Trust Public Board of Directors · 2 days ago · Trust Board of Directors- Public – Thursday 24 September 2020 Page 1 of 3 Trust Public Board of Directors Agenda Date: Thursday

Trust Board of Directors- Public – Thursday 24 September 2020

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Trust Public Board of Directors Agenda Date: Thursday 24 September 2020 Time 1000 - 1300

Venue: Skype Call

Chair: Tony Fox (TF), Chairman

Members:

Tim Bishop (TB), Gail Bragg (GB), Nick Cullen (NC), Jessica Cunningham (JC), Tony Fox (TF), Martin Holloway (MH), Jonathan James (JJ), Venessa James (VJ), Minesh Khashu (MK), Paul Love (PL), Vikki Mathews (VM), Clare Melbourne (CM), Andy Smith (AGS) William Warrender (WW) and Jenny Winslade (JW)

Attendees: Marty McAuley (MM), Yvonne Burke (YB) – Unison and

Margaret Batty – Governor

Minutes: Julie Smalley (JS)

Opening Business 1000 - 1030

No Topic Purpose Format Lead

1 Check In - Verbal TF

2 Welcome and Introductions. Apologies: Martin Holloway

Information Verbal TF

3 Declarations of Interest Information Verbal MM

4 Questions from the Public Information Verbal MM

5 Minutes of Previous Meeting: 30 July 2020 Approval Paper 1 MM

6 Action Point Register Approval Paper 2 MM

7 Report from the Chairman Assurance Verbal TF

8 Report from the Chief Executive Assurance Verbal WW

9 Patient Experience Assurance Verbal JW


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Operations 1030 - 1050

10 Executive Director Report: Operations Assurance Paper 3 JC

11 Integrated Corporate Performance Report Assurance Paper 4 JC/JW

Every Patient Matters 1050 - 1150

12 Executive Director Report: Quality and Clinical Care Assurance Paper 5 JW

13 Committee Assurance Report – 13 August 2020 Assurance Paper 6 VJ

14 Quality Account Approval Paper 7 JW

Every Team Member Matters 1150 - 1200

15 Executive Director Report: People and Culture Assurance Paper 8 CM

16 Workforce Race and Disability Equality Standard Report

Approval Paper 9 CM

Every Pound Matters 1200 - 1230

17 Executive Director Report: Information Management and Technology (IM&T)

Assurance Paper 10 TB

18 Executive Director Report: Finance Assurance Paper 11 JJ

19 Charitable Funds Annual Account 2019/20 Approval Paper 12 JJ

20 Committee Assurance Report – 10 September 2020 Assurance Paper 13 GB

Governance, Risk and Audit 1230 - 1250

21 Revised Trust Constitution Approval Paper 14 MM

22 Joint Board Assurance and Risk Report Assurance Paper 15 JW

23 Committee Assurance Report – 10 September 2020 Assurance Paper 16 PL


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Items for information 1250 - 1255

24 Summary Report – Suspected Coronavirus (COVID-19) in SWASFT March-May 2020 -

Information Paper 17 JW

25 Quality Committee Minutes –

16 April 2020 Information Paper 18 MH

26 Audit and Assurance Committee Minutes –

16 June 2020 Information Paper 19 PL

Closing Business 1255 - 1300

27

Questions Arising from the Meeting

Any Other Business

Identification of New Risks (incl. Health & Safety) and New Legislation

- Verbal TF

28

Exclusion of the Press and Public

To consider whether pursuant to the provisions of section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, the press and public be excluded from the remainder of the meeting on the grounds that publicity would be prejudicial to the public interest by reason of the confidential nature of the business about to be transacted.

Approval Verbal TF

29 Check Out - Verbal TF

Date of Next Meeting: 26 November 2020 Dartington Hall, Totnes, TQ9 6EL 1000 - 1300

Paper 1

Z:\Meetings\Board & Committee Meetings\Board of Directors\Board Papers\2020-21\4. 24 September 2020\Public\Paper 01 - Minutes\DRAFT Trust Public Board Meeting Minutes 30 July 2020 V2.docx

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Minutes Trust Public Board of Directors

Date: 24 September 2020

Paper Title: Minutes of Trust Public Board of Directors Meeting 30 July 2020

Prepared by: Julie Smalley, Executive Assistant and Business Manager to Chief Executive

Presented by: Tony Fox, Chairman

Action: Approval

Recommendation: The Trust Board of Directors is asked to review and approve the Minutes from the Trust Public Board of Directors Meeting on 30 July 2020.

Confidentiality Status Implications

Trust Public Board of Directors Meeting 30 July 2020 at 10:00 hours Skype Members: Mr T Fox TF Chairman Mr W Warrender WW Chief Executive Mr P Love PL Non-Executive Director Mrs V James VJ Non-Executive Director Mrs G Bragg GB Non-Executive Director Dr J Richards JR Non-Executive Director Dr A Smith AGS Executive Medical Director Mr T Bishop TB Executive Director of IM&T Mrs J Winslade JW Executive Director of Quality and Clinical Care Mrs A Beet AB Executive Director of People and Culture Mrs J Cunningham JC Executive Director of Operations Mr J James JJ Acting Executive Director of Finance Non Members: Mr M McAuley MM Trust Secretary Observers:


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Mr B Sivewright BS Appointed Governor for Air Ambulance Charities Ms C Melbourne CM Deputy Director of People and Culture

No Agenda Item Action

1.0 Welcome, Introduction & Apologies

1.1 1.2 1.3

TF welcomed everyone to the meeting and thanked them for attending. TF welcomed; Will Warrender to his first Trust Public Board Meeting as Chief Executive of the Trust. Clare Melbourne who would be covering for the Executive Director of People and Culture during Amy Beet’s Maternity Leave. Bill Sivewright, Appointed Governor for Air Ambulance Charities. Apologies were received from Martin Holloway, Professor Minesh Khashu and Nick Cullen.

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Questions from the Public

3.1 There were no questions from the public on this occasion.

4.0 Minutes of Previous Meeting: 28 May 2020

4.1 The Minutes of the previous Meeting of 26 March 2020 were approved as a correct record of proceedings.

5.0 Action Point Register

5.1 The Action Point Register was reviewed and approved by the Trust Board of Directors.

6.0 Patient Experience

6.1 6.2

The Executive Director of Quality and Clinical Care presented the Patient Experience. A complaint had been received in February 2019 from the wife of a patient who was having a heart attack and died. The complaint was with regards to the lack of staff engagement with her during the event and about their lack of compassion.


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6.3 6.4 6.5 6.6 6.7

The Executive Director of Quality and Clinical Care advised the Trust Board of Directors that communication is a common theme in complaints. GB asked if the Emergency Care Assistant (ECA) had received feedback as it may have been that the ECA did not know what to say. The Executive Director of Quality and Clinical Care advised that those involved had been notified and supported by the local Operations Officer. Comms is an issue and work has been undertaken with the People and Culture Directorate, Operations Directorate and Learning and Development Team to ensure this is addressed. The Executive Director of Operations asked if a reflective piece had been done by the member of staff. ACTION: The Executive Director of Quality and Clinical Care would check for the reflective piece. VJ noted that compassion can be a difficult quality to display for many. It may well be that this person found it hard due to the shocking circumstances. As reflective pieces from our people there may also be a requirement for training. The Executive Director of People and Culture suggested that the experience could be anonymised and used during induction of ECAs and frontline staff to emphasize the importance of engaging with the family. The Executive Director of Quality and Clinical Care advised that the team was going to review bringing to life the experiences so that they can be used in a positive way. A previous experience had already been shared where a member of the public attended the Trust Board and was very happy for their story and the video to be shared and that had been useful. The Executive Director of Quality and Clinical Care confirmed that the process and response to the complainant had been completed in 2019. The Chief Executive was concerned that there was a trend and that the training needed to be addressed. ACTION: JW to take a deep dive in relation to communication complaints to the Quality Committee in November 2020. Quality Committee would continue to monitor complaint themes and trends

JW JW

7.0 Report from the Chairman

7.1 Board engagement:

Regular catch ups with the Chief Executive

Catch up calls and portfolio re-aligning for the NEDs – written to STP/ICS Chairs to advise that the NEDs will attend meetings across the region.

Catch ups / welfare calls with the Executive Team.

Visited new Exeter Ambulance Station/Exeter HART Base Station.

Continuing to look at how NEDs can seek assurance whilst social


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distancing measures in place. GB had recently trialed a day of Skype calls with team members across her portfolio / Trust areas including; Governors, County Commander, Peer Support Guardian, Hub people and these were very useful. The Dee Nix, Lead Governor joined the Governor Meeting with local Governors from GB’s area. Dee would be writing a piece for the Governors Newsletter and suggesting role out to the NEDs. It was noted that the Trust Secretary would be available to set up the Skype Calls.

Chief Executive and NEDs visited to West Midlands Ambulance Service Hub.

Recruitment for Interim Executive Director of People and Culture had taken place.

Committee engagement since May Board:

Audit and Assurance Committee end of June for accounts.

Finance Committee.

People and Culture Committee.

Health, Safety, Security and Infection Prevention Control (HSSIPC) Committee.

Governor Engagement:

Regular monthly catch up calls with Governors.

First Council of Governors Meeting with the new Chief Executive took place at the beginning of July 2020.

External engagement:

SW Regional Chairs call

Call with Chairs of Torbay Hospital, Bristol Royal Infirmary and Gloucestershire Hospitals and Dorset CCG.

SWASFT BAME Forum meetings.

AACE BME conversation via Zoom.

SW Regional call with; Elizabeth O’Mahony, all Trust Chairs/CEOS and STP/ICS Leads and Chairs and Simon Stevens, Chief Executive of the NHS, to review contingency plans and what the next six months might look like for the NHS.

AACE Chair’s call.

8.0 Report from the Chief Executive

8.1 8.2

The Chief Executive updated on the Trust Board on his Tour of the Trust to meet our people. The Chief Executive had attended; AACE Meetings, Regional Chief Executive


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8.3 8.4 8.5

Meetings and Commissioners. The Chief Executive had a planned Introductory Meeting with the High Sheriff of Somerset on 3 August 2020. The Chief Executive and Nick Cullen, NED had visited West Midlands Ambulance Service Hub at Rubery. This visit provided a useful insight into lessons learned from their Target Operating Model. The Chief Executive noted the increased activity levels and the impact on the service and wider NHS in the region.

9.0 Executive Director Report: Operations

9.1 9.2 9.3 9.4 9.5 9.6 9.7

The Executive Director of Operations gave a presentation on the work of the Operations Directorate for assurance to the Trust Board of Directors. The Executive Director of Operations gave assurance that on review of the national averages of performance the Trust was sitting well in terms of the metrics and she had no concerns. National call answering and pick up was within 5 seconds and the Trust was sitting at 99-100%. The Executive Director of Operations that for the mean call answering time of 3 seconds all trusts were performing incredibly well. All ambulance services are well below the national target. For National Ambulance Benchmarking Category 1 Mean Response Time of within 7 minutes the Trust was doing well at 6 mins 41 seconds. For the Category 2 mean the Trust missed the target by a small amount of time above 18 minutes. The latest data for July 2020 showed that there were seven Trusts above 18 minutes and three Trusts operating the layer below, below 15 minutes. The Executive Director of Operations advised that the detail on this was included in the Integrated Corporate Performance Report today. The Executive Director of Operations advised that Fleet, Logistics and the Make Ready Teams had been welcomed into the Operations Directorate. The Executive Director of Operations reported that the Specialist Paramedics had been supporting the closing of calls in the Hubs. The Conveyance Team was reviewing performance in terms of COVID and the weather. The Team would be able to track forecast against planned levels of activity and this would be monitored at the Trust Resource Management Group (RMG) weekly.


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9.8 9.9 9.10 9.11

Forecasting Tool: Next steps would be the presentation of the resourcing position and then the next phase would be to link that to performance with the aim to bring the forecast view for resourcing to the Trust Board of Directors. The medium term view would be added to the Annual Resilience Plan to sweep up winter and create a medium term rolling view. ACTION: The Executive Director of Operations would bring the Forecast Medium Term View Presentation to the Trust Board of Directors in September 2020. TF asked if there was anything for the forecasting of Category 2s. The Executive Director of Operations advised that the first steps would be to get the forecasting right and square away the resourcing link and then once confidence was achieved the Team would turn their attention to the performance output. The Team does have a measure of performance hours per incident but would want to take the further step to produce a more accurate prediction of performance. The Chief Executive asked if the Team was in contact with the Meteorological (Met) Office. The Executive Director of Operations confirmed that the Trust Forecasting and Capacity Planning Manager was working closely with the Met Office. The Trust Board of Directors took assurance from the Executive Director Report: Operations.

JC

10.0 Integrated Corporate Performance Report (ICPR)

10.1 10.2 10.3 10.4 10.5

The Executive Director of Operations presented the ICPR for assurance to the Trust Board of Directors. The Executive Director of Operations highlighted the Resource Hours Per Incident (RHPI) and the Trust Board of Directors noted that compared to 2019 resourcing was up by 20%. The Trust Board of Directors noted that for the Category 3 mean there had been a 30 minute improvement. PL noted the improvement in sickness absence and asked if this was attributed in part to increased infection prevention and control and whether there was anything driving that or helping embed that going forwards. The Executive Director of Operations advised that all staff felt a responsibility to be at work or functioning during the pandemic. Some pressure was now returning to some areas with spikes in short term sickness. Work was being undertaken to return to focusing attention to detail with timeliness of sickness reviews. The Chief Executive recognised that once the challenge of the pandemic was


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10.6

realised our people had pulled together. Welfare of our people and how this is provided had been one of the highest areas of feedback during his Tour of our people and the Trust following his appointment in July 2020. The Executive Director of People and Culture supported the learning taken from those who had to self-isolate during COVID. There had been a significant amount of upset and distress from those members of our people because they were unable to work and be part of the SWASFT team. The Trust Board of Directors took assurance from the ICPR and congratulated the Directorates that the Trust had been green across all metrics for June and July.

11.0 Executive Director Report: Quality and Clinical Care

11.1 11.2 11.3 11.4 11.5

The Executive Director of Quality and Clinical gave a presentation on the work of the Quality and Clinical Directorate for assurance to the Trust Board of Directors. The Executive Director of Quality and Clinical Care advised that the decision had been made previously at the Board to not have follow ups regarding Patient Experiences presented to the Trust Board as this meant the Trust Board would be focusing on the follow up and not the experience. Feedback on how to present the experience in the future was welcomed. The Patient Experience presented to the Trust Board would be moving to a virtual platform for the meetings moving forward. GB noted from the earlier discussion that poor attitude of our people was a principle theme and asked if that was a recent increase. The Executive Director of Quality and Clinical Care advised poor attitude and comms may have increased due to the change in profile of complaints over the preceding months. Delays had been a significant area of complaints but they had decreased as resourcing plans had been implemented. ACTION: Complaint themes and trends would continue to be shared with the Trust Board and in depth at the Quality Committee. JR asked if there had been an increase in complaints month on month profile and noted the need to ensure the Trust learns from them. JR asked if it had been an increase in terms of usage of the service and conveyance. The Executive Director of Quality and Clinical Care advised that the Team would need to review that. ACTION: The Executive Director of Quality and Clinical Care would present the complaint data and a monthly breakdown at the next Quality Committee. ACTION: The Executive Director of Quality and Clinical Care to develop the Patient Experience stories for future Trust Board Meetings.

JW JW JW


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11.6 11.7 11.8 11.9 11.10 11.11 11.12 11.13 11.14 11.15

The Executive Director of Quality and Clinical Care reported on the video for BLS with sign language this was the first produced by an ambulance service. A focus for Public Engagement this year will be with BAME and excluded groups and those with learning disability in order to deliver the requirements of the NHS Constitution and Accessible Information Standards The Trust Board noted that the Patient Engagement Manager would be reviewing this and reporting through the Quality Committee. Updates were received by the Trust Board on Always Events, work on the Quality Account and the recommendations from the Quality Priorities. Restart Heart would be a digital event this year. The Executive Director of Quality and Clinical Care reported on the process for Medicines Governance and the new suite of Patient Group Directives. The Executive Director of Quality and Clinical Care advised that a Group had been established to develop prescribing indicators which would be reported through to Quality Committee in due course. Previously the Trust Board of Directors had been made aware of the work being undertaken for Technicians to be able to administer Salbutamol and Ipratropium for asthma patients. The MHRA had not identified a concern with this practice and the Executive Director of Quality and Clinical Care reported that the CQC had now confirmed support for the decision as patient safety was paramount. Updates were provided on Working Safely. Messaging #Unacceptable and the increase in violence and aggression against staff. The Trust Board of Directors noted the article in the Bulletin from a member of staff. The Quality Committee was reviewing the impact of COVID and the care provided.The concerns raised by the CQC in relation to DNAR was in progress supported by the Executive Medical Director. The Executive Director of Quality and Clinical Care advised that the Coroners would be returning and would start to re-list cases in the autumn and this will have significant resource issues. The Trust currently had 54 active inquests. The Executive Director of Quality and Clinical Care reported on safeguarding including themes and trends and advised that a more detailed analysis would be coming for the next Quarter. A report on the work of the clinical team was presented and COVID-19 Antibody Testing. The learning would be taken to the Flu Vaccine Programme Board to


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11.16 11.17

ensure any common themes were taken forward into this year’s flu programme. For flu the learning from last year was that the County Co-ordination Centres had been highly valuable and the internet system had helped. GB asked what the NEDs/Trust could do to support the Team with the Review Learn Improve (RLI) and Inquests. The Executive Director of Quality and Clinical Care advised there may be a need to bring in additional short term support. Root Cause analysis skills can be difficult to source. Welfare support was in place for the Team as they are hearing about difficult events and there was a need to think about a continued focus on patient complaints and experiences moving forwards. It was noted that members of the Trust Board had chaired some RLIs and this had led to greater depth of connection with RLIs and Inquests. The Trust Board of Directors took assurance from the Executive Director Report - Quality and Clinical Care.

12.0 Executive Director Report: Medical

12.1 12.2 12.3 12.4

The Executive Medical Director gave a presentation on the work of the Medical Team within the Quality and Clinical Care Directorate for assurance to the Trust Board of Directors. The Executive Medical Director advised that the national results were awaited of how the telephone triage process during a pandemic worked and what has been learned. Attached to that was the issue around the escalation of responses in preparation for what was feared would be an overwhelming COVID response. Those escalation levels had been put in place. Nationally this remains at Level 1. The National Paramedic Mental Health Consensus Statement Project included suicides and best practice in supporting the mental health of our people. The effect of COVID on Mental Health had been included. GB asked how the pandemic had changed the profile of what the public call the service for. The Executive Medical Director advised that there was some change in the percentage of Category 2 and 3 partly because of the changes in the codes that pre-dated the COVID codes. Regarding no send that was built into the escalation levels and the Trust had not had to escalate to high levels. The Executive Director of Operations advised Category 2 calls dropped by about 10%. This had helped the Trust to prioritise the double crewed ambulance (DCA) resourcing. The Executive Director of Quality and Clinical Care advised that the Head of Research and Audit would be attending the Quality Committee in August 2020 to report on this and a report would be brought to the September 2020 Trust Board of Directors.


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12.5 12.6 12.7 12.8

The Executive Medical Director updated on regional work including; handover delays were a high priority with hospitals struggling with the flow in Emergency Departments. Additional information in the Summary Care Records was noted. The Executive Medical Director hoped that the change in position made as an emergency for COVID of ‘opt out’ not ‘opt in’, would remain as this had had a positive impact in our people having a greater understanding of the patients. The Chief Executive updated the Trust Board of Directors with regards to the BAME Forum and Equality, Diversity, Inclusion role within the Trust noting that this had been extremely well received in the BAME community. This dedicated role would help the Trust to move forwards with challenges that those groups with protected characteristics face. The Trust Board agreed and acknowledged this decision. The Trust Board of Directors took assurance from the Executive Director Report: Medical Director.

13.0 Executive Director Report: People and Culture

13.1 13.2 13.3 13.4 13.5

The Deputy Director of People and Culture gave a presentation on the work of the People and Culture Directorate for assurance to the Trust Board of Directors. The Deputy Director of People and Culture reported on the launch of the Paramedic Apprenticeship allowing equal opportunity with rotation of cohorts across the Trust. Over 200 applications had been received for the first two cohorts and standard of those applicants was high. Of those applicants received 40 would be brought forwards in conjunction with Cumbria University. The Trust Board of Directors noted that the Recruitment Plan for People Plan 1 had been achieved. The Team would now be working towards People Plan 2. The Graduate campaign had commenced. Due to COVID the Student Paramedic Conference had not taken place this year. However, 170 successful graduates had been recruited against a target of 167. The Deputy Director of People and Culture advised that the job description on the Equality, Diversity and Inclusion Lead role was being developed and there would be consultation with the Equality Steering Group. Our people returning to work was discussed and the Trust Board of Directors noted that this was being supported with advice from Occupational Health. TF noted that the Trust was an exemplar in ensuring environments are set up safely.


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13.6

The Trust Board of Directors took assurance from the Executive Director Report: People and Culture.

14.0 People and Culture Committee Assurance Report – 16 July 2020

14.1 14.2 14.3

JR presented the People and Culture Committee Assurance Report from the meeting on 16 July 2020. JR congratulated the Trust on all the work on wellbeing. No questions were raised by the Trust Board of Directors. The Trust Board of Directors took assurance from the People and Culture Committee Assurance Report – 16 July 2020.

15.0 Executive Director Report: Information Management and Technology (IM&T)

15.1 15.2 15.3 15.4 15.5 15.6

The Executive Director of IM&T presented on the work of the IM&T Directorate for assurance to the Trust Board of Directors. The National Mobilisation App (NMA Lite) would be rolled out to all responding officers. The Trust Board of Directors noted the benefits to the Community First Responders (CFRs) and the positive response received to date. TF also noted that the response on social media for NMA lite had been excellent and commended the provision of these upgrades. The Trust Board of Directors noted that the work progresses on Electronic Care System 2 (ECS2). The Executive Director of IM&T provided on update on the hear and treat efficiency improvements with the Video Consultation Trial which would end in mid-August 2020. TF asked what the plan would be to expand video consultation. The Executive Director of IM&T advised it had been good to get the feedback from the Hub Clinicians with a unanimous decision from them to continue this work. It was anticipated that this would be with a small number but still a good percentage of the queue. Testing and preparation was underway for the electronic and automated system for monitoring stores. The Information Governance update included a noted that the submission for the Data Security Toolkit, due in March 2020, had been extended to the end of September 2020. The Trust planned to submit by the end of July 2020. The Executive Director of IM&T confirmed that there had been no breaches of confidentiality in the past two months.


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15.7 15.8 15.9 15.10 15.11

Information Governance Mandatory Training was at a positive 91%. The Executive Director of IM&T updated the Trust Board of Directors on the CCTV retrieval work noting this had been a positive piece of work in reassuring our people on the work being undertaken, particularly in relation to the support of them following assaults. TF asked if there would be a fully integrated Business Information Team. The Executive Director of IM&T advised not at the current time but the different teams were working very well together and there had been the development of the Professionals Group, looking at matrix management and ways of delivering capability, using to best effect the information specialists from across the Trust to share knowledge, experience and manage capabilities. VJ asked if remote working during COVID-19 had pushed up demand on information management/business information services. The Executive Director of IM&T advised that the Professionals Group was developing the ‘Reportal’ which would be a Google type landing page where key words could be inputted to retrieve information and data. The Trust Board of Directors took assurance from the Executive Directors Report: IM&T.

16.0 Executive Director Report: Finance

16.1 16.2 16.3 16.4 16.5

The Acting Executive Director of Finance gave a presentation on the work of the Finance Directorate for assurance to the Trust Board of Directors. The Trust Board of Directors received an update on the Financial Position for 2020/21. The Capital 2020/21 was reviewed and acknowledged by the Trust Board of Directors. Significant capital bids had been made to NHS Improvement for COVID costs. The Trust awaits the decision from the Government on those expenditures. Trust Charities work had progressed and the Trust had received a grant from NHS Charities Together COVID-19 appeal fund. All opportunities to promote the charity throughout the pandemic had been taken. The Finance Directorate had welcomed Estates and Stores into the Directorate following the recent change in the organisational structure. With the increase in PPE the stores model was being reviewed and taken forwards. The Trust Board of Directors noted the additional storage site in Exeter.


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16.6 16.7

VJ noted the uncertainty’s with financials and wanted to reconfirm what the Trust thinking was in relation to a COVID-19 second wave predicted this winter. The Acting Executive Director of Finance advised that the delayed guidance for the rest of the year was that the NHS Finance Committee was having those conversations and negotiations were in place with Government about the process for the rest of the year. The Trust Board of Directors took assurance from the Executive Director Report: Finance.

17.0 Finance Committee Assurance Report – 16 July 2020

17.1 17.2

GB presented the Finance Committee Assurance Report from the meeting on 16 July 2020. The Trust Board of Directors took assurance from the Finance Committee Assurance Report – 16 July 2020.

18.0 Joint Board Assurance and Risk Report

18.1 18.2 18.3 18.4 18.5

The Executive Director of Quality and Clinical Care presented the Joint Board Assurance and Risk Report for assurance to the Trust Board of Directors. The Executive Director of Quality and Clinical Care advised that the Trust would be changing focus on risk over the coming months. The transition to Pentana had taken place and this had significantly improved the management of risks and compliance. The team was reviewing the opportunity to use Pentana for reporting of compliance and this would include oversight of a number of areas including; RLI actions and CQC actions for better improved focus. Further work on risk will develop a focus on implementing risk appetite, greater use of Pentana and key risk indicators. GB and PL were working with the Team on these issues. The Board Assurance Framework (BAF) was reviewed. The Executive Director of Quality and Clinical Care advised that the incident stacking risk increased score was included, this was now 20. The Executive Director of Quality and Clinical Care advised that monitoring aggregated risks would be taken and a revised BAF would be developed The Trust Board of Directors took assurance from the Joint Board Assurance and Risk Report.


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19.0 Audit Committee Assurance Report – 18 June 2020

19.1 19.2

PL presented the Audit Committee Assurance Report from the meeting on 18 June 2020. The Trust Board of Directors took assurance from the Audit Committee Assurance Report – 18 June 2020.

20.0 People and Culture Committee Minutes

16 April 2020

20.1 The Trust Board of Directors noted the People and Culture Committee Minutes from 16 April 2020.

21.0 Audit and Assurance Committee Minutes

5 March 2020

21.1 The Trust Board of Directors noted the Audit and Assurance Committee Minutes from 5 March 2020.

22.0 Questions Arising from the Meeting Any Other Business Identification of New Risks (Incl. Health & Safety) Identification of New Legislation

22.1 22.2 22.3 22.4

Questions Arising from the Meeting There were no questions arising from the meeting. Any Other Business TF wished the Executive Director of People and Culture all the very best with her maternity leave. Identification of New Risks No new risks were identified. Identification of New Legislation No new legislation was identified.

23.0 Exclusion of the Press and Public

To consider whether pursuant to the provisions of section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, the press and public be excluded from the remainder of the meeting on the grounds that publicity would be prejudicial to the public interest by reason of the confidential nature of the business about to be transacted


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23.1 Nothing to report.

Signed:

(Chair)

Dated:

Copies of the approved final minutes are available from the meeting administrator on request.

Paper 2

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

25-Jul-19 11.14

Executive Director

Report: Quality and

Clinical Care

The Executive Director of Quality and Clinical would look at

producing Driver Diagrams for the Flu Campaign and Learning

Disabilities Strategy with smart aims included

JW 26/09/2019

Update September 2020:

The Learning Disability Strategy requires engagement

with service users which will recommence in Q2.An

update will be brought back to the Trust Board of

Directors on 26 November 2020.

30-Jan-20 10.10

Executive Director

Report: Quality and

Clinical Care

Executive Director of Quality and Clinical Care to include in the

report how many Adverse Incidents, RLIs and moderate harms

there had been. The Chief Executive advised that the reflection

needed to be around the performance target on this. The Trust

was not required to deliver 100% on this so every category for

Ambulances should be reviewed. This was a general patient

safety target.

JW 26/03/2020


The Long Wait Report is now quarterly as agreed at

the Quality Committee. The Q2 report will be

completed and reported to the Quality Committee on

12 November 2020. This will then be presented to the

Board of Directors on 26 November 2020.

30-Jan-20 9.6Communications

Update

MM to add Engagement and Communications Stakeholder

Engagement plans for the future for the new Communications

Lead to the Trust Board Seminar Agenda.

MM 26/03/2020


An update on the Trust Communications Strategy has

been added to the Board Seminar Cycle of Business.

30-Jan-20 24.5

Joint Board

Assurance and Risk

Report

Review of the Joint Board Assurance and Risk Report at the

Trust Board Seminar. Trust Secretary to add to the Agenda.JW/MM 26/03/2020


A review of the Joint Board Assurance and Risk

Report has been commissioned. Executive Director of

Quality and Clinical Care and Gail Bragg leading with

support from team. This has been added to the Board

Seminar Cycle of Business.

Trust Public Board Meeting Action Point Register - 2019-20

At each Trust Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This document has been created to

keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since the last meeting.

28-Nov-19 24.6Executive Director

Report: IM&T

Trust Secretary to add Deep Dive on Service Desk Team and

Frontline Interaction to the next Audit and Assurance Committee

Agenda and to a future Trust Board of Directors Meeting.

MM 30/01/2020


Deep Dive on Service Desk Team and Frontline

Interaction was presented to the Audit and Assurance

Committee on 5 March 2020. Update on this work was

again presented to the Audit and Assurance

Committee on 10 September 2020.

ACTION COMPLETE

28-Nov-19 25.6

Assurance Report:

Audit and Assurance

Committee – 19

September 2019

Cyber Risk and Security to come to future Board Seminar. Trust

Secretary to add to the schedule.MM 30/01/2020

Update June 2020:

Following review of the seminar cycle of business,

Chairman requested that this is picked up at the Audit

and Assurance Committee. Due to delay caused by

Covid-19 this has been presented to the Audit and

Assurance Committee on 10 September 2020.

ACTION COMPLETE

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

28-May-20 10.18

Executive Director

Report: Quality and

Clinical Care

The Executive Director of Quality and Clinical Care to take the

RIDDOR reporting process and the Health & Safety Strategy and

Objectives to the People and Culture Committee.

JW 24/09/2020


The Strategy is currently being written and will be

taken to the People and Culture Committee on 15

October 2020.

30-Jul-20 9.8Executive Director

Report: Operations

The Executive Director of Operations would bring a Mid Term

View Presentation to the Board in September 2020. JC 24/09/2020


Work on the Mid Term View has begun. This will be

reported to the Executive Directors Group on 22

September 2020 then to Trust Board of Directors on

26 November 2020.

30-Jul-20 6.7 Patient Experience

JW to take a deep dive in relation to communication complaints

to the Quality Committee in November 2020. Quality Committee

would continue to monitor complaint themes and trends

JW 24/09/2020


The Executive Director of Quality and Clinical Care

will take a Communication Complaints Deep Dive to

the Quality Committee on 12 November 2020

30-Jul-20 11.3

Executive Director

Report: Quality and

Clinical Care

Complaint themes and trends would continue to be shared with

the Trust Board and in depth at the Quality Committee. JW 24/09/2020



will take a Communication Complaints Deep Dive to

the Quality Committee on 12 November 2020

30-Jul-20 11.4

Executive Director

Report: Quality and

Clinical Care

The Executive Director of Quality and Clinical Care would

present the complaint data and a monthly breakdown at the next

Quality Committee.

JW 24/09/2020


This action is duplicated with action 11.3. As with 11.3

a Deep Dive will take place and be reported to the

Quality Committee on 12 November 2020.

Trust Public Board Meeting Action Point Register - 2020-21

At each Trust Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This document has been created to

keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since the last meeting.

28-May-20 10.19

Executive Director

Report: Quality and

Clinical Care

Clinical Audit on suspected COVID-19 Patients to be submitted to

the Executive Directors Group, Quality Committee and Trust

Board of Directors by the Executive Director of Quality and

Clinical Care.

JW 30/07/2020


Clinical Audit have prepared a report for March - May

data. This report was presented to the Quality

Committee on 13 August 2020. The report has been

added to the agenda to be presented to the Board of

Directors on 24 September 2020.

30-Jul-20 11.5

Executive Director

Report: Quality and

Clinical Care

The Executive Director of Quality and Clinical Care to develop the

Patient Experience stories for future Trust Board Meetings. JW 24/09/2020


Patient Stories have now resumed being presented to

the Trust Board of Directors from 24 September 2020.

ACTION COMPLETE

28-May-20 13.8

Executive Director

Report: People and

Culture

The Executive Director of People and Culture to share the

Optima data with the Trust Board of Directors at a future meeting.AB/CM 30/07/2020


Optima data has been shared with the People and

Culture Committee. The Deputy Director of People and

Culture gave a verbal update to the Trust Board of

Directors on 30 July 2020.

ACTION COMPLETE

28-May-20 13.30

Executive Director

Report: People and

Culture

The Executive Director of People and Culture to provide pay

information for Operational Services to GB.AB/CM 30/07/2020


Executive Director of Finance has personally brief GB

on pay information of Operational Services.

ACTION COMPLETE

30-Jul-20 6.3 Patient Experience

The Executive Director of Operations asked if a reflective piece

had been done by the member of staff. ACTION: The Executive

Director of Quality and Clinical Care would check for the reflective

piece.

JW 24/09/2020



has check on what work was done and has confirmed

that a reflective piece of work was undertaken.

ACTION COMPLETE

Paper 3

Executive Board Report:

Name: Jessica Cunningham

Executive Director of Operations

People Plan 1 Formally Closed Implemented in Full

PRE POST Increase Increase %

DCA Hours /

Week

STRUCTURAL

ROTA

32,206 38,963 +6,757 +21%

% DCAs in the

Fleet

78% 86% +8%

Number of

DCAs at Peak

during a 24

hour period

270 314 +44 +16.3%

Total of ALL

Vehicle Hours

including DCAs

41,396 45,555 +4,159 +10%

Structural Rotas and Surge Capability Source OL235, Excluding SPs

Hours per

Week

At Height of

First COVID 19

Pandemic

(End April

2020)

Resourcing @

Same Point

Previous Year

2019

Structural

Rota at end of

People Plan 1

Strutural Rota

at end of

People Plan 2

DCA 44,053 31,977 38,963 42,085

PSV 3,897 864 856 856

Total

Conveying

47,950 32,841 39,819 42,941

Level of Surge

Required

through non

core

resourcing

Assuming

First Peak

resourcing

levels were

repeated

+15,109

This illustrates

how important

the changes

have been

+8,131 +5,009

As the

structural rota

increases the

amount of

surge reduces

RRV 5,722 8,786 5,736 2,704

Total inc RRV 53,672 41,627 45,555 45,645

Quarters 3 + 4 Conveying Vehicles Forecast This is the internal Trust Forecast and will continually update

The resourcing cover is based on a RHPI of 2.7 – This is a figure for planning purposes.

The RHPI has been 3.1 when the Trust has performed but there is some expected efficiency as the

structural rotas go in and the profile of resources also start to better align

Current level of resource (Actual) is between 42,000 and 43,000

If the second phase of the People Plan is approved then by 31 January the structural rota will be

around 42,941

There is still a significant gap to close

At height of COVID 19 conveying resources 47,950

W/C Forecast

Conveying

Responses at

Scene

If RHPI is set at

2.7 the

Conveying Cover

Required

7/9/20 16,888 45,597

5/10/20 17,167 46,352

2/11/20 17,213 46,474

7/12/20 17,684 47,748

4/1/21 17,632 47,607

1/2/21 17,650 47,655

1/3/21 17,562 47,417

5/4/21 17,493 47,231

August Handover Delays Summary

Comparison Nationally

August 2020 SWASFT % SWASFT National

Average – All

Trusts

Average of

Programme

Trusts

Notes

15-30 Min Delay 7,867 in August

up from 7,185 in

July

21.5% 33.35% 39.04% 2 Trusts – BRI and Southmead above national

average 36.5% and 36.1% respectively

30-60 1,991 in August

up from 1,457 in

July

5.5% 8.68% 10.79% 4 Trusts above national average

60+ 763 in August up

from 290 in July

235 Bath

233 in Plymouth

2.1% Trust

bottom line

RUH and

Plymouth 9.3%

1.38% 2.17% 7/18 Trusts (excluded BCH) in SW that are

above the national average for +60 minutes in

August:

1. Bath – 235 (9.3%) 2. Derriford – 233 (9.3%) 3. BRI – 64 (2.9%) 4. Swindon – 38 (1.6%) 5. Poole – 38 (2.3%) 6. Salisbury – 17 (1.5%) 7. Weston – 19 (1.9%)

4 above the most challenged Trust level

Bath, Derriford, BRI and Weston

Paper 4

Trust Board of Directors – Public - Thursday 24 September 2020

Page 1 of 1

Meeting: Trust Board of Directors - Public

Date: Thursday 24 September 2020

Paper Title: Integrated Corporate Performance Report (ICPR)

Prepared by: Paul Quick, Performance Manager

Presented by: Jessica Cunningham, Executive Director of Operations Jennifer Winslade, Executive Director of Quality and Clinical Care

CQC Domain: Safe Effective Responsive

Strategic Goal: Every Patient Matters

Action: Assurance

Recommendation: The Trust Board of Directors are asked to take assurance from the contents of the Integrated Corporate Performance Report (ICPR)

Page 1 of 10

Integrated Corporate Performance Report

August 2020

Page 2 of 10


Introduction 1.

The Integrated Corporate Performance Report (ICPR) includes: 1.1.

Executive Summary - highlights the key areas of note and interest to the Trust Board. This summary includes details of any areas of significant exception where the Trust is either ‘off plan’ or below target, together with the key actions that are being taken to address under-performance;

Information Pack – the comprehensive data set includes graphs and tables covering the full list of KPIs and metrics monitored by the Trust. Where available forecast information has also been included within graphs and tables in the Information Pack.

COVID-19 2.

There have been a total of 15,810 lab confirmed COVID-19 cases across the South West 2.1.

up to the 12 September 2020. The daily case numbers within the South West region have been the lowest of any region in England and the rate of growth on a daily basis has also been lower than any other region. This has reduced the impact of any potential ‘peak’ in pressures on the NHS systems in the local area compared to the initial forecasts. At the end of August into the beginning of September 2020 there is evidence of an increase in the daily case numbers as represented in the graph below. Peak case numbers rose to around 150 cases per day; however this remains significantly lower than the numbers seen during the peak of the first wave of COVID-19 cases seen during April and May 2020.

Recent increases in case numbers in the South West reflect the recent national trend 2.2.

showing increases in cases and the national decision to introduce the Rule of 6 with effect from 14 September 2020. However the increases in the South West remain at lower levels than seen across the rest of England at this time.

South West Region Daily Number of PHE COVID-19 Positive Cases (blue line = rolling 7 day average)

Current data indicates that the Reproduction rate (R rate) for the South West has increased 2.3.

slightly and is currently estimated at between 0.9 and 1.2. Any R rate above 1.00 is a concern as it implies that the virus is spreading across the South West, and close monitoring of this rate is required during September to assess the level of impact on COVID-19 case numbers.

Page 3 of 10

For the week commencing 5 September 2020 the national case rate per 100,000 head of 2.4.

population was 26.6 cases, this compares to a South West average of 8.6 cases. During July and August 2020 the area of Swindon was placed on the Government ‘Watch List’ due to high number of cases, in part linked to an outbreak at a Logistics depot. In recent weeks case numbers in Swindon have reduced and for the week commencing 5 September the case numbers per 100,000 head of population in Swindon had reduced from a peak of around 50 cases per 100,000 to 6.3 cases per 100,000.

Additional monitoring of the number of COVID-19 cases (both suspected and confirmed) 2.5.

was introduced at the beginning of March 2020 and information on the incident numbers has been provided below in two formats:

The number of calls identified as potential COVID-19 cases during the telephone triage process - not all of these cases will receive an ambulance response at scene as they may more appropriately be directed to self-care pathways;

The number of incidents identified by the Clinician at scene where the patient has COVID-19 symptoms - a high proportion of these may be included within the telephone triage figures but are identifications following a face to face assessment at scene by a Clinician (monitoring only introduced from 18 March 2020).

In terms of ambulance incident numbers relating to potential COVID-19 patients the Trust 2.6.

reported a steady day on day increase in numbers through to the middle of April, peaking at around 4,500 potential cases per week identified during the telephone triage process (around 1,800 cases identified at the scene by a clinician). During June, July and August potential COVID-19 case numbers have been much lower than those seen at peak. It is noted that for the week commencing 7 September 2020 the Trust did report a marginal increase in both the cases identified through telephone triage and assessed at scene, this position will be closely monitored over the coming weeks.

Ambulance Activity 3.

The initial impact on overall activity volumes was seen at the end of February 2020 with 3.1.

increases in the daily incident numbers leading into the early part of March 2020. This increase included a high number of calls being passed from the NHS 111 service providers who were receiving extremely high volumes of calls following Government advice to call 111 with any symptom queries.

Page 4 of 10

However following a number of actions taken nationally during March 2020 (including the 3.2.

introduction of social distancing and lockdown measures) the ambulance service saw incident numbers reduce. The reductions in activity related to:

Reduction in incident numbers received from Healthcare Professionals (HCPs) – these would normally be incidents originating from GPs and other HCPs undertaking home visits to patients and referring them into hospitals. Changes in utilisation of HCPs and reductions in a number of regular practices therefore reduced this workflow to the ambulance service in recent weeks;

General reductions in all incident types which coincided with the introduction of social distancing and isolation measures nationally. For example a reduction in the volume of traffic on the roads has led to a reduction in the number of road traffic collisions.

The number of ambulance incidents received during recent months has increased 3.3.

compared to those reported in April and May 2020. The Trust had been anticipating a sharper increase in activity during June 2020 as the national lockdown measures were released, however the delay in the re-opening of pubs and restaurants to the 4 July impacted on the rate of activity increase reported during June.

During August the continued easing of lockdown measures and return to ‘normal’ has seen 3.4.

increased movement of the public and ambulance activity volumes have increased as a result. This has been further impacted by the exceptional weather seen in the latter part of July leading into August with additional visitor numbers as the school holidays commenced and increased movement of the resident population.

This culminated in activity rising above the levels seen in the equivalent period last year 3.5.

from the end of July onwards. This is in contrast to activity levels being consistently below last year’s levels during April, May and June. Across the month of August 2020 the Trust received an average of 18,771 incidents per week, this compares to an average of only 15,830 incidents during April 2020 (up 19%) and 17,849 incidents in August 2019 (up 5%).

The sharp rise in activity volumes has caused substantial pressures on Trust operational 3.6.

resources with an average of over 420 additional incidents per day across the South West compared to April 2020.

Page 5 of 10

A&E (999) Contract 4.

During Q1 of 2020/21, as highlighted earlier in this report, the impact of COVID-19 saw an 4.1.

initial reduction in the overall volume of incidents received, however during recent weeks (as highlighted in the graph below) activity is rising well above the levels seen in the equivalent week last year.

The A&E Contract for 2019/20 was for 930,104 annual ambulance incidents. Due to the 4.2.

impact of the COVID-19 pandemic the contract negotiations for 2020/21 have been delayed. In the interim period the Trust has based all contract activity assessments on the same contract incident numbers for 2020/21(ie 930,104 incidents).

For the period 1 to 31 August 2020 the A&E incidents numbers were 5.17% higher than the 4.3.

equivalent period last year and 8.89% above contracted volumes. For the year to date (1 April 2020 to 31 August 2020) A&E incident numbers were 5.24% below last year and 1.40% below contract volumes. However there are variances across the CCG areas with 2.48% year on year reduction in Somerset CCG and a 7.50% reduction in Kernow CCG.

A&E (999) Operational Resources 5.

As part of the Trust operational ‘Surge’ plans the Trust introduced additional operational 5.1.

resources (including third party resources, ERAs and Fire & Rescue Service PSVs) to supplement the current operational resources. These additional resources were planned to

Page 6 of 10

meet the additional, anticipated activity impact of COVID-19 and the potential of increased abstractions (due to COVID-19 illness and isolation of staff with COVID symptoms).

Within initial modelling scenarios a high volume of COVID-19 cases across the South West 5.2.

was expected to have a significant impact on the number of SWASFT staff absent due to COVID-19 related sickness and/or isolation compliance. With overall COVID-19 case numbers in the South West much lower than initially anticipated; the impact on Trust level abstractions was also lower than anticipated. This enabled the Trust to deliver consistently strong resourcing levels with the support of the COVID-19 Surge Management Plan additional resources.

During April 2020 the Trust reported a steady increase in operational resourcing. The graph 5.3.

below plots the conveying resource hours per week (Double Crewed Ambulances and Patient Support Vehicles) from August 2019 to date. The Trust increased the conveying resource capacity from around 39,000 weekly resource hours in Quarter 4 of 2019/20 to around 47,000 hours on the road per week at the end of April. The increased resourcing levels continued through May and June 2020 but reduced marginally during July and August to around 45,000 hours per week.

In response to the anticipated pressures from the COVID-19 outbreak, the Trust has also 5.4.

introduced additional resources into the Clinical Hubs to increase the resilience in Call Answering, Dispatch and Clinical Advice.

ARP Response Times 6.

May 2020 Jun 2020 Jul 2020 Aug 2020

Mean

90th

Centile

Mean 90

th

Centile Mean

90th

Centile

Mean 90

th

Centile

Category 1 0:06:48 0:12:12 0:06:42 0:12:12 0:06:48 0:12:42 0:07:24 0:14:00

Category 2 0:17:24 0:34:06 0:18:24 0:36:12 0:20:00 0:40:12 0:24:18 0:49:36

Category 3 0:32:18 1:11:54 0:37:12 1:24:36 0:48:54 1:54:00 1:11:00 2:52:42

Category 4* 0:51:48 1:53:12 1:03:48 2:30:18 1:17:54 2:57:00 1:41:42 3:58:18

*Following changes in the triage categories the average number of Category 4 incidents per day has reduced from 46 incidents per day in August 2019 to around current volumes of around 25 incidents per day and has therefore increased the challenge in targeting improvements at this small number of lower acuity incidents.

Page 7 of 10

The increasing activity pressures impacted on the Trust response times during August 2020 6.1.

despite the maintenance of strong resourcing levels (as a result of the Trust resilience plans). Increases were seen in all response time metrics, rising above the national standard levels for all except the Category 1 (90th Centile) metric.

Mean Category 1 incident response times across the Trust show expected variation in the 6.2.

month of August 2020, with the longest mean response times in Kernow CCG (8 mins 54 secs), compared to 6 mins 06 secs in the more urban area of Bristol, North Somerset and South Gloucestershire CCG. Mean category 1 response times in 2 of the 7 CCGs were below (better than) the 7 minute national standard.

It is important to note that the Category 1 incidents represent around 7% of all incidents 6.3.

received by the Trust (equating to around 196 incidents per day in August 2020). 59.1% of incidents in August 2020 received a response within 7 minutes and 91.9% of Category 1 incidents received a response within 15 minutes.

The summary of performance against the Category 1, 2 and 3 response time metrics on a 6.4.

weekly basis from 20 July 13 to September 2020 within the table below, with the Trust showing increases in Category 2 and Category 3 response times as activity levels rose above 18,500 incidents per week. The longest response times were reported for the weeks commencing 10 August and 7 September when activity levels were exceptionally high with over 19,200 incidents on both weeks. To put this into context the Trust has only reported 9 other weeks in the last 3 years when activity has risen above the 19,200 incident level and all of these weeks have been in the winter months of December and January.

Week Commencing

National Standard 20 Jul 27 Jul 03 Aug 10 Aug 17 Aug 24 Aug 31 Aug 07 Sep

Number of Incidents n/a 18,059 18,604 18,960 19,882 18,089 18,173 18,534 19,220

Category 1 Mean Response Time

7 mins 6 mins 59 secs

6 mins 57 secs

7 mins 32 secs

7 mins 28 secs

7 mins 07 secs

7 mins 30 secs

7 mins 16 secs

7 mins 32 secs

Category 1 90

th Centile Response Time


12 mins 46 secs

14 mins 26 secs

14 mins 05 secs

12 mins 57 secs

14 mins 10 secs

13 mins 04 secs

14 mins 20 secs



23 mins 20 secs

25 mins 04 secs

27 mins 12 secs

22 mins 31 secs

22 mins 52 secs

23 mins 59 secs

27 mins 50 secs

Category 2 90



47 mins 56 secs

51 mins 21 secs

55 mins 46 secs

45 mins 29 secs

46 mins 43 secs

49 mins 18 secs

57 mins 30 secs


1 hour 51 mins 34 secs

67 mins 49 secs

78 mins 57 secs

94 mins 01 secs

58 mins 42 secs

57 mins 17 secs

70 mins 59 secs

97 mins 37 secs

Category 3 90


2 hours 2 hrs 01

mins 2 hrs 47

mins 3 hrs 17

mins 3 hrs 50

mins 2 hrs 17

mins 2 hrs 13

mins 2 hrs 43

mins 4 hrs 06

mins

Page 8 of 10

When we relate the resource hours provided to the level of incidents that required a 6.5.

response at scene this ratio of resource hours to activity improved during April 2020 to around 3.4 conveying resource hours per incident at scene. As the metric increased, the response times improved. During recent months the additional activity has seen a reduction in this metric and an associated increase in the response times, increasing above the 18 minutes national standard as the resource hours per incident dropped below 3.0, reducing to 2.57 hours per incident for the week commencing 7 September when the Category 2 mean response time increased to over 27 minutes. This metric of Resource Hours per Incident is seen as a strong indicator for potential performance.

Week Commencing 20 Jul 27 Jul 03 Aug 10 Aug 17 Aug 24 Aug 31 Aug 07 Sep

Number of Incidents Requiring a Response at Scene

16,103 16,525 16,683 17,239 16,081 16,194 16,422 16,903

Operational Conveying Resource Hours Provided

45,577 45,023 44,844 45,223 45,293 45,255 44,530 43,493

Ratio of Conveying Resource Hours Provided to Incidents with a Response

2.83 2.72 2.69 2.62 2.82 2.79 2.71 2.57


20 mins 56 secs

23 mins 20 secs

25 mins 04 secs

27 mins 12 secs

22 mins 31 secs

22 mins 52 secs

23 mins 59 secs

27 mins 50 secs

The ARP performance figures for ambulance trusts in England are included within the 6.6.

Information Pack to provide benchmarking of response times and the other Ambulance Quality Indicator metrics, but a summary of the performance against the response time standards for August 2020 is provided in the table below.

It is acknowledged that some national variance in response times will be due to the 6.7.

extremely rural nature of the South West geography and improvements are anticipated as a result of the Trust improvement plans.

Nationally ambulance services across England have experienced similar variation in 6.8.

response times during 2020 with the impact of COVID-19 and changing activity volumes. The graph below represents the changes in the Category 2 mean response times across the ambulance services between January and August 2020. This represents an increasing trend in the Category 2 mean response times compared to May 2020 and returning closer to those response times seen in January and February 2020.

AQI Response Time Metrics - August 2020

National

Standard

National

AverageSWASFT EEAS EMAS LAS NEAS NWAS SCAS SECAMB WMAS YAS

Category 1 Mean 0:07:00 0:07:06 0:07:23 0:07:13 0:07:08 0:06:22 0:06:28 0:07:27 0:06:29 0:07:53 0:06:56 0:07:24

Category 1 90th Centile 0:15:00 0:12:40 0:13:58 0:12:56 0:13:22 0:10:49 0:11:09 0:12:35 0:12:05 0:14:50 0:12:09 0:12:44

Category 2 Mean 0:18:00 0:20:03 0:24:17 0:22:39 0:22:25 0:14:12 0:23:28 0:27:37 0:17:06 0:18:57 0:12:09 0:18:29


Category 3 Mean 1:00:00 0:56:42 1:10:58 1:01:54 0:55:39 0:35:58 1:04:39 1:29:22 0:54:55 1:34:11 0:29:15 0:39:55


Page 9 of 10

Our People Plan 7.

The Trust has developed ‘Our People Plan’ to deliver and accommodate the additional 7.1.

people that the additional investment funding will enable. Utilising the analysis undertaken by ORH, Our People Plan identifies the most effective location of the Trust people and vehicles in order to meet the current levels of demand, provide the highest quality care for patients and move towards achieving the national ARP performance standards.

The graphs below represent the current forecast establishment positions for both Lead 7.2.

Clinicians and Emergency Care Assistants compared to both historic levels and funded positions outlining the current, expected increases through to March 2021 (the blue columns within the graph representing the forecast figures).

The establishment forecasts are updated in collaboration with the Operational team on a 7.3.

monthly basis, but due to the timing of this report the latest available forecast is always one month in arrears, therefore the position within the graphs below represents a representation of the forecast produced based on the end of July 2020 establishment position.

As at the end of July 2020 the Trust was 23.68 WTE below plan numbers for Lead 7.4.

Clinicians. Increases in the funded establishment in May 2020 and further increases in July 2020 shows a forecast shortfall increasing to 44 WTE at the end of August 2020 before improvements are expected following the introduction of new Graduate Paramedics during Q3 of 2020/21. The Trust remains on forecast to deliver above the required establishment levels identified through the People Plan process by the end of March 2021, however this

Page 10 of 10

additional resource is expected to be utilised to meet the Trust future operational resource plans which are being confirmed during Q2 of 2020/21.

The recruitment cycle for Lead Clinicians in the ambulance service is driven to a large 7.5.

extent by the Graduate Paramedic workforce. With students graduating during Q3 of each financial year the Trust anticipates a large increase in the Lead Clinician numbers from October 2020 onwards (becoming available ‘on the road’ from November 2020 onwards), moving the Trust closer to plan numbers at the end of Q3 2020/21.

Emergency Care Assistants were under establishment levels at the end of July 2020 (-7.6.

85.42 WTE). Further increases in funded establishment were introduced in July 2020 which increased the under establishment position during the month. Planned recruitment throughout the remainder of the year is then expected to improve this position across the remainder of the financial year. The Trust is currently forecasting a shortfall of 10 WTE (0.9% below funded levels) at the end of March 2021.

The Trust is currently working to confirm the Operational Plans for 2020/21 which may see 7.7.

further changes to both the Clinical Hubs and Frontline Lead Clinician/Emergency Care Assistant establishment requirements. These Operational Plan will include updated recruitment plans to deliver any additional workforce required and are expected to be confirmed during Q2 of 2020/21.

Urgent Care Centre (Tiverton) Performance 8.

The primary performance measure within this contract is the 4 hour waiting time standard. 8.1.

In August 2020, 1,462 of 1,467 patients were seen within 4 hours giving performance of 99.66% against the 95% performance target. Performance above target levels has been delivered consistently since contract inception along with a local standard to triage patients within 15 minutes. In August 2020, 99.02% of patients were triaged in 15 minutes against a target of 95%.

Finance and Use of Resources 9.

The Trust Financial Position for month five of 2020/21 (period to 31 August 2020) is: 9.1.

The Trust has reported a breakeven position for month five;

This position includes the costs and income associated with the Trust response to COVID-19;

NHSE/I have extended the Interim Financial Regime to cover Months five and six, the terms of the successor regime have yet to be confirmed;

The Trust has spent £4,679k capital year to date and is forecasting to spend its full CDEL of £17,790k. This spend will be the net position of capital spend and receipts from disposals and external funding;

The Trust cash position at the end of August is £47,807k, which is £23,183k above plan due to contract payments being received a month in advance under the terms of the Interim Financial Regime.

