54) (8.82) 2.72Total 8.70 0.97 3.90 2.93 1.01 6.58 5.57

(4.42) (1.47) 0.37 1.83 (10.16) (9.86) 0.30

Variance to Budget

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In the Corporate Division non-pay is showing an adverse variance for the month of £0.18m and £2.1m year to date driven largely by additional consultancy expenditure which is currently £1.6m above plan.

3 Cost Improvement Programme At month 6 YTD the Trust has achieved £1,568k of the planned £1,920k, a shortfall of £352k. Further detail is provided in the separate Cost Improvement Report. 4 Risk Rating The “Finance and use of resources metric” forms part of NHS Improvement’s Single Oversight Framework. It is scored between 1 (best) and 4 (worst). The rating for September is a 1:

Table 4 Finance and Use of Resources

Metric Plan Rating for September

Capital Service Capacity 4 4 Liquidity 4 4 I&E margin 4 4 Variance from Plan 1 1 Agency spend 1 1 Weighted Average 2.8 2.8 Overall Rating after Overrides 3 3

The ‘Underlying Financial Performance’ risk on the Corporate Risk Register is rated 20 (extreme).

6 Analysis of Supplier Payment Performance Our Cash position has limited the Trust’s ability to pay suppliers within standard payment terms since 2018/19. To temporarily relieve the constant pressure faced by the Trust in managing demands for payment we have requested support from our NWL CCGs in advancing an additional month’s contract income. These funds were received in August and have allowed us to substantially reduce our outstanding creditors. Alongside this we are looking to secure working capital support from NHSi in order to continue making timely supplier payments. Our future cash position will also be greatly assisted by our delivery of the Trust’s CIP programme in year.

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Table 5 Analysis of Payment Position

Better payment practice code

Actual Actual Actual Actual Actual Actual Actual Actual 30/09/2019 30/09/2019 31/08/2019 31/08/2019 YTD YTD YTD YTD Number £'000 Number £'000

Non NHS Total bills paid in the year 45,563 89,784 40,352 76,365

Total bills paid within target 12,063 51,654 9,756 42,153 Percentage of bills paid within target 26.5% 57.5% 24.2% 55.2%

NHS Total bills paid in the year 1,168 17,681 1,146 16,438

Total bills paid within target 96 7,830 92 6,695 Percentage of bills paid within target 8.2% 44.3% 8.0% 40.7%

Total Total bills paid in the year 46,731 107,465 41,498 92,803

Total bills paid within target 12,159 59,484 9,848 48,848 Percentage of bills paid within target 26.0% 55.4% 23.7% 52.6%

The above table shows the Trust’s performance against the Better Payment Practice Code against a target of 95%. Due to our constraints in our cash position we were unable to achieve the target of 95%, however compared to start of the year we were able to achieve a target percentage of 67.9%, compared to 55.4% in the current period. This was due to receiving loans at the start of the year.

7 Full Year Forecast

The finance teams are currently updating the full year forecast position although this has not been completed at the time of submission of papers for TME.

8 Key Messages

• The Trust has managed to hit its Q2 control total but underlying performance will need to improve if it

is to maintain meet this target in Q3 and Q4.

• The overspends in Medicine on Medical and Nursing are a concern and will need to be tightly managed over the coming months.

• The unidentified and underperforming Cost Improvement Plan needs to be addressed urgently to maintain the Trust’s position going forward, PA Consulting continue to work with the Trust to support the identification and delivery of efficiency schemes.

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Appendices

Appendix 1 Activity and Income

Point of Delivery

YTD Plan Activity YTD Actual

Activity

YTD Act Variance

% YTD Plan Income

YTD Actual Income

YTD Inc Variance

%

A&E Hillingdon A&E 34,342 34,226 (116) -0.3% 5,711 6,215 504 8.8% MIU 15,266 16,298 1,032 6.8% 1,133 1,205 72 6.3%

A&E Total 49,608 50,524 916 1.8% 6,844 7,420 575 8.4% Critical Care

Adult CC 2,706 2,415 (291) -10.8% 3,002 2,610 (391) -13.0% Neonatal 3,491 3,603 112 3.2% 1,849 1,865 16 0.9%

Critical Care Total 6,197 6,018 (179) -2.9% 4,851 4,475 (375) -7.7% Inpatients

Births 2,183 2,142 (41) -1.9% 7,355 6,924 (431) -5.9% Chemotherapy 646 759 113 17.5% 116 161 45 38.8% Daycase 12,167 12,266 99 0.8% 9,890 9,523 (367) -3.7% Elective 1,532 1,345 (187) -12.2% 5,871 5,050 (822) -14.0% Emergency 15,145 16,631 1,486 9.8% 24,958 26,877 1,919 7.7% Excess Beddays 5,116 4,348 (768) -15.0% 1,565 1,373 (192) -12.3%

Inpatients Total 36,790 37,491 701 1.9% 49,755 49,908 153 0.3% Outpatients, AEC & Community

Outpatients 238,865 234,319 (4,546) -1.9% 27,134 26,410 (723) -2.7% Ambulatory Care 7,660 5,979 (1,681) -21.9% 2,481 2,308 (173) -7.0% Community 10,594 9,575 (1,019) -9.6% 1,226 1,151 (76) -6.2%

