The Hillingdon Hospitals NHS Foundation Trust Part …...2019/03/27 · The Hillingdon Hospitals NHS Foundation Trust Part I (Open) Meeting of the Board of Directors Wednesday 27th

The Hillingdon Hospitals NHS Foundation Trust

Part I (Open) Meeting of the Board of Directors

Wednesday 27th March 2019, 2pm Board Room, Hillingdon Hospital

Item Status Presenter Page Introductory

1 Welcome and apologies for absence information Chair Verbal

2 Declaration of hospitality, Declaration of amendments to the Register of Interests, Declarations of Interest on items on the Agenda

decision Chair Verbal

3 Minutes of the Part I (Open) meeting 30th January 2019 decision Chair

4 Action Log decision Chair

5 Declaration of Any Other Business information Chair Verbal

6 Patient Story information J Walker Verbal

7 Chair’s Report information Chair Verbal

8 Chief Executive’s Report information S Tedford

Strategy & Governance 9 Operational Plan 2019 -2020 decision J Seez 10 Hillingdon HealthCare Partners Business Case decision J Walker

11 RM Partners Alliance Memorandum of Understanding decision D Spencer 12 Emergency Preparedness, Resilience and Response monitor D Spencer 13 Medical Engagement Scale: Summary Feedback monitor J Walker 14 Local EU Exit Planning Update monitor T Roberts

15 Board Committee Terms of Reference decision S Tedford

16 Annual Report & Accounts 2018-19 - process and timeline

information D Stonehouse

Performance & Assurance 17 Financial Performance Report – February 2019 (Month11) monitor D Stonehouse 18 NHS Improvement Undertakings: progress update and

assurance monitor D Spencer / D

Stonehouse 19 Integrated Quality & Operational Performance – February

2019 monitor D Spencer / J

Walker / T Roberts

20 Care Quality Commission compliance and quality improvement

monitor J Walker

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3

19

22

2643

51545864

68

71

7481

87

100

21 Staff Survey 2018 - Outcomes monitor T Roberts 22 People Strategy 2017-22 Update monitor T Roberts 23 Biannual Medical Education Report monitor C Cale 24 Safer Nurse Staffing Update monitor J Walker

25 Clinical Negligence Scheme for Trusts (CNST) incentive scheme for Maternity safety actions.

decision

26 Data Security & Protection Toolkit decision D Stonehouse

Information 27 Reports back from Committees – Finance & Performance,

Quality & Safety, Audit & Risk, Charitable Funds, Nominations, Remuneration

information Committee Chairs

28 Minutes of Committee meetings information Committee Chairs

29 Use of Trust Seal information M Sims Verbal

Questions from the Public 30 Questions from the Public

This item is an opportunity for members of the public to ask questions to the Board on matters that relate to the Board agenda. Where possible, questions should be sent to the Trust Secretary, by Monday 25th March 2019 in order that the Board can ensure the information is available to answer the question raised.

discussion Chair Verbal

Date of next Meeting 31 Date of next meeting - Wednesday 22nd May 2019 at

Hillingdon Hospital information Chair

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107

114119

126

132

136

143

145

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE PART I (OPEN) MEETING OF THE BOARD OF DIRECTORS HELD ON WEDNESDAY 30TH JANUARY 2019 AT 2PM

HILLINGDON HOSPITAL IN THE BOARD ROOM

MEETING HELD IN PUBLIC

Present: Richard Sumray Chair Soraya Dhillon Deputy Chair and Non-Executive Director Lis Paice Non-Executive Director Richard Whittington Non-Executive Director Linda Burke Associate Non-Executive Director Sarah Tedford Chief Executive Abbas Khakoo Medical Director Terry Roberts Director of People and Organisational Development Joe Smyth Chief Operating Officer Matt Tattersall Finance Director Jacqueline Walker Director of Patient Experience and Nursing

In Attendance: J Philpot Director of Strategic Estate Development and Asset

Management James Ross Director of Strategy and Transformation Mike Sims Trust Secretary Cathy Cale Appointed Interim Medical Director Liza Haynes Therapy Assistant Practitioner, Mount Vernon Hospital

Members of the Public: G McMillan V Murphy G Singh

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Action Introductory 1 Welcome and Apologies for Absence

The Chair welcomed all to the meeting, in particular C Cale who would commence as Interim Medical Director in February.

He went on to report that this K Edelman had resigned from his position as a Non-Executive Director (NED) with effect from the end of December 2019, and that this would be the last Board meeting for J Smyth, M Tattersall and A Khakoo who would all leave their posts at the end of January. He also reported that this would be the last Board meeting for J Philpot who would be leaving the Trust at the end of February. He thanked all for their contributions to the Trust.

He passed on congratulations to A Khakoo and J Walker for their appointments at Brunel University London (BUL) as honorary clinical professors.

2. Declaration of hospitality, Declaration of amendments to the Register of Interests, Declarations of Interest on items on the Agenda

S Dhillon declared she had been appointed as the Senior Independent Director on the Board of NHSI Digital.

3 Minutes of the Part I (Open) meetings of 26th September 2018

Accuracy P4 – Welcome and Apologies - Tedman should read Tedford P 5 and 6 – Patient Story – C Navaroe should read C Navaro

With these amendments the minutes were approved as an accurate record of the meeting

4 Action Log

The following actions were accepted as completed; 198, 259, 260, 261, 263, 265, 266, 268, 269, 270 and 271.

• 258 – Shared learning on discharge – not yet due• 262 – Update on operational grip; delay codes and discharges – will be

covered in the Performance Report on agenda – completed

J Walker

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• 264 – Summary of service hotspots - will be covered in thePerformance Report on agenda – completed

• 267 – Sepsis KPIs – will be available for the March Board performancereport

C Cale

5 Declaration of Any Other Business

None

6 Patient Story

J Walker introduced Liza Haynes, Therapy Assistant Practitioner, and partner to the patient who was the focus of the story.

She explained that on 12/11/18, her partner had been sanding down a metal rail when he experienced pain in his left arm. He went to the Minor Injuries Unit at Mount Vernon Hospital (MVH) and had an x-ray where it was found that he had a piece of copper wire embedded in his arm. She mentioned the friendly and efficient service he received from this department. At this appointment, the nurse spoke to the orthopaedic team at Hillingdon site regarding the need for surgical intervention. This was around 17:30 that evening. The orthopaedic team informed the nurse that they needed him to come to Hillingdon Hospital the next day to the day surgery unit at 12:30 to remove the embedded wire. Her partner was given a letter to confirm this arrangement. On 13/11/18, he went to the 7th floor as instructed and was asked to wait. He proceeded to watch others come in and be seen before him with no communication about what was happening. He asked why he was not being seen and was told staff were awaiting for his notes. He then waited longer before asking again but felt the nurse behind the desk was abrupt and dismissive of his request, saying again they were still awaiting the notes. At this time he became upset at the rude manner of the nurse and called Liza to assist. Liza had gone to the Minor injuries unit at MVH (where the notes would have been held) where she witnessed a receptionist receive a call from Hillingdon site asking for these notes to be faxed over. By now he had been waiting around 3 hours with no communication on what was happening. A consultant then spoke to him and told him that the surgery would unfortunately have to be cancelled due to bed pressures. She explained that although the consultant gave apologies her partner had missed a full says work for which he would not be paid as he was self-employed. The consultant contacted an orthopaedic specialist nurse requesting she speak to him to re-arrange the appointment. The nurse hand wrote an appointment for 27/11/18 at 12:30 at the day unit again on the 7th floor. He went for his pre-operative checks at that time to avoid further delays. On 20/11/18 her partner received a text reminding him of his appointment

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on the 27/11/18 at 12:30. On 27/11/18, they both attended the appointment on the 7th floor . On arrival he was asked to go to Pinewood ward day care. Once there, the staff nurse had no record of him being on the list for that day. When they informed the staff nurse that the that the orthopaedic specialist nurse had arranged this, the ward nurse asked them to wait while she called her. The orthopaedic specialist nurse attended and asked whether they had received a letter that asking them to attend Trinity ward on 28/11/18. Staff could not answer why her partner had not received a text to inform him of this change in arrangements. She said no one could answer this question and could only apologise, repeating that a letter should have been sent out. When asked to give proof that the letter was sent, they were told that they would have to go “administration” to sort the problem out for themselves.

She said they both felt the requirement to keep them informed was passed between staff with no ownership being taken throughout this sequence of events.

She also pointed out an additional consequence was that her partner had missed another day of paid work and that on returning home the letter advising of the change in appointment had only just arrived, meaning it was more than likely to have been posted out too late. She went on to say that her partner eventually had his operation on 28/11/18 but suggested splitting the list and staggering patient arrival times rather than calling all patients in at 7.30am would also be useful in improving the patient experience.

The Chair said this was an example of appalling internal communications where no individual had taken responsibility for the patient and his concerns.

J Walker said that it was very disappointing to note the experience and that this was not in line with the Trust’s CARES values and that she had already given feedback to the surgery team on the case and the specific actions required to address the issues raised. Namely; • All patients to be called on short notice changes• Use of an electronic system for trauma list patients• Include trauma patient lists at morning clinical huddles

S Tedford said that she had personally passed on thanks to Lisa Haynes for raising these concerns which showed the impact not just upon the patient but also his partner and work colleagues.

J Smyth said that the story could be used to help other staff learn from her own experience as a staff member. He agreed that staggered admissions should be feasible had already asked the divisions to review this.

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L Burke said she was concerned about the initial part of the story where the patient had been told the reason for delay was the unavailability of patient notes but then this had switched to being insufficient beds as the stated reason. She added that the system that works had to be one where a named person is in charge of keeping patients informed. S Tedford agreed this needed to be reviewed in terms of how patients were kept informed.

The Chair said that he wished to thank both Lisa Haynes and her partner for bringing forward the story and that the Board would pick up the issue in particular of calling in all patients on the list at the same time as well as the overall issue of patient communication.

The Patient Story was noted

D Spencer

7 Chair’s Report

The Chair reported on the position with the well led review by Deloitte that had commenced in autumn of last year had been placed pause until the end of July 2019 given the significant churn currently taking place with the Board leadership team.

The Report was noted

8 Chief Executive Report

S Tedford introduced a report for information which updated the Board on; • Executive Appointments• Christmas Period• Discharge Planning• A&E Attendance• Flu• NHS Long term Plan• The Ward Accreditation Programme

She explained she had met with Hillingdon HealthCare Partners to discuss the development of the integrated care system and the meeting had been very productive, in particular in using workforce and transformation teams jointly across the borough.

She said that an offer for the post of Finance Director had been made and that the interview for the Chief Operating Officer post would be taking place shortly.

S Dhillon asked whether the overall lack of movement in the flu vaccination rates from last year should be regarded as something of a failure. T

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Roberts responded by saying he did not feel this was the case, but there was a recognition that the project required more clinical service leads to act as champions next year.


Strategy and Governance 9 Review of Executive Structure

S Tedford introduced a report for decision asking the Board to; • Approve the proposal to establish the post of Deputy CEO of Strategy

as a voting member of the Board• Approve the Proposal to create the post of Director of Estates as a non-

voting member of the Board• Approve the reallocation of portfolios as detailed in the report

She said that whilst the Trust was seen as a medium sized hospital the challenges it faced were significant and to address them, it was essential that the right leadership team was in place and she believed these proposals created the structure for these challenges to be addressed.

M Tattersall said he was happy to support the recommendations, but that the Trust should be mindful to ensure that any future review of the number of NEDs required on the Board should be based on a case that was clearly made for the requirement of their skills as opposed to only appointing to meet the constitutional requirement that existed where there must be at least the same number of NEDs as Executives on the Board.

The Chair said he believed there was a growing portfolio required for the work of non-executive directors which would need consideration.

S Dhillon agreed a further report on the size and composition of the Board would need to be reported back following a NED recruitment exercise.

The Board agreed; • To approve the proposal to establish the post of Deputy CEO of

Strategy as a voting member of the Board• To approve the Proposal to create the post of Director of Estates

as a non-voting member of the Board• To approve the reallocation of portfolios as detailed in the report

10 Patient Experience and Engagement Strategy 2019-2022

J Walker introduced a report for decision asking the Board to approve the Patient Experience and Engagement Strategy 2019-2022.

She explained that;

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• The Strategy set out the Trust’s intention to ensure the best possibleexperience for patients, carers, their relatives and the community.

• The Strategy was based on what patients have told the Trust throughstories, complaints and concerns, compliments, national and localsurveys, patient and public forums, social media and feedback fromHealthwatch Hillingdon.

• The Strategy se out the commitment to working in partnership withpatients

• The Strategy embodied the Trust’s CARES values

L Paice said that the Lay Strategic Forum was particularly concerned about transforming the waiting experience for patients as had emerged, for example as referenced earlier in the patient story.

S Dhillon said it would be useful to have the views of the Equality Diversity and Inclusion (EDI) Committee consider the equalities commentary in the Strategy.

The Chair agreed that the Experience and Engagement Group (EEG) should monitor the metrics that would evidence the delivery of the Strategy. He proposed that a report back on outcomes should be considered by the Board in January 2020.

The Board agreed; To approve the Patient Experience and Engagement Strategy 2019-2022

T Roberts

M Sims

11 Consultation on Quality Report Priorities for 2019-20

J Walker introduced a report for decision asking the Board to; • Note the outcome of the consultation event with key stakeholders• Agree the proposed priorities that have been put forward as quality

priorities for the Quality Report as recommended by the Quality andSafety Committee

• Agree the key quality indicators to be included taking into considerationthe Single Oversight Framework metrics

She said that; • The Quality and Safety Committee had received and commented on the

Quality Priorities at its January meeting and was in agreement with theproposed priorities

• There had been a number of suggestions put forward from differentsources on the quality priorities for 2019/20 that had been consideredalongside those priorities within the Trust’s Quality and SafetyImprovement Strategy, progress against CQC standards and the aim toimprove all dimensions of the quality of care.

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• The Trust had listened to its key stakeholders and particularly itspatients and the public to ensure that the quality priorities it agreedreflected the outcomes of consultation.

The Chair said that the training proposals were too generic and there needed to be a clearer focus on which training requirements were a priority.

L Paice asked whether Clinical Fridays would be important in terms of developing training. J Walker responded by saying that Clinical Fridays were very important as staff shared ideas and visited each other’s clinical areas as part of making training real in practice.

S Dhillon asked whether these recommendations were in alignment with other training priorities. J Walker said she believed the priorities were aligned with the training requirements that had emerged following the Care Quality Commission’s (CQC) inspection.

The Board agreed; • The priorities put forward as the quality priorities for the Quality

Report as recommended by the Quality and Safety Committee• The key quality indicators to be included taking into consideration

the Single Oversight Framework metrics

12 Nursing Workforce Safe Staffing Establishment Review

J Walker introduced a report for decision asking the Board to approve the proposal to apply the revision to establishments for the new financial year 2019/20.

She explained that an establishment review of inpatient medical and surgical wards had been undertaken, triangulating acuity and dependency data, Care Hours per Patient Day, assessment of skill mix and findings from a deep dive review of establishments with NHS Improvement and that evidence-based tools, best practice guidance and professional judgment were used to identify recommended changes.

Additionally she asked Board to note the points in the report on safe at night nursing levels.

R Whittington sought clarification on whether the financial impact of the changes was cost neutral or not. J Walker confirmed the impact was cost neutral.

L Burke asked whether the Executive was assured the perception of staff was that they have the correct nursing staffing levels as, anecdotally, she believed nursing staff were not saying this and in particular the balance between permanent and non – permanent staff. J Walker said she would

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agree that permanent staff may perceive staffing levels to be too low where they might be too involved in assisting temporary staff who might not understand local processes.

L Paice asked whether the calculations included specialing nursing and J Walker confirmed that the safer nursing staffing tool required specialing to be included.

The Chair asked whether other issues at Fleming ward complicated the safer staffing levels. J Walker confirmed this was not the case.

The Board agreed; The Nursing Workforce Safe Staffing Establishment Review

13 The NHS Long Term Plan

J Ross introduced a presentation for discussion on the NHS Long Term Plan.

He pointed to the fact that, at its heart, a key component of the Plan was the development of Local Integrated Healthcare Systems and in this respect the Trust, Hillingdon and the North West London (NWL) sector was well developed compared with many other systems in this respect.

The Chair said; • For the most part the contents of the Plan should not present a surprise

in terms of healthcare thinking and from the Trust’s perspective itneeded to pick out what needed to be delivered by the Hillingdon HealthCare Partners (HHCP) locally and the NWL system in general.

• The Trust needed to catch up on being digitally enabled• The Trust needed to develop an innovative workforce strategy and in

this respect the relationship with BUL was key.

L Paice said that the Trust should continue to promote evidence based prevention, social prescribing and self-care management through the HCCP.

S Dhillon sought clarification on how the Board would be kept informed of developments at the Sustainability and Transformation Partnership (STP) level. S Tedford confirmed as CE she sat on the STP Board and would be able to keep the Board informed.

R Whittington sought clarification on how the Trust would contribute to the NWL priority of lowering air pollution in relation to the Long Term Plan. J Ross said this was currently a gap in the NWL Plan and the system would need to work up how it could make an impact on this target.

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The Chair said that Local Authorities needed to find ways to be more involved in delivering on the Long Term Plan through public health as well as work with HCCP on delivering integrated care systems.

The Presentation was noted

14 Impact of Brexit; Implications and Actions

T Roberts introduced a report for discussion explaining the work underway and the assessment of risk in relation to EU Exit readiness with specific reference to; • supply of medicines and vaccines• supply of medical devices and clinical consumables• supply of non-clinical consumables, goods and services• workforce• reciprocal healthcare• research and clinical trials• data sharing, processing and access

The Chair asked what the Executive felt was currently the most significant risk. T Roberts and S Tedman both identified that it was the anxiety felt by approximately 300 EU nationals in the workforce in terms of their jobs and future at the Trust.

The Board agreed that a further report back should come to the March meeting and the following actions should be taken; • A letter of support from the Board sent to the individual staff affected• A report back on the percentage of pipeline staff that may be affected

for March• A report back on risks in relation to critical plant for March


T Roberts

T Roberts

T Roberts

Performance and Assurance 15 Winter Plan 2018/19 review – progress report

J Smyth introduced a monitoring report asking the Board to note progress to date on delivery of the winter plan 2018/19. He said that the focus of the plan was to reduce lengths of stay, prevent admissions ensuring there was sufficient inpatient capacity to meet demand over the winter period, preventing the opening of Edmunds ward and that the plan also focused on improving processes in A&E to ensure a safer department and delivery of the A&E trajectory to achieve 90% by the end of December 2018.

S Dhillon said she understood there may be an issue about the level of referral from the Urgent Care Centre (UCC) to the Rapid Assessment Medical Unit (RAMU) and sought an update. J Smyth reported that the level

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of referrals from GPs was generally appropriate but confirmed there was an issue about referrals from UCC.

L Paice sought an assurance that patients were safe in being transferred between UCC and A&E. J Smyth confirmed escorts remained in place and this had not been an issue to date.

S Tedford added that teambuilding experts would be working with all of the A&E team in the near future as the issue of leadership and communication had now been identified as they key factor holding back a steady improvement in overall A&E performance.

The Chair commented that the Trust had done well to keep escalation wards closed, had performed better than last year over the winter period although trajectories were still not , as yet, being achieved.


16 Integrated Quality & Operational Performance October 2018

J Smyth introduced a report for monitoring asking the Board to review the analysis of quality, experience and operational performance for December 2018 in relation to the CQC’s intelligent monitoring systems domains; safe, caring, effective, responsive and well-led.

The Chair pointed out that the report did not contain performance data on diagnostics and ultrasound. J Smyth confirmed he agreed this should be the case and he would pass details to the informatics team that this data had to be included. He explained, however, that there was a backlog of 800 cases over 6 weeks in diagnostics and ultrasound and it would take the department until May to rectify the backlog position. L Burke whether the Trust had taken any action to assess the risk of harm to patients in this backlog group. J Smyth confirmed the list had been reviewed and prioritised.

A Khakoo asked that future reports contain more divisional analysis on fractured neck of femur patients. J Walker said that the Board should note the Never Events that took place in December and January which were booth being treated as Serious Incidents.

S Tedford confirmed that the Executive would review issues on Fleming ward and report back to the Board.

The Chair summarised by saying; • The report still needed to be analytical as opposed to descriptive• The report needed in particular to explain the reasons why vacancy and

D Spencer

D Spencer

J Walker / D Spencer

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sickness rates were worsening • He had been discussing with the CEO the requirement to establish a

People Committee of the Board where these indicators could bescrutinised in more detail


17 Financial Performance – December 18 (Month 9)

M Tattersall introduced a report for monitoring stating that the month 9 financial position showed; • A M9 deficit of £2.4m, £1.3m behind plan, and £0.2m adverse to

forecast for month• A year to date deficit of £18.4m, £12.3m adverse to plan• Agency expenditure of £0.8m in month, a small decrease on previous

month• That pay overspend reduced to £0.6m in month, £0.1m better than

forecast• Efficiency savings of £1.1m in month• Capital expenditure of £0.6m in month• A Cash position of £1.0m at month end

He explained that the £2.2m support funding from NWL Clinical Commissioning Groups (CCGs) would now not be received, although the Trust had not, as yet, formally conceded the position.

He told the Board that the Trust had to submit a Board Assurance Statement to NHSI as part of a protocol for forecast change and that he could confirm the Board had been made of all material issues, and he would be asking to Chair, Chair of Audit and the CEO to sign off the statement on behalf of the Board.

The Chair confirmed that the Finance and Performance Committee continued to scrutinise the monthly financial position and that over the last three months there was now consistency between monthly projections and actuals which was a positive sign.


18 NHSI Improvement Undertakings: progress update and assurance

J Smyth introduced a report for monitoring asking the Board to note progress and assurance provided in the report to be presented to NHSI on Undertakings relating to A&E, finance and governance as agreed in June 2018.

He pointed out that following the departure of Hunter Healthcare the A&E

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action plan being reported to NHSI had been revised.

The Chair added that discussions on A&E performance had mostly already been covered under the Winter Planning and Integrated Performance items on the agenda.


19 Thematic Care Quality Commission Action Plan

J Walker introduced a report providing assurance control monitoring, specifically relating to areas of improvement arising from the requirement notice received from the CQC inspection.

She reported that; • 17 of the 18 actions relating to the CQC Requirement Notice have been

met;• 13 of the 14 ‘must do’ and 64 of the 70 ‘should do’ actions outlined in

the inspection report had been completed.• The Themed Clinical Fridays’ process had been developed to provide a

consistent approach to continuous quality improvement which washaving a positive impact on staff behaviours and providing evidence ofimproved standards and compliance.

L Paice gave assurance to the Board that the plan had been reviewed in detail at its January meeting.

A Khakoo said that whilst the plan was to be welcomed there needed to be a focus on clinical engagement. J Walker confirmed that as part of the Trust’s quality undertakings to NHSI this would be considered at the March meeting.

L Paice said that she had picked up at Kingston NHS Foundation Trust that staff had open access to physiotherapy services and asked the Executive to consider whether this might be feasible at Hillingdon.


T Roberts

20 Corporate Risk Register

J Walker introduced a report for monitoring asking the Board to review and challenge the extreme level Corporate Risks and progression of risk mitigation as well as note the Audit and Risk Committee had reviewed all high and extreme risks at its meeting on 14th January agreeing to escalate all unassured risks to Board.

S Tedford confirmed that the Executive did intend to review all unassured

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risks and would report back on progress to the March Board.


S Tedford

21 Board Assurance Framework (BAF)

J Walker introduced a report for monitoring providing the Board with an assessment of the extent to which the Trust was managing the key risks to achieving its strategic objectives.

S Tedford asked the Board to note that currently the Good Governance Institute (GGI) was reviewing the BAF for the Trust in accordance with good governance principles.


22 Condition of the Estate update

J Philpot introduced a presentation for discussion updating the Board on; • Backlog liability• Investment• Life expired plant and hire equipment• Failed and failing pipework• Risks• Impact on patient experience

L Paice asked whether there was assurance that the trust was not putting patients at risk in terms of legionella. J Walker said that the Trust was following very strictly the instructions of the authorised engineer in this matter and as a consequence it was reasonable to say the Trust did not have to shut down any services as a result.

S Dhillon sought clarification on what level of capital would need to be invested over the next 5 to 6 years just to keep the site safe. J Philpot said that one of the reasons for carrying out the risk assessment on the estate jointly with NHSI was to ensure there was agreement on precisely what that level of capital investment would need to be.

The Chair said the Board looked forward to receiving the jointly agreed estates risk assessment.