Appendix A:


Information Pack

August 2020

Integrated Corporate Performance Report 1

Actual TargetVar to

TargetPY Actual

Var to

PYActual Target

Var to

TargetPY Actual

Var to

PYActual Target

Var to

TargetPY Actual

Var to

PY

32.68% A&E Incidents 83,131 76,341 8.89% 79,047 5.17% 374,256 379,583 -1.40% 394,955 -5.24%

52.75% Category 1 Mean Response Time 0:07:24 0:07:00 0.4 0:07:12 0.2 0:06:54 0:07:00 -0.1

10.66% 9.00% 1.66% Cate 1 90th Centile Response Time 0:14:00 0:15:00 -1.0 0:13:12 0.8 0:12:36 0:15:00 -2.4

28.88% 27.00% 1.88% Category 1T 90th Centile Response Time 0:17:18 0:30:00 -12.7 0:21:06 -3.8 0:16:06 0:30:00 -13.9

77.99% Category 2 Mean Response Time 0:24:18 0:18:00 6.3 0:27:54 -3.6 0:19:42 0:18:00 1.7

83.92% 90.00% -6.08% Category 2 90th Centile Response Time 0:49:36 0:40:00 9.6 0:58:00 -8.4 0:39:36 0:40:00 -0.4

96.76% 97.00% -0.24% Category 3 Mean Response Time 1:11:00 1:00:00 11.0 1:14:24 -3.4 0:43:48 1:00:00 -16.2

52.17% Category 3 90th Centile Response Time 2:52:42 2:00:00 52.7 2:57:36 -4.9 1:39:42 2:00:00 -20.3

Category 4 90th Centile Response Time 3:58:18 3:00:00 58.3 3:28:12 30.1 2:43:12 3:00:00 -16.8

Actual Nat AvgVar to

Nat AvgPY Actual

Var to

PYCall Answering Mean (secs) (vs National Average) 3 3 0

STEMI - Mean time from call to catheter insertion (hrs:mins) 2:11 2:16 0:05 Call Answering 95th Centile (secs) (vs National Average) 3 8 -5

STEMI - 90th Centile time from call to catheter insertion (hrs:mins) 2:59 3:09 0:10 Call Answering 99th Centile (Secs) (vs National Average) 32 48 -16

Stroke - Mean time from call to hospital arrival 01:42 01:28 0:14 Time Lost to Handover Delays Over 15 Mins (hrs:mins) 3450:24 1696:38 103.37% 9423:46 8672:26 8.66%

Stroke - 50th Centile time from call to hospital arrival (hrs:mins) 01:25 01:15 0:10 % of Handovers in Excess of 15 Mins 32.18% 25.03% -7.15% 27.43% 25.52% -1.92%

Stroke - 90th Centile time from call to hospital arrival (hrs:mins) 02:38 02:18 0:20 Time Lost to Handover to Clear Over 15 Mins (hrs:mins) 3817:42 3688:09 3.51% 18038:43 17380:18 3.79%

Stroke - Mean time from arrival at hospital to CT scan (hrs:mins) 01:22 01:22 0:00 % of Handover to Clear in Excess of 15 Mins 47.69% 49.06% -1.36% 50.84% 47.68% 3.17%

Stroke - 50th Centile time from arrival at hospital to CT scan (hrs:mins) 00:26 00:37 0:11

Stroke - 90th Centile time from arrival at hospital to CT scan (hrs:mins) 03:58 03:37 0:21 Actual TargetVar to

TargetPY Actual

Var to

PYActual Target

Var to

TargetPY Actual

Var to

PY

Stroke - Mean time from arrival at hospital to thrombolysis (hrs:mins) 01:00 00:58 0:02 Tiverton UCC % Triage Commenced in 15 Mins 99.02% 95.00% 4.02% 99.79% -0.78% 99.42% 95.00% 4.42% 99.29% 0.13%

Stroke - 50th Centile time from arrival at hospital to thrombolysis (hrs:mins) 00:55 00:50 0:05 Tiverton UCC % Cases Completed in 4 Hrs 99.66% 95.00% 4.66% 99.39% 0.27% 99.59% 95.00% 4.59% 99.33% 0.27%

Stroke - 90th Centile time from arrival at hospital to thrombolysis (hrs:mins) 01:39 01:37 0:02

Actual Plan Var to Plan PY ActualVar to

PY

Actual TargetVar to

TargetPY Actual

Var to

PY8.5 0.0 8.5

4,281.4 4,231.4 50.02 4,050.2 231.22 0.5 0.0 0.5

1,911.0 1,905.3 5.72 1,771.5 139.51 0.00% 0.00% 0.00%

1,221.1 1,208.9 12.16 1,102.2 118.84 0.00% 0.00% 0.00%

461.8 432.4 29.41 426.8 35.05 540.40% 0.00% 540.40%

629.1 623.5 5.59 579.4 49.74 3.00 0.00 3.00

8.92% 11.04% -2.12% 98% 85% 13%

4.88% 4.00% 0.88% 5.91% -1.03% 14.34% 5.00% 9.34%

87.00% 85.00% 2.00% 87.95% -0.95% 0.95% 5.00% -4.05%

Pe

op

le

Pe

rfo

rma

nc

eF

ina

nc

e

Pa

tie

nt Nov-19

AQI Clinical Indicators

Reported in Arrears to Other Data Feeds - In Month Performance

% of suspected stroke or unresolved transient ischaemic attack pateints assessed

face to face that received an appropriate diagnostic bundle (Quarterly)

Aug-20

Trust Staff Sickness %

Trust Staff Appraisal Completion %

Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group

survival rate

% of patients with ROSC receiving a post-ROSC care bundle (Quarterly)

% of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG

receiving an appropriate care bundle (Quarterly)

A&E Emergency Care Assistant Establishment WTE

A&E Hub Total Establishment WTE

Outcome from Cardiac Arrest - Return of Spontaneous Circulation (ROSC) at time of

arrival at hospital (overall)

Outcome from Cardiac Arrest - ROSC at time of arrival at hospital (Utstein

Comparator Group)

Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate

Establishment and Staff Metrics - In Month Performance

Trust Total Establishment WTE

% of SEPSIS Patients with National Early Warning Score (NEWS) of 7 or more who

received the Sepsis Care Bundle (Quartlery - June, Sept, Dec and Mar)

Trust Total Staff Turnover %

Urgent Care Services

Aug-20 YTD

YTDAQI Clinical Indicators

Reported in Arrears to Other Data Feeds - Monitored on a Rolling 12 Month

Basis

Dec-18 to Nov-19A&E Performance Metrics

Aug-20

Financial Metrics

Capital Service Cover

Liquidity Days

I&E Margin %

Aug-20

A&E Lead Clinician Establishment WTE

Support Staff Establishment WTE

Debtors Over 90 Days %

Creditors Over 90 Days %

Variance in I&E Margin as % of Plan

Agency Spend Variance to Cap (YTD) %

Use of Resources Rating

Capital Expenditure vs Plan YTD

Ambulance Response Programme (ARP) - Response Times

NHS England has also developed a guide to the new Ambulance Standards, which outline the purpose of ARP and the new ambulance standards that have been introduced.

A copy of this ‘easy read’ document can be found on the NHS England website: www.england.nhs.uk/publication/new-ambulance-standards-easy-read-document/

Target/

KPIYTD Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

0:07:00 0:06:54 0:06:30 0:06:48 0:06:42 0:06:48 0:07:24

0:15:00 0:12:36 0:11:36 0:12:12 0:12:12 0:12:42 0:14:00

0:30:00 0:16:06 0:14:48 0:15:42 0:15:54 0:16:00 0:17:18

0:18:00 0:19:42 0:17:12 0:17:24 0:18:24 0:20:00 0:24:18

0:40:00 0:39:36 0:33:30 0:34:06 0:36:12 0:40:12 0:49:36

0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00 0:07:00

0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00 0:15:00

0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00 0:30:00

0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00 0:18:00

0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00 0:40:00

1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00 1:00:00

2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00 2:00:00

3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00 3:00:00

Further information on the Ambulance Response Programme, the ambulance standards and a copy of Sheffield University’s report on ARP can be found on the NHS England website: www.england.nhs.uk/urgent-emergency-care/arp/

Category 1 Response Time - 90th Percentile (hrs:mins:secs)

Category 2 Response Time - Mean (hrs:mins:secs)


Category 1 (Transport) Response Time - 90th Percentile (hrs:mins:secs)

ARP 2.3 Performance Metrics -Response Times


0:05:00

0:05:30

0:06:00

0:06:30

0:07:00

0:07:30

0:08:00

0:08:30

0:09:00


National Standard Upper Control Limit Lower Control Limit

Mean (from Jul 18 to date) Forecast Performance

0:08:00

0:09:00

0:10:00

0:11:00

0:12:00

0:13:00

0:14:00

0:15:00

0:16:00

0:17:00

Category 1 90th Centile Response Time



0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00

0:24:00

0:26:00

0:28:00

0:30:00

0:32:00

0:34:00

0:36:00

0:38:00

0:40:00




0:25:00

0:30:00

0:35:00

0:40:00

0:45:00

0:50:00

0:55:00

1:00:00

1:05:00

1:10:00

1:15:00

1:20:00

1:25:00





Ambulance Response Programme (ARP) - Response Times

NHS England has also developed a guide to the new Ambulance Standards, which outline the purpose of ARP and the new ambulance standards that have been introduced.

A copy of this ‘easy read’ document can be found on the NHS England website: www.england.nhs.uk/publication/new-ambulance-standards-easy-read-document/

Target/


1:00:00 0:43:48 0:31:06 0:32:18 0:37:12 0:48:54 1:11:00

2:00:00 1:39:42 1:09:30 1:11:54 1:24:36 1:54:00 2:52:42

n/a 1:08:00 0:52:54 0:51:48 1:03:42 1:17:54 1:41:42

3:00:00 2:43:12 1:57:42 1:53:12 2:30:18 2:57:00 3:58:18


ARP 2.3 Performance Metrics -Response Times

Further information on the Ambulance Response Programme, the ambulance standards and a copy of Sheffield University’s report on ARP can be found on the NHS England website: www.england.nhs.uk/urgent-emergency-care/arp/


Category 4 (999) Response Time - Mean (hrs:mins:secs)

Category 4 (999) Response Time - 90th Percentile (hrs:mins:secs)

0:00:00

0:10:00

0:20:00

0:30:00

0:40:00

0:50:00

1:00:00

1:10:00

1:20:00

1:30:00

1:40:00

1:50:00

2:00:00

2:10:00




0:00:00

0:20:00

0:40:00

1:00:00

1:20:00

1:40:00

2:00:00

2:20:00

2:40:00

3:00:00

3:20:00

3:40:00

4:00:00

4:20:00

4:40:00

5:00:00




0:00:00

0:30:00

1:00:00

1:30:00

2:00:00

2:30:00

3:00:00

3:30:00

4:00:00


Upper Control Limit Lower Control Limit Mean (from Jul 18 to date) Forecast Performance

0:00:00

1:00:00

2:00:00

3:00:00

4:00:00

5:00:00

6:00:00

7:00:00

8:00:00





Target/


0:06:42 0:06:24 0:06:12 0:06:18 0:06:54 0:07:18

0:05:48 0:05:36 0:05:42 0:05:48 0:05:54 0:06:06

0:07:00 0:06:48 0:07:00 0:06:42 0:06:42 0:07:30

0:06:30 0:06:00 0:06:36 0:06:24 0:06:18 0:07:00

0:07:00 0:06:42 0:07:06 0:07:12 0:07:00 0:07:06

0:08:18 0:07:36 0:08:06 0:08:06 0:08:06 0:08:54

0:07:36 0:07:18 0:07:18 0:07:12 0:07:18 0:08:24

0:07:00 0:06:54 0:06:30 0:06:48 0:06:42 0:06:48 0:07:24

0:12:24 0:11:42 0:10:30 0:11:48 0:13:06 0:14:12

0:09:54 0:09:00 0:09:42 0:09:42 0:09:54 0:10:42

0:12:24 0:12:06 0:12:30 0:11:42 0:11:48 0:13:42

0:11:24 0:10:24 0:11:12 0:11:24 0:11:06 0:12:24

0:13:12 0:11:36 0:13:30 0:13:30 0:13:18 0:13:36

0:15:54 0:13:48 0:15:00 0:15:36 0:16:30 0:17:48

0:14:24 0:13:06 0:14:24 0:13:30 0:14:00 0:16:00

0:15:00 0:12:36 0:11:36 0:12:12 0:12:12 0:12:42 0:14:00

Bath & North East Somerset, Swindon & Wiltshire CCG

Somerset CCG

Trust Total

Gloucestershire CCG

Kernow CCG

Devon CCG

Devon CCG

Somerset CCG

Trust Total

Bristol, North Somerset & South Gloucestershire CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

ARP 2.3 Performance Metrics - Category 1 Mean Response Times by CCG

ARP 2.3 Performance Metrics - Category 1 90th Percentile Response Times by CCG



Dorset CCG

0:04:00

0:05:00

0:06:00

0:07:00

0:08:00

0:09:00

0:10:00

0:11:00Category 1 - Mean Response Time by CCG

Bath & North East Somerset,Swindon & Wiltshire CCG

Bristol, North Somerset &South Gloucestershire CCG

Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

0:08:00

0:10:00

0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00Category 1 - 90th Centile Response Time by CCG



Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

National Average 0:07:06

EMAS 0:07:13

EOEAS 0:07:08

LAS 0:06:22

NEAS 0:06:28

NWAS 0:07:27

SCAS 0:06:29

SECAMB 0:07:53

SWASFT 0:07:23

WMAS 0:06:56

YAS 0:07:24

0:05:00

0:06:00

0:07:00

0:08:00

0:09:00

0:10:00

EMAS EOEAS LAS NEAS NWAS SCAS SECAMB SWASFT WMAS YAS

National Ambulance Benchmarking - Category 1 Mean Response Time August 2020

National Average National Standard Performance


EMAS 0:12:56

EOEAS 0:13:22

LAS 0:10:49

NEAS 0:11:09

NWAS 0:12:35 SCAS

0:12:05

SECAMB 0:14:50

SWASFT 0:13:58

WMAS 0:12:09

YAS 0:12:44

0:08:00

0:09:00

0:10:00

0:11:00

0:12:00

0:13:00

0:14:00

0:15:00

0:16:00

0:17:00

0:18:00


National Ambulance Benchmarking - Category 1 90th Centile Response Time August 2020



Target/


0:20:30 0:19:42 0:18:18 0:17:54 0:20:30 0:25:12

0:16:30 0:14:12 0:15:06 0:17:18 0:15:54 0:19:06

0:18:42 0:15:42 0:16:12 0:17:30 0:19:06 0:23:24

0:18:18 0:16:18 0:16:00 0:16:54 0:18:48 0:22:18

0:17:54 0:17:48 0:16:42 0:17:18 0:17:48 0:19:30

0:24:48 0:18:06 0:20:12 0:21:06 0:26:12 0:34:00

0:24:18 0:21:06 0:22:00 0:22:48 0:24:42 0:29:24

0:18:00 0:19:42 0:17:12 0:17:24 0:18:24 0:20:00 0:24:18

0:40:54 0:38:48 0:36:18 0:35:24 0:40:18 0:51:36

0:32:00 0:26:06 0:29:00 0:33:24 0:30:18 0:39:06

0:37:48 0:30:42 0:32:06 0:34:24 0:38:54 0:47:36

0:36:42 0:31:54 0:30:48 0:33:06 0:37:36 0:45:00

0:34:18 0:34:42 0:31:42 0:33:18 0:34:24 0:36:48

0:49:48 0:34:30 0:39:24 0:40:42 0:51:36 1:08:36

0:47:24 0:41:06 0:42:42 0:44:42 0:47:00 0:57:06

0:40:00 0:39:36 0:33:30 0:34:06 0:36:12 0:40:12 0:49:36Trust Total

Somerset CCG

Devon CCG

Devon CCG


Dorset CCG

Kernow CCG

Gloucestershire CCG

Trust Total




Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG



0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00

0:24:00

0:26:00

0:28:00

0:30:00

0:32:00

0:34:00

0:36:00

0:38:00




Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

0:20:00

0:25:00

0:30:00

0:35:00

0:40:00

0:45:00

0:50:00

0:55:00

1:00:00

1:05:00

1:10:00

1:15:00

1:20:00




Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard


EMAS 0:22:39

EOEAS 0:22:25

LAS 0:14:12

NEAS 0:23:28

SCAS 0:17:06

SECAMB 0:18:57

SWASFT 0:24:17

WMAS 0:12:09

YAS 0:18:29

0:06:00

0:08:00

0:10:00

0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00

0:24:00

0:26:00





EMAS 0:46:20

EOEAS 0:46:46

LAS 0:27:00

NEAS 0:48:04

SCAS 0:34:08

SECAMB 0:34:57

SWASFT 0:49:33

WMAS 0:22:21

YAS 0:38:00

0:10:00

0:15:00

0:20:00

0:25:00

0:30:00

0:35:00

0:40:00

0:45:00

0:50:00





Target/


0:46:54 0:37:06 0:32:30 0:36:06 0:53:06 1:15:24

0:40:18 0:24:54 0:28:06 0:38:00 0:45:30 1:08:00

0:40:06 0:28:00 0:29:12 0:35:36 0:44:24 1:04:42

0:41:30 0:30:54 0:31:30 0:34:12 0:44:54 1:07:36

0:36:18 0:31:48 0:29:06 0:31:48 0:38:12 0:49:42

0:51:00 0:29:18 0:35:30 0:40:06 1:01:30 1:36:30

0:59:30 0:42:06 0:47:42 0:49:24 1:08:06 1:35:06

1:00:00 0:43:48 0:31:06 0:32:18 0:37:12 0:48:54 1:11:00

1:47:42 1:25:42 1:12:30 1:22:36 2:06:06 3:08:12

1:33:36 0:52:24 1:02:36 1:27:42 1:48:48 2:49:18

1:30:54 1:02:12 1:04:24 1:19:42 1:42:48 2:32:24

1:35:24 1:09:00 1:09:48 1:17:54 1:43:48 2:41:18

1:20:42 1:09:18 1:01:48 1:10:30 1:30:42 1:50:18

1:53:18 1:00:24 1:19:48 1:31:06 2:23:06 3:53:00

2:10:24 1:33:12 1:40:42 1:49:06 2:32:54 3:56:06

2:00:00 1:39:42 1:09:30 1:11:54 1:24:36 1:54:00 2:52:42

Dorset CCG

Gloucestershire CCG

Kernow CCG

Devon CCG

Somerset CCG

Trust Total




Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

Devon CCG




0:20:00

0:30:00

0:40:00

0:50:00

1:00:00

1:10:00

1:20:00

1:30:00

1:40:00

1:50:00

2:00:00




Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

0:40:00

1:00:00

1:20:00

1:40:00

2:00:00

2:20:00

2:40:00

3:00:00

3:20:00

3:40:00

4:00:00

4:20:00

4:40:00

5:00:00




Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard


EMAS 1:01:54 EOEAS

0:55:39

LAS 0:35:58

NEAS 1:04:39

NWAS 1:29:22

SCAS 0:54:55

SWASFT 1:10:58

WMAS 0:29:15

YAS 0:39:55

0:10:00

0:20:00

0:30:00

0:40:00

0:50:00

1:00:00

1:10:00

1:20:00

1:30:00





EMAS 2:30:09 EOEAS

2:14:03

LAS 1:21:15

NEAS 2:36:02

NWAS 3:27:07

SCAS 2:08:18

SECAMB 3:31:37

SWASFT 2:52:44

WMAS 1:02:22

YAS 1:34:56

0:20:00

0:40:00

1:00:00

1:20:00

1:40:00

2:00:00

2:20:00

2:40:00

3:00:00

3:20:00

3:40:00

4:00:00





Target/

KPIYTD

1:11:36 1:05:30 0:52:42 1:02:30 1:26:54 1:35:30

1:06:30 0:44:06 0:51:42 1:14:54 1:24:18 1:33:00

1:08:36 0:52:54 0:49:42 1:06:48 1:20:36 1:38:48

1:03:24 0:50:00 0:50:30 0:58:18 1:03:12 1:45:00

1:01:24 0:46:18 0:46:18 0:58:24 1:14:18 1:23:48

1:14:06 1:03:42 0:57:18 0:52:00 1:18:24 2:11:24

1:15:54 1:00:24 0:58:30 1:07:06 1:17:54 2:05:42

n/a 1:08:00 0:52:54 0:51:48 1:03:42 1:17:54 1:41:42

2:43:12 2:10:54 1:48:12 2:37:36 3:01:30 3:44:54

2:32:00 1:43:36 1:55:12 2:32:12 3:35:12 3:33:00

2:48:24 2:07:36 1:46:24 2:59:18 3:35:06 3:49:48

2:37:00 2:08:42 1:55:24 2:23:18 2:14:00 4:02:36

2:20:06 1:39:48 1:32:24 2:14:36 2:48:36 3:09:30

2:59:18 2:14:18 2:28:24 1:55:36 2:57:54 4:42:42

3:05:54 2:32:36 2:18:48 2:30:18 3:25:00 5:41:48

3:00:00 2:43:12 1:57:42 1:53:12 2:30:18 2:57:00 3:58:18Trust Total


Devon CCG



Gloucestershire CCG

Somerset CCG

Trust Total



Kernow CCG

Devon CCG


Somerset CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Dorset CCG

1:00:00

2:00:00

3:00:00

4:00:00

5:00:00

6:00:00

7:00:00

8:00:00

9:00:00

10:00:00 Category 4 - 90th Centile Response Time by CCG Bath & North East Somerset,Swindon & Wiltshire CCG


Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

0:00:00

0:30:00

1:00:00

1:30:00

2:00:00

2:30:00

3:00:00

3:30:00

4:00:00 Category 4 - Mean Response Time by CCG Bath & North East Somerset,

Swindon & Wiltshire CCG


Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total


EMAS 1:21:01

EOEAS 1:20:46

LAS 1:09:24 NEAS

1:01:06

SCAS 1:25:05

SWASFT 1:41:40

WMAS 0:40:33

YAS 1:07:07

0:20:00

0:30:00

0:40:00

0:50:00

1:00:00

1:10:00

1:20:00

1:30:00

1:40:00

1:50:00

2:00:00



National Average Performance


EMAS 3:06:17 EOEAS

2:49:31 LAS

2:25:10

NEAS 2:29:36

NWAS 3:47:57

SCAS 3:07:46

SWASFT 3:58:17

WMAS 1:34:53

YAS 2:42:23

0:30:00

1:00:00

1:30:00

2:00:00

2:30:00

3:00:00

3:30:00

4:00:00

4:30:00

5:00:00





Target/


0:08:42 0:08:06 0:07:36 0:09:12 0:08:54 0:09:24

0:07:00 0:07:00 0:06:36 0:07:06 0:07:18 0:07:06

0:08:36 0:08:06 0:08:42 0:08:12 0:08:18 0:09:24

0:07:48 0:07:36 0:07:54 0:07:36 0:07:30 0:08:24

0:08:06 0:08:00 0:08:18 0:08:18 0:08:06 0:08:00

0:10:42 0:09:42 0:09:54 0:10:48 0:10:12 0:11:54

0:09:30 0:09:06 0:09:54 0:08:48 0:08:54 0:10:24

n/a 0:08:30 0:08:06 0:08:18 0:08:24 0:08:18 0:09:06

0:16:54 0:14:48 0:14:18 0:17:18 0:17:48 0:17:48

0:12:06 0:10:18 0:11:18 0:12:06 0:12:24 0:12:24

0:15:42 0:14:30 0:16:54 0:15:24 0:14:30 0:17:24

0:14:30 0:14:24 0:12:54 0:14:36 0:14:12 0:15:48

0:15:42 0:15:18 0:15:42 0:16:30 0:15:54 0:15:36

0:20:30 0:18:54 0:17:30 0:20:42 0:19:30 0:24:42

0:17:30 0:16:12 0:19:12 0:15:48 0:17:24 0:18:24

0:30:00 0:16:06 0:14:48 0:15:42 0:15:54 0:16:00 0:17:18

Gloucestershire CCG

Dorset CCG


Devon CCG

Somerset CCG

Trust Total

Kernow CCG

Kernow CCG

Somerset CCG

Trust Total

Dorset CCG

Gloucestershire CCG

ARP 2.3 Performance Metrics - Category 1 (Transport) 90th Percentile Response Times by CCG



Devon CCG

ARP 2.3 Performance Metrics - Category 1T Mean Response Times by CCG


0:10:00

0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00

0:24:00

0:26:00

0:28:00

0:30:00

0:32:00

0:34:00Category 1T - 90th Centile Response Time by CCG



Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total

National Standard

0:00:00

0:02:00

0:04:00

0:06:00

0:08:00

0:10:00

0:12:00

0:14:00

0:16:00

0:18:00

0:20:00Category 1T - Mean Response Time by CCG



Devon CCG

Dorset CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG

Trust Total


EMAS 0:14:26

EOEAS 0:10:33

LAS 0:09:13

NEAS 0:07:28

NWAS 0:10:19

SCAS 0:09:24

SECAMB 0:09:43 SWASFT

0:09:05

WMAS 0:07:48

YAS 0:08:55

0:06:00

0:07:00

0:08:00

0:09:00

0:10:00

0:11:00

0:12:00

0:13:00

0:14:00

0:15:00

0:16:00


National Ambulance Benchmarking - Category 1T Mean Response Time August 2020

National Standard National Average Performance


EMAS 0:32:24

EOEAS 0:19:31

LAS 0:15:39

NEAS 0:13:05

NWAS 0:17:48

SCAS 0:18:31

SECAMB 0:17:38

SWASFT 0:17:19

WMAS 0:13:38

YAS 0:16:05

0:08:00

0:10:00

0:12:00

0:14:00

0:16:00

0:18:00

0:20:00

0:22:00

0:24:00

0:26:00

0:28:00

0:30:00

0:32:00

0:34:00


National Ambulance Benchmarking - Category 1T 90th Centile Response Time August 2020



PeriodNational

Average

East

Midlands

East of

EnglandLondon North East North West

South

Central

South East

Coast

South

Western

West

MidlandsYorkshire

Aug-20 38 41 37 66 29 30 37 47 33 24 36

Aug-20 69 74 65 134 59 53 72 61 56 42 63

Aug-20 3 4 2 2 7 1 5 3 3 1 5

Aug-20 8 4 5 4 26 1 5 15 3 2 33

Aug-20 48 45 32 70 56 28 66 67 32 9 104

Aug-20 2.17 1.82 2.42 2.57 2.01 2.16 2.13 2.14 2.19 1.98 1.97

Aug-20 1.66 1.45 1.72 2.00 1.53 1.76 1.58 1.56 1.67 1.43 1.56

Aug-20 1.35 1.29 1.52 1.38 1.29 1.30 1.36 1.39 1.34 1.29 1.33

Aug-20 1.09 1.05 1.14 1.10 1.09 1.07 1.09 1.07 1.09 1.06 1.09

Aug-20 1.60 1.47 1.85 1.46 1.61 1.44 1.52 1.86 1.54 1.67 1.51

Aug-20 1.08 1.05 1.15 1.11 1.07 1.06 1.16 1.06 1.06 1.04 1.08

Aug-20 1.56 0.98 1.74 1.32 1.73 1.21 1.61 1.81 1.42 2.30 1.54

Aug-20 1.04 0.71 1.13 1.05 1.08 0.98 1.20 1.05 1.04 1.03 1.10

Call Answering - 95th Percentile Answer Time (Seconds)

Mean Number of Ambulance Resources Arriving at Scene per Category 4 (999) Incident

Mean Number of Ambulance Resources Allocated per Category 3 Incident

Call Answering - 99th Percentile Answer Time (Seconds)

Mean Time To Identify Category 1 Incidents (where Category 1 incidents are identified with Nature

of Call or Pre-Triage Questions) (Seconds)90th centile Time To Identify Category 1 Incidents (where Category 1 incidents are identified with

Nature of Call or Pre-Triage Questions) (Seconds)


Mean Number of Ambulance Resources Arriving at Scene per Category 2 Incident



Call Answering - Mean Answer Time (Seconds)


Mean Number of Ambulance Resources Allocated per Category 4 (999) Incident

Ambulance Quality Indicators 2.3 Metrics - National Benchmarking

38

41

37

66

29

30

37

47

33

24

36

0 10 20 30 40 50 60 70

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

Mean Time to Identify Cat 1 (NOC and PTQ)

3

4

2

2

7

1

5

3

3

1

5

0 1 2 3 4 5 6 7 8

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

Mean Call Answer Time (Secs)

8

4

5

4

26

1

5

15

3

2

33

0 5 10 15 20 25 30 35

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

95th Percentile Call Answer Time (Secs)

1.66

1.45

1.72

2.00

1.53

1.76

1.58

1.56

1.67

1.43

1.56

0.00 0.40 0.80 1.20 1.60 2.00 2.40

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

Mean Number of Ambulance Resources Arriving at Scene (Cat 1 Incidents)

1.09

1.05

1.14

1.10

1.09

1.07

1.09

1.07

1.09

1.06

1.09

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire


1.08

1.05

1.15

1.11

1.07

1.06

1.16

1.06

1.06

1.04

1.08

0.95 1.00 1.05 1.10 1.15 1.20

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire


1.04

0.71

1.13

1.05

1.08

0.98

1.20

1.05

1.04

1.03

1.10

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

Mean Number of Ambulance Resources Arriving at Scene (Cat 4 (999) Incidents)

69

74

65

134

59

53

72

61

56

42

63

0 20 40 60 80 100 120 140 160

National Average

East Midlands

East of England

London

North East

North West

South Central

South East Coast

South Western

West Midlands

Yorkshire

90th Percentile Time to Identify Cat 1 (NOC and PTQ)


YTD Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

384,390 73,088 78,042 76,329 80,271 76,660 74,530 76,927 77,243 82,580 81,760 73,293 79,899

394,955 77,513 79,779 77,773 80,843 79,047 77,761 81,736 81,725 88,353 81,630 76,150 80,720

374,256 67,833 72,517 71,980 78,795 83,131

-5.24% -12.49% -9.10% -7.45% -2.53% 5.17%

379,583 73,043 77,069 75,141 77,989 76,341 74,858 78,665 78,099 84,129 81,702 72,850 80,218

-1.40% -7.13% -5.91% -4.21% 1.03% 8.89%

A&E Incident Numbers

Variance 2019/20 vs 2018/19

Contract A&E Incident Numbers 2019/20

Variance Actual vs Contract 2019/20

Actual A&E Incident Numbers 2017/18



55,000

60,000

65,000

70,000

75,000

80,000

85,000

90,000

Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21


Actual A&E Incident Numbers 2017/18 Actual A&E Incident Numbers 2018/19

Actual A&E Incident Numbers 2019/20 Contract A&E Incident Numbers 2019/20

15,000

16,000

17,000

18,000

19,000

20,000

21,000

01

/04

/20

19

08

/04

/20

19

15

/04

/20

19

22

/04

/20

19

29

/04

/20

19

06

/05

/20

19

13

/05

/20

19

20

/05

/20

19

27

/05

/20

19

03

/06

/20

19

10

/06

/20

19

17

/06

/20

19

24

/06

/20

19

01

/07

/20

19

08

/07

/20

19

15

/07

/20

19

22

/07

/20

19

29

/07

/20

19

05

/08

/20

19

12

/08

/20

19

19

/08

/20

19

26

/08

/20

19

02

/09

/20

19

09

/09

/20

19

16

/09

/20

19

23

/09

/20

19

30

/09

/20

19

07

/10

/20

19

14

/10

/20

19

21

/10

/20

19

28

/10

/20

19

04

/11

/20

19

11

/11

/20

19

18

/11

/20

19

25

/11

/20

19

02

/12

/20

19

09

/12

/20

19

16

/12

/20

19

23

/12

/20

19

30

/12

/20

19

06

/01

/20

20

13

/01

/20

20

20

/01

/20

20

27

/01

/20

20

03

/02

/20

20

10

/02

/20

20

17

/02

/20

20

24

/02

/20

20

02

/03

/20

20

09

/03

/20

20

16

/03

/20

20

23

/03

/20

20

30

/03

/20

20

06

/04

/20

20

13

/04

/20

20

20

/04

/20

20

27

/04

/20

20

04

/05

/20

20

11

/05

/20

20

18

/05

/20

20

25

/05

/20

20

01

/06

/20

20

08

/06

/20

20

15

/06

/20

20

22

/06

/20

20

29

/06

/20

20

06

/07

/20

20

13

/07

/20

20

20

/07

/20

20

27

/07

/20

20

03

/08

/20

20

10

/08

/20

20

17

/08

/20

20

24

/08

/20

20

31

/08

/20

20

All Ambulance Incidents per Week

Bath & North East Somerset, Swindon &

Wiltshire CCG 53,391 14%

Bristol, North Somerset & South Gloucestershire

CCG 60,753 16%

Devon CCG 85,401 23%

Dorset CCG 57,419 15%

Gloucestershire CCG 38,947 11%

Kernow CCG 38,881 11%

Somerset CCG 38,500 10%

Unknown CCG 964 0%

Ambulance Incidents by CCG Year to Date



53,391 9,871 10,376 10,121 11,194 11,829

60,753 11,067 11,861 11,795 12,708 13,322

85,401 15,137 16,569 16,602 18,086 19,007

57,419 10,478 11,258 10,965 12,009 12,709

38,947 7,365 7,355 7,450 8,201 8,576

38,881 6,598 7,390 7,425 8,422 9,046

38,500 7,112 7,527 7,463 7,972 8,426

964 205 181 159 203 216

374,256 67,833 72,517 71,980 78,795 83,131

-5.19% -11.59% -9.24% -8.51% -4.19% 7.84%

-6.21% -11.42% -8.65% -9.25% -6.53% 4.84%

-5.15% -14.57% -10.56% -5.77% 0.24% 4.81%

-4.96% -11.14% -6.74% -7.30% -4.04% 4.10%

-4.83% -7.85% -10.16% -7.46% -1.41% 2.41%

-7.50% -21.73% -12.37% -9.14% -0.57% 6.07%

-2.48% -7.88% -5.31% -4.92% -0.81% 6.31%

-5.24% -12.49% -9.10% -7.45% -2.53% 5.17%

1.42% -2.41% -3.38% -3.35% 2.87% 13.33%

-2.68% -7.25% -6.42% -4.61% -2.49% 7.25%

-4.95% -13.00% -10.31% -6.34% -0.89% 5.58%

0.26% -5.37% -2.33% -2.74% 2.20% 9.14%

2.49% 1.46% -4.49% -1.17% 3.60% 13.07%

-9.48% -20.29% -14.62% -11.88% -3.67% 2.19%

5.66% 1.79% 3.14% 1.68% 7.50% 13.91%

-1.40% -7.13% -5.91% -4.21% 1.03% 8.89%Trust Total

Dorset CCG

Devon CCG

Gloucestershire CCG

Kernow CCG

Somerset CCG



A&E Incident Numbers % Variance Actual vs Contract 2020/21



Devon CCG

Gloucestershire CCG

Kernow CCG

Dorset CCG



Dorset CCG

Gloucestershire CCG

Trust Total

A&E Incident Numbers % Variance 2020/21 vs 2019/20

Unknown CCG

Kernow CCG

Somerset CCG

Somerset CCG


Trust Total

Devon CCG


Target/


10.49% 10.87% 10.01% 9.52% 10.16% 11.77%

38.67% 44.98% 39.75% 37.34% 36.02% 36.24%

4.90% 4.69% 5.20% 5.22% 4.94% 4.50%

45.93% 39.45% 45.04% 47.92% 48.88% 47.49%

49.16% 55.85% 49.75% 46.86% 46.18% 48.01%

54.07% 60.55% 54.96% 52.08% 51.12% 52.51%EMAS EOEAS LAS NEAS NWAS SCAS SECAMB SWASFT WMAS YAS

PeriodNational

Average

East

Midlands

East of

EnglandLondon North East North West

South

Central

South East

Coast

South

Western

West

MidlandsYorkshire

Aug-20 7.8% 8.5% 8.3% 9.5% 7.0% 10.1% 9.8% 7.2% 5.0% 4.0% 8.8%

Aug-20 32.9% 31.0% 33.2% 30.9% 28.6% 29.2% 34.6% 33.7% 39.0% 37.8% 28.9%

Aug-20 5.3% 6.0% 2.5% 5.4% 8.2% 6.7% 5.7% 1.6% 4.2% 6.2% 7.8%

Aug-20 54.0% 54.5% 56.0% 54.3% 56.1% 54.1% 50.0% 57.5% 51.9% 52.1% 54.6%

Aug-20 46.0% 45.5% 44.0% 45.7% 43.9% 45.9% 50.1% 42.5% 48.1% 47.9% 45.4%

46.0% 46.0% 46.0% 46.0% 46.0% 46.0% 46.0% 46.0% 46.0% 46.0%

Ambulance Quality Indicators 2.3 Metrics - National Benchmarking

% of Incidents Resolved Without Any Conveyance (Non Conveyance)

% of Incidents Resolved Without Conveyance to ED (Non Conveyance to ED)

See & Treat %

See & Convey Non ED %

See & Convey ED %

% of Incidents Resolved Without Conveyance to ED (Non Conveyance to ED)

% of Calls Closed with Telephone Advice or Referral to Other Service

(Hear & Treat)

% of Calls Closed following Treatment at Scene but No Conveyance Required

(See & Treat)

% Of Calls Closed with Conveyance to a Non Emergency Department

(See & Convey Non ED)

% Of Calls Closed with Conveyance to an Emergency Department

(See & Convey ED)

Hear & Treat %

A&E Contract Incident Outcomes

Hear & Treat % 10%

See & Treat % 39%

See & Convey Non ED % 5%

See & Convey ED % 46%

A&E Contract Incident Outcomes (YTD)

National Average 46.0%

EMAS 45.5%

EOEAS 44.0%

LAS 45.7%

NEAS 43.9%

NWAS 45.9%

SCAS 50.1%

SECAMB 42.5%

SWASFT 48.1%

WMAS 47.9%

YAS 45.4%

41%

42%

43%

44%

45%

46%

47%

48%

49%

50%

51%


AQI - Percentage of Incidents Resolved Without Conveyance to an Emergency Department



Source of A&E Contract Incidents

256,768 46,492 48,585 48,503 54,792 58,396

34,321 6,148 7,037 6,930 7,224 6,982

83,167 15,193 16,895 16,547 16,779 17,753

374,256 67,833 72,517 71,980 78,795 83,131


Category of A&E Contract Incidents

22,968 3,841 3,963 4,260 4,823 6,081

180,656 30,486 33,566 35,136 39,425 42,043

98,483 19,912 20,287 18,754 19,746 19,784

5,051 1,159 986 982 974 950

16,950 3,154 3,691 3,578 3,368 3,159

50,148 9,281 10,024 9,270 10,459 11,114

374,256 67,833 72,517 71,980 78,795 83,131 0 0 0 0 0 0 0

Total

Category 1

Category 2

Total

HCP/IFT Level 3/4

NHS 111 Incidents

Category 4 (999)

Category 3

Public Incidents

HCP Incidents

Category 5

Public Incidents 69%

HCP Incidents 9%

NHS 111 Incidents 22%

Source of A&E Incidents (YTD)

Category 1 6%

Category 2 48%

Category 3 26%

Category 4 (999) 1%

HCP/IFT Level 3/4 5%

Category 5 14%

Category of A&E Incidents (YTD)



211,325 41,943 42,928 41,523 42,674 42,257 41,690 44,651 44,177 46,602 44,541 40,681 36,908

53,927 11,057 10,653 10,514 11,124 10,579 11,889 13,586 13,342 14,457 13,803 12,433 11,041

25.52% 26.36% 24.82% 25.32% 26.07% 25.03% 28.52% 30.43% 30.20% 31.02% 30.99% 30.56% 29.91%

8672:26 1888:49 1668:03 1615:39 1803:14 1696:38 1944:26 2358:29 2415:44 2796:27 2517:33 2342:48 1947:34

56:40 62:57 53:48 53:51 58:10 54:43 64:48 76:04 80:31 90:12 81:12 80:47 62:49

186,578 29,153 35,468 37,420 41,744 42,793

51,185 7,700 8,700 9,555 11,458 13,772

27.43% 26.41% 24.53% 25.53% 27.45% 32.18%

9423:46 1100:58 1263:40 1569:08 2039:34 3450:24

61:35 36:41 40:45 52:18 65:47 111:18

195,921 38,863 39,762 38,483 39,560 39,253 38,559 41,294 40,976 43,349 41,274 37,929 34,789

93,411 17,420 18,999 18,629 19,106 19,257 18,236 18,248 18,483 19,074 18,321 17,324 17,789

47.68% 44.82% 47.78% 48.41% 48.30% 49.06% 47.29% 44.19% 45.11% 44.00% 44.39% 45.67% 51.13%

17380:18 3166:59 3442:17 3452:54 3629:59 3688:09 3434:54 3394:42 3543:33 3725:44 3493:02 3426:55 3795:04

113:35 105:33 111:02 115:05 117:05 118:58 114:29 109:30 118:07 120:11 112:40 118:10 122:25

173,222 26,906 32,830 34,774 38,820 39,892

88,073 15,246 17,397 17,429 18,975 19,026

50.84% 56.66% 52.99% 50.12% 48.88% 47.69%

18038:43 3435:31 3643:01 3473:06 3669:21 3817:42

117:54 114:31 117:31 115:46 118:22 123:09

Average Operational Resources Hours Lost to Handover to Clear Delays in Excess of 15 Minutes per Day 2019/20

Average Operational Resources Hours Lost to Handover Delays in Excess of 15 Minutes per Day 2020/21

Total Number of Handovers in Excess of 15 Minutes 2020/21

Handover Delays

% of Handovers in Excess of 15 Minutes 2020/21

% of Handovers in Excess of 15 Minutes 2019/20

Total Operational Resources Hours Lost to Handover Delays in Excess of 15 Minutes 2019/20

Total Number of Handovers Reported at Acute Hospitals 2020/21

Total Operational Resources Hours Lost to Handover to Clear Delays in Excess of 15 Minutes 2019/20

Handover to Clear Delays

Average Operational Resources Hours Lost to Handover Delays in Excess of 15 Minutes per Day 2019/20

Total Number of Handover to Clears in Excess of 15 Minutes 2019/20

% of Handover to Clear Times in Excess of 15 Minutes 2019/20

Total Number of Handover to Clear Times Recorded at Acute Hospitals 2020/21

Total Number of Handover to Clears in Excess of 15 Minutes 2020/21

Total Number of Handover to Clear Times Recorded at Acute Hospitals 2019/20

Total Operational Resources Hours Lost to Handover to Clear Delays in Excess of 15 Minutes 2020/21

Average Operational Resources Hours Lost to Handover to Clear Delays in Excess of 15 Minutes per Day 2020/21

% of Handover to Clear Times in Excess of 15 Minutes 2020/21

Total Operational Resources Hours Lost to Handover Delays in Excess of 15 Minutes 2020/21

Total Number of Handovers Reported at Acute Hospitals 2019/20

Total Number of Handovers in Excess of 15 Minutes 2019/20

0:00

12:00

24:00

36:00

48:00

60:00

72:00

84:00

96:00

108:00

120:00

132:00

144:00

Average Time Lost to Handover Delays in Excess of 15 Minutes per Day

Upper Control Limit Lower Control Limit Mean Forecast Performance

0:00

12:00

24:00

36:00

48:00

60:00

72:00

84:00

96:00

108:00

120:00

132:00

144:00

Average Time Lost to Handover Over to Clear Delays in Excess of 15 Minutes per Day

Upper Control Limit Lower Control Limit Mean Forecast Performance



11,759 1,727 2,320 2,594 2,572 2,546

1,993 313 380 380 457 463

1,577 598 641 185 104 49

16,756 2,655 3,324 3,389 3,708 3,680

7,053 1,074 1,379 1,373 1,632 1,595

17,313 2,597 2,940 3,489 4,075 4,212

11,482 1,872 2,132 2,341 2,547 2,590

11,372 1,781 2,144 2,330 2,501 2,616

6,497 989 1,195 1,327 1,533 1,453

9,693 1,578 1,890 1,887 2,137 2,201

9,355 1,552 1,757 1,882 2,029 2,135

14,254 2,002 2,648 2,799 3,219 3,586

13,159 2,059 2,478 2,666 2,945 3,011

12,282 1,789 2,396 2,552 2,728 2,817

5,565 897 1,045 1,091 1,288 1,244

15,217 2,386 2,890 3,187 3,323 3,431

10,613 1,473 1,882 2,190 2,450 2,618

3,999 753 714 415 1,057 1,060

6,639 1,058 1,313 1,343 1,439 1,486

186,578 29,153 35,468 37,420 41,744 42,793 0 0 0 0 0 0 0


17:11 14:20 16:03 18:55 16:45 18:47

09:56 09:36 08:42 10:42 10:15 10:13

12:34 12:06 12:15 13:38 14:49 13:37

14:45 11:26 11:20 10:42 13:44 24:55

07:09 08:24 07:35 06:52 06:42 06:36

13:08 12:26 11:26 12:59 12:59 14:59

12:35 11:13 12:51 11:30 12:48 14:04

10:23 10:50 10:03 09:48 10:14 11:00

09:28 09:52 09:48 09:33 09:00 09:18

15:05 13:37 13:05 14:07 16:04 17:43

14:26 13:51 12:50 13:13 15:16 16:26

12:20 12:02 10:47 11:14 13:57 13:03

09:34 09:56 08:48 09:05 09:30 10:25

16:34 13:49 12:56 14:28 15:57 23:51

10:52 09:58 10:15 09:21 11:04 13:09

15:11 15:07 14:36 15:00 14:55 16:08

09:08 09:53 09:13 09:05 08:09 09:36

13:39 12:10 13:22 13:50 13:42 14:42

10:59 11:19 10:50 10:39 10:46 11:22

09:22 12:00 11:39 12:03 12:44 15:06 00:00 00:00 00:00 00:00 00:00 00:00 00:00

Number of Handovers by Acute Hospital

Weston General Hospital

Yeovil District Hospital

Torbay Hospital

Total All Hospitals

Cheltenham General Hospital

North Devon District Hospital

Musgrove Park Hospital

Bristol Royal Infirmary

Derriford Hospital

Great Western Hospital

Southmead Hospital

Salisbury District Hospital

Southmead Hospital

Torbay Hospital



Total All Hospitals

Royal Devon & Exeter Hospital

Dorset County Hospital

Gloucester Royal Hospital




Royal Bournemouth Hospital

Royal Cornwall Hospital

Average Handover Time per Incident (Mins:Sec)



Poole Hospital


Royal United Hospital Bath


Derriford Hospital





Poole Hospital


Bristol Royal Hospital for Children




Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes (Hours:Mins)

1098:58 107:22 188:22 311:01 211:15 280:56

57:58 8:01 9:38 14:19 13:36 12:22

70:34 22:57 25:49 11:31 6:55 3:20

1637:08 102:46 133:32 163:18 334:06 903:24

72:09 24:23 18:56 10:39 8:08 10:01

808:16 108:03 86:38 152:34 165:01 295:58

586:35 69:49 126:08 86:07 128:03 176:25

245:47 39:33 38:58 44:24 49:29 73:20

120:35 20:21 26:30 26:49 23:32 23:21

662:12 76:28 77:52 104:48 177:31 225:29

558:36 82:14 74:22 83:48 142:12 175:58

646:35 80:25 74:35 100:12 203:30 187:51

205:02 40:31 31:09 33:56 40:38 58:45

1106:49 88:14 95:07 148:15 217:42 557:28

175:19 21:46 24:34 18:45 41:31 68:41

842:04 129:09 140:17 172:37 169:46 230:13

164:58 26:00 26:44 34:48 23:41 53:43

186:50 21:08 29:11 19:34 48:47 68:08

177:13 31:37 35:10 31:32 34:01 44:50

9423:46 1100:58 1263:40 1569:08 2039:34 3450:24 0:00 0:00 0:00 0:00 0:00 0:00 0:00

No. of Datix

Reports

No. of

Incidents

No. of Datix

Reports

No. of

Incidents

No. of Datix

Reports

No. of

Incidents

No. of Datix

Reports

No. of

Incidents

No. of Datix

Reports

No. of

Incidents

44 303 19 253 25 50

0 0 0 0 0 0

0 0 0 0 0 0

46 1,083 9 92 37 991

0 0 0 0 0 0

15 81 1 15 14 66

15 100 8 58 7 42

6 19 1 4 5 15

0 0 0 0 0 0

2 3 1 2 1 1

19 47 3 3 16 44

19 257 1 4 18 253

0 0 0 0 0 0

28 203 5 31 23 172

4 4 0 0 4 4

11 31 3 23 8 8

0 0 0 0 0 0

1 15 0 0 1 15

2 3 0 0 2 3

0 0 0 0 0 0

0 0 0 0 1 2

5 7 3 2 2 5

217 2,156 54 487 164 1,671 0 0 0 0

YTD Q1 2020/21 Q2 2020/21 Q3 2020/21 Q4 2020/21




Poole Hospital





Total All Hospitals









Total All Hospitals

Southmead Hospital



Torbay Hospital




Poole Hospital



Southmead Hospital

Derriford Hospital


Royal Gwent Hospital

Number of Datix Reports Completed in Relation to Patients Held in Ambulances

at Acute HospitalsNote - Datix reports may relate to a number of incidents at a hospital on a specific day, therefore where available the number of

incidents has also been recorded alongside the number of Datix reports completed.

Neville Hall Hospital

St Michaels Hospital


Derriford Hospital




Torbay Hospital





Target/


90.00% 89.2% 98.4% 96.2% 92.2% 91.4% 89.2%

90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Vehicle deep cleaning compliance with schedule (A&E)

(based on 42 day vehicles deep clean compliance metric)

Other Performance Metrics

98.4% 96.2% 92.2% 91.4% 89.2%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Vehicle Deep Clean Compliance (A&E Vehicles)


Local

Performance

Threshold

Rolling 12

MonthsDec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

n/a 3,638 297 351 343 325 338 274 262 308 261 292 283 304

n/a 32.68% 31.31% 29.63% 33.24% 30.46% 31.36% 38.69% 33.97% 34.74% 30.27% 35.96% 33.92% 29.93%

n/a 618 38 53 62 56 59 46 39 52 54 48 53 58

n/a 52.75% 55.26% 49.06% 61.29% 46.43% 55.93% 60.87% 58.97% 57.69% 42.59% 52.08% 58.49% 37.93%

Ambulance Quality Indicators - Clinical Indicators

Outcome from Cardiac Arrest - Number of Patients who had resucitation commenced/continued by ambulance

service following cardiac arrest

Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (overall)

Outcome from Cardiac Arrest - Number of Patients who had resucitation commenced/continued by ambulance

service following cardiac arrest (Utstein Comparator Group)

As part of the Ambulance Response Programme review of Clinical Outcomes, new timelines measures weere introduced for STEMI and Stroke, superseding the previous measures.

Full definitions can be found at www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators

Due to the coronavirus illness (COVID-19) and the need to release capacity across the NHS to support the response, NHS England have paused the collection and publication of national ambulance clinical data.

Cardiac Arrest Data:

Delivery of early access, early Cardio-pulmonary Resuscitation (CPR), early defibrillation and early Advanced Life Support (ALS) is vital to reduce the proportion of patients who die from out of hospital cardiac arrest.

Patients in cardiac arrest will typically have no pulse and will not be breathing. We show, of patients for whom resuscitation was commenced or continued by ambulance staff out-of-hospital, how many had return of spontaneous circulation (ROSC), with a pulse, on arrival at hospital and how many survived to be

discharged from hospital.

Starting from April 2018, these data are supplied by Ambulance Services via the University of Warwick Out of Hospital Cardiac Arrest Outcomes (OHCAO) study, rather than directly to NHS England.

Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (Utstein Comparator

Group)

15%

20%

25%

30%

35%

40%

45%

Ap

r-1

6

May-1

6

Ju

n-1

6

Ju

l-1

6

Au

g-1

6

Se

p-1

6

Oct-

16

No

v-1

6

De

c-1

6

Ja

n-1

7

Feb-1

7

Mar-

17

Ap

r-1

7

May-1

7

Ju

n-1

7

Ju

l-1

7

Au

g-1

7

Se

p-1

7

Oct-

17

No

v-1

7

De

c-1

7

Ja

n-1

8

Feb-1

8

Ma

r-1

8

Ap

r-1

8

May-1

8

Ju

n-1

8

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct-

18

Nov-1

8

De

c-1

8

Ja

n-1

9

Feb-1

9

Ma

r-1

9

Ap

r-1

9

May-1

9

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

No

v-1

9

Outcomes from Cardiac Arrest - Return of Spontaneous Circulation

Performance Local Performance Threshold Upper Control Limit Lower Control Limit Mean

25%

35%

45%

55%

65%

75%

Ap

r-16

May-1

6

Jun

-16

Ju

l-1

6

Au

g-1

6

Se

p-1

6

Oct-

16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Ap

r-1

7

May-1

7

Jun

-17

Ju

l-1

7

Au

g-1

7

Se

p-1

7

Oct-

17

No

v-1

7

Dec-1

7

Jan

-18

Fe

b-1

8

Ma

r-1

8

Ap

r-1

8

May-1

8

Jun

-18

Jul-1

8

Au

g-1

8

Se

p-1

8

Oct-

18

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-1

9

May-1

9

Jun

-19

Ju

l-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

No

v-1

9

Outcomes from Cardiac Arrest - Return of Spontaneous Circulation (Utstein Comparator Group)


National Average 55.17% EMAS

46.86%

EOEAS 53.37%

LAS 60.45%

NEAS 56.29%

NWAS 55.52%

SCAS 56.35%

SECAMB 53.39%

SWASFT 52.57%

WMAS 57.63%

YAS 59.46%

40%

45%

50%

55%

60%

65%

70%

Date EMAS EOEAS LAS NEAS NWAS SCAS SECAMB SWASFT WMAS

Outcomes from Cardiac Arrest - Return of Spontaneous Circulation (Utstein Group) - April 2019 to November 2019



EMAS 28.14%

EOEAS 27.60%

LAS 33.58%

NEAS 33.02%

NWAS 32.94%

SCAS 30.59%

SECAMB 27.00%

SWASFT 33.55%

WMAS 33.42%

YAS 29.40%

20%

25%

30%

35%

40%


Outcomes from Cardiac Arrest - Return of Spontaneous Circulation - April 2019 to November 2019



Local

Performance

Threshold

Rolling 12


n/a 3,594 295 347 338 318 335 269 262 308 260 286 275 301

9.00% 10.66% 8.81% 8.36% 8.88% 10.69% 9.85% 12.27% 9.92% 12.01% 16.15% 9.79% 10.91% 11.63%

n/a 606 38 53 59 55 59 45 39 52 54 45 49 58

27.00% 28.88% 31.58% 26.42% 22.03% 27.27% 28.81% 35.56% 41.03% 34.62% 27.78% 20.00% 30.61% 25.86%

n/a 477 114 127 131 105

tbc 77.99% 67.54% 85.04% 83.97% 73.33%

n/a 1,614 425 346 428 415

tbc 52.17% 49.65% 50.44% 53.90% 54.75%

Sepsis Data:

Sepsis is a time-critical condition. Early recognition and management of sepsis in the pre-hospital setting can reduce mortality and improve the health and well-being of patients. Making a diagnosis quickly and ensuring early transport of a patient to an appropriate Emergency Department capable of providing further

tests, treatment and care (including appropriate antibiotics for those who are eligible) represents a standard of ambulance care.

Ambulance Clinical Indicators

Outcome from Cardiac Arrest - Number of patients with ROSC

Outcome from Cardiac Arrest - Survival to Discharge - Number of patients who had resuscitation by ambulance service

following cardiac arrest

Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate

Outcome from Cardiac Arrest - percentage receiving post-ROSC care bundle

Outcomes from Sepsis for Ambulance Patients - number of suspected Sepsis and patients with National Early

Warning Score (NEWS) of 7 or more

Outcomes from Sepsis for Ambulance Patients - percentage of suspected Sepsis and patients with National Early

Warning Score (NEWS) of 7 or more who received the Sepsis care bundle

Outcome from Cardiac Arrest - Survival to Discharge - Number of patients who had resuscitation by ambulance service

following cardiac arrest (Utstein Comparator Group)

Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Ap

r-1

6

Ma

y-1

6

Ju

n-1

6

Ju

l-1

6

Au

g-1

6

Se

p-1

6

Oct-

16

No

v-1

6

De

c-1

6

Ja

n-1

7

Feb-1

7

Mar-

17

Ap

r-1

7

May-1

7

Ju

n-1

7

Ju

l-1

7

Au

g-1

7

Se

p-1

7

Oct-

17

No

v-1

7

De

c-1

7

Ja

n-1

8

Feb-1

8

Mar-

18

Ap

r-1

8

Ma

y-1

8

Jun

-18

Ju

l-1

8

Au

g-1

8

Se

p-1

8

Oct-

18

No

v-1

8

De

c-1

8

Ja

n-1

9

Feb-1

9

Mar-

19

Ap

r-1

9

Ma

y-1

9

Ju

n-1

9

Jul-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

No

v-1

9

Outcomes from Cardiac Arrest - Survival to Discharge Rate


0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Ap

r-16

Ma

y-1

6

Jun

-16

Jul-1

6

Au

g-1

6

Se

p-1

6

Oct-

16

Nov-1

6

Dec-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Ap

r-17

Ma

y-1

7

Jun

-17

Jul-1

7

Au

g-1

7

Se

p-1

7

Oct-

17

Nov-1

7

Dec-1

7

Jan

-18

Fe

b-1

8

Ma

r-1

8

Ap

r-18

Ma

y-1

8

Jun

-18

Jul-1

8

Au

g-1

8

Se

p-1

8

Oct-

18

Nov-1

8

Dec-1

8

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-19

Ma

y-1

9

Jun

-19

Jul-1

9

Au

g-1

9

Se

p-1

9

Oct-

19

Nov-1

9

Outcomes from Cardiac Arrest - Survival to Discharge Rate (Utstein Comparator Group)



EMAS 8.05%

EOEAS 9.00%

LAS 9.19%

NEAS 8.01%

NWAS 8.44%

SCAS 11.17%

SECAMB 8.35%

SWASFT 11.50%

WMAS 12.49%

YAS 9.12%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%


Outcomes from Cardiac Arrest - Survival to Discharge Rate - April 2019 to November 2019



EMAS 28.63%

EOEAS 30.75%

LAS 28.42% NEAS

27.08%

NWAS 24.76%

SCAS 33.52%

SECAMB 26.01%

SWASFT 30.17%

WMAS 32.92%

YAS 33.33%

15%

17%

19%

21%

23%

25%

27%

29%

31%

33%

35%


Outcomes from Cardiac Arrest - Survival to Discharge Rate (Utstein Group) - April 2019 to November 2019



Local

Performance

Threshold

Rolling 12


n/a 1,045 250 247 266 282

90.00% 83.92% 84.80% 81.78% 83.08% 85.82%

n/a 1,784 154 155 163 171 140 134 144 143 142 144 146 148

n/a 1,507 133 126 132 150 122 121 124 113 113 116 133 124

tbc 02:13 02:22 02:22 02:24 02:23 02:17 02:19 02:27 02:18 02:26 02:28 02:11

tbc 03:04 03:29 03:25 03:21 03:09 03:07 03:22 03:38 03:10 03:30 03:23 02:59

Ambulance Clinical IndicatorsST-segment elevation myocardial infarction (STEMI) Data:

STEMI is a type of heart attack, determined by an electrocardiogram (ECG) test. Early access to reperfusion, where blocked arteries are opened to re-establish blood flow, and other assessment and care interventions, are associated with reductions in STEMI mortality and morbidity.