Outpatients, AEC & Community Total 257,119 249,873 (7,246) -2.8% 30,841 29,868 (972) -3.2% Other (incl CQUIN)

Other including Rehab & CQUIN 59,174 61,685 2,511 4.2% 16,666 17,956 1,290 7.7%

Contract alignment

0 15 15 Other (incl CQUIN) 59,174 61,685 2,511 4.2% 16,666 17,971 1,305 7.8% Grand Total 408,887 405,591 (3,297) -0.8% 108,957 109,643 686 0.6%

Income Income from NWL CCGs is shown in line with the block contract agreement for 2019/20. Actual performance to month 6 is in line with plan and no adjustment was needed for the tolerance or marginal rate. No additional funding to support 52 week waiting time performance is shown in the position as it is now not certain that the funding is available. It is not known if the Trust will incur penalties for 52 week breaches for the patients added to the waiting list in-year therefore, this is a risk to the future position. Income for non-North West London CCGs was down against plan, due to Herts Valley and Thames Valley activity underperformance of £1.3m. We are not expecting to recover this loss in activity to date and the forecast assumes the current run rate. In month, Non-NHS Clinical income is just behind plan, due to low ICR (RTA) income. Income from Overseas Visitors is on plan again this month, although it is still £0.3m behind plan year-to date. Having met the financial plan for quarter 2, we have accrued for Provider Sustainability Funding (PSF) and Financial Recovery Fund (FRF).

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A&E activity continues to perform above plan by 1.8%, slightly greater than previous months. This has delivered an additional £575k at full cost. Adult critical care remains below plan by 2.9%, an improvement on the previous reported position. Work is ongoing within the Medical Division to ensure that all patients outside the ITU Ward are identified as critical care and recorded appropriately to ensure the maximum income can be achieved. Day case & elective activity remains a concern, particularly within the Surgical Division. Activity is below plan and there is a loss of income due to case mix across specialties. Under performance on income is currently £1.2m. The Surgical Division are in the process of implementing a recovery plan however, this is unlikely to deliver the full income lost to date and there is a significant risk that the majority of this activity will be for NWL CCGs and there is no agreement in place to fund over-performance. This will also lead to higher costs to deliver this activity, some of which will be at waiting list payment rates. Emergency activity is above plan by 9.8% on activity and 7.7% on income. This is a change to the previously reported position due to the recoding and repricing of activity through the Clinical Decision Unit which is classed as emergency activity. Outpatients have continued to underperform on activity and income. Hillingdon CCG remains behind plan by £500k which is offset by the over performance for Ealing CCG of £546k. This is due to higher than expected births and emergency activity from Ealing which is a shift in market share from London North West Healthcare. ‘Other contracts’ include Herts Valley CCG which has seen a decrease in referrals since February across all specialties but mainly General Surgery, Pain, T&O & Dermatology. The reason for this reduction is due to repatriation to local Hertfordshire Hospitals and the introduction of community based services. It is expected to continue for the rest of the financial year.

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Appendix 2 Bank and Agency Expenditure by Staff Group and Division

Appendix 3 Non-Pay Variance to Plan

Staff Group Division Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 YTD Total YTD Bank YTD AgencyMEDICAL PAY Surgical Division (0.26) (0.27) (0.28) (0.31) (0.35) (0.27) (1.74) (1.59) (0.15)

Medical Division (0.49) (0.48) (0.45) (0.48) (0.51) (0.24) (2.65) (1.53) (1.12)Women & Children's Division (0.04) (0.04) (0.04) (0.06) (0.05) (0.04) (0.27) (0.17) (0.11)Clinical Support Services (0.09) (0.10) (0.10) (0.11) (0.09) (0.11) (0.61) (0.26) (0.35)Central Budgets 0.00 0.00 0.00 0.00 0.03 0.00 0.03 0.03 0.00

MEDICAL PAY Total (0.89) (0.89) (0.87) (0.96) (0.97) (0.66) (5.24) (3.52) (1.72)NURSES & MIDWIVES PAY Surgical Division (0.16) (0.12) (0.15) (0.15) (0.18) (0.14) (0.90) (0.52) (0.39)

Medical Division (0.65) (0.56) (0.50) (0.51) (0.55) (0.51) (3.27) (1.47) (1.81)Women & Children's Division (0.09) (0.13) (0.11) (0.10) (0.12) (0.10) (0.64) (0.48) (0.17)Clinical Support Services (0.01) (0.01) (0.01) (0.01) (0.01) (0.01) (0.07) (0.07) (0.01)Corporate (0.04) (0.03) (0.05) (0.03) (0.04) (0.06) (0.25) (0.19) (0.07)Central Budgets 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) (0.00) (0.00) 0.00

NURSES & MIDWIVES PAY Total (0.95) (0.86) (0.81) (0.81) (0.90) (0.82) (5.15) (2.72) (2.43)HCAS & SUPPORT PAY Surgical Division (0.03) (0.04) (0.04) (0.04) (0.05) (0.05) (0.26) (0.26) 0.00

Medical Division (0.23) (0.16) (0.15) (0.16) (0.20) (0.16) (1.05) (1.05) 0.00Women & Children's Division (0.01) (0.03) (0.03) (0.02) (0.03) (0.02) (0.14) (0.14) 0.00Clinical Support Services (0.03) (0.02) (0.02) (0.02) (0.02) (0.03) (0.14) (0.14) 0.00Corporate (0.07) (0.06) (0.08) (0.07) (0.06) (0.05) (0.39) (0.09) (0.29)

