Enc 00
MEETING OF THE TRUST BOARD OF
STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST
Wednesday 27 January 2016 at 10.00hrs to 13.15hrs
Brampton Room, Morston House, Newcastle under Lyme
AGENDA
Item
Enc
Description
Time
1.
Verbal
Welcome and Apologies
David Pearson
10.00
2.
Verbal
Questions from Members of the Public
David Pearson
10.05
3.
Verbal
Declarations of Interest
David Pearson
10.10
Minutes of the last Staffordshire and Stoke on Trent Partnership NHS
4.
Enc 01
10.15
Trust Board meeting held on 25 November 2015 and matters arising
David Pearson
5.
Enc 01A
Ambassador for Cultural Change Report
6.
Enc 02
Chief Executive Officer Report
Helene Donnelly
10.25
Stuart Poynor
10.45
Assurance Reports – Chairs of the Quality Governance, Finance
7.
Enc 03
11.00
Investment and Performance, Workforce Matters and Audit Committees
David Pearson, John Scarpello, Andy Talbot and Gary Crowe
Break
11.10
Assurance
8.
Enc 04
Corporate Risk Register
Rose Goodwin
11.20
9.
Enc 05
Safe Nursing Staffing
Rose Goodwin
11.30
10.
Enc 06
Quality Report
Rose Goodwin
11.50
11.
Enc 07
Integrated Performance Report–Month 8
Jonathan Tringham
12.10
12.
Enc 08
Finance Report – Month 8
Jonathan Tringham
12.25
13.
Enc 09
Responsible Officer Medical Revalidation Q3 Report
James Shipman
12.40
14.
Enc 10
Workforce – Partnership Approach
Tina Harkin/Julie Tanner
12.50
Page 1 of 2
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12.55
Any Other Business
15.
Verbal
•
Review of meeting and outcomes
•
Review of risks
David Pearson
lunch
16.
Verbal
Break for lunch
13.00
Date of Next Meeting: Wednesday 24 February 2016, Boardroom 1, Edric
House, Rugeley, WS15 1UW
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REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
01
Subject:
Minutes of the Staffordshire and Stoke on Trent Partnership NHS Trust
Board Meeting on Wednesday 25 November 2015
Strategic Goal:
(tick as applicable)
x
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
x
We will work with users and carers to deliver integrated systems, simply and
effectively
x
Our organisation will develop and deliver sustainable, innovative services that
support independence
x
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
x
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Mr David Pearson, Interim Chairman
Recommendation:
For Approval &
Assurance
x
For Discussion
For Information
PURPOSE OF THE REPORT:
The unapproved draft minutes of the Staffordshire and Stoke on Trent Partnership NHS Trust
Board meeting held on Wednesday 25 November 2015 are enclosed for review and approval.
INTER DEPENDENCIES:
Legal and/or Risk
The Trust Board reviews the outcomes of each meeting and considers
whether any risks should be referred to the Executive Risk Management
Committee for review and reporting onto the Corporate Risk Register.
Clinical
See content of Sub-Committee meeting minutes
Financial
See content of Sub-Committee meeting minutes
HR
See content of Sub-Committee meeting minutes
Staff and Trade
Union involvement
actions
undertaken/planned
See content of Sub-Committee meeting minutes
Social Care
See content of Sub-Committee meeting minutes
Page 1 of 20
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Patient & Public
Involvement
The Patient/Staff story informs the Trust Board of any developments or
improvements to the Services that we provide
Equality Impact
See content of Sub-Committee meeting minutes
Information exempt
from Disclosure
This is a public document
Requirement for
further review
Action arising from the Minutes are tracked and reviewed each month
RECOMMENDATIONS:
The Trust Board is requested to appraise and approve the minutes of the Trust Board Meeting
held on Wednesday 25 November 2015 and to review and discuss progress or further action for
the outstanding actions.
Page 2 of 20
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Meeting of the Trust Board of Directors of
Staffordshire and Stoke on Trent Partnership NHS Trust
Wednesday 27 January 2016
Morston House, The Midway, Newcastle under Lyme, Staffordshire, ST5 1BQ
Overdue
On Target
Action Complete
ACTION TRACKER
Action
Date of
No.
Meeting
Action
Status/
Due Date
2015.890 28 10 15
Deep dive workshop
experience to be set up
on
2015.890 28 10 15
The Medical Director to incorporate
patient and carer experience into the
Clinical Strategy.
27 01 16
2015.892 28 10 15
Assurance to be provided regarding the
reduction in the number of social care
unallocated cases.
27 01 16
Comments (incl. interface with/
reference to another Committee/
Sub Committee/Working Group)
patient 27 01 16
Responsible Officer
RAG
Rating
Head of Service User
and Carer Experience
Medical Director
Complete. This is covered within
the Social Care programme and
updates provided to the QGC
meetings.
Director of Operations
Page 3 of 20
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Action
Date of
No.
Meeting
Action
Status/
Due Date
Comments (incl. interface with/
reference to another Committee/
Sub Committee/Working Group)
Responsible Officer
This was not able to be added to
the Corporate Risk Register due to
timing issues of the Executive Risk
Management Committee. It will be
referred to the Executive Risk
Management Committee for review
on the 14th December
Associate Director of
Quality
RAG
Rating
2015.894 28 10 15
Re-ablement to be added to the
Corporate Risk Register.
27 01 16
2015.910 25 11 15
Weekly briefing to be prepared for NonExecutive Directors to update them on
CQC and any other matters. This
briefing would start in December.
27 01 16
Chief Executive Officer
2015.912 25 11 15
Column to be added to the safer staffing
report to include actual bed numbers on
wards
27 01 16
Interim Director of
Nursing & Quality
2015.912 25 11 15
Interim Director of Nursing & Quality to
raise the issue of flexing the ratios by
utilizing Health Care Support Workers
on those wards where the acuity of the
patients is lower at the Financial
Recovery Group and report the
outcomes of this work to the next
meeting of the Board.
27 01 16
2015.913 25 11 15
The Interim Director of Nursing & Quality 27 01 16
would raise the health and safety
Completed. Reviewed at EMT
Interim Director of
Nursing & Quality
Completed. The Chair of Falls
Committee will report any issues
Interim Director of
Nursing & Quality
Page 4 of 20
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Action
Date of
No.
Meeting
Action
Status/
Due Date
element linked with falls with the Chair
of the Falls Prevention Panel.
2015.913 25 11 15
Interim Director of Nursing & Quality
arrange a “deep dive” into Falls at a
Quality Governance Committee meeting
in this year’s cycle of business.
Comments (incl. interface with/
reference to another Committee/
Sub Committee/Working Group)
Responsible Officer
RAG
Rating
relating to Health & Safety
27 01 16
This is already included in the cycle
of business
Interim Director of
Nursing & Quality
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MEETING OF THE TRUST BOARD OF
STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST
Wednesday 25 November 2015
Brampton Room, Morston House, Newcastle under Lyme
Present:
David Pearson
Gary Crowe
Jane Gaddum
Rosie Goodwin
Geraint Griffiths
Kieron Murphy
Elizabeth Jarrett
Stuart Poynor
Dr James Shipman
Julie Tanner
Jonathan Tringham
Paul Weston
DP
GC
JG
RG
GG
KM
EJ
SP
JSh
JkT
JT
PW
Interim Chairman
Non-Executive Director
Non-Executive Director
Interim Director of Nursing & Quality
Deputy Chief Executive
Director of Operations
Non-Executive Director
Chief Executive Officer
Medical Director (part)
Director of Workforce & Development
Director of Finance & Resources
Non-Executive Director Designate
Apologies:
Dr John Scarpello
Andy Talbot
JS
AT
Non-Executive Director
Non-Executive Director Designate
In attendance
Andrew Errington
Nic Glover
Chris Beswick
Melanie Print
AE
NG
CB
MP
Professional Head of Social Work
Executive Assistant to Chairman and CEO
Staffside Representative
Company Secretary
2015.904
Welcome and Apologies
The Interim Chairman welcomed Board Members, Staff Members and Members of
the Public.
Apologies were received from John Scarpello and Andy Talbot.
2015.905
Questions from Members of the Public
The Interim Chairman invited questions from the members of the public, confirming
that there would be a further opportunity at the end of the Board to ask questions of
the Board.
2015.906
Declarations of Interest
The Interim Chairman asked if Trust Board Members had any declarations of
Page 6 of 20
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interest to declare.
The Medical Director referred to his standing declaration that he is employed (part
time) as a salaried GP within the local health economy.
Non-Executive Director Designate, Mr Weston declared he was the Chief Financial
Officer for Housing and Care 21 Ltd.
The Interim Chairman welcomed Claire Neill the Trust’s new Associate Director of
Communications to the Trust.
The Interim Chairman informed Board Members that Keele University School of
Nursing and Midwifery’s Mentor of the Year Award has been won by Hannah Beech
from Clayton District Nursing Team, who was highly praised by two students with
comments “I have nothing but praise for Hannah and I was genuinely disappointed
when I left the placement area. She is a fantastic mentor in a fantastic placement
area and feel very lucky to have been able to work there” and “Hannah is an
inspiration, very patient centred and knowledgeable. She has given me much
needed confidence to progress in my career and I have gained skills and
knowledge that have proved invaluable”.
The Interim Chairman informed Board Members that Steve Kenyon, Clinical Lead
for the Continence Team in the North was one of a small number of specialist
clinicians, MPs and other stakeholders from across the UK to be invited to a
Parliamentary Reception at the House of Commons on 4 November 2015.
The Interim Chairman informed Board Members of the very sad news that Sarah
Whittingham, one of the Trust’s Community Staff Nurse/Specialist Practitioner
Student in Alrewas had passed away tragically and unexpectedly at the weekend.
The Interim Chairman informed Board Members that Sarah’s Team were being
supported.
2015.907
Minutes of the meeting and matters arising
The Interim Chairman referred Trust Board Members to the minutes of the Trust
Board meeting held on 28 October 2015 and Board Members agreed the minutes
as a correct record apart from the following changes:
•
•
•
•
•
Page 5 – title change, Interim Medical Director to Medical Director
Page 5 – title change Paul Weston, Non-Executive Director to NonExecutive Director Designate
Page 5 – title change Andrew Errington from Professional Head of Social
Care to Professional Head of Social Work
Page 10, 2015.893, first sentence should read …Board Members which
now annexed (for this month a sample)… instead of Board Members which
now annexed (fir this month a sample)…
Page 15, 2015.898, fourth paragraph last sentence should read
“…preparing a report as SIRO for the FIP Committee” and not “…FIP
Commitment”
Board Members went through the action tracker and noted that all actions were
either on target or complete.
2015.908
Patient story
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The Interim Chairman Mr Pearson welcomed Mr and Mrs Abbotts to the meeting.
Mr and Mrs Abbotts informed Board Members that Mr Abbots had been receiving
care for many years from the Bucknall ILCT and has remained highly independent,
with support from Mrs Abbotts as his carer; they can contact the Community
Matron, Morlich Barnett, should Mr Abbotts symptoms change but they generally
manage his COPD.
Mr and Mrs Abbotts informed Board Members that Mr Abbotts had been diagnosed
with terminal liver cancer and that Bucknall ILCT immediately contacted the cancer
and supportive therapies team to provide guidance and assistance to Mr and Mrs
Abbotts, as well as the oncology specialists at the Royal Stoke Hospital. Following
oral chemotherapy, Mr Abbotts experienced a number of severe side effects which
required additional medication and the Douglas Macmillan Hospice provide
palliative care and support.
Around the time of the diagnosis, Mrs Abbotts suffered from a back injury; she was
unable to continue caring for Mr Abbotts. Bucknall ILCT worked with the
Intermediate Care Team to provide ongoing personal care, support and assistance
to Mr Abbotts. The two teams, along with the Douglas Macmillan, offered support
and comfort to Mr & Mrs Abbotts, as they had lost a significant element of their
independence, whilst also having to come to terms with the diagnosis of terminal
liver cancer. Following the involvement of the Douglas Macmillan, Bucknall ILCT
worked with Mr Abbotts’ GP to arrange a DS1500, providing them with end of life
care funding.