23 Learning from Deaths


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24 Annual Report on Safe Working Hours- Doctors in Training - November 2017-October 2018 A Khakoo introduced a report for monitoring which provided assurances to the Board on the progress being made to ensure that doctors’ working hours were safe. He added that, henceforth, the Board would receive an Annual report in November 2019 and a half yearly update in July. The Chair asked whether A Khakoo believed there would be a more representative Junior Doctor Group after April 2019. A Khakoo said that under the leadership of S Barnes, Director of Medical Education, this would be the case. S Dhillon suggested that digital solutions should be maximised to increase participation on the group. The Report was noted

25 Safer Nurse Staffing - update The Report was noted

26 Safer Medical Staffing Update A Khakoo introduced a report for monitoring which updated on; • Strengthening risk management and governance • Providing safe cover over seven days: new roles and ways of working • Current medical staffing gaps and actions • Physician Associate expansion • Next steps The Chair said he believed this was a good report in that it was analytical and also provided solutions. L Burke said that the workforce issues reflected many of the same themes occurring in nursing in terms of enabling innovative rather than relying upon traditional people solutions. The Report was noted

Information 27 Report back from Committees – Finance & Transformation, Quality

and Safety, Audit & Risk, Charitable Funds, Nominations, Remuneration. The Report was noted

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28 Minutes of Committee Meetings


29 Use of Trust Seal


Questions from the Public 30 Questions from the Public

Question: What sort of skills training do healthcare assistants receive? Response: They receive bespoke training including having to obtain a care certificate as well as a more generic training.

Question: Why are there medical service shortages? Response: Recruiting permanent doctors is a challenge nationally for the NHS.

Question: Why has this Board not discussed the closure of Michael Sobell house? Response: Hillingdon Hospitals is the landlord. It is the role of the East and North Herts Trust Board to debate any service aspects.

Question: How is it possible the Board has today decided to appoint a Deputy CEO but that person has already been appointed? Response: An interim appointment had been made and the Board has now agreed to make a permanent appointment.

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Trust Board Part I Action Log

March 2019

Action No.

Meeting Date

Item Action Lead Due Date Comments

258 Nov 18 Patient Story Topaz Team to share learning with other Teams on co-ordinating discharges with Local Authority

JW February 19 (to Board)

Discussed with Topaz Team and Director of Midwifery. Meeting organised for Topaz Team to meet with Trust Discharge Team and Head of Site/ADoN to discuss their working with LA colleagues and the learning - completed.

262 Nov 18 Performance October 2018

COO to provide verbal update at January Board on the following in relation to A&E performance; operational grip and control delay codes and usage, daily discharges

JS January 19 (to Board)

This was covered off in the Performance Report at the January meeting - completed

264 Nov 18 Performance October 2018

T Roberts said his January 19 performance report would include a summary of service “hotspots” in relation to vacancy rates, staff turnover and sickness

TR January 19 (to Board)

This was covered off in the Performance Report at the January meeting - completed

267 Nov 18 Sepsis Policy Ensure Sepsis screening and time to treatment are included in the March Board KPIs

CC March19 (to Board)

Sepsis screening via HObs (paper in ED) has been rolled out. We have previously provided performance metrics based on snapshot audit of notes. With the electronic system, the intention is that we will have a more comprehensive report. On pulling the initial data, data integrity issues were identified, which are being resolved. The plan is for a draft report for April Deteriorating Patient Group, then aim for QSC/Trust Board in May - completed

272 Jan 19 Patient Story Confirm back to Board who is responsible for keeping patients informed for elective procedures given patient was given different reasons for having too rebook – i.e. notes unavailable / then said booked

DSp March 19 (to Board)

The admission team are responsible for keeping patients informed. This patient was a trauma patient that was transferred to MVH for treatment. The teams will ensure there is better handover arrangements in the future to prevent confusing

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for different day messages being sent to patients - completed

273 Jan 19 Patient Experience & Engagement Strategy

Ensure Strategy is presented to EDI Committee for comment

TR May 19 (to Board)

Not yet due

274 Jan 19 Patient Experience & Engagement Strategy

Represent progress report on Strategy in January 2020

MS January 20 (to Board)

Noted for forward plan - completed

275 Jan 19 Brexit Report Establish percentage of potential EU affected citizens in Trust employment pipeline (doctors, nurses, HCAs etc)

TR March 19 (to Board)

An update will be presented at the March Board under the EU Exit item

276 Jan 19 Brexit Report Report back on EU procurement pipeline for critical plant and risks


An update will be presented at the March Board under the EU Exit item

277 Jan 19 Brexit Report Write to all potentially affected EU permanent and bank staff an individual letter of support from the Board


Completed

278 Jan 19 Brexit Report Provide verbal update to February Board Seminar. Provide formal update report to March meeting.


On March Agenda - completed

279 Jan 19 Performance Report Include diagnostic and ultrasound KPIs in future Performance Reports


Completed

280 Jan 19 Performance Report Include more specific detail on Fractured Necks in future Performance Reports


Not completed for March – will be included from May 19

281 Jan 19 Performance Report Review performance issues on Flemming Ward and report back

JW / DSp

May 19 (to Board)

Not yet due

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282 Jan 19 CQC Report Consider whether open access to physiotherapy services can be considered for all staff as opposed to only through Occupational Health (Kingston model)

TR May 19 (to Board)

Not yet due

283 Jan 19 Corporate Risk Register

Return a report to Board on unassured risks

JW March 19 (to Board)

Update on position with unassured risks included in the CEO report. CEO commissioning overhaul of the risk register with external experts - completed

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Board of Directors: 27 March 2019 Agenda Item: 8

Title CEO Report

Report author Sarah Tedford, CEO

Report sponsor Sarah Tedford, CEO

Status of Report Public Private Internal

☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information

☐ ☐ ☒

Summary Provides update on external strategic development and items of interest within the Trust

Recommendations The Board of Directors is invited to note the update Links to Corporate Objectives Meeting compliance and reporting requirements.

Impact

Quality and Safety None specific to this report

Legal None specific to this report

Financial None specific to this report

Human Resources None specific to this report

Equality and Diversity None specific to this report Engagement and communication None specific to this report

22

Chief Executive’s Report

This paper provides the Board with an overview of matters to bring to the Boards attention which are not covered elsewhere on the agenda for this meeting. The Board is asked to note the content of this report.

Internal Matters

Executive Appointments I am delighted to confirm that Jason Seez has been appointed as Deputy CEO and Director of Strategy. Jason brings a wealth of board level experience to the Trust.

David Stonehouse has been with us since February as Interim Director of Finance and Jenny Greenshields has been appointed as our permanent Director of Finance and will start at the trust on April 1st. It has been a pleasure to welcome David and I would like to express my sincere thanks for his leadership of our finance team and management of our challenging financial position.

Dr Dean Spencer is our Interim Chief Operating officer and patients and staff are already benefiting from his focus on both improving how quickly we are able to treat patients coming to us as emergencies and those needing routine care. Dean joined us from NHS Improvement.

Tahir Ahmed will join the trust at the end of May as our Director of Estates, a vital and important role as we seek to prepare an immediate plan for managing our current estate risks, as well as developing a short, medium and long term plan for our future estate.

Sarah Pinch has been providing the trust with communications and reputation management advice and leadership and we are grateful for her assistance.

A&E Attendance The Trust continues to underperform on the waiting standard for patients attending the A&E department where it is expected that 95% of patients are treated within 4 hours. In February, 81% of patients were treated within 4 hours. Additional investment to expand the department with larger assessment areas and extra services delivered in the community have only made marginal improvements over the winter period. The Care Connections Teams in the community are helping keep patients from coming into hospital and, as a consequence, our admissions are reducing. During April the Trust and Social Care community services will be putting together an improvement plan to prepare for the coming year, including next winter. Improvement in the emergency pathway remains a key objective for the coming year.

Our People The national NHS staff survey results for Hillingdon Hospitals makes for concerning reading and we are implementing a detailed and focus action plan. Ensuring our people are engaged and involved in the future of our trust is vital to delivering good patient care.

23

In addition to the national staff survey we have undertaken an additional piece of research looking at how we communicate and engage with our staff, the findings from this will be triangulated with the national staff survey and other insights (including medical engagement information) to develop our communications and engagement strategy which will come to the next Trust Board Meeting. This is a vital piece of work and one I commend to the board.

Corporate Risk Register review The Audit and Risk Committee (ARC) reviewed all the high and extreme risks on the corporate risk register at its meeting on 14th January 2019. The Committee agreed there should be an escalation of all high and extreme corporate risks that were not assured in relation to lack of assurance of mitigating actions to adequately reduce risk. In response to this escalation the Executive Management Team agreed to undertake a review of all corporate risks on the risk register that are currently not assured.

Following a detailed review of the corporate risk register by the Executive Team it has been agreed that a complete overhaul of the register is required to ensure risks are clearly captured and articulated, that controls and gaps are well understood and provide focus to ensure appropriate Board discussion on risk tolerance and effective mitigating actions. This is in line with the Deloitte LLP review recommendations for the Trust to review its risk management processes and policy as part of a strengthened governance approach.

This is recognised as a large, important and urgent piece of work which will need dedicated resource to progress and ensure the review is thorough and fit for purpose. A revised register will be presented to the Audit and Risk Committee and Trust Board once this review has taken place.

It is to be noted that since the ARC meeting in January four of the eleven risks which were not assured are now assured following a review by the relevant risk/Executive lead. Of the remaining risks that are not assured there has been no change to the residual risk grading. Risk 751 – Gaps on junior doctor rotas is a new and not assured risk.

External Matters

Strategic Outline Case (SOC) The trust remains committed to leading on the development of a Strategic Outline Case (SOC) for the Brunel Academic Health Campus. We are working with our partners in the local health economy to document strategic proposals that will deliver the new proposed integrated care model, in line with the requirements of the new care model and to improve the quality our hospital estate. The partner agencies are finalising the programme budget for the development of the SOC and the trust has recently committed to spending £250k on leading the development of the SOC in 2019/20. The next stage will be establishing a programme team with the necessary capacity and capability, supported by robust governance systems.

24

Things to celebrate In December colleagues involved in caring for major trauma patients in all specialities received the excellent news that the North West London Trauma Network was ranked first, nationally. Also in December, Abbas Khakoo, our then Medical Director and Jacqueline Walker, our Director of Nursing received Honorary Professorships from Brunel University acknowledging their work.

The nuclear medicine SPECT CT team was recognised by the British Nuclear Medicine Society, as one of three finalists alongside King’s College and Southampton University Hospital for the firsts BNMS Innovative Team of the Year Award 2019.

One of the highlights since the last board meeting was seeing so many hospital supporters, running and supporting the Hillingdon Hospital 10k and half marathon. So many people turned as supported, runners and physios. This year we had 37 runners, last year we had four. And it would have been more, but some runners (as is often the case) had a few injuries in training coming up to the event. I would like the board to express its sincere thanks to David and Shirley from the hospital charity and all of their volunteers and supporters. I know Shirley put in a huge amount of work helping to organise the event, support all our runners and fundraisers. Money is still coming in but the current total is £8,000, we hope to get to £10,000.

The HR team have been shortlisted for two awards by the Healthcare People Management Association, namely The Capsticks Award for Innovation in HR: Collaborative international recruitment for physicians’ associates; and The Social Partnership Forum Award for partnership working between employers and trade unions: Collaborative people strategy development. And our Beds Maintenance and Facilities Catering teams, are both shortlisted in the Team of the Year category in the HEFMA (Health Estates and Facilities Management Association) Awards 2019.

25


Title Operational Plan, 2019/20

Report author James Ross, Director of Transformation and Strategy, and Gordon MacMillan, Assistant Director of Strategy and Business Development

Report sponsor Jason Seez, Deputy CEO


☒ ☐ ☐

Purpose of Report For Decision

For Assurance

For Information

☒ ☐ ☐

Summary

This paper contains the final version of the Operational Plan FY19/20, which incorporates comments from the Trust’s Governors and Non-executive Directors. This is contained within the appendices pack although attached to this report at the request of the Director of Finance is a summary of financial planning assumptions that support the Operational Plan for 2019-20.

Recommendations

The Board is invited to approve the Operational Plan FY19/20 for submission to NHSI on or before 4th April. This is subject to final editions, made by the Executive, which align the submitted version to the detail of the contract signed with Hillingdon CCG. These include agreed activity trajectories, together with finalised plans for workforce and finance.

Links to Corporate Objectives The Operational Plan supports all strategic priorities.

Impact

Quality and Safety Legal

Financial As detailed in the Operational Plan Human Resources

Equality and Diversity

There are no direct equality and diversity impacts from this plan. There will be a number of business cases arising from the annual planning process, some of which are signposted within this overall plan. These will be brought forward in due course, and each will be subject to the full equality and diversity review and assessment process

Engagement and Communication

Previous consideration at Board or Committees: 27 February: Board Seminar to review draft plan and agree strategic priorities FY19/20 6 March: TME review of draft plan submission 7 – 11 March: Governors’ consultation 14 March Non-Executive Directors’ page-turn with lead executive authors 20 March Consideration at Finance and Performance Committee

26

2019/20 Financial Plan – Update:

March 2019

27

Introduction

The Trust has been refining the plan for 2019/20 in light of the guidance and the control total letter, this report gives an update on progress so far.

• The Draft Plan submission took place on 12th February and included the Operational PlanDocument, as well as the financial plans, workforce plans and activity plans.

• Since February, the forecast outturn has deteriorated, impacting on the baseline starting point for theplan

• Cost pressures have been refined with divisional teams on a bottom up basis.

• Contract Negotiations are nearing completion, but there remains discussion over Growth/QIPP anda tolerance of 1% in either direction on 18-19 outturn, plus a marginal rate of 70% for activity aboveor below this.

• In order to achieve our Control Total we have to deliver a further £3.7m of CIP.

• The worked up CIP proposals currently being finalised with the support of Kingsgate have a highincome component, predicated on expected growth in demand. They are being refreshed on a ‘cashout’ basis to reflect CCG QIPP initiatives holding demand flat.

28

Draft Financial Plan 2019/20

Adj Donated -185Plan on a Control Total basis 6,323

Control Total 2,668

Variance from CT 3,655

The remainder of the pack details;

• Key movements on the bridge between2018/19 to 2019/20

• Highlights key plan changes since theFebruary iteration

• Service developments that cannot beaccommodated within the plan

AnnualPlan

£000sOperating IncomeNHS Clinical Income 220,400Non-NHS Clinical Income 3,362Other Operating Income 26,620

Total Operating Income 250,382Operating ExpensesEmployee Expenses (181,305)Drugs (18,254)Clinical Supplies and Services (25,898)Other Operating Expenses (35,761)

Total Operating Expenses (261,218)

EBITDA (10,836)

Depreciation (9,475)Interest Income/Expense (3,512)PDC Dividend Expense (3,760)

Surplus(Deficit) before Exceptionals (27,583)

Provider Sustainability Funding 4,687Financial Recovery Fund 14,807MRET 1,581Gains/(Loss) on Investment Properties 0Profit/(Loss) on the Disposal of Assets 0

Surplus(Deficit) after Exceptionals (6,508)

29

Draft Financial Plan 2019/20

5ANForecast Out-turn

Non-Recurrent

in 1819

Pathology Contract Transfer FYEs

New Cost Pressures

Service Developments in

1920 CNST

NHS Supply Chain

First Cut Plan CIPs Inflation

Provider Sustainability Fund

Financial Recovery

Fund MRETActivity Growth

CCG QIPP

Grand Total

Feb Plan

Movement

NHS CLINICAL INCOME -221,568 447 7,791 -830 -2,401 -3,838 -6,131 6,131 -220,400 -222,423 2,023NON-NHS CLINICAL INCOME -3,296 -66 -3,362 -3,360 -2OTHER OPERATING INCOME -27,965 1,463 788 -185 21 -400 -342 -4,687 -14,807 -1,581 -47,695 -48,235 540PAY 177,441 -557 2,159 427 467 -4,651 6,018 181,305 181,563 -258DRUGS 18,646 -4 -500 112 18,254 18,176 78SUPPLIES & SERVICES - CLINICAL 32,834 92 -8,579 1 1,873 14 -459 -710 449 382 25,898 24,465 1,433OTHER NON-PAY 34,229 -1,768 307 1,058 69 2,110 -92 -910 759 35,761 36,415 -654DEPRECIATION 9,212 200 63 9,475 9,300 175INTEREST EXPENSE 3,240 190 129 3,559 3,331 229INTEREST RECEIVABLE -47 -47 -54 7DIVIDENDS PAYABLE 3,749 11 3,760 3,676 84INVESTMENT PROPERTY REVAL -2,000 2,000 0 0Grand Total 24,474 1,677 0 2,473 3,708 625 2,110 -555 -8,000 4,529 -8,525 -14,807 -1,581 -5,749 6,131 6,508 2,853 3,655

Adj Donated -185Plan on a Control Total basis 6,323

Control Total 2,668

Variance from CT 3,655

Recurrent elements of Month 10 - 12 forecast expenditure movements are captured within the cost pressure line

30

Movement from February plan

Pay New Management Structure £195k (£429k total)

Reworked inflation numbers

Removal of Renal Nurse & Diabetic Consultant which would be funded from growth

Non Pay Change to Forecast Outturn £331k

£250k Brunel S.O.C.

£473k Consultancy

£116k Ealing Hospital Maternity facility rental

Less: Removal of Contingency £1,700k

Increase in CNST Maternity Discount assumed £249k

NHS Supply Chain pricing change £92k

Increase in capital assets due to bid £175k

Income

NHS Clinical Income

Decrease in Forecast Outturn £1380k

Income CIP movement £306k

Non recurrent movement £379k

Other Operating Income: Change to Forecast Outturn £415k

Clinical Supplies & Services

Change to Forecast Outturn £175k

Pathology £1,393k

Less NHS Supply Chain pricing change £459k

31

Pressures included in the plan

• Brunel Strategic Outline Case (SOC) development £250k

• Consultancy/contingency for new programmes £510k

• THH share of potential NWL Pathology deficit in 2019/20 £1m

32

Pressures not included in the plan (after removal of contingency) and next steps to address

• Backfill for Safeguarding Training – £500k– Nursing could be included in current ST&M training potential for impact in Q4

• Therapies 7 day service - £500k– Division/Kingsgate to develop business case showing potential benefits to LOS and bed closure

programme• Maternity Continuity of Care £250k

– The CCG is not willing to fund the increased ratios, therefore this cannot be a penalty in 2019/20 viathe SDIP. Division to develop a business case that gives a trajectory to when we would be compliant,Trust to show that it is using ‘best endeavours’ to comply.

• Segregate Obstetrics & Gynaecology rotas - £300k– As above: Division to develop a business case that gives a trajectory to when we would be compliant,

Trust to show that it is using ‘best endeavours’ to comply.• Colorectal Business Case - £153k

– Discuss a local price for the nurse led activity with CCG – early indications show this would beacceptable.

OD Programme (£300k) assumed to be funded externally

33

How to address the gap

• Increase CIP requirement to £11.7m alongside the following actions:

• Urgently re-appraise existing CIP schemes for over-reliance on incomeschemes and convert to ‘cash out’

• Seek to identify marginal rate activity that is required for NWL providers to bepaid at full cost

• Review any discretionary costs that have been included within the plan

• Given the high risk in the plan the profile for delivery will be carefully profiled inthe context of the expected month 12 exit run-rate.

34

2019/20 CIP Planning Kingsgate Summary

Income (Patient care activities) - This is the net contribution after cost of deliveryIncome (Patient care activities) - All high risk due to NWL proposed tolerance of 1%£300k still to be identified

Currently being refreshed

35

Contract Negotiations

• Contract negotiations have progressed and stage 5 offer for NWL is circa£183.8m

• Trust difference of circa £0.5m on forecast outturn assumptions for2018/19

• Currently Growth offered is equal to QIPP of £7.2m• Trust view that growth is lower at £6m, so have adjusted QIPP accordingly• NWL STP are looking for a contract tolerance of 1% across all activity with

a 70% marginal rate thereafter. Acceptance that Hillingdon has moredeveloped QIPP than other CCGs so would be prepared to allow localagreement on proposals, however a tolerance on elective work wouldimpact any activity above contract levels

• Payment for RTT backlog would be separate to this arrangement –however Trust backlog is not high compared to others

• Heads of Terms to be signed by Thursday 21st March

36

Profiled Runrate

• The draft Profile Base Case is presented as per our plan and is subject to minor refinement of phasings with divisions.

• Given the level of risk within the plan, there is no upside case.

• A further downside scenario is presented and reflects • £4m of identified CIP does not deliver • The £3.7m gap cannot be identified • £1m of winter pressures are incurred in the latter half of the year.

• The other key point to highlight is failure to deliver Quarterly profile to plan triggers

loss of PSF £4,687k and FRF £14,807k, if not recovered by year end.

37

Profiling Informed by Run-Rate – Base Case Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total

NHS CLINICAL INCOME -18,949 -17,034 -18,755 -17,471 -18,880 -18,373 -18,000 -19,544 -18,361 -17,918 -18,836 -17,557 -18,839 -219,570NON-NHS CLINICAL INCOME -264 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -3,362OTHER OPERATING INCOME -2,416 -3,291 -3,291 -3,293 -3,616 -3,616 -3,617 -4,267 -4,267 -4,265 -4,591 -4,591 -4,593 -47,295PAY 15,368 15,494 15,494 15,494 15,494 15,491 15,491 15,499 15,499 15,500 15,500 15,500 15,500 185,956DRUGS 1,585 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 18,754SUPPLIES & SERVICES - CLINICAL 2,318 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 26,605OTHER NON-PAY 2,927 3,098 3,098 3,098 3,024 3,024 3,024 3,025 3,025 3,025 3,025 3,025 3,025 36,517DEPRECIATION 792 790 790 790 790 790 790 790 790 790 790 790 790 9,475INTEREST EXPENSE 290 297 297 297 297 297 297 297 297 297 297 297 297 3,559INTEREST RECEIVABLE -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -47DIVIDENDS PAYABLE 308 313 313 313 313 313 313 313 313 313 313 313 313 3,760REVALUATION OF INVESTMENT PROPERTY 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1,956 3,163 1,441 2,724 917 1,421 1,793 -391 791 1,238 -6 1,272 -12 14,352Month 12 adjusted for inflation, NHS SC & Pathology

CIPs (including Gap)Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total

NHS CLINICAL INCOME -34 -34 -34 -57 -57 -57 -136 -136 -125 -159 -148 147 -830NON-NHS CLINICAL INCOME 0OTHER OPERATING INCOME -12 -12 -12 -20 -20 -20 -48 -48 -44 -56 -52 -56 -400PAY -130 -130 -130 -217 -217 -217 -521 -521 -478 -608 -565 -914 -4,651DRUGS -15 -15 -15 -25 -25 -25 -60 -60 -55 -70 -65 -70 -500SUPPLIES & SERVICES - CLINICAL -21 -21 -21 -35 -35 -35 -85 -85 -78 -99 -92 -99 -710OTHER NON-PAY -27 -27 -27 -45 -45 -45 -109 -109 -100 -127 -118 -127 -910DEPRECIATION 0INTEREST EXPENSE 0INTEREST RECEIVABLE 0DIVIDENDS PAYABLE 0UNIDENTIFIED GAP -617 -617 -617 -617 -617 -617 -3,700

0 -240 -240 -240 -400 -400 -400 -1,577 -1,577 -1,497 -1,737 -1,657 -1,737 -11,700

MONTH 12 COMPARED TO PLAN AFTER CIPsMonth 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total

NHS CLINICAL INCOME -18,949 -17,068 -18,790 -17,505 -18,937 -18,430 -18,057 -19,680 -18,497 -18,043 -18,995 -17,705 -18,693 -220,400NON-NHS CLINICAL INCOME -264 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -3,362OTHER OPERATING INCOME -2,416 -3,303 -3,303 -3,305 -3,636 -3,636 -3,637 -4,315 -4,315 -4,309 -4,647 -4,643 -4,649 -47,695PAY 15,368 15,364 15,364 15,364 15,277 15,274 15,274 14,978 14,978 15,022 14,892 14,935 14,586 181,305DRUGS 1,585 1,548 1,548 1,548 1,538 1,538 1,538 1,503 1,503 1,508 1,493 1,498 1,493 18,254SUPPLIES & SERVICES - CLINICAL 2,318 2,196 2,196 2,196 2,182 2,182 2,182 2,132 2,132 2,139 2,118 2,125 2,118 25,895OTHER NON-PAY 2,927 3,071 3,071 3,071 2,978 2,978 2,978 2,916 2,916 2,925 2,898 2,907 2,898 35,608DEPRECIATION 792 790 790 790 790 790 790 790 790 790 790 790 790 9,475INTEREST EXPENSE 290 297 297 297 297 297 297 297 297 297 297 297 297 3,559INTEREST RECEIVABLE -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -47DIVIDENDS PAYABLE 308 313 313 313 313 313 313 313 313 313 313 313 313 3,760REVALUATION OF INVESTMENT PROPERTY 0 0 0 0 0 0 0 -617 -617 -617 -617 -617 -617 -3,700