Starting with November 2017 data, the National Institute for Cardiovascular Outcomes Research (NICOR) have supplied data from their Myocardial Ischaemia National Audit Project (MINAP) for STEMI patients. These data include counts of patients and, for those patients, the time from ambulance call to insertion of a

catheter for primary percutaneous coronary intervention (PPCI): inflation of a balloon inside a blood vessel to restore blood flow to the heart.

Outcome from Acute STEMI - Number of patients with a pre-hospital diagnosis of suspected STEMI confirmed on

ECG - Quarterly Data from 2018 (Jan, Apr, Jul and Oct)

Outcome from Acute STEMI - % of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG

receiving an appropriate care bundle - Quarterly Data from 2018

Outcome from Acute STEMI - Number of paitents directly admitted with an initial diagnosis of 'definite Myocardial

Infarction'

Outcome from Acute STEMI - Number of paitents directly admitted with an initial diagnosis of 'definite Myocardial

Infarction' who had primary percutaneous coronary intervention (PPCI)

Outcome from Acute STEMI - Mean time from call for help to catheter insertion for angiography for paitents directly

admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes)

Outcome from Acute STEMI - 90th centile time from call for help to catheter insertion for angiography for paitents

directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes)

National Average 2:16

EMAS 2:27

EOEAS 2:21

LAS 2:27

NEAS 5:25

NWAS 2:24

SCAS 1:52

SECAMB 2:14

SWASFT 2:11 WMAS

2:01

YAS 2:18

1:30

2:00

2:30

3:00

3:30

4:00

4:30

5:00

5:30

6:00


Outcome from Acute STEMI - Mean time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hrs:mins) - November 2019



EMAS 3:40 EOEAS

3:12

LAS 3:18

NEAS 7:46

NWAS 3:18

SCAS 2:33

SECAMB 3:14 SWASFT

2:59 WMAS

2:48

YAS 3:17

2:00

2:30

3:00

3:30

4:00

4:30

5:00

5:30

6:00

6:30

7:00

7:30

8:00

8:30


Outcome from Acute STEMI - 90th Centile time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hrs:mins) - November 2019


1:30

1:40

1:50

2:00

2:10

2:20

2:30

2:40

Outcome from Acute STEMI - Mean time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hrs:mins)

Performance Upper Control Limit Lower Control Limit Mean

2:00

2:10

2:20

2:30

2:40

2:50

3:00

3:10

3:20

3:30

3:40

3:50

4:00

4:10

Outcome from Acute STEMI - 90th Centile time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hrs:mins)



Local

Performance

Threshold

Rolling 12


n/a 8,090 850 897 755 890 480 567 577 536 664 603 661 610

tbc 01:27 01:22 01:23 01:24 01:30 01:37 01:43 01:47 01:35 01:39 01:38 01:42

tbc 01:18 01:14 01:15 01:16 01:23 01:20 01:27 01:29 01:20 01:25 01:23 01:25

tbc 02:14 02:06 02:13 02:12 02:11 02:43 02:39 02:59 02:28 02:39 02:47 02:38Outcome from Stroke for Ambulance Patients - 90th centile time from call to hospital arrival for patients either FAST

positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes)

Outcome from Stroke for Ambulance Patients - Number of patients either FAST positive, or with provisional daignosis

of stroke transported by the Ambulance Service

Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST


Outcome from Stroke for Ambulance Patients - 50th centile time from call to hospital arrival for patients either FAST


Ambulance Clinical IndicatorsStroke Data: The FAST procedure helps assess whether someone has suffered a stroke:

• Facial weakness: can the person smile? Has their mouth or eye drooped?

• Arm weakness: can the person raise both arms?

• Speech problems: can the person speak clearly and understand what you say?

• Time to call 999 for an ambulance if you spot any one of these signs.

1:001:051:101:151:201:251:301:351:401:451:501:552:00

Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins)


1:00

1:05

1:10

1:15

1:20

1:25

1:30

1:35

1:40

Outcome from Stroke for Ambulance Patients - Median time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins)


1:201:301:401:502:002:102:202:302:402:503:003:103:20

Outcome from Stroke for Ambulance Patients - 90th Centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins)



EMAS 1:38 EOEAS

1:32

LAS 1:10

NEAS 1:34

NWAS 1:26

SCAS 1:19

SECAMB 1:30

SWASFT 1:42

WMAS 1:14

1:00

1:10

1:20

1:30

1:40

1:50

2:00


Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins) - November 2019



EMAS 1:25

EOEAS 1:18

LAS 1:04

NEAS 1:22

NWAS 1:15

SCAS 1:07

SECAMB 1:10

SWASFT 1:25

WMAS 1:05

0:50

1:00

1:10

1:20

1:30

1:40


Outcome from Stroke for Ambulance Patients - Median time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins) - November 2019



EMAS 2:42

EOEAS 2:23

LAS 1:43

NEAS 2:24 NWAS

2:18

SCAS 1:58

SECAMB 2:24

SWASFT 2:38

WMAS 1:55

1:40

1:50

2:00

2:10

2:20

2:30

2:40

2:50


Outcome from Stroke for Ambulance Patients - 90th Centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins) - November 2019



Local

Performance

Threshold

Rolling 12


n/a 7,460 605 652 565 624 603 654 643 581 666 590 671 606

tbc 01:25 01:22 01:19 01:18 01:24 01:19 01:14 01:14 01:16 01:15 01:28 01:22

tbc 00:29 00:34 00:35 00:36 00:27 00:30 00:30 00:29 00:31 00:29 00:32 00:26

tbc 03:30 03:17 03:38 03:14 04:02 03:33 03:20 03:19 03:14 03:13 03:41 03:58


Outcome from Stroke for Ambulance Patients - Number of stroke patients in SSNAP who had a CT scan

Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in

SSNAP who had a CT scan (hours:minutes)

Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to CT scan for stroke patients in

SSNAP who had a CT scan (hours:minutes)

Outcome from Stroke for Ambulance Patients - 90th centile time from arrival at hospital to CT scan for stroke patients

in SSNAP who had a CT scan (hours:minutes)

0:50

1:00

1:10

1:20

1:30

1:40

1:50

Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hrs:mins)


0:20

0:25

0:30

0:35

0:40

0:45

Outcome from Stroke for Ambulance Patients - Median time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hrs:mins)


2:00

2:30

3:00

3:30

4:00

4:30

Outcome from Stroke for Ambulance Patients - 90th Centile time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hrs:mins)



EMAS 1:34

EOEAS 1:22 LAS

1:18 NEAS 1:17

NWAS 1:06

SCAS 1:27

SECAMB 1:10

SWASFT 1:22

WMAS 1:46

YAS 1:30

0:50

1:00

1:10

1:20

1:30

1:40

1:50

2:00


Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hrs:mins) - November 2019



EMAS 0:52

EOEAS 0:40

LAS 0:27

NEAS 0:37

NWAS 0:37

SCAS 0:40 SECAMB

0:38

SWASFT 0:26

WMAS 0:48

YAS 0:42

0:20

0:25

0:30

0:35

0:40

0:45

0:50

0:55


Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hrs:mins) - November 2019



EMAS 3:47 EOEAS

3:41 LAS 3:40

NEAS 3:45

NWAS 2:45

SCAS 3:36

SECAMB 2:57

SWASFT 3:58

WMAS 4:43

YAS 3:44

2:402:503:003:103:203:303:403:504:004:104:204:304:404:50


Outcome from Stroke for Ambulance Patients - 90th Centile time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hrs:mins) - November 2019



Local

Performance

Threshold

Rolling 12


n/a 862 65 75 66 58 64 69 78 73 79 79 77 79

tbc 01:00 00:58 00:57 01:03 00:57 01:02 01:00 01:02 01:01 01:02 01:10 01:00

tbc 00:56 00:50 00:52 00:52 00:52 00:54 00:54 00:52 00:55 00:52 01:00 00:55

tbc 01:37 01:40 01:35 01:50 01:24 01:50 01:50 01:46 01:47 01:45 01:40 01:39

n/a 3,441 775 868 920 878

97.00% 96.76% 98.45% 98.16% 98.15% 98.86%

Outcome from Stroke for Ambulance Patients - Number of stroke patients in SSNAP who had thrombolysis


Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients

in SSNAP who had thrombolysis (hours:minutes)

Outcome from Stroke for Ambulance Patients - Number of suspected stroke or unresolved transient ischaemic attack

pateints assessed face to face - to be published 4 times a year (Feb, May, Aug and Nov)

Outcome from Stroke for Ambulance Patients - % of suspected stroke or unresolved transient ischaemic attack

pateints assessed face to face that received an appropriate diagnostic bundle (Feb, May, Aug and Nov)

Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to thrombolysis for stroke patients

in SSNAP who had thrombolysis (hours:minutes)

Outcome from Stroke for Ambulance Patients - 90th centile time from arrival at hospital to thrombolysis for stroke

patients in SSNAP who had thrombolysis (hours:minutes)

0:40

0:45

0:50

0:55

1:00

1:05

1:10

1:15

Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins)


0:30

0:35

0:40

0:45

0:50

0:55

1:00

1:05

Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins)


0:50

1:00

1:10

1:20

1:30

1:40

1:50

2:00

2:10

Outcome from Stroke for Ambulance Patients - 90 Centile time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins)



EMAS 1:04 EOEAS

1:00

LAS 0:46

NEAS 0:51

NWAS 0:58

SCAS 0:50

SECAMB 1:09

SWASFT 1:00

WMAS 0:58

YAS 1:04

0:30

0:40

0:50

1:00

1:10

1:20


Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins) - November 2019



EMAS 0:56 EOEAS

0:52

LAS 0:38

NEAS 0:43

NWAS 0:56

SCAS 0:44

SECAMB 0:58 SWASFT

0:55 WMAS

0:54 YAS 0:51

0:30

0:40

0:50

1:00

1:10

1:20


Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins) - November 2019



EMAS 1:49 EOEAS

1:43

LAS 1:22

NEAS 1:37 NWAS

1:29 SCAS 1:29

SECAMB 1:32

SWASFT 1:39 WMAS

1:33

YAS 2:05

1:00

1:10

1:20

1:30

1:40

1:50

2:00

2:10

2:20


Outcome from Stroke for Ambulance Patients - 90th Centile time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hrs:mins) - November 2019



Target/


9,152 1,855 1,848 1,700 1,923 1,826 1,934 1,764 1,641 1,775 1,713 1,525 1,197

5,493 560 895 1,110 1,350 1,578

6,970 1,425 1,356 1,405 1,392 1,392 1,343 1,274 1,235 1,212 1,240 1,177 1,505

-21.19% -60.70% -34.00% -21.00% -3.02% 13.36%

Target/


9,490 1,860 1,890 1,774 2,005 1,961 1,965 1,807 1,697 1,846 1,736 1,585 1,251

9,426 1,844 1,880 1,755 1,998 1,949 1,933 1,792 1,683 1,809 1,721 1,572 1,238

95.00% 99.33% 99.14% 99.47% 98.93% 99.65% 99.39% 98.37% 99.17% 99.18% 98.00% 99.14% 99.18% 98.96%

5,181 528 854 1,073 1,259 1,467

5,160 526 852 1,065 1,255 1,462

95.00% 99.59% 99.62% 99.77% 99.25% 99.68% 99.66%

9,397 1,860 1,865 1,754 1,979 1,939 1,926 1,778 1,670 1,801 1,721 1,565 1,234

9,330 1,815 1,860 1,742 1,978 1,935 1,924 1,775 1,670 1,801 1,721 1,565 1,234

95.00% 99.29% 97.58% 99.73% 99.32% 99.95% 99.79% 99.90% 99.83% 100.00% 100.00% 100.00% 100.00% 100.00%

5,007 515 844 1,013 1,213 1,422

4,978 515 844 1,007 1,204 1,408

95.00% 99.42% 100.00% 100.00% 99.41% 99.26% 99.02%Target Call 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Tiverton UCC - Number of Patients Seen within 4 Hours 2019/20

Tiverton UCC - % of Patients Seen within 4 Hours 2019/20

Tiverton UCC - Number of Cases 2019/20

Tiverton UCC - Number of Patients Triaged within 15 Minutes 2019/20

Tiverton UCC - % of Patients Triaged within 15 Minutes 2019/20


Tiverton UCC - Number of Patients Triaged within 15 Minutes 2019/20

Tiverton UCC - % of Patients Triaged within 15 Minutes 2019/20


Tiverton Urgent Care Centre

Tiverton Urgent Care Centre Activity - Actual 2019/20

Tiverton Urgent Care Centre Activity - Actual 2020/21

Tiverton Urgent Care Centre Activity - Contract Baseline

Percentage Actual vs Contract - Tiverton Urgent Care Centre Activity

Tiverton Urgent Care Centre


Tiverton UCC - Number of Patients Seen within 4 Hours 2019/20

Tiverton UCC - % of Patients Seen within 4 Hours 2019/20

0

500

1,000

1,500

2,000

2,500


Tiverton Urgent Care Centre Activity

Actual 2018/19 Actual 2019/20 Contract 2018/19 (19/20 to be agreed)

0

500

1,000

1,500

2,000

2,500

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Tiverton Urgent Care Centre - % of Patients Seen Within 4 Hours

Number of Cases % of Patients Seen Within 4 Hours Target

0

500

1,000

1,500

2,000

2,500

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Tiverton Urgent Care Centre - % of Patients Triaged Within 15 Minutes

Number of Cases % Triaged Within 15 Minutes Target


Staff Metrics - Establishment and Staff Turnover

Trust Summary- Staff Metrics


Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Trust Total Establishment - Actual WTE 4,000.07 4,010.30 4,022.90 4,051.09 4,050.15 4,064.36 4,127.17 4,157.69 4,117.25 4,205.44 4,197.45 4,233.10 4,268.53 4,173.74 4,233.70 4,241.38 4,281.37

Trust Total Establishment - Funded WTE 3,997.82 3,998.82 3,990.92 4,045.62 4,044.32 4,041.27 4,159.97 4,166.97 4,167.07 4,182.21 4,182.21 4,182.21 4,251.62 4,150.41 4,149.01 4,230.35 4,231.35

Variance 2.25 11.48 31.98 5.47 5.83 23.09 -32.80 -9.28 -49.82 23.23 15.24 50.89 16.91 23.33 84.69 11.03 50.02

Vacancy % 0.1% 0.3% 0.8% 0.1% 0.1% 0.6% -0.8% -0.2% -1.2% 0.6% 0.4% 1.2% 0.4% 0.6% 2.0% 0.3% 1.2%

Support Services - Actual WTE 576.51 579.09 574.56 583.11 579.37 589.46 593.84 602.80 598.09 613.45 616.48 621.48 621.02 626.66 637.67 631.13 629.11

Support Services - Funded WTE 591.34 596.34 597.14 591.84 590.54 587.49 587.49 583.49 582.59 580.99 580.99 580.99 630.22 625.92 624.52 623.52 623.52

Variance -14.83 -17.25 -22.58 -8.73 -11.17 1.97 6.35 19.31 15.50 32.46 35.49 40.49 -9.20 0.74 13.15 7.61 5.59

Vacancy % -2.5% -2.9% -3.8% -1.5% -1.9% 0.3% 1.1% 3.3% 2.7% 5.6% 6.1% 7.0% -1.5% 0.1% 2.1% 1.2% 0.9%

A&E Operations Establishment


Lead Clinician - Actual WTE 1,777.70 1,766.71 1,761.13 1,764.77 1,771.48 1,783.39 1,831.23 1,862.97 1,852.03 1,868.97 1,871.48 1,891.61 1,892.88 1,890.30 1,884.74 1,888.43 1,910.99

Lead Clinician - Funded WTE 1,807.90 1,807.90 1,801.88 1,826.88 1,826.88 1,826.88 1,890.06 1,897.06 1,901.06 1,891.05 1,891.05 1,891.05 1,879.43 1,893.30 1,893.30 1,903.27 1,905.27

Variance -30.20 -41.19 -40.75 -62.11 -55.40 -43.49 -58.83 -34.09 -49.03 -22.08 -19.57 0.56 13.45 -3.00 -8.56 -14.84 5.72

Vacancy % -1.7% -2.3% -2.3% -3.4% -3.0% -2.4% -3.1% -1.8% -2.6% -1.2% -1.0% 0.0% 0.7% -0.2% -0.5% -0.8% 0.3%

Emergency Care Assistants - Actual WTE 1,062.08 1,077.22 1,100.85 1,108.69 1,102.23 1,101.17 1,098.33 1,092.40 1,076.40 1,112.15 1,105.91 1,108.35 1,124.13 1,136.95 1,190.04 1,202.59 1,221.07

Emergency Care Assistants- Funded WTE 958.42 958.42 958.42 993.42 993.42 993.42 1,048.94 1,048.94 1,048.94 1,075.69 1,075.69 1,075.69 1,107.49 1,137.54 1,137.54 1,208.91 1,208.91

Variance 103.66 118.80 142.43 115.27 108.81 107.75 49.39 43.46 27.46 36.46 30.22 32.66 16.64 -0.59 52.50 -6.32 12.16

Vacancy % 10.8% 12.4% 14.9% 11.6% 11.0% 10.8% 4.7% 4.1% 2.6% 3.4% 2.8% 3.0% 1.5% -0.1% 4.6% -0.5% 1.0%

Total A&E Operations Establishment - Actual WTE 2,884.20 2,891.35 2,910.26 2,921.34 2,922.74 2,934.09 2,976.83 3,004.09 2,978.14 3,034.83 3,027.71 3,052.99 3,073.60 3,083.04 3,127.71 3,146.42 3,190.46

Total A&E Operations Establishment - Funded WTE 2,823.02 2,824.02 2,815.56 2,875.56 2,875.56 2,875.56 2,994.26 3,005.26 3,006.26 3,023.00 3,023.00 3,023.00 3,043.18 3,092.10 3,092.10 3,174.44 3,175.44

Variance 61.18 67.33 94.70 45.78 47.18 58.53 -17.43 -1.17 -28.12 11.83 4.71 29.99 30.42 -9.06 35.61 -28.02 15.02

Vacancy % 2.2% 2.4% 3.4% 1.6% 1.6% 2.0% -0.6% 0.0% -0.9% 0.4% 0.2% 1.0% 1.0% -0.3% 1.2% -0.9% 0.5%

1,7

77.7

0

1,7

66.7

1

1,7

61.1

3

1,7

64.7

7

1,7

71.4

8

1,7

83.3

9

1,8

31.2

3

1,8

62

.97

1,8

52.0

3

1,8

68.9

7

1,8

71.4

8

1,8

91.6

1

1,8

92

.88

1,8

90.3

0

1,8

84.7

4

1,8

88.4

3

1,9

10.9

9

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1,900

2,000


A&E Operations - Lead Clinician Establishment

Lead Clinician - Actual WTE Lead Clinician - Funded WTE

1,0

62

.08

1,0

77.2

2

1,1

00.8

5

1,1

08.6

9

1,1

02.2

3

1,1

01.1

7

1,0

98.3

3

1,0

92.4

0

1,0

76.4

0

1,1

12.1

5

1,1

05.9

1

1,1

08.3

5

1,1

24.1

3

1,1

36.9

5

1,1

90.0

4

1,2

02

.59

1,2

21.0

7

500

600

700

800

900

1,000

1,100

1,200

1,300


A&E Operations - Emergency Care Assistants Establishment

Emergency Care Assistants - Actual WTE Emergency Care Assistants- Funded WTE

57

6.5

1

579.0

9

574.5

6

58

3.1

1

579.3

7

589.4

6

593.8

4

602.8

0

598.0

9

61

3.4

5

61

6.4

8

621.4

8

62

1.0

2

62

6.6

6

637.6

7

631.1

3

62

9.1

1

0

100

200

300

400

500

600

700


Support Services Establishment

Support Services - Actual WTE Support Services - Funded WTE

4,0

00.0

7

4,0

10.3

0

4,0

22.9

0

4,0

51.0

9

4,0

50

.15

4,0

64.3

6

4,1

27.1

7

4,1

57.6

9

4,1

17.2

5

4,2

05.4

4

4,1

97.4

5

4,2

33

.10

4,2

68.5

3

4,1

73.7

4

4,2

33.7

0

4,2

41

.38

4,2

81.3

7

3,200

3,400

3,600

3,800

4,000

4,200

4,400


Trust Total Establishment

Trust Total Establishment - Actual WTE Trust Total Establishment - Funded WTE


A&E Clinical Hub Establishment


Clinician- Actual WTE 70.91 70.42 65.53 69.45 67.83 70.83 67.33 64.50 62.67 67.88 66.38 65.00 67.50 69.50 68.69 68.19 68.70

Clinician - Funded WTE 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00 74.00

Variance -3.09 -3.58 -8.47 -4.55 -6.17 -3.17 -6.67 -9.50 -11.33 -6.12 -7.62 -9.00 -6.50 -4.50 -5.31 -5.81 -5.30

Vacancy % -4.2% -4.8% -11.4% -6.1% -8.3% -4.3% -9.0% -12.8% -15.3% -8.3% -10.3% -12.2% -8.8% -6.1% -7.2% -7.9% -7.2%

Total A&E Clinical Hub Establishment - Actual WTE 415.90 423.78 421.28 425.19 426.75 418.59 437.91 431.66 422.85 434.38 429.35 433.60 449.13 464.04 468.33 463.83 461.80

Total A&E Clinical Hub Establishment - Funded WTE 430.74 429.74 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39 432.39

Total Variance -14.84 -5.96 -11.11 -7.20 -5.64 -13.80 5.52 -0.73 -9.54 1.99 -3.04 1.21 16.74 31.65 35.94 31.44 29.41

Vacancy % -3.4% -1.4% -2.6% -1.7% -1.3% -3.2% 1.3% -0.2% -2.2% 0.5% -0.7% 0.3% 3.9% 7.3% 8.3% 7.3% 6.8%

Trust Total Staff Turnover


Turnover % (excl redundancies) 11.81% 11.86% 11.83% 11.10% 11.04% 10.76% 10.80% 10.86% 10.66% 10.42% 11.56% 10.36% 10.14% 9.61% 9.47% 9.18% 8.92%

AE Operations Turnover % (excl redundancies) 8.40% 8.69% 8.83% 8.42% 8.46% 8.08% 8.00% 7.94% 7.99% 7.76% 8.27% 7.67% 7.62% 7.16% 6.91% 6.39% 6.30%

A&E Operations Turnover % (Lead Clinician) 8.75% 8.96% 8.91% 8.78% 8.57% 8.38% 8.22% 8.11% 7.91% 7.60% 8.43% 7.45% 7.58% 7.22% 6.88% 6.37% 6.24%

A&E Operations Turnover % (Emergency Care Assistants) 7.91% 8.37% 8.75% 7.90% 8.51% 7.90% 7.99% 8.01% 8.47% 8.38% 8.11% 8.21% 7.86% 7.22% 6.91% 6.36% 6.34%

A&E Clinical Hub Turnover % (excl redundancies) 21.50% 21.33% 22.03% 21.07% 19.78% 20.52% 20.64% 22.13% 20.64% 20.34% 22.13% 22.40% 21.91% 20.51% 20.83% 20.39% 20.10%

70

.91

70.4

2

65

.53

69

.45

67.8

3

70.8

3

67

.33

64

.50

62

.67

67

.88

66

.38

65.0

0

67

.50

69.5

0

68.6

9

68

.19

68

.70

0

10

20

30

40

50

60

70

80


A&E Clinical Hub - Clinician Establishment

Clinician- Actual WTE Clinician - Funded WTE

41

5.9

0

42

3.7

8

42

1.2

8

42

5.1

9

426.7

5

41

8.5

9

437.9

1

431.6

6

422.8

5

43

4.3

8

429.3

5

433.6

0

44

9.1

3

464.0

4

468.3

3

46

3.8

3

461.8

0

200

250

300

350

400

450

500


A&E Clinical Hub - Total Establishment

Total A&E Clinical Hub Establishment - Actual WTE Total A&E Clinical Hub Establishment - Funded WTE

8.75% 8.96% 8.91% 8.78% 8.57% 8.38% 8.22% 8.11% 7.91% 7.60% 8.43%

7.45% 7.58% 7.22% 6.88% 6.37% 6.24%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%


A&E Operations - Lead Clinician Turnover

A&E Operations Turnover % (Lead Clinician)

7.91% 8.37% 8.75% 7.90%

8.51% 7.90% 7.99% 8.01% 8.47% 8.38% 8.11% 8.21% 7.86%

7.22% 6.91% 6.36% 6.34%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%


A&E Operations - Emergency Care Assistants Turnover

A&E Operations Turnover % (Emergency Care Assistants)

21.50% 21.33% 22.03% 21.07% 19.78% 20.52% 20.64%

22.13% 20.64% 20.34%

22.13% 22.40% 21.91% 20.51% 20.83% 20.39% 20.10%

0%

5%

10%

15%

20%

25%

30%

35%

40%


A&E Clinical Hub - Staff Turnover (exc Redundancies)

A&E Clinical Hub Turnover % (excl redundancies)

11.81% 11.86% 11.83% 11.10% 11.04% 10.76% 10.80% 10.86% 10.66% 10.42%

11.56% 10.36% 10.14%

9.61% 9.47% 9.18% 8.92%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%


Trust - Staff Turnover (exc Redundancies)

Turnover % (excl redundancies)


Staff Metrics - Operational 'On the Road' Establishment Forecast

The Operational establishment position is also analysed based on the date when the staff become operationally available (ie when new staff become operationally active after initial training and induction periods)

In order to produce this adjusted position a set of simple rules have been agreed between Operations and HR which are applied to the date that a new member of staff commences employment with the Trust:

Lead Clinicians - 4 weeks after their commencement date Emergency Care Assistants - 8 weeks after their commencement date

Clinical Hub Call Takers - 8 weeks after their commencment date Clinical Hub Clinicians - 4 weeks after their commencement date

The position detailed in the tables below are based on the forecast establishment positon at the time of the report. All of the figures below are based on the date the staff become operationally available.

The funded WTE lines for all areas of the establishment forecast have been updated to reflect the expected/planned levels of establishment within the Trust People Plan.

Trust Total

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22

Lead Clinician - Actual 'On the Road' WTE 1,613.90 1,603.51 1,603.23 1,600.13 1,607.36 1,642.80 1,660.12 1,683.73 1,702.31 1,686.61 1,718.62 1,716.75 1,723.45 1,712.81 1,722.55 1,722.90 1,702.23 1,719.05 1,732.87 1,761.42 1,778.25 1,757.07 1,779.89 1,789.22

Lead Clinician - Funded WTE 1,635.33 1,635.33 1,635.33 1,673.19 1,673.19 1,673.19 1,733.37 1,741.37 1,744.37 1,734.36 1,734.36 1,734.36 1,722.74 1,735.61 1,735.61 1,746.58 1,746.58 1,746.58 1,746.58 1,746.58 1,746.58 1,746.58 1,746.58 1,746.58

Variance -21.43 -31.82 -32.10 -73.06 -65.83 -30.39 -73.25 -57.64 -42.06 -47.75 -15.74 -17.61 0.71 -22.80 -13.06 -23.68 -44.35 -27.53 -13.71 14.84 31.67 10.49 33.31 42.64

Vacancy % -1.3% -1.9% -2.0% -4.4% -3.9% -1.8% -4.2% -3.3% -2.4% -2.8% -0.9% -1.0% 0.0% -1.3% -0.8% -1.4% -2.5% -1.6% -0.8% 0.8% 1.8% 0.6% 1.9% 2.4%

Emergency Care Assistant - Actual 'On the Road' WTE 994.35 1,008.97 1,033.15 1,039.93 1,057.43 1,055.39 1,048.03 1,043.05 1,062.55 1,062.80 1,034.06 1,074.88 1,075.90 1,094.73 1,106.74 1,122.29 1,156.63 1,157.48 1,152.60 1,161.44 1,183.29 1,184.14 1,166.48 1,197.33

Emergency Care Assistant - Funded WTE 958.42 958.42 958.42 993.42 993.42 993.42 1,048.94 1,048.94 1,048.94 1,075.69 1,075.69 1,075.69 1,107.49 1,136.34 1,136.34 1,207.71 1,207.71 1,207.71 1,207.71 1,207.71 1,207.71 1,207.71 1,207.71 1,207.71

Variance 35.93 50.55 74.73 46.51 64.01 61.97 -0.91 -5.89 13.61 -12.89 -41.63 -0.81 -31.59 -41.61 -29.60 -85.42 -51.08 -50.23 -55.11 -46.27 -24.42 -23.57 -41.23 -10.38

Vacancy % 3.7% 5.3% 7.8% 4.7% 6.4% 6.2% -0.1% -0.6% 1.3% -1.2% -3.9% -0.1% -2.9% -3.7% -2.6% -7.1% -4.2% -4.2% -4.6% -3.8% -2.0% -2.0% -3.4% -0.9%

Total A&E Operations Establishment - Actual 'On the Road' WTE 2,608.25 2,612.48 2,636.38 2,640.06 2,664.79 2,698.19 2,708.15 2,726.78 2,764.86 2,749.41 2,752.68 2,791.63 2,799.35 2,807.54 2,829.29 2,845.19 2,858.86 2,876.53 2,885.47 2,922.86 2,961.54 2,941.21 2,946.37 2,986.55

Total A&E Operations Establishment - Funded WTE 2,593.75 2,593.75 2,593.75 2,666.61 2,666.61 2,666.61 2,782.31 2,790.31 2,793.31 2,810.05 2,810.05 2,810.05 2,830.23 2,871.95 2,871.95 2,954.29 2,954.29 2,954.29 2,954.29 2,954.29 2,954.29 2,954.29 2,954.29 2,954.29

Variance 14.50 18.73 42.63 -26.55 -1.82 31.58 -74.16 -63.53 -28.45 -60.64 -57.37 -18.42 -30.88 -64.41 -42.66 -109.10 -95.43 -77.76 -68.82 -31.43 7.25 -13.08 -7.92 32.26

Vacancy % 0.6% 0.7% 1.6% -1.0% -0.1% 1.2% -2.7% -2.3% -1.0% -2.2% -2.0% -0.7% -1.1% -2.2% -1.5% -3.7% -3.2% -2.6% -2.3% -1.1% 0.2% -0.4% -0.3% 1.1%

Clinical Hub


Call Takers - Actual 'in The Room' WTE 144.77 149.63 148.84 148.92 145.52 140.95 143.83 144.21 161.75 163.63 156.84 151.76 162.55 160.55 164.15 167.36 176.36 173.36 171.36 174.36 177.36 180.36 173.36 202.36

Call takers - Funded WTE 144.22 144.22 144.22 144.22 144.22 144.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22 154.22

Variance 0.55 5.41 4.62 4.70 1.30 -3.27 -10.39 -10.01 7.53 9.41 2.62 -2.46 8.33 6.33 9.93 13.14 22.14 19.14 17.14 20.14 23.14 26.14 19.14 48.14

Vacancy % 0.4% 3.8% 3.2% 3.3% 0.9% -2.3% -6.7% -6.5% 4.9% 6.1% 1.7% -1.6% 5.4% 4.1% 6.4% 8.5% 14.4% 12.4% 11.1% 13.1% 15.0% 16.9% 12.4% 31.2%

Dispatchers - Actual 'In The Room' WTE 120.00 122.40 123.17 122.84 123.95 127.97 128.47 127.70 131.70 128.20 126.19 112.69 114.61 113.60 112.10 112.40 111.46 110.52 109.58 118.64 117.70 116.76 115.81 124.87

Dispatchers - Funded WTE 124.45 124.45 127.10 127.10 127.10 127.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10 117.10

Variance -4.45 -2.05 -3.93 -4.26 -3.15 0.87 11.37 10.60 14.60 11.10 9.09 -4.41 -2.49 -3.50 -5.00 -4.70 -5.64 -6.58 -7.52 1.54 0.60 -0.34 -1.29 7.77

Vacancy % -3.6% -1.6% -3.1% -3.4% -2.5% 0.7% 9.7% 9.1% 12.5% 9.5% 7.8% -3.8% -2.1% -3.0% -4.3% -4.0% -4.8% -5.6% -6.4% 1.3% 0.5% -0.3% -1.1% 6.6%

Clinician - Actual 'In The Room' WTE 67.91 69.92 65.54 64.95 67.83 66.83 66.33 65.09 62.67 65.38 66.39 66.50 57.22 59.11 59.81 58.81 56.93 55.06 58.18 56.30 60.43 58.55 56.68 60.80

Clinician - Funded WTE 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00 66.00

Variance 1.91 3.92 -0.46 -1.05 1.83 0.83 0.33 -0.91 -3.33 -0.62 0.39 0.50 -8.78 -6.89 -6.19 -7.19 -9.07 -10.94 -7.82 -9.70 -5.57 -7.45 -9.32 -5.20

Vacancy % 2.9% 5.9% -0.7% -1.6% 2.8% 1.3% 0.5% -1.4% -5.0% -0.9% 0.6% 0.8% -13.3% -10.4% -9.4% -10.9% -13.7% -16.6% -11.8% -14.7% -8.4% -11.3% -14.1% -7.9%

Forecast WTE Based on Operational and Recruitment AssumptionsActual WTE

Forecast WTE Based on Operational and Recruitment AssumptionsActual WTE

1,400

1,450

1,500

1,550

1,600

1,650

1,700

1,750

1,800


Lead Clinician 'On the Road' Establishment

Lead Clinician - Actual 'On the Road' WTE Lead Clinician - Funded WTE

0

50

100

150

200

250

Clinical Hub - Call Takers Establishment

Call Takers - Actual 'in The Room' WTE Call takers - Funded WTE

0

10

20

30

40

50

60

70

80

Clinical Hub - Clinician Establishment

Clinician - Actual 'In The Room' WTE Clinician - Funded WTE

0

20

40

60

80

100

120

140

Clinical Hub - Dispatchers Establishment

Dispatchers - Actual 'In The Room' WTE Dispatchers - Funded WTE

800

850

900

950

1,000

1,050

1,100

1,150

1,200

1,250


Emergency Care Assistant 'On the Road' Establishment

Emergency Care Assistant - Actual 'On the Road' WTE Emergency Care Assistant - Funded WTE


Staff Metrics - Sickness

Trust Total Sickness Abstraction %


Trust Total Long Term Sickness % 3.68% 4.06% 3.15% 3.88% 4.02% 3.20% 2.76% 3.42% 4.46% 3.46% 3.47% 2.63% 2.92% 2.35% 2.48% 2.24% 2.76%

Trust Total Short Term Sickness % 2.07% 1.66% 2.71% 2.05% 1.89% 2.35% 3.13% 2.24% 2.28% 2.70% 2.23% 2.52% 1.11% 1.55% 1.53% 1.96% 2.12%

Trust Total Sickness % 5.75% 5.72% 5.86% 5.93% 5.91% 5.55% 5.89% 5.66% 6.74% 6.16% 5.90% 5.15% 4.03% 3.90% 4.01% 4.20% 4.88%

Trust Total Sickness KPI 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

A&E Operational Sickness Abstraction % A&E Clinical Hub Sickness Abstraction %

A&E Operations Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

A&E Operations Long Term Sickness % 4.34% 4.30% 3.71% 3.94% 3.69% 3.61% 3.42% 3.56% 4.00% 4.09% 3.75% 2.81% 2.64% 2.73% 2.62% 2.54% 2.95%

A&E Operations Short Term Sickness % 1.77% 1.47% 1.97% 1.71% 2.19% 1.98% 2.12% 1.85% 2.62% 2.04% 1.90% 2.48% 0.80% 1.46% 1.50% 1.57% 1.66%

A&E Operations Total Sickness % 6.11% 5.77% 5.68% 5.65% 5.88% 5.59% 5.54% 5.41% 6.62% 6.13% 5.65% 5.29% 3.44% 4.19% 4.12% 4.11% 4.61%

A&E Sickness KPI 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

A&E Clinical Hub Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

A&E Clinical Hub Long Term Sickness % 5.02% 5.03% 5.72% 6.30% 5.22% 4.41% 5.66% 5.81% 6.43% 5.70% 4.68% 3.36% 2.97% 3.24% 2.42% 3.49% 4.66%

A&E Clinical Hub Short Term Sickness % 2.47% 2.96% 4.27% 3.36% 3.20% 3.53% 3.93% 3.13% 4.40% 3.27% 2.93% 3.25% 1.20% 2.04% 2.78% 2.96% 3.74%

A&E Clinical Hub Total Sickness % 7.49% 7.99% 9.99% 9.66% 8.42% 7.94% 9.59% 8.94% 10.83% 8.97% 7.61% 6.61% 4.17% 5.28% 5.20% 6.45% 8.40%

A&E Sickness KPI 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

Trust Total Sickness % Support Services Sickness %

Support Services Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Support Services Long Term Sickness % 1.44% 1.97% 1.04% 2.53% 2.46% 0.68% 1.03% 2.20% 2.60% 1.41% 2.05% 1.25% 0.38% 0.36% 1.40% 0.95% 1.44%

Support Services Short Term Sickness % 0.94% 0.92% 2.20% 1.56% 0.93% 1.80% 3.02% 1.76% 0.82% 1.98% 1.61% 1.46% 0.21% 0.70% 0.76% 1.63% 1.71%

Support Services Total Sickness % 2.69% 2.44% 1.74% 2.00% 2.64% 2.52% 3.04% 3.80% 3.67% 3.25% 3.66% 2.71% 0.59% 1.06% 2.16% 2.58% 3.15%

Support Services Sickness KPI 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

0%

1%

2%

3%

4%

5%

6%

7%

8%

A&E Operational Sickness %

Sickness % SWASFT Target Upper Control Limit Lower Control Limit Mean

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

A&E Clinical Hub Sickness %


0%

1%

2%

3%

4%

5%

6%

Support Services Sickness %


0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Trust Total Sickness %



Staff Metrics - Staff Appraisal Completion %



Trust Total % Appraisals Completed 86.19% 87.12% 87.07% 86.14% 87.95% 87.01% 84.02% 81.00% 80.93% 83.47% 84.20% 78.93% 74.63% 80.38% 86.32% 86.87% 87.00%

A&E Operations % Appraisals Completed 88.18% 89.48% 90.23% 90.60% 91.55% 92.29% 89.33% 87.00% 86.41% 89.93% 90.51% 85.06% 80.53% 84.83% 91.00% 91.41% 91.03%

A&E Clinical Hub % Appraisals Completed 80.11% 79.83% 76.64% 71.11% 75.07% 67.97% 68.39% 66.00% 64.91% 70.49% 71.87% 67.41% 64.58% 68.18% 70.74% 72.73% 70.51%

Support Services % Appraisals Completed 88.75% 88.66% 85.47% 82.12% 84.38% 80.57% 75.15% 72.00% 73.35% 72.87% 76.41% 71.03% 66.13% 66.53% 73.66% 73.58% 78.06%

Appraisals Completion KPI 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

86.1

9%

87.1

2%

87.0

7%

86.1

4%

87.9

5%

87.0

1%

84.0

2%

81.0

0%

80.9

3%

83.4

7%

84.2

0%

78.9

3%

74.6

3%

80.3

8%

86.3

2%

86.8

7%

87.0

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Trust Total Appraisals Completed %

Trust Total % Appraisals Completed Appraisals Completion KPI

88.1

8%

89.4

8%

90.2

3%

90.6

0%

91.5

5%

92.2

9%

89.3

3%

87.0

0%

86.4

1%

89.9

3%

90.5

1%

85.0

6%

80.5

3%

84.8

3%

91.0

0%

91.4

1%

91.0

3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


A&E Operations - Appraisals Completed %

A&E Operations % Appraisals Completed Appraisals Completion KPI

80.1

1%

79.8

3%

76.6

4%

71.1

1%

75.0

7%

67.9

7%

68.3

9%

66.0

0%

64.9

1%

70.4

9%

71.8

7%

67.4

1%

64.5

8%

68.1

8%

70.7

4%

72.7

3%

70.5

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


A&E Clinical Hub - Appraisals Completed %

A&E Clinical Hub % Appraisals Completed Appraisals Completion KPI

88.7

5%

88.6

6%

85.4

7%

82.1

2%

84.3

8%

80.5

7%

75.1

5%

72.0

0%

73.3

5%

72.8

7%

76.4

1%

71.0

3%

66.1

3%

66.5

3%

73.6

6%

73.5

8%

78.0

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Suport Services - Appraisals Completed %

Support Services % Appraisals Completed Appraisals Completion KPI


A&E Service Line Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Number of A&E Incidents 77,513 79,779 77,773 80,843 79,047 77,761 81,736 81,725 88,353 81,630 76,150 80,720 67,833 72,517 71,980 78,795 83,131 0 0 0 0 0 0 0

Number of Adverse Incidents Reported 390 405 381 397 336 384 424 399 431 559 505 575 437 450 576 521 594

Adverse Incidents per 1,000 A&E Incidents 5.0 5.1 4.9 4.9 4.3 4.9 5.2 4.9 4.9 6.8 6.6 7.1 6.4 6.2 8.0 6.6 7.1

Adverse Incidents reported relating to medication administration, prescription and supply errors 80 62 71 78 59 75 76 74 70 52 42 46 46 66 48 74 63

Adverse Incidents reported relating to medication administration, prescription and supply errors per

1,000 A&E Incidents1.0 0.8 0.9 1.0 0.7 1.0 0.9 0.9 0.8 0.6 0.6 0.6 0.7 0.9 0.7 0.9 0.8

Number of Adverse Incidents Reported Relating to the Trust 280 312 296 313 233 286 289 316 309 444 352 426 328 332 439 358 365

Number of Adverse Incidents Reported Relating to external services 110 93 85 84 103 98 135 83 122 115 147 149 109 118 137 163 229

Number of Adverse Incidents Closed 381 382 399 369 323 408 371 410 393 575 471 690 484 409 506 432 522

Number of Adverse Incidents Currently Under Investigation (as of last day of month) 164 202 195 193 195 216 187 214 208 443 459 158 132 172 224 279 292

Percentage of Review, Learn & Improve Incident (alsoo known as Serious Incidents) investigations

completed within 60 working days50% 0% 100% 0% 0% 33% 100% 20% n/a 0% 25% 0% 43% 50% 17% 0% 33%

Review, Learn & Improve Incidents Identified in Month 3 3 2 2 7 1 5 5 3 3 7 2 3 8 5 9 4

Review, Learn & Improve Incidents Investigated and Presented to Panel 2 4 4 2 0 2 4 1 4 5 6 4 6 3 3 4 6

Review, Learn & Improve Incidents Currently Under Investigation 11 7 8 9 12 9 8 12 13 11 11 9 6 11 13 18 17

Never Events' Identified in Month (included in Serious Incidents figure above) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Moderate Incidents confirmed in Month 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 1 2

Number of Moderate Incidents confirmed in Month per 1,000 A&E Incidents 0.00 0.00 0.00 0.00 0.01 0.00 0.01 0.00 0.00 0.00 0.00 0.00 0.01 0.00 0.01 0.01 0.02

Number of Moderate Incidents Under Investigation 0 0 0 0 1 1 2 0 0 0 0 0 1 0 1 1 3

Percentage of Moderate Incidents closed in the month which were investigated within 35 working days n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 100% n/a n/a 0%

Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is

possible) in accordance with the Duty of Candour 50% 100% 50% 50% 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 75% 100% 80%

Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in

accordance with Duty of Candour100% 100% n/a 33% 100% 75% 0% 100% 100% n/a 100% 100% 100% 100% 100% 100% 100%

Central Alert System (CAS) received 5 7 7 11 3 7 21 16 13 12 21 15 19 15 10 13 11

Central Alert System Warnings (outside deadline) 2 1 2 0 0 0 3 0 0 4 3 3 2 0 3 0 0

Of the Adverse Incidents Reported:

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5


Number of Adverse Incidents Reported per 1,000 A&E Incidents

Adverse Incidents per 1,000 A&E Incidents Median

0.0

0.2

0.4

0.6

0.8

1.0

1.2


Adverse Incidents Relating to Medication Administration, Prescription and Supply Errors Reported per 1,000 A&E Incidents

Adverse Incidents reported relating to medication administration, prescription and supply errors per 1,000 A&E Incidents Median

0

1

2

3

4

5

6

7

8

9

10


Number of Review, Learn & Improve Incidents (also known as Serious Incidents) Reported

Review, Learn & Improve Incidents Identified in Month Median

0.00

0.01

0.01

0.02

0.02

0.03

0.03


Number of Moderate Harm Incidents Reported per 1,000 A&E Incidents

Number of Moderate Incidents confirmed in Month per 1,000 A&E Incidents Median


A&E Service Line Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Number of Ombudsman referrals upheld 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Complaints Reported 94 95 101 116 81 97 82 62 77 88 75 66 52 62 83 83 74

Number of Complaints Reported per 1,000 A&E Incidents 1.21 1.19 1.30 1.43 1.02 1.25 1.00 0.76 0.87 1.08 0.98 0.82 0.77 0.85 1.15 1.05 0.89

Number of Complaints Closed (resolved with the Complainant and all investigations completed) 73 87 84 102 86 85 83 87 54 105 69 57 60 62 60 69 60

Number of Complaints Resolved (with the Complainant but internal investigation ongoing) 1 3 1 1 2 3 3 2 16 2 0 0 5 5 4 6 6

Number of Complaints Open (not resolved with the complainant and currently under investigation) 56 73 68 73 58 64 52 46 33 40 45 29 28 18 43 46 47

Number of Complaints where an investigation has been returned but the complainant is still awaiting

feedback.12 13 18 21 15 9 7 5 8 7 11 20 8 12 16 18 21

Total PALS Reported 61 58 49 65 72 61 54 67 55 77 68 47 50 60 46 75 64

Total PALS Closed 55 71 41 65 71 58 60 44 75 77 70 47 51 52 50 71 56

Total PALS Currently ongoing 23 30 25 29 29 22 34 33 21 27 18 13 24 20 21 27 26

Number of Security Incidents Reported (SIRS)(A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents)

94 112 103 90 122 115 123 112 106 146 115 112 126 132 135 178

Number of Security Incidents Closed (SIRS)(A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents)

71 104 112 93 122 132 110 88 69 1 307 25 4 267 10 78

Number of Security Incidents Currently Under Investigation (SIRS)(A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents)

21 40 28 27 50 36 41 54 91 209 95 168 n/a 181 292 382

Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected.

Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc.

Number of Safeguarding Referrals 1,637 1,966 1,969 1,950 2,019 1,991 2,122 2,228 2,408 2,578 2,454Data Not

Available2,036 2,359 2,651 2,864 3,017

Number of Safeguarding Referrals per 1,000 A&E Incidents 21.1 24.6 25.3 24.1 25.5 25.6 26.0 27.3 27.3 31.6 32.2 30.0 32.5 36.8 36.3 36.3

The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on

where they are receive in the Trust.

0

20

40

60

80

100

120

140


Number of Complaints Reported

Number of Complaints Reported Median

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60


Number of Complaints Reported per 1,000 A&E Incidents

Number of Complaints Reported per 1,000 A&E Incidents Median

0

20

40

60

80

100

120

140

160

180

200


Number of Security Incidents Reported

Number of Security Incidents Reported (SIRS)(A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents)

Median

10

15

20

25

30

35

40


Number of Safeguarding Referrals per 1,000 A&E Incidents

Number of Safeguarding Referrals per 1,000 A&E Incidents Median


Tiverton Urgent Care Centre Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Tiverton Urgent Care Centre Activity 1,855 1,848 1,700 1,923 1,826 1,934 1,764 1,641 1,775 1,713 1,525 1,197 560 895 1,110 1,350 1,578 0 0 0 0 0 0 0

Number of Adverse Incidents Reported 2 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 2

Adverse Incidents per 1,000 Patients 1.1 0.0 0.0 0.5 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.1 0.9 0.0 1.3

Adverse Incidents reported relating to medication administration, prescription and supply errors 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Adverse Incidents reported relating to medication administration, prescription and supply errors per

1,000 Patients0.5 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6

Number of Adverse Incidents Reported Relating to the Trust 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 2

Number of Adverse Incidents Reported Relating to external services 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Adverse Incidents Closed 1 2 0 1 0 0 0 0 1 0 0 0 0 2 1 0 0

Number of Adverse Incidents Currently Under Investigation (as of last day of month) 0 0 0 0 0 1 1 1 0 1 1 2 2 1 0 0 0

Percentage of Review, Learn & Improve Incident (alsoo known as Serious Incidents) investigations

completed within 60 working daysn/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Review, Learn & Improve Incidents Identified in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Review, Learn & Improve Incidents Investigated and Presented to Panel 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Review, Learn & Improve Incidents Currently Under Investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Never Events' Identified in Month (included in Serious Incidents figure above) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Moderate Incidents confirmed in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Moderate Incidents confirmed in Month per 1,000 Patients 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Number of Moderate Incidents Under Investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Percentage of Moderate Incidents closed in the month which were investigated within 35 working days n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is

possible) in accordance with the Duty of Candour n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in

accordance with Duty of Candourn/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Of the Adverse Incidents Reported:

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4


Number of Adverse Incidents Reported per 1,000 Tiverton Urgent Care Centre Patients

Adverse Incidents per 1,000 Patients Median

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7


Adverse Incidents Relating to Medication Administration, Prescription and Supply Errors Reported per 1,000 Tiverton Urgent Care Centre Patients

Adverse Incidents reported relating to medication administration, prescription and supply errors per 1,000 Patients Median

0

1

2

3

4

5


Number of Review, Learn & Improve Incidents (also known as Serious Incidents) Reported

Review, Learn & Improve Incidents Identified in Month Median

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00


Number of Moderate Harm Incidents Reported per 1,000 Tiverton Urgent Care Centre Patients

Number of Moderate Incidents confirmed in Month per 1,000 Patients Median


Tiverton Urgent Care Centre Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Number of Ombudsman referrals upheld 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Complaints Reported 1 1 1 0 0 0 0 1 0 1 3 1 0 0 1 0 1

Number of Complaints Reported per 1,000 Patients 0.54 0.54 0.59 0.00 0.00 0.00 0.00 0.61 0.00 0.58 1.97 0.84 0.00 0.00 0.90 0.00 0.63

Number of Complaints Closed (resolved with the Complainant and all investigations completed) 1 2 1 2 0 0 0 0 1 0 2 1 0 0 1 0 1

Number of Complaints Resolved (with the Complainant but internal investigation ongoing) 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Complaints Open (not resolved with the complainant and currently under investigation) 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 1

Number of Complaints where an investigation has been returned but the complainant is still awaiting

feedback.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0

Total PALS Reported 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

Total PALS Closed 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0

Total PALS Currently ongoing 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

Number of Security Incidents Reported (SIRS) 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

Number of Security Incidents Closed (SIRS) 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0

Number of Security Incidents Currently Under Investigation (SIRS) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected.

Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc.

Number of Safeguarding Referrals 8 2 5 6 3 4 0 4 2 7 2Data Not

Available1 4 4 0 4

Number of Safeguarding Referrals per 1,000 A&E Incidents 4.3 1.1 2.9 3.1 1.6 2.1 0.0 2.4 1.1 4.1 1.3 1.8 4.5 3.6 0.0 2.5

The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on

where they are receive in the Trust.

0

1

2

3

4


Number of Complaints Reported

Number of Complaints Reported Median

0.00

0.50

1.00

1.50

2.00

2.50


Number of Complaints Reported per 1,000 Tiverton Urgent Care Centre Patients

Number of Complaints Reported per 1,000 Patients Median

0

1

2

3

4

5


Number of Security Incidents Reported

Number of Security Incidents Reported (SIRS) Median

0

1

2

3

4

5


Number of Safeguarding Referrals per 1,000 Tiverton Urgent Care Centre Patients

Number of Safeguarding Referrals per 1,000 A&E Incidents Median


South Western Ambulance Service NHS Foundation Trust

Financial Performance - Summary Dashboard

Better Payment Practice Code KPI YTD Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Better Payment Practice Code NHS (Value) % 95% 98.06% 98.38% 97.06% 99.31% 99.63% 95.29% 98.34% 97.51% >95% <95%

Better Payment Practice Code NHS (Volume) % 95% 94.06% 95.51% 99.00% 99.00% 96.00% 80.00% 98.50% 86.16% >95% <95%

Better Payment Practice Code Non NHS (Value) % 95% 99.43% 99.70% 98.92% 99.50% 99.38% 99.66% 99.36% 99.54% >95% <95%

Better Payment Practice Code Non NHS (Volume) % 95% 98.80% 98.95% 98.73% 99.34% 98.14% 98.38% 99.03% 98.40% >95% <95%

Other Key Financial Metrics KPI YTD Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debtors >90 Days Past Due as a % of Total Debtor Balances 5.00% 14.34% 10.17% 10.28% 15.49% 14.34% 42.91% 15.49% 42.91% <5% >5%

Creditors >90 Days Past Due as a % of Total Creditor

Balances5.00% 0.95% 0.18% 0.16% 0.63% 0.95% -0.20% 0.63% -0.20% <5% >5%

Capital Expenditure as a % of Plan (Min)

(YTD position reported each month)85.00% 98% 100% 32% 20% 22% 98% 20% 98% >85% <85%

Cost Improvement Programme (CIP) as a % of Plan

(YTD position reported each month)100.00% n/a n/a n/a n/a n/a n/a n/a n/a >85% <85%

Single Oversight Framework - Use of Resources KPI YTD Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Q1 Q2 Q3 Q4

Capital Service Cover 8.5 9.0 8.7 8.7 8.5 8.5 8.7 8.5

Capital Service Cover Metric Score 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

Liquidity 0.5 1.0 1.7 2.6 3.6 0.5 2.6 0.5

Liquidity Metric Socre 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

I&E Margin (%) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

I&E Metric Score 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00

Distance from Control Total/Financial Plan 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Distance from Control Total/Financial Plan Metric Score 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

Agency Spend Variance to Cap (YTD) 540.4% n/a 544.8% 575.2% 569.3% 540.4% 575.2% 540.4%

Agency Metric Score 4.00 1.00 4.00 4.00 4.00 4.00 4.00 4.00

Use of Resources Metric 3.00 2.00 3.00 3.00 3.00 3.00 3.00 3.00

The Debtors over 90 days old has increased to £940k in August 2020 and the percentage of debtors that are over 90 days has increased to 42.9%

Also within the debtors over 90 days old is a large NHS debtor of £580k which has been acknowledged and the Trust is working with the NHS organisation to resolve during September 2020.

Comments:

Of the outstanding balance £202k relates to salary repayments, of which £100k is currently subject to agreed staged re-payment plans.