Mr Abbotts said that whilst he is still suffering from COPD and terminal liver cancer,
he continues to be as independent as he can with the aid of Mrs Abbots and
attributes this to the continued, outstanding care which went above and beyond
what was expected from the Partnership Trust teams. Mr and Mrs Abbotts noted
that during such a time of crisis for the couple, the stability offered to them both by
Community Matron Barnett and her team was exceptional.
The Interim Chairman thanked Mr and Mrs Abbotts for attending the Trust Board to
inform Board Members of their story and personally thanked Morlich Barnett for the
exemplary care and support that she had provided to them.
2015.909
Chief Executive Officer Report
The Chief Executive Officer referred Members of the Board to his report which
highlighted a number of national and local items as follows:
Matters of national significance:
• NHS Confederation;
• Government response to the House of Commons Health Select Committee
report on End of Life Care;
• CQC’s proposed changes to fees and the move to a risk based regime;
• NHS bodies proposals on changes to safe staffing guidance;
• NHS Employers welcomes lifting of restrictions on nurses being recruited from
outside the EU;
• Public health cuts in the upcoming spending review;
• NHS Clinical Commissioners and NHS Providers news;
• Changes to the National tariff;
• Ofsted ratings for CCGs;
• Patient power;
Page 8 of 20
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•
•
•
•
Neglect claims for older people rise as services are cut;
Nurse validation faces two year delay;
NHS to remove names from job applications to prevent discrimination;
News from NHS England.
Matters of local significance:
• HSJ award;
• National award for Stoke Speech and Language Therapist;
• User Carer Experience;
• CQC visit;
• Offender Health.
The Chief Executive Officer appraised the Board of the initial feedback from CQC;
the recognition that staff were caring and compassionate and the steps that had
been implemented to address matters highlighted by CQC; and the prospective
timeline for the publication of the Inspection Report; CQC had highlighted that “staff
were a credit to our Trust” but there are a number of concerns that we have
committed to address as a priority.
The Chief Executive Officer informed Board Members that the Trust was finding
itself in a very challenging position; appraised them of the outcomes of the limited
assurance report of the Internal Auditors which had been discussed at the
Executive Management Team on the 24th November; reporting that a more directed
financial recovery would be implemented and that he would continue to drive the
financial recovery and CIP recovery through his chairmanship of the Financial
Recovery Group and the CIP Scrutiny Panel. The Director of Finance & Resources
would discuss in further detail in his report.
The Chief Executive Officer informed Board Members that the Trust had not been
successful in its tender bid for offender health; the bid had been awarded to a
private company. Non-Executive Director, Mrs Gaddum asked for feedback on why
the Trust had not won the tender. The Deputy Chief Executive reported that
successful bidder could demonstrate better partnership working with a mental
health partner and drug and alcohol support.
The Chief Executive Officer informed Board Members that Staffordshire County
Council had asked for and been granted an extension with regard to the Quarter 2
review of the Section 75 agreement; there would be a need for an extra-ordinary
Board meeting to discuss the outcome of the Quarter 2 review.
Board members discussed availability and it was agreed that an extra-ordinary
Board meeting would be convened for the 16th December 2015.
The Interim Chairman urged that the reports to be made to this meeting are
referred to Board members well in advance of the meeting.
The Chief Executive Officer informed Board Members that there were ongoing
challenges within the local health economy at the current time due to the continuing
negotiations around the Step Up and Step Down specifications and the localities for
these services; no contract variation had yet been agreed with the commissioners.
Non-Executive Director Designate, Mr Weston asked for more clarity regarding
information in the report and the context for the Trust.
Non-Executive Director, Mrs Jarrett asked if the information in the report could be
Page 9 of 20
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put together in sections.
The Chief Executive Officer agreed that the contents of the report needed to be
reframed within a context which is meaningful and relevant to the Trust.
The Trust Board noted the contents of the Chief Executive Officer report.
2015.910
Assurance Reports –Quality Governance Committee
Quality Governance Committee
The Interim Chairman and Chairman of the Quality Governance Committee, Mr
Pearson presented the assurance report for the Quality Governance Committee in
relation to the matters and business of the meeting of 11 November 2015 and
reported the following items of business which the Committee had agreed to refer
to the Board for its consideration and required action as appropriate:
•
The Committee received an escalation report from the Safety & Effectiveness
Sub-committee concerning a trend in the cancellation of secondary care
appointments for offenders as a result of insufficient escorts. All cancelled
visits have been logged as an incident. The Committee was appraised of the
actions taken to mitigate this risk, including notification to the Commissioners
and the Prison Governors of the need for additional escorts. The Specialist
Divisional Business Meeting will maintain oversight of this risk.
•
The Committee reviewed an assurance report into the outcomes of the reviews
undertaken by the Mortality Review Group; there has been an increase in the
number of deaths principally due to the high numbers of palliative care
patients. The Medical Director reported that as the Trust had had to flex the
Grange Ward criteria to receive palliative care cases from Royal Stoke the
Chair of the Clinical Quality Review Meeting has agreed to review palliative
care provision. This report is shared with Commissioners through the Clinical
Quality Review Meeting. The Committee has requested that the learning
actions which relate to the admission of frail patients outside normal medical
staffing hours are addressed in the Hospital Transfers Meeting and through the
Discharge Policy (which is due to be submitted to the Committee in January
2016) so as to ensure that any discharges are safe.
•
The Committee received an outline of the Healthcheck “early warning system”
and were not assured that this had been embedded into the governance of
quality; the Committee recommended that the Director of Operations report
back to the Committee in January with a flow chart which maps the reporting,
triggers and escalations of the “early warning system” into the governance of
quality and confirmation as to the thresholds which would trigger a quality visit,
together with the timeline as to when this process is to be fully implemented.
•
The Committee received a verbal update as to the initial overview of the Care
Quality Commission; they were assured by the Chief Executive Officer that
immediate action has been taken to address the initial concerns raised by the
Care Quality Commission; Executive Director leads have been assigned to
each of these actions and a full report will be made to the next meeting of the
Committee. The Executive Management Team will monitor weekly progress
and will escalate any risks to the Board.
Non-Executive Director, Mrs Gaddum asked for clarification on the point regarding
Page 10 of 20
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the escalations from the CQC Inspection, and the need for oversight by the Board.
The Chief Executive Officer assured Mrs Gaddum and the Board that there would
be a weekly briefing prepared for Non-Executive Directors to update them on CQC
and any other matters. This briefing would start in December.
SP
The Trust Board received the assurance report of the Chair of the Quality
Governance Committee into the matters and business arising from the
meeting of the Committee on the 11 November 2015.
Audit Committee
The Chairman of the Audit Committee, Mr Crowe presented the assurance report
for the Audit Committee in relation to the matters and business of the meeting of 13
November 2015 and he referred the Board to the following items of business for its
consideration and required action as appropriate:
•
The Committee reviewed the Internal Audit Progress report. It recommended
that the actions relating to the “limited assurance” audit of the Burton Agency
Account are prioritised for closure and it has reiterated its expectation that all
actions are responded to and closed within the timeframes agreed with the
Internal Auditors.
•
The Committee would advise the Board that the meeting took some time to
review and consider the Internal Auditors report into “financial management
and CIP arrangements”; the Committee welcomed the fact that audit testing
has confirmed that each CIP is supported by a Project Initiation Document and
a Quality Impact Assessment and that improved delivery and accountability is
delivered through the Chief Executive Officer’s chairmanship of the CIP
Scrutiny Committee; these actions address the concerns highlighted by the
Internal Auditors earlier in the year.
•
It is of concern that this report is of “limited assurance”. The Committee has
recommended that the outcomes of the Internal Auditors’ review are reported
to the Executive Management Team for immediate implementation of those
actions required to address the limited assurance, with an update report to the
Board by the Chief Executive Officer. The Committee has welcomed the
assurances of the Director of Finance & Resources that the performance
management framework is re-instated as an immediate priority.
The Deputy Chief Executive urged that a full response is made to the Internal Audit
report at the next Audit Committee so that we can mitigate the limited assurances
that were reviewed at the Executive Management Team meeting on the 25th
November.
The Chief Executive Officer reported that he will personally review all Schemes
prior to the next meeting of the CIP Scrutiny Panel and he will respond to those
recommendations in the Report which have been assigned to him as the
Accountable Officer.
Non-Executive Director Gary Crowe sought confirmation that all Executive Directors
understood the context of the limited assurances and urged that a collective
response is made.
The Chief Executive Officer reported that he will secure that a collective response is
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made.
Councillor Jones noted that the Trust’s liquidity score had decreased and asked
whether the External Auditors had expressed any concerns as to whether the Trust
could continue to demonstrate that it was a going concern.
The Director of Finance & Resources responded that the liquidity score is 2; we
have a cash balance of £8.7M which has decreased as a result of outstanding
debts, principally monies due from Stoke on Trent City Council; no concerns have
been raised by the External Auditors and no conditions were applied in their audit of
the Accounts for 2014/15.
The Trust Board received the assurance report of the Chair of the Audit
Committee into the matters and business arising from the meeting of the
Committee on the 13 November 2015 and noted the steps that were being
taken to address the limited assurances reported in the Internal Auditors
report into financial management and CIP.
2015.911
Corporate Risk Register
The Interim Director of Nursing & Quality presented the Corporate Risk Register to
Board Members for their review; informing the Board that the Risk Register has
been reviewed and the following changes were made at the Executive Risk
Management Committee on 9 November 2015.
• One risk was identified for de-escalation from the Corporate Risk Register:
Lack of integrated management information to support planning and
delivery of services.
The Interim Director of Nursing & Quality informed Board Members that the
Committee reviewed the quarterly review report of all risks 12 and above. The
Committee discussed the emerging risks and reviewed the risks so as to identify
any new risks for escalation to the Corporate Risk Register. Two risks were
identified for further review prior to escalation onto the Corporate Risk Register and
will be reviewed at the next Committee.
The Trust Board noted the updated version of the Corporate Risk Register
appended to this Report and noted the actions that are being taken to
manage the reported risks.
2015.912
Safer Nursing Staffing
The Interim Director of Nursing & Quality presented the Safer Nursing Staffing
report to Board Members providing an overview of nurse staffing levels in the
Community Hospitals of the Partnership NHS Trust during October 2015.
The Interim Director of Nursing & Quality informed Board Members that key points
to note in the report are:
•
Safe staffing has been maintained throughout October 2015 across all 4
Community Hospitals operated by the Partnership Trust.
•
The number of shifts being characterised as being of professional concern
(red) has increased to from 7 to 16. Late transfers of patients (after 9pm), late
notice sickness and unpredicted changes in patient acuity have all contributed
to this change.
•
The number of shifts characterised as amber has risen by 3% from 19.4% to
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•
•
•
•
22.4%
The number of shifts with only 1 RN on duty has doubled to 18 from
September 2015’s figures.
Ward 2 at Cheadle remains an outlier against registered nurse to patient ratios
during day time shifts and Cottage Ward at Leek Moorlands Hospital exceeds
the best practice ratio for night time shifts. There have been no patient safety
issues reported on these wards related to staffing.
There has been an increase in shifts not meeting the agreed establishment
figures for registered nursing staff as a result of vacancies, sickness and the
agreed D2A project establishment profile.
The number of shifts with additional care worker on duty continues to climb in
response to the need to carry out close supervision and monitoring for those at
risk of falls.
The Interim Chairman was concerned about the late transfers of care and the
reported information on the decrease in the successful recruitment to nurse
vacancies.
The Interim Director of Nursing and Quality assured the Interim Chairman that
these late transfers are monitored; three late transfers had happened on one late
shift; and one patient had required 1:1 care; all late transfers are incident reported
and the handovers monitored.