1,956 2,923 1,201 2,484 517 1,021 1,393 -1,968 -785 -259 -1,743 -384 -1,749 2,65238

Profiling Informed by Run-Rate – Downside Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9Month 10Month 11Month 12 Total

NHS CLINICAL INCOME -18,949 -17,034 -18,755 -17,471 -18,880 -18,373 -18,000 -19,544 -18,361 -17,918 -18,836 -17,557 -18,839 -219,570NON-NHS CLINICAL INCOME -264 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -3,362OTHER OPERATING INCOME -2,416 -3,291 -3,291 -3,293 -3,616 -3,616 -3,617 -4,267 -4,267 -4,265 -4,591 -4,591 -4,593 -47,295PAY (plus Winter Pressure £1m) 15,368 15,494 15,494 15,494 15,494 15,491 15,491 15,599 15,599 15,600 15,733 15,733 15,734 186,956DRUGS 1,585 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 1,563 18,754SUPPLIES & SERVICES - CLINICAL 2,318 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 2,217 26,605OTHER NON-PAY 2,927 3,098 3,098 3,098 3,024 3,024 3,024 3,025 3,025 3,025 3,025 3,025 3,025 36,517DEPRECIATION 792 790 790 790 790 790 790 790 790 790 790 790 790 9,475INTEREST EXPENSE 290 297 297 297 297 297 297 297 297 297 297 297 297 3,559INTEREST RECEIVABLE -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -47DIVIDENDS PAYABLE 308 313 313 313 313 313 313 313 313 313 313 313 313 3,760REVALUATION OF INVESTMENT PROPERTY 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1,956 3,163 1,441 2,724 917 1,421 1,793 -291 891 1,338 227 1,505 222 15,352Month 12 adjusted for inflation, NHS SC & Pathology

CIPs (including Gap)Loss of £4m CIP and gap not closed Month 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9Month 10Month 11Month 12 TotalNHS CLINICAL INCOME -17 -17 -17 -28 -28 -28 -68 -68 -62 -80 -74 73 -415NON-NHS CLINICAL INCOME 0 0 0 0 0 0 0 0 0 0 0 0 0OTHER OPERATING INCOME -6 -6 -6 -10 -10 -10 -24 -24 -22 -28 -26 -28 -200PAY -65 -65 -65 -109 -109 -109 -261 -261 -239 -304 -282 -457 -2,326DRUGS -8 -8 -8 -13 -13 -13 -30 -30 -28 -35 -33 -35 -250SUPPLIES & SERVICES - CLINICAL -11 -11 -11 -18 -18 -18 -43 -43 -39 -50 -46 -50 -355OTHER NON-PAY -14 -14 -14 -23 -23 -23 -55 -55 -50 -64 -59 -64 -455DEPRECIATION 0INTEREST EXPENSE 0INTEREST RECEIVABLE 0DIVIDENDS PAYABLE 0UNIDENTIFIED GAP

0 -120 -120 -120 -200 -200 -200 -480 -480 -440 -560 -520 -560 -4,000

MONTH 12 COMPARED TO PLAN AFTER CIPsMonth 12 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9Month 10Month 11Month 12 Total

NHS CLINICAL INCOME -18,949 -17,051 -18,772 -17,488 -18,909 -18,402 -18,029 -19,612 -18,429 -17,980 -18,915 -17,631 -18,766 -219,985NON-NHS CLINICAL INCOME -264 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -280 -3,362OTHER OPERATING INCOME -2,416 -3,297 -3,297 -3,299 -3,626 -3,626 -3,627 -4,291 -4,291 -4,287 -4,619 -4,617 -4,621 -47,495PAY 15,368 15,429 15,429 15,429 15,385 15,382 15,382 15,338 15,338 15,361 15,429 15,451 15,277 184,630DRUGS 1,585 1,555 1,555 1,555 1,550 1,550 1,550 1,533 1,533 1,535 1,528 1,530 1,528 18,504SUPPLIES & SERVICES - CLINICAL 2,318 2,206 2,206 2,206 2,199 2,199 2,199 2,174 2,174 2,178 2,167 2,171 2,167 26,250OTHER NON-PAY 2,927 3,085 3,085 3,085 3,001 3,001 3,001 2,971 2,971 2,975 2,961 2,966 2,961 36,062DEPRECIATION 792 790 790 790 790 790 790 790 790 790 790 790 790 9,475INTEREST EXPENSE 290 297 297 297 297 297 297 297 297 297 297 297 297 3,559INTEREST RECEIVABLE -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -47DIVIDENDS PAYABLE 308 313 313 313 313 313 313 313 313 313 313 313 313 3,760REVALUATION OF INVESTMENT PROPERTY 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1,956 3,043 1,321 2,604 717 1,221 1,593 -771 411 898 -333 985 -338 11,352

39

Capital

• The updated Capital Plan Allocations are included here with the internal funding from Depreciation.

• Equipment is very tight as after the Mammography and Interventional Scanner only £200k remains for other equipment

• IT have prioritised their requirements by scheme, but have had to exclude some essential software upgrades

• The Trust has refreshed the Emergency Capital bid which is now phased as £8.2m in 2019/20 and £1.8m in 2020/21. Afurther bid will also be prepared for £6m of equipment.

CategoryOriginal

allocation

A & E Phase 4 (delayed

from

Brought forward from

2018/19

Radiology Allocation

PDC 2019/20

Requests from

Departments Difference£000 £000 £000 £000 £000 £000 £001

Backlog Maintenance 3,153 1,000- 400 300- 2,253 18,294 16,041 A&E Refurbishment 500 2,030 2,530 2,530 - ITC 1,070 400- 670 3,446 2,776 New Medical Equipment 1,300 185 1,485 4,596 3,111 Developments - - - Capital Salaries 410 410 450 40 Contingency 1,030 1,030- - - Current Finance Lease payments Estimate 1,190 1,190 1,190 - LIFT Capital Element 250 250 250 - Capital Repayments of Loans 390 390 390 -

Total Internal funding from Depreciation 9,293 0.00 0.00 -115 9,178 31,146 21,968

Backlog Maintenence funded from Capital Bid 8,185 8,185 8185 -

Total Capital from Internal and External Source 17,478 - - 115- 17,363 39,331 21,968

40

Cash

• The Trust will be able to draw down £2.6m of deficit support in 2019/20.• This has been applied for in April and approved. The Trust can also apply

for PSF and FRF cash support in advance of receiving the cash, whichwould be £19.5m for the full year, but will repay when it is receivedquarterly.

• Not withstanding this, based on the first cut plan submission the Trust willneed to apply for a working capital facility of £5m as short term support ifthe level of creditors is not to become unsustainable.

41

Key next Steps

• The plan is high risk in the context of the level of CIP requirement, which needs tobe driven on a ‘cash out’ basis.

• Whilst assumptions around ramp up are prudent we will need to ensure we haveappropriate support to deliver transformation with current internal and externalcapability in place

• Kingsgate will be retained to maintain pace around delivery and to work up newinitiatives

• Working closely with our CCG to ensure QIPPs manage growth pressureseffectively will be vital in mitigating other cost base pressures

42


Title Hillingdon Health and Care Partners – Integrated Business Case

Report author Keith Spencer, Director of Integration and Delivery, Hillingdon Health and Care Partners

Report sponsor Jason Seez, Deputy CEO


☒ ☐ ☐


For Assurance

For Information

☒ ☐ ☐

Summary

Formed April 2017 as an Accountable Care Partnership, HHCP delivers integrated care services. This Integrated Business Case (contained within the Appendices pack) seeks

to prevent unnecessary, unplanned hospital admissions and ED attendances by 15% of the population who are at greatest risk.

Recommendations

The Board of Directors is invited to approve the Integrated Business Case as recommended by the Finance and Performance Committee and provide for a maximum potential downside risk of £481,000 in financial year 2019/20. The Committee recommends also that approval is made subject to the proviso that the Trust is not subject to any double jeopardy arising from the application of the risk and gain share proposed within this IBC and any similar arrangement arising out of current NWL contract discussions.

Links to Corporate Objectives A clinically led service strategy that responds to the needs of patients and other health and social care partners.

Impact

Quality and Safety An improved service that responds to the needs of patients and other health and social care partners.

Legal

Financial

Potential gains of £481,000 in Year 1 arising from reduced non-elective admissions to our hospitals. This is mirrored by a downside risk of the same quantum if community-based interventions prove ineffective at

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managing demand. Gains in Year 3 rise to £1.6m with no comparable increase in downside risk.

Human Resources To enable more agile working and improved productivity (c20%).


A full Equality Impact Assessment has been undertaken and is available on request. It is expected that there will be a positive overall equality impact since the increase in scope outlined in the IBC encompasses a broader age range than the original scope of the Care Connection Teams. The new model of care will actively improve equality of opportunity – including for a number of ‘protected’ groups as outlined in the EIA, which also provides examples of how specific equality gaps have been identified.

Engagement and communication

To communicate progressive and innovative change to the local population.

Previous consideration at Board or Committees:

27 February 2019 Board Seminar: considered within the Operational Planning session;

6 March 2019 TME: internal discussion to clarify operational implications;

20 March 2019 F&PC: considered and recommended for approval by Board of Directors subject to the proviso set out above.

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Hillingdon Health and Care Partners – Integrated Business Case

Background to Hillingdon Health and Care Providers

Formed April 2017 as an Accountable Care Partnership, HHCP delivers integrated care services. It is not a constituted body, but represents a collaboration of statutory and third sector providers which operate within the framework of an alliance agreement. An overview is appended to this briefing (The Evolution of Integrated Place-Based Commissioning in Hillingdon).

The organisation is an outcome of The Sustainability & Transformation Plan for North West London (2016), which stated an ambition to ‘integrate third sector organisations within Accountable Care Partnerships with single points of access and geographically-based consortiums’ (Delivery Area 2). HHCP have adopted an outcomes-focussed approach, transforming discrete pathways in turn. MSK services provided the initial focus (2018); ophthalmology and planned care are the priorities for 2019.

HHCP Integrated Business Case

Hillingdon has higher non-elective (NEL) admission rates in several areas when compared to England and peer group average. 3% of the local population (6,417 people) account for 50% of all emergency hospital admissions, 21% of which could be avoided because they are sensitive to ambulatory care.

This business case seeks to prevent unnecessary, unplanned hospital admissions and ED attendances by 15% of the population who are at greatest risk. This cohort includes patients in care homes, patients at risk of falls, patients in the final year of life and frequent ED attenders. Proposed interventions are evidence-based and fully compliant with the NHS Long Term Plan.

The proposal integrates health and care through a 24/7 population-based model. Built from General Practice in eight neighbourhoods, with wrapped around community and mental health services the model provides high quality care through pro-active and preventative action to stop people becoming unwell. Three core services will be provided by multi-disciplinary teams in the home and community:

1. Integrated neighbourhood teams working with GPs to manage local population health2. Active case management preventing hospital admissions by 15% of population at greatest risk3. Time limited, integrated, health and social care services to minimise time spent in hospital.

The third component of the business case is of greatest relevance to the Trust. It comprises a reformed intermediate tier of services to support faster recovery from illness. This includes preventing unnecessary stays in hospital and premature admission to long-term residential care, as well as facilitating timely discharge from hospital and maximising independent living.

Activity Headlines FY2019-20

If the interventions funded by this business case were not delivered, A&E activity would grow by 4.8% and non-elective admissions would increase by 5.3%.

The integrated business case seeks to flat-line this projected activity growth, by increasing the number of people whose care is actively case-managed by Care Connection Teams, from 3,500 to 5,500. Consequently, hospital activity for this cohort is expected to reduce and the CCG has adjusted its projections for The Trust, accordingly. A review of the effectiveness of CCTs has recently been completed by HCCG and a summary of the outcomes is provided as an appendix to this briefing paper

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Links to Divisional Plans

The Integrated Business Case mainly affects the operational plan of the Trust’s Medicine & Emergency Division. Improving the interface between hospital and community services remains a divisional priority – notably, by strengthening ambulatory care pathways. Rachel Tustin, the Divisional ADO, is a member of the HHCP Senior Operational Leadership Team, and has been actively involved in designing the ‘intermediate tier services’, which constitute a central plank of the business case. The impact of the HHCP interventions (mainly on NEL admissions) has been included within the CCG QIPP plans and hence is being modelled through into divisional activity and business plans.

Workforce Headlines

Planned service developments will enable more agile working and improve productivity (up to 20%). These efficiencies will arise from applying technology to improve workflow, reduce waste, and prevent duplication by removing the demarcations that have developed over time between staff groups.

Workforce plans will pursue a “Preferred Place of Care Culture”, ensuring all care takes place in the community unless there is an overriding clinical need for a hospital admission. This has the additional benefit of developing a multi-skilled workforce working across boundaries in a fully integrated system.

Financial Headlines

Currently, in Hillingdon the NHS overspends by £32.5m pa. Services within the scope of this proposal account for about a third of that sum, generating a recurrent annual system net deficit of ~£11.2m.

The Integrated Business Case seeks to realise system-wide savings of £29.8m. (net) over 5 years from April 2019. It represents an initial step in financial planning to deliver future system-wide control totals. The financial strategy rests on managing demand for acute services by investing funds, which have been allocated for future activity growth, into preventative interventions.

Success is contingent upon interventions being effective and changing the trajectory of non-elective activity. In FY2019/20, it’s anticipated that net cost savings of £2.61m. will be realised. The table below illustrates that these comprise gross savings of £4.7m. less re-provision costs of £2.14m.

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Proposed Risk / Gain Share

Significantly, the system-wide financial risk is limited to the re-provision costs, alone. Further, it’s split equally between commissioner and providers (£1.07m. each). Hence, if the interventions prove to be unsuccessful, either in full or part, then HHCP faces a combined downside risk of £1.07m. Providers propose to allocate risk in the proportions below, with the lion’s share shouldered by the public sector:

The Hillingdon Hospitals NHS FT 45% (risk exposure = £481,000) Central & North West London NHS FT 45% (risk exposure = £481,000) Hillingdon Primary Care Confederation Limited 5% (risk exposure = £54,000) Hillingdon H4All Community Interest Company 5% (risk exposure = £54,000)

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Proposed Monitoring and Oversight

Implementation is overseen by The Provider Board, on which our COO and FD are represented. Monitoring with business intelligence provides an ‘early warning system’ to manage financial risk. The practicalities of service delivery are co-ordinated by HHCP Senior Operational Leadership

Team, with representation by ADO of the Trust’s Medicine & Emergency Division. New roles may be created for non-executive directors of constituent organisations to oversee the

governance of HHCP, and provide assurance to their sovereign Boards.

Top Five Risks

1. Sovereign bodies of provider organisations don’t approve the business case2. It proves difficult to recruit community-based staff into the Care Connection Teams3. The interventions fail to prevent non-elective activity incurred by the target population4. Business Intelligence systems fail to measure variance against plan, with fidelity5. Governance arrangements fail to monitor and manage risk, adequately

Internal Governance Processes to approve the Integrated Business Case

27 February Board Away-day: Considered within the Operational Planning session. 6 March TME: Internal briefing to clarify operational implications. 20 March Finance & Performance Committee: Submission of business case for approval. 27 March Board Meeting: Endorsement of business case by Trust Board

Next Steps ICS Governance

Integrated Care Systems will be the principal vehicle for implementing the NHS Long Term Plan, and HHCP aspires to fulfil this role. Hillingdon CCG and the Local Authority have been invited to join the partnership.

HHCP propose to strengthen governance structures and functions in order to deliver a greater portfolio of services. This agenda item is tabled for discussion at the March Provider Board meeting.

CCG Review of Effectiveness of Existing Care Connection Teams

The early work of HHCP has focussed on improving care to the over 65 population (with a value of in scope services circa £90m), with the aim of enabling care to be delivered in the most appropriate setting and tackling the growth in inappropriate non-elective admissions for this cohort. The key operational focus of the HHCP to date has been the implementation of 15 Care Connection Teams (CCTs) and the H4ALL Wellbeing service, across Hillingdon. These CCTs are responsible for proactively case managing at any one time, the care of 750 patients with 1 or more long term conditions, most at risk of a non-elective episode, and work closely with the new wellbeing service and existing services. The service went live in September 2017.

FINDINGS

The CCG commissioned an evaluation of CCT effectiveness in January 2019 and found that the Teams reduced both non-elective admissions and ED Attendances for the in-scope cohort of patients as well as having high patient satisfaction rates. This is set out below:

1. A&E Impact

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During the year prior to the implementation of CCT’s (2016-17), the A&E attendances for those patients who would subsequently be in scope to CCT’s were increasing at a rate of 34 A&E appointments per month. In 2018/19, post implementation of CCT’s they are reducing at an average rate of 10 A&E appointments per month.

The total A&E activity for in scope CCT patients showed a rise of 72% from 2016-17 to 2017-18 pre the implementation of CCT’s. Comparing 2017-18 to 2018-19 (FOT),, the activity now shows a predicted decrease of 35% for the in-scope cohort. Similarly, the cost increased by 42% from 2016-17 to 2017-18 and is now showing a predicted decrease of 53% between 2017-18 and 2018-19.

2. Inpatient Spell Impact

During the year immediately prior to the implementation of CCT’s (2016-17), the inpatient spells for patients who would subsequently be in scope to CCT’s were increasing at a rate of 10 inpatient spells per month. Post implementation of CCT’s, the Inpatient spells started to reduce at an average rate of 7 spells per month and by M9 2018-19 they had returned to the lower levels seen in 2016-17. The total Inpatient activity for in scope CCT patients showed a rise of 76% from 2016-17 to 2017-18 pre-implementation of the new model. Comparing 2017-18 to 2018-19 post implementation, the inpatient activity has effectively been flatlined.

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Title RM Partners Memorandum of Understanding

Report author D Spencer Interim Chief Operating Officer Report sponsor D Spencer Interim Chief Operating Officer


☒ ☐ ☐


For Assurance

For Information

☒ ☐ ☐

Summary

In May 2018, the RM Partners Executive Group (Chief Executives from the ten partner Trusts, and the two STPs Senior Responsible Officers for Cancer) agreed to develop an overarching MOU for partners to cover the 2019/20 funding round.

NHS England requires an MOU to be in place between the Cancer Alliance and its partner organisations before 2019/20 funding is released. The attached overarching MOU would, therefore, need to be signed by all partners by 31 March 2019 in order not to delay the start of 2019/20 projects. The MOU is included within the appendices pack for Board reports.

Recommendations The Board is invited to approve the RM Partners MOU

Links to Corporate Objectives

To improve the present A&E 4 hour standard; the 18 week Referral to Treatment; to meet Cancer targets; to complete the CQC action plan; to Implement year 2 of the Quality and Safety Improvement Strategy and to maintain a finance and use of resources score of 3 in meeting the Trust’s control total.

Impact

Quality and Safety

To improve all constitutional standards in providing high-quality patient care and safety and to Implement year 2 of the Quality and Safety Improvement Strategy.

Legal

Financial To maintain a finance and use of resources score of 3 in meeting the Trust’s control total.

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Human Resources



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1. This paper sets out a Memorandum of Understanding (MOU) for RM Partners,the West London Cancer Alliance hosted by The Royal Marsden FoundationTrust, in which this Trust is a partner.

2. In May 2018, the RM Partners Executive Group (Chief Executives from the tenpartner Trusts, and the two STPs Senior Responsible Officers for Cancer) agreedto develop an overarching MOU for partners to cover the 2019/20 funding round.All cancer transformation funding is distributed to Cancer Alliances for allocationout to receiving organisations as per agreed project plans. NHS England requiresRM Partners to have an MOU in place with each partner in order to distribute itstransformation funding. RMH also requires MOUs for each transaction, tomanage the significant risk it assumes as RMP’s host. To date, over 70 MOUshave been exchanged between RM Partners and other organisations in order toallocate transformation funding to receiving organisations. It is hoped that asingle overarching MOU will reduce the bureaucracy associated with thesetransactions.

3. The MOU (contained within the appendices pack) reflects RM Partners’objectives and principles as set out in the Target Operating Model agreed by theRM Partners Executive Group May 2017. In the first instance, it covers the2019/20 funding period, and contains the clauses which are common to allcurrent MOUs.

4. It is currently understood that NHS England requires an MOU to be in placebetween the Cancer Alliance and its partner organisations before 2019/20funding is released. The attached overarching MOU would therefore need to besigned by all partners by 31 March 2019 in order not to delay the start of 2019/20projects.

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Title Emergency Preparedness Resilience and Response (EPRR)

Report author(s) Jayne Austin: Emergency Planning and Liaison Officer Vikas Sharma: Assistant Director of Integrated Governance

Report sponsor Dean Spencer, Interim Chief Operating Officer


☒ ☐ ☐


☒ ☒ ☐

Summary

To report to the Board on the 2018–19 Emergency Preparedness, Resilience and Response (EPRR) Assurance outcome and the Trust’s declaration and self-assessment against the NHS Core Standards for 2018 – 19 (full report contained within the Appendices pack)

Recommendations

The Board is invited to: 1. Review the report;2. Note the assurance in relation to the Trust’s emergency

preparedness compliance with the Civil Contingencies Act2004.

Links to Strategic Objectives Ensuring we have safe, high quality sustainable acute services.

Impact

Quality and Safety X

Legal X

Financial

Human Resources Equality and Diversity Engagement and communication X

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Emergency Preparedness Resilience and Response (EPRR)

1. Introduction

The NHS must be able to plan for and respond to a wide range of emergencies and business continuity incidents that could affect health or patient safety. These could be anything from severe weather to an infectious disease outbreak or a major transport accident. Under the Civil Contingencies Act (2004) (CCA 2004), the Trust must demonstrate that we can effectively respond to emergencies and business continuity incidents while maintaining services to patients. This work is referred to as Emergency Preparedness, Resilience and Response’ (EPRR).

Under the definition of the CCA 2004, all Acute Trusts are classed as Category 1 Responders by being organisations at the core of health emergency response. To be compliant with the Act the Trust has to meet a set of core standards that are assessed annually by the EPRR Department of NHSE (London Region) who in turn report to the national team and thence to the Secretary of State. The Trust is a member of the North West London Network for EPRR.

2. Key Statutory Obligations of the CCA 2004 for the Trust.

a) have a nominated Director level Accountable Emergency Officer who will beresponsible for EPRR, a designated Emergency Planning Liaison Officer and aBusiness Continuity Manager.

b) contribute to area planning for EPRR through local health resilience partnerships andother relevant groups.

c) have suitable, proportionate and up to date plans to cover the Trust response toexternal Major Incidents and Business Continuity / Critical Incidents.

d) have business continuity plans as identified in national and community risk registers.

e) training and exercising must include:

i. a communications exercise every six months;

ii. a desktop exercise once a year;

iii. a major live exercise every three years.

f) have appropriately trained competent staff and suitable facilities available round theclock to effectively manage an emergency and business continuity incident.

g) share resources as required to respond to an emergency or business continuityincident.

h) have arrangements in place to inform, warn and advise the public during an incident.

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3. EPRR Highlights/Exercising in 2018/19

a) Roll out of Evacuation Sheets and Staff Training

Following the learning outcomes from the Evacuation Exercise, the Trust haspurchased evacuation sheets to be placed on beds in the tower block at THH andtwo 1st floor wards at MVH. The sheets enable patient evacuation to be performedsafely in a faster time with less risk of injury to staff and patients.

b) Pandemic Influenza Table Top Exercise

In June 2018 the Trust conducted a multi-agency Pandemic Influenza table topexercise to test the organisations ability to respond to a Country wide infection.The exercise highlighted key learning outcomes which were embedded into the TrustInfluenza pandemic Plan. As a result of this in the NHSE Annual Assurance the Plan’srating was increased from amber to green and deemed to be fully compliant.

Trust Compliance

1. The Chief Operating Officer holds the post of the Accountable Emergency Officer. TheExecutive Director of the Patient experience and Nursing has responsibility for themanagement and delivery of business continuity. A part time dedicated EmergencyPlanning Liaison Officer (EPLO) is in post and the Governance Systems and BusinessContinuity Manager (at approx. 0.1wte allocated resource) to deal with the TrustsEPRR.

2. The Trust has an overarching EPRR policy which outlines key responsibilities and theTrust process for dealing with EPRR.

3. The Trust has in place an EPRR Committee chaired by the Director of OperationalPerformance with senior staff from all key areas in attendance thus ensuring cohesiveand inclusive planning and to oversee and operationally manage the EPRR agendaand Trust action plan.

4. The Trust has developed a number of plans to ensure its resilience in line with theCCA 2004 including Major Incident, Business Continuity / Critical Incident Plans(overarching, service level, threat specific and ICT) Evacuation, Heatwave,Mass Prophylaxis Distribution, VIP, Pandemic Influenza, Incident Communication,Lockdown.