Financial Performance - Statement of Comprehensive Income

Statement of Comprehensive Income Actual Budget Variance

Period Ending 31/08/2020

Month 5

£'000 £'000 £'000

Income:

A&E Income (113,185) (101,487) (11,697) 1&2

IUC Income (669) (85) (584) 2

PTS Income (10) 539 (550)

HART Income (2,864) (2,864) - 1

Other Income (6,629) (9,566) 2,936 1

Total Income (123,357) (113,462) (9,895)

Expenditure:

Employee Benefits (Pay) 89,554 81,413 8,141 2 &3

Drugs 183 180 2

Medical 3,369 2,343 1,026

ICT 3,725 3,148 578

Estates 3,072 3,487 (415)

Fleet Expenses 3,072 2,076 996

Fuel 2,266 3,027 (761)

Vehicle Insurance 907 935 (27)

Vehicle Leasing 381 522 (140)

Education & Training 663 1,328 (665)

Other 10,224 8,826 1,397 2

Total Operating Expenses 117,415 107,284 10,132 2 &3

EBITDA (5,942) (6,179) 237

EBITDA % 4.82% 5.45%

Profit/Loss on Asset Disposal (25) - (25) 4

Depreciation 5,267 5,353 (86)

Impairments

Total Operating (Surplus)/Deficit (699) (826) 126

Total Interest Receivable - (93) 93

Total Interest Payable (7) (6) -

PDC Dividend 706 925 (219)

Net (Surplus)/Deficit - - -

Comments:

1 QT1 funding regime in place of contract

2 IUC income above plan due to service extension in April

3 Additional Covid costs and Income

4 Profit on disposal of vehicles

Year to Date



Financial Performance - Statement of Financial Position

31-Mar-20

Statement of Financial Position Actual Actual Budget Variance Actual Budget Variance

Period Ending 31/08/2020

Month 5

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Non-Current Assets

Property, Plant & Equipment & Intangible Assets, Net 103,479 102,774 102,644 130 1 109,583 107,422 2,161

Trade & Other Receivables Non-Current 752 681 652 29 2 541 512 29

Total Non-Current Assets 104,231 103,455 103,296 159 110,124 107,934 2,190

Current Assets

Inventories 2,077 2,039 2,110 (71) 2,100 2,100 -

NHS Trade Receivables, Current 771 621 1,921 (1,300) 3 1,850 1,850 -

Non NHS Trade Receivables, Current 697 827 600 227 3 970 970 -

Other Receivables, Current 1,215 742 497 245 897 486 411

Prepayments, Current, Non-PFI related 1,962 4,487 3,000 1,487 2 2,904 2,209 695

Other Financial Assets, Current 2,428 6,373 856 5,517 4 58 69 (11)

Cash and Cash Equivalents 30,440 47,807 24,624 23,183 5 20,501 15,372 5,129

Current Assets 39,589 62,896 33,608 29,288 29,280 23,056 6,224

Non Current Assets Held for Sale 275 275 275 - - -

Total Current Assets 39,864 63,171 33,883 29,288 29,280 23,056 6,224

TOTAL ASSETS 144,095 166,626 137,179 29,447 139,404 130,990 8,414

Current Liabilities - -

Deferred Income (1,225) (22,990) (411) (22,579) 6 (342) (347) 5

NHS Trade Payables (547) (539) (178) (361) 7 (547) (250) (297)

Non-NHS Trade Payables (2,300) (1,920) (1,703) (217) 7 (2,500) (2,500) -

Capital Accruals (5,203) (4,710) (1,766) (2,944) 1 (7,736) (1,997) (5,739)

Other Liabilities (7,114) (7,295) (6,650) (645) 8 (7,250) (6,900) (350)

Borrowings (487) (491) (449) (42) (53) (9) (44)

Other Financial Liabilities (11,996) (12,969) (9,962) (3,007) 9 (11,523) (10,495) (1,028)

PDC Dividend Payable, Current - (691) (1,075) 384 10 - - -

Provisions for Liabilities and Charges (8,949) (8,885) (8,949) 64 (1,927) (1,991) 64

Total Current Liabilities (37,821) (60,490) (31,143) (29,347) (31,878) (24,489) (7,389)

Net Current Assets/(Liabilities) 1,768 2,406 2,465 (59) (2,598) (1,433) (1,165)

TOTAL ASSETS LESS CURRENT LIABILITIES 106,274 106,136 106,036 100 107,526 106,501 1,025

Non-Current Liabilities

Finance Leases, Non-Current (1,831) (1,823) (1,831) 8 (1,823) (1,831) 8

Long Term Borrowings - - - - - - -

Other Financial Liabilities, Non-Current - - - - - - -

Provisions, Non-Current (4,805) (4,675) (4,567) (108) (4,740) (4,632) (108)

Trade and Other Payables, Non-Current - - - - - - -

Total Non-Current Liabilities (6,636) (6,498) (6,398) (100) (6,563) (6,463) (100)

TOTAL ASSETS EMPLOYED 99,638 99,638 99,638 - 100,963 100,038 925

Represented By

Public Dividend Capital 50,396 50,396 50,396 - 51,321 50,396 925

Income & Expenditure Account 34,191 34,440 34,411 29 11 34,783 34,719 64

Revaluation Reserve 15,051 14,802 14,831 (29) 12 14,859 14,923 (64)

TOTAL TAXPAYERS EQUITY 99,638 99,638 99,638 - 100,963 100,038 925

Comments:1 Property, Plant and Equipment - 2020/21 Capital behind plan (£117k), depreciation £364k behind plan and sale of vehicles £117k = (£130k).

2 Prepayments - IT Maintenance, Rent and Subs above plan (based on August 2019 actual)

3 Receivables - CCG s paid invoices ahead of plan.

4 Other Assets -Covid-19 & salary recharges

5 Cash - ahead plan due to Deferred income ahead of plan NHSIE paying in advance, capital accruals and other financial liabilities (accruals) ahead of plan.

6 Deferred Income - NHSIE paying in advance.

7 Trade payables - More creditors due to COVID-19.

8 Other Liabilities - More NI for pay, overtime due to COVID-19.

9 Other Financial Liabilities - More accrual for pay, overtime and agency, fire responders due to COVID-19.

10 PDC Dividend Payable - More cash in bank due to NHSIE paying in advance.

11 Income & Expenditure - More excess depreciation than plan £29k

Year to Date Forecast


12 Revaluation Reserve - (£29k) more excess depreciation than plan.


Paper 5


Name: Jennifer Winslade

Executive Director of

Quality & Clinical Care

Health, Safety and Security Violence and Aggression

• NHS Violence Prevention and Reduction Standards are currently in consultation and

due to be released December 2020.

• SWASFT have granted funding for a Violence Reduction and Security Manager until

31 March 2021 to help ensure compliance with standards and HSE requirements.

• NHSE are currently in discussion about provision of funding a degree level

qualifications for those taking a lead in violence reduction roles. CPD modules will

also be developed.

• NHSE are currently in discussion about provision of funding to Trusts for body worn

cameras. This will be led by Trusts currently undertaking pilot trials.

• SWASFT Violence and Aggression Group re-convening September 2020 to aide

violence prevention and reduction.

01/04/2020 -31/08/2020 01/04/2019 -31/08/2019

Abuse other (incidents reporting information about

patients or others) 69 72

Aggressive behaviour 173 113

Inappropriate behaviour 81 31

Physical assault by patient 110 82

Physical assault by public 10 2

Racial abuse 4 0

Threatening behaviour 42 22

Uncooperative behaviour 11 10

Verbal abuse 214 197

Totals: 714 529

Patient Safety

3

• 13 RLIs (including one near miss) confirmed during July and August 2020

• 6 - A&E Ops

• 7 - Hubs

• Themes/Incidents of Note

• Ineffective Breathing

• Discharging on Scene

• Missed opportunity to refer patient to mental health services

• DNAR interpretation

• Action Themes

• Bias

• Challenging Clinical Decision Making

• Mandatory Clinical Guideline Review

Note - Increase in the number of RLIs for 2020/21 compared to 2019/20

Think 111 First • National integrated programme to improve outcomes and experience of urgent and emergency

care

• keep patients safe and allow them to maintain social distancing systems are asking them to call

NHS 111 before they go to the Emergency Department

• The ambition then is for NHS 111 to then book them into a time slot at the emergency department,

or at the most appropriate local service for the patient

• NHS 111 First will ensure that patients can access the clinical service they need, first time, with the

convenience of a booked appointment or time slot if they need to attend an emergency department

Key Risks

• Unheralded patients presenting at Emergency Departments could be asked to dial 111 (Cornwall

tried this but changed process due to an AI when a patient deteriorated in the ED car park)

• Increase in 111 traffic will inevitably result in an increase in 999 traffic

• Mitigation includes validation of CAT 3 & 4 999 dispositions. However, little confidence in current

staffing levels to facilitate this

• Second Wave, Winter, and ‘Think 111 First’ could be a

perfect storm and overburden 111 and therefore 999

Areas adopting

• Cornwall live (no impact felt on 999 as of yet)

• Devon aiming for soft launch 1st October

• Other areas progressing at pace.

Patient Experience and Engagement Patient Experience Feedback - Themes

• Perceptions of attitude

• Pain management

• Management of patients suffering mental health episodes

• Patients being asked to walk to the ambulance

Adverse Incidents -Themes

• Hospital handover delays

• Delays in ambulance attendance

Patient Engagement - Work streams

• Accessibility – Accessible communication

• Public Health – RSAH on 16 October

• EDI – AACE Clinical presentations, uniforms

Paper 6


Page 1 of 3

Committee Assurance Report

Name of Meeting Quality Committee

Date 13 August 2020

Committee Chair Venessa James (VJ)

Members Present Jenny Winslade (JW) Jessica Cunningham (JC), Minesh Khashu (MK) Andy Smith (AGS)

Apologies Richard Marlow (RM) and Yvonne Burke (YB)

In attendance Will Warrender (WW), Adrian South (AS), Sarah James (SJ), Marty McAuley (MM), Tony Fox (TF), William Lee (WL), Richard Garment (RG) and David Phillips (DP)

Number of items on agenda 24

Report from Chairman VJ noted the ongoing work on the corporate dashboard with discussions how to ensure how it works and vital indicators with sub-committees into the dashboard development. There is development on the new trust strategy looking at the direction of travel for the trust, where the trust sees itself in 3,5,10 years. This is still in the early stages but it is anticipated the final strategy will be ready by late March 2021. Items which were approved

Minutes of previous meeting 14 May 2020.

Quality Report 2019-20.

Acceptance of Enhanced Hear and Treat as Business as Usual.

Review, Learn and Improve (RLI) Policy.

Clinical Scope of Practice (Including extended skills) Policy.

Chaperone Policy.

Clinical Hub Remote Clinical Triage Audit Policy.


Page 2 of 3

Items for Assurance

Action point registers; noted that the remaining actions for 2018-19 and 2019-20 will be brought to the committee on 12 November 2020. Action register 2020-21, two actions remain open, CAT2 long waits, an update will be provided at the September 2020 Board and Safeguarding sharing with external agencies is subject to ongoing discussions.

The EPRR and Specialist Practice Department have made progress with regard to managing compliance against the national and contractual standards for EPRR and interoperable capabilities as well as the wider Quality Assurance Improvement Programme of the department.

Summary Report – Suspected Coronavirus (COVID-19) in SWASFT March-May 2020, the Research, Audit and Improvement Team have completed a huge amount of work and the report is aimed to provide a summary of the audits conducted throughout March, April & May 2020 and the information has been shared with commissioners.

Executive Director Report – Quality and Clinical Care, Antibody testing was offered to 100% of staff over a 6 week period with 81.69% delivered.

Patient safety has had an upsurge of RLIs with 17 in the first quarter which is a significant increase. This has impacted the team considerably and additional funding for extra resources has been obtained. There has seen an increase in Oesophagel Intubation which questions whether paramedics should be intubating, there are benefits and risks but WMAS do not allow their paramedics to intubate.

Medicine governance – Indicators to support Specialist Paramedics prescribing are being developed as part of the dashboard. The decision that technicians can continue to administer the prescription only medicines. Salbutamol and Ipratropium.has been supported by Executive Directors and was agreed by Quality Committee following a review by the CQC of their guidance.

Ineffective Breathing – Actions ongoing and risk assessment to be completed.

Communication Complaints – 1 July 2019 – 30 June 2020, 917 patient experience, 403 related to poor staff communication. In the same period 4191 plaudits were received. A deep dive is to be completed and brought back to the November Committee.

Executive Director Report Operations, Extended delays and long waits – CAT1 to CAT4 up to the 20 July 2020, which is 18 months of data, clear trend, we put in additional resources during COVID and you can see where it drops but we have gone back up again.


Page 3 of 3

Call audit – Clinical compliance good, non-clinical have struggled during COVID as they were deployed to call answering. Working on a recovery plan and will be back up to the previous level by the end of September 2020.

The Executive Medical Report was taken as read.

Items for Information

Review, Learn, Improve (RLI) Incidents relating to the identification of ineffective breathing descriptors used by ‘999 callers.

Health, Safety, Security and Infection, Prevention and Control Committee Terms of Reference.

Medicines Governance Minutes.

Paper 7


Page 1 of 2



Paper Title: Quality Report 2019-20

Prepared by: Nick Hunt, Corporate Governance Manager

Presented by: Jennifer Winslade, Executive Director of Quality and Clinical Care

CQC Domain: Well Led

Strategic Goal:

Every Patient Matter

Every Team Member Matters

Every Pound matters

Action: Approval

Recommendation: The Trust Board of Directors is asked to approve the Quality Report 2019/20.

Forward Look:

The Quality Report 2019-20 provides our patients and the public with examples of the improvement work that teams are delivering across the organisation, and demonstrates that the Trust always aims to deliver high quality, safe, cost-effective and sustainable healthcare services that meet the high standards that our patients deserve. As a Foundation Trust we are required to compile a Quality Report which is historically submitted within the Trust’s Annual Report as well as a standalone document to NHSI. Due to the impacts of COVID-19 NHSI released guidance to advise that Foundation Trusts only needed to submit a Quality Account (a shorter document than the Quality Report) and that this did not require to be submitted alongside the Annual Report and therefore a revised submission date of December 2020 was advised. This year there is also no requirement for the Trust’s external auditors to make an opinion on the report or provide an audit of key metrics. Many of our stakeholders have expressed that in line with guidance they will not make comment on the Quality Report this year. However, with the newly extended deadline we will ensure that the opportunity for comment is still provided and any statements received will be included within Annex 1 of the Report. On 13 August 2020 the Quality Committee approved the Quality Account 19/20 for finial ratification from the Board.

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Contents Introduction ............................................................................................................................................ 2

Welcome to the South Western Ambulance Service NHS Foundation Trust ..................................... 2

Inayah Aged Seven Praised for Brave 999 Call for Mum .................................................................... 5

Care Quality Commission (CQC) .......................................................................................................... 7

Freedom to Speak Up and Whistleblowing ........................................................................................ 8

Quality Account - Part 1 ........................................................................................................................ 10

Statement on quality from the Chief Executive of the NHS foundation trust .................................. 10

Part 2 - Priorities for improvement and statements of assurance from the board .............................. 12

Priorities for Improvement ............................................................................................................... 12

Quality Priorities for Improvement 2019/20 .................................................................................... 12

Quality Priorities for Improvement 2020/21 .................................................................................... 22

Statements of assurance from the board ......................................................................................... 28

Learning from Deaths ....................................................................................................................... 32

Reporting against core indicators ..................................................................................................... 33

Part 3 – Other Information ................................................................................................................... 33

Overview of Quality of Care 2019-20................................................................................................ 34

Patient Safety ................................................................................................................................ 34

Patient Experience ........................................................................................................................ 36

Performance Indicators .................................................................................................................... 43

Ambulance Response Indicators ................................................................................................... 43

Stroke 60 Minutes ......................................................................................................................... 44

Return of spontaneous circulation (ROSC) ................................................................................... 44

Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees ............................................................................................................................. 44

Clinical Commissioning Groups ......................................................................................................... 44

Health Overview & Scrutiny Committees ......................................................................................... 45

Healthwatch ...................................................................................................................................... 45

Other ................................................................................................................................................. 45

Annex 2: Statement of directors’ responsibilities for the quality report.............................................. 46

Glossary of Terms and Acronyms ......................................................................................................... 48

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Introduction

Welcome to the South Western Ambulance Service NHS Foundation Trust We provide a wide range of emergency and urgent care services across a fifth of England covering Cornwall and the Isles of Scilly, Devon, Dorset, Somerset, Gloucestershire, Wiltshire and the former Avon area. Our operational area, covering 10,000 square miles, is predominantly rural, but includes large urban areas such as Bristol, Plymouth, Exeter, Bath, Swindon, Gloucester, Bournemouth and Poole. SWASFT is the primary provider of 999 services across the South West. The Trust employs more than 4,000 staff and we have 96 ambulance stations, three clinical control rooms, six air ambulance bases and two Hazardous Area Response Teams (HART).

The Trust serves a total population of over 5.5 million and is estimated to receive an influx of over 23 million visitors each year. The operational area is predominantly rural but also includes large urban centres including Bristol, Plymouth, Exeter, Bath, Swindon, Gloucester, Bournemouth and Poole.

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South Western Ambulance Service NHS Foundation Trust (SWASFT) provides the following services. Emergency ambulance 999 services (A&E) Medical emergencies happen at all times of the day and night. SWASFT operates a 24-hour clinical response to 999 calls to ensure patients receive the right care as quickly as possible – wherever and whenever they need it. Urgent Care Services (UCS) The centre, at Tiverton and District Hospital, Kennedy Way, Tiverton, is open seven days a week between 8am and 10pm and is staffed by a team of highly qualified general practitioners (GPs) and nurse practitioners. You do not need an appointment to visit the centre and we will provide treatment for a host of minor injuries and ailments. NHS 111 call-handling for Dorset NHS 111 is designed to make it easier for you to access local NHS healthcare services. You can dial 111 when you need medical help fast but it is not a 999 emergency. NHS 111 is a fast and easy way to get the right help, whatever the time. NHS 111 is available 24-hours-a-day, 365 days a year. Calls are free from landlines and mobile phones. The Trust held the NHS 111 contract until 31 March 2020 and this was taken over by Dorset Health Care. **Please note: This service was transferred to Dorset Health Care in April 2020. Air Ambulance The Trust provides the clinical teams for four air ambulances (one in Cornwall and the Isles of Scilly, one shared across Dorset and Somerset, one in Wiltshire and one based near Bristol).

https://www.swast.nhs.uk/welcome/hcps/

https://www.swast.nhs.uk/welcome/recruitment/

https://www.swast.nhs.uk/welcome/patient-and-public-engagement/

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What is the Quality Account and what does it mean to

our Patients

The Quality Account is a report about the quality of services offered by an NHS healthcare provider, in this case the South Western Ambulance Service Foundation Trust. The reports are published annually by each provider, including the independent sector, and are available to the public. Quality Accounts are an important way for local NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders. The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive, and patient feedback about the care provided.

The Quality Account provides our patients and the public with examples of the improvement work that teams are delivering across the organization, and demonstrates that the Trust always aims to deliver high quality, safe, cost-effective and sustainable healthcare services that meet the high standards that our patients deserve.

Quality Account

Clinical Effectiveness

Patient Experience

Patient Safety

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Inayah Aged Seven Praised for Brave 999 Call for Mum

A seven-year-old girl was officially commended for saving her mum when she had a severe allergic reaction to an ice cream. Mariyam Yasmin, 31, had an anaphylactic shock after consuming a Nestle Nobbly Bobbly ice lolly at home in the Moorlands area of Bath. She was struggling to breathe, shaking, and needed urgent medical help. Her daughter, Inayah, called 999 and told South Western Ambulance Service NHS Foundation Trust (SWASFT) Call Handler Lydia Gardiner what was wrong. Inayah remained calm, was able to give her mum a vital injection, and greeted crews when they arrived. Mariyam was taken to hospital for observation following the incident on 30 June. Inayah made a special visit with her family to the SWASFT Control Centre in Bristol on Wednesday 24 July to be formally recognised for her actions. She was presented with a certificate from SWASFT Chief Executive Ken Wenman to congratulate her for knowing what to do in an emergency. Inayah said: “I tried to stay calm and not be scared. I’m pleased mummy is better now.” Marijam said: “It felt like someone was trying to strangle me. I couldn’t breathe properly. It was really scary. “Thankfully Inayah knew exactly what to do, and she did everything perfectly. We’re so proud of her.” Emergency Medical Dispatcher, Lydia, praised Inayah. She said: “Inayah was fantastic. She confidently told me her address, and said her mum was having an allergic reaction after eating an ice cream. She remained so calm and told me exactly what was happening.

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“I was very impressed when she gave her mum her EpiPen straight away, before I even gave her the instructions. She knew exactly what to do. She answered all my questions perfectly, and listened really well to everything. She really was brilliant and is a credit to her mum.” Mariyam said Inayah had been curious about what to do in an emergency after seeing an elderly man fall over in the street. So Inayah’s dad, Juhal, taught her how to respond. She said: “Inayah was very curious. So her dad explained what to do, and taught her how to use the house phone which she used to call 999. She’s even memorised our postcode.” Control Room Dispatcher Victoria Fido organised for crews to attend the incident. Paramedics Alex Nicolson and Rebecca Fey were the first responders on scene. They were followed by Paramedic Heidi Hodgson and Emergency Care Assistant Tina Robins. Paramedic Rebecca Fey said: “Little Inayah was standing at the front door when we arrived, and took us to her mummy. Then she announced that she needed to contact her daddy, because he was at work. She was so calm and brave in a scary situation.” SWASFT encourages parents to teach their children what to do in an emergency. That includes showing them how to call 999, making sure they know their address, and ensuring they are aware of any known health problems in the family.

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Care Quality Commission (CQC) The Trust maintains its registration with the CQC with no conditions and is proactive in ensuring compliance with CQC regulations through the maintenance of a centralised evidence system and a CQC Compliance Team. In July 2019, the Trust’s NHS 111 service received an announced focused inspection of the Effective and Well-Led domains. The Well-Led domain retained its rating of ‘Good’ with the Effective domain being rated as ‘Requires Improvement’. The NHS 111 service retained it’s ‘Good’ overall rating.

CQC Domain July 2019 rating

Safe Good

Effective Requires Improvement

Caring Good

Responsive Good

Well Led Good

OVERALL Good

The Trust underwent its second comprehensive CQC inspection under the new inspection regime of the Trust in June and July 2018. The Trust’s core services of Emergency and Urgent Care (A&E 999) and Emergency Operations Centres (EOCs or Clinical Hubs) were inspected as part of this inspection. The Trust was awarded an overall rating of ‘Good’ following this inspection. The following table details the breakdown of CQC rating:

SAFE EFFECTIVE CARING RESPONSIVE WELL LED OVERALL

Emergency and Urgent Care (A&E 999)

Requires Improveme

nt

Requires Improvemen

t

Outstanding

Good Requires

Improvement

Requires Improvemen

t

Emergency Operations

Centre (Clinical Hubs)

Good Good Outstandin

g Good Good Good

Urgent and Emergency Care (Tiverton Urgent

Care Centre)

Requires Improveme

nt Good Good Good Good Good

Resilience Outstandin

g Good Good Good Outstanding Outstanding

Out of Hours (Dorset)

Requires Improveme

nt Good Good Good Good Good

OVERALL Requires

Improvement

Good Outstandin

g Good Good Good

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All of the CQC reports following inspections of the Trust are available at: https://www.cqc.org.uk/provider/RYF The Trust was pleased that the CQC recognised the care and compassion that staff demonstrate every day when treating patients in its rating of ‘Outstanding’ of the Caring domain. The Trust is also incredibly proud of the improvements made to the Effective and Well-Led domains since the CQC’s last inspection in June 2016. Each year, the Trust develops a Quality Assurance Plan (QAP) which seeks to address ‘Must Do’ and ‘Should Do’ actions given to us by the CQC and to further embed quality across the organisation. Must Do and Should Do actions can be found on pages 9 to 12 of the Trust’s most recent CQC report. This plan builds on the learning and recommendations from CQC inspections, feedback from staff and the input of Executive Directors. Reporting and accountability for this plan is through the Trust’s Quality Committee.

Freedom to Speak Up and Whistleblowing What is freedom to speak up?

We know that sometimes our staff can find it difficult to speak up about issues affecting patient safety or staff experience. They may not know who to speak up to. They may feel that anything they do raise might not be taken seriously, or that nothing will be done as a result.

It is really important that everyone understands and feels confident to raise concerns while at work and know that those concerns will be listened to and supported to raise them.

Every NHS trust and Foundation trust in England has a Freedom to Speak Up Guardian and last year they handled over 6,700 cases brought to them by NHS workers How can our staff raise their concerns? In many circumstances the easiest way for our staff to raise any concerns is through their line manager, however where they do not feel that this is appropriate there are several other options that any members of staff can take. These include our: Freedom to Speak up Guardian - Acts as an independent and impartial source of advice to employees at any stage of raising a concern Peer Support Guardians – Enabling local peer level support and those individuals who have also been trained in order to provide an impartial source of advice to employees at any stage of raising a concern Freedom to Speak Up Champions – Members of our HR Business Partner Team

https://www.cqc.org.uk/provider/RYF

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If the staff members still remains concerned they are able to contact our: Executive Director with responsibility for whistleblowing Non-Executive Director with responsibility for whistleblowing Raising your concern with an outside body Alternatively, any staff member can raise their concerns outside the organisation with:

NHS Improvement for concerns about: - NHS trusts and foundation trusts are being run - providers with an NHS provider licence - NHS procurement, choice and competition - the national tariff

Care Quality Commission for quality and safety concerns

NHS England for concerns about: - primary medical services (general practice) - primary dental services - primary ophthalmic services - local pharmaceutical services

Health Education England for education and training in the NHS

NHS Protect for concerns about fraud and corruption.

How can our staff remain confident and feel safe about speaking up If a member of staff raises a genuine concern, they will not be at risk of losing their job or suffering any form of reprisal as a result. We will not tolerate the harassment or victimisation of anyone raising a concern. Nor will we tolerate any attempt to bully them into not raising any such concern. Any such behavior is a breach of our values as an organisation and, if upheld following investigation, could result in disciplinary action. Provided that the staff member is acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concerns. We hope that our staff will feel comfortable raising their concerns openly, but we also appreciate that they may want to raise it confidentially and therefore, we will keep their identity confidential, if that is what they want, unless we are required to disclose it by law (for example, by the police). How do we communicate with our staff during the process? The Trust is committed to treating all staff with respect at all times and will thank them for raising any concerns. They will discuss their concerns to ensure that we understand exactly what they are worried about. We will advise them about how long we expect the investigation to take and keep them up to date with its progress. Wherever possible, we will share the full investigation report with the staff member (while respecting the confidentiality of others).

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Quality Account - Part 1

Statement on quality from the Chief Executive of the NHS foundation trust Welcome to the Quality Account and Report for 2019/20, I am delighted to be presenting this report

to you. The Quality Account and Report sets out the progress we have made in the delivery of safe

and high quality care. It also identifies the challenges and opportunities the Trust has faced during

the year in providing the best possible care to the people of the South West and the communities we

serve. With the global Covid-19 pandemic there has never been a greater need to ensure that quality

of care is at the forefront of the work we do, ensuring that our patients and our people remain safe.

The Trust has continued to strive to deliver excellent patient care despite the many challenges that

the Trust and the NHS face not only in our ‘normal’ state of business but also during the final quarter

of the year when the pandemic started to take hold. The Trust has been instrumental in supporting

local STPs and communities in the delivery of the transformation of Urgent and Emergency Care

pathways as well as ensuring that we focus on the Trust priorities for improving the quality of urgent

and emergency care and subsequently delivering a safe and sustainable response to Covid 19.

Our team members are at the heart of the organisation and in delivering our strategic goals of Every

Patient Matters, Every Team Member Matters and Every Pound Matters it is our duty to create a

culture in which they are supported and enabled to deliver compassionate high quality care and

where they feel supported to raise concerns when things go wrong.

The delivery of National targets ensure that the response times for the most unwell patients are

improved and that every patient receives the most appropriate response for their needs. Delivery of

high quality, safe, compassionate and responsive care to all patients is at the heart of our approach

to care and this is achieved by ensuring that our clinicians are supported in the workplace through a

culture of inclusivity, empowerment and innovation.

We remain at the forefront of the delivery of innovative urgent and emergency care and I am

extremely proud of our people who, even in the most challenging circumstances, demonstrate the

utmost dedication and professionalism at all times. The Trust remains one of the best Ambulance

Services in the country for reducing inappropriate conveyance of patients to Emergency

Departments allowing people to be cared for in their own homes when it is safe and appropriate to

do so. This can only be achieved through competent and highly skilled people and not only ensures

that people are able to receive more appropriate care closer to home, it also supports the local

health and social care systems reducing the long term impact of inappropriate hospital admissions.

We continue to work in partnership with the other Emergency Services and local Health and Social

Care partners in the delivery of excellence of the care we provide and we would like to thank them

for their continued support for us.

The Trust is committed to improving the experience of people using our services and we have

continued to focus on learning and improvement as a result of the feedback from patients and our

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people and through learning from Patient Safety issues. The Trust continues to lead and participate

in significant programmes of research supporting Quality Improvement and, looking ahead to

2020/21, we will look to expand the programme for Quality Improvement, developing a Quality

Faculty and engaging with our people in the development of this.

As the new Chief Executive for SWASFT I have reflected on the achievements we have made in

improving the quality of care and on the development of a positive culture for our people in which

clinical innovation, care and compassion can flourish. I look forward to the year ahead and the

opportunity we will have as a Trust to make further improvements in the quality of care for patients

as we embed the quality priorities and our cultural development programme. I am delighted to be

leading the Trust and taking forward the organizational quality priorities

The Report also looks forward to the year ahead and the improvements in quality we plan to make

over the coming year. With the change in leadership of the Trust we will continue to focus on care,

compassion, respect for all as well as ensuring our people have the right conditions to provide

excellent care.

For 20/21 we will focus on the following quality priorities:

Implementation and Embeddedness of the Trust’s Learning from Deaths process

The development of accessible information - To identify improvements related to accessible

information, focusing on patients with additional needs to ensure parity of esteem in the

care provided

Sepsis - To ensure that patients with this time critical presentation receive the best possible

care across the South West.

At the centre of the provision of high quality care are our people and the Board is committed to

improving their health and wellbeing. During difficult and challenging times I am humbled by the

commitment and compassion of our people in caring for patients and I am immensely proud of the

service they provide to the people of the South West.

I confirm that to the best of my knowledge, the information in this quality report is accurate and

reflects a balanced view of the Trust, our achievements and future ambitions.

Chief Executive

XX XX 2020

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Part 2 - Priorities for improvement and statements of assurance from the board

Priorities for Improvement This section of the quality report describes areas for improvement in the quality of relevant health services that the South Western Ambulance NHS Foundation Trust intends to provide or subcontract in 2019/20.

Quality Priorities for Improvement 2019/20

Patient Safety Development and implementation of Mortality Reviews Why a Priority? In 2016 the Care Quality Commission published their report ‘Learning, candour and accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England’ which made specific recommendations predominantly focusing on maximising learning from deaths. This led to the National Quality Board (NQB) releasing ‘National Guidance on Learning From Deaths’ in March 2017 to act as a framework for identifying, reporting, investigating and learning from deaths in care. At the time of publishing the Trust’s Quality Priorities for 2019/20 specific guidance had been published for acute hospital trusts, but there was no guidance in place for ambulance trusts. At the time of writing the 2019/20 Quality Priorities there was no requirement for ambulance trusts to undertake mortality reviews, however it was recognised by the Trust that learning from deaths of people in our care has the potential to improve the quality of care we provide to patients and their families. It was proposed that the Trust developed a mortality review process as one of its Quality Priorities for 2019/20. It was noted that the milestones for each quarter may have required amendment dependent on the timing and content of any published national guidance for ambulance trusts. Following consultation with the National Ambulance Service Medical Directors’ group, the National Ambulance Service Quality Governance and Risk Directors’ group, and patient groups convened by NHS England, the document ‘A framework for NHS ambulance trusts in England on identifying, reporting, reviewing and learning from deaths in care’ was published in July 2019. Aim To develop and implement a mortality review process to learn from deaths. Did we achieve this priority? Yes. This Priority Was Achieved.

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During 2019/20 we undertook the following initiatives: Following publication of the document ‘A framework for NHS ambulance trusts in England on identifying, reporting, reviewing and learning from deaths in care’ a paper summarising the requirements of the national guidance was presented to the Quality Committee in July 2019. The Trust identified a Board lead for Learning from Deaths; this is the Executive Director of Quality and Clinical Care. A Non-Executive Director whose responsibility it was to have oversight of the Learning from Deaths process was also identified by the Board of Directors. The Trust’s Head of Patient Safety and Risk developed a generic Learning From Deaths Policy for utilisation by all ambulance trusts. This document was approved by the National Ambulance Risk and Safety Forum to encourage consistency throughout the country. A task and finish group was established to prepare the Trust for implementation of the guidance; progress reports were provided to the Quality Committee throughout the year. A review of the Datix system (used to record adverse incidents and complaints) was undertaken to ensure that any concerns raised by service users, staff and other healthcare organisations which relate to the death of a patient could be identified. Sources of data to inform the remaining categories to be reviewed were identified and discussions took place with NHS Improvement regarding the challenges associated with obtaining data on the deaths of patients after contact with the Trust. The Trust’s Learning from Deaths Policy, which met the requirements of the national guidance, was approved by the Board of Directors on 28 November 2019 and published on the Trust website on 30th November 2019. The first cohort of national training was due to take on the 7th January 2020, however this was replaced with a workshop which focused on interpretation of the national guidance. Although a date for the actual training has not yet been announced the Trust made the decision to continue with the implementation of the Learning From Deaths Policy. An ambulance service specific Structured Judgement Review template and guidance, based on that provided to acute trusts, was developed by the Trust for use by those undertaking the reviews. The Trust’s implementation of the Learning From Deaths (LFD) process commenced during quarter 4 of 2019/20 with 36 Stage 1 reviews and one Stage 2 review taking place prior to the challenges experienced as a result of COVID-19. Due to the requirements of the clinicians and medical practitioners involved in the process to undertake COVID-19 the process was paused in March 2020. Actions to be carried forward into 2020/21 The Trust’s Learning From Deaths process was paused in the latter part of 2019/20 due to the challenges faced by the Trust and wider NHS in respect of COVID-19. The process will recommence and be embedded through the Trust’s Quality Priorities for 2020/21. Board Sponsor Jenny Winslade, Executive Director of Nursing and Quality Implementation Lead

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Vanessa Williams, Head of Patient Safety and Risk

Patient Experience Continue to implement improvements to patient experience using Always Events methodology in end of life care Why a Priority? Improvements in patient safety and experience is frequently driven by patient and staff feedback. In 2018/19, the Trust focused on understanding patients’ experience of using ambulance services when under the care of a hospice. This work stream was supported by a nationally designed project called ‘Always Events’. During 2019/20, the Trust will focus on implementing the outcomes from the first phase. Proactively involving patients and service users to identify what matters to them and what they expect in episodes of care with health services can positively impacts on the safety and experience of patients. Using the ‘Always Events’ methodology will contribute to this, as it focusses on co-designing services with patients. The Always Events programme has four distinct phases:

1. Set up and Oversight; 2. Co-designing and testing; 3. Reliably Implementing; 4. Sustaining and Spreading.

This Quality Priority links to the following Trust strategic goal:

Every Patient Matters Aim To implement improvements identified from patient and family feedback, focusing on use of the ambulance service as part of end of life care. Indicators

1. A measurement plan will be developed which uses quality improvement methodology. 2. An agreed implementation plan will be in place. 3. A measure of improvement in patient and family experience.

Initiatives Quarter 1:

Evaluate the patient and family feedback and identify a small number of areas to ‘test’. Quarter 2:

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Using quality improvement methodology, including a measurement plan, undertake a series of small tests of change to test improvements developed following feedback received during 2018/19, ensuring that patients and stakeholders remain involved in the process

Report to the Quality Committee on the progress of Phase 1. Quarters 3 and 4:

Based on the outcome of the tests of change, adopt a spread / implementation plan

Report to Quality Committee on the progress of Phase 2.

Develop a staff learning package to reflect findings

Undertake engagement with the end of life care patient group to ascertain whether improvements have improved patient and family experience.

Report to Quality Committee on the progress of Phase 3 and plans for moving to Phase 4. How will we know we have achieved this priority? Measurement will demonstrate improvements in patient safety and experience. Improvement in patient and family experience feedback. Did we achieve this priority? Yes, we undertook an extensive program of patient engagement including face to face interviews, questionnaires and online feedback. We have completed 3 hospice visits, Rowcroft Hospice in Torquay, Hospiscare in Exeter and Leckhampton Court in Gloucester. The visits have been incredibly helpful and a strong theme has emerged. We have also communicated a questionnaire online through various social media feeds and met with people face to face who were interested in passing on their feedback. The first question asked “Have you ever contacted the ambulance service for your current condition?” and the second question asked “If you were to contact the ambulance service for your current condition what is/ would be important to you? (What should always happen?)” It was clear that the subject in question would be emotive from the start, we were clear that these questions would remain as a guide to the conversation rather than a set format. During the interview process the people talked around the questions, thus the information gathered was analysed as a set, rather than under the question headings. Feedback from patients, families and their carers has been content analysed where strong themes emerged. The most salient theme is communication, this includes feeling informed, being treated with care, dignity and compassion. This was not surprising as good patient care relies heavily on good communication. To indicate the level of importance of this issue it was often the case that respondents spoke positively about their experience, praising the crew for their support. Whilst asking them to recount their journey from the beginning it often transpires that other elements of the care they received were perceived as less positive but these are forgotten in light of the person centered approach from the crew. Less favourable themes focused on delays and the fears and anxieties faced by patients, their families and their carers during that time. It was highlighted that each episode when using 999 brought fresh anxieties and fear, wondering if this would be final for the patient.

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It was particularly emotive to hear patient families speak of their loved ones having had “a good death” and praising our staff for their care. Patients at end of life and their families are aware of the finite nature of their lifespan, this makes every interaction they have with health services heightened with emotions. Some concerns were raised regarding commissioning gaps for end of life patients including patients who needed to move within their household and those who need transport from the hospice to the hospital and back. Based on the information gathered we are making a number of recommendations to our staff group, as well as flagging up any commissioning gaps through existing networks. We have also developed a staff package looking at compassionate communication and end of life care, this is being delivered by the Trust’s MacMillan Cancer Care Team. Actions to be carried forward to 2020/2021: We will speak with patients groups to ensure the recommendations from this piece of work is relevant to their experience and ensure staff training continues to safeguard future learning. Board Sponsor Jennifer Winslade, Executive Director of Nursing and Clinical Care Implementation Lead Sharifa Hashem, Patient Engagement Manager

Clinical Effectiveness Cardiac Arrest Aim To improve survival to discharge following out of hospital cardiac arrest across the South West. Outcome Return of Spontaneous Circulation (ROSC) is the first important step towards the end goal of complete recovery and discharge from hospital without neurological impairment. Both ROSC and Survival to Discharge (STD) rates have improved across the Trust and SWAST is now above the national average for these Ambulance Clinical Quality Indicators (ACQIs). Cardiac Arrest last month of nationally published data, November 2019

Performance Indicator Locally Set Threshold

Trust Performance National Average

ROSC 24% 29.93% 28.8%

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Survival to Discharge 9% 11.3% 7.8%

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Indicators for 2019-20 • Improved utilisation of non – core resources for Category 1 incidents • Increased training of non – clinical SWAST employees • Improved ACQI performance for cardiac arrest indicators 1. Improved dispatch of Trust Responding Officers, CFRs and BASICS assets This will be achieved by:

Clinical Hub staff education and process package

Embedding the new Special Incident Desk

Commitment from Responding Officers across Directorates to attend Category 1 incidents when requested to do so

This will be measured by comparing the number of Category 1 incidents allocated to non-core resources during each quarter of 2018-19, compared to the same quarter in 2019-20

Outcome

75% of all non-clinical SWAST employees to have attended an awareness session on delivering basic life support and the use an automated external defibrillator (AED) within the past 2 years, by 31/03/2020

This will be achieved by delivering a series of awareness sessions

This will be measured by monitoring the percentage of non-clinical staff recorded as attending an awareness session

Outcome Engagement of non-clinical staff has continued with the CFR team who have offered a number of BLS and AED awareness sessions across multiple sites.

Venue Number trained Year

ASOC 3 2018

East Hub 42 2018-19

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HQ Exeter 48 2019

Taunton 4 2018

Dorchester 3 2018

Additional quarterly sessions had been planned but are currently on hold due to the COVID-19 pandemic and the vast majority of non-clinical staff working from home. 2. Post ROSC care bundle completion within period of ROSC

This will be achieved through an education package for ambulance clinicians, and an emphasis on the current guidance.

This will be measured through the national ACQI submissions. Outcome

All SWAST front line clinicians (who were not abstracted or on long term sickness) received additional face to face education regarding the delivery and recording of the post ROSC care bundle during the annual ALS assessment.

Engagement with Enhanced Care teams (HART and HEMS) was undertaken to ensure that post ROSC interventions delivered by these groups were clearly documented.

Delivery/recording of the post ROSC care bundle is better now than in April 2018, however, for the most recent data submission (now submitted on a quarterly basis) there were two elements of the care bundle in particular (BM and BP) that were lower compliance. The data is sensitive to small changes as the total number of cases is relatively low, however, this will need to be further addressed through communications to and engagement with all front line staff groups during 2020-2021. Post ROSC care bundle delivery to last quarter; table

12-lead ECG

BM recorded

EtCO2 recorded

O2 administered

BP recorded

Saline administered

Month

83.8% 94.6% 99.1% 89.2% 95.5% 95.5% Apr 18

92.8% 93.8% 97.9% 97.9% 97.9% 100.0% Jul 18

95.2% 88.6% 96.2% 95.2% 91.4% 94.3% Oct 18

91.0% 85.6% 98.2% 97.3% 85.6% 93.7% Jan 19

96.9% 90.6% 100.0% 99.2% 97.6% 98.4% Apr 19

95.5% 91.0% 100.0% 99.2% 96.2% 97.0% Jul 19

94.5% 89.1% 96.4% 98.2% 88.2% 96.4% Oct 19

Post ROSC care bundle delivery to last quarter; chart

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General Review of Actions

- Community engagement has been a significant focus of this priority and having partnered with Gloucestershire Rugby the Trust successfully launched the CPR campaign on Saturday 26 October live at the Premiership game against Wasps Rugby. The Trust also aligned with the national Restart a Heart Campaign 16 October 2019, with six events taking place across the Trust’s geography and a total of 16,046 being taught CPR by our staff.

- Trust guidance has been updated, taking in account best practice and ensuring guidance

around end of life patients and the decision to perform CPR is more robust.

- Work has commenced with the Clinical Hubs to understand how the Trust can work to reduce time to dispatch resources and identify the barriers that would impact on this.

- Work continues to engage with County Commanders, Operations Officers and Learning and

Development teams to promote the post return of spontaneous circulation (ROSC) care bundle

- QCPR manikins have been purchased and are on all ambulance stations, Trust training venues Trust HQ and St James.

- GoodSAM has had a positive effect on the non- core response to incidents where CPR is in

progress. Next Steps

- Community engagement had been planned to continue with schools, businesses and local groups with a steering group having been implemented to lead this work. Unfortunately, due to the COVID-19 pandemic, all public engagement regarding cardiac arrest is currently suspended and all members of the steering group have been drawn into other areas of work.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Apr-18

Jul-18

Oct-18

Jan-19

Apr-19

Jul-19

Oct-19

Jan-20

Apr-20

Jul-20

Oct-20

Jan-21

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- All clinical staff are to be familiarised with delivering CPR to the three age groups: adult, juveniles and neonatal. Unfortunately, due to the COVID-19 pandemic, routine staff training is currently suspended, however, educational packages have been developed and will be ready to deliver once the Trust returns to business as usual.

- The 2020-2021 Development Day Training Needs Analysis has been agreed and will include face

to face facilitated learning and an on-line learning package for resuscitation and which will include post-ROSC actions (to be delivered when L&D return to BAU post COVID-19).

- In 2019, QCPR manikins were placed on every ambulance station across the Trust. A QCPR

competition/prize draw had been planned to encourage staff to undertake self-directed CPR CPD. Unfortunately, due to the COVID-19 pandemic, this has not been launched. The competition will be re-considered once the Trust returns to BAU.

- Work is taking place around delivering a structured de-brief and CPR review session to those

staff involved in resuscitation incidents. Unfortunately, due to the COVID-19 pandemic, this has not been progressed.

- A comprehensive training package was being developed for Operations Officers to support

front line crews and decision making during resuscitation incidents, however, due to the COVID-19 pandemic, the pilot site OO engagement day (scheduled for April 2020) was postponed. This work will be re-considered once the Trust returns to BAU.

Continuing Risks

- ECS2 will be required to include the same standard of programmed functionality as ECS1, with regards to the Cardiac Arrest tab and the prompt function, in order to continue with ACQI prompts.

- Capacity of the Learning and Development Team to develop and deliver additional

resuscitation training packages and record keeping programming.

- Operational support for CPR training – Abstraction of staff from frontline duties, opportunistic CPR engagement from Operations Officers

- An appetite for inclusion of a short CPR assessment with the career conversation.

- Capacity of the Research and Development teams to obtain and upload statistics.

- Loss of momentum of public engagement due to capacity and COVID-19.

- In order to capture >75% of non- clinical staff, BLS and AED awareness needs to be made

mandatory for all non-clinical staff and should be built in to the Career Conversation or GRS for managers to record that they’ve seen someone’s certificate.

Author Amy Sainsbury, Senior Clinical Lead Data provided by Dr. Sarah Black (DClinRes), Head of Research, Audit and Improvement

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Quality Priorities for Improvement 2020/21 Following consultation, the following quality priorities for improvement 2019/20 have been agreed:

Patient Safety Implementation and Embeddedness of the Trust’s Learning from Deaths process Why a priority? In December 2016 the Care Quality Commission published ‘Learning, candour and accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England’. In response, in March 2017 the National Quality Board (NQB) published the first national guidance on learning from deaths for NHS acute, mental health and community trusts which led to significant progress in the way those trusts review and learn from deaths. In the summer of 2018 the Department of Health and Social Care announced its intention to extend the principles of learning from deaths to NHS ambulance trusts and primary care. In July 2019 the National Quality Board published ‘National guidance for ambulance trusts on Learning from Deaths: A framework for NHS ambulance trusts in England on identifying, reporting, reviewing and learning from deaths in care’. As part of the Trust’s Quality Priorities for 2019/20 and, in accordance with the national guidance, in November 2019 the Trust published its Learning from Deaths Policy which was approved by the Board of Directors. Although the national training which was due to be provided to ambulance trusts did not take place, the Trust made the decision to continue with the implementation of the Learning from Deaths Policy which commenced during quarter 4 of 2019/20. This was paused in March 2019 due to the challenges facing the organisation in respect of COVID-19 which resulted in clinicians and medical practitioners responsible for undertaking the learning from death reviews focusing on the Trust’s response to the coronavirus. The Trust recognises the vital role that the Learning from Deaths process has in improving patient safety and has therefore agreed that further implementation and embeddedness of the process will be one of its Quality Priorities for 2020/21. The milestones for each quarter may be amended dependent on the timing and content of any national training and provision of further guidance such as a defined methodology for ambulance trusts. This Quality Priority links to the following Trust strategic goal:

Every Patient Matters Aim To further implement and embed the Trust’s Learning from Deaths process. Indicators

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1. The Trust will have fully implemented an agreed process for learning from deaths via mortality

reviews. 2. The Trust will demonstrate that it has undertaken the required number of mortality reviews for

each quarter. 3. The Trust will have published findings of the mortality reviews undertaken during the year. Initiatives Quarter 1 –

Identify the Non-Executive Director with responsibility for oversight of mortality reviews; the Non-Executive Director previously responsible for Learning from Deaths has left the Trust.

Recommence the implementation of the Learning from Deaths Policy using the process introduced during 2019/20.

Review further ambulance service specific guidance, as it becomes available, to ensure that the process the Trust has implemented reflect this.

Access national training on the structured judgement review methodology for the specific individuals identified as undertaking the reviews, as this becomes available.

Confirm sources of data to inform the Learning from Death reviews. Quarter 2 –

Continued implementation of the Learning from Deaths process.

Agree process for sharing learning from the process with staff.

Produce a Learning from Deaths report for the Board of Directors based on the findings of the reviews undertaken during Quarter 1 and which reflects the content required within the national guidance.

Integrate Learning from Deaths within the Trust’s Review, Learn and Improve processes.

Using quality improvement methodology, review the sustainability of the Trust’s Learning from Deaths process.

Report to the Quality Committee on the progress of implementation of the quality priority. Quarter 3 –

Continued implementation of the Learning from Deaths process.

Produce a Quarter 2 Learning from Deaths report for the Board of Directors.

Implement process for sharing identified learning with staff.

Undertake review of methodology used and make recommendations regarding any further development.

Incorporate learning from the process within the Trust’s Quality Improvement Programme.

Report to the Quality Committee on the progress of implementation of the quality priority. Quarter 4 –

Continued roll out of the Learning from Deaths process.

Using quality improvement methodology review the effectiveness of the process.

Report to the Board of Directors on the findings and learning from Quarter 3 reviews, including information as required within national guidance.

How will we know we have achieved this priority?

The Trust will have an established process for learning from deaths

The Trust will be able to demonstrate triangulation of learning from mortality reviews with

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learning from patient safety and the experience of patients. Board Sponsor Jenny Winslade, Executive Director of Quality and Clinical Care Implementation Lead Vanessa Williams, Head of Patient Safety and Risk

Patient Experience The development of accessible information Why a Priority? It is recognised that patients with accessible needs and those living with disabilities can have worse health outcomes, and a part of that related to the availability of accessible information and communication. Proactively involving patients and service users to identify what matters to them and what they expect in episodes of care with health services can positively impacts on the safety and experience of patients. This quality priority will look for patient involvement in improving our service aligned to the Trust’s commitment that every patient matters. Ambulance services offer transient care in times of emergency or unplanned urgent needs. Due to the complexity of this priority and the current climate we anticipate this will be a two year phased plan using a quality improvement methodology, with the first year focusing on identifying and analysing already existing data held within the Patient Safety, Patient Experience and Clinical Care team. The second phase will look at developing change and testing it with patient groups before final implementation. This Quality Priority links to the following Trust strategic goal:

Every Patient Matters Aim To identify improvements related to accessible information, focusing on patients with additional needs to ensure parity of esteem in the care provided. Indicators

1. We will review existing internal feedback relating to accessibility held within the Patient Safety, Patient Experience and Clinical Care teams.

2. Using the information provided draw up a periodisation plan for Trust actions

3. We will work with partner organisations and charities to implement small tests of change to

improve accessible communication for patients

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Initiatives Quarter 1:

Produce formal review and identify existing resources within the Trust relating to accessible information as phase 1 of the work stream.

Quarter 2:

Identify external resources relating to accessible needs in relation to patients and the identified patient groups

Form a small working group to enable a well rounded delivery.

Report to the Quality Committee on the progress of Phase 1. Quarters 3 and 4:

Analyse the information identified in Quarter 1 and 2 and form themes to be used for small tests of change

Report to Quality Committee on progress.

Develop Trust resources aimed at improving accessibility of information

Develop a communications plan to share with stakeholders and patients and seek feedback to ensure information captured is reflective of patient needs.

Review progress and make plans to move on to year 2. How will we know we have achieved this priority? Measurement will demonstrate improvements in patient safety and experience. Board Sponsor Jennifer Winslade, Executive Director of Quality and Clinical Care Implementation Lead Sharifa Hashem, Patient Engagement Manager

Clinical Effectiveness Sepsis Background Sepsis is a medical emergency which can have devastating consequences and a high mortality rate. It is often under-recognised and frequently under-treated in both the hospital and pre-hospital environment when it is still potentially reversible. From the c100,000 cases of sepsis each year in the UK, there are an estimated c40,000 deaths. The burden of sepsis is highest in low- and middle-income regions and it also remains the leading cause of maternal mortality in the UK. In addition to its impact on mortality, for those who survive, the physical and psychosocial sequelae of sepsis have long-term consequences for survivors’ quality of life. Sepsis can be defined as a life-threatening organ dysfunction due to a ‘dysregulated host response to

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infection’ (the immune system going awry in the face of an infection) Uncomplicated sepsis, such as that caused by flu and other mild viral infections, is common and can usually be treated in the community. ‘Red Flag’ sepsis arises when in addition to sepsis, there is evidence of organ dysfunction or tissue hypo-perfusion. If hypo-perfusion remains despite adequate fluid resuscitation, the patient will enter septic shock. Patients with septic shock are time critically ill, with a mortality rate of 50%. The successful management of sepsis requires a high index of suspicion and early recognition which includes the need to obtain an accurate NEWS2 score. The delivery of the Sepsis care bundle is also essential and is a national Ambulance Clinical Quality Indicator (ACQI):

Recording of base line observations

Administration of O2

Administration of fluid

Pre-alert to receiving Emergency Department

The Trust’s care bundle compliance is currently 57.8% (as of December 2019; now reported on quarterly) which is the lowest of all UK Ambulance Trusts. Sepsis also continues to be a theme within inquests across the Trust region. In May 2017 the Seventieth World Health Assembly adopted a resolution on sepsis which included a need to ensure education and guidance is in place across organisations. Education regarding NEWS2 was last delivered on Development Day 1 2019/20 (Risk in Older Adults) and on Sepsis during Development Day 2016/17 (Spotting the sick child). There was also an update to Trust Clinical Guidance in 2015/16 and in 2019, this was superseded by JRCALC guidance. Aims To ensure that patients with this time critical presentation receive the best possible care across the South West. Indicators

1. Increased awareness regarding Sepsis recognition and management (to include NEWS2) for front line SWAST employees

2. Improved compliance with the ACQI for Sepsis; the completion of the Sepsis care bundle Initiatives

1. Increased awareness regarding Sepsis (to include NEWS2) for clinical SWAST employees. This will be achieved by:

Production of a Trust ‘Clinical News’ with a Sepsis focus to include key themes and an interactive quiz

Promotion of the national NEWS2 and UK Sepsis Trust on-line training packages (clinicians to submit evidence of completion for CPD)

Production of an i-learn video as a CPD offering* to staff with a link through the Bulletin (staff to demonstrate evidence of completion)

*NB. As Sepsis has not been defined within the 2020-21 Training Needs Analysis, and, as the Learning and Development team are currently abstracted to provide support to other teams during COVID-19, this element of formal staff education cannot be guaranteed.

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This will be measured by:

Monitoring engagement with the Clinical News quiz

Monitoring staff completion of the training package 1. Improved Sepsis care bundle completion This will be achieved through:

A communications package for ambulance clinicians

Adjustments to ECS This will be measured by:

The national ACQI submissions. 2. Public facing communications to re-invigorate the need to act swiftly for this time critical

condition. This will be achieved through:

A public facing communications plan to include British Sign Language and translation into multiple languages

Particular focus on regions of low income and/or where English is not the first language. This will be measured through:

Engagement team work plan

Monitoring Trust website activity

Engage with key stakeholders/ focus groups to obtain qualitative feedback.

How will we know we have achieved this priority? Measurement will demonstrate improvements in ACQI performance for Sepsis indicators. Figure 1. Driver diagram

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Board Sponsor Jennifer Winslade, Executive Director of Quality and Clinical Care Implementation Lead Amy Sainsbury, Senior Clinical Lead Dr. Sarah Black (DClinRes), Head of Research, Audit and Improvement

Statements of assurance from the board 1. During 2019/20 the South Western Ambulance NHS Foundation Trust provided and/or

subcontracted two relevant health services.

Emergency (999) Ambulance Service;

Urgent Care Service (NHS 111; GP Out-of-Hours and Tiverton Urgent Care Centre);

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1.1 The South Western Ambulance NHS Foundation Trust has reviewed all the data available to them on the quality of care in two of these relevant health services

1.2 The income generated by the relevant health services reviewed in 2019/20 represents

89.53% of the total income generated from the provision of relevant health services by the South Western Ambulance Service NHS Foundation Trust for 2019/20.

2 During 2019/20 one national clinical audit and no national confidential enquiries covered relevant health services that South Western Ambulance Service NHS Foundation Trust provides.