The Director of Workforce & Development reported that special measures had been
applied to the recruitment to these vacancies but we remained in competition with
other providers.
Non-Executive Director, Mrs. Jarrett asked how we systematically reviewed the
patient experience for those patients who had been subject to the late transfers?
The Interim Director of Nursing and Quality responded that patients and families
were met with and the patient experience information was triangulated with safer
staffing reports.
Non-Executive Director Designate, Mr. Weston asked if there was any scope to
tighten up on the staffing ratios due to the financial predicament the Trust found
itself in. The Interim Director of Nursing & Quality responded that there is a
recognition that we need to flex the ratios by utilizing Health Care Support Workers
on those wards where the acuity of the patients is lower; she will raise this at the
Financial Recovery Group and report the outcomes of this work to the next meeting
of the Board.
RG
The Medical Director reported that we are achieving a ratio of 1:7 which is better
that many Acute Trusts and that only 1.5% of the Trust’s shifts were of professional
concern.
Councillor Jones asked what actions the Trust was undertaking regarding its use of
agency staff.
The Director of Workforce & Development reported that the national caps for
agency staff were now in force and that she was confident that with the
implementation of the Trust wide Bank the agency bill will be significantly reduced.
The Medical Director asked for a column to be added to the report to include the
actual bed numbers.
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The Director of Operations reported to the Board that whilst there were no
mandated safe staffing ratios in community nursing he had recognized that it is
operationally imperative that we assure ourselves that the ratios in community
nursing are safe; he indicated that Operations had developed a template for the 32
teams which looked at a range of indicators, such as sickness, incidents, staffing
and complaints; these are RAG rated and assigned to managers and he reviews
the actions taken to make the teams safe. This had been approved at the Executive
Management Team and is now reported to the Clinical Quality Review Meeting.
The Company Secretary advised the Board that in the context of the discussions
today the recommendations that the Trust “be assured that the Trust is compliant
with safe staffing nursing” cannot be endorsed; as such the Board can only endorse
the proposition that there are controls in place to systematically monitor compliance
with safe staffing guidance..
Board Members agreed and recommended that the report content is noted
and that the Board is assured that the organisation has controls in place to
systematically monitor its compliance with safe nurse staffing guidance for
October 2015.
2015.913
Quality Report
The Interim Director of Nursing & Quality presented the Quality report to Board
Members which provide the experience, safety, and effectiveness data of service
users and carers during September 2015.
The Interim Director of Nursing & Quality outlined the key points of note in the
report, reporting that there had been an increase in falls (with no increase in harm)
and that this is due to the need to get patients mobilised so that they can become
independent; it is part and parcel of their rehabilitation before they are discharged.
The Medical Director asked whether we captured “other harm” such as a loss of
confidence and a decline in mobility as a result of increased length of stays.
The Interim Director of Nursing & Quality reported that we can examine these
issues at a “deep dive” into Falls at the Quality Governance Committee.
Board members agreed and asked that the Interim Director of Nursing & Quality
arrange a “deep dive” into Falls at a Quality Governance Committee meeting in this
year’s cycle of business.
RG
Non-Executive Director Designate, Mr Weston asked for clarification on social care
complaints in relation to the quality of care and services provided by other
providers.
The Company Secretary reported that the County Council undertake quality
monitoring of those providers with which we contract for services such as
domiciliary care and residential care, as the County Council manage these
contracts; any concerns are reported to the Quality Team.
The Board discussed and noted the quality indicators in the dashboard of the
key points for September 2015.
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2015.914
Integrated Performance Report – Month 7
The Director of Finance and Resources presented the Month 7 Integrated
Performance Report to Board Members which provided a concise integrated view
of performance across the organisation for October 2015; informing Board
Members that of the 59 performance indicators with targets attached, 40 are green,
5 are amber and 14 are red.
There is to be a review of the suite of the KPIs that the Trust reports against so that
there is a more proportionate and contextual overview of the key areas of
performance that the Board should be concerned with.
The Director of Finance and Resources informed Board Members that key areas of
strong performance improvement include:
•
Customer satisfaction with social care support increased from 66% to 73% in
October against a target of 72%. For the first time in the year we have no red
indicators in the Quality section of the quadrant.
The Director of Finance and Resources informed Board Members that key
performance concerns include:
•
•
•
•
•
The only indicator rated “red” in the Quality Assessment continues to be the
percentage of harm free care in the safety thermometer (90.9% against a
target of 95%).
Social care delayed transfers of care still show no sign of improvement, and
deteriorated slightly further in September.
Most other underperforming social care indicators remain fairly static with no
signs of decisive improvement. This includes: reablement leading to no need
for on-going support, proportion of clients in receipt of direct payments, and
reviews. New performance improvement plans were launched in October and
are now being embedded at Team level. Agreement has been made to an
increase in interim capacity to support reviews.
CIP delivery is ahead of schedule (130%), financial performance has
deteriorated, mostly due to adult social care demand pressures.
Despite stable patterns of improvement, appraisals (73.65%) and training
compliance (83.29%) remain below their respective targets (95%, and 90%).
The Director of Finance & Resources referred the Board to Annex 5 – the Self
Certification Board Statement; reporting that he and the Company Secretary had
appraised the Finance & Performance Committee that the report could not report
compliance with statement 10 having regard to the deteriorating financial position
and the limited assurance report of the Internal Auditors as reported in the context
of the Finance Report (Agenda item 8 refers).
The Board agreed that a non-compliance statement should be reported.
The Chief Executive Officer asked what this meant for the Trust.
The Company Secretary reported that on reporting non-compliance it is necessary
for a report to be made to the TDA as to the steps that will be taken to enable the
Board to report compliance with this statement; this can then be monitored by the
Board; the report would need to be made by the Chief Executive Officer as the
Accountable Officer.
Page 15 of 20
Enc 01
The Interim Chairman asked the Director of Operations what was being done to
improve operational performance in relation to each of the areas against which
operational performance continued to perform poorly; were their improvement
plans in place; and who monitored them?
The Director of Operations assured the Board that there was a detailed
improvement plan in place for each indicator which is supported by an
implementation group; the Executive Management Team had supported
investment in additional OTs (contracted through a supplier on a framework) to
secure the delivery of quicker assessments and reviews; he recognises his own
accountability to deliver better operational performance; and he reported that he
was confident that these measures would significantly improve the performance of
the “red” indicators,
The Trust Board noted the content of the executive summary and
performance scorecard and endorsed the proposal that non-compliance with
statement 10 should be reported against the Self-certification Board
Statement.
2015.915
Finance Report – Month 7
The Director of Finance and Resources presented the Month 7 Finance Report to
Board Members and asked them to consider the financial outlook arising from this.
The Director of Finance and Resources informed Board Members that the Trust is
reporting an actual deficit of £4.920m at the end of Month 7, representing an
adverse variance of £3.871m against an internal budgeted deficit to date of
£1.049m. This compares to the revised planning position submitted to the Trust
Development Authority (TDA) of £4.114m deficit at this stage; performance at
Month 7 has drifted seriously above the level expected, with much of this
attributable to Adult Social Care (ASC) demand pressures in the South of the
county, particularly in residential care where there remained continuing difficulties in
finding beds into which placements could be made.
The Director of Finance and Resources informed Board Members that as
highlighted in the planning and monitoring reports presented to the Trust Board
over previous months, the risks in delivering the Cost Improvement Programme
(CIP) target, and ASC spend within the resource provided under the second term of
the Section 75 Agreement with Staffordshire County Council (SCC), are critical to
the Trust’s financial prospects for the financial year.
He appraised the Board of the in-month (“run-rate”) deficit of £1.1m, representing
an increase over the “run-rate” at Month 6 (£0.5m deficit).
It is in excess of the planned deficit of £0.3m; this position includes the full YTD
value of the Trust’s negotiating stance with regard to the closure of wards at
Longton Cottage Hospital and the Trust’s evaluation of the funding due from
Staffordshire County Council under the inflationary provisions of the risk-share
agreement; he appraised Board Members that this is predicated on the recovery of
£1.5M. The forecast deficit in Adult Social Care will be £3.9M unless both the full
risk share is secured from the County Council and the Social Care Transformation
Plan delivers to the quantum that has been reported to the Board.
The Director of Finance and Resources informed Board Members that the best
Page 16 of 20
Enc 01
case position of £2.015m submitted to the TDA in September has to now be
regarded as daunting and that the achievement of this position is dependent upon
full delivery of “best case” scenarios in relation to CIP savings, financial recovery
programmes, the risk-share negotiations with the County Council, and containment
of the underlying “run rate”.
He reported to the Board that contractual pressures will increase over the next
Quarter and that the disparity that existed between the parties in negotiating the
contract variation relating to the re-design of services in the North economy (“stepup/step-down”), as articulated to the Trust Board last month, has been mitigated
through the Commissioners accepting the Trust’s cost model, subject to an
independent “due diligence” of the model.
The Director of Finance and Resources informed Board Members that it is
imperative that every opportunity is taken to maximise cost reductions and increase
income.
The Chief Executive Officer reported that it had been agreed that all corporate and
managerial vacancies in Operations are frozen subject to a business case which is
predicated on “invest to save” principles.
Councillor Jones noted that the Council was also in a difficult financial position; it
could not rely on its reserves to cover off the Adult Social Care deficit; the risk
share was not agreed and he would question the capability of the Trust to deliver
the benefits of integration as evidenced by the static performance in undertaking
reviews and the need to better show the benefits of Reablement services; the driver
for the variance appears to solely relate to the failure to deliver the CIP?
The Chief Executive Officer reported to Councillor Jones that the Trust delivered on
its contract with the Council over the three years from 2012 to 2015 at a cost to the
Trust of £1M; a matter of public record, as evidenced by our Public Accounts; the
accountability for delivering the Adult Social Care Transformation Programme was
joint as between the Director of Operations and the Interim DASS; and he will
appreciate that the new Section 75 Agreement had been redrawn so as to
emphasis better partnership working.
The Director of Finance & Resources reiterated the principles of joint partnership
and reported to the Board that in recent years the Trust has moved from an
investment of £1,190 per client to £890 per client; this is the cost to the County
Council of commissioning Adult Social Care; it benchmarks within the lowest
quartile of Councils In England and that fundamentally there is a need to agree
what level of commissioned investment (per client) is sufficient to deliver the
services and care that the Trust is commissioned to deliver; the Trust has invested
in additional OTs to undertake reviews so as to ascertain whether the cost of care
(against assessed need) can be reduced.
The Chief Executive Officer reported that the Council had recently agreed that the
Trust could become a provider of domiciliary care; a position they had resisted until
recently as they had been keen to manage this market.
Councillor Jones reported that Healthwatch had undertaken a review of a
residential home in a morning – could the Trust do this?
Non-Executive Director, Mrs Jarrett reported that Healthwatch do not do full reviews
such as a review of records, care and medicines and asked what was driving the
Page 17 of 20
Enc 01
demand in the South as it is focussed on Adult Social Care.
The Director of Finance & Resources reported that it is a different model in the
South with fewer Community Hospitals and limited Discharge to Assess capacity;
this meant that patients were discharged from Acute Care to their homes or
Residential/Nursing Care.
Non-Executive Director Mr Crowe asked whether we can be confident that we will
deliver the best case scenario?
The Director of Finance & Resources informed the Board that we approaching the
end of Quarter 3 and unless the financial recovery can be ramped up and the
savings from the Transformation Programme for Adult Social Care start to rapidly
deliver then we will not achieve the best case scenario.
Non-Executive Director Designate, Mr Weston asked if the £9.7m was a projected
best or worst case scenario and the Director of Finance & Resources confirmed this
figure was if the Trust continued with the current run rate.
The Medical Director asked if the domiciliary care issue was on the Corporate Risk
Register for both the Council and the Trust.