5. The Trust maintained a rating of highly substantial assurance against the CoreStandards review for 2018/19.

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EPRR Core Standards Compliance Matrix

Domain Fully Compliant

Partially Compliant

Not Compliant

Actions

Governance 5 1 The Trust declared partial compliance with regard to EPRR resource. A part time dedicated Emergency Planning Liaison Officer (EPLO) is in post and the Governance Systems and Business Continuity Manager (at approx. 0.1wte allocated resource) to deal with the Trusts EPRR. This limits our ability to strengthen the Trusts EPRR arrangements particularly with regard to exercising and testing, post incident reporting/learning and provision of training.

Action: Director of Operations to present a business case for dedicated EPRR resource. Duty to risk assess 2

Duty to maintain plans 13 1 Partial compliance with standard Shelter and evacuation: The Trust is complaint with the evacuation part of this standard however the standard also requires provision for whole site shelter.

Action: Representatives from the CCG, Harefield Hospital, NHSE and CNWL are joining the Trust EPLO at a meeting with The London Borough of Hillingdon Emergency Response Manager to establish a mutual aid policy for shelter in the unlikely event of a whole hospital evacuation.

Command and control 2

Training and exercising 3

Response 7

Warning and informing 3

Cooperation 3

Business Continuity 9

CBRN 14

Total 61 2 0

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Title Medical Engagement Scale: Summary Feedback

Report author Dr Catherine Cale, Interim Medical Director Report sponsor Dr Catherine Cale, Interim Medical Director


☒ ☐ ☐


For Assurance

For Information

☐ ☒ ☐

Summary

Further to the CQC inspection March/April 2018 the Trust received a number of quality undertakings from NHSI, including the development of a Board-approved plan to improve and measure medical engagement.

As part of the Trust’s response to this, the medical engagement scale was undertaken at THH in October2018, with a report provided to the Trust in January 2019. This report provides a summary of the outcomes of that assessment.

Recommendations

The Board is invited to note and discuss the report in the context of assurance to date and the wider work on engagement and organisational development underway in the Trust.

Links to Corporate Objectives To recruit, retain and develop high-calibre staff through effective support and engagement.

Impact

Quality and Safety

The development work on our clinical strategy provides an opportunity to engage staff in the improvement of their current service in meeting patient needs.

Legal

Financial

Human Resources

To recruit, retain and develop high-calibre staff through effective support and engagement. It is proposed that action plans will be discussed and monitored at

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the new People Committee.



Full plans will be developed in conjunction with the medical staff in the hospitals, aligned to the broader work around communication, engagement and organisational development being undertaken for all staff in the Trust.

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Medical Engagement Scale: Summary Feedback

Background

Further to the CQC inspection March/April 2018 (published 24/7/18), The Hillingdon Hospitals received a number of quality undertakings from NHSI. This included the development of a Board-approved plan to improve and measure medical engagement.

As part of the Trust’s response to this, the medical engagement scale was undertaken at THH in October2018, with a report provided to the Trust in January 2019.

This report provides a summary of the outcomes of that assessment. The information provided in the report triangulates with, and should be seen in the context of, the Staff Survey results and other staff feedback. Plans to improve medical engagement are only one part of the broader trust plans around organisational development and actions outlined here are only a part of the composite plan.

MES Scales

The Medical engagement scale has been developed over a number of years, and provides an assessment against an external normative database of over 120 UK Trusts and more than 17,500 medical staff. It consists of assessment against 3 meta scales and 6 subscales. A summary of these is provided in the appendix.

Summary of Findings at THHT

• 106 medical staff responded to the survey (92 consultants). This represents 50% ofconsultant staff. A small number of SAS staff also responded.

• Average levels of medical engagement fell in the low or lowest segment for all scaleswhen compared to the normative database (120 trusts).

• Engagement in women and children was dramatically better than in all other divisions(below). When split by specialty, only ophthalmology, O&G and paediatrics hadscores in the medium/high or highest relative engagement zones.

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• Further work is required to understand this stark difference between divisions• It is notable that ratings from consultants with managerial responsibility (n=28) were

higher than for those consultants without managerial responsibility (n=62) for themajority of the scales.

• 26 senior managers were also asked to gauge levels of medical engagement. Theyover-estimated the medical engagement in a number of domains:

Meta 1 Working in a collaborative culture Meta 2: Having Purpose and Direction Meta 3: being valued and empowered

o The most marked of these was Meta 1: working in a collaborative culture(overestimated by approx. 16%)

o In most organisations, the MES finds that management underestimatesmedical engagement, strengthening this finding of an apparent disconnect inperceptions of managers and consultant colleagues.

Dissemination of findings

The full survey has been shared with Divisional Directors. A full discussion with clinical specialty leads is planned for 4 April 2019.

A summary has been shared with all consultants via email, and consultant forums and specialty meetings (see below) will be used to engage the consultant body in development of the full action plan

Actions to improve medical engagement

Full plans will be developed in conjunction with the medical staff in the hospitals, and aligned to the broader work around communication, engagement and organisational development being undertaken for all staff in the organisation.

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Plans will be agreed by the end of April 2019. Fundamental to the success of any plan is to ensure that we support people to feel valued and be part of the solution. We need to create an environment which provides all our staff with “time to talk” and to feel that their views matter and are taken into consideration when decisions are made.

The work which we are progressing on our clinical strategy and the Hillingdon Improvement plans involve clinical staff and provide an opportunity to engage staff in the improvement of their current service and the future vision for both their service and the whole organisation.

This survey predominantly looked at consultant staff engagement. The Trust has a junior doctors forum, but this mainly focusses on contractual issues in line with the requirements of the new contract. The DME is working with the trainees to re-launch this forum to ensure we have the opportunity to better engage our trainees and use their feedback and ideas for the benefit of patient care. A number of forums for improved communication with all staff at THH have been developed since this survey was undertaken. These include regular team brief, all staff forums and a consultant forum. These are led by the CEO with Executive colleagues.

We are reviewing current provision for development of management and leadership skills for our consultant staff. At present, we provide a 1 year programme for new consultants, and opportunities to attend external courses for clinical leaders. We will consider the introduction of a rolling development programme for specialty leads, divisional directors and others in leadership roles. This will be designed to provide them with the skills they require as well as developing a cohort of leaders with the skills to work as a team to improve patient care.

There is an existing programme of clinical audit half days in a number of areas. We will review the use of these to incorporate sharing of learning and information and improve engagement. As part of this, we will consider aligning the timing of days to facilitate cross-specialty and whole consultant body activities.

Conclusion

The medical engagement scale demonstrated a significantly low scores in 3 of the 4 divisions, and a disconnect between the perceptions of senior managers and consultants. We are developing an action plan to address this. The final plan will be developed with input from the consultant body, and will be a part of the broader communication, OD and engagement work already underway in the Trust. The plans will be discussed and monitored at the new People Committee.

Action requested of the Board

The Board is asked to note and discuss this report.It is suggested that an update be brought back to the Board in six months time, at which time the Board will be asked to consider whether a repeat of the MES is required to assess the impact of actions.

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Appendix Detail of MES Scales

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Title Local EU Exit Planning Update

Report author Rachel Stanfield, Deputy Director of People & Organisational Development

Report sponsor Terry Roberts, Director of People & Organisational Development

Status of Report Public Private Internal ☒ ☐ ☐


For Assurance For Information

☐ ☐ ☒

Summary

The Department of Health & Social Care (DHSC) has issued guidance to the NHS regarding European Union (EU) Exit Operational Readiness. This report summarises the work being undertaken by the Local EU Exit Group across key areas and highlights risks and mitigating actions in the appendix in the separate appendices pack

Recommendations The Board is invited to note the report and suggest any appropriate amendments.

Links to Corporate Objectives To recruit, retain and develop high-calibre staff.

Impact

Quality and Safety To continue to provide the best level of patient care and safety through the recruitment and retention of clinical staff.

Legal

Financial

Human Resources

The Trust had 348 EU staff in post in February 2019. The Local EU Exit Group is identifying potential staff shortages caused by EU Exit across the health and care system.



The Trust continues to communicate with all staff through Trust-wide emails and the General Bulletin, as well as directly with EU staff.

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Introduction The Department of Health & Social Care (DHSC) has issued guidance to the NHS regarding European Union (EU) Exit Operational Readiness1. All organisations are advised to undertake local EU Exit readiness planning, local risk assessments and plan for wider potential impacts. The Trust is doing this through its Local EU Exit Group, Chaired by the Director of People & Organisational Development (OD).

National structures have also been established by the DHSC, including a national Operational Response Centre, supported by an Operational Support Structure for EU Exit, coordinated by NHS England and NHS Improvement. The Trust is linked into these structures and is working with system partners to ensure there is a co-ordinated approach.

Key areas of work set out in the Guidance are:

• supply of medicines and vaccines;• supply of medical devices and clinical consumables;• supply of non-clinical consumables, goods and services;• workforce;• reciprocal healthcare;• research and clinical trials; and• data sharing, processing and access.

This paper summarises for the Trust Board the work being undertaken by the Local EU Exit Group across these key areas and highlights risks and mitigating actions.

1. Governance and infrastructure

The Trust is taking all required steps to ensure local preparedness, as follows:

• Responding to the Operational Guidance: an action plan is in place (Appendix 1) forall actions in the operational guidance, including a RAG rating for each. The Trust hasall the required communication channels in place to await and respond to additionalguidance as it emerges and additional actions are added to the action plan as required

• Establishing response arrangements: the Trust has put in place all arrangementsrequired including identification of the Senior Responsible Officer and a working group ofSubject Matter Experts (Appendix 2)

• Communication and engagement: the Trust continues to communicate with all staffthrough Trust-wide emails and the General Bulletin, as well as directly with EU Staff.The People & OD team are working with Divisions to communicate directly with EU staffand to pick up on and address specific issues, e.g. the issues relating to Spanish nurses.It is anticipated that the submission of sitreps will commence the week commencing 18thof March 2019.

2. Medicines and vaccines

1 https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

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https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

Key actions in this area cover the prevention of stockpiling, linking into national and regional planning, communications with patients and staff. The Trust’s Chief Pharmacist is leading the necessary actions in this area (Appendix 1). Actions to be completed:

• Pharmacists and emergency planning staff should meet at a local level to discuss andagree local contingency and collaboration arrangements – this meeting is scheduled for14 March 2019

• Ensure there are no DAT scan bookings for the first week in April 2019 until weunderstand whether the supply from the EU of the isotope used has been affected.

3. Medical devices and clinical consumable goods (MDCC)

The DHSC is developing national plans to ensure the continued movement of medical devices and clinical consumables supplied from the EU. All Trust MDCC suppliers are part of the NHS Supply Chain and are covered by nationally work. The Trust has noted that there is no need to stockpile additional MDCC beyond business as usual stock levels and has undertaken all necessary actions in this area (Appendix 1).

4. Supply of non-clinical consumables, goods and services

NHS Trust procurement leads were asked to undertake internal reviews of purchased goods and services to understand any risks to operations if there is disruption in supply. The Trust has a small list of suppliers and has not identified any non-clinical consumables, goods or services that are at risk.

5. Workforce

The Trust had 348 EU staff in February 2019. Trend data shows increasing numbers of EU staff since the 2016 Referendum (303 in June 2016). Band 5 nurses showed a decrease after the Referendum but numbers have been steadily climbing since August 2017, although they have not recovered their pre-June 2016 level.

Actions to be completed:

• Identify potential staff shortages caused by EU Exit across the health and care system,such as in adult social care, and understand the impact that would have on the Trust –follow up queries sent to London Borough of Hillingdon to assess this.

6. Reciprocal healthcare

Reciprocal healthcare is a key area of risk in a no-deal scenario. There are an estimated 890,000 UK nationals in the EU who are currently benefitting from EU reciprocal healthcare arrangements; repatriation could lead to a significant increase in demand. The Trust has undertaken all the actions currently required in this area and will respond to additional actions identified after the planned NHSI meeting on 11 March 2019, which is expected to issue further guidance.

7. Research and clinical trials

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This area has been reviewed. There are no risks to note and no specific actions to complete (Appendix 1).

8. Data sharing, processing and access

In a no-deal scenario the UK would become a ‘third country’ for the purposes of GDPR without an ‘adequacy’ decision. To maintain data flows, appropriate safeguards as set out in GDPR would need to be agreed and applied by the sharing data controllers and/or data processors in the EEA and the UK.

Actions to be completed:

• Complete the Data Security and Protection Toolkit assessment – to be completed by theend of March 2019.

9. Next steps

The Local EU Exit Group will continue to meet on a weekly basis and continue to close off actions and record in the action plan between meetings. New actions and guidance as it emerges is sent to the Group by the SRO and these are added to the workplan.

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Title Board Committee Terms of Reference

Report author Michael Sims, Trust Secretary

Report sponsor Sarah Tedford, CEO


☒ ☐ ☐



☒ ☐ ☐

Summary

The Trust has carried out a review of the Terms of Reference of its current Board Committees, namely Audit & Risk, Quality & Safety and Finance & Performance measured against best sector practice. In addition, it is proposed to create a new People Committee to have oversight of the Trust’s workforce and development strategy. The TOR are contained within the Appendices pack.

Recommendations

The Board is invited to approve the Terms of Reference of all four Assurance Committees, delegating responsibility to the Chair of the Board to make minor modifications to the Terms of Reference in consultation with Committee Chairs.


To have robust assurance mechanisms in place in advising the Board on the Trust’s core statutory responsibilities and activities.

Impact

Quality and Safety

To continue to provide the best level of patient care and safety through robust assurance mechanisms.

Legal

To be fully compliant in accordance with all relevant legislation relating to the Trust’s governance, constitution and operation.

Financial

To have robust mechanisms in place to monitor and audit the Trust’s financial performance, sustainability and accountability for the use of public funds.

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Human Resources

To ensure that the Trust recruits, develops and retains high-calibre, motivated staff in the delivery of patient care and safety through the People Strategy.


To ensure that the Trust complies with its E&D obligations and commitments.


To demonstrate responsive governance best practice in serving the health needs of the local population.

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Board Committee Terms of Reference

1. In Spring/Summer 2018, Committee of the Board carried out a detailed self-assessment which resulted in a number of recommendations being maderelating to Terms of Reference. Following the publication of the CQC Report,further changes were proposed and implemented (eg the Finance &Transformation Committee was re-named Finance & Performance) andstrategy and operational planning became a core part of that Committee’sremit.

2. Subsequently, in the light of the governance review performed by the GoodGovernance Institute (GGI), all Board Committee Terms of Reference havebeen benchmarked against best sector practice. Revised draft Terms ofReference have been drawn up in a more consistent corporate format andare now presented for the Board’s consideration and approval.

3. In addition to the three existing primary assurance committees (Audit & Risk,Finance & Performance and Quality & Standards), the Chair, in consultationwith the Chief Executive, has proposed creating a new People Committee inorder to strengthen the Trust’s governance with regard to overseeingimplementation of the People Strategy and important staff-related matters.

4. Subject to the Board’s approval, it is proposed that the Chair will havedelegated authority to make minor modifications to the draft Terms ofReference in consultation with Committee Chairs.

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Title Process for the Approval of the Annual Report and Accounts, 2018-19


Report sponsor David Stonehouse, Interim Finance Director


☒ ☐ ☐


For Assurance

For Information

☐ ☐ ☒

Summary In accordance with the NHS Act 2006, the Foundation

Trust Constitution requires the Trust to prepare an Annual Report and submit it to NHS Improvement.

Recommendations The Board of Directors is invited to note the process for the production of the Annual Report and Accounts, 2018/19.

Links to Corporate Objectives Meeting compliance and reporting requirements.

Impact

Quality and Safety To include Quality and Performance Reports related to patient safety

Legal

To include Accounting Officer’s Statement of Responsibilities and to fulfil obligations under NHS Act 200o

Financial To include Auditor’s opinion and certificate on the Annual Accounts

Human Resources Annual Report includes reference to workforce and people strategy

Equality and Diversity Reports to include reference to Trust’s strong commitment to equality and diversity policy and strategy


Annual Report & Accounts to be presented Annual Members’ Meeting and to be made available more widely to the public

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Annual Report and Accounts 2018/19

1. In accordance with the NHS Act 2006, the Foundation Trust Constitution requiresthe Trust to prepare an Annual Report and submit it to NHS Improvement. TheAnnual Report and Accounts must consist of:

• The Annual Report which includes the performance report, accountabilityreport, quality report and accounts

• The Accounting Officer’s statement of responsibilities• The Auditor’s opinion and certificate• The Annual Governance Statement• The foreword to the Accounts which should state that the accounts are

prepared in accordance with paragraphs 24 and 25 of Schedule 7 to the 2006Act

• Four primary financial statements (Statement of Comprehensive Income,Statement of Financial Position, Statement of Changes in Taxpayers’ Equity anda Statement of Cash Flows)

• The notes to the Accounts.

2. The timescale for this submission of the Annual Report and Accountsand subsequent circulation is shown below, together with key deadlinesand dates:

Date To Action Required May – to be finalised

QSC Recommends draft Quality Account to ARC for approval

Week commencing 13 May

ARC ARA to ARC for final approval and recommendation to Board

22 May Board Approval of Annual Report and Accounts 23 - 28 May Chair and Chief

Executive Report any final amendments on the change log for approval

29 May NHSI Requirement is that Accounts submitted to NHSI by 12.00, midday and Quality Account submitted to NHSI by 5.00pm – in practice the complete Annual Report (word version only) will be submitted

21 June Parliament 1st Step Format of ARA must be checked with DFH Parliamentary Office

24 June NHSI Reply to NHS Improvement’s letter regarding events after the reporting date of 29th May

25 June Parliament 2nd Step ARA must be submitted to DFH Parliamentary Office

9 July Council of Governors

Receipt of ARA and External Auditor’s Report on 2018/19 Accounts and Quality Account

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19 July NHSI Submit final full Annual Report including full statutory accounts to NHS Improvement

19 September Annual Members’ Meeting

Motion to receive the ARA

3. It should be noted that the Board must also confirm that the Directors consider thatthe Annual Report and Accounts taken as a whole, is fair, balanced, understandableand provides the information necessary for patients, regulators and stakeholders toassess the Trust’s performance, business model and strategy.

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Title Financial Performance Report - February 2019 Month 11

Report author Mel Hughes, Deputy Director of Finance

Report sponsor David Stonehouse, Interim Director of Finance


☒ ☐ ☐


For Assurance

For Information

☐ ☒ ☐

Summary

This report provides oversight to the Trust Board (through the Finance and Performance Committee each month) on progress against the financial targets of the Trust and the actions required to ensure the control total is met.

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


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



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FINANCIAL REPORT FEBRUARY 2019 (MONTH 11)

1. EXECUTIVE SUMMARY

Key Points to note at Month 11 against plan and our internal forecast • M11 deficit of £3.7m, £2.8m behind plan, and £0.4m adverse to forecast

for month.• Year to date deficit of £25.5m, £18.0m adverse to plan.• Agency expenditure of £1.0m in month, a reduction from previous month.• Pay overspend of £1.2m in month, but on forecast.• Finance and Use of Resources score of 3.• Efficiency savings of £1.0m in month.• Capital expenditure of £0.9m in month.• Cash position of £3.1m at month end.

The actual position for February was a £3,731k deficit this is £383k adverse to the internal forecast deficit of £3,348k. This result is worse than the forecast submitted to NHSI at Month 9 by £1,267k and will impact our M9 forecast for the year end. We have given an initial assessment of the year end forecast subsequent to the deterioration reported at month 10 which is that the Trust will have a yearend deficit of £27.2m. This is £19.5m above the original plan and £4.5m above the month 9 forecast of £22.7m

Pay was in line with internal forecast and non pay better than forecast by £162k, however income was behind forecast by £597k with Clinical income making up most of this variance.

Activity Based Clinical Income

Annual Plan Actual Variance Plan Actual Variance M11 ForecastVariance from M11 ForecastVariance fromPlan to-date to-date to-date In Month In Month In Month as at NHSIM9 Forecast as at M10 Forecast

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Operating IncomeNHS Clinical Income 220,643 201,863 202,420 557 17,781 17,655 (126) 18,419 (764) 18,192 (537)Non-NHS Clinical Income 2,763 2,531 2,716 185 231 114 (117) 273 (159) 258 (144)Other Operating Income 28,820 26,385 25,733 (652) 2,393 2,337 (56) 2,445 (108) 2,253 84

Total Operating Income 252,226 230,779 230,869 90 20,405 20,106 (299) 21,137 (1,031) 20,703 (597)

Operating ExpensesEmployee Expenses (168,103) (153,992) (162,954) (8,962) (13,969) (15,153) (1,184) (15,105) (48) (15,146) (7)Drugs (18,452) (16,896) (16,960) (64) (1,457) (1,442) 15 (1,532) 90 (1,569) 127Clinical Supplies and Services (29,070) (26,578) (30,274) (3,696) (2,360) (3,042) (682) (2,797) (245) (3,031) (11)Other Operating Expenses (33,622) (30,787) (31,454) (667) (2,821) (2,879) (58) (2,837) (42) (2,925) 46

Total Operating Expenses (249,247) (228,253) (241,642) (13,389) (20,607) (22,516) (1,909) (22,271) (245) (22,671) 155

EBITDA 2,979 2,526 (10,773) (13,299) (202) (2,410) (2,208) (1,133) (1,277) (1,968) (442)

Depreciation (9,722) (8,910) (8,413) 497 (812) (751) 61 (763) 12 (791) 40Interest Income/Expense (3,448) (3,144) (2,890) 254 (302) (262) 40 (251) (11) (281) 19PDC Dividend Expense (3,749) (3,441) (3,441) 0 (308) (308) 0 (317) 9 (308) 0

p ( )Exceptionals (13,940) (12,969) (25,517) (12,548) (1,624) (3,731) (2,107) (2,464) (1,267) (3,348) (383)

Provider Sustainability Funding 6,181 5,459 0 (5,459) 721 0 (721) 0 0 0 0Gains/(Loss) on Investment Properties 0 0 0 0 0 0 0 0 0 0 0Profit/(Loss) on the Disposal of Assets 0 0 0 0 0 0 0 0 0 0 0

Surplus(Deficit) after Exceptionals (7,759) (7,510) (25,517) (18,007) (903) (3,731) (2,828) (2,464) (1,267) (3,348) (383)

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Clinical Income in February was behind plan by £126k in month and behind internal forecast by £537k.

The activity based elements of Clinical Income were £750k behind forecast overall, with Daycase, births and outpatients having a combined adverse variance of £630k. The recovery plans have not been achieved in month and this has put further pressure on the year end forecast.

The Surgery division was behind their forecast by £414k on activity based income. The Division had planned to catch-up on low activity levels in January and December, but this has not happened with 163 Daycases not delivered and only 12 additional elective inpatients. There has been some cancellation of patients due to non-elective pressure.

The Medicine division was behind forecast by £80k with good performance on Emergency Admissions (plus £240k), offset by Critical Care and Ambulatory Care.

In Women’s and Children the division was behind forecast by £390k, births were behind forecast by 26, (£123k) and thus Neonatal bed days were also down by 192, (£97k). Outpatients were below forecast levels by 440 (£94k).

In CCSS the division is ahead of forecast by £128k with over performance on outpatients of 2032 £146k being held down by a small underperformance on Daycases.

We are assuming clinical income will deliver to forecast in March.

Non-NHS Clinical Income

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Income from Overseas Visitors was again below planned and forecast levels, by its nature this income is received in peaks and troughs, RTA cases, recovered in month from the previous poor level, to nearer to plan.

Other Operating Income

Education and Training income and income from SLAs with third parties is lower in the second half of the year. Some of the reduced E&T income will be reflected in lower pay costs. The café has done better than expected since it opened helping the position.

Pay has met forecast levels in February which is a positive given the large deterioration in January levels. Agency costs were down compared to January by £213k, medical locums were down by £156k and nursing by £103k, A&C up by £22k and Prof & technical up by £25k other areas remained stable. .

Drugs were below plan levels by £15k, and below forecast by £127k.

Clinical supplies were above planned levels but on the forecast this month. We have had further discussions with North West London Pathology regarding the yearend position; the £1m deficit assumed within our year end risks last month has reduced to £950k.

Other Operating Expenses were below forecast by £46k this is a reversal of last month’s position, reductions in expenditure on Consultancy, and premises costs, plus the leases for the Paul Strickland building has now been agreed so the bad debt provision has been released.

Interest Expensed is now in line with both plan and forecast.

The Trust has assumed that it will not receive Provider Sustainability Fund (PSF) in month or year to date, as financial performance is below plan, and A&E achievement is below trajectory, this has impacted the position by £5,459k year to date.