HCAS & SUPPORT PAY Total (0.37) (0.31) (0.32) (0.31) (0.36) (0.30) (1.97) (1.68) (0.29)ADMIN & CLERICAL PAY Surgical Division (0.02) (0.01) (0.02) (0.01) (0.02) (0.02) (0.10) (0.10) 0.00

Medical Division (0.01) (0.01) (0.01) (0.01) (0.02) (0.02) (0.09) (0.09) 0.00Women & Children's Division (0.01) (0.01) (0.01) (0.01) (0.01) (0.01) (0.05) (0.05) 0.00Clinical Support Services (0.02) (0.02) (0.02) (0.02) (0.02) (0.02) (0.13) (0.13) 0.00Corporate (0.12) (0.15) (0.13) (0.11) (0.11) (0.12) (0.74) (0.48) (0.26)Central Budgets 0.00 0.00 0.00 0.01 0.00 0.00 0.01 0.01 0.00

ADMIN & CLERICAL PAY Total (0.19) (0.20) (0.18) (0.16) (0.18) (0.19) (1.09) (0.83) (0.26)SCI, THERAPUTIC & TECH PAYSurgical Division (0.04) (0.03) (0.03) (0.03) (0.03) (0.04) (0.20) (0.19) (0.00)

Medical Division (0.02) (0.01) (0.01) (0.00) (0.01) (0.01) (0.05) (0.02) (0.03)Women & Children's Division (0.00) (0.00) 0.00 (0.00) (0.00) 0.00 (0.00) (0.00) 0.00Clinical Support Services (0.13) (0.11) (0.13) (0.10) (0.13) (0.12) (0.72) (0.26) (0.46)Corporate (0.00) (0.00) 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 0.00Central Budgets (0.00) (0.00) (0.00) (0.00) (0.00) (0.00) (0.02) (0.02) 0.00

SCI, THERAPUTIC & TECH PAY Total (0.18) (0.15) (0.17) (0.14) (0.17) (0.17) (0.99) (0.49) (0.49)ESTATES PAY Surgical Division (0.01) (0.01) (0.01) (0.01) (0.01) (0.01) (0.05) (0.05) 0.00

Medical Division 0.00 0.00 0.00 0.00 (0.00) 0.00 (0.00) 0.00 0.00Clinical Support Services (0.00) (0.00) (0.00) (0.00) (0.00) (0.00) (0.01) (0.01) 0.00Corporate (0.04) (0.03) (0.05) (0.05) (0.05) (0.04) (0.26) (0.21) (0.05)

ESTATES PAY Total (0.05) (0.04) (0.05) (0.06) (0.06) (0.05) (0.31) (0.27) (0.05)HEALTHCARE SCIENTISTS PAYMedical Division (0.01) 0.00 (0.00) (0.00) (0.00) (0.00) (0.02) (0.01) (0.01)

Clinical Support Services (0.01) (0.03) (0.02) (0.02) (0.02) (0.02) (0.12) (0.08) (0.03)HEALTHCARE SCIENTISTS PAY Total (0.02) (0.02) (0.02) (0.03) (0.02) (0.03) (0.14) (0.10) (0.04)Grand Total (2.64) (2.48) (2.43) (2.47) (2.66) (2.22) (14.89) (9.60) (5.29)

BANK & AGENCY EXPENDITURE

Annual Plan Actual Variance Plan Actual VariancePlan In Month In Month In Month YTD YTD YTD£m £m £m £m £m £m £m

Non-PayClinical Supplies & Services (25.10) (2.13) (2.26) (0.14) (12.83) (12.75) 0.08Drugs - PbR Excluded (12.64) (1.05) (0.90) 0.16 (6.32) (5.94) 0.37Drugs - In Tariff (5.32) (0.48) (0.54) (0.06) (2.90) (3.04) (0.14)General Supplies & Services (3.65) (0.32) (0.37) (0.05) (1.92) (2.04) (0.12)Establishment (5.82) (0.51) (0.59) (0.08) (3.11) (3.25) (0.13)Premises and Fixed Plant (8.30) (0.79) (0.43) 0.36 (4.71) (4.35) 0.36CNST (8.71) (0.91) (0.91) (0.00) (5.45) (5.46) (0.01)Other Non-Pay (9.91) (0.54) (0.76) (0.22) (3.52) (4.79) (1.27)

Total Non-Pay Costs (79.45) (6.72) (6.76) (0.04) (40.75) (41.60) (0.85)

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Appendix 4 Trust Run Rate

The table below looks at the actual monthly income and costs over the previous 6 months. This table enables the Trust to review and identify trends or unusual peaks in expenditure or income, these can be reviewed and where necessary future mitigating action put in place to manage or avoid these variations.

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Appendix 5 Cash flow

The Trust’s cash position is forecast daily, forward for 12 months. The current difficulties experienced by the Trust in meeting our supplier’s payment terms continues to be reviewed with a full forecasting exercise being undertaken to identify the cash requirements going forward and implications should no further cash support be available from NHSi.