Non-Executive Director Mrs Gaddum asked whether the loss of recent tenders in
Offender Heath and East Staffordshire would impact on this year’s financial position
or next year’s financial position?
The Director of Finance & Resources confirmed that the school nursing tender
would affect this year’s financial position and the East Staffs and Offender Health
would affect next year.
Councillor Jones commented that the Clinical Commissioning Groups in North
Staffordshire were ineffective.
The Interim Chairman stated that we need absolute clarity as to what can be
delivered under the Transformation Programme for Adult Social Care; that the
report into the Quarter 2 review (for Adult Social Care) needs to be made available
to Board Members well in advance of the Extraordinary Board Meeting and that the
principles of partnership will need to be reinforced at the forthcoming Trust Board to
Cabinet meeting in early December.
The Interim Chairman asked for assurance that a more directed approach to
financial recovery be agreed by the Executive Directors.
The Chief Executive Officer reiterated that he would be chairing the Financial
Recovery Group and he would reiterate to all members of that Group as to the
imperative to secure financial recovery in the terms outlined to the Board today.
The Company Secretary advised the Board that the recommendations were
seeking their active consideration as what steps should be implemented to secure
financial recovery; reiterating that the Board has agreed to report non-compliance
with statement 10 of the Self-certification Statement and as such the Board need
actively consider what actions they should endorse to secure the best prospects of
financial recovery.
The Trust Board reviewed in detail the forecast financial performance of the
Page 18 of 20
Enc 01
Trust at the end of October 2015 (Month 7) and fully endorsed the following
actions to achieve a best case position of a deficit of £2.015m:
•
•
•
•
•
•
•
•
•
•
•
•
•
2015.916
Review of all Agency Staff
Ensure appropriate accounting for capital expenditure
Review of 2016/17 CIP schemes for pull forward
Review areas for invest to save in ASC
Review of Nursing levels in Community Hospitals
Income Maximisation
Review of over performing services
Cost benefit analysis for recruitment
Freeze on Management posts above Band 7 subject to demonstrating
ROI
Ensure recovery under Risk share with SCC
Review Consultant job plans
Acceleration of Social Care Transformation
Directed control of discretionary expenditure
Board Assurance Framework
The Company Secretary presented the Board Assurance Framework to Board
Members informing them that the Board Assurance Framework (BAF), annexed to
the report is the second iteration of the BAF, changes having been made as a
consequence of an advisory review by the Internal Auditors. This report highlights
the changes made and the next steps to secure implementation of those changes.
The Company Secretary outlined the changes that had been made following the
interim review by the Internal Auditors and the agreement of the Audit Committee to
the same, as follows:
•
•
•
•
“High” signifying full assurance has been provided over the effectiveness of the
reported controls supported by independent testing;
“Medium” signifying that some assurances are in place and/or the controls are
still maturing so the effectiveness of the same cannot be fully assessed. The
presumption is that the efficacy of the controls will improve;
“Low” signifying that the assurance that has been provided is showing poor
effectiveness of controls, this maybe evidenced by independent testing by the
Internal Auditors, other agencies and regulators.
This iteration of the BAF applies an indicative confidence rating to the relevant
controls.
The interim review of the BAF by the Internal Auditors has reported that:
• “Currently the level of comfort in the assurances provided is not recorded in
the BAF. This is considered to be good practice”.
Assurances which are categorised as low will be prioritised for review by the Audit
Committee.
The next iteration of the BAF (to be reported to the Audit Committee and Board In
January 2016) and will incorporate revised and clear actions with a cross reference
to any supporting evidence e.g. positive assurance report from the Internal
Auditors.
Non-Executive Director Gary Crowe endorsed the changes that had been approved
Page 19 of 20
Enc 01
at the Audit Committee, the continuing support and input from the Company
Secretary in improving the BAF and pointed out the Committee would be looking for
better operational assurance, the Director of Operations having attended the
Committee to assure them that this is a priority; the Committee will test these
assurances, over the next Quarter of its business cycle, by reference to the
confidence score that has been assigned to the assurances received.
The Trust Board:
• reviewed this iteration of the BAF and endorsed the proposition that the
assurance level assigned to each assurance is reviewed and confirmed
by the relevant Executive Director;
• endorsed a review of the assurances assigned to the relevant principal
Committees by the sponsor Committee supported by an assurance
report to the Audit Committee by the Chair of each Committee;
• supported a development session of the Board with CW Audit Services,
the Chair of the Audit Committee and the Company Secretary into the
further development of the Board Assurance Framework and the
supporting escalation framework for risks and assurances early in 2016.
2015.917
Any Other Business
None.
Review of meeting and outcomes
The Interim Chairman, Mr Pearson asked Board Members for any comments
regarding the meeting; Members of the Board responded that they had felt it was a
much more focussed and positive meeting.
2015.918
Date of next meeting
The next Public Trust Board Meeting will be held on Wednesday 27 January 2016
at Morston House, Newcastle under Lyme.
Page 20 of 20
Enc 01A
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
01A
Subject:
Report of the Ambassador for Cultural Change – Quarter 3 – Raising
Concerns
Strategic Goal:
(tick as applicable)
x
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
x
We will work with users and carers to deliver integrated systems, simply and
effectively
x
Our organisation will develop and deliver sustainable, innovative services that
support independence
x
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
x
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Helene Donnelly, Ambassador for Cultural Change
Recommendation:
For Approval &
Assurance
For Discussion
x
For Information
PURPOSE OF THE REPORT:
To provide an overview and update to the Trust Board on Raising Concerns to the period ending on
31 December 2015.
INTER DEPENDENCIES:
Legal and/or Risk
A national framework for raising concerns – “Freedom to Speak Up” has
been the subject of consultation. Once launched the Trust will need to
ensure that its procedures and supporting policies for raising concerns are
aligned to the national framework.
Clinical
Clinical risks that are highlighted within any concern raised are referred to
the Medical Director / Interim Director of Nursing & Quality for review.
Financial
Some concerns may require additional investment to mitigate the risks of
low staff morale/capacity.
HR
Workforce risks that are highlighted within any concern raised are referred
to Director of Workforce & Development for review.
Staff and Trade
Union involvement
None at this time
Page 1 of 2
Enc 01A
actions
undertaken/planned
Social Care
None at this time.
Patient & Public
Involvement
Patient concerns are addressed through PALs/Complaints and frontline
staff.
Equality Impact
An equality impact assessment of the new Freedom to Speak Up
framework will be undertaken.
Information exempt
from Disclosure
None.
Requirement for
further review
Quarterly report to the Board
RECOMMENDATIONS:
The Trust Board is requested to review and discuss the Raising Concerns report of the
Ambassador for Cultural Change.
Page 2 of 2
Enc 02
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT
PARTNERSHIP NHS TRUST BOARD
TO BE HELD ON: 27 January 2015
Enclosure:
02
Subject:
Chief Executive Officer Report
Strategic Goal:
(tick as applicable)
Director Lead:

We will provide high quality and safe services which provide an excellent experience
and best possible outcomes

We will work with users and carers to deliver integrated services, simply and
effectively

Our organisation will develop and deliver sustainable, innovative services that
support independence

Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values

We will make excellent use of our resources and improve levels of efficiency across
our services
Stuart Poynor, Chief Executive Officer
Recommendation: For Approval &
Assurance
For Discussion
For Information
x
PURPOSE OF THE REPORT
To provide members of the Partnership Trust Board with an update from the Chief Executive
Officer.
KEY POINTS
LOCAL
We put quality first
•
We submitted the first response to the Care Quality Commission on time and have
received three draft reports (Brighton House, Living Independently Staffordshire)
•
Good partnership working helped manage winter pressures
•
World Aids Day and HIV testing week were both celebrated
•
A lot of work has been done to raise the profile of preventing pressure ulcers
1
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•
Our therapy services have been recognised in a number of different ways
We focus on people
•
After almost 30 years pioneering rehabilitation medicine, Professor Ward retires
•
All 14 community nurses supported by the Trust to undertake the Specialist Practitioner
Qualification are now in district nursing sister positions
•
Keele University recognised our practice educator mentors
•
Our visual impairment rehabilitation officers secured the NHS Collaboration award for their
work with Staffordshire Fire and Rescue Service.
•
The family nurse partnership celebrated the latest cohort of mums to graduate from the
programme
•
The New Year gave us the opportunity to promote our healthy lifestyle service, Together 4
Health
•
Our joint social care transformation programme with Staffordshire County Council is
progressing well
•
Bronze, silver and gold awards made.
We take responsibility
•
What our patients, service users and carers can expect from us when things go wrong
•
Following national changes to the way health visiting is commissioned, we are organising
our staff along the boundaries of the two local authorities within which we work
•
We are leading the way on integration by delivering the multi-specialist community
provider model set out in the five year forward view, published October 2014.
NATIONAL
•
2015 spending review offered local authorities the opportunity to increase council tax by
2% to contribute to the funding of social care. The NHS will receive a real-terms funding
increase of £10bn between now and 2020/21
•
The latest planning guidance has been issued and introduces the requirement for a health
economy-wide five year sustainability and transformation plan
•
Boards have been asked to consider quality and finances on equal footing
•
£1.8bn sustainability fund announced
•
Lord Carter has written to the Secretary of State saying that the NHS will be able to
generate £5bn of efficiency savings by 2020, if certain conditions are in place
•
Additional arrangements have been put in place relating to agency costs
•
A national Freedom to Speak up Guardian has been appointed
•
A consultation on the Care Quality Commission’s fee structure is open
•
CCG leaders have called for the ‘ban’ on mergers to be lifted
•
The latest workforce data shows that district nursing has seen a fall. The majority of extra
nurses have been employed by the acute sector. Health visitor numbers have increased
nationally.
INTER DEPENDENCIES:
Legal and/or risk
None
Clinical
None
Financial
None
2
Enc 02
HR
None
Social care
None
Patient & public
involvement
Patients, family members and carers inform the CEO of the details of
their experience of receiving care during his visits to frontline services
Staff and Trade Union
involvement actions
undertaken/ planned
None
Information exempt
from disclosure
The report is a public document and available to members of the public
via the Partnership Trust website
Requirement for
further review
None
RECOMMENDATIONS / ACTION REQUIRED
The Trust Board is asked to note the contents of the Chief Executive Officer’s report.
3
Enc 02
Local
We put quality first: we deliver quality and do the very best we can.
Care Quality Commission
We responded to the first deadline of the Care Quality Commission’s warning notice
on time. A steering group is meeting weekly to monitor the actions in our
improvement plan, which is being delivered by the operational delivery group. The
steering group escalates issues to the Executive Management Team, if necessary,
following each meeting. Overall oversight is provided by the Quality Governance
Committee.
There is a lot to do before the final deadline of 29th February, but progress is being
made at pace.
We have received draft inspection reports for Brighton House and the Living
Independently Staffordshire teams in the North and South of the county. These are
registered separately, as required by the CQC. We have until 25th January to check
for factual accuracy and they will be published on or shortly after 25th.
Managing winter pressures
At the beginning of December, the health and care economy hosted a press
conference to explain to the people of North Staffordshire, how we would manage
winter pressures.
As expected, the two Bank Holiday weekends led to increased demand for health
and care services. Our staff worked with University Hospitals North Midlands NHS
Trust (UHNM), and neighbouring Acute Trusts, to identify people suitable for care at
home, in line with our Home First philosophy. Our community teams also worked
hard to maintain people in their own home. When the pressure at Royal Stoke
Hospital became really great, we opened an additional ward at Cheadle Hospital.
Despite everyone’s best efforts, some patients at UHNM still experienced trolley
waits.
Celebrating sexual health services
World Aids Day is marked every December and last month saw Leicester sexual
health team up with Leicester City Council, local MPs and local voluntary sector
organisations LASS and Trade to sign the ‘Halve It pledge’ – a national pledge
committing Leicester, Leicestershire and Rutland to halve late HIV diagnoses by
2020.