Key Performance Indicators

Surplus/(Deficit) (£3,731k) ↑ Risk Rating 3 ↔ Agency expenditure £956k ↓ Efficiency Savings £920k ↓ Pay Variance £1,184k ↑

2. FINANCE IMPROVEMENT PROGRAMME

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The Trust has developed plans totalling £13.6m against a target of £12.03m; this includes the £4.86m of opportunities identified in the recovery action plans, the M6 re-forecast & work with the Kingsgate. However due to poor financial performance & under-delivery of FIP in M10 the year end forecast outturn position has dropped to £11.29m, which is £735k below target.

Performance Category Target Plan Forecast

Outturn 18/19

Variance Target to Identified

Plan

Variance Target to Forecast

Outturn Clinical Support Services 2,247,443 688,538 697,575 (1,558,905) (1,549,868)

Corporate 2,349,404 2,461,887 2,251,507 112,483 (97,897)

Medical Division 3,380,330 3,955,001 3,181,104 574,671 (199,226)

Surgical Division 2,679,840 2,248,626 1,898,776 (431,215) (781,064)

Women & Children’s Division 1,374,344 1,165,169 1,055,368 (209,175) (318,976)

Trust-wide 0 3,143,403 2,211,354 3,143,403 2,211,354

Totals 12,031,361 13,662,623 11,295,685 1,631,262 (735,676)

M11 delivered £920k against a planned target £1.56m (achieved 58%), areas of under-performance remain Medical Productivity (£103k), Non-Pay (£64k) & Nursing (£59k). Additionally performance against recovery actions was behind plan (£296k).

Nursing Productivity delivery against plan was heavily impacted by the reduction in available bank staff so off-framework usage has not reduced from January levels. Off-framework agencies were used to fill over 150 shifts in February & January as opposed to 115 shifts in December & 25 shifts in November; off-framework agency usage is reviewed on a case by case basis with executive sign-off required and monitored daily.

The increased planned FIP delivery in M12 at £3.34m is supported by a Property Revaluation at £2.7m

3. YEAR END FORECAST

Subsequent to the deterioration at Month 10, forecasts were updated and recovery actions taken forward with divisions. This resulted in a year end forecast movement of £3.2m, plus a net £1.4m of significant risks deemed highly likely to crystalize. This was reported to NHSI at the February Performance Oversight Meeting. This has been updated to take into account Month 11 results which give a likely year end deficit of £27.2m.

This does assume the overall month 12 income position delivers to forecast, which in aggregate terms does not look unrealistic when compared to previous months.

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The risk of a deterioration in forecast was also independently assessed by the Good Governance Institute in January, who reported a risk of between £1.55m and £7m over and abover £22.7m. Of the key risks they highlighted income underdelivery and the pathology service cost pressures have crystallised.

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 February is a 3:

Metric Plan Rating for February Capital Service Capacity 4 4 Liquidity 1 4 I&E margin 4 4 Variance from Plan 1 4 Agency spend 2 1 Weighted Average 2.4 3.4 Overall Rating after Overrides 3 3

The ‘Underlying Financial Performance’ risk on the Corporate Risk Register is rated 20 (extreme). The year to date financial position is worse than anticipated and exposes a gap in control on the underlying financial run rate.

5. BALANCE SHEET AND CASH

The month end cash position was £3.1m, having received £1.7m deficit support in February. The Trust has now reached the limit for deficit support for the year; however the movement in forecast now allows for a further request for £2.9m support, this request has been approved by NHSI, and will be received in April. The cash position remains stretched however through improvement in our debtor’s management we are able to maintain supplier payments into the latter half of the month, with payments totalling £2m planned to be made before month end

Better Payment Practice Performance

Performance against the better payment practice code was 57.5% for Non NHS suppliers and 24.9% for NHS organisations. The cash position will mean that our creditor days push out towards 90 by the year end

Capital

Capital spend was £856k in month and is forecasting £10.5m for year end. PDC has been applied for £213k for the Radiology imaging network and £16k for Pharmacy equipment. It was established that the A&E scheme would need to be delayed and completed in2019/20, this left an underspend against the scheme which was reallocated to equipment and Estates backlog maintenance. Due to the

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asbestos found in the boiler house the purchase of the boiler has been delayed, therefore £400k of IT licenses have been brought forward from the 2019/20 plan to offset the underspend. Much of the equipment is being leased so will be shown in Month 12. However there is still much to be purchased and delivered before the end of March. The Capital Planning Group confirmed that plans are in place to ensure delivery of the forecast.

6. KEY MESSAGES

• Month 11 position is in line with the M10 revised forecast on expenditurehowever income was significantly below planned levels.

• Pay levels were within forecast – Agency usage has reduced from theJanuary levels.

• The forecast for planned activity for March must be achieved to reduceany further deterioration in yearend position. This is being focused on bythe Executive team with divisions.

• Recovery plans have been implemented for reducing the pay bill inMarch are being overseen on a weekly basis by the Executive withsupport from Kingsgate

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Title NHS Improvement Undertakings: Progress Update & Assurance

Report author Melissa Mellet ,Director of Operations

Report sponsor Dean Spencer, Interim Chief Operating Officer and David Stonehouse ,Interim Director of Finance


☒ ☐ ☐


For Assurance

For Information

☐ ☒ ☐

Summary

This report provides oversight to the Trust Board (and through the Finance and Performance Committee on alternative months) on progress against the undertakings made by the Trust to NHS Improvement. These undertakings relate to A&E; Finance; Governance and Programme Management.




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 and Diversity Engagement and Communication

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UNDERTAKINGS

This report provides oversight to the Trust Board (through the Finance and Transformation Committee on alternative months) 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 includes detail in relation to the Hillingdon Emergency Care improvement Programme.

A&E

1. The Trust has provided to NHS Improvement a Board-approvedplan for A&E performance recovery (“the A&E Plan”) as agreedwith NHS Improvement. This included:

• the key milestones and how they will be achieved;

• what resources the Trust has in place to deliver the A&E Plan;

• the key risks to delivery, monitoring and mitigations;

• the key performance indicators (KPIs) to monitor the A&E Plan;and

• how the Board will have oversight and overall governance overthe A&E Plan

Plan provided by NHSI

2. The Trust will provide to NHS Improvement a monthly Boardapproved report on progress against the A&E Plan, which includesthe following:

• progress being made against the key milestones;• if there are any areas of slippage against milestones, how

performance will be recovered and monitored; and,• Any key risks to delivery of the Plan, and the related

mitigations.

See Appendix 1

3. The Trust to engage with external supplier: Complete Hunter Healthcare work procured and delivered. Contracted ended 30/11/18 30 further days agreed to complete scope commenced w/c 11/3/19

4. The Trust Fortnightly oversight meetings in lace at system level by NHSI

The table below provides an update on the milestones for January 2019 and actions taken where these were not achieved. Please note the RAG rating in this report is refreshed and there may be some variation from appendix 1.

Undertaking Status Finance

5. The Trust will develop a financial plan to March

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2020 (“the Financial Plan”) which includes: • an understanding of the underlying financial

position and a detailed analysis of thecauses of the underlying position;

• a well-developed CIP plan which takes intoaccount all relevant operational productivityopportunities; and

• a link to workforce optimisation.

• A drivers of deficit paper has beenprovided to NHSI

• The Trust’s Long Term Financial Model isbeing updated

• The existing FIP plan takes account ofopportunities as identified in the ModelHospital. The plan to March 2020 willfurther explore these opportunities

• The Trust’s People Strategy will beembedded within the financial plan

6. The Trust will keep both the Financial Plan underreview and provide regular highlight reportsincluding key performance indicators and attendregular update meetings, the content and timing ofwhich will be agreed with NHS Improvement.

• The Trust continues to engage with NHSIthrough: an open invite to the new weekly“check and challenge” divisional reviews;monthly returns; monthly oversightmeetings; and at other times as required.

Governance 7. The Trust will undertake an externally

commissioned governance review to inform thestrengthening of governance arrangements to becompleted by a date to be agreed with NHSImprovement. The scope and supplier will beagreed with NHS Improvement

8. The Trust will address the findings of thegovernance review. The timing of delivery of therecommendations will be agreed by NHSI and theTrust will provide assurance to NHS Improvement ifrequested on progress with delivery.

• Deloitte have undertaken the governancereview to a scope agreed with NHSI.

• Deloitte have not yet released the reportand the Board will consider its findingsonce received

9. The Trust will work with a Senior Board Advisorwho may be appointed by NHS Improvement toassist the trust’s executive team with the delivery ofthe Plans identified within these undertakings.

• NHS Improvement has not as yet madeany such appointment.

10. The Trust will co-operate and work with suchpartner organisations (this may include one or more‘buddy trusts’) which may be appointed by NHSImprovement to support and provide expertise tothe Trust and to assist the Trust with the delivery ofone or more of the Plans identified within theseundertakings and the quality of care the Trustprovides. The scope and scale of any such supportwill be directed by NHS Improvement.

• NHS Improvement has not as yet madeany such appointment.

Programme management 11. The Trust will ensure adequate senior management

(PMO resource) to support the executive team todeliver the undertakings above.

• The Trust has already appointed to theAssociate Director of PMO role thatsupports the Financial ImprovementProgramme

• The Trust has appointed Kingsgate tosupport delivery of financial recovery

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• The arrangements need revising andagreeing for 19/20

• Completion March 2019

The Trust will implement sufficient programme management and governance arrangements to enable delivery of these undertakings.

The programme management and governance arrangements must enable the Board to:

• obtain clear oversight over the process indelivering these undertakings;

• obtain an understanding of the risks to thesuccessful achievement of the undertakingsand ensure appropriate mitigation; and

• hold individuals to account for the deliveryof the undertakings.

• The undertakings will be monitored by theFinance & Performance Committee and theTrust Board

• The arrangements need revising andagreeing for 19/20

• Completion March 2019

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.

• Agreed

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.

• Agreed

Quality Undertakings (October 2018)

The Care Quality Commission (CQC) inspection report of the Trust published in July 2018 noted a number of issues that the Trust needed to deal with, and rated the Trust Inadequate in the Safe domain. In addition, NHS Improvement (NHSI) noted through its ongoing oversight of the Trust, poor performance in patient surveys (National Inpatient Survey and the A&E Patient Survey) and significant issues relating to sepsis management.

Based on the CQC’s inspection report and NHSI’s own work with the Trust, NHSI concluded that there were reasonable grounds to suspect that the Trust was in breach of its provider licence in relation to the delivery of quality.

In October 2018 NHSI decided to propose and accept enforcement undertakings from the Trust pursuant to its powers under section 106 of the Health and Social Care Act 2012 (the Act”) in respect of the Trust’s quality issues. These are set out as below and will be included in the existing report presented to the Trust Board on the undertakings related to A&E, finance and governance:

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Undertaking Progress 1. 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.

A detailed governance review was undertaken by Deloitte LLP between September and November 2018 with recommended improvement measures provided on 29th January 2019. These include recommendations against the eight Key Lines of Enquiry within NHSI’s Well Led Framework for Governance.

The Trust will be working through the high priority measures that have been recommended from the review to ensure there is improved Board and organisational effectiveness.

The Trust is currently working with the Good Governance Institute to introduce a structured and customised board development programme in order to improve the impact and overall effectiveness of the Board. This is particularly important in light of several senior executive and non-executive leadership role changes.

In addition a review of the Trust’s corporate governance arrangements is underway in order to align the Board committee structure more closely with the Trust’s strategic priorities, including review of terms of reference, membership and reporting and escalation arrangements.

A performance management and accountability framework and a more robust integrated performance report are under development to ensure there is clarity on expectations and consistency in performance reporting across the Trust, aligned to the Trust’s strategic objectives.

An independent, evidence-based follow-up review by Deloitte LLP will take place in August 2019 to assess whether or not key outcomes measures have been met.

2. 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.

The Quality and Safety Committee (QSC) received a draft CQC Assurance Framework in Feb. 2019. This was developed to provide clarity on controls that are in place, the assurance structures that exist to review whether the controls are effective, and the outstanding gaps and actions. This will now need further review and development as a result of the current corporate governance review that is underway and the detailed overhaul of the Trust’s CQC improvement plan.

3. 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. In particular this includes:

a. Ensuring that acomprehensive CQC actionplan is discussed by theBoard

A detailed CQC action plan was approved by the QSC and the Trust Board in Nov ‘18 and this was subsequently reviewed by the QSC at its Dec ‘18 and Jan ‘19 meetings. This was developed as a result of the outputs of the Quality Summit with the Trust’s key stakeholders. The initial must/should do action plan that was developed in response to the requirement notice issued by the CQC and the core services’ improvement actions was reviewed by the QSC in August 2018. This has been tracked via the Regulation and Compliance Committee, and the monthly meetings with the Trust’s commissioners and with NHSI.

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b. Review of actions such thatthey completed within thetime agreed and that keymilestones and agreedoutcome measures aredelivered.

The areas for improvement from the 2018 CQC inspection report are large and wide‐reaching. There are also significant dependencies and risks. In order to manage these and to create the controls that the Trust requires, a programme approach is to be adopted to draw the elements of change and improvement together. By taking this approach a new Quality Improvement Plan has been developed to provide overarching oversight of the work streams to ensure that improvement work is not duplicated or omitted in error, and that the risk of conflicting actions / priorities are well managed. This is to be presented to the Trust Board in March 2019 and the progress monitored in detail by the QSC moving forward.

4. The Trust will review and revise the Trust’s risk management policy/procedures and associated governance processes by January 2019.

The Deloitte LLP assessment provided to the Trust on 29th January included a review of KLOE 5 of the well led framework for governance - Are there clear and effective processes for managing risks, issues and performance - this resulted in the recommendation for the Trust to review its current risk management arrangements for moderation and escalation of risks to improve their effectiveness.

It has been agreed that the Trust will be critically reviewing its governance processes for risk management which includes an overhaul of the corporate risk register to ensure risks are clearly captured and articulated, that controls and gaps are well understood and provide focus to ensure appropriate Board discussion on risk tolerance and effective mitigating actions. A revised register will be presented to the Audit and Risk Committee and Trust Board once this review has taken place. This is a large piece of work that needs dedicated support to progress and ensure the review is thorough and fit for purpose.

5. 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.

The Medical Engagement Scale tool was utilised to undertake a survey of medical engagement in October 2018 with a report provided in January 2019; the results have been analysed and a summary will be presented to the Trust Board in March 2019. Actions to improve medical engagement across the Trust will be part of a wider organisational development strategy and programme for the Trust.

In addition, NHSI noted that the undertakings already agreed with NHSI in relation to programme management for the A&E and finance undertakings (already outlined in the report) will also to apply to those related to quality.

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Title Integrated Quality and Operational performance – February 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

Dean Spencer, Interim Chief Operating Officer Dr Cathy Cale, Interim Medical Director Jacqueline Walker, Chief Nurse Terry Roberts, Director of People and Organisational Development


☒ ☐ ☐


For Assurance

For Information

☐ ☒ ☐

Summary This report provides oversight to the Trust Board on progress against the quality and performance standards the Trust seeks to meet as either national or local standards.




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

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efficient and effective manner


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


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

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1. Summary

The format of the performance dashboard reflects the core principles of the fiveDomains set out in the Care Quality Commission's Intelligent Monitoring System(Caring, Well-led, Effective, Safe and Responsive). This is an exception report with fullanalysis of the data contained within the appendices that are in the appendixsupplement. The Model Hospital group comparators for performance are: Ashford & StPeters Hospitals NHS Foundation Trust, Barnsley Hospital NHS Foundation Trust,Burton Hospitals NHS Foundation Trust, Croydon Health Services NHS Trust,Gateshead Health NHS Foundation Trust, Harrogate and District NHS Foundation Trust,James Paget University Hospitals NHS Foundation Trust, Kingston Hospital NHSFoundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, Milton KeynesUniversity Hospital NHS Foundation Trust, North Middlesex University Hospital NHSFoundation Trust, Northern Devon Healthcare NHS Trust, Queen Elizabeth HospitalKing's Lynn NHS Foundation Trust, Salisbury NHS Foundation Trust, South TynesideNHS Foundation Trust and Southport and Ormskirk Hospital NHS Trust.

2. Key Highlights

2.1 Safe

Falls Performance analysis

The Trust target for rate of falls was not achieved in February (5.1 per 1000 bed days against a target of 4.6). Performance was outside the Trust’s internal target but remained better than the last published national benchmark. Year-to-date performance is marginally above target with a rate of 4.6 falls per 1000 bed days.

There were a total 59 falls in inpatient areas compared to 72 in January; there were also 10 falls in non-inpatient areas, specifically the Emergency Department.

1 fall in February resulted in fractured neck of femur, bringing the year-to-date total to 7 falls resulting in fracture. This is within target.

Incidence in the department will be monitored to identify whether this is an emerging trend requiring action

Key risks and challenges: High Impact Improvement Actions: • The year-end target will only be achieved if

the downward trend in rate of falls continuesin March

• The prevalence of high risk patients assertspressure on achieving the target

• Extended stays increases the risk of fallsoccurring in the Emergency Department dueto environmental and operationalconsiderations compared to an inpatientward

• Ward safety huddles review patient safetyrisks and mitigating actions

• Matrons to robustly review patientsidentified as a at risk, ensuring appropriateplans in place

• Divisions to ensure performance per ward isreviewed at Ward Managers’ KPI meetings

• Emergency Department to consistentlyensure each patient’s risk of falls isassessed and preventative measuresimplemented

• Quality and consistency of falls riskassessments and care plans to be includedin Themed Clinical Friday programme

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Fractured neck of femur patient in theatres within 36 hours: Performance analysis

January performance was at 86.7% against 90% target (2 patients of 15 did not receive treatment within the national standard of going to Theatre within 36 hours). Year to date the performance is 81.4%. (31 patients out of 167 Action: The Division of Surgery have been tasked with improving performance into the next financial year and will produce an action plan to address the areas of improvement required. Serious Incidents / Never Events

Performance analysis 6 Serious incidents were declared in February and 100% were reported onto StEIS within 2 working days. There were no Never Events in February. Performance has shown significant improvement over the last 3 months in comparison to previous months within the financial year. There is however more improvement required to improve compliance and to ensure timely implementation of actions and dissemination of learning. The aim is to consistently achieve 90%+ from July 2019 onward. Backlog overdue SIs 9 SIs are overdue, 4 of these are at the approval stage. Lead Investigators for the remaining 5 have been given until 22nd March to submit their reports for approval. Actions taken to date: • First RCA training session has taken place. 23 members of staff attended the one-day training

course (to increase the pool of SI Investigators) • Daily review of moderate and above incidents with oversight from Chief Nurse and Medical

Director. (to improve time-to-declaration) • Weekly email reminders and hotlist of SIs sent to investigating officers, Divisional leads, and line

managers. (to ensure timely completion of investigations) • Instigated Surgery Division weekly SI review meeting (to enable prompt review, assignment and

completion of SI Investigations) • Agreed scope of work re review of SI and Incident management with Dr Jane Carthey. (to

identify compliance and efficiency opportunities) • Funding for SI Lead Investigator agreed for 2 months (to clear the backlog as funded by NHSI) Key risks and challenges: High Impact Improvement Actions: • The CCG have issued a Contract

Performance Notice due to the Trust not meeting the key standards for investigation timelines.

• Learning may not be disseminated in time to reduce the likelihood of similar incidents occurring.

• Appoint an interim lead SI investigator. • Ensure April 1x RCA, 2x Human Factors and

4x Duty of Candour sessions are well attended.

• Clear the remaining backlog of overdue SIs. • Ensure lead investigators and panels are

assigned within 5 working days of declaration to avoid delays in the investigation process.

• Recruit to 1x vacant Clinical Governance Facilitator post (advertised).

• Streamline the SI process and documentation with support of Dr Jane Carthey.

• Implement a robust process for the review and monitoring of SI action plans.

• Focus on improving the quality of reports first time.

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• Implement a structured and effective processof disseminating and sharing the learning.

• Write a business case to support substantiveSI lead investigator post (May 2019).

• Revise the Incident and SI Policy to reflectand changes in process

Mortality (HSMR) Performance analysis

HSMR data The 12 month rolling HSMR data is to November 2018. For all admissions, including weekends, HSMR shows a very small upward trend, but remains within the expected range: all admissions 97.0 (range 90.2-104.1), weekend only admissions 94.6 (range 81.3-109.5). Palliative Care coding remains good: 3.9 (range 3.6-4.1).

SHMI data SHMi is the ratio between the number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures. SHMI includes patients who die either while in hospital or within 30 days of being discharged and doesn't exclude patients receiving palliative care. Latest SHMI data was published February 2019, and relates to discharges within October 2017 to September 2018. The Trust SHMI value is 0.9588, which is 'as expected'. 101 of the 131 other Trusts included are also 'as expected'.

Action: Mortality figures continue to be reviewed at the bi-monthly Mortality Surveillance Group

Medicines Safety Thermometer Performance analysis

Medicines Reconciliation within 24 hours The Trust target is 70% once the 7 day working service (medicines reconciliation at weekends) is fully embedded during April 2019. This will improve the number of patients having their medicines reconciled within 24 hours of admission and achievement of this KPI is on track. Progress with this KPI is monitored by the Medication Safety Committee.

Omitted doses The Trust target is 18% by year end. 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. Pharmacy bulletin on how to access medication out of hours was re-launched and distributed to all wards in December 2018 and also sent to CSPs. There is a drug stock holding list available on the intranet so there is easy access to check availability of medication across the hospital. Nurses are encouraged to review drug charts during every handover to ensure there are no missed doses before they commence their shift and ward managers/matrons are asked to do spot checks on the ward to identify any missed doses. The Chief Pharmacist and Medication Safety Officer carry out weekly walkabouts on wards and will spot check knowledge of staff regarding missed doses. This KPI is on track. Progress with this KPI is monitored by the Medication Safety Committee which is also tasked with delivery of other identified actions to further support sustained performance for this KPI.

Allergy Status The National average is > 98%. The Trust target is 98% and is reliant upon implementation of Electronic Prescribing and Medicines Administration (EPMA) for which the majority of Trusts nationally have in place.

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Maternity Safety Thermometer Performance analysis

The Trust narrowly missed the 95% harm-free care target in February, achieving 92.3%. Year to date position is not available.

Although the target was not achieved, this was a significant improvement compared to January (68.8%). Key risks and challenges: High impact improvement actions: • The Maternity Safety Thermometer is

collected and administered by the maternityteam.

• Data is submitted at point of collection, notvia the Information team

• Senior midwifery team and Information teamhave worked together to ensure data issubmitted and retrieved in timely manner.This has been embedded since Quarter 3.

• The Maternity Matron personally overseesdata collection and sharing of results acrossthe maternity unit to facilitate learning andimprovement

2.2 Caring

Friends and Family Test Performance analysis

Two areas failed to achieve response targets:

• A&E Care (A&E and MIU combined): Response Rate 5.7% (target 20%). This is a slightimprovement, for the second consecutive month, but remains significantly below where itneeds to be.

• The combined score is comprised of A&E 1.05% (44 responses) and Minor injuries Unit14.01% (312 responses).

• Outpatient Care: Response Rate 4.53% (1090 responses) against a target of 6%.

One area failed to achieve target satisfaction score:

• Outpatient Care: 92.9% of respondents indicated they would recommend the service.

Key risks and challenges: High impact improvement actions: • The required response targets for A&E

Care and Outpatients have beensignificantly missed over sustainedperiod of time

• Awareness campaigns and trial of I-padsto capture patient responses in theemergency Department have failed todeliver improvement

• Risk of Contract Performance Notice

• The Head of PPE has developed a businesscase in conjunction with the ADN in A&E toapply for funding to introduce SMS texting inA&E, Paediatric A&E, Minor Injuries andAcute Medical Unit.

• The Trust's IT department has identified asystem to generate SMS texting in-house, atsignificantly reduced cost.

• In-house solution to be implemented on trialbasis in April

• If the trial solution is unsuccessful, thebusiness case will be submitted in May2019.

• Outpatients – volunteer manager to allocatevolunteers to outpatients to collect feedbackfrom patients.

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2.3 Responsive

18 weeks Referral to Treatment (RTT) – Incomplete standard

Performance analysis In February the Trust performance for RTT was 88.1%, against the 92% constitutional standard. This is an improvement in performance. 2018/19 contractual target is to maintain last year’s waiting list size. The total waiting list size was 22758 in February against the target of 22773 (2017/18). This position needs to be maintained for March to ensure we hit the target. There were zero 52 breaches in December. Diagnostic Waiting Time and Activity (DM01) This data has not been presented to the Trust Board for the last year. DM01 is the measure of the current waiting times of patients still waiting for 15 key diagnostic tests or procedures at the month end. This data is split by number of weeks waiting, and by test. Diagnostics test activity across the month is also collected broken down by waiting list, planned and unscheduled. The monthly diagnostics collection is used to measure performance against the diagnostic operational standard (less than 1% of patients should wait 6 weeks or more for a diagnostic test). Up until November 2018 the Trust was achieving was sustaining 99% of patients receiving their diagnostic within 6 weeks. An issue in non-obstetric ultra sound meant that the Trust dropped its performance 77%. There is a plan and trajectory to get performance back to 99% by the end of March. The performance is currently at 96.3% and on trajectory. Key risks and challenges: High impact improvement actions: • ASIs not currently reported on the PTL.