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19£000s £000s £000s £000s £000s £000s

NHS CLINICAL INCOME MAIN NHS CLINICAL INCOME 15,093 17,432 16,027 16,959 16,595 17,786EXCLUDED DRUGS INCOME 1,049 976 1,106 1,090 945 1,223EXCLUDED DEVICES INCOME 107 144 119 164 162 117OTHER DIVISIONAL NHS CLIN INC 332 366 381 522 445 501

NHS CLINICAL INCOME Total 16,581 18,919 17,633 18,735 18,148 19,627

NON-NHS CLINICAL INCOME ICR/RTA 78 124 91 114 77 71OVERSEAS INCOME 93 75 42 157 95 155PRIVATE PATIENT & NCA 19 18 16 21 24 22

NON-NHS CLINICAL INCOME Total 191 217 149 293 196 249

OTHER OPERATING INCOME TRAINING & EDUCATION 720 722 752 800 739 713NON-PAT SERV TO OTHER WGA 618 641 642 611 632 630RENTAL INC FROM OPER LEASES 259 258 262 256 272 262CAR PARKING INCOME 149 159 161 157 186 179CATERING INCOME 139 122 142 123 126 144OTHER INCOME 276 185 265 416 346 243

OTHER OPERATING INCOME Total 2,161 2,087 2,224 2,364 2,302 2,171

PAY NURSES & MIDWIVES PAY (4,867) (4,674) (4,663) (4,612) (4,696) (4,591)MEDICAL PAY (4,409) (4,361) (4,382) (4,509) (4,547) (4,334)HCAS & SUPPORT PAY (1,977) (1,864) (1,913) (1,896) (1,917) (1,912)ADMIN & CLERICAL PAY (1,860) (1,764) (1,774) (1,732) (1,756) (1,811)SCI, THERAPUTIC & TECH PAY (1,480) (1,403) (1,402) (1,370) (1,393) (1,410)MANAGERS PAY (515) (537) (528) (470) (507) (490)ESTATES PAY (321) (298) (316) (319) (319) (310)HEALTHCARE SCIENTISTS PAY (213) (202) (197) (201) (196) (202)DIRECTORS PAY (103) (115) (142) (90) (102) (99)APPRENTICESHIP LEVY (58) (62) (58) (60) (58) (61)

PAY Total (15,803) (15,281) (15,376) (15,260) (15,492) (15,220)

DRUGS DRUGS - PbR EXCLUDED (1,014) (990) (1,039) (1,190) (817) (895)DRUGS - IN-TARIFF (575) (414) (458) (579) (477) (539)

DRUGS Total (1,589) (1,404) (1,497) (1,769) (1,293) (1,434)

SUPPLIES & SERVICES - CLINICAL SUPPLIES & SERVICES - CLINICAL (1,943) (2,101) (2,061) (2,328) (2,051) (2,260)SUPPLIES & SERVICES - CLINICAL Total (1,943) (2,101) (2,061) (2,328) (2,051) (2,260)

OTHER NON-PAY CLINICAL NEGLIGENCE (909) (909) (909) (908) (909) (911)ESTABLISHMENT EXPENSES (516) (498) (425) (636) (649) (589)PREMISES EXPENSES (843) (863) (695) (759) (759) (428)SUPPLIES & SERVICES - GENERAL (329) (349) (306) (361) (324) (370)CONSULTANCY (124) (238) (287) (493) (453) (308)TRANSPORT (132) (177) (168) (160) (195) (156)OTHER NON-PAY (353) (272) (345) (275) (283) (299)

OTHER NON-PAY Total (3,206) (3,304) (3,135) (3,592) (3,571) (3,061)

DEPRECIATION (800) (763) (763) (760) (760) (759)INTEREST EXPENSE (283) (295) (290) (297) (303) (288)INTEREST RECEIVABLE 7 5 6 6 4 9DIVIDENDS PAYABLE (294) (294) (293) (294) (294) (99)FINANCIAL RECOVERY FUND 740 740 741 987 987 987PROVIDER SUSTAINABILITY FUND 234 234 442 312 312 313MARGINAL RATE EMERG TARIFF 132 131 132 132 132 131

Grand Total (3,874) (1,109) (2,088) (1,470) (1,684) 365

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Cash Flow Forecast 19-20Act Act Act Act Act Act Fcast Fcast Fcast Fcast Fcast Fcast

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20INCOME £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Clinical Income 16,667 16,894 16,716 17,933 33,606 15,202 17,427 12,430 17,431 17,431 17,431 5,000

Education and Training 1,964 - - 2,268 - - 2,237 - - 2,237 - -

Other Income 3,035 1,585 3,243 2,916 3,745 3,522 2,878 1,752 1,685 1,750 1,685 2,474

HMRC - 1,008 385 - 1,027 398 284 284 284 284 284 284

STF 974 974 974 3,568 1,299 4,224 - 1,950 1,948 2,274 2,274 2,276

MRET 395 - - 395 - - 395 - - 395 - -

Loan ITFF 5,611 - - - - - - - - - - -

Working capital loan - - - - - - - 15,000 - - - 15,000

Other Receipts 318 613 56 364 104 109 577 129 104 129 104 104

TOTAL RECEIPTS 28,964 21,074 21,374 27,444 39,781 23,455 23,798 31,545 21,452 24,500 21,778 25,138

PAYMENTS

Pay Costs (14,913) (14,769) (14,565) (14,657) (14,832) (14,953) (15,309) (15,147) (15,147) (15,487) (15,147) (15,147)