2.1 During that period South Western Ambulance Service NHS Foundation Trust participated in 100% of the national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

2.2 The national clinical audits that South Western Ambulance Service NHS Foundation Trust was eligible to participate in during 2019/20 are as follows:

NHS England Ambulance Quality Indicators: Clinical Outcome measures covering:

Outcome from cardiac arrest – return of spontaneous circulation (ROSC)

Outcome from cardiac arrest – survival to discharge

Outcome from acute ST-elevation myocardial infarction (STEMI)

Outcome from stroke

Outcome from sepsis

Outcome post return of spontaneous circulation (ROSC) 2.3 The national clinical audits that South Western Ambulance Service NHS Foundation Trust

participated in during 2019/20 are as follows:

NHS England Ambulance Quality Indicators: Clinical Outcome measures covering:

Outcome from cardiac arrest – return of spontaneous circulation (ROSC)

Outcome from cardiac arrest – survival to discharge

Outcome from acute ST-elevation myocardial infarction (STEMI)

Outcome from stroke

Outcome from sepsis

Outcome post return of spontaneous circulation (ROSC)

2.4 The national clinical audits and national confidential enquiries that South Western Ambulance Service NHS Foundation Trust participated in, and for which data collection was

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completed during 2019/20, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

National Clinical Audit*

*This data covers the reporting period from April – Nov 2019

Number of cases eligible for inclusion

Number of cases

submitted

Percentage of cases

submitted

NHS England AQI: outcome from cardiac arrest – ROSC

a) Overall b) Utstein comparator group

a) 779 b) 215

a) 779 b) 215

a)100% b)100%

NHS England AQI: outcome from cardiac arrest – survival to discharge

a) Overall b) Utstein comparator group

a) 264 b) 121

a) 264 b) 121

a)100% b)100%

NHS England AQI: outcome from STEMI (care bundle)

665 665 100%

NHS England AQI: outcome from stroke (diagnostic bundle)

2623 2623 100%

NHS England AQI: outcome from post ROSC (care bundle)

2052 2052 100%

NHS England AQI: outcome from sepsis (care bundle)

843 843 100%

2.5 The reports of 1 national clinical audit were reviewed by the provider in 2019/20 and South Western Ambulance Service NHS Foundation has taken the following actions to improve the quality of healthcare provided:

Updated prompts on the electronic patient clinical record to remind clinicians of care bundle elements and increase compliance.

Developed Quality Improvement projects to understand barriers to the call taking process for cardiovascular events.

Established clinical priority plans aligned to key national indicators.

2.6 The The reports of 6 local clinical audits were reviewed by the provider in 2019/20 and South Western Ambulance Service NHS Foundation Trust took the following actions to improve the quality of healthcare provided:

Liaison with the Learning and Development Department to ensure audit recommendations are reinforced during development days and 1:1 Learning Development Review sessions.

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Supporting Health Care Professionals with their awareness of alternative patient pathways.

Rationalising the range of burns dressing available.

Provision of updated guidance to staff through an app.

3 The number of patients receiving relevant health services provided or subcontracted by South Western Ambulance Service NHS Foundation Trust in 2019/20 that were recruited during that period to participate in research approved by a research ethics committee was 374.

4 A proportion of South Western Ambulance Service NHS Foundation Trust’s income in 2019/20 was conditional on achieving quality improvement and innovation goals agreed between South Western Ambulance Service NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework

4.1 Further details of the agreed goals for 2019/20 and for the following 12 month period are

available electronically at https://www.england.nhs.uk/nhs-standard-contract/cquin

5 South Western Ambulance Service NHS Foundation Trust is required to register with the Care Quality Commission

5.1 Its current registration status is ‘registered without compliance conditions’.

South Western Ambulance Service NHS Foundation Trust has the following conditions on registration: None. The Care Quality Commission has not taken enforcement action against South Western Ambulance Service NHS Foundation Trust during 2019-20.

6 South Western Ambulance Service NHS Foundation Trust has not participated in any special

reviews or investigations by the Care Quality Commission during 2019-20

7 South Western Ambulance Service NHS Foundation Trust did not submit records during 2019-20 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data

8 The Data Security and Protection Toolkit has been launched as a direct replacement for the

IG Toolkit. This is designed as an annual submission of the Trust to demonstrate assurance in the areas of data security and information governance compliance. Due to the outbreak of the COVID-19 Corona Virus the deadline for Toolkit submission has been extended and NHS Trusts are now required to submit their toolkit returns by no later than 30th September 2020. A selection of the Trust’s evidence submission was reviewed by internal audit previously in February 2020 and was found to be of a good standard. South Western Ambulance Service NHS Foundation Trust (SWASFT) is working to the timescale that our Toolkit return will be completed prior to the September deadline and will be a compliant submission, pending a successful mandatory training pass score of 95%. As of August 2020 the Trust can demonstrate that 93.6% of staff have completed their training

https://www.england.nhs.uk/nhs-standard-contract/cquin

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9 The South Western Ambulance Service NHS Foundation Trust was not subject to the

Payment by Results clinical coding audit during 2019-20 by the Audit Commission

10 South Western Ambulance Service NHS Foundation Trust will be taking the following action to improve data quality:

Continue to maintain and develop the existing data quality processes embedded within the Trust.

Hold regular meetings of the Information Assurance Group and work to reinvigorate focus in this area across the trust.

Conduct a review of the reporting streams for data quality concerns across the Trusts and streamline data quality processes.

Ensure completion and return of the monthly Data Quality Service Line Reports.

Continue to provide Data Quality Assurance Reports to the Board of Directors.

Where external assurance of data quality is required, commission an independent review from the Trust’s internal audit provider

The Information Assurance group has refreshed its Terms of Reference to focus more on data quality

Additional checks and consistency has been introduced through the use of techniques such as mandatory fields and scripts have been added to main Clinical Hub (CAD) and Electronic Patient Care record (ECS) systems

A project has been established to support further ‘front-line’ data quality with regards to patient details through increased access to the national NHS ‘Summary Care Record’

The Trust’s main Information database has had enhancements to its management processes

Significant strides have been made to further align reporting to meet the needs of Directorates and Departments

Learning from Deaths

In 2016 the Care Quality Commission published their report ‘Learning, candour and accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England’ which made specific recommendations predominantly focusing on maximising learning from deaths. This led to the National Quality Board (NQB) releasing ‘National Guidance on Learning From Deaths’ in March 2017 to act as a framework for identifying, reporting, investigating and learning from deaths in care.

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Following consultation with the National Ambulance Service Medical Directors’ group, the National Ambulance Service Quality Governance and Risk Directors’ group, and patient groups convened by NHS England, the document ‘A framework for NHS ambulance trusts in England on identifying, reporting, reviewing and learning from deaths in care’ was published in July 2019. The Trust’s Policy on Learning From Deaths, which follows the national guidance, was approved by the Board of Directors in November 2019 and published on the Trust’s internet. The national guidance for ambulance trusts states that learning from death reviews should commence in quarter 4 of 2019/20 and publish the findings from the reviews within the Board of Directors papers from quarter 1 2020/21. Evidence of learning and actions taken as a result of the learning from death reviews should be included within the Trust’s Quality Account from 2021.

Reporting against core indicators

1 The percentage of patients with a suspected ST elevation myocardial infarction who received an appropriate care bundle from the Trust during the reporting period was 83.64%

2 The percentage of patients with a suspected stroke assessed face to face who received an appropriate care bundle from the Trust during the reporting period was 98.38%

3 The Trust received 3223 patient safety related incidents within the reporting period 19/20.

46 (1.4%) of the 3223 incidents were declared as Serious Incidents.

South Western Ambulance Service NHS Foundation Trust considers that this data is as described for the following reasons:

The Trust has a good culture for reporting adverse incidents.

Information is provided to the NRLS electronically through the upload of data taken from the Trust’s adverse incident reporting system.

The Trust has taken the following actions to improve this number, and so the quality of its services, by:

- Continuing to encourage the reporting of adverse incidents by all members of staff so learning can occur at all levels of the Trust.

- Reviewing the mechanisms for learning from adverse incidents to ensure this is done quickly and effectively, and disseminated to staff so they have continued confidence in the reporting system.

- Reviewing the mapping of coding of patient safety incidents with the NRLS to ensure reporting is consistent with national requirements

Part 3 – Other Information

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Overview of Quality of Care 2019-20

Patient Safety

1 Incident Reporting As reported previously, the Trust has a central reporting system for adverse incidents, including near misses, as well as Moderate Harm Incidents (MIs) and Serious Incidents (SIs). All core service lines for the Trust; A&E and Urgent Care Services (UCS) are covered in the patient safety measures reported within this section, including the table below which sets out the categories and numbers of patient safety incidents managed by the Trust

Other Patient Safety Measures

2019-20 2018-19

Adverse Incidents3 7,678 7,896

Moderate Harm Incidents 2 8

Serious Incidents 46 25

It should also be noted that the figures for Moderate Harm and Serious Incidents are for those incidents confirmed as meeting the necessary criteria within the reporting timeframe 3The Trust uses a local definition for Adverse Incidents which is based upon national guidance. Any event or circumstance arising that could have or did lead to unintended or unexpected harm, loss or damage to any individual or the Trust is classified as an adverse incident. 4 The Trust uses the national criteria for Serious and Moderate Incidents set by NHS England in the Serious Incident Framework https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt- framwrk-upd.pdf

2 Central Alert System

The Central Alert System (CAS) is a national electronic web-based system developed by the Department of Health, the National Patient Safety Agency (NPSA), NHS Estates and the Medicines and Healthcare products Regulatory Agency (MHRA). This aims to improve the systems in NHS Trusts for assuring that safety alerts have been received and implemented. During 2019/20 the Trust acknowledged 99% of CAS notifications within 48 hours. The number of notifications received is set out in the following table.

Other Patient Safety Measures

2019-20 2018-19

Central Alert System (CAS) Received

138 110

3 Review, Learn, Improve Incidents (formerly known as Serious Incidents)

https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf



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For an organisation to be truly open, transparent and above all safe for our patients, the Trust encourages a reporting culture and full participation in the process of reviewing incidents that meet NHS England’s definition of a Serious Incident. The Trust’s cultural review, undertaken in 2018/19, identified a perception by some staff of the SI process as punitive and closely aligned to disciplinary or capability processes. To support a change in perception and to ensure staff are fully involved in the investigations, the Trust re-branded and relaunched the process in April 2019 as the ‘Review, Learn and Improve (RLI) process’. A fundamental part of the Trust’s risk management system is appropriately managing RLIs to ensure lessons are learned. RLIs are identified through a systematic review of internally reported adverse incidents, healthcare professional feedback and patient feedback. All incidents that are believed to potentially meet the national criteria set by NHS England are passed to the clinically qualified Patient Safety Manager or nominated clinical deputy for preliminary review, before being circulated to the dedicated RLI and and Moderate Harm decision making group, which consists of two clinicians and a governance representative. Other specialties are also invited to attend to contribute and advise on individual cases. RLI investigations are considered within RLI Review Meetings, which are designed to identify organisational learning. These meetings are chaired by a Clinical Director or Deputy Director. All staff involved in the incident are invited to attend, as this provides the best opportunity for the Trust to identify learning. Learning can either be at a local, Trust wide or at times national level (and beyond), for example referring learning to the International Academy of Emergency Dispatch to aid the improvement of the Medical Priority Dispatch System. An RLI Action Plan is maintained to monitor progress against actions identified and this is monitored on a monthly basis by the Commissioning Support Unit. It is important to note that the proportion of RLIs as a percentage of patient contact activity remains very low. Overall, more RLIs were confirmed during 2019/20, compared with the previous year. Three of these related to Integrated Urgent Care (specifically the 111 Service Line), with the remainder related to the A&E Service Line. For the A&E Service line the predominant themes throughout the year were cardiac assessment (face to face and remote), ECG recognition, neurological assessment (face to face), recognition of ineffective breathing descriptors during remote triage, address entry within the computer aided dispatch system and delays to ambulance attendance.

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4 Moderate Harm Incidents The number of Moderate Harm incidents identified has reduced from 2018/19, with three fewer incidents being identified. Two Moderate Harm incidents were identified, both relating to ‘long lies’ as a result of ambulance delays due to demand.

Patient Experience

1 Patient Experience Patient Experience is made up of the sum of all the interactions that a patient, or their family/care network, have with the Trust. Patient experience and patient engagement provide the best source of information to understand whether the services delivered by the Trust meet the expectations of the patient, their family and/or representatives, including assessing whether a quality service is provided. The following table shows some of the Trust’s existing methods and quantitative information on service user experience. The Trust received a combined number of 1,309,227 patient contacts (A&E Activity and Urgent Care Services) against a total of 1063 complaints (one complainant contact equates to one complaint) equating to 0.08% of all patient contacts. 5 The Trust has defined a complaint as any expression of dis-satisfaction from a patient, or their duly authorised representative, or any person who is affected by, or likely to be affected by, the action, omission or decision of the Trust, whether justified or not.

Patient Experience Measures 2019/20 2018/19

Patient, Advice and Liaison Service (PALS) – Lost Property, signposting to other services etc

863 914

Health Service Ombudsman complaints upheld 0 0

Compliments 2,293 2,653

2 Comments, Concerns and Complaints

All comments, concerns and complaints (referred to hereafter as ‘Patient Experiences’ otherwise known as PEs) are dealt with in line with the Trust’s Complaints Policy. This ensures that all service users feel that their feedback has been taken seriously, are dealt with appropriately and reported with complete transparency. Of the 1063 complaints received during the reporting period, the Patient Experience team, by employing an informative, calm, sensitive and reassuring approach, were able to close, on receipt, 294 (equating to 28%) of these. These were closed with assurances given to, and agreement from, complainants that the necessary information would be passed to the relevant operational sectors/regional service lines. Many Trust complaints are multifaceted, citing several areas of concern. Each concern is coded to report four subject areas in order to illustrate transparency and trends. The

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following table sets out the number of complaints received in 2019/20.

Subject Complaints

Access and Waiting 475

Communication 450

Clinical Care 327

Security Vehicles and Driving Issues 99

The majority of complaints relate to Access and Waiting. Demand on the service and the associated impact on the availability of resources is a consistent factor as evidenced by the high number of complaints received during year. A fundamental part of the Trust’s complaint handling process is to ensure that remedial actions highlighted as a result of complaint investigations are appropriately managed to ensure lessons are learned. All remedial actions are identified, logged and monitored to ensure completion. It is the responsibility of the Investigating Officer (IO) to ensure staff receive feedback and closure when they have been the subject of a complaint as this is an excellent way to share any learning arising from the complaints process.

3 Learning from Patient Safety Incidents

The Trust introduced a Leadership Forum which brings together learning from complaints, adverse, review, learn and Improve incidents, moderate incidents, claims and inquests. Identified themes and learning are discussed in this forum and these discussions inform a number of Trust projects. In addition key learning is reflected in statutory, mandatory and essential training programmes. Identified projects include:

ECG recognition;

Ineffective breathing descriptors;

Intubation.

In addition, the Trust continues to share learning via the Trust’s Bulletin. Articles include;

Trauma – Mechanism of Injury article;

Mental Health Assessment vs Mental Capacity Assessment article;

Professional Challenge – to encourage and remind staff, regardless to grade, that it is appropriate to challenge clinical decisions;

The importance of accuracy and completeness when completely documentation within the ePCR;

ECG interpretation – acute coronary syndrome;

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Overtaking when approaching a junction;

Intelligent use of emergency warning equipment. Further, the Trust produces quarterly Patient Safety and Experience Reports which are presented to the Trust’s Quality Committee. This summarises themes and learning arising from Patient Safety incidents dealt with by the Quality and Clinical Care, incorporating, RLI, Adverse Incidents, Comments, Concerns and Complaints.

In addition a quarterly Patient Safety and Experience Report is presented to the Trust’s Board of Directors. This also includes Claims and Inquests information.

The principle theme emerging from incidents and complaints relates to delays due to demand. However, in October 2019, the Trust agreed to part of a national pilot, commissioned by the National Health Service England through the Association of Ambulance Chief Executives to look at the call script being used when describing that help is being arranged. The purpose of this is to better manage service user expectation, allowing them to make informed decisions as to what to do next in respect of their healthcare needs. The Trust’s new call script was introduced in February 2020 and is used for incidents that have been categorised as requiring a Category 3 or Category 4 response. Anecdotal evidence suggests that, as a result of the new call script, services users expectations are being better managed so less negative feedback will be reported to the Trust in respect of ambulance delays. Further trends have been identified in relation to non-conveyance of patients, long lies following falls, management of fractures, lack of immobilisation, trauma - consideration of the potential severity of the mechanism of injury, ambulances being held outside of EDs due to hospital capacity, infection prevention and control and communication issues relating to COVID19, missed Welfare Calls, categorisation of calls from health care professionals and inappropriate booking of ambulances by the 111 service

4 Compliments The Trust receives telephone calls, letters and emails of thanks from many patients every week. Wherever possible this gratitude is passed directly onto the members of staff who attended the patient or service user. 2,293 compliments were received during 2019/20; a decrease of 14.97% on 2018/19. These provide important assurance for the Trust in public recognition for staff and their contribution to excellence in service standards and demonstrate the continuing public confidence in the Trust. The Trust defines a compliment as any recognition by a member of the public or other Health Care Professional, for the contribution of staff in delivering a high standard of service.

5 Duty of Candor

On 1 April 2013, the contractual Duty of Candour was introduced for all NHS Trusts to

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communicate and apologise, in a timely manner, to patients or their next of kin when there has been an adverse incident which has resulted in moderate or severe harm or death. This duty became regulatory on 27 November 2014 and was included within the Health and Social Care Act 2008 (Regulated Activities) as Regulation 20. The Trust has had a formal Duty of Candour (DOC) process in place since this time. Linked to the DOC duty, the Trust recognised the need to change its Serious Incident process. Feedback received from staff indicated that the language used, such as ‘serious’, ‘investigation’ and ‘panel’ were perceived as punitive and may have impacted on the willingness for staff to highlight concerns and engage with the review of incidents where potential harm had been caused . The Trust introduced the Review, Learn, Improve (RLI) process to replace the Serious Incident process, which was supported and agreed with Trust commissioners. The RLI process has an increased emphasis on both staff and family support. The RLI process has proven to be, not only more family focused, but has increased confidence and participation from staff involved in both RLI and Moderate Harm reviews. As part of the new RLI process the Trust has employed a Family Liaison Officer (FLO) to enhance the Trust’s Duty of Candour arrangements. The FLO acts as a point of contact for all patients and families involved in the RLI and Moderate Harm reviews. The role of the FLO is to:

Engage and support patients and families.

Provide a single point of contact within the organisation

Provide a platform from which patients and families can voice any concerns or, as is often the case, to provide positive feedback to crews.

Seek patient and family views about their experiences of care received from the trust.

Act as a conduit into any investigation that may be taking place.

Be open and honest at all times, including when this may be a difficult conversation to undertake.

Provide details of support agencies that may be available

Provide any necessary apologies on behalf of the trust.

When a Patient Safety incident is identified as a RLI or Moderate Harm incident, the Trust FLO undertakes a risk assessment and then establishes contact with the patient or their next of kin within 10 working days of declaration. The initial notification is verbal, where possible, and telephone conversations take place on a recorded line. Where the patient cannot be contacted in person, a letter is sent via recorded delivery, inviting the patient or next of kin to make contact. Unless the patient or next of kin declines further updates, the verbal notification is followed by a written notification. This letter includes:

Confirmation of the verbal conversation;

A further apology from the Trust;

Confirmation of the Family Liaison Officer and Investigating Officer’s details;

The source of the original notification of the incident;

Brief, factual, details of the incident;

Confirmation that an investigation is taking place;

A written summary of any discussions had during the initial verbal contact;

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Confirmation of agreements made with regards further contact and future arrangements for sharing of the final report.

The FLO (or, in their absence, another nominated member of staff) maintains contact, where agreed with the patient or next of kin, and upon completion of the RLI or Moderate Harm incident, the FLO arranges for the final report to be shared with the patient or next of kin within 10 working days of being finalised by the Trust and Lead Commissioner. The disclosure of the report can be in writing, via a face to face meeting or by both methods and is completed in accordance with the patient or next of kin’s wishes. The Patient Safety Officer records and monitors the Trust’s compliance with its Duty of Candour, including open communication with the patient or their next of kin. Where individuals cannot be contacted or traced, the Trust maintains a comprehensive record of all attempts to make contact. The Board of Directors and Quality Committee are provided with quarterly reports on the Trust’s compliance with the Duty of Candour. In addition, and to provide external assurance, monthly compliance checks were undertaken by the Commissioning Support Unit during 2019/20.

6 Patient Engagement During 2019/20 the Trust continued to develop its patient engagement activities, ensuring that its services are responsive to individual needs, are focused on patients and the local community and supporting its ongoing commitment to improving the quality of care provided. The patient engagement team and the patient experience team source patient stories for use at the start of each meeting of the Board of Directors and of the Council of Governors. Previously these stories were written testimonies read out by a member of the forum; however, over the last few years the Trust enhanced this project and has begun to invite patients into the Board meeting to share their stories in person where possible. This activity has continued to be a positive experience not only for the meeting members, but also most importantly for the patients involved.

7 Care Opinion Patients and their relatives and careers can post details of their experience on the “Care Opinion” website, with these posts being available to anybody visiting the site. The Trust responds to every comment about its service. Where the feedback is negative or indicates service failure, the individual who provided the comments is invited to contact the Trust directly with further details so that the concerns can be addressed by the patient experience team. Where the post is positive and the incident in question can be identified, the posting is passed directly to the member(s) of staff involved. If there is insufficient detail the patient engagement team will respond requesting additional information in order to be able to convey the positive feedback. During the year 36 stories relating to the trust have been posted on Patient Opinion. This is a decrease of 14% compared to last year. The continued decrease is likely to be due to the cessation of advertising of the site; as the Trust chose not to renew its subscription

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to the Care Opinion site. The increasing popularity of social media may also be a contributing factor, indicating a change in the way members of the public interact with healthcare services.

8 Patient Experience Surveys

The Trust audits a random sample of 1% of patient contacts every month for its NHS111 contracts and separately for the GP Out of Hours contracts, with care being taken to ensure that the survey is not sent to anyone whom it would not be appropriate to contact, for example a sensitive case that may be related to a safeguarding concern. A paper questionnaire is sent to respondents, which also contains a link to the online survey. The survey includes a series of questions under the following headings:

Friends and Family Test

Getting through

After the call

Satisfaction

Use of NHS111/Out of Hours telephone service and satisfaction with the NHS

Caller/patient information The Trust provides a monthly report to its Commissioners on the number of calls taken; and the forms returned within that period, with a detailed report being submitted every six months. During the year a total of 2482 surveys were sent out, 600 people responded to the survey in respect of their NHS111 experience; equating to a response rate of 24%. These responses highlighted that further consideration needs to be given to communication about the process of the service to manage patient expectations, whilst the issue of being given the wrong advice was also raised. Some of the comments provided by survey respondents have raised issues about triage; the perception that questioning is too long and unhelpful, with respondents indicating that the questioning left them feeling frustrated. A small number of survey respondents have stated that the attitude from the call handler was less than favorable. Many positive comments relate to patients feeling grateful for the service; with respondents citing how the staff they spoke to or were attended by were helpful and caring. Many respondents spoke about the reassuring nature of the service and the excellent guidance that is being offered. It is also noted that positive comments far outweigh the negative comments.

9 Friends and Family Test (FFT) for Patients

The FFT is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. The Trust offers the FFT to patients who receive ‘See and Treat’ care across the 999 and Urgent Care service lines; this means care delivered to patients when they are seen by a Trust clinician and the patient is not conveyed to any receiving facility.

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Response rates to the FFT are poor. A review of response rates across all ambulance services identifies that this is an issue across the country. In addition, it is difficult to directly compare data as each Trust is using a different response method and so it cannot be used as a reliable bench mark. Despite the low response rate, the Trust continues to receive largely positive feedback to the FFT. However, this in itself provides a challenge for service development based on these responses as the only consistent theme offered in the feedback is that of praise and gratitude. The FFT results for 2019/20 are:

Recommend? April May June July Aug Sept Oct Nov Dec Jan Feb March

Would 93% 100% 100% 100% 75% 100% 100% 100% 100% 60% 100% 95%

Would not 0% 0% 0% 0% 0% 0% 0% 0% 0% 20% 0% 1%

10 Public and Patient Involvement

The Patient Engagement team continued to support spreading Cardio Pulmonary Resuscitation (CPR) and automated external defibrillation (AED) awareness through their summer activities having undertaken 302 patient and public engagement events in 2019/20. Over 16,300 members of the public were trained through engagement activities and school visits. The vast majority of this took place for Restart a Heart Day on 16 October where the Patient Engagement team planned 7 large public events, one in each county, to teach the public CPR, these ran concurrently with school events aimed at CPR awareness. This was one of the largest scale of events nationwide including historic and notable sites such as Stonehenge, The Eden Project and Bristol College Green. This year also saw the public launch of Saving Lives Together Campaign aimed at improving bystander CPR skills and dispelling myths, this was launched at Gloucester Rugby Club with the full support of the team and a young female cardiac arrest survivor. Engagement activities had a focus on seldom heard groups and this year saw the introduction of the Pride Ambulance which attended a large number of LGBT Prides across the South West. Seldom Heard events also included BME community events and activities aimed at inclusion for people with learning difficulties. We are particularly proud to have further engaged with seldom heard groups both through local community events and Trust run events working alongside the HR team to ensure a future work force reflects the community we serve. Two ‘Healthwatch’ open days were held at Trust headquarters in Exeter, in August and February. All events were successfully attended by members of Healthwatch from across our region. The Trust showcased topics related to the Quality Priorities as well as general updates from teams across the Trust. This establishes a relationship with Healthwatch and therefore the wider public across the Trust geography, thereby supporting engagement with the Trust Strategy and its associated development. The Trust continues to engage with local Health, Overview and Scrutiny Panels as well as NHS Clinical Commissioning Groups regarding any changes to policy or procedures. In addition we attend meetings with a specific focus on our Quality Account and the

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priorities described within to ensure transparency and ongoing review.

Performance Indicators

Ambulance Response Indicators

1. South Western Ambulance Service NHS Foundation Trust considers that this data is as described for the following reasons:

National guidance and definitions for Ambulance Quality Indicators have been reviewed and information systems have been established to report in line with the national standards.

Information for ambulance trusts response time performance is reported on a monthly basis by NHS England.

Definitions, interpretations and calculations are reviewed as part of the work by the National Ambulance Information Group for the system indicator data as part of the Ambulance Quality Indicators.

2. South Western Ambulance Service NHS Foundation Trust has taken the following actions to

improve the response times, and so the quality of its services, by 31 March 2021:

South Western Ambulance Service NHS Foundation Trust secured an additional investment of £12m as part of the 2019/20 A&E contract negotiations to enable the Trust to invest in significant increases in operational resources over a two year period.

The investment has developed our People Plan to recruit more than 240 additional frontline operational staff over this two year period, with recruitment commencing in 2019/20 and scheduled to be concluded by March 2021.

These additional staff alongside a £6.7m OHSC Fleet Capital Investment during 2018/19 will provide the additional resources on the road to deliver improvements in the response times for all incident categories.

The fleet investment has also enabled the Trust to commence changes to the mix of vehicle within its operational fleet, increasing the proportion of proportion of double crewed ambulances and reducing the number of solo responder vehicles.

To accommodate the additional recruitment a Trust wide review of rotas has been completed to profile resources to meet the current demand for ambulance services in the South West.

Due to the time required to achieve the recruitment plans for the Trust improvements in response times were not anticipated until Q3 and Q4 of 2019/20, with further improvements anticipated in 2020/21.

ARP Response Category National Standard

Trust Performance 1 Apr 2018 to 31 Mar 2019

Trust Performance 1 Apr 2019 to 31 Mar 2020

Category 1 - Mean Response Time

7 Minutes 7 minutes 18 seconds 7 minutes 03 seconds

Category 1 - 90th Centile Response Time


Category 1T - 90th Centile Response Time


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1 Hour 1 hour 12 minutes 09 seconds 1 hour 17 minutes 13 seconds


2 Hours 2 hours 47 minutes 44 seconds 3 hours 04 minutes 03 seconds


n/a 2 hours 06 minutes 25 seconds 1 hours 33 minutes 55 seconds


3 Hours 4 hours 40 minutes 36 seconds 3 hours 41 minutes 50 seconds

Stroke 60 Minutes

1 Stroke 60 minutes has not been measured nationally in 2018-19 and therefore South Western Ambulance Service NHS Foundation Trust is unable to report on this.

Return of spontaneous circulation (ROSC)

1 Return of spontaneous circulation (ROSC) where the arrest was bystander-witnessed and the initial rhythm was ventricular fibrillation (VF) or ventricular tachycardia (VT) the average for the year of the monthly reported performance was 52.75%* *Please note this figure includes data submitted to NHSE up to November 2019 only.

2 South Western Ambulance Service NHS Foundation Trust considers that this data is as described for the following reasons:

Information is collated in accordance with the technical guidance for the ACQIs and this work is subject to internal audit on an annual basis.

3 The South Western Ambulance Service NHS Foundation Trust intends to take the following actions to improve this data and so the quality of its services, by:

Undertaking a programme of quality improvement activity across all areas.

Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees

Clinical Commissioning Groups

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Health Overview & Scrutiny Committees

Healthwatch

Other

Page | 46

Annex 2: Statement of directors’ responsibilities for the quality report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the quality report, directors are required to take steps to satisfy themselves that:

the content of the quality report meets the requirements set out in the NHS foundation trust annual reporting manual 2019/20 and supporting guidance Detailed requirements for quality reports 2019/20

the content of the quality report is not inconsistent with internal and external sources of information including: – board minutes and papers for the period 01 April 2019 to 31 May 2020

- papers relating to quality reported to the board over the period April 2019 to 31 March 2020

- feedback from commissioners dated

- feedback from governors dated

- feedback from local Healthwatch organisations dated

- feedback from overview and scrutiny committee dated

- the trust’s complaints report published under Regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated

- the latest national staff survey

- the Head of Internal Audit’s annual opinion of the trust’s control environment dated: n/a

- CQC inspection report dated 27/09/2018

the quality report presents a balanced picture of the NHS foundation trust’s performance over the period covered

the performance information reported in the quality report is reliable and accurate

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there are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice

the data underpinning the measures of performance reported in the quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review

the quality report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the quality accounts regulations) as well as the standards to support data quality for the preparation of the quality report.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report. By order of the board 00.00.2020 Date Chairman

00.00.2020 Date Chief Executive

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Glossary of Terms and Acronyms

Term Description

111 National phone number for people to access non-emergency healthcare and advice

A&E Accident and Emergency

ACQIs Ambulance Clinical Quality Indicators – a set of nationally agreed measures for ambulance trusts which reflect best practice and stimulate continuous quality improvement.

AI - Adverse Incident

Any event or circumstance that could have or did lead to unintended or unexpected harm, loss or damage to any individual or the Trust.

Adverse incidents may or may not be clinical and may involve actual or potential injury, mis-diagnosis or treatment, equipment failure, damage, loss, fire, theft, violence, abuse, accidents, ill health, near misses and hazards.

Board of Directors Executive body responsible for the operational management and conduct of the organisation

Clinical Audit A quality improvement process that seeks to improve patient care and outcomes by measuring the quality of care and services against agreed standards and making improvements where necessary.

CCGs Clinical commissioning groups – GP-led commissioners of local healthcare services

Clinical Guidelines Trust documents which introduce guidance which is either not considered within the scope of the JRCALC guidelines, or where further clarification is required.

Clinical Hub SWASFT term for control room where phone calls to the Trust are handled.

CoG Council of Governors – elected body that acts as guardians of NHS Foundation Trust, holding the board of directors to account and representing views of staff, public and other stakeholders

CQC Care Quality Commission - the independent regulator of health and adult social care.

CQUIN Commissioning for Quality and Innovation payment framework enables commissioners to reward excellence, by linking a proportion of healthcare providers’ income to the achievement of local quality improvement goals.

DH Department of Health – the government department that provides strategic leadership to the NHS and social care organisations in the UK

ECS Electronic Care System – allows the Trust to electronically capture exchange and report on patient information.

Executive Directors

Senior members of staff – including the Chief Executive and Finance Director – who sit on the Board of directors, have decision-making powers and a defined set of responsibilities.

FAQ Frequently asked questions

FFT Friends and Family Test – NHS single question survey which asks patients whether they would recommend the service received to their friends and family.

NHS FT National Health Service Foundation Trust – A not-for-profit, public benefit corporation which is part of the NHS and created to devolve decision-making from central government to local organisations and communities.

Page | 49

Governance ‘Rules’ that govern the internal conduct of an organisation by defining the roles and responsibilities of key offices/groups and the relationships between them, as well as the process for due decision making and the internal accountability arrangements

GP General Practitioner

Health Service Ombudsman

Full title is the Parliamentary and Health Service Ombudsman established by Parliament to investigate complaints that individuals have been treated unfairly or have received poor service from government departments, the NHS and other public organisations in England.

Healthwatch

Organisations comprised of individuals and community groups working together to improve health and social care services. They represent the views of the public, people who use service and carers on the Health and Wellbeing boards set up by local authorities.

HOSCs Health Overview and Scrutiny Committees – local authority committees with powers to scrutinise local health services to ensure improvements are made and inequalities reduced.

Hospital Episode Statistics

A data warehouse containing details of all admissions, outpatient appointments and A&E attendances at NHS hospitals in England.

ICPR

Integrated Corporate Performance Report – a document which reports the Trust’s progress against its business plans; highlights where performance targets have not been met; describes the corrective action and timescales to address any performance issues.

IG

Information Governance is a framework which brings together all the legal rules, guidance and best practice that apply to the handling of information. It demonstrates that an organisation can be trusted to maintain the confidentiality and security of personal information and is consistent in the way in which it handles personal and corporate information.

JRCALC Guidelines National clinical practice guidelines for NHS paramedics developed by the Joint Royal Colleges Ambulance Liaison Committee.

KPIs Key performance indicators – a set of quantifiable measures used to demonstrate or compare performance in terms of meeting strategic and operational objectives.

Local Clinical Audit

A quality improvement project involving healthcare professionals evaluating aspects of care they have selected as being important to the organisation and service users.

Moderate Harm Incident

A patient safety incident that resulted in a moderate increase in treatment and that caused moderate, but not permanent, harm to one or more patients. A moderate increase in treatment is defined as a return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancellation of treatment, or transfer to another area such as intensive care as a result of the incident.

National Clinical Audit

A clinical audit involving healthcare professionals across England and Wales in the systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care.

The priorities for national clinical audits are set centrally by the Department of Health and all NHS Trusts are expected to participate in the national audit programme.

NEDs Non-Executive Directors – members of the Board of Directors, but not part of the

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executive management team

NICE National Institute for Health and Clinical Excellence – independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.

NRLS National patient safety incident database.

OoH Out of Hours – a service which enables patients to access a GP out of normal practice hours.

PALS Patient Advice and Liaison Service – a confidential advice, support and information service in respect of health related matters.

Patient Opinion An independent website where people can post their experiences of using a health care service.

Payment by Results

The payment system in England under which Commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient’s healthcare needs.

PPI Patient and Public Involvement – the process of engaging with the needs and expectations of patients and the wider public in order to inform service development and delivery.

Priorities for Improvement

There is a national requirement for NHS Trusts to select three to five priorities for quality improvement each year. These priorities must reflect the three key areas of patient safety, patient experience and patient outcomes.

Right Care Trust initiative to work with local health communities to ensure that patients receive the right care, in the right place at the right time, resulting in patients being treated without the need to attend an Emergency Department.

RoSC Return of spontaneous circulation – desirable clinical outcome of a patient in cardiac arrest

Secondary Uses Service

A national NHS database of activity in Trusts, used for performance monitoring, reconciliation and payments.

Sepsis A life threatening condition that arises when the body’s response to an infection injures its own tissues and organs.

SI – Serious Incident

An incident requiring investigation that has resulted in one or more of the following:

Unexpected or avoidable death;

Serious harm;

Prevents an organisation’s ability to continue to deliver health care services;

Allegations of abuse;

Adverse media coverage or public concern;

Never events (serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.)

SPoA Single point of access – a contact point which health and social care professionals can use to arrange the right care for urgent and non-urgent patient needs

STEMI ST elevation myocardial infarction – particular type of heart attack determined by an electrocardiogram (ECG) test

SWASFT South Western Ambulance Service NHS Foundation Trust

Triage Process for assessing and sorting patients based on their need for or likely benefit

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from immediate medical treatment to ensure a fair, appropriate allocation of resources

Page | 52

© South Western Ambulance Service NHS Foundation Trust 2018 If you would like a copy of this report in another format including braille, audio tape, total communications, large print, another language or any other format, please contact: Email: [email protected] Telephone: 01392 261649 Fax: 01392 261510 Post: Communications Department, South Western Ambulance Service NHS Foundation Trust, Abbey Court, Eagle Way, Exeter, Devon, EX2 7HY

Paper 8


People and Culture

Name: Clare Melbourne


People and Culture

• Alignment of People and Culture Strategy with NHS People Plan – focus on wellbeing, staff

development, Equality, Diversity and Inclusion, flexible working.

• Since 1 August 2020, 130 of the 264 employees who were shielding due to being at ‘high

risk’ from Covid have been supported to return to work with reasonable adjustments and

supportive measures put in place. We continue to work with those remaining shielded or on

alternative duties to return to their substantive roles.

• Sickness absence rate for August 2020 (excluding those shielding and self-isolating) is

4.9%. August 2019 rate was 5.9%.

• Trust-wide appraisal rate for August is 87%.

• Overall Trust compliance for all E-mandatory training is 84% (against a target of 85%).

Monthly Mandatory Training Cup introduced to encourage inter-departmental competition –

the first winners were HART South for Operations, and the People and Culture Directorate

for Corporate Services.

• Graduate campaign progressing in line with workforce plan – 170 successful to date against

target of 167.

• Submission of WRES and WDES national data in August 2020, with final reports due to be

published by 31 October 2020.

Highlights

• Last session of the ACT (Aspire, Connect, Transform ) programme being completed virtually in

October. The programme has been rolled out to 350 of our Leaders which was the first

programme delivered to leaders at all levels across the Trust.

• Ongoing ACT offering being finalised and will be offered as a virtual delivery to new leaders, or

those who were unable to complete the original programme. Due to start November 2020.

• Dedicated Leadership Development page on Swastcpd.co.uk is live to host leadership

resources, bitesize sessions, virtual training and facilitated sessions in line with Leadership

Strategy.

• Reintroduction of Staff Wellbeing Engagement Group to take place on 29 September 2020.

• Launch of Rainbow Badge Scheme to promote and encourage equality, diversity and inclusion

Trust-wide in August 2020 with around 90 requests so far.

• Development Day 1 is being delivered virtually. Current compliance is 32%, against a 28%

trajectory. The Head of Resourcing has agreed the abstraction plan to achieve 85%

compliance this year.

• Regional engagement with HEIs/HEE to transform practice placement and support the growth

of AHPs across the region.

Highlights

Covid Risk Assessments –

NHSI/E Return • Revision and relaunch of risk assessment process for groups more vulnerable to Covid following

feedback – Your Needs Reviews undertaken for all BAME colleagues and those with serious health

conditions.

• NHSI/E requirement to offer risk assessment to all staff, and inclusion of males into ‘at risk’ group.

• Risk assessment and survey sent to all staff directly and promoted via Bulletin throughout August, with

direct emails to those who had not yet completed.

• Communications supported by County Commanders and promotion via local channels.

• Each time the risk assessment and survey has been shared with a covering email, explaining the

purpose of the risk assessment and the importance of returning it.

• Action plan and full detail of metrics shared with NHSI/E.

Key Questions Not including refusals –

NHSI/E Criteria

Including

refusals –

own data

Have you offered a risk assessment to all staff? Yes Yes

What % of all your staff have you risk assessed? 100% 39%

What % of risk assessments have been completed for staff who are

known to be ‘at-risk’ (includes BAME, male, certain health conditions,

pregnant, age-related) with mitigating steps agreed where necessary?

100% 46%

What % of risk assessments have been completed for staff who are

known to be from a BAME background, with mitigating steps agreed

where necessary?

100% 100%

Communication Metrics*

Social

Media

Media

Bulletin

286k impressions

163 new followers

766 mentions

798

Total external

articles

generated

36.08m

Total news

reach

Design

37,459 total views

4 bulletins

delivered

20 jobs

completed

• Support to Chief Executive meet and

greets across the regions in addition to

Darren Jones MP visit in Bristol.

• Sharing of key messages with our

people including thanks from Will,

sharing staff stories, and promotion of

internal achievements.

• Promotion of key initiatives such as

Emergency Services Day and National

Suicide Prevention Day.

• Pursuing proactive media opportunities

such as a BBC Spotlight video to

highlight surge in demand during

summer holidays.

• Media coverage in relation to assault

incident in Bristol under the

#unacceptable campaign which was

also shared internally with colleagues.

• Continued promotion of the service via

social media including sharing of

Government guidance, and #choose

well messaging such as this media

article ahead of bank holiday.

*Data taken from August 2020

Key updates:

31 new jobs

requested

47 Design jobs

in progress

455 new followers

227,137k total reach F

B

Tw

itte

r

50 Total news

articles

£3.11m

Total news

value

Ins

ta 7,402

followers 46

posts

8,859

Highest

post reach

https://www.itv.com/news/westcountry/2020-08-13/influx-of-tourists-and-easing-of-lockdown-blamed-for-rise-in-emergency-incidents

https://www.dailymail.co.uk/news/article-8655501/Police-hunt-cyclist-leaned-window-ambulance-SPAT-paramedics-face.html

https://www.dorsetecho.co.uk/news/18683858.dorset-ambulance-services-urges-people-think-twice-calling-999/

https://www.dorsetecho.co.uk/news/18683858.dorset-ambulance-services-urges-people-think-twice-calling-999/

Paper 9


Page 1 of 2



Paper Title: Workforce Race and Disability Equality Standard Report

Prepared by: Lucy Manning, Head of Employee Relations

Michelle Stevens, Senior HR Business Partner

Presented by: Clare Melbourne, Executive Director of People and Culture


Strategic Goal: Every Team Member Matters

Action: Approval

Recommendation: The Trust Board of Directors is asked to approve the report for publication.

Forward Look:

The Workforce Race and Disability Equality Standard report for 2019/2020 outlines the Trust position in relation to the national metrics. The report also outlines key achievements relating to the Equality, Diversity and Inclusion workstreams and plans to build on this over the next 12 months.

Trust Board of Directors –Public - Thursday 24 September 2020

Page 2 of 2

Workforce Race and Disability Equality Standard Report

1. Introduction 1. 1 The Workforce Race and Disability Equality Standard report for 2019/2020 outlines the

Trust position in relation to the national metrics. 1. 2 These metrics were reported into the national team by the deadline of 31 August 2020. 1. 3 The report itself, which provides a more detailed summary of the Trust’s work in relation to

Equality, Diversity and Inclusion is required to be published both internally and externally by 31 October 2020.

2. Summary 2.1 The following key points are covered in the report:

2.1.1. Positive improvements seen in both WRES and WDES 2019/2020 staff survey returns; 2.1.2. Established Equality, Diversity and Inclusion work programme progressed through our

Equality Steering Group; 2.1.3. Planned appointment of an Equality, Diversity and Inclusion Lead to support continued

delivery against strategy; 2.1.4. Inclusion in the NHS Partners Programme for 2020/21 following successful competitive

application process; 2.1.5. Increased engagement with and learning from our people’s feedback.

3. Recommendation 3.1 The Trust Board of Directors is asked to take approve the report for publication. Clare Melbourne Executive Director of People and Culture

South Western Ambulance Service NHS Foundation Trust Workforce Race Equality Standard (WRES) &

Workforce Disability Equality Standard (WDES) 2019/2020 Report

Executive Summary • Positive improvements seen in both WRES and WDES 2019/2020 staff survey

returns

• Established Equality, Diversity and Inclusion work programme progressed through our Equality Steering Group

• Planned appointment of an Equality, Diversity and Inclusion Lead to support continued delivery against strategy

• Inclusion in the NHS Partners Programme for 2020/21 following successful competitive application process

• Increased engagement with and learning from our people’s feedback

Workforce Race Equality Standard and Workforce Disability Equality Standard Background

• The Workforce Race Equality Standard (WRES) was introduced by the NHS Equality and Diversity Council (EDC) for all NHS Trusts in April 2015. The WRES is a mandatory requirement embedded within the NHS Contract to ensure effective collection, analysis and use of workforce data. This is to ensure that employees from black and minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace.

• The Workforce Disability Equality Standard (WDES) was also commissioned by the Equality and Diversity Council (EDC), and was introduced in 2019 and is also mandated through the NHS Contract. It aims to support positive change for existing employees and enable a more inclusive environment for disabled people working in the NHS.

Progress in 2019/20 Databook

We have made our diversity data more accessible to our people through the Databook which shows a number of metrics in relation to our workforce profile, recruitment, internal development programmes, talent pool and employee relations. This is published quarterly to all our people via our intranet pages.

We have recently been recognised by the Department for Work and Pensions, having received Disability Confident Leader status, one of only six NHS organisations nationally to achieve leadership status.

Disability Confident Leader Status

Progress in 2019/20 Stonewall Diversity Champion We are a Stonewall Diversity Champion and have revised some of our key policies to ensure they are inclusive, regardless of gender, gender identity or sexual orientation, and we have also produced our very first Transgender Inclusion Policy.

Bristol Engagement Calendar The BNSSG area is the only area within the Trust where the percentage of BME staff is not comparable with the BME population, to address this and increase representation the Trust has developed the Bristol Recruitment and Engagement Plan. The plan included a presence in the locality every month during 2019, this included community newsletters, careers fairs, and community events.

The community events are aimed at increasing awareness of our opportunities, and gaining a greater understanding of barriers to

recruitment. These events have been led by HR Services with support from the Trust’s BAME Forum.

Progress in 2019/20 What the WRES data tells us between 2018/19 and 2019/20 The 2019 NHS Staff Survey has shown significant improvements: • Decrease of 12% in the percentage of staff who have experienced discrimination at work from a manager / team leader or other colleagues. • Increase of 34.8% in staff believing the organisation provides equal opportunities for career progression or promotion. • Decrease of 26.1% from in the percentage of staff experiencing harassment, bullying or abuse from staff.

What the WDES data tells us between 2018/19 and 2019/20 The Trust has also seen improvement across all the WDES indicators from the 2019 staff survey, whilst these are smaller improvements than those shown in the WRES, the Trust has a clear focus on this agenda moving forwards and will work towards improvements in the coming year. • Decrease of 4.5% in the percentage of staff who have experienced bullying and harassment from managers. • Increase of 13.1% in the percentage of staff who feel there is equal opportunities for career progression. • Decrease of 3.1% of staff feeling pressured to come into work when they are not well. Diversity & Inclusion Champions

We have an initial team in place to support the Trust with its Diversity & Inclusion agenda. At the current time, we have the following: • Michelle Stevens – Diversity & Inclusion Champion (Disabilities) • Ramses Becerra – Diversity & Inclusion Champion (BAME) • Val Nash – Diversity & Inclusion Champion (LGBT+)

The team in conjunction with the People & Culture Directorate, the Equality Steering Group and all of our people will work to support instilling a diverse and accepting workplace culture throughout the Trust. We want to ensure that we value each person as an individual and respect their diverse aspirations, belies and priorities.

Forward Plan Head of Equality, Diversity & Inclusion • We will shortly be advertising to recruit to a full time Head of Equality, Diversity & Inclusion to enable us to take forward this agenda and embed across the

Trust.

NHS Employers Partner Programme • Following our submission into a competitive application process our Trust was delighted to be offered a place onto this programme. The programme supports

health and care organisations to foster and develop inclusive workplace cultures where uniqueness of beliefs, backgrounds, talents, capabilities and ways of living are welcomed and celebrated, and is closely aligned to the Equality Delivery System (EDS2). Over the past ten years this programme has worked with 300 Trusts, and we feel privileged to be a part of this programme that commences in September 2020.

NHS Charities Together Covid-19 Appeal • This latest grant will be used to provide specific support to our staff and volunteers who are disproportionately affected by COVID-19. This includes our

BAME colleagues, people who are disabled and those who have an underlying health condition. The grant will be predominantly used to fund two part time outreach worker positions within the Trust’s Staying Well Service to offer immediate support to these people, and their families. Supported by our Lead Mental Health Practitioner, the outreach workers will offer practical support to families to improve their social situation, alongside the Staying Well Service who offer support to improve their overall wellbeing individually but also as a family.

Covid Support and Risk Assessments • At the beginning of the pandemic all employees who had serious health conditions, or fell into a high risk category, were offered a risk assessment. This

enabled additional supportive measures, reasonable adjustments or temporary redeployment to a different role or working from home. • Our BAME employees were identified as being higher risk towards the end of April, and from this date all of our BAME employees were offered a risk

assessment which enabled the same supportive measures, reasonable adjustments or temporary redeployment. Members of the People and Culture Directorate have attended the BAME forum to listen to their feedback and experiences from the risk assessments, and we have adapted and improved our approach to ensure we have met each of their individual needs in the most supportive way possible.

• Care packages were shared with our shielding employees in May to ensure they knew our Trust was thinking about them, and that we look forward to when it is safe for them to return to work.

• The Trust’s management teams have maintained regular contact with these groups who have either been working in alternative roles or away from the workplace, and we are now in the processing of conducting further risk assessments since the government advised from 1 August these employees can return to work, if it is safe for them to do so.

Next Steps • The WRES and WDES data for the 2020/21 national return was submitted on 31 August 2020. The

national reports will be published in early 2021, and will provide our Trust with important WRES and WDES data comparisons against all other Trusts key performance indicators, to support our ongoing monitoring and review of each of our work streams.

• Our Trust’s Equality, Diversity and Inclusion Work Programme has been and will continue to be a key priority for our people, and aligned to the recently published NHS People Plan.

• We will continue to progress our Equality, Diversity and Inclusion Work Programme, which is monitored and reviewed through our Equality Steering Group. This group will also review our WRES and WDES data to increase our understanding, and form the basis of future engagement, partnership working and delivery of objectives and new initiatives.

• The Equality, Diversity and Inclusion Work Programme will be supported and progressed through the planned recruitment of the Equality, Diversity & Inclusion Lead, as they support our Trust to continue to work towards the national indicators as well as ensuring diversity and inclusion is embedded in everything that we do.

Workforce Race Equality Standard (WRES) Data

No Indicator Description WRES Data Findings for 2018/2019 WRES Data Findings for 2019/2020

Workforce Indicators:

1. Percentage of staff in each of the AfC Bands 1-9 and VSM (including Executive Board members) compared with the percentage of staff in the overall workforce.

Total in Workforce: 4489 Total % of BME staff 1.6% (72) Non-Clinical Staff Clinical Staff Band1 0 0 Band 2 0 0 Band 3 10 19 Band 4 5 0 Band 5 1 7 Band 6 2 12 Band 7 5 2 Band 8+ 5 2 VSM 0 2

Total in Workforce: 4686 Total % of BME staff 2.1% (98) Non-Clinical Staff Clinical Staff Band1 0 0 Band 2 1 0 Band 3 6 22 Band 4 1 2 Band 5 1 27 Band 6 2 17 Band 7 9 0 Band 8+ 8 1 VSM 0 0

No Indicator Description WRES Data Findings 2018/2019 WRES Data Findings 2019/2020

2. Relative likelihood of staff being appointed from shortlisting across all posts.

Our reporting functionality does not currently link the data from NHS jobs to ESR due to different systems being used. However, data collated via the data book for the period 2018/19 shows: Paramedics: 5 BAME applicants/ 3 shortlisted, 1 pending assessments, 1 successful, 1 withdrawn, 1 unsuccessful ECAs: 23 BAME applicants/10 shortlisted, 6 pending assessments, 0 successful, 1 withdrawn, 3 unsuccessful

Our reporting functionality does not currently link the data from NHS jobs to ESR due to different systems being used. However, data collated via the data book for the period 2018/19 shows: Paramedics: 12 BAME applicants/ 7 shortlisted, 1 pending assessments, 1 successful, 3 withdrawn, 0 unsuccessful ECAs: 33 BAME applicants/ 13 shortlisted, 6 pending assessments, 1 successful, 4 withdrawn, 2 unsuccessful

3. Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation.

0% 0%

4. Relative likelihood of staff accessing non-mandatory training and CPD

Non mandatory data does not link in to ESR

Non mandatory data does not link in to ESR. This is currently under review however, and will be available for next years submission

No Indicator Description WRES Data Findings 2018/2019

WRES Data Findings 2019/2020

National NHS Staff Survey Indicators:

5. KF25: Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months

White 46% BME 53%

White 45.8% BME 47.8%

6. KF26: Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months.

White 27% BME 53%

White 27.5% BME 26.1%

7. KF21: Percentage believing that the Trust provides equal opportunities for career progression or promotion

White 69% BME 23%

White 74.7% BME 56.6%

8. Q217: In the last 12 months have you personally experienced discrimination at work from any of the following: (manager / team leader or other colleagues).

White 13% BME 29%

White 11% BME 17.4%

No Indicator Description WRES Data Findings for 2018/2019

WRES Data Findings for 2019/2020

Board Representation Indicator:

9. Percentage difference between the organisations’ Board voting membership and its overall workforce.

White 88% BME 12%

White 88% BME 12%

Workforce Disability Equality Standard Data No Metric Description WDES Data Findings 2018/2019 WDES Findings 2019/2020

Workforce Metrics:

1. Percentage of staff in AfC pay bands and very senior managers (including Executive Board members) compared with the percentage of staff in the overall workforce.

Total in Workforce: 4480 Total % of disabled staff 2% (107) Non-Clinical Staff Clinical Staff Cluster 1: 1% 4% Cluster 2: 2% 4% Cluster 3: 0% 1% Cluster 4: 0% 0%

Total in Workforce: 4686 Total % disabled staff 3% (128) Non-Clinical Staff Clinical Staff Cluster 1: 4% 2% Cluster 2: 4% 3% Cluster 3: 3% 0% Cluster 4: 0% 0%

2. Relative likelihood of disabled staff compared to non-disabled staff being appointed from shortlisting across all posts.

Our reporting functionality does not link the data from NHS jobs to ESR.

Our reporting functionality does not link the data from NHS jobs to ESR. This will be reviewed moving forwards to ensure the full ESR capability is utilised.

3. Relative likelihood of disabled staff compared to non-disabled staff entering the formal capability process, as measured by entry into the formal capability procedure.

Percentage for 2019 was 2% Percentage for 2020 was 0%

No Metric Description WDES Data Findings 2018/2019 WDES Findings 2019/2020

National NHS Staff Survey Metrics:

4. Q13: Percentage of disabled staff compared to non-disabled staff experiencing harassment, bullying or abuse from: i. Patients/service users, their relatives or other

members of the public ii. Managers iii. Other colleagues

Disabled Not Disabled

57% 44% 27% 14% 27% 17%

Disabled Not Disabled

50% 45% 22% 14% 26% 19%

5. Q14: Percentage of disabled staff compared to non-disabled staff believing that the Trust provides equal opportunities for career progression or promotion.

Disabled 54% Non-Disabled 71%


6. Q11: Percentage of disabled staff compared to non-disabled staff saying that they have felt pressure from their manager to come to work, despite not feeling well enough to perform their duties.



7. Q5: Percentage of disabled staff compared to non-disabled staff saying that they are satisfied with the extent to which their organisation values their work.



No Metric Description WDES Data Findings 2018 – 2019 WDES Findings 2019 – 2020

The following NHS Staff Survey metric only includes the responses of disabled staff.

8. Percentage of disabled staff saying that their employer has made adequate adjustment(s) to enable them to carry out their work.

57%

58%

NHS Staff Survey and the engagement of Disabled Staff:

9. a

b)

The staff engagement score for disabled staff, compared to non-disabled staff and the overall engagement score for the organisation. Has your Trust taken action to facilitate the voices of disabled staff in your organisation to be heard?

Disabled 5.7 Non-Disabled 6.2 Overall 6.1 The Trust’s Equality Steering Group (ESG) brings together representatives from across the equality strands to discuss and take forward initiatives to support our disabled staff.

Disabled 5.9 Non-Disabled 6.3 Overall 6.2 As part of the work of the ESG, one specific initiative has been for volunteer participants from the E&D Steering Group to work together to develop their personal story in a format which can then be linked to training, education and awareness raising for staff.

Board Representation Metric:

10. Percentage difference between the organisations’ Board voting membership and its overall workforce.

By voting membership of the Board 0% By Exec membership of the Board 0%

By voting membership of the Board 0% By Exec membership of the Board 0%

Equality, Diversity and Inclusion Work Programme Respect, dignity, compassion & inclusion are at the core of our Trust.

We value every person as an individual, respect their aspirations and commitments in life by providing a positive working environment for our people to promote supportive, open cultures that helps everyone to their job to the best of their ability

No WRES / WDES Indicator Action Detail

1 Engaging with and recruiting from the community we serve

1.1 WRES Indicator 2 WDES Indicator 2

Addressing areas of under-representation celebrating diversity. Development of a recruitment campaign that celebrates diversity.