• Work underway to make visible ASI and add them to the waiting list.

• Ongoing increased resourcing of waiting list validation process

• Specific action plans for key specialties: T&O (medical engagement and productivity); Pain (move to a more nurse-led follow-up model, business case to increase consultant establishment from 4.0 to 5.0 WTE); General Surgery (rebalance capacity between O/P and theatre lists)

Cancer performance

Performance analysis

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In January the Trust did not meet the all of the National Cancer standards. The National Standards were achieved for 31 day decision to treat to treatment, Consultant upgrade and 31 day subsequent treatment for Surgery. National Standards were not achieved for 2WW (92.4% against the 93% target). The 62 day standard was 83% against the 85% target. 62 day screening was 66.7%.

Key risks and challenges: High impact improvement actions: • Quarter 4 - 62 performance is at risk if we

are unable to deliver the required actions in the Colorectal pathway.

• Diagnostics (CT) capacity, both scanning and reporting, remain a risk to delivering to target

• The fragmentation of MDT coordinators across divisions and their limited bandwidth due to dual-roles creates a risk that the tracking and escalation of potential breach patients will not be sufficiently timely

• ‘Colorectal Straight to Test’ is the biggest impact for the 62 Day pathway. A business case for two nurses and one administrator will increase triage rates for c.45% to c 100%.

Four Hour Emergency Care Transit Time Standard

Performance analysis The Trust failed to hit the 95 % constitutional standard for Emergency Care. Performance was 80.1% (All type) in February 19 against a trajectory of 94% (All type). The LAS handover times continue with sustained improvement. Last February 2018 the average handover time was 30 mins and this February this is now 18 mins. Key risks and challenges: High impact improvement actions:

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• Non-admitted breaches remain a risk particularly during out of hours. In December, the average non-admitted breaches were 43 a day (55% of total). This is further exacerbated on the days when ED has over 50 patients in the department causing limited spaces for assessment and treatment

• Specialty delays in assessing and then treating patients in ED also result in further non-admitted breaches. This amounts to about 5 to 10 a day

• Inconsistent use of CDU by the ED team on a 24/7 basis is also an issue that is causing breaches to occur during out of hours

2.4 Well Led PDR Compliance

Performance analysis PDR compliance remains at 98.6%, higher than last year’s performance (98.34%). Key risks and challenges: High impact improvement actions: • Achieving 100% PDR completion across

all directorates/divisions. • Supporting managers and staff through

the ePDR process on iDevelop to facilitate more timely submissions and reporting.

• Support those outstanding staff to complete/report PDRs.

Identify reasons for non-completion to tailor support provided from L&OD team.

Mandatory Training

Performance analysis Compliance has increased to the third highest level of the year 91.25%. However three courses are under target. Key risks and challenges: High impact improvement actions: • Continued effort to reach targets for Data

Protection & Security, Fire Safety Level 1 and Infection Control Level 2. Maintaining the upward trend and ensuring all courses are within target.

• Reviewing training capacity against demand for subjects at risk and arrange additional sessions where required.

• Regular monitoring of temporary staffing STaM compliance, ensuring no new joiners to the Bank who are non-compliant and suspending from the Bank

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where workers do not become compliant. Auto-generated reports being sent to the triumvirate on a Monday morning – with view to extending to rest of divisional management team, being discussed at DTMs.

Vacancy and Voluntary Turnover Rates Performance analysis

Both vacancy and voluntary turnover rates have increased in February to 12.08% and 13.65% respectively. Key risks and challenges: High impact improvement actions: • Preventing turnover and vacancy rates

from increasing further.Returning time to hire to within target andreducing voluntary leavers to help reducevacancy rates.

• Bespoke recruitment and retentioncampaigns, for example:- ED review of Middle Grade rotas and

rotational programmes for MGs/SHO- AMU Clinical Model 9 Registrar

programme exploring agencies andMTI scheme

- Explore developmental roles for band2 to band 3 HCAs

- Updating adverts, attending wardmanagers meeting forrecruitment/interview training,gathering insight from student nursesto understand how to improveexperiences

• Tight management of the overseas nurserecruitment agency to ensure thepipeline is maintained

• Review of the overseas nurse pipeline toensure even distribution as far aspossible across wards with the highestneed (focus on Medicine as Surgerydivisions nearly fully established)

• Supporting recruitment team to eliminateblockages to reduce time to hire, with afocus on Band 5 N&M staff

• Refocus and refresh the NHSI RetentionProgramme to provide greater emphasison solutions and engagement across thekey areas of: flexible working; bullyingand harassment; engagement andcareer developmentImplement the organisation-wide ODprogramme, bringing in expert externalsupport to build skills and capability andstrengthen staff engagement

Sickness Absence

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Performance analysis Sickness has reduced to 4.07% with 3474 days lost and a £297,175 estimated salary cost. Key risks and challenges: High impact improvement actions: • Increasing manager capability to

progress long-term sickness cases• Reducing sickness absence rate to

below Trust targetAdditional costs of agency/bank coverdue to short term sickness

• Weekly performance & review (PAR)meetings with Execs to review sicknessdata from the roster and ensure divisionsprogressing with their cases in a timelymanner

• Review and implementation of revisedSickness Absence Policy & guidance

• Ongoing management of cases viaregular one to one meetings withmanagers and HRCs – particular focuson hotspot areas i.e. Hayes Ward anddetermine if any trends in sicknessabsence (i.e. what are the reasons forsickness)

• Monthly case conferences with OH todiscuss and resolve difficult and long-term sickness cases

Accelerate the health & wellbeinginitiatives within the People Strategy tocombat stress at work, includingcoaching conversations and EDIinterventions

Temporary Staffing Usage and Price Caps Performance analysis

A reduction in both agency and bank spend to under £1m each. However Feb was the 4th highest spend of the year. Key risks and challenges: High impact improvement actions: • Reducing reliance on agency medical

bookings as all booked shifts are overNHSI price cap.Reducing the use of off-frameworkagencies for nursing shifts.

• Greater scrutiny and oversight of agencybookings at weekly PAR and Execs.

• Further monitoring and utilisation ofPatchwork to include those outstandingservices yet to go-live on the system.

• Review of current medical and non-medical vacancies including therecruitment stages to support reductionin agency usageContinued implementation of theConsolidated Temporary Staffing Planand review at the WTSB

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Title Care Quality Commission Compliance & Quality Improvement

Report author Jacqueline Walker, Chief Nurse

Report sponsor Jacqueline Walker, Chief Nurse


☒ ☐ ☐

Purpose of Report

For Decision For Assurance For Information

☒ ☐ ☐

Summary

The purpose of this report is to provide assurance on progress of work against the improvement activities that support the Trust in achieving an improved Care Quality Commission rating in its future assessment. The paper outlines progress against the current action plan in relation to closure of must/should do actions and the development of the Trust-wide Improvement Plan which is superseding the thematic action plan that was previously developed and reviewed at the Quality and Safety Committee and Trust Board. The Improvement Plan progress will be reported to the next Quality and Safety Committee meeting and May Trust Board.

Recommendations The Board is invited to approve the Hillingdon Improvement Plan approach.

Links to Corporate Objectives Aim 5: Delivery Area 5: Ensure we have safe, high quality sustainable acute services

Impact

Quality and Safety

To continue to provide the best level of patient care and safety and to achieve an improved future CQC rating.

Legal

Financial

Human Resources



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Care Quality Commission Compliance & Quality Improvement

1. Introduction

The purpose of this paper is to outline the current position with the CQC action plan, describe how the action plan has been developed into the Trust’s preferred quality development plan type structure, whilst linking to other areas of work and recommend how this will be put into practice as a plan across the organisation.

2. Context

The Trust has made improvements since the CQC inspection in March / April 2018. These improvements are across a wide range of areas including improvement required in day‐to‐day operational performance. Following the 2018 CQC inspection there was a requirement for the Trust to produce and manage a specific CQC action plan which covered a number of core services. The Trust has produced a more holistic quality and safety development approach without losing the rigor and discipline put in place to deliver the CQC action plan. In order to effectively manage and control all the various elements of change including dependencies and risks, whilst delivering benefits to the Trust, the establishment of a holistic Improvement plan has been recommended.

3. Current Position

The current CQC action plan concentrates on six core services with 98 actions covering all aspects of the CQC Requirement Notices, Must do and Should do recommendations.

The core services are:

• Critical Care• End of Life Care• Medical Care• Outpatients• Surgical Care• Urgent and Emergency Services

4. Next stage plans

In order to respond to the CQC feedback from the 2018 inspection, and to address feedback from the CCG and NHSI, the current CQC action plan has been reviewed and developed further. The following list includes the areas that the new Improvement Plan will encompass.

Based on the feedback received, further work will include:

• Embedding incidents and complaints management, learning and sharing lessons learned• Improving incident management systems and processes that are lean and practical• Improving serious incident management systems and processes• Develop better risk and incident management training• Improve the application of Duty of Candour /MCA /DoLS• Re-visit of the Board Assurance Framework and associated Committees and meetings,

including Terms of Reference and reporting structure.• Embedding Corporate and Clinical Governance

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• Improve policy management• Refresh the Quality Impact Assessment• Embed the management and training of Sepsis throughout the organisation• Improve the management of the deteriorating patient• Further management of the A&E processes and plans• Embedding the transitional care of children and young people throughout the organisation• Safer care is explored further, policies, plans and processes in place• Improving safeguarding across throughout the Trust• Improve Medicines Management across the organisation• Embed End of Life Care and Mortality with all clinical staff including correct coding• Core data quality improvement• Enhanced Hospital at Night service• Medical devices polices, record keeping and training• Monitoring and improvement of operational standards and national quality requirements

5. Establishing the Hillingdon Improvement Plan

All of the areas of work described above are large and wide‐reaching. There are also significant dependencies and risks attached to them. In order to manage these risks and dependencies, and to create the controls that the Trust and regulators require, it is suggested that a planned approach is adopted to draw the elements of change and improvement together. By taking this approach the Hillingdon Improvement Plan will provide oversight of workstreams to make sure that improvement work is not duplicated or omitted in error, and that the risk of conflicting actions or priorities are managed. Following several discussions with executive directors it was widely agreed that this should be a recognisable plan of work that is distinct and different from previous plans.

There will be 13 workstreams and they will have Senior Responsible Owners (SRO) from Executive Board members of the Trust. The SRO has overall accountability for their workstreams and has responsibility for ensuring it meets its objectives and realises the expected benefits. This does not mean that the SRO has to undertake all the work, but they

must assure themselves that progress is being made in line with the plans and expected outcomes. The overall management role will be fulfilled by the Deputy Chief Executive. All individual workstreams will have a workstream lead who will be responsible for the delivery of all milestones and actions.

Workstreams

• Safety Culture (extraction in Appendix 1)• Governance• Deteriorating Patient• ED• Transitional Care• Safe care• Safeguarding• Medicines Management• End of Life and Mortality• Data Quality• Hospital at Night

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• Medical Devices• Standards and Requirements

6. Governance

The current CQC action plan has wide‐ranging actions some of which are very large and make reporting difficult. In order to bring a hierarchy and therefore granularity to the plan the structure below is suggested.

The new Hillingdon Improvement Plan breaks the projects down into key milestones, milestones and actions so that delivery and reporting can be effectively managed at all levels. Practically this also enables action lists to be generated so that project activity can be delivered in a staged, methodical way rather than trying to work through the plan as a whole. It is suggested that formal reporting is done at key milestone or milestone level and that a single report is produced that is used for all communication regarding the plan.

An Improvement Board has been established to meet fortnightly to review progress against the Improvement plan, highlighting any issues that are challenging the completion of tasks and where support may be required to identify assurance and monitoring arrangements. Key stakeholders: CQC regional team, our CCG colleagues, our local Healthwatch colleagues and NHSI have been invited to attend the meetings on a monthly basis. This will ensure positive engagement and provide external assurance on the Trusts improvement work. This board will report to the Trust Management Executive and then to the Quality and Safety Committee. The Thematic Action Plan will not be updated going forward as the suggested Hillingdon Improvement Plan will supersede it.

7. Current Activities

WalkaboutsA second round of Board leadership safety walkabouts were completed between November 2018-January 2019 with Non-Executive Directors visiting 37 clinical areas to review the steps staff have taken to address issues identified during the Round One visits, to discuss any unresolved safety concerns and to highlight what quality improvement initiatives they are currently working on. A detailed report was provided to the QSC in January outlining the good practice observed during these visits and areas of ongoing concern which included estates maintenance, storage and space difficulties, cleanliness, staffing and equipment issues. Concerns that are identified are being raised with divisional management teams and corporate support services in order to support staff in resolving some of the challenges they are experiencing in delivering a quality service.

It was agreed that the NED-led safety walkabouts should continue on a quarterly basis with each NED participating in an average of three walkabouts per quarter, usually visiting two areas per visit – a commitment of around 2 hours/month. A third round of visits is now underway with a planned review of the programme at the July 2019 QSC.

Infection Prevention and Control

In addition to these walkabouts the Chief Nurse is conducting infection prevention and control reviews with the Soft Facilities Team, Estates staff and the Infection Control Team in order to raise standards with regard to cleanliness and repair of the environmental fabric in the form of remedial works. Themed Fridays and the ward and department accreditation programme as outlined below are also offering robust methods of assessing quality and supporting staff to improve standards in their clinical areas.

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8. Themed Fridays and Ward and department accreditationThemed Fridays have continued to take place every week with a different theme presented by a Subject Matter Expert. These sessions continue to provide essential support to wards and departments by providing information and guidance on best practice and regulatory compliance. Themes in February 2019 have included Safer Sharps management, Venous Thromboembolism risk assessment, medical devices management and Mental Capacity Act and Deprivation of Liberty Safeguards compliance. The results from the Themed Fridays are now available to Ward and Department Managers to enable lessons to be learned and action plans to be put in place to deal with any challenges/non-compliances that are highlighted through this process.

The process has been enthusiastically received by staff who utilise the opportunity to benchmark themselves against others and learn from their peers. Feedback from staff has indicated positive changes in staff behaviours with many stating they feel valued and see their contribution making a difference to patient care.

Results from previous Themed Fridays:

Theme Number of areas visited

Number of questions Overall compliance score

Medicines Management

27 18 77%

Health and Safety 23 19 80%

Resus trolleys/DNACPR

23 15 90%

Safer Sharps 28 15 88%

VTE 28 15 55%

Sepsis – 12 wards visited

• The theory of sepsis management presentation was given by Lead Nurse QualityImprovement & Clinical Standards, followed by a talk on Clinical Management of Sepsis bythe Lead Nurse for Critical Care Outreach. The emphasis was on nursing assessment andsubsequent action.

• Attendees and NEWS (National Early Warning Score) and Sepsis Project Team leads visiteda number of wards to raise awareness of sepsis and undertake scenario training usingclinical case scenarios.

• Outcome: There was a good awareness of sepsis on the wards. Work to embed sepsisscreening and action processes will continue. 83 members of staff were trained using thesepsis scenarios.

• It was recognised that work is also required to embed the NEWS/SBAR (Situation,Background, Assessment, Response) process to ensure appropriate NEWS calls are put out.Nurses should first assess their patients and consider need, rather that automatically puttinga call out when a score of 5 or more is triggered. Also, if the medical team are on the ward aNEWS call is not required as the team can be summoned immediately for help.

Actions are being taken by Subject Matter Experts on completion of the audits with regard to themes that have been identified across departments to ensure there is Trust-wide change. A good example

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of this is reviewing the availability and knowledge of literature available to be provided to patients in relation to Venous Thromboembolism, and the training provided to junior doctors when they join the Trust.

In addition immediate feedback is given to the ward managers/nurse in charge with any actions that can be taken by the ward team to improve performance. Divisional performance reports are a work in progress to ensure that there is reporting to the divisional management team.

The Ward and Department Accreditation programme roll out began on Friday 8th March 2019, at Mount Vernon Hospital. A total of 30 staff were engaged in the process and made up review teams assessing several clinical areas and wards on the Mount Vernon site. Feedback was provided to the clinical teams on the day and grading scores were provided with regard to compliance against the Key Lines of Enquiry (KLOE) utilised by the CQC during their inspections. Daniels ward was awarded a Silver status with no red flags during the assessment period; the other clinical areas were recorded as ‘white’ due to red flags being noted on the day. These areas will have unannounced visits within a two week period and should the red flag issues be resolved they will be given the accreditation grading that the review team felt the ward should be awarded in relation to the KLOE; these included silver and bronze grading’s. On 15th and 22nd March, the inpatient wards at the Hillingdon Hospital are being assessed and accredited accordingly. The model being used is based on the roll out of the ward and department accreditation programme at Chelsea and Westminster NHS Foundation Trust which has seen improvement in standards of practice and compliance; colleagues from CWHT joined the review teams on the MVH site, and are joining us for the assessments taking place on 15th and 22nd March.

9. Working in conjunction with the Hillingdon Improvement Practice (HIP)

The Hillingdon Improvement Practice (lean methodology) will be used to drive improvement forward as identified through the Improvement plan.

10.1 Action required by the Board

The Trust Board is asked to:

• Approve the Hillingdon Improvement Plan approach.

(Workforce Group)

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106


Title Staff Survey 2018: Key Findings

Report author Mette Lasceiwicz, Assistant Director of Learning & Organisational Development



☒ ☐ ☐


For Assurance

For Information

☐ ☐ ☒

Summary

The Trust participates in a national Staff Survey annually. The attached report provides a summary of key findings across 10 key themes arising out of the 2018 Survey. Full details are contained within the appendix within the appendices pack.

Recommendations The Board is invited to note the report and the next steps, and to recommend any additional actions they consider necessary.


The Trust’s workforce is the primary enabler in providing safe, quality care to patients.

Impact

Quality and Safety

Legal Providing a safe and secure working environment for all staff.

Financial

Human Resources

To ensure that the Trust recruits, develops and retains a motivated and high-calibre workforce in the delivery of patient care and safety.


To ensure that the Trust complies with its E&D obligations, policy and strategic commitments.


Staff engagement is a key indicator of morale and well-being and the Trust is committed to improving these important indicators.

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Staff Survey 2018: Key Findings

1. Introduction

This report presents the key messages from The Hillingdon Hospitals NHSFoundation Trust national Staff Survey 2018, an analysis of our current position andnext steps.

From October – December 2018 50% of staff completed the Survey. This was adecrease of 3% from 2017, and it was noted in the November Trust Board that wewere struggling with engagement to complete the Survey in the aftermath of our CQCresults, our deteriorating financial position and challenged A&E performance.However, this result remains above the average national response rate of 44% and isstill an improvement from our 2015 33% response rate.

This paper outlines:

i) Summary results, including key changes from last yearii) Analysisiii) Action planningiv) Next steps.

3. Summary Results

Results have previously been expressed through ‘key findings’. This year, these arereplaced by ‘themes’, which cover ten areas of staff experience. These ten areasare: Equality, Diversity & Inclusion, Health & Wellbeing, Immediate Managers,Morale, Quality of Appraisals, Quality of Care, Safe Environment – Bullying &harassment, Safe Environment – Violence, Safety Culture, and Staff engagement.All ten themes are scored on a scale from 0-10. We have scored below average onseven out of the ten themes, and have only equalled the national average for theremaining three (Quality of Appraisals; Quality of Care; and Safe Environment –Violence).

A full summary of the results are included in Appendix 1.

3.1 Morale and Staff Engagement

This is the first year Staff Morale is measured. The Trust’s score was 5.8%, compared to the national average of 6.1%. The Staff Engagement score was 6.9% compare to the national average of 7.0%. This is the first time in five years that the Trust’s Staff Engagement score has been lower than the national average.

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3.2 Last year 2017 THH top 5 indicators compared to 2018 results

The table below show the five areas in which the Trust performed best last year and what has happened this year.

Top Five Indicators 2017 Change in 2018

Staff motivation at work Not a question this year so unable to compare

% of staff appraised in the last 12 months

92.3% report having had an appraisal in the last 12 month compared to 93.1% in 2017. This is still well above the average of 87.7%

Quality of appraisals This score has fallen from 5.7% to 5.4% and is now in line with the national average

% of staff experiencing physical violence from patience, relatives or the public

At 12.7%, this score is better than the national average of 14.3%. The best organisation reports 10.1%

% of staff/colleagues reporting most recent experience of violence

At 70.7% this score is better than the national average of 65.6%. However, there is a negative downward trend over the last three years

3.3 Last year 2017 bottom 5 (6) indicators compared to 2018 results where possible The table below show the worst five areas indicators from 2017 and what has happened this year (where the comparison is possible).

Worst Five Indicators 2017 Change in 2018

% of staff reporting errors, near misses or incidents witnessed in the last month

Increas to 95.3% from 94.2% in 2017 - a 5 year positive trend that now puts the Trust above national average

% of staff experiencing discrimination at work in the

For discrimination from members of the public: increased from 8.6% -10.5% with the national average at 6.1%

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last 12 months For discrimination from manager or other colleagues: improved, from 12.7%-10.9%. It is still well above the national average of 7.7%

% of staff experiencing physical violence from staff in the last 12 months

Increased from 2.8% - 3.4% this year. National downward trend and average of 1.6%.

% of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months

This has gone up year on year for the last 5 years from 29.6% in 2014 to 30.5% in 2017 and now 32.3% in 2018. This is compared to a stable 5 year national average of 28.4%

% of staff believing that the organisation provides equal opportunities for career progression or promotion

The score has worsened to 77.1% and is below the national average of 83.9%. National scores have also shown a slight, but significant decline in the context of WRES data

3.4 Biggest changes compared to 2017

The areas of the Staff Survey that show the biggest adverse change in from 2017 are in four areas: Quality of care, Health & Wellbeing, Safety Culture and Staff Engagement.

4.0 Analysis

Overall results

The overall results of the Staff Survey 2018 across all ten themes show adverse changes from last year. The results indicate a worsening staff experience, including staff perceptions of quality of care as well as staff engagement. For those indicators where the Trust performed most strongly in 2017, several do remain above the national average, for example, the percentage of staff/colleagues reporting most the recent experience of violence and quality of appraisal; however, performance has not been maintained at the same level. In those areas where the Trust performed worst in 2017, there has been some positive progress, in that the percentage of staff reporting errors, near misses or incidents witnessed in the last month is now above the national average. However, the remaining indicators continue to worsen, or remain worse than the national average, and are of particular concern. These are:

• % of staff experiencing discrimination at work in the last 12 months

• % of staff experiencing physical violence from staff in the last 12 months

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• % of staff experiencing harassment, bullying or abuse from patients, relatives orthe public in the last 12 months

• % of staff believing that the organisation provides equal opportunities for careerprogression or promotion.

Along with some additional areas, these require deep dive analysis to understand further.

Workforce Race Equality Standard (WRES) indicators

Four WRES indicators are driven by the Staff Survey results.

Indicator/ Staff Survey question Movement

% staff experiencing harassment, bullying or abuse from relatives, patients or the public in the last 12 months

This indicator has got worse with more of our BAME (Black, Asian and Minority Ethic) staff experiencing this type of harassment, bullying or abuse, and it is also worse than the Group median

% staff experiencing discrimination from a manager, team leader or other colleague in the last 12 months

This indicator has got better for our BAME staff in the organisation and is also now better than the Group median

% believing that the Trust provides equal opportunities for career progression or promotion

This indicator has stayed the same as last year, although it remains worse than the Group median

% experiencing harassment, bullying or abuse from staff in the last 12 months

This indicator has got worse for our BAME staff and is the same as the Group median

This shows that whilst fewer of our BAME staff are experiencing discrimination from a manager or colleague, more are experiencing harassment, bullying or abuse from the public and from staff. The same percentage of BAME staff believe the Trust provides equal opportunities for progression. This indicates that the EDI (Equality, Diversity & Inclusion) interventions we have put in place have been helpful, but that more time and resource is required if they are to have a wholesale impact. In particular, time and capacity for the Trust’s Equality and Diversity Network leads, together with specialist external EDI support would help to push this agenda forward at pace.

Context

50% of staff completed the Survey, which is above the national average, though lower than the previous year. As noted above, this lower level of engagement with the Survey was highlighted in November 2018, prior to the survey close. Low response rates are an indicator of low engagement. There have been some key changes in the organisational context since 2017, which are likely to have caused both lower levels of response as well as the worsened results. These changes include:

• A deterioration in the financial position, impacting staff experience and perceptionsof care quality;

• The Clinical Quality Commission (CQC) Inspection Report, published in July 2018,which has impacted staff morale;

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• Increasing demand, particularly in emergency care, which has placed increasingpressure on staff across the organisation as well as in A&E Department itself;

• Increasing pressure on staff experience and patient care from the aged anddilapidated estate.