The month before was national HIV testing week and the Trust’s sexual health teams
offered free and confidential HIV testing in a variety of locations to residents of
Stoke-on-Trent and North Staffordshire. An art exhibition titled ‘HIV Unfolded’ was
held at AirSpace Gallery in Hanley, with artists and local people sharing a snapshot
of HIV from their perspective.
Profiling pressure ulcers
Since the last Board meeting, we have done a lot to raise the profile of pressure
ulcers. Staff form the tissue viability team helped spread key prevention messages to
patients and members of the public at Haywood Hospital as part of World Pressure
Ulcer Day on 19 November. We have since launched our pressure ulcer campaign,
‘React to Red’. The Trust’s tissue viability team offered advice and information about
how to prevent pressure ulcers in their early stages at a series of drop-in sessions at
Haywood Hospital on Thursday 17 December. Tissue viability specialists also went e
on to wards to discuss with staff, patients and their carers and families, the signs and
actions to be taken if you ‘React to Red’.
4
Enc 02
Recognition for our physiotherapists
At the end of November, members of the Trust’s Integrated Physiotherapy and Pain
Service (IPOPS) had the opportunity to share their expertise with 180 GPs from
Coventry and Rugby CCG at an education workshop. Six Extended Scope
Practitioners from the IPOPS team were invited to share their knowledge by Dr
Ralph Mitchell.
Last month, the same team was visited by the Chartered Society of Physiotherapy
(CSP) and the European Senior Golf Tour. The service welcomed Steve Tolan,
Head of Practice and Development at CSP and Orlaith Buckley, Consultant
Physiotherapist at European Senior Golf Tour. Steve Tolan offered mentorship to the
service’s clinical leads Denise Softley and Paula Deacon during his visit to the
Lichfield and Tamworth based team. Steve, who described IPOPS as ‘the most
famous musculoskeletal management service in the UK’, looked at the clinical data
that the team has collected over the last five years and discussed how they could
share this information both nationally and internationally.
In November, the Trust’s Occupational Therapy service for children rolled out a
training package on Developmental Coordination Disorder (DCD), designed for
teaching staff and Special Educational Needs Coordinators in primary schools in
Staffordshire and Stoke on Trent.
The training afforded an important opportunity to develop and strengthen partnership
working between health and educational services. It is anticipated that the
strengthening of this partnership will enable better working and more effective
outcomes for the children and families we work with.
In October, the Trust welcomed four senior physiotherapists from Hong Kong who
were selected by Hong Kong Health Authority to complete a training programme in
the UK. The group of physiotherapists spent 10 days with Keele University and the
Trust. During their time here, they had the opportunity to complete the
Biopsychosocial Management of Complex Patients with Back Pain course with the
Trust’s Consultant Physiotherapist, Gail Sowden at Keele University. They also
undertook an international learning package at Haywood Hospital and got the
chance to shadow physiotherapists at various musculoskeletal (MSK) outpatient
clinics across the Trust.
This serves us well as we look to recruit more allied health professionals.
We focus on people: we treat people as individuals and take time to
respect and understand their point of view.
Celebrating excellence awards
The shortlisting has now taken place for our annual awards, the ceremony for which
will take place on Friday 11th March. There were 279 nominations across the 12
categories.
Professor Ward retires
Professor Anthony Ward, retired at the end of last month. For almost 30 years, he
pioneered cutting edge rehabilitation medicine and training at our North Staffordshire
Rehabilitation Centre, gaining international reputation for his expertise and research
in the management of spasticity and in brain injury and stroke rehabilitation.
Professor Ward founded the North Staffordshire Rehabilitation Centre in 1988 as the
sole consultant in rehabilitation medicine in the West Midlands region and only the
5
Enc 02
seventh to be appointed in the country. The centre is now recognised as a pioneer
for research, training, innovation and exemplar clinical service.
Investing in our nurses
We have always valued specialist practice and in recent years have encouraged
community nursing staff to take the Specialist Practitioner Qualification (SPQ) course
to enhance their skills. A recent study by the Queen’s Nursing Institute highlights the
value of the SPQ. The work, funded by the Department of Health, identifies key
themes including direct benefits to patient care, personal and professional
development, the benefit to employing organisations, and cost savings. We have
supported 14 community nurses to completing the course so far and all are now in
District Nursing Sister positions. These practitioners hold the NMC recordable
qualification of a ‘specialist practitioner’ which supports them in exercising higher
levels of judgement, specialist knowledge and decision making in clinical practice.
Their training could not have been achieved without the support and dedication of
their Community Practice Educators and Community Practice Teachers who
facilitate the learning in practice throughout the 12 month programme.
Practice Educator Mentor awards
Last year, Keele University School of Health and Rehabilitation launched their
Practice Educator Mentor awards. Physiotherapy students had the opportunity to
nominate a Practice Educator who they felt had been outstanding in their educator
role in supporting student education and providing an exceptional physiotherapy
placement experience. Four of these awards were given to physiotherapists from the
Partnership Trust.
• Elizabeth Hallam – Physiotherapist, Biddulph Primary Care Centre
• Janet Smith – Physiotherapist, Community Respiratory Team, Greyfriars Therapy
Centre
• Vanessa Clayton – Physiotherapist, Longton Cottage Hospital
• Joseph Wright – Physiotherapist, Bentilee Neighbourhood Centre
Recognition for visual impairment
Visual impairment rehabilitation officers from the Trust won a national award in
recognition of their joined up working with Staffordshire Fire and Rescue Service to
raise awareness of the difficulties people living with visual impairments experience
on a daily basis. The NHS Collaboration award is given to the NHS Trust which has
worked best with other public/private sector organisations to engage the local
community in preventative campaigns. The collaborative working involves the
rehabilitation team providing practical and interactive training to firefighters in
Staffordshire to help build a greater understanding of how conditions such as
blindness or partial sightedness affect a person’s livelihood.
Success of the Family Nurse Partnership programme
Last month, more than a dozen young mums joined family nurses at Cannock Chase
Children’s Centre to celebrate their graduation from the Family Nurse Partnership
programme. The Family Nurse Partnership provides a wide range of pre and postnatal support to first time mothers aged between 16 and 19, who access the service
before week 29 of pregnancy. The family nurses provide weekly and fortnightly
sessions which are one-to-one and tailored to the needs of the mother and child,
until the child reaches the age of two.
6
Enc 02
Together 4 Health
We took advantage of the New Year to promote our healthy lifestyle service. The
service is commissioned by public health at Staffordshire County Council and
comprises services we used to provide such as Healthy Kid5 and Time to Quit.
Social care transformation
The joint transformation programme with Staffordshire County Council is progressing
well. Strategic priorities have been identified and investment, both time and money,
has been made in the actions identified for this financial year.
The personalisation agenda continues to be seen as important with the recognition
that service users show greater levels of satisfaction and reduced costs wherever
direct payments are used. We have launched a staff engagement programme to
raise the profile of independence as part of the social care transformation
programme. Staff will be supported to focus on delivering creative solutions to
promoting independence with service users.
Service user and carer experience
GOLD is awarded to North DESMOND Team
For the completion of their monthly target sample of Service User and Carer
experience surveys
•
Achieving a Friends and Family Test score of 99% of respondents who would
recommend the service
SILVER is awarded to Sycamore Ward - Palliative Care
•
For the completion of their monthly target sample of Service User and Carer
experience surveys
•
Achieving a Friends and Family Test score of 100% of respondents who
would recommend the service
BRONZE is awarded to Cannock LIS
•
For the completion of their monthly target sample of Service User and Carer
experience surveys
•
Achieving a Friends and Family Test score of 100% of respondents who
would recommend the service
We take responsibility: we take personal ownership of things and
see them through; we focus on finding solutions.
Saying sorry when things go wrong
Our patients, service users and carers can expect us to say sorry when things go
wrong and harm is caused while in our care. The most common form of harm that
occurs are falls and pressure ulcers. If harm is identified, the staff member involved
in giving care and support will:
• Reduce any risk of further harm
• Give a verbal apology/acknowledgement of the harm to the patient and explain
what has gone wrong
• Complete incident report including information on Duty of Candour
• Document discussion in medical records.
7
Enc 02
Within 10 days, the staff member must send a letter to the patient detailing the
incident and explaining that an investigation is underway. An investigation will take
place and written feedback is given to the patient and or relative/carer if the patient
lacks capacity.
Changes to health visiting
Following a national change in commissioning arrangements, Stoke on Trent City
Council and Staffordshire County Council now commission our health visiting
service. In response to this, Staffordshire County Council issued a revised service
specification, which requires us, as provider, to work within their boundaries. This will
mean that families who are registered with a GP in Staffordshire but live in a different
local authority will experience a change in health visitor. We are starting to receive
records from neighbouring authorities, who are making the same change.
The new model will allow us to focus resources where they are needed most, in
areas of highest deprivation. It will also allow our health visitors to work with a
defined community to develop local solutions to their needs.
We are already working in this way in Stoke on Trent.
Leading the way on integration
Last month saw over 70 staff from health and social care gather together to start to
plan a future model of integrated care. The event was jointly hosted by Jane
Gaddum, Non-Executive Director at the Trust, Dr Chandra Kanneganti, from
Goldenhill Medical Practice and Practice Manager, Linda Allen, from Millrise Medical
Practice. It brought together community health services, patient representatives, and
adult social care, with federations of GP practices and mental health to discuss a
new model of care called a multi-specialist community provider (MSCP).
The aim of multi-specialist community providers is to improve co-ordinated care, to
provide care closer to home, and to reduce the number of unnecessary trips to
hospital as a result. This is in line with the NHS Five Year Forward View, published
in October last year. As part of this, five different models are being tested by 50 sites
(called Vanguard sites) across the country. We are taking the learning from the
national Vanguards and are hoping to set up four Early Implementer Sites within
Staffordshire and Stoke on Trent, the first one to be established covers the North
East (NEB) area of Stoke on Trent.
National
2015 Spending Review
A concise joint briefing has been produced by Health Foundation, The King's Fund
and the Nuffield Trust. On care, its analysis is that new powers to raise Council Tax
by up to 2 per cent to spend on social care will provide flexibility for local authorities
but are unlikely to raise as much as the government suggests and could
disadvantage deprived areas with low tax bases. It asserts that the additional funding
will not be enough to close the social care funding gap which they estimate will be
somewhere between £2 billion and £2.7 billion in 2019/20, depending on how much
is raised through the Council Tax precept. Social care also faces additional cost
pressures from implementing the National Living Wage which will add another £800
million to these estimates, leaving an estimated total funding gap of between £2.8
billion and £3.5 billion by the end of the parliament. Public spending on social care
as a proportion of GDP will fall back to around 0.9 per cent by 2019/20, despite the
ageing population and rising demand for services.
8
Enc 02
On health, the Spending Review announced that the NHS will receive a real-terms
funding increase of £10 billion over the period from 2014/15 to 2020/21. It also
announced that £6 billion of this funding would be front-loaded by 2016/17. The
government argued that this delivers the £8 billion it had promised to fund the NHS
five year forward view. The rest of the stated increase comprises additional funding
for the current year announced in last year's Autumn Statement.
Other inclusions:
•
Bursaries for student nurses to be removed and replaced with student loans.
•
Creation of up to 10,000 new nursing training places.
•
More than £5bn for health research, including genomics and dementia.
•
State pension to increase to £119.30 per week next year.
•
A new single tier pension payment of £155.65 for new pensioners from next
year
•
An apprenticeship levy to raise £3bn a year, set at 0.5 per cent of the payroll
bill but with a £15,000 allowance for employers to offset the levy.
Planning guidance
This year, we will be required to produce two plans:
1. A five year sustainability and transformation plan (STP), covering the period October
2016 to March 2021 subject to a formal assessment in July 2016 following submission in
June 2016.