Develop materials that promote the Trust as a place to work for everyone and from all backgrounds, in order to continuously develop this message, continue to engage with minority communities. Progress open day events (recruitment), as well as big events in the Trust area. Progress virtual engagement events as we progress through the pandemic. Inclusion statement included in all recruitment promotion and campaigns, and widely promoted to all.


Addressing areas of under-representation. Review potential barriers to recruitment and make proposals to overcome these.

Impact assess the recruitment process starting with Emergency Care Assistants. Consider potential barriers around entry level qualifications to applicants from BAME communities and those with disabilities. Develop proposals/initiatives which seek to address these.

2 Improving the experience of our existing workforce

2.1 WRES Indicator 4

Consider a BAME Mentoring Programme to improve the experience of our existing workforce.

Develop a dedicated BAME Mentoring Programme linking with partner organisations as necessary to build a network of mentors best placed to support the development aspirations of BAME colleagues.


To improve equality, diversity and inclusion awareness of all people that join us to enable the Trust to become an Employer of Choice. Include equality, diversity and inclusion in the new corporate induction that will be for all new starters to the organisation.

Launch an induction process for all new starters, and internal promotions within the Trust. Raised awareness within regard to equality, diversity and inclusion within corporate induction and ongoing training that is linked to leadership development.

2.3 WRES Indicator 5, 6 & 8

WDES Indicator 4

To introduce training to all staff to raise awareness of Diversity & Inclusion as well as eliminate bullying, harassment, discrimination and other unwanted behaviours. Raising awareness and understanding.

Ensure training and education is available for all of our people, and educates around the importance of equality, diversity and inclusion for all of our people. Continue to learn from our BAME and disabled people to understand their experiences, and adapt our training material according to their feedback.


Improve opportunities for employees, particularly for under presented groups to promote inclusion. Support positive action initiatives to increase the number of females in leadership roles.

Develop positive action initiatives to proactively promote leadership opportunities to our BAME, disabled and female colleagues.

3 To improve the quality and extent of data in order to better inform Equality, Diversity and Inclusion

3.1 Continue to monitor workforce and pay and ensure any gaps are identified and address appropriately reporting through the annual Gender Pay Gap initiative.

Reporting into statutory process for monitoring Gender Pay annually and using data to inform initiatives to support closing the gender pay gap across the organisation.

3.2

Ensure the Trust is able to obtain appropriate data from its employees to support accurate reporting.

Raise awareness of the importance of disclosing data, how and why this data is used as part of the equality, diversity and inclusion workstreams. Raise awareness as to why this data is important, and showcasing where it has provided benefits to particular groups to encourage disclosure. Promote data through the People and Culture Databook which is produced quarterly.

3.3

WRES and WDES – all indicators

Ensure the Trust is able to report accurately and respond to actions that are a result of WRES and WDES. To agree actions as a result of data submission, as well as based on the findings of the national reports, to compare ourselves to other Trusts and share best practice.

Review data and produce actions plans to ensure initiatives respond to findings. Consider and research national reports to understand best practice and develop internal initiatives. Share data in various forums, including with the Trust’s Equality Steering Group to ensure outputs from data form part of the ongoing work programme.

3.4

Complete and submit reports to ensure compliance with National requirements: Gender Pay 2020 WRES 2020 WDES 2020

To complete accurate returns submissions in a timely manner, compare national comparators to ensure continued monitoring against strategy. Adapt and respond to data as required.

4 Celebrating and Promoting Diversity & Inclusion

4.1

WRES Indicator 8 WDES Indicator 4,

8 & 9

Support improved experiences of staff who have a protected characteristic. Showcasing of positive examples of staff living and working with disabilities to highlight support that can be offered and the benefit of compassionate management in difficult circumstances.

Volunteer participants from the Trust to work together to develop their story in a format which can then be linked to training, education and awareness raising for staff. Where possible record video blogs, to bring their experiences to life, and ensure their message is shared widely and is as informative as possible.

4.2

WRES Indicator 5, 6, 6 & 8

WDES Indicator 5 & 5

Ensure all existing staff and those recruited are equipped to support equality, diversity and inclusion and challenge negative behaviours.

Continue to educate and train all of our people to ensure everyone has a clear expectation in respect of equality, diversity and inclusion that is explained in language that resonates and celebrates and promotes this as core value within our Trust.

4.3 Raise awareness to demonstrate our commitment to equality, diversity and inclusion. Develop inclusion allies initiative to visibly show our commitment to inclusion.

Inclusion Champions have been appointed with focus on race, disability and LGBT equality. Introduce an allies network, and visible branding. Design and engage a training offering on equality, diversity and inclusion and a formal equality impact assessment to embed inclusion in all that we do.

4.4

Celebration of Religious Festivals & Events (i.e. PRIDE, Student Conference ). Support ongoing festivals to raise awareness amongst our people as well as celebrate with our people.

Celebrate those festivals and events that are important to our people and continue to develop an inclusive culture. Take every opportunity to educate our people around different beliefs and the importance of inclusion and diversity within our Trust.

4.6

Organise annual LGBT Conference for all ambulance services. Celebrate and raise awareness of LGBT issues with all staff and encourage attendance across the sector at the event.

Paper 10


Name: Tim Bishop


IM&T

ICT • ICT remain focused on continuing to ensure the high availability of

information and services. At this time of high demand close monitoring

of the CAD continues

• Social distancing in the Bristol and Exeter Hubs has been

implemented including key work is starting around the upgrade to the

telephony and voice recording platform

• The Hub PLID (PC) upgrade in Bristol is 95% complete

• ICT continue to support the Dorset 111 service with technology

requirements with the service migrated to Dorset Health Care

• Server & client patching efficiency is improving, with 96% of all

servers fully patched within 2 weeks of release in August 2020

• Client security patching has steadily improved from 60% in April 2020 to

79% in June 2020 and to 88% in August 2020

• We have undertaken a Business Continuity exercise that included a

number of ICT and Cyber-security related injects – debrief awaited

• The Trust has signed up to the Microsoft Office 365 NHS deal (N365)

Information & Governance • Completion of the DSPT is required as a mandatory annual assurance return for all

organisations that process personal and sensitive information. The Trust is due to submit its

final assessment by the end of September 2020. Evidence collation for the Trusts

submission has been compiled with 114 out of 116 requirements met. The two remaining

exceptions relate to IG Training. Leading up to the submission of the Data Security and

Protection Toolkit (DSPT) the Trust’s Internal Audit function has reviewed the proposed

evidence for the new requirements. The Trust’s submission will be monitored through both

the Information Governance Group and the Audit and Assurance committee.

• Mandatory Information Governance training remains a key area of delivery for the Trust.

Demonstrable assurance that all staff have received an appropriate level of mandatory

training is a core requirement of the DSPT. As of September 2020 a small cohort of staff

(0.6%) are required to complete their training to ensure the 95% compliance is achieved.

Every effort is being made to ensure the Trust meets this requirement and is able to declare

a successful compliance return.

• For the period in question statutory compliance for Subject Access Requests is 99%.

Compliance in responding to Freedom of Information requests is improving and now

stands at 80%.

• Work is currently ongoing together with Templar Executives Ltd to ensure the Trust’s IG

policy suite is at an appropriate level to ensure CORS compliance and support the delivery

of cyber essential plus for the Trust.

Programme Management Office - Headlines Emergency Services Mobile Communications Programme

• Local automated Emergency Services Network coverage testing (based on EE network) remains on hold.

• National ARP Control Room Solution testing continues.

Ambulance Radio Programme – National Mobilisation App (Lite)

• Preparation continues towards transitioning to the national ARP Data Centre.

• Responding Officer implementation was delayed – plan now being drafted to move this on.

IMS (Medicines)

• On hold to allow focus on IMS (PPE). Business Case will be refreshed once it is confirmed what Trust operating model

for stores, logistics and medicines management requires from and Inventory Management System.

IMS (PPE)

• PPE and Medicines environments have been successfully merged allowing project closure to be progressed.

Electronic Care System 2

• Working with Ops, Unison and Suppliers to agree vehicle installations.

• ECS1 tablets are now ‘end of life’, therefore even more crucial to deploy ECS2 tablets.

Digital & Information Transformation

• Video Consultation continues to be trialed in the Clinical Hub receiving very positive feedback. Business Case to be

updated to reflect costs and approve full product implementation.

Vital Signs Monitoring & Defibrillator

• Memorandum of Understanding completed. First batch of ZOLLS have been ordered for new fleet vehicles.

• With the capital budget for 20/21 unconfirmed, the completion of the project by end May 22 is at risk.

• Introduction of the new functionality ‘Case Review’ will also impact timelines / benefits.

Our People Plan 1

• Project now formally closed after successful implementation

Our People Plan 2 (Phase 1)

• 5 of 13 stations are now live with new rota patterns. Further 3 due to go live early October.

Information Management Update OL062 My Performance – for Operations Directorate colleagues

This report shows job cycle times for each member of road staff to enable them to see themselves in relation to trust

targets, aspirations and their (anonymised) peers. It has received extremely positive feedback in it’s UAT phase and,

after some minor adjustments, will be going live on the 21st of September to County Commanders and Operational

Officers trust wide. All being well it will progress to all road staff on the 28th of September. The management report,

which shows the same data from a high viewpoint, will be live soon after that.

Average Response Times (ART) – as part of a national trial

IM are continuing to progress national work with the Average Response Time project where we are liaising with London

Ambulance Service to bring together two very different approaches to giving patients a clear picture of how long they

might be waiting for their ambulance on Cat 3 and 4 calls..

Web Applications

The IM team are developing new web applications which are expanding the capability of the trust and saving money on

third party developers. Three applications are currently in development, one for the Information Professionals Group to

help manage a consistent view of reports, another for the IT team to help keep track of trust radios and the EPRR team

to help them keep track of hospital bed states.

Recruitment

IM have successfully recruited two new resources on a

12 month fixed term contract who will help with our complex

requests, the backlog for which continues to rise at present

staffing levels as demand rises in excess of the ability to deal

with it. IM are considering workflows and activities to bring this

Queue down but the completion of OL062 will help a lot.

Simpler requests are under control.

0

50

100

150

200

250Complex In

Complex Out

ComplexOustanding (rolling)

15/09/2020 Power BI

wch-imweb01.swast.nhs.uk/Powerbireports/powerbi/IM_999_PowerBI_Reports/OL301-IMT Statistics Report 1/1

IG - Number of IG Incidents Reported by Date

0 50IG - Number of IG Incidents Reported

Dat

e

Jul 2018

Jan 2019

Jul 2019

Jan 2020

Jul 2020

Date

IG - Number of FOIRequests Received

in this Month

IG - Number of FOIRequests Received in

this Month which werecompleted within 20

days

IG - FOIs Completedwithin 20 working

days

IG - Number of SARRequests Received in

this Month

IG - Number of SARRequests Received in this

Month Which werecompleted within

deadline

IG - SARs Completedwithin deadline

IG - Number of IGIncidents Reported

IG - Number ofDPIA Completions

IG - DSP (was IGToolkit)

Compliance

01 August 2020

01 July 2020

01 June 2020

01 May 2020

01 April 2020

01 March 2020

01 February 2020

01 January 2020

01 December 2019

01 November 2019

01 October 2019

01 September 2019

01 August 2019

01 July 2019

01 June 2019

01 May 2019

01 April 2019

01 March 2019

01 February 2019

01 January 2019

25

35

13

19

16

21

39

35

19

41

33

38

33

32

40

40

34

48

32

45

25

28

10

11

12

14

27

31

18

40

28

32

30

30

39

39

33

44

31

45

100%

80%

77%

58%

75%

67%

69%

89%

95%

98%

85%

84%

91%

94%

98%

98%

97%

92%

97%

100%

449

499

391

323

361

351

378

407

327

370

359

335

365

385

309

354

346

331

343

364

430

493

391

323

356

350

373

399

324

364

356

333

361

383

306

354

341

328

335

357

96%

99%

100%

100%

99%

100%

99%

98%

99%

98%

99%

99%

99%

99%

99%

100%

99%

99%

98%

98%

46

68

52

57

28

42

42

43

45

39

46

39

31

55

45

56

56

41

57

45

2

1

2

1

2

1

0

0

0

1

1

0

0

0

1

0

0

1

1

1

98%

98%

79%

79%

79%

79%

79%

52%

52%

52%

52%

0%

0%

0%

0%

0%

0%

100%

71%

71%

IG - DSP (was IG Toolkit) Compliance and IG - DSP Compliance Target by Date

0%

20%

40%

60%

80%

100%

-1

0

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Date

IG -

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(was

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nce

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et

Jan 2019 Jan 2020

0%

98%100%

52%52%

0%

79%

0% 0%

71%

0%

IG - DSP (was IG Toolkit) Compliance IG - DSP Compliance Target

IG - Number of DPIA Completions by Date

0

1

2

3

4

Date

IG -

Num

ber

of D

PIA

Com

plet

ions

Jan 2019 Jan 2020

0

2

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1

2

0

1

2

1

00

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1

0

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0

1

0 0

IG - Number of SAR Requests Received in this Month, IG - SARs median, IG - Target for SARs Completed …

0

100

200

300

400

500

0%

20%

40%

60%

80%

100%

Date

IG -

Num

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Jan 2019 Jan 2020

295

449

270

323

407

274

385364

327309

327 335370354 351

331

391

IG - Number of SAR Re… IG - SARs median IG - Target for SARs … IG - SARs Compl…

IG - Number of FOI Requests Received in this Month, IG - FOI median, IG - Target for FOIs Completed withi…

0

20

40

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DateIG

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Jan 2019 Jan 2020

39

25

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13

23

39

19

47 45

34 35

41

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21

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IG - Number of FOI Re… IG - FOI median IG - Target for FOIs … IG - FOIs Complet…

OL301 - IMT Stats Report - IG

15/09/2020 Power BI


Number of 'Open' requests by Year and Priority

0 20 40 60 80 100 120 140 160 180

Year

2017

2018

2019

2020 4

4

5 69

18

6

3

92

51

13

3

3

Priority (Blank) P1 - Critical P2 - High P3 - Normal P4 - Low P5 - Awaiting Auto Allocation

Number of requests received since 1st Jan 2017

4209 (73.01%)

1180 (20.47%)

376 (6.52%)

GroupIM 1st Line

IM 2nd Line

IM Work Programme

Number of requests received by Group and Year

0

500

1,000

1,500

2,000

Year2017 2018 2019 2020

Group IM 1st Line IM 2nd Line IM Work Programme

Number of requests not closed

27 (9.85%)

204 (74.45%)

43 (15.69%)

GroupIM 1st Line

IM 2nd Line

IM Work Programme

Count of Group by Priority and Request Status

Priority

Coun

t of G

roup

P3 - Normal P2 - High P1 - Critical P4 - Low (Blank) P5 - AwaitingAuto Allocation

129

76

21

Request Status Awaiting 3r… Awaiting Rel… Awaiting T… Awaiting … Onhold Open Pending …

Request ID by Year

0

2,000

4,000

6,000

Date Closed Year

Req

uest

ID

(Blank) 2017 2018 2019 2020 Total

3728475

688

619 255 5765

Increase Decrease Total

Estimated # of days to complete open items

0

200

400

600

Group

Est D

ays

(IM)

IM 2nd Line IM Work Programme IM 1st Line

651

448

7

OL301- IMT Stats Report - IM

15/09/2020 Power BI


ICT - Median for servers, ICT - Proportion of Servers with current AV definitions less than 1 day old and ICT - Tar…

0%

20%

40%

60%

80%

100%

Date

ICT

- M

edia

n fo

r se

rver

s, IC

T -

Prop

ortio

…

Jan 2019 Jul 2019 Jan 2020 Jul 2020

87%

100%100%

89%99% 100%

93%

ICT - Median for servers ICT - Proportion of Servers with current AV defini… ICT - Target proportion of serv…

Date

IT - Totalnumber of

calls loggedwith the IT

Service Desk

IT - TotalNumber of

callsresolved by

the IT serviceDesk

IT -Number ofoutstanding servicedesk calls

IT - ServiceDesk CallsOpen for 1month or

less

IT - ServiceDesk Calls

Open for 1-2 months

IT - ServiceDesk Calls

Open for 2-3 months

IT - ServiceDesk CallsOpen for

more than 3months

ICT -Number of

Servers

ICT -Proportion ofServers with

NoOutstanding

Patches

ICT - Numberof Servers

with currentAV definitions

less than 1day old

ICT - Proportionof Servers with

current AVdefinitions lessthan 1 day old

ICT - Numberof Clients

ICT - Number ofClients with AVDefinitions < 1

day old

ICT - Proportionof Clients withAV Definitions

< 1 day old

01 August 2020

01 July 2020

01 June 2020

01 May 2020

01 April 2020

01 March 2020

01 February 2020

01 January 2020

01 December 2019

01 November 2019

01 October 2019

01 September 2019

01 August 2019

01 July 2019

01 June 2019

01 May 2019

01 April 2019

01 March 2019

01 February 2019

01 January 2019

2,315

2,644

2,616

2,720

3,062

3,234

2,836

3,060

1,189

2,415

3,269

2,743

2,212

2,337

2,218

2,462

2,347

2,542

2,374

2 944

2,316

2,523

2,687

2,733

3,348

3,076

2,859

2,860

2,155

2,522

3,214

2,464

2,219

2,350

2,167

2,446

2,380

2,380

2,413

3 078

360

362

276

312

347

536

638

543

385

449

806

860

486

485

504

450

573

517

346

388

230

264

213

251

0

342

414

366

238

276

536

615

327

311

308

305

382

366

227

274

67

57

40

31

0

77

103

84

65

76

151

148

100

101

116

95

101

96

78

58

39

26

10

9

0

51

55

45

28

34

57

46

35

48

56

36

58

37

23

36

24

15

13

21

0

66

64

48

54

63

62

51

24

25

24

14

32

18

18

20

247

247

251

247

247

246

219

219

209

210

210

214

196

0

95%

96%

96%

95%

99%

100%

100%

89%

99%

68%

57%

70%

65%

247

247

251

247

247

246

218

196

207

196

196

196

0

0

100%

100%

100%

100%

100%

100%

100%

89%

99%

93%

93%

92%

1,506

1,506

1,704

1,506

1,631

1,623

1,635

1,662

1,645

1,527

0

1,546

0

2,031

1,459

1,440

1,621

771

1,532

1,437

1,460

1,444

1,513

1,429

1,418

853

97%

96%

95%

51%

94%

89%

89%

87%

92%

94%

92%

42%

IT - Total number of calls logged with the IT Service Desk and IT - Total Number of calls resolved by the IT service Desk by D…

0

1,000

2,000

3,000

4,000

Date

IT -

Tot

al n

umbe

r of

cal

ls lo

gged

with

the

IT S

ervi

ce D

e…

Jan 2019 Apr 2019 Jul 2019 Oct 2019 Jan 2020 Apr 2020 Jul 2020

2,6222,315

3,269

1,189

3,060

2,212

3,2342,944

2,6162,374

2,2182,462

2,743

2,415

2,785 2,3163,3482,1553,2142,2192,446 2,8592,380 2,687

IT - Total number of calls logged with the IT Service Desk IT - Total Number of calls resolved by the IT service Desk

ICT - Median Updates, ICT - Proportion of Servers with No Outstanding Patches and ICT - Target Proportion of Ser…

0%

20%

40%

60%

80%

100%

Date

ICT

- M

edia

n U

pdat

es, I

CT -

Pro

port

ion

of…

Jan 2019 Jul 2019 Jan 2020 Jul 20200%

95%100%

70%

57%

99%89%

95%

68%

ICT - Median Updates ICT - Proportion of Servers with No Outstanding P… ICT - Target Proportion of Serv…

ICT - Proportion of Clients with AV Definitions < 1 day old and ICT - Target Proportion

40%

60%

80%

100%

Date

ICT

- M

edia

n Cl

ient

, ICT

- P

ropo

rtio

n of

…

Jan 2019 Jul 2019 Jan 2020 Jul 2020

72%

97%

42%51%

94% 94%

87% 89%92%

ICT - Median Client ICT - Proportion of Clients with AV Definitions < 1 d… ICT - Target Proportion of Client…

IT - Service Desk Calls Open for 1 month or less, IT - Service Desk Calls Open for 1-2 months, IT - Service Desk Calls Open f…

0 100 200 300 400 500 600 700 800 900IT - Service Desk Calls Open for 1 month or less, IT - Service Desk Calls Open for 1-2 months, IT - Service Desk Calls Op…

Dat

e

Jan 2019

Apr 2019

Jul 2019

Oct 2019

Jan 2020

Apr 2020

Jul 2020

274

230

615

213

238

305

414

382

227

264

311

276

251

366

366

308

327

536

342

58

67

151

31

65

103

100

101

116

95

96

57

101

148

76

84

77

78

40

36

39

58

55

28

57

35

56

36

37

48

46

34

45

51 66

63

48

32

62

54

64

51

IT - Service Desk Calls Open for 1 … IT - Service Desk Calls Ope… IT - Service Desk Calls … IT - Service Desk Calls …

OL301 - IMT Stats Report - IT

15/09/2020 Power BI


PMO - Median, PMO - Proportion of projects in progress and Closed projects with up to date mandatory controls in place and P…

70%

80%

90%

100%

Date

PMO

- M

edia

n, P

MO

- P

ropo

rtio

n of

pro

j…

Apr 2019 Jul 2019 Oct 2019 Jan 2020 Apr 2020 Jul 2020

76%71%

96%

71%

87%

83%

94%

87%

71%

94%

88%

94%

87%89%

71%

94%

PMO - Median PMO - Proportion of projects in progress and Closed projects wit… PMO - Target Proportion of projects i…

Date

PMO - ProjectsIn Initiation

PMO - ProjectsIn Progress

PMO - ProjectsClosed

PMO - Number ofprojects In progress,

projects with approvedProject

Mandate/ProjectInitiation

Document/BusinessCase

PMO - Proportion ofprojects in progress,

projects with approvedProject

Mandate/ProjectInitiation

Document/BusinessCase

PMO - Number ofProject Controls

Required

PMO - Number ofprojects in progressand Closed projects

with up to datemandatory projectcontrols in place

PMO - Numberof projects in

progressProjects

PMO - Number ofprojects in

progress Projectswith regular

progress reports

PMO - Proportion ofprojects in progress

with regularprogress reports

01 August 2020

01 July 2020

01 June 2020

01 May 2020

01 April 2020

01 March 2020

01 February 2020

01 January 2020

01 December 2019

01 November 2019

01 October 2019

01 September 2019

01 August 2019

01 July 2019

01 June 2019

01 May 2019

01 April 2019

1

1

1

0

0

1

1

1

1

1

2

2

2

0

3

0

3

4

4

4

4

4

3

3

3

3

5

4

4

6

0

6

0

5

0

0

0

0

0

0

2

2

2

2

2

2

0

0

0

0

0

4

4

4

4

4

3

3

3

3

5

4

3

6

0

6

0

5

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

75%

100%

0%

100%

0%

100%

24

24

24

24

24

18

18

18

18

30

24

24

36

0

30

0

30

17

17

17

17

20

17

17

17

17

26

21

23

32

0

26

0

26

4

4

4

4

4

3

3

3

3

5

4

4

6

0

6

0

5

4

4

4

4

4

3

3

3

3

5

4

4

6

0

6

0

5

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

100%

0%

100%

PMO - Proportion of projects in progress with regular progress reports by Date

80%

85%

90%

95%

100%

Date

PMO

- P

ropo

rtio

n of

pro

ject

s in

pro

gres

s w

ith …

Apr 2019 Jul 2019 Oct 2019 Jan 2020 Apr 2020 Jul 202080%

100%100% 100%100% 100%100% 100% 100%

PMO - Proportion of projects in progress, projects with approved Project Mandate/Project Initiation Document/Business Case and PMO - Target Proportion of projects in progress and Closed projects with approved Project Mandate/Project Initiation Docume…

75%

80%

85%

90%

95%

100%

Date

PMO

- P

ropo

rtio

n of

pro

ject

s in

pro

gres

…

Apr 2019 Jul 2019 Oct 2019 Jan 2020 Apr 2020 Jul 2020

80%

100%100%

75%

100%100% 100%100% 100% 100% 100% 100%100% 100% 100% 100%

PMO - Proportion of projects in progress, projects with approved Project Mandate/Project Initiation Document/Business Case PMO - Target Proportion of projects in progress and Closed projects with ap…

OL301 - IMT Stats Report - PMO

Paper 11


Jonathan James

Acting Executive Director

of Finance

Financial Position 2020/21 • The Trust is operating within the Interim Financial Regime as set out

by NHS England/ Improvement (NHSE/I) for the first six months of

2020/21;

• This regime has replaced the usual financial arrangements with the

Trust Commissioners;

• The regime is based on a block and top up payment in advance and

a retrospective ‘true up’ payment;

• The Trust has reported a breakeven position at month five;

• This includes the additional costs of COVID-19;

• NHSE/I are reviewing the financial regime for the rest of 2020/21.

The Trust will continue to receive a block and top up payment, but

the ‘true up’ payment element will be replaced by a fixed allocation;

• The Trust anticipates activity growth through the remaining part of

the year and awaits formal notification of the value of funding

available to deliver this activity;

Capital 2020/21 • NHSE/I have introduced a new capital regime for 2020/21. This is

based on a system allocation;

• The Trust has been allocated an expenditure limit of £17,790k for

2020/21, this is the net of £20,890k of planned expenditure with

£2,175k of receipts from disposals and £925k of Critical

Infrastructure Risk (CIR) PDC capital funding;

• The Trust has spent £4,679k at month five on capital;

• The Trust has submitted a number of capital bids to NHSE/I for

additional capital to be spent by 31 March 2021;

• The Trust continues to forecast the full expenditure of its capital

plans and develop scenarios to take into any additional funding

available.

Charity FY2020/2021 (4 months) income: £103,086 expenditure: £45,948;

Phase grant of £66,500 from NHS Charities Together COVID-19

appeal fund. Charity nearing completion of the disbursement of gifts

to all staff from this phase;

Further grant of £50,000 received to support the health and

wellbeing of those staff disproportionately affected by Covid-19.

Operational Planning • In line with ‘Third Phase of NHS Response to Covid-19’ (NHS Letter

31 July 2020), SWASFT has been working with Dorset Integrated

Care System to develop a draft System Recovery Plan 20/21

(Dorset CCG being the coordinating commissioner);

• Plan aims to deliver system partners priorities, national Phase 3

requirements and in-year priorities from Dorset Long-Term Plan and

will include activity, workforce and finance;

• A first draft submission was made on the 1 September.

Estates, Stores &

Target Operating Model

• Significant work continues on the Trust estates strategy: • Significant work on property in line with critical infrastructure and station

rota changes;

• Plans in progress to secure backlog maintenance works during 2020/21;

• Work to decommission Exeter station expected October 2020 following

relocation to Skypark and decommissioning of the services based at

Chippenham ahead of their reprovision.

• Trust continues to progress action for ‘Working Safely during COVID’,

current phase focused on enabling some return to the office for HQ

staff;

• Interim stores model continues with significant surge to manage

volume of deliveries as a result of coronavirus;

• Exeter stores have temporarily relocated ahead of securing a long

range site for Exeter stores, given the uplift in stock, PPE, product

volume & turnover.

Paper 12

Trust Board of Directors – Public– Thursday 24 September 2020

Page 1 of 2

Meeting: Trust Board of Directors – Public


Paper Title: Charitable Funds Accounts 2019-20

Prepared by: Martin Ford, Income Accountant

Presented by: Jonathan James Acting Executive Director of Finance

CQC Domain:

Well Led

Responsive

Caring

Strategic Goal: Every Pound Matters

Action: Approval

Recommendation: The Trust Board of Directors is asked to approve the 2019-20 Charitable Accounts and associated details.

Trust Board of Directors – Public– Thursday 24 September 2020

Page 2 of 2

Charitable Funds Accounts 2019-2020

1. Introduction

1.1 The Charitable Accounts are attached for 2019-2020. The Accounts have been considered and recommended for approval by both the Finance Committee on 16 July 2020 and the Trust Confidential Board of Directors on 30 July 2020.

1.2 Following consideration of the Charitable Accounts by the Trust Confidential Board of

Directors, minor formatting changes have been made. However, the changes have no impact on the financial position which has previously been audited by the Trust External Auditors.

2. Current position and Forecast view

2.1 The Charity has invested heavily in Medical Equipment in 2019-20 the majority of which has been for Community First Responder Groups. The Community First Responder Groups have invested amongst other things in ‘Razior Chairs’ used to lift fallen patients. The decision to invest in Medical Equipment and Staff Welfare in 2019-20 has resulted in a net outflow of funds of £79k this compares to a net inflow £83k in 2018-19.

2.2 A substantial proportion of Income invested in this Medical Equipment has come from Tesco’s Bag for Help and is still following into the Charity in 2020-21. Whilst there was a net outflow in 2019-20 as the Charity was investing there has been a net inflow in to the Charity in the first quarter of 2020-21 of £69k.

3. Recommendation 3.1 The Trust Board of Directors is asked to approve the 2019-20 Charitable Accounts and

associated documentation. Martin Ford Income Accountant

SOUTH WESTERN AMBULANCE SERVICE FOUNDATION TRUST FUND

TRUSTEE'S REPORT & ANNUAL FINANCIAL STATEMENTS

FOR THE YEAR ENDED 31 MARCH 2020

South Western Ambulance Service Foundation Trust Fund

Contents

Page(s)

Trustee's Annual Report

Reference and Administrative Details 1 - 2

Structure, Governance and Management of Charitable Funds 3 - 7

Auditors' Report 8 - 9

Financial Statements

Foreword to the accounts 10

Statement of Financial Activities for the year ended 31 March 2020 11

Balance Sheet as at 31 March 2020 12

Cash Flow Statement 13

Notes to the Financial Statements 14-20


Trustee's Report for the Year ended 31st March 2020

The Trustee is pleased to present its annual report together with the consolidated financial

statements of the charity for the year ending 31 March 2020.

The financial statements for the year ended 31 March 2020 have been prepared by the Corporate Trustee in

accordance with the Charities Act 2011 and Accounting and Reporting by Charities, Statement of

Recommended Practice applicable to charities preparing their financial statements in accordance with the

Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102) (effective 1 January 2015).

The Trustee is encouraged to see the Charity in continued good financial health. Donations have increased

by 53% year on year; key contributors to this exceptional year include significant grants of £112k from

Groundwork UK (Tesco Bags for Help scheme) to purchase lifting chairs for Community First Responder Groups

in the South West.

Legacy income has also increase in 2019-20 and by its nature is difficult to predict, Legacy income still remains

important to the charity allowing development of impactful initiatives, one of which is to create a 'People

Development' fund to provide bursaries to enable staff to develop their careers within the Trust.

It is most encouraging that our patients and the general public continue to give their support and show their

appreciation for the care and support that they, or their loved ones, have received from the Trust.

The Trustee would like to thank supporters for their continued generosity which has enabled the South Western

Ambulance Charity to go the extra mile for our exceptional people, our volunteer heroes and the communities we

served during 2019-20

Reference and Administrative details

Registered Charity Number: 1049230

Address of Charity: South Western Ambulance Service Foundation Trust Fund

Trust Headquarters

Unit 3, Abbey Court

EXETER

Devon

EX2 7HY Contact: Jonathan James Tel: 01392 261519

Trustee Arrangements:

The South Western Ambulance Service NHS Foundation Trust is the Corporate Trustee of the Charity.

The voting members of the NHS Trust Board who served during the year and up to the date of approval

were as follows:

Mr Tony Fox Chair

Mr Ken Wenman Chief Executive

Mrs Jennie Kingston Deputy Chief Executive/ Executive Director of Finance (Left April 2019)

Mr Jonathan James Acting Executive Director of Finance

Dr Andy Smith Executive Medical Director

Mrs Amy Beet Executive Director of People and Culture

Mr Tim Bishop Executive Director of Information Management & Technology (IM&T)

Mrs Jennifer Winslade Executive Director of Quality and Clinical Care

Mrs Jessica Cunningham Executive Director of Operations

Mrs Vanessa James Non Executive Director

Mr Paul Love Non Executive Director

Mrs Gail Bragg Non Executive Director

Mrs Rakhee Rankin Non Executive Director (left December 2019)

Professor Minesh Khashu Non Executive Director

Page 1


Reference and Administrative details (cont'd)

The Board Members who served as Members of the Charitable Funds Committee during the year

were as follows:

Tony Fox Chair

Ken Wenman Chief Executive

Mr Jonathan James Acting Executive Director of Finance

Mr Paul Love Non Executive Director

Mrs Susan Bradford Non Executive Director

Under the Charitable Funds Committee terms of reference the Committee is appointed by the Trust from

amongst executive and non executive directors of the Trust and consists of not less than three members.

Bankers:

Citibank

Citigroup Centre

25 Canada Square

Canary Wharf

LONDON

E14 5LB

Royal Bank of Scotland

London Corporate Service Centre

2.5 Devonshire Square

PO Box 39952

LONDON

EC2 4XJ

Solicitors:

Bevan Brittan LLPKings Orchard1 Queen Street

BRISTOL

BS2 0HQ

Internal Auditors:

PwC

2 Glass Wharf

Bristol

BS2 0FR

External Auditors:

KPMG LLP (UK)

66 Queen Square

Bristol

BS1 4BE

Page 2


Structure, Governance and Management of Charitable Funds

The Charity was created by Trust Deed on the 15th August 1995 and named as the Westcountry Ambulance

Services Trust Fund. On 1st July 2006, following the merger of Westcountry Ambulance Services NHS Trust with

Dorset Ambulance NHS Trust, the Charity was renamed the South Western Ambulance Service Trust Fund.

On 1 March 2011, the Corporate Trustee attained Foundation Trust status, and, accordingly, the Charity's name changed to

the South Western Ambulance Service Foundation Trust Fund.

Following the acquisition on 1 February 2013 of the Great Western Ambulance Service NHS Trust by the Corporate

Trustee, the net assets of the Great Western Ambulance Charity were transferred to the South Western Ambulance

Service Foundation Trust Fund on that date.

The Charity consists of a number of designated funds relating to individual ambulance stations and departments

within South Western Ambulance Service NHS Foundation Trust. The Charity manages spending through local fund

managers who are allocated groups of funds within their local areas, to spend within agreed authorisation

limits. The fund managers for each of the designated funds manage these funds in accordance with the standing

financial instructions and standing orders and powers of delegated authority set by the Corporate Trustee.

The Corporate Trustee oversees the work of the fund managers and has the power to revoke a fund manager's remit,

or subject to any specific donor restriction or direct the use to which funds are put.

The Corporate Trustee is the South Western Ambulance Service NHS Foundation Trust, and the executive and non-

executive directors of the Trust Board share responsibility to ensure that the NHS body fulfils its duties as Corporate

Trustee when it manages the charitable funds.

The Board of the South Western Ambulance Service NHS Foundation Trust on behalf of the Corporate Trustee has

delegated responsibility for managing the charitable funds to the Charitable Funds Committee.

The Executive Director of Finance is responsible for the day to day management and control of the administration

of the charitable funds. The Executive Director of Finance also has particular responsibility to ensure that spending

is in accordance with the objects and priorities agreed by the Charitable Funds Committee and the Board;

that the criteria for spending charitable monies are fully met; that full accounting records are maintained and that

devolved decision making or delegated arrangements are in accordance with the policies and procedures set out by

the Board on behalf of the Corporate Trustee.

The Charitable Funds Committee is in place to oversee the work of, and to advise, or direct, the Executive Director

of Finance.

The membership of the Committee comprises the Board Members listed in the Reference and Administrative

Details on page 2. Membership of the Committee changes as Board Membership changes, new Board Members

become Charitable Committee Members and leave as they leave the Board.

Strategic Objectives and Activities

The Charity's objectives are as follows:

"The trustees shall hold the trust fund upon trust to apply the income, and at their discretion so far as may be

permissible, the capital, for any charitable purpose or purposes relating to the National Health Service wholly or

mainly for the service provided by the South Western Ambulance Service NHS Foundation Trust".

The overall objective of the Charity is to fund activities that benefit patients of the NHS thus providing a public benefit.

Examples of these activities would be the welfare and training of staff and providing medical equipment and training

to First Responder Groups.

Page 3



Strategic Objectives and Activities (cont'd)

The South Western Ambulance Service Foundation Trust Fund is funded by donations and legacies received

from patients, their relatives, the general public and external organisations.

The overall strategy of the charity is to provide support by supplying grants for:

Staff Expenditure, including Motivation of staff, by improving staff facilities and providing services that

Training and staff development. improve staff wellbeing and thereby of indirect benefit to patients.

Equipment Medical and other equipment in addition to that normally provided by the

NHS.

Whilst respecting the wishes of the donors, the Corporate Trustee has ultimate discretion to apply the charitable

funds, in accordance with the NHS Act 1977 sections 93 and 94, where service changes have taken place or it is

impractical to maintain a separate fund.

Review of Finances, Activities, Achievements & Performance of the Charitable Funds.

In order to fulfil its charitable aims and objectives, the strategy of the South Western Ambulance Service Foundation

Trust Fund is to support its individual special charities and funds by providing grants to benefit patients and ambulance

staff by purchasing supplementary equipment and services that would not be funded through exchequer sources.

The charity has recently embarked on proactive fund raising activities however still relies heavily upon the generosity of

patients, their relatives and other donors who are familiar with, or have experience of, the services undertaken by South

Western Ambulance Service NHS Foundation Trust. Notwithstanding this position, the Trust will continue to facilitate

donations made to the Charitable Funds.

During 2019-20 the Charity paid grants of £382,716 and these are detailed in Note 5 of the financial statements.

The grants relate to staff welfare, development and training and the purchase of medical and other equipment.

Of this £100,044 was granted for staff training costs and contributions to staff welfare.

Medical and other equipment expenditure totalled £282,712 for the year, whilst relating to the purchase of medical

equipment for the use of the responder groups and elsewhere. Other equipment was also purchased for crew rooms

of ambulance stations including TV, audio and other equipment.

In 2019-20 the Charity received £270,324 of donation income and legacy income of £56,572

Bank interest received totalled £3,644 for the same year. In addition, receipts from Gift Aid amount to £4,666.

The Charity does not employ any staff so has no staff cost see note 7.

The overall financial performance recorded a net decrease in total funds of £79,448 which represents approximately

17.4% of funds available at 1 April 2020.

This overall position is represented by the following movements:

£

Decrease in Designated Unrestricted Funds (37,382)

Decrease in Restricted Funds (42,066)

The Charity through its grants has seen staff morale benefit from the provision of station equipment.

Medical equipment has also been provided which has benefitted patient care.

Members of the Charitable Funds Committee have agreed a charge will be made for costs relating to the management

and governance of the Trust Fund.

Public Benefit

The Trustee confirms that it has complied with the duty in section 17 of the Charities Act 2011 to have due regard

to public benefit guidance published by the Charity Commission. The Charity's activities provide for direct and indirect

public benefit by granting expenditure on goods and services for the benefit of patients of the NHS. The provision of

the Charity's service is restricted to the geographical area in which it operates. There are no private benefits to any

members of the Corporate Trustee, staff or volunteers of the Charity. The Trustee is satisfied that the aims of the

Charity are achieved and that the Public Benefit requirements are fully met.

Page 4




Future Development and Plans

A conservative expenditure plan for FY2020/2021 has been developed which aims to manage stakeholder expectations whilst also

recognising the current limitations of planning based on historical analysis. Priority for charitable expenditure will be to maintain a

Minimum Viable Charity (MVC) which comprises working capital and a provision to ensure continuity of key regular charitable

activities. Further charitable expenditure will be based on a prioritised plan and will be subject to a quarterly review of available

funds.

Investment Policy and Performance

The charity's investment powers are broad but subject to a restriction that no speculative or hazardous investments

are allowed.

There were no investments during the year to 31st March 2020.

Reserve Policy

Having carefully considered the best interests of the Charity and its beneficiaries the Trustee Board believes it

appropriate to aim to hold £60,500 free reserves. £32,500 is required for working capital and £28,000 is provided to

ensure continuity of regular charitable activities” [for a period of 12 months]. As at 31st March 2020, the Charity holds

£60,500 of free reserves.

Asset Management Policy

The Charity's policy provides that any asset purchased to the value of £5,000 or more and with a useful life greater than one

year shall be recorded in the Corporate Trustee's Asset Register as a donated asset and not as an asset of the Charity.

There were no such assets recorded in 2019-20.

Grant Making Policy

This year the charity made grants of £382,716 constituting 92% of total charitable resources expended. In making grants

the Trustee requires that the activity falls within the objects of the charity, that the grant request is supported by

the appropriate authorisation and that funds are available to meet the request.

Risk Management Policy

The major risks to which the charity is exposed have been identified and considered. They have been reviewed

and systems established to mitigate those risks.

The major risks identified are:

* Insufficient resource

* Insufficient income to maintain a Minimum Viable Charity (MVC)

* Damage to reputation

Page 5




Statement of Trustees’ responsibilities in respect of the Trustees' annual report and financial statements

Under the [trust deed [and rules] of the charity] and charity law, the trustees are responsible for preparing the Trustees'

Annual Report and financial statements in accordance with applicable law and regulations. [the trustees have elected to prepare

the financial statements in accordance with UK Accounting Standards, including FRS 102 The Financial Reporting Standard

applicable in the UK and Republic of Ireland. ]

The financial statements are required by law to give a true and fair view of the state of affairs of the charity and of the excess of

[income over expenditure]/[expenditure over income] for that period.

In preparing these financial statements, generally accepted accounting practice entails that the trustees:

· select suitable accounting policies and then apply them consistently;

· make judgments and estimates that are reasonable and prudent;

· state whether applicable UK Accounting Standards and the Statement of Recommended Practice

have been followed, subject to any material departures disclosed and explained in the financial statements;

· state whether the financial statements comply with the trust deed [and rules],subject to any material

departures disclosed and explained in the financial statements ;] and

· assess the charity's ability to continue as a going concern, disclosing, as applicable, matters related

to going concern; and

· use the going concern basis of accounting unless they either intend to liquidate the charity or to cease

· operations, or have no realistic alternative but to do so.

The trustees are required to act in accordance with the trust deed [and the rules] of the charity, within the framework of trust

law. They are responsible for keeping proper accounting records, sufficient to disclose at any time, with reasonable

accuracy the financial position of the charity at that time, and to enable the trustees to ensure that, where any statements

of accounts are prepared by them under section 132(1) of the Charities Act 2011, those statements of accounts comply

with the requirements of regulation under that provision. They are responsible for such internal control as they determine

to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error,

and have general responsibility for taking steps as are reasonably open to them to safeguard the assets of the charity and

to prevent and detect fraud and other irregularities.

The trustees are responsible for the maintenance and integrity of the financial and other information included on the

charity's website. Legislation in the UK governing the preparation and dissemination of financial statements may differ

from legislation in other jurisdictions.

Page 6




By Order of the Trustee

Signed:

Will Warrender

Chief Executive …………………………… Date……………………………

Jonathan James

Acting Executive Director of Finance …………………………… Date………………………………

Page 7

Independent auditor’s report to the Trustees of South Western Ambulance Service Foundation

Trust Fund

Opinion

We have audited the financial statements of South Western Ambulance Service Foundation Trust Fund (“the

charity”) for the year ended 31 March 2020 which comprise the statement of financial activities, balance sheet and

statement of cash flows and related notes, including the accounting policies in note 1.

In our opinion the financial statements:

give a true and fair view of the state of the charity’s affairs as at 31 March 2020 and of its incoming resources

and application of resources for the year then ended;

have been properly prepared in accordance with UK accounting standards, including FRS 102 The Financial

Reporting Standard applicable in the UK and Republic of Ireland; and

have been properly prepared in accordance with the requirements of the Charities Act 2011.

Basis for opinion

We have been appointed as auditor under section 149 of the Charities Act 2011 (or its predecessors) and report in

accordance with regulations made under section 154 of that Act.

We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable

law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are

independent of the charity in accordance with, UK ethical requirements including the FRC Ethical Standard. We

believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.

The impact of uncertainties due to the UK exiting the European Union on our audit

Uncertainties related to the effects of Brexit are relevant to understanding our audit of the financial statements. All

audits assess and challenge the reasonableness of estimates made by the directors, related disclosures and the

appropriateness of the going concern basis of preparation of the financial statements. All of these depend on

assessments of the future economic environment and the charity’s future prospects and performance.

Brexit is one of the most significant economic events for the UK, and at the date of this report its effects are subject

to unprecedented levels of uncertainty of outcomes, with the full range of possible effects unknown. We applied a

standardised firm-wide approach in response to that uncertainty when assessing the charity’s future prospects and

performance. However, no audit should be expected to predict the unknowable factors or all possible future

implications for a charity and this is particularly the case in relation to Brexit.

Going concern

The trustees have prepared the financial statements on the going concern basis as they do not intend to liquidate the

charity or to cease its operations, and as they have concluded that the charity’s financial position means that this is

realistic. They have also concluded that there are no material uncertainties that could have cast significant doubt

over its ability to continue as a going concern for at least a year from the date of approval of the financial statements

(“the going concern period”).

We are required to report to you if we have concluded that the use of the going concern basis of accounting is

inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that

basis for a period of at least a year from the date of approval of the financial statements. In our evaluation of the

trustees’ conclusions, we considered the inherent risks to the charity’s business model and analysed how those risks

might affect the charity’s financial resources or ability to continue operations over the going concern period. We

have nothing to report in these respects.

However, as we cannot predict all future events or conditions and as subsequent events may result in outcomes that

are inconsistent with judgements that were reasonable at the time they were made, the absence of reference to a

material uncertainty in this auditor's report is not a guarantee that the charity will continue in operation.

Other information

The trustees are responsible for the other information, which comprises the Trustees’ Annual Report. Our opinion

on the financial statements does not cover the other information and, accordingly, we do not express an audit

opinion or, except as explicitly stated below, any form of assurance conclusion thereon.

Page 8

Our responsibility is to read the other information and, in doing so, consider whether, based on our financial

statements audit work, the information therein is materially misstated or inconsistent with the financial statements

or our audit knowledge. We are required to report to you if:

■ based solely on that work, we have identified material misstatements in the other information; or

■ in our opinion, the information given in the Trustees’ Annual Report is inconsistent in any material respect with

the financial statements.

We have nothing to report in these respects.

Matters on which we are required to report by exception

Under the Charities Act 2011 we are required to report to you if, in our opinion:

■ the charity has not kept sufficient accounting records; or

■ the financial statements are not in agreement with the accounting records; or

■ we have not received all the information and explanations we require for our audit.

We have nothing to report in these respects.

Trustees’ responsibilities

As explained more fully in their statement set out on page 6, the trustees are responsible for: the preparation of

financial statements which give a true and fair view; such internal control as they determine is necessary to enable

the preparation of financial statements that are free from material misstatement, whether due to fraud or error;

assessing the charity’s ability to continue as a going concern, disclosing, as applicable, matters related to going

concern; and using the going concern basis of accounting unless they either intend to liquidate the charity or to

cease operations, or have no realistic alternative but to do so.

Auditor’s responsibilities

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from

material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable

assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK)

will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are

considered material if, individually or in aggregate, they could reasonably be expected to influence the economic

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

A fuller description of our responsibilities is provided on the FRC’s website at

www.frc.org.uk/auditorsresponsibilities.

The purpose of our audit work and to whom we owe our responsibilities

This report is made solely to the charity’s trustees as a body, in accordance with section 149 of the Charities Act

2011 (or its predecessors) and regulations made under section 154 of that Act. Our audit work has been undertaken

so that we might state to the charity’s trustees those matters we are required to state to them in an auditor’s report

and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to

anyone other than the charity and its trustees as a body, for our audit work, for this report, or for the opinions we

have formed.

Jonathan Brown

for and on behalf of KPMG LLP, Statutory Auditor

Chartered Accountants

66 Queen Square

Bristol

BS1 4BE

[Date]

KPMG LLP is eligible to act as an auditor in terms of section 1212 of the Companies Act 2006

Page 9

http://www.frc.org.uk/auditorsresponsibilities


Annual Accounts for the

year ended 31 March 2020

Foreword to the accounts

These accounts for the year ended 31 March 2020 are presented

to the Charity Commission pursuant to the Charities Act 2011

Signed

Will Warrender

Page 10


STATEMENT OF FINANCIAL ACTIVITIES FOR THE YEAR ENDED 31 MARCH 2020

Unrestricted Restricted Total Total

Funds Funds year ended year ended

31 March 31 March

Note 2020 2019

£ £ £ £

Income and endowments from:

Donations and Legacies 2 126,326 200,570 326,896 202,033

Charitable Activities 3 4,666 180 4,846 2,149

Investment Income 9 2,245 1,399 3,644 2,568

Total Income 133,237 202,149 335,386 206,750

Expenditure on:

Charitable activities 5 170,619 244,215 414,834 123,262

Total resources expended 170,619 244,215 414,834 123,262

Net (expenditure)/Income (37,382) (42,066) (79,448) 83,488

Net Movement in Funds (37,382) (42,066) (79,448) 83,488

Reconciliation of Funds

Total Funds brought forward at 1 April 12 318,963 217,841 536,804 453,316

Fund balances carried forward at 31 March 12 281,581 175,775 457,356 536,804

The notes on pages 14 to 20 form part of these financial statements.

All gains and losses recognised in the year are included in the Statement of Financial Activities.

All results derived from continuing operations.

Page 11


BALANCE SHEET AS AT 31ST MARCH 2020

Note Unrestricted Restricted Total Total

Funds Funds 31 March 2020 31 March 2019

£ £ £ £

Current assets:

Debtors 10 1,603 0 1,603 335

Cash and cash equivalents 281,378 176,206 457,584 562,323

Total Current Assets 282,981 176,206 459,187 562,658

Creditors:

Creditors amounts falling due within one year 11 1,400 431 1,831 25,854

Net Current Assets 281,581 175,775 457,356 536,804

Total Assets less current liabilities 281,581 175,775 457,356 536,804

Net Assets 281,581 175,775 457,356 536,804

The Funds of the Charity:

Restricted income funds 12 a) 0 175,775 175,775 217,841

Unrestricted income funds 12 b) 281,581 0 281,581 318,963

Total Charity Funds 281,581 175,775 457,356 536,804

The financial statements pages 14 to 20 were approved by the Board and signed by order

of the Trustee on 24th September 2020

Will Warrender

Chief Executive …………………… Date………………………………

Jonathan James

Acting Executive Director of Finance …………………… Date………………………………

Page 12


CASH FLOW STATEMENT FOR YEAR ENDED 31 MARCH 2020

Total Total

year ended year ended

31 March 31 March

2020 2019

£ £

Net income/(expenditure) for the reporting period (as per the statement of financial activities) (79,448) 83,488

Adjustments for:

Dividends, interest and rents from investments (3,644) (2,568)

(Increase)/decrease in debtors (1,268) 43,281

Increase/(decrease) in creditors (24,023) 15,890

Net cash provided by (used in) operating activities (108,383) 140,091

Cash flows from operating activities:

Net cash provided by (used in) operating activities (108,383) 140,091

Cash flows from investing activities:

Dividends, interest and rents from investments 3,644 2,568

Net cash provided by (used in) investing activities 3,644 2,568

Change in cash and cash equivalents in the reporting period (104,739) 142,659

Cash and cash equivalents at 1 April 2019 562,323 419,664

Cash and cash equivalents at 31 March 2020 457,584 562,323

Page 13


Notes to the financial statements

1 Accounting Policies

(a) Basis of preparation

The financial statements have been prepared under the historic cost convention and in accordance with Accounting and

Reporting by Charities: Statement of Recommended Practice applicable to Charities preparing their accounts in

accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS102) (effective

1 January 2015), (Charities SOPR (FRS 102)), the Financial Reporting Standard applicable in the UK and Republic of

Ireland (FRS 102) and the Companies Act 2006.

In preparing the financial statements and after consideration, the trustees are of the opinion the Statement of Financial

show a true and fair record.

(b) Preparation of the financial statements on a going concern basis

The Trustees have prepared the financial statements on a going concern basis which they consider is appropriate for the following

reasons. The business model of the charity is such that its charitable activities are limited to those which is has sufficient funds to

support from the excess of funding received over the costs of administering the charity. The charity therefore has no specific

commitments and no committed costs beyond its fixed costs of operation which are detailed in note [4].

The Trustees have reviewed cash flow forecasts for a period of 12 months from the date of approval of these financial statements

which indicate that the charity will have sufficient funds to meet its liabilities as they fall due for that period. The Trustees have

also considered the implications of COVID-19 on those cash flow forecasts and consider that as a result of the charities operating

model explained above, even if no further funding is received in the 12 months period, the charity has sufficient cash reserves to pay

all committed costs. As a result, the Trustees consider it appropriate for the financial statements to be prepared on a going concern

basis.

(c) Funds structure

Where there is a legal restriction on the purpose to which a fund may be put, the fund is classified as a restricted

fund and is where the donor has expressly directed for the donation to be spent in furtherance of a specified charitable

purpose. Unrestricted designated funds are sub analysed between particular ambulance station area funds to which the donor

has expressed a preference and the Trust unrestricted funds designated on a county basis, where there are no

directions attached to the donation and which are applicable for any purpose at the Trustee's unfettered discretion.

Transfers may arise, for example, where there is a release of restricted to unrestricted funds or charges are made

from the unrestricted to other funds.

(d) Incoming resources from donations

All incoming resources are included in the Statement of Financial Activities as soon as the following three factors

are met:

(1) Entitlement- arises when a particular resource is receivable or the charity's right becomes legally enforceable;

(2) Certainty- when there is a reasonable certainty that the incoming resources will be received, the charity is

legally entitled to the income, and

(3) Measurement- when the monetary value of the incoming resources can be measured with sufficient reliability.

(e) Incoming resources from legacies

Legacies are accounted for as incoming resources, either upon receipt or when the receipt of the legacy is reasonably

certain; this will be once confirmation has been received from the representatives of the estate(s) that payment of the

legacy will be made or property transferred and once all conditions attached to the legacy have been fulfilled and the

amount of incoming resources is known with reasonable certainty.

(f) Resources expended and irrecoverable VAT

All expenditure is accounted for on an accruals basis and has been classified under headings that aggregate all costs

related to the category. All expenditure is recognised once there is a legal or constructive obligation committing the

charity to the expenditure. Irrecoverable VAT is charged against the category of resources expended for which it was

incurred.

Page 14


Notes to the financial statements (cont'd)

(g) Allocation of overhead and support costs

Overhead and support costs have been allocated between Charitable Activities and Governance Costs.

The analysis of overhead and support costs and the bases of apportionment applied are shown in Note 4.

Where costs are shared by two or more charitable activities, support costs have been apportioned between

categories, for example financial administration costs, on the basis of the proportion that each of Staff Education

& Welfare Costs and Equipment Costs bears to the total of these categories and these are analysed in Note 5.

(h) Trustee Expenses

No Trustee expenses have been incurred within the accounting year 2019-20.

(i) Charitable activities

Costs of charitable activities comprise all costs identified as wholly or mainly incurred in the pursuit of the

charitable objects of the charity. These costs, where not wholly attributable, are apportioned between the categories

of charitable expenditure in addition to direct costs. The total costs of each category of charitable expenditure,

therefore, include support costs and an apportionment of overheads as shown in Note 5.

(j) Governance costs

Governance costs comprise all costs identifiable as wholly or mainly incurred attributable to ensuring the public

accountability of the charity and its compliance with regulation and good practice. These costs include costs related

to statutory audit together with an apportionment of overhead and support costs.

(k) Taxation

The Charity is a registered charity, and as such is entitled to certain tax exemptions on income and profits from

investments and surpluses on any trading activities carried on in furtherance of the charity's primary objectives, if

these profits and surpluses are applied solely for charitable purposes.

(l) Liabilities

Liabilities are recognised as resources expended when there is a legal or constructive obligation committing the Charity

to expenditure.

(m) Judgements and estimates

No judgements or estimates have had to be made when preparing the Financial Statements.

2 Income from Donations and Legacies Unrestricted Restricted Year ended Year ended

Funds Funds 31 March 31 March

2020 2019

Total Total

£ £ £ £

Donations 71,300 199,024 270,324 176,413

Legacies 55,026 1,546 56,572 25,620

Total 126,326 200,570 326,896 202,033

3 Income from Charitable Activities Unrestricted Restricted Year ended Year ended

Funds Funds 31 March 31 March

2020 2019

Total Total

£ £ £ £

Gift Aid receipts 4,666 180 4,846 2149

Total 4,666 180 4,846 2,149

Page 15



4 Governance Costs

Governance Cost are apportioned across Charitable Activities in the proportion that Staff Welfare and also

Equipment relates to total charitable activities.