Soft intelligence from across the organisation, including feedback from the Staff Side Chair, indicates that these factors have been a significant driver of the Staff Survey scores this year.

Challenges and constraints

The pressures outlined above have also constrained the organisation’s capacity and capability to address the known issues from the previous Staff Survey, and have mitigated the success of those actions that have been put in place, at both corporate and Divisional levels. The ‘You said, We did’ campaign during the 2018 Survey highlighted the work carried out in response to the 2017 survey (Appendix 2), however, the indications from the 2018 Survey are that staff did not feel that follow up from the previous Survey has been undertaken consistently, timely or at all.

The NHSI Retention Programme included specific actions to address the Staff Survey 2017 results. A KPMG internal audit report in October 2018, which reviewed the NHSI Retention Programme noted that delivery had been constrained by working groups’ focus on known problems, rather than on implementing and testing innovative solutions. They also noted a lack of capacity to support the working groups to deliver, and poor understanding of roles and responsibilities.

5.0 Action planning

The framework for action planning this year is shown below.

Action Dates

Embargo lifted and more data released 26 Feb

Board report & Corporate action plan 6 Mar

Comms to all staff about key themes (including outline of what happens next)

7 Mar

NHSI Retention group refocused; data sent to divisions, analysis completed, and priorities agreed

w/c 11 Mar

Comms sent from divisions (including invites to focus groups/survey) w/c 18 Mar

OD programme commissioned w/c 1 & 8 Apr

Focus groups & survey (using open questions) – improve accessibility, analysis of focus groups

w/c 8/15 Apr

Agreeing action plan & then communicate to all staff w/c 15/22 Apr

Monthly review of action plan with divisions Ongoing

You said, we did campaign Sept 2019

Key actions at a corporate level to address the results this year will be:

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• Delivery of key People Strategy initiatives: this is set out in a separatePeople Strategy Update to the Trust Board in March 2019

• The planned organisation-wide OD programme: this will focus on buildingthe skills and capability we need across the organisation to deliver the bestfor our patients and staff. This programme will also facilitate the change inculture and delivery that is needed and address our engagement scores

• Prioritisation and reinvigoration of the NHSI Retention Programme: this hasWorking Groups which have a pivotal role to play in addressing issues suchas bullying and harassment; staff engagement; career development andflexible working. Members of the Groups will need to prioritise attendanceand delivery of the plans, supported by the People & OD team.

6.0 Next steps

The immediate next steps are to:

• Commission the OD programme, ensuring the support for staff engagement• Review the NHSI Retention Programme and ensure all KPMG recommendations

are addressed with the Working Group ADoN Sponsors• Develop Divisional action plans and monitor delivery at Performance Reviews.

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Title People Strategy 2017-22 Update

Report author Rachel Stanfield, Deputy Director of People & Organisational Development


Status of Report Public Private Internal ☒ ☐ ☐



☐ ☐ ☒

Summary

The Trust’s People Strategy 2017-22 is a key initiative to support delivery of the overall Trust vision and strategy, and to address critical people issues, including recruitment, retention and health and wellbeing. This report summarises progress to date, including the proposal to establish a dedicated People Sub-Committee of the Board to strengthen governance over people issues and strategy. The appendix in the appendices pack contains an overview of the stategy.

Recommendations The Board is invited to note the report and the next steps, and to recommend any additional actions they consider necessary.

Links to Corporate Objectives The Trust’s workforce is the primary enabler in providing safe, quality care to patients.

Impact

Quality and Safety

Legal Providing a safe and secure working environment for all staff.

Financial

Human Resources To ensure that the Trust recruits, develops and retains a motivated and high-calibre workforce in the delivery of patient care and safety.

Equality and Diversity To ensure that the Trust complies with its E&D obligations, policy and strategic commitments.


Staff engagement is a key indicator of morale and well-being and the Trust is committed to improving these important indicators.

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Background The Trust’s People Strategy 2017-22 is a key initiative to support delivery of the overall Trust vision and strategy, and to address critical people issues, including recruitment, retention and health and wellbeing. The People Strategy was developed through extensive consultation with staff and was approved by the Trust Board in September 2017. It includes a range of actions to address these issues across all staff groups. These actions were to ensure that they respond to the relevant pressures.

This paper outlines:

1. People Strategy: implementation to date

2. Impact on key metrics

3. Analysis

4. Next steps.

People Strategy: implementation to date As outlined in the 2018 updates to the Trust Board, multiple initiatives across the People Strategy’s five pillars have been implemented. These include development of the employer brand, streamlined e-recruitment processes, overseas nurse recruitment, implementation of iDevelop, the Learning Management System (LMS), establishment of the Hillingdon Clinical School, and the development of a Coaching Conversations (1:1) Policy. An up to date summary of implementation is included in Appendix 1.

Impact on key metrics The People Strategy included key metrics by which to measure success. The table below illustrates the quantifiable metrics and the change since July 2017, before the Strategy was implemented.

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Metric Target (2022) July 2017 Jan 2019 Movement Comments

Vacancy rate 8% 15.32% 10.94% Nursing vacancies remain higher than the Trust total and requires more, sustained work

Voluntary turnover 13% 14.75% 13.06%

Nursing turnover is rising – out of step with the Trust trend and retention efforts require much more sustained input from managers

Time to hire Top quartile 57 days 37.5 days Target achieved – top quartile

STaM compliance 95% 89.63% 91.49% Current Trust target (85%) is being exceeded

% staff leaving within 12 months Reduce by 10% 15% 9.6% Target achieved

Sickness absence 3% 3.22% 4.76% Increased in 2018/19 over the previous year

Staff Survey Engagement Score Top 20% 7.10 (out of 10) 6.9 (out of 10) Top 20% in 2017

Agency spend Within Carter average £1,156,175 £1,168,209

Agency spend was consistently lower (between £600k and £900k) across 2018/19 than in 2017/18, until Jan 2019 – indicating a short-term loss of grip & control, rather than a longer term problem

Number of staff accessing non-mandatory training 80 (September 2017) 110 (2018/19) We have seen a decrease in

HEENWL funding in 2018/19

% Apprenticeship Levy utilisation 100% n/a 24%

Workforce Race Equality Standard (WRES)

The target here was to improve scores across all indicators. Performance has deteriorated against all WRES indicators where data is available between 2017 and 2019

See the Staff Survey Update paper presented at the March 2019 Trust Board for more detail

For more detail on the WRES scores, see the Staff Survey Update paper submitted to the Trust Board in March 2019.

Analysis

Overall delivery People Strategy implementation has been most successful in the case of organisation-wide projects and process improvements, led by the People & OD team, with support from the Divisions. These include the end-to-end recruitment system, development of the employer brand, direct engagement for agency payments, and the LMS. These have delivered major improvements in key metrics such as vacancy and turnover rates, STaM compliance, time to hire and agency spend.

Whilst these improvements are significant, they have tended to be transactional, structural interventions, rather than transformational interventions designed to tackle culture and behaviours, transform management practice and deliver transformed ways of working, such as the implementation of new roles. Our metrics show an increase in sickness absence and a lowering of staff engagement scores, as well as deteriorating WRES scores. These are indicators of increased pressure on our staff, as well as a reflection on the degree to which managers and leaders have the capacity and capability to engage with the more transformational interventions that are required to respond to this increased pressure. It is these more transformational elements of the People Strategy that now require greater emphasis across the organisation.

Specific challenges There remain specific challenges with delivery regarding nurse recruitment, which is not improving at the same rate as other staff groups. Evidence indicates that effective overseas nurse recruitment is determined by the countries that the nurses are sourced from, and by building a credible reputation in those countries. Prior to 2017, the Trust focused only on EU recruitment. EU countries are associated with lower retention rates, and recruits tend to stay

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only one or two years. Since 2017, we have been targeting India and the Philippines, which tend to have retention periods of five to ten years. Overseas nurse recruitment in India and the Philippines is a relatively ‘slow burn’, as it takes time to build a reputation and competition across Trusts is high; however, the scale of recruitment is balanced against quality of induction and support and the economic benefits of retention. Our in-house OSCE training programme is demonstrating success rates (95% first time pass rate) well above average. This builds the Trust’s reputation overseas and therefore the pipeline of nurses. We need to ensure that the resources and support for effective onboarding are in place for these nurses when they arrive, at both local and corporate levels. We are pursuing collaborative overseas recruitment across London and the STP which will support recruitment at a scale currently not possible within the Trust’s resources.

Overseas recruitment creates a steady pipeline though it is only one recruitment initiative. The People Strategy includes a range of interventions to build nursing numbers and we need to maintain a mixed approach. Retention of all our nurses is equally, if not more important, and is discussed below.

Reducing agency expenditure remains an area of intense focus. Good progress was made from the end of 2017/18 and throughout the most of 2018/19, via implementation of the 247Time Direct Engagement model and improved grip and control. Levels of agency expenditure were consistently lower each month in 2018/19 than the previous year. However, January 2019 has seen a sudden spike in expenditure, indicating a temporary reduction in grip and control. We are addressing this through the Consolidated Temporary Staffing Plan, which is reviewed monthly by the Workforce Transformation Steering Board (WTSB). Current actions include: auditing use of 247Time and ensuring 100% compliance; reviewing processes for booking temporary staff, particularly out of hours; and implementing weekly People and Activity Review (PAR) meetings, led by Executive Directors.

Context The organisational context has significantly changed since the People Strategy was developed. Key points to note are:

• A deterioration in the financial position

• The Clinical Quality Commission (CQC) Inspection Report, published in July 2018, withan overall ‘requires improvement’ rating

• Increasing demand, particularly in emergency care

• A deterioration in operational performance (NHS Constitutional Standards)

• Increasing pressure from the aged and dilapidated estate and difficulty in mitigating theimmediate, high risks it presents

• Need for a clearer clinical strategy for the organisation.

As this context affects our people so directly, these changes have adversely impacted on key metrics, particularly sickness absence and staff engagement scores. This means that those elements of the People Strategy aimed at supporting our people and building their capability and capacity, now also require greater emphasis than originally envisaged.

Challenges and constraints

The changing context has also adversely impacted the capacity and capability of the organisation to engage with and deliver the People Strategy, and particularly the more transformational elements of it, at the pace required. This was highlighted by the KPMG internal audit report in October 2018, which reviewed the delivery of those People Strategy initiatives in the NHSI Retention Programme. KPMG noted that delivery had been constrained by working groups’ focus on known problems, rather than on implementing and

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testing innovative solutions. They also noted a lack of capacity to support the working groups to deliver.

Governance and accountability KPMG also highlighted the clearly defined governance structure overseeing the Retention Programme but noted that this had ‘not operated as designed’. Accountability was identified as needing to be strengthened, and whilst this was partly due to the need to improve process and recordkeeping, it was also linked by KPMG to poor understanding of roles and responsibilities. The Retention Programme is a good example of key People Strategy initiatives being seen as ‘HR projects’, rather than essential frontline operational management tasks, which are necessary to support our staff and patients. KPMG also noted the need to strengthen reporting and monitoring of these initiatives at both Trust Board and Sub-Committee level.

Next steps Key next steps are:

1. Implement an organisation-wide OD programme: this will focus on building the skillsand capability we need across the organisation to deliver the best for our patients andstaff. It will give greater emphasis and resource to enabling key initiatives within thePeople Strategy, such as leadership and management development. Perhaps mostimportantly, this will give renewed impetus to our CARES values and support a culture ofaccountability and responsibility. Values-based behaviours are hardest to maintain attimes of great pressure, yet this is when they are most important. The OD programmeshould ensure that we develop and support our staff through the current challenges andchanges so that we demonstrate our CARES values

Timeframe: this is expected to be an 18-month work programme. A specification isdrafted for commissioning external support and project initiation is expected in April 2019.

2. Establish a dedicated People Board Sub-Committee: this will strengthen governanceand ensure a greater focus and emphasis on people issues, as well as effectiveprioritisation of People Strategy initiatives, improved scrutiny and accountability andsupport for Trust Board oversight

Timeframe: it is expected that this will be established within Quarter 1, 2019/20.

3. Accelerate the health & wellbeing initiatives within the People Strategy: this includesspecific health and wellbeing initiatives, such as stress management, however, it isessential that this also includes initiatives that support our staff and equip our managersto take the decisions that they need to. These initiatives include rolling out coachingtraining and coaching conversations, addressing bullying and harassment, supportingflexible working and career development

Timeframe: the People Strategy includes a milestone plan to deliver key health andwellbeing initiatives and we will now bring these forward where possible to deliver by theend of 2019/20.

4. Realignment of the People Strategy with emerging Trust objectives and strategies: asnoted, the context has shifted since the initial People Strategy development. The Trusthas an emerging three-year improvement journey, with underpinning objectives. Theseobjectives will be further developed, with refreshed clinical and corporate strategies; it isimportant that the People Strategy is aligned to this emerging direction.

Timeframe: this has inter-dependencies with other workstream including the ODProgramme and the clinical strategy; however, we expect this to be completed by the endof Q1, 2019/20.

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Title Bi-Annual Medical Education Report

Report author Dr Stella Barnes, Director of Medical Education (DME)

Report sponsor Dr Catherine Cale, Interim Medical Director


☒ ☐ ☐


For Assurance

For Information

☐ ☐ ☒

Summary

There are currently 201 doctors in training at Hillingdon Hospital (Including GPVTS) with a fill rate of 93% (14 Vacancies). The quality of training is assessed by the annual GMC National Training Survey. Currently, detailed assurance regarding Medical Education is not consistently provided to the Board or its Sub-Committees. With the formation of the proposed People Committee, more detailed reports will be provided to that committee to strengthen the assurance provided. Benchmarking data is contained in the appendix in the appendices pack

Recommendations

The Board is invited to note and comment on the report, in particular: • Continued concerns about out of hours working, as

highlighted in the HEE Risk Based Review, conducted in September 2018;

• Plans for the Hospital at Night team;• The success of the medical education team in being

awarded bid funds and other funds for training from HEE;• Plans for the establishment of a Junior Doctors’

Representation Group.


The Trust’s workforce is the primary enabler in providing safe, quality care to patients.

Impact

Quality and Safety

Legal

Financial

Human Resources To ensure that the Trust recruits, develops and retains a motivated and high-calibre workforce in the delivery of

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patient care and safety.

Equality and Diversity To ensure that the Trust complies with its E&D obligations, policy and strategic commitments.


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Introduction

There are currently 201 doctors in training at Hillingdon Hospital (Including GPVTS) with a fill rate of 93% (14 Vacancies). The quality of training is assessed by the annual GMC National Training Survey, which all trainees are required to complete anonymously, and by Health Education England (HEE). HEE monitor Trust action plans from their visits and the GMC NTS. The Trust also provides training for Medical students from Imperial and Physicians Associate students from Brunel University.

The Board is asked to note that the structure and content of this report is under review. Currently, detailed assurance regarding Medical Education is not consistently provided to the Board or its Sub-Committees. With the formation of the proposed People Committee, more detailed reports will be provided to that committee to strengthen the assurance provided.

1. Challenges identified in the last report and progress against them

a) To reduce the medical staffing out of hours risk on the Corporate RiskRegister by implementing the Hospital at Night (HAN) recommendations.

i. The Hospital at Night plans have been agreed and are in the processof being implemented.

• Two technicians have been appointed to perform basic clinicalprocedures overnight (eg phlebotomy), start dates in March andApril;

• An administrator has been employed to take over theadministrative tasks of the clinical site practitioner (CSP) freeingthem for clinical work. They are currently working 2 evenings perweek and further recruitment is underway

ii. HEE has provided £70,000 to support training for the HAN team. Thisis funding:

• Training for technicians to perform basic procedures• Equipment for training, e.g. blood taking arms, ECG machine• Prescribing courses for CSPs who cannot currently prescribe• Simulation training for the HAN team• iPads for the simulation centre to simulate eObs for use in

deteriorating patient and other scenarios.

b) Establishing an effective junior doctors’ representative body, to addressconcerns affecting all junior doctors, including those not in training posts.A scoping exercise is underway to seek junior doctor opinion about the formatof the JDRG & to draw up terms & conditions, with the aim of having the firstmeeting by the end of May.

c) Gaps in rotas are being addressed by divisions with a robust recruitment planand developing a future vision for the workforce. More detail on this wasprovided in the Safer Medical Staffing Report from January 2019.

d) Implement the action plan agreed as a response to the GMC survey to ensurethat quality of training improves in areas where there were concerns.

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See section 2.

2. Health Education England (HEE) Initiatives

a) As detailed in the last report, communication from HEE to local educationproviders (LEPs) has been poor, for example in giving trusts timely informationabout trainees and in answering queries. As a result, HEEs Health EducationTeam (HET.) have committed to visit trusts and meet with local medicaleducation teams to share information. The first of these meetings happened atHillingdon in autumn 2018. This is a positive initiative, but its effectiveness willneed to be evaluated overt time.

b) HEE are investing in a programme of support for trainees returning after a periodof absence. The trust was successful in bidding for this pilot initiative money,gaining money to deliver teaching locally to supervisors, simulation training forreturning trainees, a champion for returning trainees and a supervisor to be apoint of contact for trainees who are out of programme. These roles are currentlyout to advert

3. Quality Assurance and Governance Process of Education

The GMC Survey 2018 (Summary included in Appendix 1)

As reported previously, 15 actions were identified from the survey, of which 11 remain open but all have plans in place.

HEE Risk Based Review

Given the high number of red outliers in the GMC survey for some of the acute medical specialties, HEE conducted a Risk Based Review in September 2018 of the acute medical specialties (higher specialist training) and emergency medicine (EM) for foundation, general practice and EM trainees. The visit team noted some areas of good practice, namely good clinical supervision and a functioning local faculty group in medicine. However, they had some concerns, particularly about out of hours pressures which resulted in the trust being given 2 immediate mandatory requirements (IMRs) and other mandatory requirements (MRs) which form the basis of an action plan. There are currently 6 open and 4 closed actions. The open actions and responses are summarized below.

Staffing Out of Hours

See Hospital at Night plans detailed in section 1 Locum middle or senior house officer grade staff are being advertised for evenings and weekends to supplement the medical on call team, although the shifts are not always filled. The longer term plan is to staff a second tier on call registrar rota to improve out of hours staffing in line with the Royal College of Physicians “Guidance on Safer Medical Staffing” document (July 2018) using international trainees and a Chief Registrar. International trainees are being interviewed in late March/early April. The Chief Registrar role is currently out to advert.

Induction to the medical take

There is no set process for induction to the medical on take. The short term plan is

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for trainees to be emailed an induction booklet and to attend the AMU weekly management meeting. Other longer term options are being explored, including the use of a Power Point or video induction programme

National Early Warning Score (NEWS) calls

The visit team required the trust to urgently review the NEWS calls system. The Trust NEWS policy has been reviewed and the modified policy is currently being trialed on Grange Ward before being rolled out across the trust. Early feedback from the junior doctors involved is that they are better able to prioritise and they feel it is a safer model.

Cardiac Arrest calls in the Emergency Department (ED)

There is a lack of clarity about who should be the lead responder to cardiac arrest calls in the emergency department (ED or medicine). This is being agreed between ED and the department of medicine.

Exception Report Logins

Some of the trainees at the visit reported that they had not received their exception report logins. All trainees attending the most recent induction have received logins, as had all the medical trainees who attended a recent focus group.

In summary, there has been progress against the actions. Due to the required long time course of some of these actions (eg recruitment) there is a risk that their impact may be insufficient to be reflected in the feedback from the 2019 GMC Trainee survey report (collects data between March & May)

4. Simulation Centre and Training

The new staffing arrangement, with a simulation centre manager and a senior clinicalfellow has provided a more coordinated approach to the management and running ofsimulation as well as developing new courses and bidding for funds to support this.The centre has been successful in bidding for funds to provide the following courses:

End of life care, run jointly by palliative care & general practice. A train the trainercourse is being held on 14th March in preparation.

Simulation training for trainees returning to practice

Multi-professional paediatric simulation for North West London, happening monthlywith good feedback.

Simulation training on prescribing and administering intravenous fluids, run jointlywith Northwick Park hospital is to be piloted at Hillingdon in MarchThe Hospital at Night simulation is reported on in section 1.

5. Junior Doctors Contract- Education Exception Reports

Full reporting on exception reports is provided in the Guardian of Safe workingreports. In the last 6 months, there have been 15 exception reports relating tomissed educational opportunities. Most of these are for foundation doctors missingtheir compulsory training session on Wednesday lunchtimes. In this time period, 8reports were from the same trainee who was on their on-call block at the time.

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Foundation doctors are not expected to attend training when they are on call and are sign posted to appropriate eLearning if they are unable to attend. The trainee in question has been reminded of how to access this training. 2 reports related to missed theatre time in orthopaedics. One was from a core medical trainee who had left clinic an hour early to help out her FY1 on the ward.

6. Supporting Trainers to Train

Faculty development sessions continue with excellent feedback. Further training isplanned over the next few months on supporting trainees returning after a period ofabsence, giving effective feedback and writing a supervisors report.

7. Undergraduate Medical Course- Imperial College

The quality of training for medical students provided by Hillingdon is assessed by theAnnual Governance and Education Monitoring Report. (GEMV) The last report inMarch 2018 was excellent with positive comments relating to clinical teachingfellows, support from the Medical Education team, and high quality formal teaching.The interim action plan in response to the visit includes visibility of educationalprogrammed activities for consultants, ensuring robust processes for studentabsenteeism, and more formalised teaching.The medical school is undergoing a major change to their curriculum with the effectof reducing the number of students at Hillingdon Hospital over the next year.Of note, the department has successfully rolled out simulation training for the year 6medical students on Medicine and surgery attachments this academic year whichhas been very well received by the students.

8. Physician Associate Masters Programme- Brunel University

The programme is now in its 3rd year with an annual intake on 20 students. There arecurrently 5 clinical students on clinical attachments in the trust. 3 consultant staffGeorgios Karagiannis, Shabana Khan & Khaled Saraya have been appointed tolecture first year students.

9. Sharing Good Practice

A group of outgoing FY1s ran a simulated bleep holding session for the new FY1s inthe August 2018 induction. The results of this exercise are being presented at theFoundation Faculty Sharing Good Practice Event on 9th March, hosted by theNational Association of Clinical Tutors (NACT) and the UK Foundation Programme(UKFPO.)

Two posters have been accepted for the SEESAM conference (promoting excellencein medical education) in Glasgow in June, one on the use of SI scenarios insimulation training & one on teaching final year medical students about dealing withdeath.

10. Plans for 2018/19

i) To continue to work with the division of medicine to implement plans inresponse to the GMC survey & HEE visit to provide sufficient staffing, supportand high quality training to acute & emergency medicine.

ii) To use training to support work force change.

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iii) To implement plans to support trainees returning to work after a period ofabsence.

iv) To implement a junior doctor representative group.

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Title Safer Nurse Staffing Update

Report author Vanessa Saunders, Deputy Chief Nurse



☒ ☐ ☐


For Assurance

For Information

☐ ☐ ☒

Summary

The purpose of this paper is to provide assurance that nurse staffing across inpatient areas in February 2019 was sufficient to support safe care and high quality patient experience. The report provides the Board with an overview of the average nurse staffing levels (actual levels against planned levels, expressed as a percentage) for February 2019, together with average Care Hours Per Patient Day (CHPPD).

Recommendations

The Board is invited to note the report, specifically: • The analysis of the data supporting this paper is that in light

of stable Nurse-Sensitive Outcome Indicators, low number ofreported suboptimal staffing incidents and stable number ofCare Hours Per Patient Day, average staffing levels inFebruary were appropriate to need;

• THH: little variance in fill rates for February compared to January although there was an overall upward trend compared to December fill rates;

• MVH: average fill rates showed an upward trend for Registered Nurses for day and night shifts. For Health Care Assistants there was little change for day shifts but an increase noted for night shifts. There was an upward trend compared to December 2018. Movement has been linked to increased activity, supported by the stable average Care Hours Per Patient Day;

• RN vacancies reduced compared to December 2018. Recruitment activity is summarised in Appendix 2;

• Use of agency Registered Nurses to support Trust staff continued to increase in February;

• Use of Health Care Assistant staff was above establishment;• Reporting is by exception (Appendix 2) where indicators have

varied significantly from target and/or increased management action is required to mitigate risk.

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Links to Corporate Objectives Delivery Area 5: Ensure we have safe, high quality sustainable acute services

Impact

Quality and Safety To continue to provide the best level of patient care and safety and to achieve an improved future CQC rating.

Legal

Financial There are no implications arising from the report.

Human Resources


There are no implications arising from the report.