Creditors (12,722) (3,931) (6,519) (11,473) (19,626) (6,575) (8,843) (10,300) (9,432) (7,727) (6,608) (7,537)

NHSLA (1,139) (1,139) (1,139) (1,139) (1,139) (1,139) (1,127) (1,127) (1,127) (1,127) - -

PDC Dividends - - - - - (1,618) - - - - - (1,914)

ITFF Loan Interest payments (114) (158) (47) (145) (13) (340) (203) (160) (55) (159) (23) (345)

Loan Repayments - (500) - - - (195) (972) (500) - - - (195)

Other Payments (3) (16) (15) (3) (14) (12) (3) - - - - -

Total Payments (28,891) (20,513) (22,285) (27,417) (35,624) (24,832) (26,457) (27,234) (25,761) (24,500) (21,778) (25,138)

NET CASH FLOW IN PERIOD 73 561 (911) 27 4,157 (1,377) (2,659) 4,311 (4,309) - - -

OPENING CASH BALANCE 1,128 1,201 1,761 850 877 5,034 3,658 998 5,309 1,000 1,000 1,000

CLOSING CASH BALANCE 1,201 1,761 850 877 5,034 3,658 998 5,309 1,000 1,000 1,000 1,000

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Board of Directors


Title NHS Improvement Undertakings: Progress Update & Assurance

Report author Piers Young, Hospital Director

Report sponsor Melissa Mellett Director of Operations


☒ ☐ ☐


For Assurance

For Information

☐ ☒ ☐

Summary

This report provides oversight to the Board on progress against the undertakings made by the Trust to NHS Improvement. These undertakings relate to A&E; Finance; Governance and Programme Management. The report was considered by the Finance and Performance Committee at its meeting on 24 October 2019.



To improve the present A&E 4 hour standard; the 18 week Referral to Treatment; to meet Cancer target; to complete the CQC action plan; to implement year 2 of Quality and Safety Improvement Strategy; to maintain finance and the use of resources score of 3 in meeting the control total.

Impact

Quality and Safety

To continue to provide the best level of patient care and safety in delivering core constitutional standards and implementing year 2 of Quality and Safety Improvement Strategy.

Legal

Financial To maintain finance and the use of resources score of 3 in meeting the control total.

Human Resources

Equality & Diversity


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REGULATORY UNDERTAKINGS Status Key: Not started = no action started to complete undertaking Ongoing = undertaking is continuous and won't be fully 'complete' On Hold = progress on undertaking has been halted Off Track = progress for completing the undertaking has deviated against plan Partially Complete = progress is on track but hasn't been completed Complete = undertaking has been actioned and is complete

The Hillingdon Hospitals NHS Foundation Trust

REF UNDERTAKING AREA CLOSED STATUS PROGRESS UPDATE

001 The Trust will provide to NHS Improvement a Board-approved plan for A&E performance recovery (“the A&E Plan”) by a date to be agreed with NHS Improvement

A&E Complete Plan was approved by NHSE/I.

002 The Trust will provide to NHS Improvement a monthly Board-approved report on progress against the A&E Plan

A&E Ongoing Included in the monthly performance reports and Provider Oversight Meeting slides

003 The Trust will engage with an external supplier, under a scope and by a date to be agreed with NHS Improvement, to provide support in the delivery of the A&E Plan

A&E Complete Complete. Hunter Healthcare work procured and delivered. Contract ended 30/11/18. Ongoing support through Positive Dynamics.

004 The Trust will agree with NHS Improvement a set of oversight arrangements to provide assurance to NHS Improvement over the Trust's actions to deliver its A&E plan

A&E Ongoing Weekly ED programme board chaired by Chief Executive with agreed metrics to provide assurance to NHSE/I.

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005 The Trust will develop a financial plan to March 2020 FINANCE Complete A driver of deficit paper has been provided to NHSE/I. The Trust's long-term financial model has been updated. Workshops have been held to review opportunities from model hospital and Getting It Right First Time, (GIRFT). The Trust's people and OD strategy is embedded within the financial plan. The Trust has engaged PA Consulting to support the divisional management teams to identify and deliver the savings target required to achieve the Trust's control total in 19/20

006 The Trust will keep both the Financial Plan under review and provide regular highlight reports including key performance indicators and attend regular update meetings, the content and timing of which will be agreed with NHS Improvement

FINANCE Ongoing The Trust continues to engage with NHSE/I through the monthly Performance Oversight Meeting (POM).

007 The Trust will undertake an externally commissioned governance review to inform the strengthening of governance arrangements to be completed by a date to be agreed with NHS Improvement. The scope and supplier will be agreed with NHS Improvement

GOVERNANCE Complete Deloitte have undertaken the governance review to a scope agreed with NHSE/I

008 The Trust will address the findings of the governance review. The timing of delivery of the recommendations will be agreed by NHSI and the Trust will provide assurance to NHS Improvement if requested on progress with delivery

GOVERNANCE On Hold Deloitte have not yet released the report. The Trust have support from Good Governance Institute (GGI) to further improve and advise on governance. NHSE/I - On hold due to original work probably not releasing the report. We will review again to determine the

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status of original undertaking.