Year ended Allocated to Residual for Year ended

31 March Governance apportionment 31 March

Allocation and apportionment to 2020 2019

Governance Costs Total Total

£ £ £ £

Financial administration 328 0 328 458

Management Fee 28,790 0 28,790 14,140

Auditors remuneration 3,000 3,000 0 3,000

Total 32,118 3,000 29,118 17,598

5 Analysis of Charitable Expenditure Charitable Charitable Year ended Year ended

Activities Activities 31 March 31 March

Unrestricted Restricted 2020 2019

Total Total

£ £ £ £

Staff Welfare, Training and Development 100,004 0 100,004 32,215

Medical and Other Equipment 41,585 241,127 282,712 73,449

Support Costs 208 120 328 458

Auditors remuneration 1,849 1,151 3,000 3,000

Management Fee 22,576 6,214 28,790 14,140

Other Resources Expended/ Fund Transfer 4,397 -4,397 0 0

Total 170,619 244,215 414,834 123,262

6 Support Cost Charitable Charitable Year ended Year ended

Activities Activities 31 March 31 March

Unrestricted Restricted 2020 2019

Total Total

£ £ £ £

Bank Charges 205 128 333 326

Administration Charges 3 -8 -5 132

Total 208 120 328 458

7 Staff Costs

There are no staff costs as no staff (2019: nil) are employed directly by the Charity.

Page 16



8 Auditors' remuneration

The audit fees of £3,000 (2019 £3,000) relates solely to the statutory audit with no additional work

undertaken. Net amount excluding VAT £2,500.

9 Investment Income Year ended Year ended

31 March 31 March

2020 2019

£ £

Cash held on Deposit - Restricted Funds 1,399 748

Cash held on Deposit - Unrestricted Funds 2,245 1,820

Total 3,644 2,568

10 Debtors Year ended Year ended

31 March 31 March

2020 2019

£ £

Other debtors 1,603 335

Total 1,603 335

11 Creditors: amounts falling due within one year Year ended Year ended

31 March 31 March

2020 2019

£ £

Other Creditors 1,831 25,854

Total 1,831 25,854

Page 17



12 Analysis of Charitable Funds

12 (a) Restricted Income Funds Balance at Incoming Resources Balance at

1 April 2019 resources expended 31 March 2020

b/fwd

£ £ £ £

FRED Equipment Fund - 20120 201,798 202,061 239,439 164,420

Wincanton Equipment Fund - 20098 2,828 20 18 2,830

HQ Equipment Fund - 20123 4,696 0 4,696 0

Saving Lives Together (Dorset) 8,519 68 62 8,525

Total 217,841 202,149 244,215 175,775

Trained and governed by the South Western Ambulance Service NHS Foundation Trust Community First

Responders are called on any time, day or night, helping to reach those patients most in need across the

South West. The FRED Equipment Fund 20120 (First Responder Emergency Defibrillator) provides for the

purchase of enhanced medical and other equipment necessary for Community First Responder Groups in

the south west region.

In 2019/2020, donation and other income was £202,060 while expenditure on equipment and other costs was

£239,439.

The Wincanton Equipment Fund 20098 provides for the equipment necessary to form and maintain the

Wincanton First Responder Group.

The HQ Equipment Fund 20123 is for the purchase of appropriate equipment for the benefit of the Ambulance

Trust and its employees. Depending on the amounts available, the Fund has been used to supply medical

equipment to ambulances and ambulance stations.

In the September 2019 Charitable Funds Committee meeting, the Committee passed a resolution to repurpose

the equipment-based restriction of the Lucas fund to provide assistance in cases of cardiac arrest. This could

include, for example the purchase of automated external defibrillator (AED) devices. A copy of the resolution

was sent to the Charity Commission for review within 60 days (i.e. 29 December 2019). As we have had no

feedback from the Charity Commission within the 60 day period this resolution has now been enacted and the

fund has been renamed: “Saving Lives Together (Dorset)”. The purpose of Saving Lives Together (Dorset)

fund will be to provide support for cases of cardiac arrest in Dorset.”

Page 18



12(b) Analysis of unrestricted funds Balance at Incoming Resources Balance at

1 April 2019 resources expended 31 March 2020

b/fwd c/fwd

£ £ £ £

County Funds

Cornwall 63,243 6,136 13,273 56,106

S&W Devon 9,007 555 3,518 6,044

N&E Devon 4,604 234 2,712 2,126

Somerset 18,175 8,311 2,308 24,178

Dorset 6,298 682 4,979 2,001

BNSSG 6,068 1,429 6,724 773

Wiltshire 5,957 2,714 4,117 4,554

Gloucestershire 16,108 10,827 3,504 23,431

Gloucester Resus Eqpt 82,456 284 56,161 26,579

General 107,047 100,462 71,719 135,790

Total 318,963 131,634 169,015 281,582

Total Unrestricted Funds 318,963 131,634 169,015 281,582

Page 19



12 b) Analysis of Unrestricted Funds (cont)

Each of the designated County unrestricted funds are for the purpose of providing benefits to staff of the area or

area office, and includes staff welfare amenities, staff development and crew room equipment.

The HQ Unrestricted Fund provides for the purchase of staff welfare amenities, development and education

and other benefits for ambulance service across the whole Trust Area.

13 Related Party Transactions

During the year neither the Corporate Trustee nor members of key management staff or parties related to them has

undertaken any material transactions with South Western Ambulance Services Foundation Trust Fund (2019: None).

In addition, no remuneration in respect of the Charitable Funds in the year to 31st March 2020 was paid to any

member of the Charitable Funds Committee or any member of the Corporate Trustee's Board (2019: None).

South Western Ambulance NHS Foundation Trust is considered to be a related party as it has incurred expenditure on

the Charity's behalf, and this expenditure has been repaid in full.

14 Contingent Liabilities

The Charity had no contingent liabilities as at 31st March 2020.

15 Immediate and ultimate parent and controlling party

The immediate and ultimate parent and controlling party is South Western Ambulance Service NHS Foundation Trust,

the Corporate Trustee.

Page 20

Paper 13


Page 1 of 2


Name of Meeting Finance Committee – Public

Date 10 September 2020

Committee Chair Gail Bragg (GB), Non-Executive Director

Members Present

Gail Bragg (GB), Non Executive Director, Tony Fox (TF), Chairman, Tim Bishop (TB). Executive Director of IM&T, Will Warrender (WW),Chief Executive, Jonathan James (JJ), Acting Executive Director of Finance, Nick Cullen, (NC), Non Executive Director

Apologies None

In attendance Marty McAuley (MM), Trust Secretary Zoe Larter (ZL), Head of Charity

Number of items on agenda 14

Items for approval:

Minutes of meeting on 16 July 2020 and Action Point Register;

South Western Ambulance Charity Policy and Procedure Review;

Trust Change Profile;

Dorset ICS Draft Phase 3 Recover Plan – The Committee received an update on the development of the Dorset ICS Plan.

Items for Assurance:

2020/21 Financial Position – A report detailing the latest position on the finance regime was presented and discussed in detail by the Committee.

The key highlights in relation to the financial position were: o The agreement of the value of the funding for the last six months of 2020/21

from NHSE/I as part of the revised NHS financial regime remained outstanding at the time of the Committee meeting;

o the Trust delivered a breakeven position for revenue at month 4 in line with plan;

o The level of funding available for the last six months of 2020/21 remains a significant risk to the Trust;

o activity has been based on 3.6% growth in line with commissioner discussions; o a discussion was held concerning the risk of losing capital and assurance

obtained of the mitigations being put in place.


Page 2 of 2

Discussion was held with regard to push stock levels and the Trusts exposure to risk in obtaining the necessary Trust required PPE. Assurance was obtained on the process and the latest position with regard to handling stock levels over and above that required.

Estate Decision Approvals – A paper detailing a range of property decisions following consideration by the Strategic Estates Programme Board was presented and approved by the Committee.

Finance Report for Charitable Fund and Income Generation Plan – The Committee received and took assurance from the July 2020 position. An update on the Income Generation plan was shared, which is to increase our focus on regular giving, to continue receiving and distributing NHS Charities Together Grants and to develop of a business case for an increase in charity resource moving forward.

Risk Register Extract – The Committee received and took assurance from a report detailing financial risks.

Programme Management Office Highlight Report - A report detailing progress against key projects being undertaken by the Trust was received and assurance taken.

Trust Change Portfolio – The Committee received and considered a concept paper for the Trust Change Portfolio and an update provided on the work undertaken to consider what this structure might look like for the Trust.

Transformation Process Flow – A flow chart detailing the IM&T Development Programme Transformation Process was presented and noted by the Committee.

Benefits Realisation Internal Audit Terms of Reference - The Committee received and considered the terms of reference of an upcoming Benefits Realisation Internal Audit which had been commissioned by the Trust to review and test the controls, systems and processes operating within the Trust in regards to the management and delivery of projects and programmes.

People Plan Two – An update on the development of the People Plan Two was shared. For assurance purposes the Committee requested a further update be presented to the Committee in November 2020.

Items for Information:

Draft Every Pound Matters Dashboard – The Committee noted progress with regard to the development of the Every Pound Matters Dashboard.

Fuel Analysis – The Committee received a paper detailing cost analysis of fuel which had been requested for assurance at a previous meeting.

The Committee noted the development of a paper detailing the benefits experienced through COVID-19 which is to be presented to the November 2020 meeting.

Paper 14


Page 1 of 4



Paper Title: Revised Trust Constitution

Prepared by: Nick Hunt, Corporate Governance Business Manager

Presented by: Marty McAuley, Trust Secretary


Strategic Goal:


Every Patient Matters

Every Pound Matter

Action: Approval

Recommendation: The Trust Board of Directors is asked to approve the revisions to the Trust’s Constitution.

Forward Look:

Following approval from the Trust Board of Directors the revised constitution will be taken to the Trust’s Annual Members Meeting (AMM) and any approved amendments will be highlighted to our regulator, NHS Improvement.


Page 2 of 4

Revised Trust Constitution

1. Introduction

1.1. A constitution is a set of fundamental principles and processes according to which a foundation trust is governed. It is one of the most important documents within any foundation trust and must comply with statutory requirements set out in legislation, such as the National Health Service Act 2006 and the Health and Social Care Act 2012.

1.1. The Trust constitution contains detailed information in areas such as the composition of the

Board of Directors and Council of Governors, as well as our membership profile, constituencies and the way our elections are run.

1.2. Any amendments to the Trust constitution require approval from both the Board of

Directors and Council of Governor. Any approved amendments must be highlighted to regulator, NHS Improvement.

1.3. On Thursday 17 September 2020 the Council of Governors formally approved the

recommendation for the revised constitution to be taken to the Trust Board of Directors for ratification.

1.4. Section two of this paper provides an outline to the changes made to the constitution.

2. Overview of Changes

2.1. Appointed Governor Seats Through identifying the benefits already being seen with existing collaboration and looking to partner with organisation where improved collaboration could support some key work streams for the Trust the Council of Governors recognised the need to implement some changes to the appointed governor seats. The below table outlines the existing appointed seats and then those newly approved by the Council of Governors. These include the addition of a Charity Seat, two youth seats and volunteer seat, which previously sat within the volunteer staff class but was reallocated as per section 2.2 of this paper.


Page 3 of 4

These changes will not only allow the Trust to open up better engagement routes for our service users but also provide some missing key demographics within the Council of Governors. Those seats being removed retain very strong and ongoing relationships with the Trust through existing collaboration.

2.2. Volunteer Staff Class Seat

Whilst reviewing the appointed governor seats there was the opportunity to consider what the current volunteer staff class offers. The volunteer staff class seat recognises the valuable role that the Community First Responder offers to the Trust. Constitutionally however, there remained an issue with a conflict between being a Public Governor and a CFR. If a public governor was also a CFR, after 12 months of responding for the Trust they would then become eligible for staff membership. This would mean that they would have to make a choice between being a public member and being a CFR. This conflict has occurred once in the last couple of years, but with the current vacancy it gives us the chance to remove the conflict. The Trust has worked with our responder department to ensure that this change is completed in a way that retains and supports the important role CFRs play in the delivery of care to our patients.

2.3. Clause 27.1.6

Within the Trust Constitution at clause 27.1.6 it sets out that: ‘the following may not become or continue as a member of the Board of Directors. A person who is a member of the Council of Governors, an executive director, non-executive director or a governor of another NHS foundation trust, or a non-executive director of another Health Service Body;

Current (9) New Approved (8)

Local Authority

Clinical Commissioning Group Clinical Commissioning Group Clinical Commissioning Group

NHS Mental Health Partnerships Air Ambulance Charities

Police Fire and Rescue

NHS Acute Trusts

Local Authority

NHS Mental Health Partnerships Air Ambulance Charities

Clinical Commissioning Group Charitable Organisation

Youth Seat 1 Youth Seat 2

Volunteer


Page 4 of 4

This clause means that the Trust are less able to be agile in our recruitment of Executive and Non-Executive Directors and the removal of this will bring us in line with other Foundation Trusts who have acknowledged the inflexibility this brings. On Thursday 27 August 2020 the Council of Governors approved the removal of the clause with the Board subsequently approve the change on Tuesday 08 August 2020.

2.4. General Refresh

A thorough review of the constitution was undertaken by Bevern Britten to remove any out of date information referencing the Trust pre-merger and also to reflect up to date information regarding our regulators.

3. Recommendation

3.1 The Trust Board of Directors are asked to approve the revisions to the Trust’s Constitution. Nick Hunt Corporate Governance Business Manager

Paper 15


Page 1 of 28

Meeting: Trust Board of Directors – Public


Paper Title: Joint Board Assurance and Risk Report

Prepared by: Emma Murgatroyd, Quality Support Manager

Vanessa Williams, Head of Patient Safety and Risk

Presented by: Jenny Winslade, Executive Director of Quality and Clinical Care

CQC Domain: Safe

Well Led

Strategic Goal:

Every Patient Matters


Every Pound Matters

Action: Assurance

Recommendation: The Trust Board of Directors is asked to take assurance from the information provided.

Forward Look:

There are 69 Significant and Moderate level risks currently open on the Trust’s Corporate Risk Register. There are 10 risks that have a current risk rating of 20 and above. These are:

The Implications of COVID-19

Incident Stacking (A&E)

Handover Delays at Hospital – Impact on Patient Safety and Resource Availability

ARP Performance Targets

Commissioner Affordability

External Impact on Finance Strategy

Cost Improvement Programme

Pollution

Changes in Activity

Responding Officers contracting or transmitting COVID-19 to family members

The focus of Quality Support Team in relation to risk management work over the next six months will be to conclude the development of Risk Tolerance levels and link these to Risk Appetite. Work will also continue with Ideagen to confirm how Risk Appetite and Tolerance can be integrated into the Trust’s Pentana Risk. A review of the Trust’s Board Assurance Framework will also take place in order to further develop it and work will also commence in conjunction with the Non-Executive Directors on the development and use of Risk Indicators.


Page 2 of 28

Joint Board Assurance and Risk Report

1. Introduction 1.1 The purpose of the joint Risk and Board Assurance report is to enable the Board of

Directors to have meaningful discussions about the management of key strategic risks that could impact upon the achievement of long term, strategic priorities.

1.2 This report is composed of two parts which taken together should enable the Board to take

assurance from the range of activities undertaken and the evidence provided. The two key parts are the Board Assurance report and the Significant Level Risk Report which is presented for information at Appendix B. Each Directorate and Risk Owner is responsible for reviewing and updating its risks on a regular basis supported by a central risk team. The Quality Risk Assurance Group (QRAG) is responsible for reviewing the content of all (Significant, Moderate and Low) risks, quality assuring and proposing changes to risks.

1.3 Board Assurance Framework – The BAF provides a simple but comprehensive method for

the effective and focused management of the principle risks to meeting the strategic objectives of the Trust and provides a structure for the evidence to support the Annual Governance Statement. The highest rated risks from the Trust’s Risk Register have been explored in more detail for the Board of Directors to be able to gain the assurance that they require that the risks are being effectively managed.

1.4 The scoring matrix for risk and assurance is in Appendix A of this report.

2. Update on Upcoming Developments 2.1 The Quality Support Team has commenced work with Directorates to split risks from

issues and identify Key Risk Indicators. As Directorates progress this work the ‘Four Ts’ of Risk Management will also be integrated.

2.2 A Pentana Risk session was held with the Audit and Assurance Committee in early

September 2020 with a further workshop planned to take place in November 2020. 2.3 Pentana Risk and Trust risk management processes familiarisation sessions are also

taking place with various Directorates to aid organisational awareness and further embed the Trust’s risk culture.

3. Board Assurance Framework Summary 2.1 The Trust’s risks are grouped into the following categories depending on risk score;

Significant level risks (red) – risks scoring 15 and above

Moderate level risks (amber) – risks scoring 10 and 12

Low level risks (green) – risks scoring 9 or below 2.2 There are currently 69 risks Significant and Moderate level risks on the Trust’s Risk

Register. The records of these risks on Pentana Risk include all identified actions


Page 3 of 28

associated with the risks. These actions have been weighted by the risk owners and therefore this report only contains actions which have been weighted as having the most impact on managing or mitigating risks.

2.3 Within future versions of the Board Assurance Framework, completed actions will be

moved to either Controls or Assurances as appropriate.

2.4 Four new Significant Level risks and three Moderate level risks have been added since the

Board Assurance Framework was last presented to the Board of Directors in July 2020 – please see pages six to nine for details. This includes one new risk scoring 20 – ‘Responding Officers contracting or transmitting COVID-19 to family members through responding to patients’ – a Deep Dive into this risk has been included at page 19.

2.5 Following the previous de-escalation of the Incident Stacking (A&E) risk, it’s score was re-

escalated to 20 (Likely, 4; Very Serious, 5) on 13 August 2020 due to a significant increase from late July 2020 in incidents and call stack. Peaks are seen especially between 1200-1600 and 2300-0200. The risk continues to be reviewed on a weekly basis by the Clinical Hub Management team to ensure that the risk can be managed dynamically and is also receiving more formal reviews by the Executive Director of Operations on a monthly basis and by QRAG on a bi-monthly basis. Call stacking levels continue to be measured and monitored continually throughout the day and live web reporting is available to provide senior management and Executive Directors with oversight.

2.6 One risk has been escalated to a score of 20 since the BAF was last presented; ‘Handover

Delays at Hospital – Impact on Patient Safety and Resource Availability’ following an increase of its Likelihood score from Possible, 3 to Likely, 4 due to the significant increase

Date Total Scored at

15 – 25 Scored at 10

– 12

Scored at Less than 9

September 2018 51 25 26 0

November 2018 56 23 33 0

January 2019 65 26 39 0

March 2019 68 25 43 0

May 2019 61 25 36 0

July 2019 61 26 35 0

September 2019 61 26 35 0

November 2019 64 32 32 0

January 2020 71 32 39 0

March 2020 68 33 35 0

May 2020 74 37 37 0

July 2020 68 30 38 0

September 2020 69 34 35 0


Page 4 of 28

seen recently in hours lost at Emergency Departments. A Deep Dive into this risk has been included at page 24.

2.7 There are ten risks that have a current score of 20 and above. These are:

Risk Current Target

Commissioner Affordability 20 20

External Impact on Finance Strategy 20 20

The Implications of COVID-19 20 16

Changes in Activity 20 16

Incident Stacking (A&E) 20 15

Handover Delays at Hospital – Impact on Patient Safety and Resource Availability

20 15

Cost Improvement Programme 20 15

ARP Performance Targets 20 15

Responding Officers contracting or transmitting COVID-19 to family members

20 10

Pollution 20 6

2.8 A deep dive has taken place for the ten risks which have a current score of 20. The Internal

Audit review of the BAF recommended that the Board of Directors receive a deep dive on risks that sit below the highest level risks on a rotational basis. The ‘Terrorist Activity’ risk has been included for the September 2020 BAF.

5

3. Heat Map Overview of September 2020 Significant and Moderate Risk Registers

3.1 The below heat maps have been populated using all 69 Significant and Moderate Level risks.

3.2 CURRENT SCORE – September 2020

Very Serious

4 12 9

Serious 18 8 1

Moderate 12 4

Low 1

Negligible

Rare Unlikely Possible Likely

Almost Certain

3.3 TARGET SCORE – September 2020

Very Serious

1 7 7 2

Serious 1 15 7 2 1

Moderate 2 2 12 5 1

Low 1 2 1

Negligible


Almost Certain

6

4. Risks by Strategic Goal 4.1 Every Patient Matters

Risk Impact Likelihood Risk Score

Date Reviewed

Trend Directorate

Incident Stacking (A&E) Very Serious Likely 20 28-Aug-2020

Operations

ARP Performance Targets Very Serious Likely 20 10-Sep-2020

Operations

Changes in Activity Very Serious Likely 20 10-Sep-2020

Operations

Handover Delays at Hospital - Impact on Patient Safety and Resource Availability

Very Serious Likely 20 10-Sep-2020

Operations

Ability to maintain the Clinical Hub Critical Systems in a timely manner due to IT expertise capacity and Hub programme capacity

Serious Likely 16 20-Aug-2020

Operations

Clinical Alerts (Warning Markers) - A&E Serious Likely 16 20-Aug-2020

Operations

Application of Safe-Holding Serious Likely 16 26-Jun-2020

Quality and Clinical Care

Safeguarding Compliance Serious Likely 16 03-Aug-2020


University Students in Placement with SWASFT Serious Likely 16 12-Aug-2020

People and Culture

Trust Flu Programme 2020/2021 Serious Likely 16 28-Aug-2020 NEW Quality and Clinical Care

Application of the National DCR Table Escalation Levels, with Protocol 36

Moderate Almost Certain 15 04-Aug-2020 NEW Operations

Cyber Security Very Serious Possible 15 15-Jul-2020 NEW IM&T

999 Non-Clinical Call Audit Compliance Moderate Almost Certain 15 27-Aug-2020

Operations

C3 CAD Failure and effect on service delivery Very Serious Possible 15 28-Aug-2020

Operations

7


Date Reviewed

Trend Directorate

Frequent Caller Team Record Management Moderate Almost Certain 15 02-Jun-2020

Operations

Clinician ECG Recognition Very Serious Possible 15 15-May-2020


Potential for unrecognised misplacement or displacement of Endotracheal Tubes

Very Serious Possible 15 15-May-2020


Trust Vehicle Security Very Serious Possible 15 17-Aug-2020


Terrorist Activity Very Serious Possible 15 30-Aug-2020

Operations

Major IT System Failure Very Serious Possible 15 11-Aug-2020

IM&T

Confidentiality, Integrity and Availability of Information Moderate Almost Certain 15 11-Aug-2020

IM&T

Locating and Accessing Patients Very Serious Possible 15 11-Aug-2020

IM&T

Operational Resources (A&E) Very Serious Possible 15 10-Sep-2020

Operations

Service Change and the impact on the Ambulance Service Very Serious Possible 15 10-Sep-2020

Operations

Timely Complaint Response Moderate Likely 12 17-Aug-2020


Infection Prevention and Control Compliance (Training and Policy)

Serious Possible 12 17-Aug-2020


Data Entry Accuracy within the 999 Clinical Hubs Moderate Likely 12 06-Aug-2020

Operations

Triage Determinant Priority Levels Serious Possible 12 06-Aug-2020

Operations

999 Clinical Call Audit Compliance Moderate Likely 12 07-Aug-2020

Operations

Implementation of the Target Operating Model Moderate Likely 12 25-Aug-2020

People and Culture

Inability to Answer 999 Calls Serious Possible 12 20-Jul-2020

Operations

Bristol Ambulance Station Refurbishment Project Serious Possible 12 25-Aug-2020

Finance

8


Date Reviewed

Trend Directorate

Electronic Care System (ECS2) Moderate Likely 12 22-May-2020

IM&T

Legacy hardware and software Serious Possible 12 11-Aug-2020

IM&T

Critical Care Doctors and BASICs Doctors procedures Serious Possible 12 14-May-2020


Review, Learn, Improve Process Serious Possible 12 17-Aug-2020


Delivery of Development Day 2 2019/20 to Operational A&E Staff – Resourcing

Serious Possible 12 23-Jul-2020

Operations

Impact of REAP Levels, and Summer, Winter and Peak pressures

Serious Possible 12 10-Sep-2020

Operations

Lifepak12 Vital Signs Monitoring Serious Possible 12 06-Aug-2020

People and Culture

Reputation Serious Possible 12 12-Aug-2020

People and Culture

Patient Care Plans stored on Trust Drives Moderate Likely 12 01-Sep-2020 NEW Operations

CFH2 Tablets Unsupported & Spare Battery Stock Low Serious Possible 12 28-Aug-2020 NEW IM&T

Mental Health Training Low Almost Certain 10 12-Aug-2020 NEW People and Culture

Failure to comply with NHS England Standards for MTFA, CBRNe, Mass Casualties and Command and Control.

Very Serious Unlikely 10 23-Jul-2020

Operations

Impact of STPs and other National Change Programs Very Serious Unlikely 10 25-Aug-2020

Finance

Care Quality Commission Very Serious Unlikely 10 08-Sep-2020


4.2 Every Team Member Matters


Date Reviewed

Trend Directorate

9

The Implications of COVID-19 Very Serious Likely 20 17-Aug-2020

Operations

Responding Officers contracting or transmitting COVID-19 to family members through responding to patients

Very Serious Likely 20 12-Aug-2020 NEW Quality and Clinical Care

Measles Serious Likely 16 17-Aug-2020


The Trust’s Recovery from the Response to the COVID-19 Pandemic

Very Serious Possible 15 30-Jul-2020

Operations

Door Access Moderate Likely 12 25-Aug-2020

People and Culture

Versaflow Respirator Hoods Moderate Likely 12 17-Aug-2020

Operations

Public Order Serious Possible 12 23-Jul-2020

Operations

Trust Premises Security Serious Possible 12 17-Aug-2020


Staff Wellbeing Serious Possible 12 12-Aug-2020

People and Culture

Dermatitis Moderate Likely 12 17-Aug-2020


Health and Safety - Strategic Oversight Very Serious Unlikely 10 17-Aug-2020


4.3 Every Pound Matters


Date Reviewed Trend Directorate

Pollution Serious Almost Certain 20 25-Aug-2020

Finance

Cost Improvement Programme Very Serious Likely 20 25-Aug-2020

Finance

External Impact on Finance Strategy Very Serious Likely 20 25-Aug-2020

Finance

Commissioner Affordability Very Serious Likely 20 25-Aug-2020

Finance

A&E & UCS Activity increases above plan Serious Likely 16 25-Aug-2020

Finance

10

Financial Position (Operations Directorate) Very Serious Possible 15 10-Sep-2020

Operations

Brexit - Deal: Impact on SWASFT Moderate Likely 12 25-Aug-2020

Finance

Enabling Strategies Serious Possible 12 25-Aug-2020

Finance

Failure to Follow Capital Expenditure Programme Serious Possible 12 25-Aug-2020

Finance

Procurement Compliance Moderate Likely 12 25-Aug-2020

Finance

Off Payroll Arrangements Moderate Likely 12 25-Aug-2020

Finance

Service Line Development Project Creep Moderate Likely 12 25-Aug-2020

Finance

5. Board Assurance – Deep Dive: Incident Stacking (A&E)

Date Added: 2017

Risk Owner: Jessica Cunningham, Executive Director of Operations

Description: Revised risk assessment reviewed by the Quality and Risk Assurance Group on 28/08/2020 - risk score agreed as 20. Whilst at the time of review there had been a reduction in the stack, the Hub management team agreed to review after the bank holiday weekend.


Pentana Risk Link: https://swambulanceservice.pentanarpm.uk/risks/show/1390545#tab_fields

Risk Score – CURRENT Risk Score - TARGET

Impact Likelihood Risk Score Impact Likelihood Risk Score

Very Serious Likely

20

Very Serious Possible

15 5 4 5 3

Proximity ONGOING

https://swambulanceservice.pentanarpm.uk/risks/show/1390545#tab_fields

11

Categories for which this risk has implications– primary category denoted by red shading Assessment History (Last 3 Assessments)

Quality Business Continuity

Financial Health & Safety

HR Reputation Regulatory Performance Date Reviewed Risk Score Status Trend

28-Aug-2020 20

Constant

27-Aug-2020 20

Constant

20-Aug-2020 20

Constant

Open Risk Actions

Action Action Progress Due Date

Total Completion of All Actions Linked to this Risk - Incident Stacking (A&E)

31-Mar-2021

Confirm the remote working plan for 2020/21 with IMT

30-Sep-2020

Dispatch Structure Review following information from ORH as part of the Sustainable Hub Project - subject to funding

31-Mar-2021

Implementation of a dedicated procured Frequent Caller Record Management System

01-Nov-2020

Target set of 100% resourcing cover for clinicians in the Hub

31-Mar-2021

Development and Implementation of Joint Transformation Plan with Commissioners

31-Mar-2021

Attend the Clinical Task and Finish Group proposed by Dorset CCG to review what else could be done to assist the Trust

31-Mar-2021

Overall Assurance Score

How much assurance

Basis for assurance Timeliness Rigour Assurance Score

2 2 3 3 10 – STRONG

6. Board Assurance – Deep Dive: ARP Performance Targets

12

Date Added: 2018

Risk Owner: Jessica Cunningham – Executive Director of Operations

Description: The potential for not achieving and sustaining national ARP performance targets which could impact on patient safety, patient experience, staff experience, the Trust's reputation and financial position. The actions described work towards the Trust's delivery of ARP standards by the end of the 2020/21.



Risk Score – CURRENT Risk Score – TARGET


Very Serious Likely

20


15 5 4 5 3

Proximity SHORT





10-Sep-2020 20

Constant

02-Jun-2020 20

Constant

24-Dec-2019 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - ARP Performance Targets

31-Mar-2021

Implementation of ARP 'Our People Plan' Phase 1

31-Mar-2021


13

Increase proportion of DCAs in the Fleet to >90%

31-Mar-2021

Work up People Plan 2 in detail

31-Jul-2020


How much assurance


2 3 3 3 11 – STRONG

7. Board Assurance – Deep Dive: The Implications of COVID-19

Date Added: 2020


Description: The risks to Trust staff and the Trust relating to suspected and confirmed COVID-19 cases. Hazards include;

Staff contracting COVID-19; Irritation to staff eyes, skin and respiratory systems as a result of the use of chlorinated solution, chlorine spray or chlorine gas; Electric shock to staff as a result of cleaning electrical items; Damage to medical equipment as a result of cleaning with chlorinated solution; Impact on the environment due to disposal of waste chlorinated solution; Business Continuity risk due to staff and supply chain shortages; Staffing shortfalls within IM&T potentially affecting the Trust's ability to maintain critical Hub systems; Risk to Trust performance; Financial impact on the Trust on COVID-19; Potential reputational damage to the Trust; Supply Chain shortages affecting PPE. uniform, fleet etc.;

14

Regulatory risk of agency staff commencing employment without DBS in place.





Very Serious Likely

20

Serious Likely

16 5 4 4 4

Proximity ONGOING





17-Aug-2020 20

Constant

16-Jul-2020 20

Constant

08-Jul-2020 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk – No Open Actions Listed (29 actions completed)

31-May-2020


How much Basis for assurance Timeliness Rigour Assurance Score


15

assurance

2 1 3 3 9 - STRONG

8. Board Assurance – Deep Dive: Commissioner Affordability

Date Added: 2018

Risk Owner: Jonathan James – Acting Director of Finance

Description: The gap between the funding available and the funding needed.


Pentana Risk Link https://swambulanceservice.pentanarpm.uk/risks/show/1390550#tab_fields



Very Serious Likely

20

Very Serious Likely

20 5 4 5 4

Proximity ONGOING





25-Aug-2020 20

Constant

20-Aug-2020 20

Constant

23-Jan-2020 20

Constant


16

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Commissioner Affordability

31-Mar-2021

Continued engagement and dialogue with Commissioners during the Interim Financial Regime implemented during COVID in relation to cost pressure, the impact of activity increases, and funding levels necessary to deliver performance

31-Mar-2021


31-Mar-2021

Development and implementation of Operating Plan 2020/21

31-Mar-2021

Development of 2021/2022 contract - subject to national guidance

31-Mar-2021

Establishment of new Commissioning Framework with Dorset CCG as Co-Ordinating Commissioner and undertaking Commissioner Support activities

31-Mar-2021


How much assurance


2 2 3 2 9 – STRONG

9. Board Assurance – Deep Dive: External Impact on Finance Strategy

Date Added: 2017


Description: Legislative, contractual or regulatory changes made by government bodies that impact on the Finance Strategy of the Trust.





17


Very Serious Likely

20

Very Serious Likely

20 5 4 5 4

Proximity ONGOING





25-Aug-2020 20

Constant

20-Aug-2020 20

Constant

16-Jul-2020 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - External Impact in Finance Strategy

31-Mar-2021

Continued engagement with NHSI on the Interim Financial Regime in 2020/21 and impact of Trust

31-Mar-2021

Establishment of risk specific teams 2020/21

31-Mar-2021

Monthly monitoring against NHSI Operational Plan 2020/21

31-Mar-2021

Ongoing monitoring of risk and briefing notes prepared for Finance Committee consideration 2020/21

31-Mar-2021

Review of procurement contracts and the financial impact of inflation for 2021/22

31-Mar-2021

18

Use of network contacts including NHS Improvement, Ambulance DOF Group, STP Finance contacts, Regional Finance Meetings etc.

31-Mar-2021


How much assurance


2 3 3 3 11 – STRONG

10. Board Assurance – Deep Dive: Cost Improvement Programme

Date Added: 2018


Description: Identification and execution of the 2 year cost improvement programme - could result in:- • lack of investment in service infrastructure; • a trigger of downside scenarios; • compromised delivery of national targets; • non delivery of Financial Plan.





Very Serious Likely

20


15 5 4 5 3


19

Proximity ONGOING





25-Aug-2020 20

Constant

16-Jul-2020 20

Constant

23-Jan-2020 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Cost Improvement Programme

31-Mar-2021

Budget setting 2021/22

31-Mar-2021

Delivery of enabling strategies 2020/21

31-Mar-2021

Engagement with the new finance regime for 2020/21 and the emerging regime for 2021/22

31-Mar-2021

Implementation of MEAP or CEAP 2020/21

31-Mar-2021

Ongoing benchmarking and alliance work plan to identify budget setting

31-Mar-2021


How much assurance


2 2 3 2 9 – STRONG

11. Board Assurance – Deep Dive: Responding Officers contracting or transmitting COVID-19 to family members through responding to patients

20

Date Added: 2020

Risk Owner: Jenny Winslade – Executive Director of Quality and Clinical Care

Description: Responding Officers contracting or transmitting COVID-19 to family members through responding to patients





Serious Almost Certain

20

Very Serious Unlikely

10 4 5 5 2

Proximity ONGOING





29-Jun-2020 20

Constant

15-Jun-2020 20

Constant

01-Jun-2020 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - RO COVID-19

01-Oct-2020

Responding Officers to be issued with IPC bags with appropriate IPC contained

01-Oct-2020

Awareness bulletin to be created to advise all staff on how long Covid19 can live on different surfaces if not cleaned appropriately

17-Aug-2020


21

Length of time COVID-19 can remain viable of different surfaces to be identified. Cleaning procedure on these different surfaces to be produced. This will require National Ambulance IPC group work

17-Aug-2020

Responding Officers to be advised to carry spare uniform in their vehicles along with toiletry items so that they can shower if needed at their nearest station

01-Sep-2020

Responding Officers to be fit tested for FFP3 masks and provided with a supply of one type of mask

31-Aug-2020

Responding Officers to double bag all clinical waste & contaminated equipment that cannot be cleaned on-scene

01-Sep-2020

Responding Officers to only book on when the RO has sufficient PPE stock

01-Sep-2020

Responding Officers who fail FFP3 testing on all masks to be provided with Powered Hood

31-Aug-2020

Where possible remove all personal items from vehicle before booking on (including child seats). It is accepted that this may not be possible

01-Sep-2020


How much assurance


0 0 0 0 0 – NONE LISTED

12. Board Assurance – Deep Dive: Pollution

Date Added: 2019

Risk Owner: Jonathan James, Acting Director of Finance

Description: Activities that could cause pollution and therefore breach regulations which can affect public health, Trust reputation and financials. Activities include; oil storage (diesel vehicle fuel, diesel generators, vehicle workshop new and waste engine oil tanks), refueling, AdBlue storage vehicle washing, separators and drainage.




22



Serious Almost Certain

20

Low Possible

6 4 5 2 3

Proximity SHORT





25-Aug-2020 20

Constant

29-Jul-2020 20

Constant

21-May-2020 20

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Pollution

31-Dec-2020

Carry out pollution risk assessments at each site where there is oil storage, AdBlue storage and vehicle washing

31-Dec-2020

Ensure spill kits are: labelled, visible, contain spill response process and their location is known to staff

31-Dec-2020

In addition to the standard content, oil spill kits to contain items specific to the site as identified by the site pollution risk assessment e.g. drain covers

31-Dec-2020

Oil and AdBlue delivery companies to provide the Trust with their spills processes

31-Aug-2020

Put in place an interceptor inspection and maintenance programme

31-Dec-2020

Put in place plan and budget to notify water companies of vehicle washing and where required obtain discharge consents for sites carrying out vehicle washing

31-Dec-2020

23

Put in place plan and budget to remove all underground storage tanks

31-Dec-2020

Raise awareness of spills SOP e.g. through Mandatory Training, Driver Training, Intranet

30-Sep-2020

Review carrying out phase 3 of the drain survey plan especially if vehicle washing is to continue at non Make Ready site

31-Dec-2020

Review drainage network and put in place plan and budget to achieve legal compliance at all sites with vehicle washing

31-Dec-2020

Review drainage surveys for make ready and fuel storage sites to identify any pathways which are non-compliant and plan any improvement works

31-Dec-2020

Share the Trust spill response process with oil delivery suppliers

30-Jun-2020

Add documented monthly visual checks of engine new and waste oil tanks by fleet

30-Sep-2020

Ensure any large (200 litre) containers of detergent/ traffic film remover are bunded and protected at non Make Ready Sites

31-Dec-2020

Ensure detergent is bunded, protected from vehicle impact and sheltered if stored outside at Make Ready Sites

30-Sep-2020

Ensure sites with oil storage and Ad Blue tanks have adequate protections around tanks e.g. barriers

31-Dec-2020

Operational staff to check spill kits are complete with appropriate signage on display and a copy of the spill response process as part of regular station visits (checks must be documented)

31-Aug-2020

Regular inspections of detergent / traffic film remover barrels to be put in place and documented to check condition to ensure no damage or weakness

30-Sep-2020

Review metal tanks for engine new and waste oil to ensure they are fit for purpose and not deteriorating and have adequate bunding

31-Dec-2020

Review requirement for vehicle washing at non Make Ready sites. If vehicle washing is to continue then the water company will need to be notified

31-Dec-2020

Review wash bay areas to ensure they are suitable i.e. suitable ground, drain pathways etc.

31-Dec-2020

Spill response process to be communicated to all Trust staff and easily accessible

30-Jun-2020


How much assurance


2 3 3 3 11 - STRONG

24

13. Board Assurance – Deep Dive: Changes in Activity

Date Added: 2018


Description: Changes in daily and hourly call volumes and incident numbers has the potential to impact on the Trust’s ability to respond with potential consequences for patient care and experience, performance and staff experience. This relates to both hub and frontline operations. Actions taken will mitigate planned changes in activity (i.e. Winter pressures, bank holidays etc.), however the Trust is unable to plan to mitigate unplanned changes in activity (e.g. flooding).





Very Serious Likely

20

Serious Likely

16 5 4 4 4

Proximity SHORT





10-Sep-2020 20

Constant

02-Jun-2020 20

Constant

24-Dec-2019 16

Increasing


25

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Changes in Activity

31-Mar-2021

As part of the Joint Plan, CCGs to mitigate growth in activity in 2020/21

31-Mar-2021

As part of the Joint Plan, implement Phase 1 of the Our People Plan

31-Mar-2021

Develop the work of the C&F Group such that it becomes part of normal business in 2020/21

31-Mar-2021

During 2020/21 move towards a flexible resourcing plan

31-Mar-2021


How much assurance


2 3 3 3 11 - STRONG

14. Board Assurance – Deep Dive: Handover Delays at Hospital - Impact on Patient Safety and Resource Availability

Date Added: 2017


Description: Handover delays at the acute hospital trusts resulting in less operational resources available to respond to other patients. This can lead to delays in attending patients who require emergency and urgent assessment, treatment and/or conveyance affecting clinical care and patient safety. Handover delays impact on the ability of the Trust to provide a timely conveying resource to patients assessed by a clinician as requiring conveyance to hospital affecting patient safety and experience and staff morale.






26

Moderate Almost Certain

15

Moderate Possible

9 3 5 3 3

Proximity ONGOING





10-Sep-2020 20

Constant

17-Aug-2020 20

Increasing

02-Jun-2020 15

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Handover Delays at Hospital

31-Mar-2021

Assess the impact of the changes to the front door arrangements as part of the response to COVID 19. Focus on impact on handover delays. County Commanders and Deputies to link in with local EDs to understand the issues in detail

30-Jun-2020

Attend monthly national Handover calls chaired by NHSE/I

31-Mar-2021

Implement HALOs in 10 hospitals subject to successful funding bid

30-Apr-2021


How much assurance


2 2 3 3 10 - STRONG

27

15. Board Assurance – Deep Dive: Terrorist Activity

Date Added: 2009


Description: The risk of a terrorist attack on the SWASFT 5 which could result in a serious effect on service delivery, staff harm and a loss of Trust infrastructure and vehicles.


Pentana Risk Link: https://swambulanceservice.pentanarpm.uk/risks/show/1390577#tab_more




15


15 5 3 5 3

Proximity SHORT





30-Aug-2020 15

Constant

23-Jul-2020 15

Constant

11-Jun-2020 15

Constant

Open Risk Actions


Total Completion of All Actions Linked to this Risk - Terrorist Activity

31-Mar-2021

IM+T Managers to receive Command and Control awareness to prepare them for working in a Trust ICC

31-Dec-2020

https://swambulanceservice.pentanarpm.uk/risks/show/1390577#tab_more

28

National review to increase HART personnel numbers

01-Mar-2021

Ongoing compliance with NHSE Core Standards and NARU Interoperability Standards

31-Mar-2021

Ongoing multiagency planning, training and exercising and compliance with requirements under the CCA 2004

31-Mar-2021

Ongoing recruitment for additional MTFA Responders and SORT to ensure the 24/7 capability

31-Mar-2021

Insider threat exercise to be planned between EPRR and Safeguarding

31-Dec-2020

Cyber security education programme to be introduced as mandatory training from March 2021

31-Mar-2021

Further work is required into relation to access control and lockdown planning

31-Aug-2020


How much assurance


2 2 2 3 9 - STRONG

16. Recommendation 16.1 The Board of Directors is asked to take assurance from the information provided and provide support for the actions on restructuring and

developing the risk framework. Emma Murgatroyd Vanessa Williams Quality Support Manager Head of Patient Safety and Risk

Appendix A – Risk Scoring Consequence score

Severity Descriptors

1 2 3 4 5

Negligible Low Moderate Serious Very Serious

Likelihood score

1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost Certain

Heat Map

Control Scoring

Score 1 2 3

Descriptor Not Effective Partially Effective Fully Effective

Control, Assurance and Action Weighting

Weight 1 2 3

Impact on Risk Minimal Moderate Significant

Very Serious 5 10 15 20 25

Serious 4 8 12 16 20

Moderate 3 6 9 12 15

Low 2 4 6 8 10

Negligible 1 2 3 4 5


Almost Certain

Risk Score 1 – 9 Low Level Risk

Risk Score 10 – 12 Moderate Level Risk

Risk Score 15 – 25 Significant Level Risk

Assurance scoring

Descriptor 1 2 3

How much? Minimal Partial Full

Basis Self-Assessment Internal Verification External Verification

Timeliness 9+ months Between 3 and 9 months Within last 3 months

Rigour Weak Moderate Strong

Score Level of assurance

0 – 5 Weak – very limited reliance

6 - 8 Moderate – limited reliance

9 - 12 Strong – strongly relied upon

1

Significant Risk Register

Generated on: 14 September 2020

Risk Risk

Description Risk Owner Controls Risk

Score Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status

Actions Progress Bar

Due Date

Incident Stacking (A&E)

Stacking of CAT2, CAT3 and CAT4 incidents outside of national thresholds calls due to the availability of resources and/or high demand could affect patient safety, patient experience, staff morale and performance.


Clinician rota revised and supplemented during COVID19 with other roles such as LDOs and Specialist Paramedics

20

28-Aug-2020

15

Attend the Clinical Task and Finish Group proposed by Dorset CCG to review what else could be done to assist the Trust

31-Mar-2021

GPs based within the Clinical Hubs to advise and assist with management of calls on weekends and bank holidays and at key times


31-Mar-2021

111 system-wide Escalation SOP agreed to increase the time for clinical validation prior to 999 transfers (subsequently reducing activity)

Dispatch Structure Review following information from ORH as part of the Sustainable Hub Project - subject to funding

31-Mar-2021

Trust ongoing roll out of People Plan 1 and for 2020/21 People Plan 2 with focus on increasing DCAs in the Fleet

Confirm the remote working plan for 2020/21 with IMT

30-Sep-2020

Appendix B

2

Risk Risk Description

Risk Owner Controls Risk Score

Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Ongoing Recruitment Programme to appoint to establishment


01-Nov-2020

Public awareness information regarding appropriate use of the 999 service

Target set of 100% resourcing cover for clinicians in the Hub

31-Mar-2021

General Broadcasts (as per SOP OP02)

SWASFT attendance at NHSE/I led Quality Surveillance Group and subsequent meetings (IQPMG, Regional IDM)

Regular agenda item at contract meetings and Exec to Exec meeting with Dorset CCG with a weekly report to Directors

Resources diverted as appropriate to incidents prioritised with a higher category

3



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Primary clinical triage undertaken on waiting patients in accordance with SOP VH07 Management of Unallocated Incidents

Specialist Paramedics and LDOs working remotely to assist (using Manchester Triage Tool)

New Resource Deployment SOP OP058 issued February 2020 (SOP is under constant review)

Revised Management of Back-Up SOP issued March 2020

COVID-19 strategy has been in place since the start of the pandemic

Protocols in place for reviewing the Escalation Plan levels

Urgent Care Desk and PTS service

4



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

implemented working with the UTV’s and additional private providers to review and move those patients in the CAT3 and CAT4 stack

The Implications of COVID-19

The risks to Trust staff and the Trust relating to suspected and confirmed COVID-19 cases. Hazards include;

• Staff

contracting COVID-19;

• Irritation to

staff eyes, skin and respiratory systems as a result of the use of chlorinated solution, chlorine spray or chlorine gas;


PPE in use in accordance to national guidance. Information will be distributed through the JRCALC app.

20

17-Aug-2020

16 No current open actions – 29

completed

Infection Prevention and Control Policy in place

Decontamination is included in national guidance. The national guidance on the JRCALC app specifies how to identify the COVID-19, clinical management, cleaning and welfare arrangements. Updates are communicated to staff via Clinical Notices

5



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

• Electric

shock to staff as a result of cleaning electrical items;

• Damage to

medical equipment as a result of cleaning with chlorinated solution;

• Impact on

the environment due to disposal of waste chlorinated solution;

• Business

Continuity risk due to staff and supply chain shortages;

• Staffing

shortfalls within IM&T potentially affecting the Trust's ability to maintain critical Hub

COVID-19 script to triage potential patients rolled out in the Clinical Hubs.

Business Continuity Plans and Risk Assessments completed at corporate and departmental levels

Standing Financial Instructions are in place to ensure effective control of expenditure

Weekly review of PO and Non PO transactions undertaken by Finance Department

Effective planning of supply requirements e.g. uniform, PPE etc.

Maintenance of Stock levels

Communications provided to staff that people who have symptoms of COVID-19 or are self-isolating should

6



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

systems;

• Risk to

Trust performance;

• Financial

impact on the Trust on COVID-19;

• Potential

reputational damage to the Trust;

• Supply

Chain shortages affecting PPE. uniform, fleet etc.;

• Regulatory

risk of agency staff commencing employment without DBS in place.

not attend work

Regular cleaning taking place at all Trust premises

Clinical guidance notes are readily available noting special measures in place to safely manage aerosol generating procedures

Cost Improve-ment Programme

Identification and execution of the cost improvement programme - could result in:-

Acting Director of Finance

Downside scenario planning identified 20

25-Aug-2020

15

Implementation of MEAP or CEAP 2020/21

31-Mar-2021

Strict controls on costs and monitoring of budgets

Ongoing benchmarking and alliance work plan to identify budget setting

31-Mar-2021

Governance

Delivery of enabling 31-Mar-2021

7



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

• lack of investment in service infrastructure; • a trigger of downside scenarios; • compromised delivery of national targets; • non delivery of Financial Plan.

Framework in place strategies 2020/21

Finance Committee

Budget setting 2021/22 31-Mar-2021

Implementation plans developed with clear accountability identified and implemented

Engagement with the new finance regime for 2020/21 and the emerging regime for 2021/22

31-Mar-2021

Recognition Agreement in place and ongoing dialogue with Staffside

Workforce Planning aligned to CIS programmes

Cost Improvement Strategy

Pollution Activities that could cause pollution and therefore breach regulations which can affect public health, Trust reputation and financials. Activities include; oil storage


Some information in ‘Fuel, Fuel Card and Fuel Key Policy’ on spill response

20

25-Aug-2020

6

Carry out pollution risk assessments at each site where there is oil storage, AdBlue storage and vehicle washing

31-Dec-2020

All above-ground diesel tanks are bunded and protected from vehicle impact

Ensure spill kits are: labelled, visible, contain spill response process and their location is known to staff

31-Dec-2020

Sites with diesel storage have spill kits

Put in place an interceptor inspection and maintenance programme

31-Dec-2020

Integrity tests are

In addition to the standard 31-Dec-2020

8



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

(diesel vehicle fuel, diesel generators, vehicle workshop new and waste engine oil tanks), refuelling, AdBlue storage vehicle washing, separators and drainage.

carried out on tanks content, oil spill kits to contain items specific to the site as identified by the site pollution risk assessment e.g. drain covers

COSSH assessments have been completed

Oil and AdBlue delivery companies to provide the Trust with their spills processes

31-Aug-2020

Drainage surveys and environmental risk assessments have been completed for some sites

Review requirement for vehicle washing at non Make Ready sites. If vehicle washing is to continue then the water company will need to be notified

31-Dec-2020

Protective barriers are installed around tanks as appropriate

Ensure sites with oil storage and Ad Blue tanks have adequate protections around tanks e.g. barriers

31-Dec-2020

Generators and vehicle workshop tanks are not near traffic routes

Put in place plan and budget to notify water companies of vehicle washing and where required obtain discharge consents for sites carrying out vehicle washing

31-Dec-2020

Trust waste management policy

Put in place plan and budget to remove all underground storage tanks

31-Dec-2020

Guidance on hazardous waste consignment note completion available on the Estates intranet

Raise awareness of spills SOP e.g. through Mandatory Training, Driver Training, Intranet

30-Sep-2020

9



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

pages

Details on replenishing spill kits included in the spill response procedure

Review carrying out phase 3 of the drain survey plan especially if vehicle washing is to continue at non Make Ready site

31-Dec-2020

Review drainage network and put in place plan and budget to achieve legal compliance at all sites with vehicle washing

31-Dec-2020

Review drainage surveys for make ready and fuel storage sites to identify any pathways which are non-compliant and plan any improvement works

31-Dec-2020

Share the Trust spill response process with oil delivery suppliers

30-Jun-2020

Add documented monthly visual checks of engine new and waste oil tanks by fleet

30-Sep-2020

Ensure any large (200 litre) containers of detergent/ traffic film remover are bunded and protected at non Make Ready Sites

31-Dec-2020

Ensure detergent is bunded, protected from vehicle impact and sheltered if stored outside at Make Ready Sites

30-Sep-2020

Operational staff to check spill kits are complete with

31-Aug-2020

10



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

appropriate signage on display and a copy of the spill response process as part of regular station visits (checks must be documented)

Regular inspections of detergent / traffic film remover barrels to be put in place and documented to check condition to ensure no damage or weakness

30-Sep-2020

Review metal tanks for engine new and waste oil to ensure they are fit for purpose and not deteriorating and have adequate bunding

31-Dec-2020

Review wash bay areas to ensure they are suitable i.e. suitable ground, drain pathways etc.

31-Dec-2020

Spill response process to be communicated to all Trust staff and easily accessible

30-Jun-2020

External Impact on Finance Strategy

Legislative, contractual or regulatory changes made by government bodies that impact on the Finance Strategy of the Trust.


Internal Employment Law expertise

20

25-Aug-2020

20

Continued engagement with NHSI on the Interim Financial Regime in 2020/21 and impact of Trust

31-Mar-2021

Procurement contracts based on multi-year agreements where possible

Establishment of risk specific teams 2020/21

31-Mar-2021

Support from NHS Improvement who

Monthly monitoring against NHSI Operational Plan

31-Mar-2021

11



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

also set the tariff inflation within contracts to consider the impact of elements such as the national set pay award

2020/21

Finance, HR and where necessary professional advisors, review financial decisions by external organisations

Ongoing monitoring of risk and briefing notes prepared for Finance Committee consideration 2020/21

31-Mar-2021

Relationships with Commissioners

Review of procurement contracts and the financial impact of inflation for 2021/22

31-Mar-2021

Submission of Annual Plan and monthly returns

Use of network contacts including NHS Improvement, Ambulance DOF Group, STP Finance contacts, Regional Finance Meetings etc.

31-Mar-2021

Liaison and communication with local NHSI contacts

Commission-er Affordability

The gap between the funding available and the funding needed.


Ongoing dialogue with NHS Improvement in relation to cost pressures and national funding decisions

20

25-Aug-2020

20

Establishment of new Commissioning Framework with Dorset CCG as Co-Ordinating Commissioner and undertaking Commissioner Support activities

31-Mar-2021

12



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Two year contract in place with Commissioners

Continued engagement and dialogue with Commissioners during the Interim Financial Regime implemented during COVID in relation to cost pressure, the impact of activity increases, and funding levels necessary to deliver performance

31-Mar-2021

Operational modelling undertaken by ORH


31-Mar-2021

National Ambulance Strategic Partnership Forum in place

Development and implementation of Operating Plan 2020/21

31-Mar-2021

Trust Financial Plan including Cost Improvement Plan approved by Trust Board of Directors

Development of 2021/2022 contract - subject to national guidance

31-Mar-2021

Joint Plan submitted to NHS England

Business Case developed to demonstrate how this will be achieved

Breakglass activity

Transformation

13



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Break Glass

Joint Plan Financial Framework agreed

Finance and Information Group in place

ARP Perform-ance Targets

The potential for not achieving and sustaining national ARP performance targets which could impact on patient safety, patient experience, staff experience, the Trust's reputation and financial position. The actions described work towards the Trust's delivery of ARP standards by the end of the 2020/21.


Extended Delay Review Process run by the Quality and Clinical Care Directorate

20

10-Sep-2020

15

Work up People Plan 2 in detail

31-Jul-2020

ORH Modelling jointly commissioned between the Trust and CCGs

Implementation of ARP 'Our People Plan' Phase 1

31-Mar-2021

Our People Plan 1 and 2

Increase proportion of DCAs in the Fleet to >90%

31-Mar-2021

Performance Improvement Plan (PIP) implemented and closed

14



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Changes in Activity

Changes in daily and hourly call volumes and incident numbers has the potential to impact on the Trust's ability to respond with potential consequences for patient care and experience, performance and staff experience. This relates to both hub and frontline operations. Actions taken will mitigate planned changes in activity (i.e. Winter pressures, bank holidays etc.), however the Trust is


Trust RMG held weekly 20

10-Sep-2020

16

As part of the Joint Plan, CCGs to mitigate growth in activity in 2020/21

31-Mar-2021

Rotas flexed for known busy periods

As part of the Joint Plan, implement Phase 1 of the Our People Plan

31-Mar-2021

Contract in place with activity profiled which is reported against

Develop the work of the C&F Group such that it becomes part of normal business in 2020/21

31-Mar-2021

Capacity and Forecasting Group established and forecasting reports generated during COVID to support Surge Planning

During 2020/21 move towards a flexible resourcing plan

31-Mar-2021

15



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

unable to plan to mitigate unplanned changes in activity (e.g. flooding).