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Safer Nurse Staffing Update

1. Overview

The purpose of this paper is to provide assurance that nurse staffing across inpatient areas in February 2019 was sufficient to support safe care and high quality patient experience. The report provides the Board with an overview of the average nurse staffing levels (actual levels against planned levels, expressed as a percentage) for February 2019, together with average Care Hours Per Patient Day (CHPPD). CHPPD is calculated by adding the hours of registered nurse/midwives (RN/RM) and the hours of health care assistants (HCA) and dividing by the number of patients at 23.59 hours; it is reported split by RN/RM and HCA, and as a total.

To provide context, vacancy and turnover data for the areas covered is also provided; a suite of Nurse Sensitive Outcome Indicators (NSOIs) for each ward is detailed in Appendix 1. This information is triangulated with other intelligence and where there is a need for enhanced surveillance or scrutiny, this is reflected in the R.A.G. rating.

Wards scored as amber in February were:

Ward Concern Risk/s Actions AMU High use of agency

staffing • Lack of continuity of

care

• Inability to fill shifts

• Financial pressure

• Reduced quality

• Poor patientexperience

• Focussed recruitment

• Robust scrutiny ofrota

• Matron reviewingpatient experiencefeedback andidentifying actions

Fleming High use of bank staffing

Friend & Family Test: 86% positive responses

Pinewood Friends & Family Test: 7% negative responses

Churchill Friends & Family Test: 8% negative responses

Further detail regarding actions for overarching themes are summarised in the exception report (Appendix 2).

2. Staffing levels against plan

Average fill rates against planned levels of RNs/RMs and HCAs are calculated, for day and night shifts. In February the overall rates (all inpatient areas per site combined) ranged from 91.6% - 115.7%, as detailed in Fig. 1 below. It can be seen there was a very slight increase in the average fill levels compared to January 2019; average CHPPD were stable compared to previous months.

The average fill rates for each ward can be viewed in Appendix 1; these range from 73.5% to 153.6% across day and night shifts. This wide variation is due to a number of factors including changes in activity (more/fewer beds in use), fluctuations in acuity and dependency, and rota gaps.

There were eight wards with average fill rates for RNs/RMs below 95% of plan. It should be noted that the service model for AMU changed in-month resulting in a change to the actual staffing requirement that was not reflected in the roster template, this will be corrected in coming months. The critical care units (ITU, CCU and NNU) vary their staffing according to activity, which is reflected in fill rates, particularly with reference to use of HCAs which are only

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utilised when additional staffing is required to support the Registered Nurses. In all instances where staffing levels were below plan, available resource was assessed against actual need in real time and mitigating actions taken by the Matrons. There were a total 15 reported incidents of suboptimal staffing for inpatient areas during February 2019, all were reported as not causing any harm.

Twenty areas reported average fill rates above 100% (i.e. above the agreed shift template) for either RNs or HCAs on day or night shifts. With the exception of Alderbourne and the critical care units, these increased fill rates are predominantly associated with Health Care Assistant (HCA) shifts and most frequently night shifts. It should be noted that where usual planned numbers are relatively small, any increase creates a large increase in terms of percentage. Underlying reasons for use of additional duties included:

• Registered Mental Health Nurses (RMN) – a total of 44 recorded shifts• Registered Nurses (RN) with specialist skills, for instance for Intensive Care, for

paediatrics or for 1:1 care of complex acutely unwell patients. In February demand ofthis nature was above establishment, examples including two patients withtracheostomy requiring increased support on Alderbourne ward, and a highly complexpatient requiring 1:1 care from a Registered Nurse throughout the month on Kennedyward.

• Additional capacity opened on CCU, resulting in 47 additional RN shifts.

In terms of Health Care Assistants, there was high use due to patients with confusion or falls risk requiring increased supervision to maintain safety, dignity and comfort.

Fig. 1 Average fill rates and monthly trends

Fig. 2 Average Care Hours Per Patient Day and monthly trends

Site Summary Data February 2019

Day Night Average fill rate RN/RM

Average fill rate Care staff

Average fill rate RN/RM

Average fill rate Care Staff

Hillingdon 95.2% 111.6 101.2% 115.7% Mount Vernon 91.6% 97.9% 92.3% 101.2%

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Site Summary Data February 2019

Care hours Per Patient Day Cumulative count of patients @ 23.59

RN/RM hours per patient day

HCA hours per patient day

Overall hours per patient day

THH 11617 5.3 3.5 8.8 MVH 771 4.5 3.9 8.4

2.1. Financial impact

The combination of shift fill-rate being above plan and high use of agency staffing creates a financial pressure. It is therefore important to ensure effective use of the available resource. A validated electronic tool is used to assess and record patient acuity levels and available staffing on each ward on every shift, the outcome of which is reviewed by the Matrons and discussed at the Trust capacity and safety huddles. Where possible, staff are redeployed between different wards when need is indicated. The senior nursing team is driving work to ensure that rosters are published well in advance so that any known gaps can be filled by the Trust’s own staff. The Lead Nurse for Mental Health is working closely with resourcing colleagues to increase the number of RMNs employed by the Trust’s temporary staffing bank. .

With regards to February, there was a total overspend of £170,655 on staffing across the medical and surgical inpatient wards. Data from the month 11 financial reports shows:

Use of RNs:

• 17.09 WTE below establishment• Overspend of £30,263, due to use of agency staffing• Highest agency spend on was on AMU

Use of HCAs

• 45.47 WTE above establishment• 17.2 WTE of the additional HCAs used were Band 3s. This is partly due to

international nurses working as HCAs whilst preparing for their OSCE examinations togain admittance to the NMC register

• Other reasons include additional duties to support patients requiring enhancedobservation or to replace a vacant RN shift when risk-assessed as appropriate.

3. Vacancies and turnover

Hillingdon Hospital 2018/19 Mount Vernon Hospital 2018/19Sept Oct Nov Dec Jan Feb Sept Oct Nov Dec Jan Feb

RN/RM 5.4 5.3 5.6 5.4 5.4 5.3 RN/RM 4.6 4.4 4.9 4.5 4.6 4.5HCA 3.8 3.6 3.7 3.4 3.5 3.5 HCA 3.5 3.8 3.8 3.7 4.1 3.9Overall average 9.2 8.9 9.3 8.8 8.9 8.8 Overall average 8.1 8.2 8.7 8.3 8.7 8.4

5.4 5.3 5.6 5.4 5.4 5.3

3.8 3.6 3.7 3.4 3.5 3.5

0123456789

10

Sept Oct Nov Dec Jan Feb

Aver

age

hour

s pe

r pat

ient

day

Hillingdon Care Hours Per Patient Day

HCA

RN/RM

4.6 4.4 4.9 4.5 4.6 4.5

3.5 3.8 3.8 3.7 4.1 3.9

0

2

4

6

8

10

12

Sept Oct Nov Dec Jan Feb

Aver

age

hour

s pe

r pat

ient

day

Mount Vernon Care Hours Per Patient Day

HCA

RN/RM

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The tables and graphs below show the number of vacancies (budgeted establishment minus filled posts), new starters and leavers for the inpatient areas covered by this report, over the last six months. The data is provided by Workforce Information and the Head of Resourcing, and is in relation to the clinical areas listed in Appendix 1 and does not represent the vacancy or turnover position for the entire nursing and midwifery staff group.

There was a downward in-month trend in RN vacancies in February, with RN vacancies dropping by just over six whole time equivalents and HCA vacancies by 12.5 whole time equivalents.

Fig. 3 Vacancy and turnover trends for inpatient areas

4. Conclusion

Spikes in activity and patient acuity on specific wards and the use of escalation capacity during February resulted in frequent use of staffing above anticipated headcount and/or financial plan. However CHPPD were stable.

Nurse-sensitive outcome indicators were in line with previous months.

Although staffing demand was increased, the data shows that action was taken to ensure staffing was also increased where indicated. It is reasonable to conclude that nurse staffing levels across inpatient areas in February were overall in line with need.

Vacancies and turnover for inpatient areas

THH 2018/19 Sep Oct Nov Dec Jan Febdraft MVH 2018/19 Sept Oct Nov Dec Jan FebdraftRN/RM Vacancies 144.94 136.83 113.91 116.97 111.15 111.5 RN/RM Vacancies 9.31 9.66 9.17 12.17 11.53 11.53HCA Vacancies 59.42 60.6 62.06 53.4 40.9 40.9 HCA Vacancies 5.11 4.31 2.31 2.31 2.31 2.31RN/RM Starters 13 14 6 7 13 11 RN/RM Starters 1 0 2 0 2 0RN/RM Leavers 14 10 10 8 5 7 RN/RM Leavers 3 1 2 1 2 0HCA Starters 0 12 5 8 13 12 HCA Starters 0 1 2 0 0 0HCA Leavers 7 3 2 3 0 3 HCA Leavers 0 0 0 0 1 0

020406080

100120140

Sep Oct Nov Dec Jan Febdraft

THH Vacancies

RN/RM Vacancies

HCA Vacancies

0.002.004.006.008.00

10.0012.0014.0016.00

Sept Oct Nov Dec Jan Febdraft

MVH Vacancies

RN/RM Vacancies

HCA Vacancies

0

5

10

15

Sep Oct Nov Dec Jan Febdraft

THH Starters and Leavers

RN/RM Starters

RN/RM Leavers

HCA Starters

HCA Leavers0

5

10

15

20

Sept Oct Nov Dec Jan Febdraft

MVH Starters and Leavers

RN/RM Starters

RN/RM Leavers

HCA Starters

HCA Leavers

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Title Clinical Negligence Scheme for Trusts (CNST) incentive scheme for Maternity safety actions

Report author Gillian Pearce, Maternity Governance Midwife; Kate Wilson Business Services Manager W&C, Nikki Jackson DD W&C



☒ ☐ ☐


For Assurance

For Information

☒ ☐ ☐

Summary

The scheme incentivises ten maternity safety actions. Trusts that can demonstrate they have achieved all of the ten safety actions will recover the element of their contribution relating to the CNST maternity incentive fund and will also receive a share of any unallocated funds. The 3 appendices in the appendices pack provide the detail of the scheme.

Recommendations

The Board are invited to confirm that: it has reviewed the current progress and interim quarterly reports and noted actions that are underway to ensure compliance with the expected standards by the relevant dates. Specifically Safety Actions 3 and 4 require sign-off in March 2019.

Links to Corporate Objectives Delivery Area 5: Ensure we have safe, high quality sustainable acute services

Impact

Quality and Safety To continue to provide the best level of patient care and safety.

Legal

Financial

The report if accepted in its entirety can result in a saving of up to 10% of the hospital premium paid into the Clinical Negligence Scheme for Trusts for Maternity services

Human Resources Equality and Diversity


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1. Introduction

NHS Resolution is operating a second year of the Clinical Negligence Scheme for Trusts (CNST) maternity incentive scheme to continue to support the delivery of safer maternity care.

The maternity incentive scheme applies to all acute trusts that deliver maternity services and are members of the CNST. As in year one, members will contribute an additional 10% of the CNST maternity premium to the scheme creating the CNST maternity incentive fund.

As in year one, the scheme incentivises ten maternity safety actions. Trusts that can demonstrate they have achieved all of the ten safety actions will recover the element of their contribution relating to the CNST maternity incentive fund and will also receive a share of any unallocated funds.

Trusts that do not meet the ten-out-of-ten threshold will not recover their contribution to the CNST maternity incentive fund, but may be eligible for a small discretionary payment from the scheme to help them to make progress against actions they have not achieved. Such a payment would be at a much lower level than the 10% contribution to the incentive fund.

The 10 criteria to be met are: (Detail shown in Appendix I).

1. Use of the National Perinatal Mortality Review Tool to review perinatal deaths2. Submission of data to the Maternity Services Data Set to the required standard3. Demonstration that transitional care facilities are in place and operational to support

implementation of the ATAIN programme4. Demonstration of an effective system of medical workforce planning5. Demonstration of an effective system of midwifery workforce planning6. Demonstration of compliance with the four elements of the Saving Babies’ Lives Care

Bundle7. Demonstration of a patient feedback mechanism for maternity services, such as the

Maternity Voices Partnership forum, regularly acting on feedback8. Evidence that 90% of each maternity staff group have attended an in-house multi-

professional maternity emergencies training session within the last training year9. Demonstration that Trust safety champions are meeting bi-monthly with board level

champions to escalate locally identified issues10. Report 100% of qualifying 2017/18 incidents under NHS Resolution Early Notification

scheme.

In order to be eligible for payment under the scheme, trusts must submit their completed Board declaration form to NHS Resolution by 12 noon on Thursday 15 August 2019, and must comply with the following conditions:

• Trusts must achieve all ten maternity safety actions, including interim deadlines andquarterly reports to The Board

• The Board declaration form must be signed and dated by the Trust Chief ExecutiveOfficer to confirm that:

o The Board are satisfied that the evidence provided to demonstrateachievement of the ten maternity safety actions meets the required standardsas set out in the safety actions and technical guidance document.

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o The content of the Board declaration form has been discussed with thecommissioner(s) of the Trust’s maternity services.

• The Board must give their permission to the Chief Executive Officer to sign the Boarddeclaration form prior to submission to NHS Resolution.

1. Progress against the 10 criteria (Appendix 1)

Safety Action 3 and 4 require review by the Trust Board March 2019:

3) Can you demonstrate that you have transitional care facilities that are in place andoperational to support the implementation of the ATAIN Programme?

An action plan is presented for sign off by the Trust Board

4) Can you demonstrate an effective system of medical workforce planning?

Proportion of trainees formally recorded in Board Minutes and the action plan to address lost educational opportunities should be signed off by the Trust Board and a copy submitted to RCOG.

Three other criteria are already compliant:

7) Can you demonstrate that you have a patient feedback mechanism for maternityservices, such as the Maternity Voices Partnership (MVP) Forum, and that youregularly act on feedback?

Yes, compliant. This will be presented to Trust Board in July 2019.

9) Can you demonstrate that the trust safety champions (obstetrician and midwife) aremeeting bi-monthly with Board level champions to escalate locally identified issues?

Yes, compliant. This will be presented to Trust Board in July 2019.

10). Have you reported 100% of qualifying 2017/18 incidents under NHS Resolution's Early Notification scheme?

Yes

Five criteria are in progress and will be reported to the Trust Board July 2019. (Submission deadline 12 noon 15th August 2019):

1) Are you using the National Perinatal Mortality Review Tool (NPMRT) to reviewperinatal deaths?

Yes this is on track and will be presented to Trust Board quarterly in May and July 2019. Interim report (for information) on cases from 3rd quarter 2018-19 (prior to dates for CNST reporting) included as Appendix 3

2) Are you submitting data to the Maternity Services Data Set (MSDS) to the requiredstandard?

MSDS (v2) readiness questionnaire must be completed and returned to NHS Digital by 1st March – this has been completed.

On track to meet standard.

5) Can you demonstrate an effective system of midwifery workforce planning?

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The Birthrate + Tool assessment was undertaken in 2016. The next assessment is due end of 2019.

Midwifery Red Flags to be presented to Trust Board in July 2019.

6) Can you demonstrate compliance with all 4 elements of the Saving Babies' Lives(SBL) care bundle?

To be presented to Trust Board in July 2019.

8) Can you evidence that 90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the lasttraining year?

This is monitored on the Maternity Dashboard. It will be on IDevelop to ensure that midwives and managers can see whether their members of staff are compliant. Weekly in house training sessions on the ward areas - training standards will be compliant prior to submission to CNST in August 2019.

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Title Data Security and Protection Toolkit; 2019 Self-Assessment

Report author Olu Fasanya, interim Information Governance Manager

Report sponsor David Stonehouse, Finance Director & Senior Information Risk Owner (SIRO)


☒ ☐ ☐



☒ ☐ ☐

Summary

The Data Security and Protection Toolkit (DSP Toolkit) was launched in April 2018 and replaces the Information Governance Toolkit. An appendix in the pack contains the toolkit action plan

Recommendations

The Board is invited to: a) note that the Trust has not yet met the standards of the DSPToolkit and is expected to be awarded a status of ‘Standards notfully met (Plan Agreed)’;

b) approve the recommendation to delegate authority to theFinance Director & Senior Information Risk Owner (SIRO) toformally submit the Data Security & Protection Toolkit self-assessment on 31 March 2019.

Links to Corporate Objectives To be compliant with legal, regulatory and statutory obligations

Impact

Quality and Safety

Legal Compliance with information governance guidance

Financial There are no financial penalties for not meeting the standard.

Human Resources Equality and Diversity


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1. Introduction

The Data Security and Protection Toolkit (DSP Toolkit) was launched in April 2018 and replaces the Information Governance Toolkit.

There is a contractual obligation to complete the toolkit and publish an assessment that evaluates whether we have provided evidence for all the mandatory evidence items and confirmed the assertions.

The status of health and care organisations’ DSP Toolkits will be shared with the Care Quality Commission, NHS England and NHS Improvement. The DSP Toolkit Status is important evidence for the Key line of enquiry on Information in a CQC Well-Led inspection.

Organisations will be listed on the DSP Toolkit with their status displayed available for commissioners, partner organisations and the public.

This report sets out the standard the Trust has achieved. Appendix I provides details of the status for each assertion.

2. Assessments

Unlike the old toolkit which was based on attaining at least a level 2 against each requirement, the DSP Toolkit expects organisations that have provided evidence to support all mandatory assertions to achieve a level of ‘Standards Met’.

With this being the first year of the DSP Toolkit Standard, organisations will be allowed to publish a DSP Toolkit if they are approaching a level of ‘Standards Met’ in all but a few areas. Such organisations will be required to provide an Improvement plan of how they are going to bridge the gap between their current position and meeting the DSP Toolkit ’Standards Met’.

Improvement plans must be approved internally with the SIRO and expected to provide regular updates on the plan’s progression to NHS Digital until it is complete

3. Peer Review

A Peer Review of the DSP Toolkit requirements was undertaken on the 11th March 2019 with the ICT Security Officer to validate the evidence and to confirm the evidence used to support the assertions prior to final submission on 31st March 2019 is correct. Following best practice, an external audit will be introduced in subsequent years to strengthen the review exercise.

4. Final Assessment

The Trust has to date, provided evidence to support 87 out of 104 assertions. 6 are partially complete and 11 will not be completed by the March 31st submission deadline. On the basis of the 11 incomplete assertions and in full anticipation that the

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improvement plan will be agreed by NHS Digital, the Trust is expected to be assessed at the level of ‘Standards not fully met (Plan Agreed).

5. Gaps

The main gaps between the current position and meeting the DSP Toolkit ‘Standard Met’ are:

1.4.1 A record (e.g. register or registers) that details each use or sharing of personal information including the legal basis for the processing and if applicable, whether national data opt outs have been applied.

1.4.2 Have information flows been approved by the SIRO or equivalent local method?

1.4.3 Date of when information flows were approved by the Board or equivalent.

1.4.5 List of systems which do not support individual login with the risks outlined and what compensating measures are in place.

1.6.5 Date of last audit of pseudonymisation, anonymisation or de-identification controls.

1.6.6 Overall findings of last audit of [pseudonymisation, anonymisation or de-identification] controls.

10.2.1 Basic due diligence has been undertaken against each supplier according to ICO guidance.

10.2.2 Percentage of suppliers with data security contract clauses in place.

An improvement plan to complete all outstanding assertions by the 31st July 2019 has been developed with an owner assigned to each action item. Progress will be reported to and monitored by the Data Security and Protection Group chaired by the SIRO. These meet every two months and report to the Audit and Risk Committee

6. Risks of non-complianceThe DSP Toolkit status including those that haven’t published a DSP Toolkit will benotified through NHS England/Improvement to the Cyber Risks and Operationsgroup and if appropriate they will be flagged as a Trust of concern.

Regulations do not stipulate a time frame for completing the improvement plan.

There are no financial penalties for not meeting the standard.

7. Board Action Required

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The Board is asked to note the expected level of ‘Standards not fully met (Plan Agreed)’ achieved by the Trust and approve the recommendation made to formally submit the Data Security & Protection Toolkit self-assessment for 2019 delegating final authority to submit the toolkit to the Finance Director.

The Board is also asked to note that an improvement plan to complete all outstanding assertions by the 31st July 2019 has been developed and it will be the responsibility of the SIRO to ensure delivery to deadlines.

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Apppendix I: 2019 Data Security & Protection Toolkit Assertions

34

3 6

4 7

3

6 1

12 6 9 9

2 2

Summary:

Complete 90 86.5%

Partially completed and can be improved 6 5.8%

Will not complete before deadline 8 7.7%

Total Assertions 104

Standard 1: Personal Confidential Data

Standard 2: Staff Responsibilities Standard 5: Process Reviews Standard 3: Training Standard 4: Managing Data Access

Standard 6: Responding to Incidents Standard 7: Continuity Planning Standard 8: Unsupported Systems Standard 9: IT Protection Standard 10: Accountable Suppliers

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Ref. Question Status Comment RAG Rating

1.3.2 Transparency information is published and available to the public.

Partially completed but can be improved

Privacy Notices should have better visibility on the Trust website

1.3.3 How have Individuals been informed about their rights and how to exercise them?


Information on data subject rights and how these rights can be exercised should be published to the Trust website

1.4.1 A record (e.g. register or registers) that details each use or sharing of personal information including the legal basis for the processing and if applicable, whether national data opt outs have been applied.

Not completed by March 31 2019 submission deadline

The record / register will be dependent on the completion of a Trust-wide data flow mapping exercise. Improvement plan will be completed by 31st July 2019.

1.4.2 Have information flows been approved by the SIRO or equivalent local method?


Dependent on completing 1.4.1

1.4.3 Date of when information flows were approved by the Board or equivalent.



1.4.4 Provide a list of all systems/information assets holding or sharing personal information.


The Trust has an information asset register which needs to be updated. Completing 1.4.1 will facilitate this.

1.4.5 List of systems which do not support individual login with the risks outlined and what compensating measures are in place.



1.6.5 Date of last audit of pseudonymisation, anonymisation or de-identification controls.


Awaiting confirmation from Informatics

1.6.6 Overall findings of last audit of [pseudonymisation, anonymisation or de-identification] controls.


Awaiting confirmation from Informatics

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3.3.1 Percentage of Staff Successfully Completing the Level 1 Data Security Awareness training.


This is expected to be at 95% but is currently at 87.8%.

3.4.2 Number of staff completing specialist Data Security Training.


Not all key roles have completed specialist data security training.

3.5.3 Percentage of Board Members completing appropriate data security and protection Training.


38% (5 out of 13) have completed training. Ideally this should be 100%.

10.2.1 Basic due diligence has been undertaken against each supplier according to ICO guidance.


Plan for completion by 31st May 2019 has been agreed with Procurement & Supplies.

10.2.2 Percentage of suppliers with data security contract clauses in place.


Will be determined when 10.2.1 is completed.

RAG Rating

Partially completed and can be improved

Will not complete before deadline

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Title Committee reports back


Report sponsor Richard Sumray, Chair


☒ ☐ ☐


☐ ☐ ☒

Summary Reports any formal escalation on areas of concern for

decision by the Board and allows feedback from Chairs

Recommendations The Board of Directors is invited to note the report Links to Corporate Objectives Meeting compliance and reporting requirements.

Impact

Quality and Safety Legal

Financial Human Resources Equality and Diversity


Finance & Performance Committee – Richard Sumray Quality & Safety Committee – Lis Paice Audit & Risk Committee – Richard Whittington Charitable Funds Committee – Richard Sumray Nominations Committee – Richard Sumray Remuneration Committee – Soraya Dhillon

Finance and Performance Committee February and March 2019 – Chair R Sumray

Escalations to the Board by the Committee – none

Quality and Safety Committee February and March 2019 – Chair L Paice


Charitable Funds Committee March 2019 – Chair R Sumray


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144


Title Committee reports back


Report sponsor Richard Sumray, Chair


☒ ☐ ☐


☐ ☐ ☒

Summary Provides the minutes of Committee meetings in the appendices pack

Recommendations The Board of Directors is invited to note the report Links to Corporate Objectives Meeting compliance and reporting requirements.

Impact

Quality and Safety

Legal Financial Human Resources

Equality and Diversity Engagement and communication

Summary of Meetings - update until 21st March 2019 Committee Meeting date

2017 Minutes included in Part I Board Papers

Notes on exclusion

Charitable Funds 20 November Yes Nominations 9 January Not yet Awaiting clearance April meeting Audit and Risk 14 January Not yet Awaiting clearance April meeting Quality and Safety 21 January Yes Finance & Performance 22 January Yes Quality and Safety 18 February Yes Finance & Performance 21 February Yes redacted in relation to a contract Quality and Safety 18 March Not yet Awaiting clearance April meeting Finance & Performance 20 March Not yet Awaiting clearance April meeting Charitable Funds 21 March Not yet Awaiting clearance June meeting

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Documents

The Hillingdon Hospitals NHS Foundation Trust Part …...2019/03/27 · The Hillingdon Hospitals NHS Foundation Trust Part I (Open) Meeting of the Board of Directors Wednesday 27th