009 The Trust will work with a Senior Board Advisor who may be appointed by NHS Improvement to assist the trust’s executive team with the delivery of the Plans identified within these undertakings

GOVERNANCE On Hold NHSE/I - We will keep on undertakings, but it may not be required following change in leadership. We will continue to monitor

010 The Trust will co-operate and work with such partner organisations (this may include one or more ‘buddy trusts’) which may be appointed by NHS Improvement to support and provide expertise to the Trust and to assist the Trust with the delivery of one or more of the Plans identified within these undertakings and the quality of care the Trust provides. The scope and scale of any such support will be directed by NHS Improvement

GOVERNANCE On Hold NHSE/I - Not been requested of the trust yet but will remain on hold until such time that an appointment is required. Also to note the trust are working with GGI.

011 The Trust will ensure adequate senior management (PMO resource) to support the executive team to deliver the undertakings above

PMO Complete The Trust has already appointed to the associate director of PMO role that supports the financial improvement programme. The Trust has had previously Kingsgate and now PA Consulting to support the programme.

012 The Trust will implement enough programme management and governance arrangements to enable delivery of these undertakings

PMO Ongoing The undertakings will be monitored by the finance and performance committee and Trust Board

013 The Trust will attend meetings or, if NHS Improvement stipulates, conference calls, at such times and places, and with such attendees, as may be required by NHS Improvement

PMO Ongoing NHSE/I - This has been completed but will kept on undertakings as ongoing.

014 The Trust will provide such reports and access to any of the trust’s advisors in relation to the matters covered by these undertakings as NHS Improvement may require

PMO Ongoing NHSE/I - This has been completed but will kept on undertakings as ongoing.

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015 The trust will undertake a review to determine the root causes of why the lack of CQC progress was not identified and acted on previously to identify actions to address the root causes and share these findings with NHSI. We understand there is an ongoing review into A&E, Finance and Quality, and a wider governance review to inform this process

QUALITY Complete It was noted that the Board had held a retrospective look back on the causes of how the decline in quality had not been identified and reported to the Board more effectively. Part of the outcome of these discussions was the decision to commission a governance review by the Good Governance Institute (GGI) to identify gaps in governance and make recommendations to strengthen reporting where necessary. It was agreed that receipt of the GGI review will meet the requirements of this undertaking. 4.9.19 GGI review of trust governance received from Trust. It should be noted the Board is still new - resulting in renewed review of current processes. In October 2019 there will also be a new Chair.

016 The trust will develop a framework for assurance of progress and quality improvement that deals with issues raised in the CQC inspection and agree these with NHSI and system partners by December 2018

QUALITY Partially Complete

Interim Chief Nurse has reported that the Quality Improvement Framework had been finalised and would shortly be shared with partners. The requirements of this undertaking would then be met 3.9.19 Request made to Deputy Chief Nurse to send Michael Fairbairn the Quality Improvement Framework.

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017 The trust will put in place a framework to ensure that patient safety issues are appropriately escalated and reviewed by the Board on an ongoing basis

QUALITY Complete The CQC action plan has been established and progress is overseen at Trust Improvement Board with attendance from stakeholder partners including NHSE/I. Additional meetings with Trust, Commissioners and NHSE/I are also held to examine evidence of progress including visits to clinical areas. These meetings report up to the Improvement Board

018 The trust will review and revise the Trust’s risk management policy/procedures and associated governance processes by January 2019

QUALITY Partially Complete

Interim Chief Nurse has reported that the Risk Management Policy and Strategy had been reviewed and revised by the GGI and was due for sign off on 17.7.19 and would then be shared with partners. The requirements of this undertaking would then be met 3.9.19 Assistant Director of Integrated Governance reports that RM Policy & Strategy are due for sign off by Audit & Risk Committee 17.10.19. and will be sent to NHSE/I on ratification

019 The trust will put in place a robust approach to improve medical engagement and to use a recognised tool to measure the level of medical engagement within the organization by January 2019

QUALITY Complete The Medical Engagement Scale tool was completed within the Jan 19 time frame. The MES report went to the March 19 Trust Board. Further actions have since been developed and implemented.

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131

Board of Directors


Title Board Assurance Framework

Report author Jason Seez, Deputy CEO Report sponsor Jason Seez, Deputy CEO

Status of Report Public Private Internal x

Purpose of Report For Decision For Assurance For Information X

Summary

Over the last six months, the leadership team has completed an extensive review of the Trust’s Board Assurance Framework (BAF), with risk management becoming embedded in the Trust’s management and performance, and assurance systems. A specially-convened Audit and Risk Committee was held in September to review in detail the Trust’s updated BAF with the internal and external auditors, governors, and regulators. The BAF was approved by the Trust’s Management Executive on 16 October 2019, and the Audit and Risk Committee on 17 October 2019. This paper provides the Board with a summary overview and invites ratification of the recommendations of the Trust Management Executive and Audit and Risk Committee to approve the BAF.

Recommendations The Board is invited to approve the Board Assurance Framework.