Handover Delays at Hospital - Impact on Patient Safety and Resource Availability

Handover delays at the acute hospital trusts resulting in less operational resources available to respond to other patients. This can lead to delays in attending patients who require emergency and urgent assessment, treatment and/or conveyance affecting clinical care and patient safety.


Escalation Process in place (handover delays)

20

10-Sep-2020

15

Assess the impact of the changes to the front door arrangements as part of the response to COVID 19. Focus on impact on handover delays. County Commanders and Deputies to link in with local EDs to understand the issues in detail

30-Jun-2020

Clinical Notice - Continuity of Care

Attend monthly national Handover calls chaired by NHSE/I

31-Mar-2021

Hospital Handover SOP written, in place and reviewed regularly by command team

Implement HALOs in 10 hospitals subject to successful funding bid

30-Apr-2021

Oversight of local systems - CCs/DCCs attend A&E Delivery Boards

Executive Director of Operations dials into regular national Hospital Handover

16



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Handover delays impact on the ability of the Trust to provide a timely conveying resource to patients assessed by a clinician as requiring conveyance to hospital affecting patient safety and experience and staff morale.

telecon chaired by NHSE

ICPR information updated in September 2019 and going forward to include summary of Datix submitted in month

Datixs are being submitted and monitored for patients being held in ambulances and crews not being able to offload

Responding Officers contracting or transmitting COVID-19 to family members through responding to patients

Responding Officers contracting or transmitting COVID-19 to family members through responding to patients.

Executive Director of Quality and Clinical Care


20

12-Aug-2020

10

Responding Officers to be issued with IPC bags with appropriate IPC contained

01-Oct-2020

Vehicle Equipment & Uniform Policy updated to indicate Responding Officers should be issued with and carry an IPC bag

Awareness bulletin to be created to advise all staff on how long Covid19 can live on different surfaces if not cleaned appropriately

17-Aug-2020

Robust recording system on the intranet available to

Length of time COVID-19 can remain viable of different surfaces to be identified.

17-Aug-2020

17



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

capture those fit tested and those outstanding and which types of mask are compatible with staff member

Cleaning procedure on these different surfaces to be produced. This will require National Ambulance IPC group work

Regular hand hygiene

Responding Officers to be advised to carry spare uniform in their vehicles along with toiletry items so that they can shower if needed at their nearest station

01-Sep-2020

Portable clinical waste bins are now able to be ordered by Responding Officers

Responding Officers to be fit tested for FFP3 masks and provided with a supply of one type of mask

31-Aug-2020

Trust issued guidance on wearing Level 2 PPE for all patients unless AGP is being performed and issued guidance on Level 3 PPE for all AGPs

Responding Officers to double bag all clinical waste & contaminated equipment that cannot be cleaned on-scene

01-Sep-2020

JRCALC app for guidance

Responding Officers to only book on when the RO has sufficient PPE stock

01-Sep-2020

Adequate levels of PPE are available across the Trust

Responding Officers who fail FFP3 testing on all masks to be provided with Powered

31-Aug-2020

18



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Hood

COVID-19 symptoms reportable to sickness line, self-isolate as per guidelines, or if family member becomes ill 14 days

Where possible remove all personal items from vehicle before booking on (including child seats). It is accepted that this may not be possible

01-Sep-2020

Waste Management Policy in place

Alcohol gel and clinell wipes available for use

Responding Officers should carry the same IPC bag contents as all frontline resources

Measles The risk of Trust staff contracting measles which could result in a prolonged absence from work and an adverse effect on staff and patient



16

17-Aug-2020

9

Staff should identify their own immunisation status through occupational health or GP if unsure

31-Dec-2020

Trust has published an A to Z of Disease Specific Precautions

SOP to be written alongside FAQs

31-Aug-2020

All new employees who are patient facing are required to undertake an Occupational Health assessment

Staff should ask to be stood down once suspected measles has been identified, clean the vehicle and ascertain if any high risk patients have been in contact

31-Aug-2020

19



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

safety. prior to employment

with them. Take steps to inform these groups and provide advice

PPE available for frontline staff who have performed a dynamic risk assessment which highlights the need for respiratory protection

Undertake exercise to ascertain which staff have and have not received immunisations against measles

31-Aug-2020

Advice/ FAQs of measles are published on the intranet

Optima hold records for some staff with immunisation deep dive in progress (2019/20)

31-Aug-2020

Cleaning schedule in place for infectious diseases in IPC A-Z

The Health, Safety and Security Department monitor all health and safety incidents and will report under RIDDOR as required

Incident Reporting Policy in place

Hand decontamination via gel and normal handwashing

20



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

available with handwashing procedures widely publicised

Ability to maintain the Clinical Hub Critical Systems in a timely manner due to IT expertise capacity and Hub programme capacity

Ability to maintain the Clinical Hub Critical Systems in a timely manner due to IT expertise capacity and Hub programme capacity (and Trust COVID-19 response), affects the department’s performance and systems stability; this can impact upon Patient Safety and Business Continuity.


Operational resilience processes in place

16

20-Aug-2020

15

Production and agreement to an Annual Clinical Hub Systems Maintenance Plan (with priority to maintenance over projects)

31-Oct-2020

Supplier support as part of contract

Review and Schedule failover fall-back testing

31-Oct-2020

Urgent fixes to issues are prioritised, and patches can be taken between releases if necessary

Test High Availability (CAD HA) Function

31-Oct-2020

Notifications from suppliers go to a trust email distribution group that covers IT, Business Systems, Clinical Hub, Training and Audit

IT on call system covers CAD as a critical service

Third party suppliers provide 24/7 back up to Gold systems

21



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

IT recruitment and development programme

Clinical Hub Business Continuity Plans

Location details to be obtained by EMDs at time of call if address not found in system

Any locations identified as missing by EMDs will then be inputted into the CAD manually by Business Systems Team

Availability of mobile data terminals/sat nav and maps in vehicles

The two Report Servers, and the Live Server which is not operational are patched monthly (but not the Live Server as it has the potential to cause an outage/downtime)

22



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

IT Work Programme recognises the types of updates and frequency expected each year

Gazetteer updated May 2020 – to be scheduled in (separate) six-week cycle – applying updates only, rather than full re-load, to ease and speed process

Map Tile updates now scheduled in six-week cycle

Clinical Alerts (Warning Markers) - A&E

A significant number of requests are received by the Trust for warning markers/clinical alerts to be added to the CAD system, to be available to clinical hub and operational staff. A delay in


Incidents with warning marker / clinical alert information held within the CAD have a warning against them; dispatchers are trained to review, and forward relevant information to the responding resources

16

20-Aug-2020

8

Health, Safety and Security Manager to obtain access to run the department’s own reports on violence and aggression warning markers held on the CAD

30-Sep-2020

The team prioritise time-critical and clinical alert requests and then

Produce a Project Plan to implement new warning marker management processes and systems to

30-Jun-2020

23



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

information being added to the CAD or a delay in removal of information once valid, could affect the delivery of patient care and result in poor patient experience

input according to the date order received

reduce and manage the risk

Light duties staff are utilised to support this work where possible

The Warning Marker on CAD will highlight any requirement to investigate further

Warnings can be applied to multiple addresses if a patient is known to spend time at different locations

Clinical Hub Managers have agreed Process Guidance to follow, including to email the Health, Safety and Security Team with details when a warning is applied

Since early 2017, all Warning Markers/ Clinical Alerts added or amended have a date set against them (so staff know

24



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

date of last review and if no date, that it pre-dates this period)

Some awareness by Hub Clinicians/staff of the names of frequent callers

Frequent Caller, and Health, Safety & Security Teams managing their own warning markers

All training (for light duties etc.) provided by the same Administrator

Trust form provided on intranet

Line Management Support (and co-operation)

Warning Marker/Clinical Alert information is managed and stored within the Manage Engine System (with emails received via nhs.net forwarded into this, to join non nhs.net emails).

25



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Post is scanned, then shredded

Standard Trust Procedure for crews to submit a Datix for near misses/incidents of note

Regular meetings relating to Hub Systems Quality Assurance held to discuss concerns and make decisions

MIS able to recover lost warning markers in to a spreadsheet

Heath, Safety and Security Team hold a separate spreadsheet so that if warnings were deleted, they could re-instate

A&E activity increases above plan

A&E activity increasing above plan meaning additional financial pressures.


Escalation Process for Expenditure overspend

16

25-Aug-2020

9

Development of Operational Plan for 20/21 based on expected income

30-Sep-2020

Negotiation with Commissioners

Develop MEAP for management of resources, agree operational actions through Service lines

31-Mar-2021

26



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

MEAP

Engagement with Dorset ICS as co-ordinating commissioner and expected lead for interim financial regime M6-12 in relation to funding allocation

31-Mar-2021

Budget setting

Discussions with NHSI/E in relation to the funding available as part of the interim financial regime and the impact of activity growth

30-Sep-2020

CIP

Engagement in AHSN learning event and development of Transformation plan with Commissioners

30-Sep-2020

A&E Work programme

Break Glass Activity Clause

Application of Safe-Holding

The risk of Trust front line staff applying safe holding in an ambulance environment which could result in staff injury, patient harm, reputational damage and legal action


Clinical Guideline CG40 De-escalation and Safe Holding provides practical guidance

16

26-Jun-2020

9

ECS2 will ensure that safe-holding will only be able to be recorded following completion and recording of a capacity assessment

31-Aug-2020

Application of chemical restraint restricted to those staff trained in application and specifically authorized by Executive Medical Director

Skills for Health Training of all staff in conflict resolution and disengagement delivered every 3 years. Provisionally safe-holding methods will be covered in the interim as a topic on the LDR shifts in 20/21 and 21/22.

31-Mar-2022

27



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

taken against the Trust. (Risk previously called 'Restraint').

Staff advised to seek police support in provision of restraint when appropriate

Monitor Staff Development Day 2 delivery and compliance with training report from Learning and Development

31-Dec-2020

Welfare support in place through the command structure

Ensure Delivery of Development Day 2

31-Dec-2020

Support provided through Senior Clinical Advisor

Mental Health guidance available on the Trust Intranet to support staff in understanding of mental health and mental capacity

Violence and Aggression Policy in place

Access to Staying Well Service for Trust staff

Airwave radio emergency button

Requirement to document any safe-holding methods used to support patient care on ePCR

28



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Safeholding Policy in place

Mental Capacity Act 2005, Mental Health Act 2007 and Care Act 2014 in place

Safeguard-ing Compliance

Risk of potential for non-compliance with Safeguarding requirements, an increase in the number of referrals and quality of referrals received affecting the safeguarding team’s capacity and potentially patient safety.


Dissemination of information and training for staff to reduce unnecessary referral activity.

16

03-Aug-2020

9

Executive Director of Quality and Clinical Care to consult with the Executive Director of Operations regarding resilience plan for deployment of a managed team of 8 light-duty staff.

31-Oct-2020

Postponement of other essential safeguarding tasks and diversion of team resources to manage referrals

Re-design of safeguarding referral system through ECS2 (linked to PIP NCD12). This project includes the design and testing of an algorithm to support referral decision-making for staff

31-Oct-2020

Temporary funding of 2.4 WTE safeguarding administrators until delivery of ECS 2 solution

Light-duty operational staff being utilised where available.

Head of Safeguarding has produced a

29



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

resilience plan for evaluation involving deployment of a managed team of 8 light-duty staff.

University Students in Placement with SWASFT

The risk of university students being in placement with SWASFT which could result in patient, staff member or student harm, a lack of oversight of placements and the university not being able to be informed in the event of an adverse incident.

Executive Director of People and Culture

Work has now been completed by ROC to add all students on to GRS

16

12-Aug-2020

8

FFP3 mask fit testing to be completed on all students during their induction

30-Jun-2020

Honorary contracts are issued to all students and are subsequently managed by Practice Placement Co-ordinators and the People and Culture Directorate

All future cohorts should not be issued with SWAST identifiable uniform and instead should wear a polo shirt identifying the university they are studying with and high viz jackets which meet our uniform standards

31-Jul-2020

Reporting of injury and harm to the patient, staff or student via Datix

All Practice Educators to be contacted to advise should the student have failed FIT testing to aid conversations at the start of the placement

30-Sep-2020

Close liaison with county command teams to ensure COVID secure risk assessments have been completed and used to inform decisions about student station allocations

Communications with the Head of Operational Service Strategy informing of the potential for increase in demand of PPE in certain localities following the commencement of placement

30-Sep-2020

Practice Placement

Consult with CCs and DCCs 30-Sep-2020

30



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Policy in place to establish and identify stations where risk is high therefore requiring the implementation of the 2 points above

Learning and Development Officers have a program in place to practically assess all students to IOSH Manual Handling standards. Matching the standard of all trust employees on induction

Exploration by partner universities around moving to the model described by Plymouth for the summative assessment for students by practice educators therefore aiding with the current challenges faced with capacity

30-Sep-2020

Students must complete all online training (including mandatory moving and handling online theory) as pre-placement preparation, provided by the universities. This is reaffirmed within the work place agreement held with each partner university

Reduce capacity through the rotation of students in placement throughout the block which would impact student placement time e.g. 30 students 6 week block may become 15 students doing 3 weeks

30-Sep-2020

Communication has gone out to all

Students to not wear SWAST identifiable uniform and to

31-Jul-2020

31



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

university students /mentors and operational management teams to ensure students are only out in placement during agreed placement blocks

instead wear clothing that meets the Uniform policy regulations

PPE guidance is held within the Practice Placement Policy and is issued to all students and universities

For students who currently wear uniform tighter controls should be enforced. This is they should not wear the uniform at any other times other than when on placement with SWAST

31-Jul-2020

University emergency contact details have been added to the SWAST on-call directory (July 2019)

Further exploration around the honorary contract for students and the death in service payment while on placement

30-Sep-2020

Security Policy in place

HEI’s own risk assessment for the students and any further requirements for the students conveyed to the PPCs for action if required

30-Sep-2020

All students receive occupational health input to SWASFT standard from the universities

Placement coordinators to manage and monitor that all ID cards for mid-course leavers/suspensions and end of course are deactivated by HR

31-Jul-2020

32



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Close contact training and assessment to include the use of PPE as per current SWAST guidelines

Practice Placement Coordinators to ensure all cards are destroyed and deactivated at the end of a course

31-Jul-2020

Document for Working safely during COVID-19 in Ambulance Service non-clinical areas

ROC and HR contacted and work ongoing to ensure that emergency NOK details are recorded for each of the students on GRS

30-Sep-2020

Review station capacity and move students where necessary

30-Sep-2020

SWAST placement team to recall any unused uniform from Universities and dispose as per Uniform Policy

31-Jul-2020

Uniform Policy to be updated 31-Jul-2020

Universities to contact HR services immediately to deactivate a proximity/ID card for students who are removed/suspended from a course before completion

31-Jul-2020

Working with HEE and HEI’s to establish new ways and models of practice placement through multi-professional/multi-establishment meetings involving programme and

30-Sep-2020

33



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

department leads and AHP placement professionals

Trust Flu Programme 2020/2021

Risk associated with the implementation of 2020/21 Influenza vaccination campaign in SWASFT.


Medicines Management and Infection Prevention and Control Policies in place

16

28-Aug-2020

6

Delivery statements made in advance by supplier to be collated by procurement and sent to Charlotte for assurance

31-Mar-2021

Communications team involvement, with the use of posters, Bulletin, social media, CBM platforms and local MDT updates

Identify non vulnerable staff who will be able to safely provide vaccine/ clinics wearing PPE

30-Sep-2020

National guidance and FAQs in place

Communications to include this information in campaign literature/ posters

30-Sep-2020

Contingency planning for reduction in staff in all areas of the Trust

Discussions on the transfers of severely ill or immunosuppressed patients, to travel with a crew who have been vaccinated

30-Sep-2020

Overall project plan in place and necessary project controls developed by project manager to ensure line of sight

Improve hand hygiene and basic Infection control measures on social media and through the bulletin

31-Mar-2021

Operations local vaccination leads, plan to ensure all staff are offered a

34



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

vaccine and documentation is captured including refusals

Reporting routines and dashboard agreed before start of programme including single source of reporting of data

Operations flu delivery resources changed to be coordinated by CCCs in the same vein as Swabbing and Anti-body testing schemes

Support from South West PHE through stakeholder meetings and conference calls

Social distancing measures to be put in place for those waiting to be vaccinated

Clinician ECG Recognition

The potential for new SWASFT staff to misinterpret


Staff working on RRVs (and DCAs in Cornwall) have an ECG device with computer

15

15-May-2020

8

Identify the current training around ECGs required for Private Providers and ensure that all clinicians within Private Providers are trained

31-Aug-2020

35



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

ECGs due to the lack of a national standard which could lead to an unsafe non-conveyance with the potential to impact on patient safety.

interpretation to support clinician interpretation

to SWASFT recognition standards

ECG interpretation related to STEMIs on development day 2018/19

Develop an ECG competency package on ESR every two years which is mandatory for all clinical staff to undertake

31-Mar-2021

Clinical Lead has delivered training session on arrhythmias to the Learning and Development Officers

Develop an ECG support tool to be implemented in ECS2 to assist with ECG interpretation while computer interpretation is not widely available

31-Jul-2020

CPD package in place

Review the potential impact on increasing validation within these groups on the Clinical Hub & Clinical Validation Process

30-Sep-2020

Partner universities have been written to asking for assurance around the Trust’s recognition standards

Identify the current training needs amongst Hub Clinicians and Clinical Validators to ensure clinicians are appropriately trained to interpret ECGs

30-Sep-2020

Trust induction for 2019/20 includes ECG session from development day 2018/19 around STEMIs

36



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

HCPC registration (for paramedics) and training records are viewed

All nurses joining the Trust on the Ambulance Nurse pathway are being provided with an intensive training/ conversion course. 1 day of dedicated ECG training is being provided on the Ambulance Nurse course by the Trust Cardiac Lead.

Ambulance Nurses will need to validate as with an NQP for a 6 month period

Potential for unrecognis-ed misplacement or displace-ment of Endotrach-eal Tubes

Potential for the misplacement or displacement of endotracheal tubes during intubation which goes unrecognised and therefore


Non intubating registered clinicians (NIRCS) will not be intubating for SWASFT.

15

15-May-2020


completed

Revised ETCO2, airways and resuscitation clinical guidelines published in December 2018 with a more robust section on the

37



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

impacts on clinical care and patient safety, affecting patient outcome.

mandatory nature of capnography.

Application of the National DCR Table Escalation Levels, with Protocol 36

Application of the National DCR Table Escalation Levels, with Protocol 36.


Use of Protocol 36 (and the escalation level of triage) will be decided at national level

15

04-Aug-2020

3

Continue to review and progress all options to maximise clinical support capacity

31-Oct-2020

EMDs can refer for clinical review if there is a potential cause for concern

Follow national guidance and monitor impact

31-Oct-2020

The EMD can override the No Send instruction if there is significant cause for concern

Seek national direction for hazards 2 and 3 and consider implementation of local workaround

07-Aug-2020

The incidents are referred to an alternative clinical service so the patient will still receive a clinical assessment (and can be referred back to 999 if required)

Review of COVID-19 Clinical Datixes

31-Oct-2020

The national datasets are regularly reviewed

38



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

and any changes go through formal governance process. Any identified concerns can be escalated

Trusts have the ability to respond higher to specific codes if there is significant cause for concern

EMDs will continue to use the EIDS (Emerging Infectious Diseases) tool on all calls not triaged through Protocol 36

Additional questioning will support appropriate response at subsequent points of patient’s journey

Support from LDOs and the Senior Clinical Team

Use of PPE is now standard practice

39



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

C3 CAD Failure and effect on service delivery

C3 CAD Failure will affect service delivery. This can be a full unplanned outage or in the form of system slow-down.


Business Continuity Plans and Processes in place

15

28-Aug-2020

15

Produce retrospective card entry guidance document

31-Oct-2020

Telephone link established between the 2 Hubs in case calls need to be passed to other dispatch areas

Test High Availability (CAD HA) Function

31-Oct-2020

EMDs take details on card and runners are put in place to deliver these to the relevant Dispatcher as soon as possible

Review and Schedule failover fall-back testing

31-Oct-2020

Quality Control checks by a designated Clinician prior to the card going to the Dispatcher, which identifies if a Hub Clinician can provide the appropriate response

Engagement with MIS CAD Supplier to reduce risk of unplanned failures

31-Oct-2020

EMDs have standalone Pro-QA to continue triage (via Admin PC)

Dispatchers can contact crews via

40



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

radio or telephone

General Broadcast is an option to ask crews who is closest

Dispatch specialists available to assist with locating/assigning responders, HEMS, HART etc.

EMD Training Guide: ‘Completing CAD System Shutdown Cards, using ProQA’

Use of additional desk space by Dispatchers, available specifically for fall-back scenarios

Cross-checks with cards and any incomplete incident record on the CAD at the time of failure using information printed from fall back guardian at the point of CAD failure

On-call rota has 3 members of staff; 2

41



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

are trained in CAD specifically

999 Non-Clinical Call Audit Compliance

Failure to meet non-clinical call audit compliance in 999 could compromise patient safety and the requirements of the licence. The potential impact could be: • The potential for the advice provided to be sub optimal; • The possibility that the quality of a member of staff’s performance may not be identified and therefore not addressed; within a timely


Monitoring and support from the Academy

15

27-Aug-2020

9

Review Establishment Levels in line with Core EMD staffing levels

03-Dec-2020

The Academy have notified that there is exemption during the COVID-19 response

Use the Reviewer Comparison Tool to manage consistency and performance of Auditors

03-Dec-2020

Clinical Hub Quality Review Group meets monthly and reviews Audit performance and learning

Establish regular levelling sessions supported by the Academy

03-Dec-2020

Senior Clinical Hub Management to monitor call volume trends, considering any requirements for additional auditors

Establishment of Quality Meeting Structure with a working group to report on trends, protocol review and staff on action plans and monitor support for staff and their performance

42



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

manner with a risk to patients; • A breach of the licencing requirements could compromise the Trust's position and reputation.

Levelling exercises

Patient Safety Team to review and only request audits where the investigation directly relates to the taking of the emergency call/s or highly significant patient safety concern

Focus on randoms (as per license requirement), new starters and staff on red level action plans

Revised Audit Policy implemented January 2020

Aqua 7 and new Performance standard reporting (June 2019) allows the Trust to identify EMDs that fall below the Trust and Individual performance thresholds

Additional shifts offered available to EMD Team

43



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Leaders (who are audit trained)

Frequent Caller Team Record Manage-ment

Should the Trust have an ineffective frequent caller record management process this would affect the Trust's duty to protect vulnerable adults resulting in a breach of safeguarding legislation.


Administration Assistant in post to support data management

15

28-Aug-2020

8


01-Nov-2020

Warning Markers on C3 will alert Hub staff to safe ways to triage following retrospective reviews of clinical need and level of clinical risk

As a Microsoft Product, Access has standard back-up

Timely resolutions from IT Service Desk

Access restricted to Frequent Caller Team and Hub Clinicians

Requirement Specification signed-off by the Frequent Caller Management Team

A dummy system will be provided for testing by the team prior to final sign-off

44



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Email communication from CSD to Frequent Caller Team about updates when unable to make amendments to the profile

LowCode, Manchester Triage System and Summary Care Record (+ Additional Information) in place to support clinical assessments for all patients

Use of the Microsoft Access Database was ceased on 25/08/2020

Trust Vehicle Security

Lack of security of Trust vehicles could impact upon patient, public and staff safety, Trust performance


CCTV Management Process

15

17-Aug-2020

10

Review of security arrangements by external consultant

30-Sep-2020

Process for selling Trust vehicles

Vehicle locking arrangements in place

Vehicle tracking

45



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

and financials.

devices

Health and Safety undertake observations of vehicles at Emergency Departments

Trust Security Policy in place

Health, Safety and Security Department carry out workplace reviews

SWAST has Accredited Security Management Specialists in place

Bulletin articles relating to security standards

County Commanders, Deputy County Commanders, Operation Officers and County Business Managers have attended training days and received information, instruction and training on Security

46



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

of Sites, Vehicles and Drugs

Front line staff are taught Conflict resolution training, and break away training

Incidents are reported to Line Manager/Duty Officer, Police, Silver Commander and the Trust via incident reporting system

Trust Control of Drugs Policy in place

All controlled drugs have to be signed in/out and this is witnessed by a fellow crew mate

On stations, vehicle keys are kept in key safes, during shifts, the keys are kept on the a member of crew, this information is being cascaded out via training

Radios can be stung to stop them

47



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

receiving any information

Security Working Group with Project Manager in place

Terrorist Activity

The risk of a terrorist attack on the SWASFT 5 which could result in a serious effect on service delivery, staff harm and a loss of Trust infrastructure and vehicles.


Trust’s policy on Prevent (incorporated in the Trust’s safeguarding policy)

15

30-Aug-2020

15

Ongoing multiagency planning, training and exercising and compliance with requirements under the CCA 2004

31-Mar-2021

Escalation, Business Continuity, Incident Response, CBRNe, Mass Casualty Distribution and Extreme Threat Plans in place

Cyber security education programme to be introduced as mandatory training from March 2021

31-Mar-2021

On-call Command Team and National Interagency Liaison Officer (NILO) available 24/7

IM&T Managers to receive Command and Control awareness to prepare them for working in a Trust ICC

31-Dec-2020

Vehicle Decommissioning process

National review to increase HART personnel numbers

01-Mar-2021

Security and Management Strategy, Vehicle Security Policy and Suspicious Packages Policy in place

Ongoing compliance with NHSE Core Standards and NARU Interoperability Standards

31-Mar-2021

48



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Lessons Identified Policy to ensure that the Trust captures and learns from incidents and exercises

Insider threat exercise to be planned between EPRR and Safeguarding

31-Dec-2020

Run, Hide, Tell and IOR (Remove, remove, remove) e-learning and awareness for all staff

Ongoing recruitment for additional MTFA Responders and SORT to ensure the 24/7 capability

31-Mar-2021

Specialist responders – HART, MTA, SORT available on duty to respond to any incidents

Further work is required into relation to access control and lockdown planning

31-Aug-2020

Human Resources procedures for supporting staff and utilisation of Peer Supporters and individuals who have received Mental First Aid Training to provide staff support

National Mutual Aid arrangements to request front line or command support to manage the incident from other Ambulance

49



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Services via the NACC

The Trust's Recovery from the Response to the COVID-19 Pandemic

The Trust Recovery from the response to the COVID-19 Pandemic.


Recovery Coordinating Group reporting directly into Trust Strategic call and overseen by Chief Executive is overseeing activity

15

30-Jul-2020

12

Detailed review of actions that need to be taken to restore ROC business as usual activity

31-Oct-2020

Clinical sub-group includes patient safety representation

COVID-19 Recovery Plan - Quality & Clinical Care Directorate

31-Mar-2021

County Commanders and DCCs have been advised to oversee Datix reports being submitted in their area in order to highlight any patient safety issues

Tactical Actions COVID-19 Recovery Plan - Quality & Clinical Care Directorate

31-Mar-2021

RLI process in place with Patient Safety team receiving all Datix reports

Embed the County Coordination Centre functions into new BAU

31-Oct-2020

Weekly Trust RMG meeting

Continual review of progress by Chief Executive

31-Dec-2020

24/7 Command Team in place

Development of Mark II Fiat DCA fleet

31-Dec-2020

50



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Incident Coordination Centre 24/7 and Trust Gold Cell staffed daily from 08:00--18:00

Trust Escalation Plan and COVID-19 Surge Plan in place

Development of a Volunteering Strategy

30-Sep-2020

Daily Strategic Call

Requirement for development of an Annual Resilience Plan

30-Sep-2020

Regular review of actions by Directors and Heads of Department led by the Executive Director of Operations

Consider 7 day fleet and logistics cover

30-Sep-2020

Weekly Recovery Coordinating Group in place

Continued development of Trust Surge Plan and no-send position

30-Sep-2020

People and Resourcing / Fleet and Logistics Constant Care subgroups in place

Continue contracting and operational planning 2020/21

31-Oct-2020

Staying Well Service and Peer Support Network in place

Continued management of BAU and COVID-19 financial regime

31-Oct-2020

Mental Health First Aiders throughout

Develop plan for NHS Charities Together Grant

31-Oct-2020

51



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Trust allocations (South Western Ambulance Charity)

Trust scheme of delegation sets out the approval of business cases and changes

Review finance structure and governance to ensure is fit for purpose

31-Oct-2020

Review of budgetary performance to identify changes in cost base and take corrective action where necessary

Clear direction from Chief Executives in relation to priorities

Regular contact with Critical Care network

Finance engagement with NHSE/I and commissioners to reach agreement on investment funding included within Interim Financial Regime

CQC preparations overseen by Quality Support Manager and the Deputy Director of

52



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Quality

The Trust has interim arrangements in place to hold additional volume. Free use of new warehouse in Exeter (as a gift to the NHS for a limited duration) and use of vacant buildings on the Chippenham estate

New arrangement for stores ordering to send order direct to counties designated sites, through amended stores ordering process and stores/logistics staff and vehicle under direction of CCCs

Existing Target Operating Model Strategic Outline Case approved at Trust Board. Amended planning assumptions presented to Board Seminar February 2020. Refresh of

53



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

outline case commencing to review new arrangements and learning from COVID

Routine programmes of activity with regular reporting to the Strategic Estates Sub-Group, Bi-monthly Strategic Estates Board, Health and Safety Committee which reports monitoring and escalation actions as and when required

Major IT System Failure

The risk of a major IT system failure, which cannot be redressed via the Trust hardware/software maintenance contracts. This could impact on the Clinical Hubs,

Executive Director of IM&T

UPS and generator back up to both HQ and St James ensure continuous power during a power cut

15

11-Aug-2020

10

Hyper V2 project to be completed, allowing servers to be virtualised across the SWAST estate increasing redundancy and resilience

31-Mar-2021

Card system can be used by the Hubs in the event of an outage (with standalone non-clinical Triage via admin PC)

4Net have been engaged to deliver a new telephony system, which will likely be rolled out in around 18 months’ time

31-Dec-2021

Staff can use Skype, landline or

All Windows 2008 servers and legacy domains to be

31-Dec-2020

54



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Telephony and/or Radio or Mobile data and may lead to a potential business continuity risk (including access to resources) in A&E or support services.

mobile phones to send information between individuals and small groups

decommissioned and remaining legacy systems to be moved to supported operating systems

Service level agreement with BT in place

CAD High Availability should be attempted again once the system has been upgraded

31-Dec-2020

On-call system backed up by supplier support

Door access system needs to be updated across the Trust

31-Oct-2020

The SWAST mail system is resilient, if your mailbox fails on one site, a copy will become active on a server on the other site

Email system to be upgraded to Clearswift, which will provide sophisticated filtering and security. Clearswift is cloud-based

31-Dec-2020

SQL databases are protected by Trust firewalls

Latest release of the CAD system to be installed

20-Sep-2020

All Trust servers are scanned for security issues via Nessus

Network team to be brought up to establishment level to enhance resilience and ability to complete project work

31-Aug-2020

Doors will work on battery power for a while assuming the battery is healthy (currently there is no replacement programme, so this cannot be guaranteed)

Review of the Service Catalogue to ensure all services are classified in accordance with legal requirements and organisational priority

30-Sep-2020

55



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

CAD system should be reviewed from technical, training, cost and performance angles and a decision made about contract renewal

31-Dec-2021

Confidentiality, Integrity and Availability of Information

These are the 3 pillars of data security, and must be kept in balance for the Trust to remain compliant under GDPR and with NHS guidelines.


SOP on Secure Transfers of Information available on IG Directorate page of the Intranet and promoted in the Bulletin

15

11-Aug-2020

12

DSPT evidence to be collated from department leads and information asset owners

31-Mar-2021

IG training module available through e-learning for health and My ESR

Leavers SOP to be created to capture the handover and deactivation of all SWAST IT equipment and access

31-Aug-2020

Regular monitoring of adverse incidents

Legacy systems to be reviewed by IM&T to support information security provisions

31-Mar-2021

Systems are backed up on shared drive with the ability for technical recovery

Maintain Information Governance training and education programme

31-Mar-2021

Ongoing IG education and communication

Mandatory training is a requirement of annual appraisals and completion must be demonstrated by new staff from April 2019 to advance through pay progression points. Existing

30-Apr-2021

56



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

staff will be subject to this procedure from April 2021

Technical solutions to prevent virus, corruptions etc. to electronic systems

Monitor staff compliance with online IG training module

30-Sep-2020

Managers and staff are advised of their IG responsibilities through a number of channels for their responsibility of accessing and managing patient and corporate information

Review departmental data flows

31-Mar-2021

Policies on Acceptable Use of IM&T Services, Access & Disclosure of Personal and Sensitive Information, Corporate Records Management and Clinical Records Management

Review of Archiving and Confidential Waste Destruction for Paper Records (IG Department reference: IG01)

30-Sep-2020

Freedom of Information and Subject Access Request SOP

Scheduled review of the Subject Access Request Standard Operating Procedure (IG Document Ref IG06)

30-Sep-2020

Assurance of

57



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

suppliers is an evidence requirement captured as part of the submission of the Data Security and Protection Toolkit

Ongoing review of suppliers by Procurement to demonstrate GDPR compliance

Cyber Security

The threat of Trust systems, service or data being breached, causing a loss of one or all of the above.


Regular server patching takes place

15

15-Jul-2020

12

Reduce generic CAD accounts, with individual sign in where possible

30-Sep-2020

IG training, including elements of cyber security are mandatory

ATP: Continued on-boarding of the IT Estate to Windows Advanced Threat Protection to meet NHS Digital standards

31-Aug-2020

24/7 on-call system in place to resolve issues

Cyber security education needs to be part of the Trust’s mandatory training. This should be progressed alongside Bulletin articles highlighting threats as they appear. Advice on working safely from home should be included in this programme

31-Mar-2021

IT accounts and key cards are removed as soon as staff leave the

Decommission old domains 30-Sep-2020

58



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Trust

The SWAST network is protected by firewalls

E-mail, Clearswift: The Trust have purchased a sophisticated email filtering service that will eventually replace the current Sophos system

30-Jun-2020

NHS Digital has a warning system in place, which informs Trusts of imminent threats and requires that they are actioned within 14 days

Firmware Patching: Patching for user devices and servers is now working well, but firmware patching still needs to be implemented

31-Mar-2021

The Trust has deployed a geographic component so that non-UK traffic is dropped, thus mitigating any attacks from outside of the UK

Hyper V2: This project will improve overall IT resilience by increasing the virtualization of servers across the Trust

31-Mar-2021

Anti-virus software is deployed to as much of the IT estate as possible

Mobile Iron: The new NMA Lite app uses Mobile Iron as its Mobile Device Management system, it is planned to roll this out to all relevant Trust devices

31-Dec-2020

IT Security Policy in place

Review of the Service Catalogue to ensure all services are classified in accordance with legal

30-Sep-2020

59



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

requirements and organisational priority

Backups are scheduled regularly

Review SC clearance requirements for both staff and contractors with direct access to Trust servers

31-Dec-2020

Management and welfare support from within the team

SIEM: A SIEM solution has been deployed to some servers, but this needs to be expanded to provide real utility

31-Dec-2020

DA system in place to ensure safe working away from the office

Telephony: DDOS protection will be improved when the Trust switches from ISDN30 to SIP circuits. The telephony upgrade project is due to take around 18 months

31-Dec-2021

The Trust needs to deploy a third party management tool, such as Cyber Ark, to ensure that all suppliers connect in a managed way and pay due respect to the Trust’s security policies

30-Sep-2020

Third Parties: Third Parties need to be made to access Trust systems securely and using predefined Trust standards rather than supplier standards

31-Dec-2020

ZScaler Review: Zscaler is used to control web traffic on the Trust network, since it was brought in during 2019,

31-Jul-2020

60



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

a review needs to take place to maximize its utility

Trust Web Site: The Trust web site needs an increased level of technical management IF the Trust does not wish to accept the reputational risk of the protracted web site outage

31-Jul-2020

Locating and Accessing Patients

Failure to locate or access a patient in a timely manner may cause a delay to the delivery of care and has the potential to result in serious harm or death.


200 Thorcom sat nav units purchased and installed

15

11-Aug-2020

10

Add to the new Management of Third and Fourth Party Calls Procedure that EMDs, on calling back the First or Second Caller, should verify the address is correct

01-Sep-2020

Address Base Premium replaced Address Base with the deployment of the new CAD

Terrafix auto-update functionality to be trialled at Bristol station

31-May-2020

Staff can ask the Hub for directions

Develop a monitored process to ensure CAD mapping and Gazetteer are updated quarterly

31-May-2020

Gazetteer is manually updated when SWAST is informed of changes made to addresses or new properties

Ensure Terrafix maps are updated under the current system at least once every 12 months

31-Oct-2020

HART crews can be dispatched to remote locations if

61



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

available where patients may be difficult to find. HART teams have additional equipment such as thermal imaging, and night vision cameras and can request access to Police drone if available

Where patients are in remote locations Police and/or Search & Rescue Organisations may be able to support searches

Map books should be available on vehicles - as a fall back

What 3 Words has been added to the CAD

Thorcom vehicles are updated by SWAST mechanics during 6 weekly services. Records for this are available from Fleet

Protocols in place

62



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

for EMDs to give pre-arrival instructions, designed to help crews find patients; these include opening the front door of the property by the caller

Location Search Training

Standard MPDS requirement to verify an address

Any additional information volunteered by a caller should be entered into the notepad (e.g. near the bridge)

Door/System codes can be entered onto the C3 CAD as a warning marker; dispatch process to pass these through to the crew if available

Financial Position (Operations Directorate)

Potential adverse financial variances in the A&E


Budget arrangements in place

15

10-Sep-2020

15

Agree Resourcing profile for 2020/21 including Agency

31-Jul-2020

Dedicated management

Ongoing contract negotiations with

30-Sep-2020

63



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

Service line impacting on the overall financial position of the Trust. Possible variance due to commissioner affordability, resourcing pressures, increased cost pressures, ability to identify recurrent cost improvements and increases in demand

accountant - revising arrangements to strengthen

Commissioners for 2020/21 (in support of the ED Finance)

Regular meetings between the Deputy Director of Finance, Executive Director of Operations, Deputy Director of Operations and the Head of Resourcing to review the resourcing forecast

Agree People Plan 2 investment - Phase 2 and 3

31-Jul-2020

Escalation process in place

Operational Resources (A&E)

Not enough operational resources available (core and other) to meet demand. The risk score is


Centralisation of ROC and GRS 15

10-Sep-2020


completed

Escalation Plan

Ongoing recruitment against agreed trajectory matching the People Plan

Provision of

64



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

dependent upon ongoing negotiations with Commissioners as part of the Joint Plan.

additional resourcing through third parties, agencies, bank and overtime

Weekly RMG meetings and regular resourcing review with Deputy Director of Finance and Head of Resourcing

Workforce Plan

Resourcing to ORH Levels (core) and therefore managing to 100%

Monitoring against ORH deliverable targets

New reports on Tableau monitor vehicle and staff hours against plan

Service Change and the impact on the Ambulance Service

Changes to Health Services (as a result of service change arising from a change in location of services, a


Engagement with Commissioners to produce Joint Transition Plan

15

10-Sep-2020

12

Deputy Director of Clinical Care and Clinical team members to continue to monitor service change using clinical team methodology for estimating and assessing the impact of service change. Operations support through attendance at A&E Delivery Boards

31-Mar-2021

65



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

change in the journey time, a change in the volume of incidents or other activity, changes in patient pathways etc., e.g. Weston ED changes, Bournemouth and Poole changes) will impact on the Trust including the availability of resources to respond safely, patient journey times (affecting patient safety and experience), staff experience, performance and finances. The forecast risk score

County Commanders attend A&E Delivery Boards

Methodology developed for estimating and assessing the impact of service change by the Medical Directorate

Ongoing communications with Commissioners regarding service changes

Trust has agreed a set of principles for service change which have been in place since July 2017

New County Commander structure gives additional oversight of potential and confirmed upcoming service changes

66



Date Risk Reviewed

Current Risk Matrix

Risk Trend

Target Score

Action Status


Due Date

varies according to adherence to the risk controls locally by external organisations.

Paper 16


Page 1 of 2


Name of Meeting Audit and Assurance Committee

Date 10 September 2020

Committee Chair Paul Love

Members Present Paul Love, Non Executive Director (PL), Martin Hollaway, Non Executive Director (MH), Venessa James, Non Executive Director (VJ)

Apologies None

In attendance

Tim Bishop, Executive Director of IM&T (TB), Jonathan James, Acting Executive Director of Finance (JJ), Jenny Winslade, Executive Director of Quality and Clinical Care (JW), Jonathan Brown (JB) – External Audit, KPMG, Duncan Laird (DL) – External Audit, KPMG, Heather Ancient (HA) – Internal Audit, PWC, Rosie Nightingale (RN) – Internal Audit, PWC Tony Hall (TH)- Local Counter Fraud, TIAA

Guests in attendance

Kevin Pointer (KP), Information Governance Manager Marty McAuley (MM), Trust Secretary

Number of items on agenda

16

Items which were approved:

Minutes and Action Point Register;

Amendment to Internal Audit Programme, 2020-21;

Quality and Risk Assurance Group Terms of Reference;

Guide to Policy and Strategy Development;

IT Business Continuity and Disaster Recovery Policy;

Corporate Records Management Policy;

Registration Authority Policy;

Personal and Sensitive Information – Access and Disclosure Policy;

Privacy Notices – Patients and Employees Items for Assurance:

Internal Audit Progress Report – Assurance was taken from the report containing activities that had been undertaken by Internal Audit. The Committee considered and agreed two additional audit reviews.

Internal Audit Review into Financial Governance – A detailed discussion was held on the findings of the review into the Trust’s Financial Governance which had been rated low risk and contained two audit recommendations. Significant assurance was


Page 2 of 2

taken from the robust systems and controls in place and in respect to the actions being taken in response to the audit recommendations.

External Audit Progress Report and Technical Update – A report into the activities undertaken by External Audit since the last Committee meeting was presented and assurance taken. It was noted that External Audit had concluded its audit into the Trust’s 2019-20 Charitable Accounts which are due to be presented to the Public Trust Board of Directors on 24 September 2020.

LCFS Counter Fraud Update– The Committee received the LCFS progress report for assurance. The Committee considered the management responses made in respect of the LCFS proactive reviews undertaken and significant assurance was taken from the actions and the proactive work taking place. It was agreed that a further report on progress in relation to the actions will be provided to the Committee in December 2020.

Significant and Moderate Level Risk Registers – The Committee was presented with a report detailing the significant and moderate level risk registers. There were two risks brought to the Committee’s attention in relation to an increased risk score of 20 in respect to Incident Stacking and Hospital Handovers. Assurance was provided of a further report being presented to the Trust Board of Directors in September in respect of risks rated 20 and above. The Committee took assurance that both elements would also be picked up as part of the planned A&E internal audit. A briefing on progress and discussions being held in relation to the Trust risk structure was shared and assurance taken. The Committee recommended a review of the areas be considered by the Quality Committee in November and a report for assurance presented to the Audit and Assurance Committee in December 2020.

Quality and Risk Assurance Group Assurance Report – A report detailing a summary of the risk assessments and Quality and Equality Impact Assessments (QEIA)s reviewed by the QRAG was presented. Further work in relation to the development of QEIAs was noted and assurance taken.

Information Governance Report April to August 2020 – The Committee considered and took assurance from a report into the Information Governance activities delivered by the Trust.

The Service Desk Deep Dive – An update on progress made following the Trust’s deep dive into its Service Desk was provided and assurance taken.

Cyber Risk and Security – A report detailing the actions being taken by the Trust in response to Cyber risk and security was presented. The Committee took assurance from the report and the controls in place for testing. It was agreed that the matter would be considered for revisiting as part of the 2021/21 Audit Plan.

Paper 17


Page 1 of 1



Paper Title: Summary Report – Suspected Coronavirus (COVID-19) in SWASFT March-May 2020

Prepared by: Katherine McNee, Clinical Quality Improvement Paramedic

Presented by: Jennifer Winslade, Executive Director of Quality and Clinical Care

CQC Domain:

Safe Effective Caring Responsive


Action: Information

Recommendation: The Trust Board of Directors is asked note the contents of this summary for information.

Forward Look:

The Research, Audit and Improvement Team will consider undertaking a re – audit of suspected coronavirus cases at such time as there is an escalation in case numbers. Routine daily reporting of case numbers will continue. Summary Report – Suspected Coronavirus (COVID-19) in SWASFT March-May 2020 was seen by the Quality Committee on 13 August 2020 and is now presented to the Trust Board


Page 2 of 10

Summary Report – Suspected Coronavirus (COVID-19) in SWASFT March-May 2020

1. Introduction

1.1 In late 2019, a novel coronavirus was identified following the emergence of a new illness with typical symptoms of fever and cough, and in some people causing shortness of breath and breathing difficulties. Coronavirus Disease 2019 (COVID-19) is Zoonotic, is believed to have emerged in bats and has now evolved and been transmitted to humans. Since its discovery, the transmission of COVID-19 is now widespread in many countries, including the UK. Transmission of the virus is usually via respiratory droplets from an infected person.

1.2 The primary symptoms of suspected COVID-19 infection include a fever, a new, continuous cough or anosmia. However, many new symptoms associated with the disease have been reported such as sore throat, hoarse voice, shortness of breath and nasal congestion as well as severe respiratory distress (SRD). The clinical definition of COVID-19 has changed as the understanding of the virus has evolved. However, the most recent definition, released on 18th May 2020 will be the definition by which this summary uses, as shown below:

Acute respiratory distress syndrome (ARDS)

OR

A high temperature (of 37.8⁰C or higher)

OR

A new persistent cough

OR

A loss of, or change in normal sense of taste or smell (anosmia)

1.3 Suspected cases of COVID-19 were audited throughout March, April and May 2020. This analysis considered not only the number of cases, but patient demographics, clinical presentation, symptom onset and severity. In total, 11,352 patient records were analysed (4,458 in March, 5,149 in April, and 1,745 May).


Page 3 of 10

2 Summary of Audit Results

2.1 Number of Suspected Cases of COVID-19 March-May 2020

Figure 1: Number of Suspected COVID-19 Cases March-May 2020

Figure 1 shows the number of suspected cases encountered by SWASFT increased sharply to a peak of 334 cases on 26/03/20, since then, the numbers of suspected cases has gradually reduced to 34 on 31/05/20.

Reporting on suspected COVID-19 was improved on 18/04/20 following the introduction of the clinical condition code “suspected COVID-19” onto the ePCR.

The clinical definition of COVID-19 changed twice between March and May, first on 09/04/20 to include a comprehensive list of clinical symptoms in addition to cough, fever and acute respiratory distress syndrome (ARDS), and again on 18/05/20 removing these additional symptoms and adding anosmia (the loss of, or change in the sense of smell or taste).

Between March and May 2020 a total of 11,352 patients were treated by SWASFT clinicians with a provisional diagnosis of suspected COVID-19.

5

334

34

0

50

100

150

200

250

300

350

400

WHO declare

COVID-19 Pandemic 09/03/20

UK lockdown Begins

23/03/20

UK Lockdown

begins easing

24/05/20


Page 4 of 10

2.2 Patient Age

Patient age ranged from between a few hours old to 106 years. The distribution of ages can be seen in Figure 2.

Figure 2: Distribution of patient ages with suspected COVID-19 between March and May 2020

2.3 Clinical Symptoms

Patients presented with an array of clinical symptoms, ranging from a mild fever to severe breathing difficulties. As ARDS is not possible to diagnose in the pre-hospital environment, data was mapped to a criteria named “severe respiratory distress” (SRD) and was defined as:

A high respiratory rate >25 breaths per minute

A low oxygen saturation:

o ≤93% in patients without COPD

o ≤87% in patients with COPD

There was almost an even split between severe symptoms such as SRD and milder symptoms (fever, cough etc.) as shown in Figure 3.

Figure 3: Split between SRD and milder symptoms such as fever, cough or other symptoms

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Under 1 1 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 andover

Notrecorded

49.51%

2.41% 5.00% 3.77%

5.60%

3.96%

13.80%

15.95%

SRD Fever Cough

Other Symptoms Fever and Cough Fever and Other symptoms

Cough and other Symptoms Fever, cough and other symptoms


Page 5 of 10

2.4 Symptom Onset to Contact with SWASFT

Figure 4 shows the time taken for a patient initially developing symptoms of suspected COVID-19 and subsequently calling for help varied between 1 day (day of onset) and 3 months.

The majority of patients called for help (either through 999 or 111 diverted to 999) between day 1 and 2 of symptom onset. There was a peak at 7 days, which correlates with the 7-day isolation period mandated by the Government, whereby patients may be calling as their symptoms have not resolved, or have gotten worse.

Figure 4: Distribution of onset time in days to contact with SWASFT

0

500

1000

1500

2000

2500


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2.5 NEWS2

NEWS2 can help to identify patients who are at risk of deteriorating. The NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice. NEWS2 can only be used in adult patients aged ≥18 years.

Figure 5: Split of NEWS2 aggregate Scores

Just under half of patients with a provisional diagnosis of suspected COVID-19 presented with a low or low-medium NEWS2, suggesting an unlikely deterioration in their condition.

2.6 Conveyance

The number of patients conveyed to the emergency department between March-May 2020 with suspected COVID-19 symptoms is shown in Figure 6.

Figure 6: Number of patients with suspected COVID-19 conveyed to hospital or left on scene March-May 2020

46.07%

3.74% 15.19%

35.01%

Low Clinical Risk 0-4 Low-Medium Clinical Risk (red score) Medium Clinical Risk 5-6 High Clinical Risk ≥7

6085, 53.60%

5267, 46.40%

Conveyed to Hosptial Discharged on Scene

NEWS2 Clinical Risk

Aggregate score 0-4 Low

Red Score of 3 in any individual parameter Low-medium

Aggregate score 5-6 Medium

Aggregate score ≥7 High


Page 7 of 10

Although more patients were conveyed to hospital than were discharged on scene, over two-thirds of patients conveyed (n=4155, 68.28%) matched the more serious criteria of SRD suggesting appropriate conveyance.

2.7 CG09: The COVID-19 Clinical Assessment and Management guideline

The COVID-19 Clinical Assessment and Management guideline (CG09) was released to clinical staff via the JRCALC application in late April 2020, providing clinicians with a comprehensive guideline in the assessment and management of patients with suspected COVID-19. This guideline categorised patients into Red, Amber or Green dependent on clinical presentation and observations and signposts onward management of patients.

Compliance with this guideline was assessed in the May 2020 audit. The majority of patients (65.79% n=1071/1628) fell into the red category and were managed appropriately as per CG09, as shown in Figure 7.

A deep dive into the Amber and Red patients that were discharged on scene following symptom resolution was conducted to assess the appropriateness of the decision. Analysis of the patient record, including the HPC and treatment summary free text boxes, as well as the second set of observations shows that all of these patients had a documented improvement in their condition, however, it is not known why the GP, OOH or COVID-19 advice line was not contacted in some cases.


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Figure 7: Flow chart detailing the conveyance decisions of suspected COVID-19 patients from the May 2020 Audit

1704 patients presenting with

suspected COVID-19 aged ≥18

years

76 patients extracted due to incomplete

observations

GREEN

278

80.94%, n=225

discharged on

Scene

19.06%, n=53

Conveyed to

hospital

RED

1071

83.75%, n=897

Conveyed to

hospital

16.25%, n=174

discharged on

Scene

78.31%, n=148

OOH/GP/COVID

-19 Advice Line

Contacted

3.17%, n=6

Refused

Transport

18.52%, n=35

Symptoms

improved after

treatment

80.46%, n=140

OOH/GP/COVID-

19 Advice Line

Contacted

12.07%, n=22

Refused

Transport

7.47%, n=12

Symptoms

improved after

treatment

AMBER

285

33.68%, n=96

Conveyed to

hospital

66.32%, n=189

discharged on

Scene


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3 Summary of Findings

Since its emergence in China in late 2019, COVID-19 has rapidly spread causing a global pandemic with the effects of COVID-19 being felt across the UK since the first reported case in February 2020.

The number of cases of suspected COVID-19 within SWASFT has followed a similar curve to that predicted, with few reported cases until 13/03/2020, then a rapid increase in the number of suspected cases presenting to SWASFT, to a plateau between 27th March and 7th April, followed by a slow decline in cases per day.

The majority of patients encountered by SWASFT clinicians were aged over 21, with peak age group of 51 to 60.

The vast array of symptoms that patients presented with were mapped within the three audits, and can be split into mild to moderate symptoms (fever, cough and anosmia) and severe symptoms (severe respiratory distress). There was almost a 50/50 split between the numbers of patients presenting with mild to moderate symptoms or with SRD.

Patients are still instructed to call 111 if they present with COVID-19 symptoms in order to be triaged and signposted for assessment and treatment. Many of these calls would have been directed to the 999 service based on the information that was passed to the call taker. As the information for this audit was extracted from the ECS reporting tool and not the CAD system, it is not possible to analyse how many of these calls were direct 999 calls or re-directs from 111.

The majority of patients made contact with the SWASFT within 2 days of symptoms presentation. After this, the next peak is at 7 days. It can be argued that this peak could be due to patients adhering to the Government’s advice to self-isolate for 7 days, expecting to make a full recovery in this time, but not becoming worried about the length of time they had been experiencing symptoms. Further small peaks at 10 and 14 days could be associated with increased concern about symptom duration.

Although ARDS cannot be diagnosed in the pre-hospital environment, it is anticipated that the longer a patient experiences symptoms, the more severe the illness. Evidence that suggests that potential ARDS develops at day 8-9 after symptom onset which may account for the small peaks at day 10 and 14.

NEWS2 can help to identify patients who are at risk of deteriorating. The NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice. NEWS2 can only be used in adult patients aged ≥18 years. A Low or Low-Medium clinical risk score suggests that a patient is unlikely to deteriorate rapidly. Just under half of the patients encountered by SWASFT clinicians (≥18 years) were categorised as low or low-medium risk. This finding correlates with the proportion of patients presenting with mild/moderate symptoms, who would be safe to discharge on scene with worsening advice, with or without senior clinical advice (e.g. GP, Respiratory Assessment Unit).

In just over half of cases, the patient was conveyed to hospital. Similarly to NEWS2 and symptom severity, this finding does not appear to be an outlier. However, it is reassuring that although 53.6% of patients, were conveyed to hospital, 68.28% of these patients matched the criteria of SRD which would suggest an appropriate conveyance.

The COVID-19 Clinical Assessment and Management guideline (CG09) was released to clinical staff via the JRCALC application in late April 2020, providing clinicians with a comprehensive guideline in the assessment and management of patients with suspected COVID-19, with particular reference to observations taken and onward management or conveyance of the patient based upon which category (Red, Amber, Green) they fell into. The majority of patients fell into the Red category, which had the highest rate of conveyance of all the groups.


Page 10 of 10

It is apparent that clinicians are following the guideline with regard to conveyance decisions, particularly when the decision is not to convey. In both Amber and Red categories, the majority of patient contacts that were discharged on scene advice had been sought from either a GP, Out of Hours service, COVID-19 advice line or the Respiratory Assessment Unit of the receiving hospital.

A deeper analysis into patients that were discharged on scene without a refusal or seeking advice (Amber n=35, Red n=12), involved analysis of the HPC and treatment summary free text boxes, as well as the second set of observations and revealed that that all of these patients had a documented improvement in their condition, robust worsening advice and were not left on their own following discharge. In addition, conveyance was discussed with all of these patients and although not refused, a holistic decision between crew, patient and family/carers present was made

4 Conclusions

This paper has aimed to provide a summary of the audits conducted throughout March, April and May 2020.

COVID-19 has caused a global pandemic since its emergence in China in late 2019. Within SWASFT, the number of suspected cases reported via ePCR rose exponentially during March, as expected, with the number of suspected cases decreasing over time, as predicted.

Clinical symptoms of patients varied, potentially due to the evolving clinical definition of suspected COVID-19 cases. However, the majority of patients who did not present with SRD symptoms primarily reported symptoms of a persistent cough and/or a fever, which is consistent with all PHE clinical definitions. The addition of anosmia in mid-May showed an increased level of reporting this symptom.

Patients presenting to SWASFT did so predominantly within 7 days of their symptoms emerging. A new finding was a link between and increasing incidence of SRD past 8 days from symptom onset

Compliance with the CG09 is complex; however, it appears conveyance decisions are being made appropriately, following the flow chart embedded within the guideline.

5 Limitations

One of the major limitations of the audits is the inability to confirm either COVID-19 or the incidence of ARDS.

Results of this audit should be viewed with caution due to the existence of differential diagnoses

6 Recommendations

The Trust Board of Directors is asked note the contents of this summary for information.

Katherine McNee

Clinical Quality Improvement Paramedic

Documents

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