This plan is being submitted by the pan-Staffordshire transformation programme being
led by Rita Symons. We have contributed the section on out of hospital care/long term
conditions.
2. One year operational plans for 2016/17. These plans will need to be ‘consistent with
the emerging STP’ and in time to enable contract sign off by end of March 2016.
The planning guidance articulates nine “must do’s” for the year ahead:
1. Develop a high quality and agreed STP and subsequently deliver agreed milestones
in 2016/17
2. Return the system to aggregate financial balance, including NHS providers engaging
with Lord Carter’s productivity work programme, and complying with agency rules, and
CCGs delivering savings by tackling unwarranted variation in demand through
implementing the RightCare programme in every locality
3. Developing and implementing a local plan to address the sustainability and quality of
general practice including workforce and workload issues
4. Getting back on track with access standards for A&E and ambulance waits (95%
patients wait no more than four hours in A&E and that ambulances respond to 75% of
Category A calls within eight minutes)
5. Improvement and maintenance of NHS Constitution standards for referral to treatment
(more than 92% patients on non emergency pathways wait no more than 18 weeks from
referral to treatment) including offering patient choice
6. Deliver Constitutional standards on cancer care, including the 62 day cancer waiting
standard and the constitutional two week and 31 day cancer standards, making progress
in earlier diagnosis and improving one year survival rates
7. Achieve and maintain the two new mental health access standards (more than 50%
people experiencing a first episode of psychosis will commence treatment with a NICE
approved package within two weeks of referral; 75% referrals to IAPT will be treated
within six weeks and 95% within 18 weeks). Continue to meet dementia diagnosis
targets
9
Enc 02
8. Deliver actions in local plans to transform care for people with learning disabilities
including enhanced community provision, reducing inpatient capacity and rolling out care
and treatment reviews
9. Develop and implement an affordable plan to make improvements in quality
particularly for organisations in special measures. In addition providers are required to
participate in the annual publication of avoidable mortality rates by individual trust.
Boards asked to consider quality and finances on equal footing
A joint letter from Jim Mackey and Professor Sir Mike Richards to all trust boards,
asks them to consider quality and finances on equal footing in their planning
decisions. This highlights that in due course Monitor, together with CQC and NHS
England, will be publishing revised National Quality Board staffing guidance and a
new metric looking at care hours per patient day, as part of CQC’s new assessment
on the use of resources. Further details on this will be published in the coming
months.
Our share of the £1.8bn sustainability fund
We have received notification that we will be getting a share of this fund. This
funding will be dependent on having:
•
A recovery plan with NHS Improvement and agreed control total for 2016/17
including capital and revenue limits
•
A plan for maintaining agreed performance trajectories for delivering quality
and access standards
•
Development of sustainability and transformation plans, including adherence
to the planning timetable
•
Compliance with all staff agency rules
•
Tangible progress towards achieving seven-day services.
Preliminary recommendations from Lord Carter’s review in to operational
productivity
This will be published at the end of this month or early February. In the meantime he
has written to the Secretary of State and in this letter he reemphasises that the NHS
will be able to generate £5bn of efficiency savings by the end of the parliament, but
only with:
a.
A single reporting framework is adopted for all trusts based on benchmarked
best practice, which in turn will also reduce and rationalise the data reporting burden
currently placed on providers by commissioners and regulators
b.
Support for addressing delayed transfers for care, which is leading to suboptimal use of clinical resources
c.
National support and coverage to help providers unlock the productivity
improvements linked to redesigning clinical services, to enable rapid adoption and
implementation by providers of the review’s recommendations
d.
Substantial improvements in workforce productivity. A 1% improvement in
workforce productivity could represent around £400m in savings.
Additional arrangements from NHS Improvement to tackle agency costs
A letter from NHS Improvement sets out:
10
Enc 02
a.
The plan to lower the agency price caps for medical and clinical staff on 1 Feb
has been restated.
b.
The ban on using agency frameworks not approved by NHS Improvement will
be extended to all staff groups from 1 April. Currently, it only applies to nursing staff.
c.
NHS Improvement has recognised that framework suppliers’ renegotiations or
retenderings with agencies will extend beyond 1 Apr. In the meantime, suppliers
must “strongly support” the price caps.
d.
NHS Improvement will in time move towards expressing price caps in a way
that defines the amount the worker receives – equivalent to standard NHS t&c – and
agencies will bid to be on-framework on the basis of their agency fees.
e.
NHSI will also take steps to stop agency workers using personal services
companies to avoid taxes.
f.
A requirement on providers to use e-rostering
National guardian for freedom to speak up appointed
The Care Quality Commission has appointed Dame Eileen Sills DBE, chief nurse at
Guy’s and St Thomas’ NHS Foundation Trust, as its first national guardian for the
freedom to speak up safely in the NHS. Dame Eileen, whose post will be
independent, will work in partnership with the CQC, NHS England and NHS
Improvement to help in leading a cultural change, initially within NHS foundation
trusts and trusts, with the aim of ensuring that healthcare staff always feel confident
and supported to raise concerns about patient care. Dame Eileen will provide advice
and support to a network of individuals within foundation trusts and trusts appointed
as local freedom to speak up guardians. Helené Donnelly is our freedom to speak up
guardian. Helené is soon to go on maternity leave and an internal secondment is
being offered to cover the period of her leave.
Bringing the Care Quality Commission's comprehensive inspections within
scope of its fee raising power
The Department of Health is consulting on a proposal to extend the CQC’s fee
raising power to cover all aspects of its comprehensive inspection programme. Its
budget is to be cut by 25% over the next four years. Its overall budget is set to fall by
13%, with the cut in its government funding balanced by an increase in the fees the
CQC charges to those it regulates. Currently, the CQC’s fees may only cover those
activities which relate to assessing whether providers are compliant with registration
requirements. The CQC's new comprehensive inspections consider the quality of
care above and beyond the registration requirements, highlighting good and
outstanding care. The inspections therefore go beyond the scope of the CQC’s fee
setting power. In a separate consultation, the CQC is asking whether it should move
to a position of full cost recovery over two years or four years. In order to proceed
with the plans to move to full cost recovery, the Department of Health must introduce
these regulations to allow the CQC to charge fees for its full inspection programme.
CCG leaders call for merger ‘ban’ to be lifted
A survey by HSJ revealed that more than half of clinical commissioning group
leaders would like NHS England to lift its informal ban on CCGs merging. Forty-six
leaders took part in the latest HSJ CCG Barometer. Fifty-nine per cent said they
believed NHS England should lift its informal ban on CCG mergers, however more
than half said mergers were unlikely to take place by 2017. Respondents were given
possible options for how CCG responsibilities might shift by April 2017 and were
asked to rate how likely these were. Almost 60% said it was likely or very likely that
their responsibilities would be transferred to a provider or groups of providers, while
11
Enc 02
45% said “sharing responsibilities and budgets with local government under
devolution arrangements” was likely or very likely, and 59% said sharing budgets
and responsibilities across groups of CCGs would take place. NHS England has not
formally banned CCG mergers, but chief executive Simon Stevens has indicated he
does not want any more to take place.
National district nurse reductions
According to the latest workforce data, the NHS is continuing to recruit record levels
of qualified nursing staff, although some groups such as district nursing have seen
double digit falls. Workforce data published by the Health and Social Care
Information Centre reveals the number of full-time qualified nursing, midwifery and
health visiting staff employed in the NHS in September 2015 rose to 317,023 –
almost 2,300 more than in August. In September 2015, 3,508 more nursing staff
were employed in the NHS compared to September 2014, with majority of the extra
staff being employed in the acute sector. While community services saw an increase
of 1,405 staff, this was largely in health visitors, which increased by 1,210.
The Royal College of Nursing has shown there are more than 10,000 vacancies for
nursing posts in London. The shortage of nurses worsened last year, with 17% of all
London's registered nursing jobs vacant, up from 14% in 2014 and 11% in 2013. The
figure is much higher than the national average of 10%.
12
Enc 03i
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
03
Subject:
Assurance Report of the Chair of the Quality Governance Committee
Strategic Goal
(tick as appropriate):
x
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
x
Our organisation will develop and deliver sustainable, innovative services that
support independence
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Melanie Print, Company Secretary
Recommendation:
For Approval &
Assurance
x
For Discussion
For Information
PURPOSE OF THE REPORT:
To receive an assurance report from the Chair of the Quality Governance Committee as to the
matters and business of the meeting of the Committee of the 13 January 2016 referred to the
Board for its consideration and action (as required).
KEY POINTS:
Items of Business for Review by the Trust Board
The following matters are referred to the Trust Board, following the meeting of the Committee on
the 13 January 2016, for its consideration and action as required:
•
The Committee reviewed the report into the procedures and control processes that have
been implemented to manage the unallocated cases in social care, noting that the waiting
list for allocation has improved and performance increased; Team Leaders have oversight
of the allocation of high priority cases; and the Divisional Business Meetings will now
review the improvement plans put in place to reduce the waiting list, any related incidents
and the impact on the care and assessment of the service user as a consequence of any
incident. The Committee has recommended that the continued delays in implementing a fix
to Care Director so as to enable Social Workers and Social Care Assessors to effectively
and efficiently manage social care allocations – Teams have had to revert to a paper based
system – are escalated by the Director of Operations to the next Cabinet to Trust Board
meeting. They commended the Chief Operating Officer – Social Care on her report and the
Page 1 of 3
Enc 03i
improvements that have been made in reducing the waiting list for social care allocations.
•
The Committee ratified a number of key policies and changes to the training of staff which
underpin the Partnership Trust’s response to the CQC Warning Notice and the embedding
of best practice. The Committee recommended that the Director of Workforce &
Development secure that the Duty of Candour training is mandated as “mandatory” for
Nursing, Clinical and other relevant staff and that a report is made to the Board to that
effect. This is an agenda item for the meeting of the Board. The Committee has direct
oversight of the actions and steps that are being taken to secure the required improvements
sought by the Care Quality Commission. The Committee has directed that if additional
investment is required so as to secure that the training and development of staff, in relation
to the Duty of Candour and the Mental Capacity Act, is undertaken promptly and effectively,
then this investment must be made.
•
The Committee deferred consideration of the Healthcheck Assurance Report; it is to be
presented by the Director of Operations to the next meeting of the Committee in February
with confirmation as to how the risks and actions referred to in the Team Plans are
escalated and referenced within the governance framework of the Partnership Trust,
together with a timeline as to when the “early warning system” is to be implemented.
•
The Committee reviewed the Transfer of Patients and Service Users Policy; it has approved
this Policy as a time limited “working draft” so that its application can be tested. Changes
are to be made so as to ensure that this Policy is linked to the Discharge Policy; the
Hospitals Full Policy and the admissions (to Community Hospitals) criteria. The Committee
has directed that this work is undertaken by the Director of Operations with the support of
the Interim Director of Nursing & Quality and the Medical Director. The Committee has
emphasized that the changes to the policy are worked up from a ward level and patient
experience context and tested with staff who receive and transfer patients. A further
assurance report is to be made by the Director of Operations to the meeting of the
Committee is March.
•
The Committee directed that the risks highlighted in the Health & Safety Quarterly Report
are reported to the Executive Risk Management Committee by the Director of Operations so
that this Committee can review the impact on staff and services.
•
The Committee welcomed the first iteration of the new Quality Dashboard; it will provide
improved oversight and quality assurance of the services and quality indicators of the
Partnership Trust; improving the governance of quality and performance in a more
streamlined and succinct manner. This work is linked to the changes to the reporting and
supporting governance of the Committee which will be made in this quarter and which are
aligned to the Well Led Framework work.
INTER DEPENDENCIES:
Legal and/or Risk
Regulatory and reputational risk as a consequence of
the issue of a warning notice by the Care Quality
Commission. The Committee has an oversight function
in relation to the actions taken to address the required
improvements referenced in the warning notice.
Clinical
Clinical risks are highlighted in the Safety &
Effectiveness report.