Links to Corporate Objectives and BAF risk reference

All

Impact

Quality and Safety x Legal x Financial x Human Resources x Equality and Diversity x Engagement and communication x Sustainability x

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Assurance goes to the heart of the work of any NHS board of directors. The provision of healthcare involves risk and being assured is a major factor in successfully controlling risk. • Assurance is the bedrock of evidence that gives confidence that risk is being controlled

effectively, or conversely, highlights that certain controls are ineffective or there are gaps that need to be addressed.

• The Board Assurance Framework (BAF) brings together in one place all of the relevant information on the risks to the board’s strategic objectives.

• It is an essential tool for trust boards, but like all tools it needs to be used with skill and diligence.

The table below summarises the extensive development programme, which encompassed both the improvement of the Trust’s management and assurance systems, which has been undertaken in the first half of the current financial year (April 2019 to September 2019). The programme was developed and implemented in partnership with expert external support, and learning from other trusts recognised for their good practice. Key area of delivery Detail Dates

Strategic objectives and risk appetite

• Agreed by the Trust Board at the Trust Board seminars, with external facilitation on the review and agreement of the Trust Board’s risk appetite.

May, June

Principal risks • Reviewed by the executive and divisional leadership teams, and then agreed by the Trust Board at Board seminars

• Monthly Risk Management Group established

• Corporate risk register, standing agenda item for the monthly Trust Management Executive meetings

July, August September onwards September onwards

Controls, assurances, gaps and actions including committee alignment

• Reviewed by the executive and divisional leadership teams

• External review of the Trust’s controls and assurances, and assurance committees. Updated terms of reference for all the Trust’s Assurance Committees, and the establishment of an assurance committee to oversee the Trust’s workforce strategic objective and strategic risks

July, August, September July, August, September

Agendas and Cycles of business

Review of cycles of business against the draft BAF. The BAF informing pre-meets in setting Board and sub-committee agendas

September onwards

Summary

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Further to completion of the programme, the updated BAF was: • Reviewed in detail by a specially convened Audit and Risk Committee in September 2019, with

the internal and external auditors, governors, and regulators. • Approved by the Trust’s Management Executive on the 16th October 2019, and the Audit and

Risk Committee on the 17th October 2019, subject to final Trust Board ratification. The Committee’s approved a suite of documentation – • The summary BAF • A ‘heat map’, summarising the residual risks, and the target risk we aim to achieve • A report on the gaps in control • A report on the gaps in assurance • Standard operating procedure, detailing how the management of the BAF will become

embedded in business as usual • The full BAF, which in effect is a detailed database for each of the Trust’s strategic objectives,

detailing the o Principal risks o Sources of assurance o Reports to Board o The progress that is expected in the next quarter o Risk rating o Effectiveness of controls

The Trust Board reviewed the Trust’s Strategic Objectives at two Trust Board seminars in May and

June 2019.

The Trust Board reviewed the Trust’s strategic objectives at two Trust Board seminars in May and June 2019. The following Strategic objectives were agreed: Quality • The care we provide to our patients will be safe, effective and result in a good experience

Performance • We will deliver the right care, at the right time, and in the right place for our patients

Strategic objectives

The development of the Trust’s strategic objectives used the main domains of a balanced scorecard approach, so as to ensure there is a clear framework running through our planning, performance and risk management processes.

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Money • We will use our resources effectively to eliminate waste, achieve financial balance, and support

the system

Workforce • We will value our people and equip them with the skills to provide the right care

Partnership working and well-led • We will work with all of our partners, including patients and the public, to deliver our strategy,

including a new hospital• We will harness the potential of our people to deliver continuous improvement.

The Trust Board reviewed the Trust’s risk appetite and principal risks in June, July and August 2019. The review was facilitated by the Good Governance Institute. Subsequently, there is ongoing monthly review of the Trust’s principal risks by the executive and divisional leadership teams at the Risk Management Group and Trust Management Executive, and at the Trust’s assurance committees.

An overview of the Trust’s principal risks, are summarised in the table below.

Quality Workforce Performance Money Well-led Partnership working

Standards of care

Recruitment & retention

Capacity and capability to meet operational performance targets

Use of resources

Management and leadership capability and capacity

Effective working with partners

Environment Supported and empowered staff

Systems and processes, and our digital capability

Estates Strategy

Skills to challenge poor performance and lead change

Engagement in the NW London system

Recruitment and retention

New roles and ways of working

Embedding our improvement methodology

Engagement with education partners

Governance Health and work-life balance

North West London Strategy

Culture

Principal risks

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The detailed suite of BAF documents approved by the Trust Management Executive and Audit and Risk Committee, incorporated two reports, which highlighted gaps in control and gaps in assurance, with an associated work programme to address the gaps. The main themes in gaps are summarised below. • Robustness of controls need to be improved • Systems and processes are not systematic • Capacity and capability of staff to deliver plans and programmes • Management governance structure • Triangulation of information and integrated performance reporting, and the need to improve

our information reporting systems and our service line reporting • Use of benchmarking information and fully referencing national comparative specialty data, and

models of best practice • Ensuring a culture of continuous learning • Strategy’s and plans needing to be updated • Strategy’s and plans not of a sufficient quality to ensure delivery, and the need to improve

alignment between our strategies and plans both internally, and externally with our partners

Progress on the delivery of the associated executive work programme to address the gaps, will be regularly reported to the Trust’s management and assurance committees. Independent review on progress will be provided by KPMG, the Trust’s internal auditors. In quarter 4 (January, February, March 2020) progress will be reviewed. Then going forward into the 2020/21 financial year, there will be ongoing review on embeddedness, and also softer cultural controls.