Financial
None at this time.
HR
None at this time.
Page 2 of 3
Enc 03i
Social Care
The functionality of Care Director is impacting on the
efficiency and effectiveness of Social Workers and
Social Care Assessors.
Staff and Trade Union involvement
actions undertaken/planned
Staff have been kept appraised of the changes to
services.
Patient & Public Involvement
The experience of Patients and Services Users and their
families is considered in the experience and
effectiveness reports to the Committee.
Equality Impact
The Committee has directed that an equality impact
assessment is referenced in the Transfers Policy with
regards to what actions are required to mitigate the risks
of transfers into and from our care.
Information exempt from Disclosure
None at this time.
Requirement for further review
None at this time.
RECOMMENDATIONS:
The Trust Board is recommended to receive the assurance report of the Chair of the Quality
Governance Committee into the matters and business arising from the meeting of the Committee
on the 13 January 2016 and to consider whether any further action is required to address the
matters highlighted in the key points above.
Page 3 of 3
Enc 03ii
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
03ii
Subject:
Assurance of Report of the Chair of the Audit Committee
Strategic Goal
(tick as appropriate):
X
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
Our organisation will develop and deliver sustainable, innovative services that
support independence
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
X
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Melanie Print, Company Secretary
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
To receive an assurance report from the Chair of the Audit Committee in relation to the matters and
business of the meeting of the Committee of the 15 January 2016 referred to the Board for its
review and action.
KEY POINTS:
Items of Business for Review by the Trust Board
The following matters are referred to the Trust Board, following the meeting of the Committee on
the 15 January 2016, for its consideration and required action as appropriate:
•
•
The Committee has directed that the actions arising from the Internal Auditors limited
assurance report into “financial management and CIP arrangements” are the subject of a
formal assurance report to the March meeting of the Committee, so that it can be confident
that the “culture of delivery of CIP” has been embedded into the cycle of Cost Improvement
Plans for 2016/17.
The Committee reviewed all outstanding actions arising from Internal Audit reports and
expressed its concern that a number of outstanding actions, ranked with a “high risk” rating,
have not been responded to. The Committee has recommended that the Director of
Finance & Resources reports their concerns to the Chief Executive Officer as the
Accountable Officer of the Partnership Trust. It is the Committee’s expectation that a
closure report will be made to it confirming what action has been taken to secure that
Page 1 of 3
Enc 03ii
•
•
•
Internal Audit recommendations are closed down on time, particularly those actions which
are allocated a “high risk” score.
The Committee welcomed the significant assurance that has been provided by the Internal
Auditors into the Financial Systems of the Partnership Trust. It has recommended that the
risks highlighted in relation to overpayments to staff are addressed by the Workforce
Matters Committee and that an assurance report is made by the Chair of that Committee to
the next meeting of the Audit Committee confirming what steps have been taken to
minimise overpayments and to secure recovery of the same, having regard to the volume
and value of overpayments made.
The Committee reviewed the limited assurances that had been made by the Internal
Auditors into the internal audit of Care Director (Client Income). It noted that the actions to
secure that full assurance can be applied to this function of Care Director, and the efficient
management of Client Income will be monitored through the Social Care Transformation
Programme; performance against this Programme is reported by the Director of Operations
to the Finance Investment & Performance Committee. The Committee reiterated its
expectation that actions arising from limited assurance reports are completed as a matter of
priority.
The Committee reviewed the Board Assurance Framework (Quarter 3 review), focussing on
those assurances which underpin the response to the CQC Warning Notice. It
recommended that those assurances which are the subject of “low confidence” ratings are
formally referred to the sponsor Committees with a direction that the relevant Committee
reviews the assurances and the actions taken to improve the confidence rating; a separate
report is to be provided by the Chair and lead Executive Director of each Committee to the
next convenient meeting of the Audit Committee.
INTER DEPENDENCIES:
Legal and/or Risk
Regulatory and reputational risk as a consequence of
the issue of a warning notice by the Care Quality
Commission. The Committee has an oversight function
in relation to the actions taken to address the required
improvements referenced in the warning notice.
Clinical
Service risks are a subset of the CQC Warning Notice.
These are monitored through the CQC Steering Group.
Financial
The risks to CIP delivery as highlighted in the limited
assurance internal audit report are monitored by the
Audit Committee and Board.
HR
None at this time.
Social Care
The actions taken to mitigate the limited assurance
applied to the audit of Care Director is being managed
through the Social Care Transformation Programme.
Staff and Trade Union involvement
actions undertaken/planned
None at this time.
Patient & Public Involvement
None at present.
Equality Impact
None at present.
Information exempt from Disclosure
None
Requirement for further review
The implementation of the actions arising from the
internal audit into financial management and CIP will be
reviewed at the Audit Committee in March 2016
Page 2 of 3
Enc 03ii
RECOMMENDATIONS:
The Trust Board is recommended to receive the assurance report of the Chair of the Audit
Committee into the matters and business arising from the meeting of the Committee of the 15
January 2016 and to consider whether any further action is required to address the matters
highlighted in the key points above.
Page 3 of 3
Enc 03
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 27th JANUARY 2016
Enclosure:
Enc 03
Subject:
Assurance Report of the Chair of the Workforce Matters Committee
Strategic Goal
(tick as appropriate):
x
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
x
Our organisation will develop and deliver sustainable, innovative services that
support independence
x
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
x
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Andrew Talbot – Non Executive Director/Julie Tanner – Director of
Workforce & Developoment
Recommendation:
For Approval &
Assurance
x
For Discussion
For Information
PURPOSE OF THE REPORT:
To receive an assurance report from the Chair of the Workforce Matters Committee in relation to
the matters and business of the meeting of the Committee on the 2nd December 2015.
KEY POINTS:
Items of Business for Review by the Trust Board
The following matters are referred to the Trust Board, following the meeting of the Committee on
the 2nd December 2015, for its consideration and required action as appropriate.
Equality Impact Assessments
The Equality and Inclusion Manager raised an issue relating to the inconsistency of policies within
the Trust not having a robust Equality Impact assessment completed on production of new policies
or the review of current versions.
There is a legal requirement on us as an organisation to ensure that this process is carried out.
The Equality and Inclusion Manager confirmed that there was work commencing with the Corporate
Governance Lead to ensure that a new process was put in place to ensure compliance. The E& I
Page 1 of 3
Enc 03
Manager was also going to draft a set of questions which this committee could use to test the
robustness of future EIA on workforce polices brought to the committee.
Recruitment Process
The Associate Director of Human Resources advised that from the original 65 action points on the
SBS Recruitment Action Plan, 38 have been closed and 27 remain in progress. Assurance was
given that the remaining 27 actions should be closed by the end of December 2015 then the
intention is to give SBS an improvement period until the end of March 2016 to reach the KPI of 14
weeks advert to fill time. The Trust also needs to make improvements at the front end of the
process with the approval of vacancies and turn round of actions. An exception sheet has been
compiled by SBS which will go to the AD for Human Resources to indicate where there are
blockages in the system attributed to Trust Managers so that these can be followed up.
As District Nursing and Community Hospitals Nursing staff is a high risk and needs a fast
turnaround these roles have been taken out of the SBS process for the time being and being dealt
with by a temporary internal recruitment team.
It was reported that there were concerns about the quality of the data being produced from the
Stepchange System administered by NHS SBS. However, a workshop had been arranged for
early January with key people attending where this will be resolved and an agreed suite of reports
identified. These reports would be reviewed at the next meeting of this committee.
Previously, all calls to SBS Recruitment were being received at a general helpdesk by staff with
very little knowledge of recruitment processes. SBS have worked with their staff and now have
recruitment specialists answering calls who have detailed knowledge and can answer queries in a
more timely manner. Feedback is showing that this seems to be working much better but will
continue to be reviewed via the Welcome Day Feedback Sheets.
Central Bank Team (renamed to Temporary Staffing Bureau - TSB)
It was reported that this newly established team had made considerable progress with recruiting
suitable people to the Trust internal bank arrangements. They had in the last 6 months doubled
the number of people available and were starting to build capacity across nearly all staff groups.
They were reporting on average an 80% fill rate across all requests.
In addition this team had taken on the role of co-ordinating all agency reuests and ensuring that
wherever possible, where bank was not available, bookings were within the tolerances set by the
Trust Development Authority/Monitor of “on framework” and “below the financial cap”. In addition
the team are co-ordinating the weekly return to the TDA on non-compliance with these
requirements.
Plans for the implementation of a neutral vendor arrangement to co-ordinate better access to
approved agencies and to provide more detailed management information was on trajectory for
going live before the end of the financial year.
INTER DEPENDENCIES:
Legal and/or Risk
Inefficient recruitment processes can lead to patient
safety risks and Trust reputational risk.
Clinical
None
Financial
None
HR
None
Social Care
None
Page 2 of 3
Enc 03
Staff and Trade Union involvement
actions undertaken/planned
Staff side are members of the Workforce Matters
Committee.
Patient & Public Involvement
None
Equality Impact
None
Information exempt from Disclosure
None
Requirement for further review
Recruitment processes under regular scrutiny by
Executive Management Team and Workforce
Information and Planning Committee.
RECOMMENDATIONS:
The Trust Board is recommended to receive the assurance report of the Chair of the Workforce
Matters Committee into the matters and business arising from the meeting of the Committee on the
2nd December 2015 and to consider whether any further action is required to address the matters
highlighted in the key points above
Page 3 of 3
Enc 03iv
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
03iv
Subject:
Assurance of Report of the Chair of the Finance Investment & Performance
Committee
Strategic Goal
(tick as appropriate):
X
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
Our organisation will develop and deliver sustainable, innovative services that
support independence
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
X
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Melanie Print, Company Secretary
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
To receive an assurance report from the Chair of the Finance Investment & Performance
Committee in relation to the matters and business of the meeting of the Committee of the 21
January 2016 referred to the Board for its review and action.
KEY POINTS:
Items of Business for Review by the Trust Board
The following matters are referred to the Trust Board, following the meeting of the Committee on
the 21 January 2016, for its consideration and required action as appropriate.
The Committee took some time to consider the Finance Report for Month 9, the Financial Outlook
for 2016/17 and the financial assumptions that underpin the proposed control total of a (net) £2.1M
deficit. The Committee recommends to the Board the following proposals to support the Trust’s
operational plan for 2016/17 under the terms of the Sustainability and Transformation Plan:
•
•
•
•
A CIP of 4% for 2016/17, the full plans for which will be reported to the Board at its February
meeting;
Break even in Adult Social Care;
Revised planning assumptions to support an overall break/even position; and
A reduction / review of loss making services consistent with the Core Services Strategy
which is to be approved by the Board.
Page 1 of 2
Enc 03iv
INTER DEPENDENCIES:
Legal and/or Risk
A failure to meet the control total reported by the TDA
will put the Trust at risk of breaching its statutory duty to
break even.
Clinical
The Core Service Strategy, of which the clinical strategy
will be a component part, will assist the Board in
agreeing the financial and service assumptions which
underpin achievement of the control total.
Financial
The financial assumptions that underpin the financial
outlook for 2016/17 are to be agreed by the Board. The
governance and delivery of CIP is being improved to
address the limited assurances reported to the Audit
Committee.
HR
None at this time.
Social Care
The renegotiation of the Section 75 Adult Social Care
quantum and outcomes of the Section 75 Agreement are
integral to the delivery of the control total for the Trust.
Staff and Trade Union involvement
actions undertaken/planned
None at this time.
Patient & Public Involvement
None at present.
Equality Impact
None at present.
Information exempt from Disclosure
None
Requirement for further review
The CIP Programme for 2016/17 will be presented to the
Board in February.
RECOMMENDATIONS:
The Trust Board is recommended to receive the assurance report of the Chair of the Finance
Investment & Performance Committee and to endorse the proposal referred to in the key points
above.