A standard operating procedure is being implemented to ensure the BAF, becomes embedded in the Trust’s management and assurance systems, and is a ‘live document’. On a monthly basis the Trust’s Risk Management Group and Trust Management Executive, will review the Trust’s principal risks. On a monthly basis the Trust Board’s assurance committees:

• Quality and Safety Committee • Finance and Performance Committee • People Committee • Audit and Risk Committee

The respective executive and non-executive director leads will ensure that the principal risks are informing the agenda, and at the meeting the supporting papers are providing timely updates on the Trust’s controls and assurances. The monthly cycle of administration will be overseen by the Assistant Director for Integrated Governance, and Trust Secretary. On a quarterly basis, the Trust Board will receive an update on the BAF.

The Board is invited to approve the Trust’s Board Assurance Framework.

Controls and assurances

Process going forward

In conclusion

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Board of Directors


Title Board Cycle of Business, 2019/20

Report author Michael Wood, Interim Trust Secretary Report sponsor Jason Seez, Deputy CEO

Status of Report Public Private Internal X

Purpose of Report For Decision For Assurance For Information X

Summary

Related to work carried out on the Trust’s Board Assurance Framework (BAF), a detailed review of the business cycle of the Board and its Sub-Committees has been carried in order to improve communications, business flow and to enhance assurance.

Recommendations The Board is invited to approve the Cycle of Business, 2019/20.

Links to Corporate Objectives and BAF risk reference

All

Impact

Quality and Safety x Legal x Financial x Human Resources x Equality and Diversity x Engagement and communication x Sustainability x

137

May Jul Sep Oct Nov Jan Feb MarMEETING DATES 22 31 25 30 27 29 19 25 Board LeadReport Deadline 14 22 16 21 18 20 10 16

Welcome & Apologies for Absence X X x x x x x x ChairDeclarations of Interest x x x x x x x x ChairMinutes x x x x x x x x ChairAction Log x x x x x x x x ChairPatient/Staff Story x x x x x x x x CNChair’s Report x x x x x x x x ChairChief Executive’s Report x x x x x x x x CEO

Hillingdon Improvement Plan x x x x x x x x COO DPE&N DPOCares + x x COO DPE&N DPOGuardian of Safe Working x x x MDMedical Education x MDMedical Re-validation x MDLearning from Deaths x x x MDSafer Staffing – Nursing/Medical x x x x x x x x CN and MDQuality Account Priorities for 2020-21 x CNFlu Plan Outcomes x DPODSerious incident Summary Report x xAnnual Complaints Report x CNCommunications Strategy x

Clinical Negligence Scheme for Trusts – Maternity Safety Actions - CHECK x x x COO

Strategic Plan, 2017-21 x x DCEOOperational Plan 19-20 x x x x x DCEOOperational Plan 20-21 x DCEOWinter Resilience x x COOKPI Review, 2020-21 x COO CN DPODBoard Assurance Framework x x x DCEOCorporate Risk Register Updates x x x DCEO

2019 2020

BUSINESS MATTERS

QUALITY MATTERS

PERFORMANCE MATTERS

138

Emergency Preparedness Resilience and Response x COOInformation Governance (Data Security and Protection Toolkit) x FDNational In-patient Survey x CNHealth & Safety Annual Report x FDResearch & Development Annual Report x MD

People Strategy x DPODEquality Diversity & Inclusion Annual Report (inc Workforce Race Equality Standard – WRES)

x DPOD

Staff Survey - outcomes x DPODFreedom to Speak Up Annual Report x DPODStaff Survey - outcomes x DPODOrganisational Development Programme x DPOD

Finance Report x x x x x x x x FDFinancial Plan, 2020 – 21 (Revenue & Capital) x x FDNHSI Undertakings? x x x x x x x x COO and FDAnnual Report & Accounts - Process and Approval x x DCEOAnnual Report & Accounts – Trust Charity - Approval x DPODEstates Report x x x x x x x x DCEODigital Strategy x x FD

Well-Led Assessment and Compliance with Code of Governance x x DCEOAudit Committee Annual Report (Statutory Committee) x Chair ARCCommittee Chair Reports x x x x x x x ChairsCommittee / Portfolio Appointments, 2019-20; compliance with FPPT for Board and Governors

x x TS

Committee / Portfolio Appointments, 2020-21; compliance with FPPT for Board and Governors

x TS

Board & Committee Self-Assessments x ChairSelf-Certification x DCEOWell-Led Assessment and Compliance with Code of Governance x x DCEOAudit Committee Annual Report (Statutory Committee) x Chair ARCUse of Trust Seal x x x x x x TS

FINANCE & RESOURCES MATTERS

WELL-LED/GOVERNANCE MATTERS

PARTNERSHIP MATTERS

WORKFORCE MATTERS

139

Integrated Care Partnership Update x x DCEO

140

Documents

Part I (Open) Meeting of the Board of Directors Tuesday 29 … · 2019-10-25 · The Hillingdon Hospitals NHS Foundation Trust Part I (Open) Meeting of the Board of Directors Tuesday