Page 2 of 2
Enc 04
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: 27 JANUARY 2016
Enclosure:
04
Subject:
Corporate Risk Register
Strategic Goal
(tick as appropriate):

We will provide high quality and safe services which provide an excellent
experience and best possible outcomes

We will work with users and carers to deliver integrated services, simply and
effectively

Our organisation will develop and deliver sustainable, innovative services that
support independence

Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values

We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Rose Goodwin – Interim Director of Nursing and Quality
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
The Corporate Risk Register is appended to this Report for review and note of the changes that
have taken placed through the Executive Risk Management Committee at its meetings on 14
December 2015 and 18 January 2016. The Board is asked to take assurance that the reported
risks are the subject of risk controls and actions to mitigate the residual risk reported on the
Register.
KEY POINTS:
Corporate Risk Register
The Risk Register has been reviewed and the following changes have been made at the Executive
Risk Management Committee.
December 2015:
• Risk Register discussed and agreed. One risk identified for de-escalation:
o Risk Ref 13 ~ sustainable plan for service delivery 2015/16
January 2016:
• Two new risks discussed and agreed for inclusion on the Corporate Risk Register:
o Risk Ref 608 ~ risk staff not fully competent and applying the principles of Mental
Capacity Act in practice
o Risk Ref 625 ~ non-compliance issues identified by Care Quality Commission which,
Page 1 of 2
Enc 04
if not addressed, could result in possible enforcement action
Risk Register Review Presentations:
•
The Committee signed off the following reviewed risk registers at the December 2015 and
January 2016 meetings:
o Nursing & Quality Directorate
o Finance Directorate
o Workforce Directorate
o Specialised Services Division
INTER DEPENDENCIES:
Legal and/or Risk
An effective Risk Management Strategy linked to the Board Assurance
Framework and the Corporate Risk Register will mitigate risks the
organisation’s Strategic Objectives and provides assurance that risks are
being managed.
Clinical
Those risks which are clinical are assigned to the relevant Directorate for
mitigation with updates through the governance of the Quality
Governance Committee.
Financial
Financial risks or risk with financial implications are escalated onto the
corporate risk register
HR
No HR risks are reported in this month’s Corporate Risk Register.
Social Care
The impact of the evolution of the integration is the subject of ongoing
review by the Executive Risk Management Committee.
Staff and Trade Union
involvement actions
undertaken/planned
Staff and trade union involvement is through either Committee (eg
workforce and health and safety) as risk are escalated/de-escalated or
through local discussions within Divisions.
Patient & Public
Involvement
We are engaging with those patients and their families who are affected
by decisions to decommission services.
Equality Impact
The impact on services which are decommissioned is assessed by the
CCGs
Information exempt
from Disclosure
None
Requirement for
further review
The Corporate Risk Register is reviewed monthly.
RECOMMENDATIONS:
The Trust Board is recommended to:
• Note the updated version of the Corporate Risk Register appended to this Report;
• Note the actions that are being taken to manage the reported risks.
Page 2 of 2
Target Risk Rating
4
3
12
3-6 Months
4
2
8
0-3 Months
Risk Proximty
Target Impact
20
Target Likelihood
5
Lead Director
4
Date Entered : 14/01/2016 10:18
Director Of Operations
16
Lead Officer
4
Director Of Operations
Cause: Qualified staff (Band 5 and above) inappropriately delivering
care that could be provided by non-qualified staff (Band 2 or 3)
Effect: Referrals of unmet need back to community services
Impact: Additional impact on the capacity of community services.
Delays to discharge from acute and community inpatient wards.
Concerns about compromise to patient safety.
4
Lead Manager
Monitoring has continued
throughout the previous
month. Non-availability of Dom
Care has been the biggest single
factor impacting on patient
flow
Director Of Operations
Continue to monitor and
review actions set out in the
Social Care Transformation
plan
Director Of Operations
Action Progress
Residual Rating
2 0 Social Care Transformation
Programme has work
streams in place to control
the risk
Actions Planned
Current Impact
5
Details of Risk Control
Current Likelihood
4
Initial Risk Rating
Initial Impact
Monthy
Insufficient standard domiciliary care and enhanced domiciliary care
11/01/2016 packages. It should be noted that this is predominantly a risk in the
North.
Initial Likelihood
Added to Register
Corporate
Operations
Directorate
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
01/08/2012
CQC Domain
SG2 Strategic Objective
Division,
Direcotrate,
Department
Safe
01
Responsive
Number
Risk Register - Corporate Risks
Cause: Care Director as a system is reported as difficult/cumbersome to
use by staff, issues with IM&T connectivity
Effect: Staff capacity reduced due to loss of productivity whilst using
the new system.
Impact: Under recovery of income
(PMO Work stream - Social Care Transformation Programme)
4
5
2 0 Action plan agreed to
address issues with the
way the system is working.
Additional capacity
secured to support Social
Care staff
User group established to
identify business process
changes
Change control group
established
Specific controls have
been included in the
transformation
programme
Monitor impact of actions
implemented for one month
then review with view to
possibly reducing the residual
risk score.
Jan 16: Continue with
transformation plan actions
including revision of Care
Director.
Jan 16: Report to Quality
Governance Committee
13/01/2016 illustrates
improvement. Issues remain in
relation to Care Director. Teams
are utilising manual recording
where necessary.
Director Of Operations
Monthy
Risk of delayed social care assessments and service provisions as a
11/01/2016 result of the issues/problems experienced with the implementation
and ongoing use of Care Director and associated loss of income.
Director Of Operations
Corporate
Operations
Directorate
01/10/2013
SG5
Safe
(PMO Work stream - Social Care Transformation Programme)
02
The next up-grade for Care
Director will be actioned by
2017 and although we have a
range of activities in train to
improve inputting the system
changes will not have the
required impact until next year.
We have a number of meetings
in place to review and improve
our performance but this is
dependent on some extra
admin staff inputting Service
Provisions etc.
Date Entered : 14/01/2016 10:24
Date Printed: 21/01/2016
Page 1 of 8
Target Risk Rating
5
2
10
6-9 Months
4
2
8
0-3 Months
Risk Proximty
Target Impact
16
Target Likelihood
4
Lead Director
4
Date Entered : 14/01/2016 10:19
Chief Executive Officer
20
Lead Officer
5
Director Of Operations
Jan 16: Continue to monitor
and review actions set out in
Social Care Transformation
Plan
4
Lead Manager
Monitoring has continued
throughout the previous
month. Non-availability of Dom
Care has been the biggest single
factor impacting on patient
flow
Director Of Operations
Monitor impact of actions
taken for one month with a
view to possibly reducing
residual risk score.
Director Of Operations
Action Progress
Residual Rating
2 0 Task and finish group to
review the effectiveness of
the current frameworks
and the capacity of the
Dom Care market place to
respond to current
demand and enhanced
packages of care. Task and
finish group reports into
the Social Care
Transformation
Programme who forecast
future activity so that a
new service can be
commissioned.
Actions Planned
Current Impact
4
Details of Risk Control
Current Likelihood
5
Initial Risk Rating
Monthy
Medium term risk for the Trust based on the re commissioning plans
11/01/2016 of the County Council for Domiciliary Care provision and the decision
to extend the existing arrangements. Co-dependency with Risk 1.
Cause: Not within the control of SSOTP - commissioning led by the
County Council
Effect: No change/improvements to provision - for a 12 month period
from April 15-March 16.
Impact: No change or enhancements to current service provision from
third party providers.
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
Corporate
Operations
Directorate
Added to Register
Division,
Direcotrate,
Department
01/04/2014
CQC Domain
SG2 Strategic Objective
Effective
03
Safe
Number
Risk Register - Corporate Risks
Cause: Inability to recruit staff to vacancies funded by Commissioners.
Effect: High pressure on services. Impact on Day and Night provision as
care carried across where visits have not been achieved.
Impact: Concerns about safety and quality of care. Low morale
amongst staff.
(PMO Work stream - Workforce)
4
4
1 6 Workforce Planning
Toolkit.
Safer Staffing
implementation
programme.
Commissioning Intentions
for 15/16 - service
specifications for district
nursing which will inform
the strategic approach by
SSOTP to provision and
staffing
To continue to monitor over
the coming months to ensure
that recruitment exceeds the
numbers of staff leaving the
service. To reduce residual
score once staffing levels
sustained.
Stoke Longton team have a
band 6 in place , reviewed need
to have more people in clinics ,
new starter in next 4 weeks .
Porthill and Chesterton have
appointed a permanent band 6
and work started to put in
place new team
Director Of Operations
Monthy
Risks to level (capacity) of service provision in the District Nursing
11/01/2016 service - North Division
Chief Operating Officer (North)
Corporate
Operations
Directorate
01/10/2014
SG2
04A
Safe Effective
Proposals have been
presented to SCC and the
Trust.
Date Entered : 14/01/2016 10:26
Safer Staffing dashboards
and monitoring.
Date Printed: 21/01/2016
Page 2 of 8
(PMO Work stream - Workforce)
Safer Staffing dashboards
and monitoring.
Some areas have achieved
staffing levels and skill mix
in line with WPT.
All red and red+ teams
have buddy system in
place.
Target Impact
Target Likelihood
Target Risk Rating
Risk Proximty
4
3
12
0-3 Months
Lead Director
16
Director Of Operations
4
Lead Officer
4
Lead Manager
Cannock - DN issues in
Cannock reducing - Hednesford
resolved - Great Wyrley easing
as vacancies filled - Rugeley Still
staffing pressures due to staff
sickness.
East - Day time teams have
minimal vacancies remaining,
Main challenge remains OOHs
due to the size of the team.
Stafford - ILCT 2 - Risk reduced
to 9 as a residual risk, as
staffing levels are improving,
bank is being used to support
ongoing vacancies.
Lichfield/Tamworth - Risk
remains unchanged. Agency
nurses continue to support the
area and are moved to support
the need as indicated.
Vacancies now recruited to and
continue to go through
recruitment checks
Seisdon CIS - Risk 313 on the
divisional plan - Budget
remains overspent and is now
an unsustainable cost pressure.
Reorganisation of boundaries is
planned by the end of January
which will further streamline
pathways and increase
efficiencies, however this will
again reduce the overall team
size as establishment is
adjusted in line with
geographical areas.
Residual Rating
Impact of actions
implemented to be monitored
over the coming month to
ensure effectiveness and then
review residual risk score with
a view to possible reduction.
Director Of Operations
Commissioning Intentions
for 15/16 - service
specifications for district
nursing which will inform
the strategic approach by
SSOTP to provision and
staffing
Action Progress
Current Impact
1 6 Workforce Planning
Toolkit.
Safer Staffing
implementation
programme.
Actions Planned
Current Likelihood
4
Details of Risk Control
Chief Operating Officer - South
Cause: Changes in the commissioning arrangements for the community
nursing workforce. Staff turnover and sickness. Underfunding of
services by Commissioners.
Effect: High pressure on services. Impact on Day and Night provision as
care carried across where visits have not been achieved.
Impact: Concerns about safety and quality of care. Low morale
amongst staff. Impact on a large number of patients.
4
Initial Risk Rating
Monthy
Risks to level (capacity) of service provision in the District Nursing
11/01/2016 service - South Division
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
South Division
Operations
Directorate
Added to Register
Safe Effective
Division,
Direcotrate,
Department
01/10/2014
CQC Domain
04B
SG2 Strategic Objective
Number
Risk Register - Corporate Risks
Date Entered : 21/01/2016 08:25
Date Printed: 21/01/2016
Page 3 of 8
2 0 Workforce Matters
SBS contract including
KPIs
Detailed
Divisional/Directorate
reports to enable
performance management.
Activity reports from SBS
Monthly employment
services board meeting to
review progress against
KPIs, weekly operational
calls.
Date Entered : 19/01/2016 14:33
3
4
12
Risk Proximty
Target Risk Rating
(PMO Work stream - Workforce)
5
12
0-3 Months
Cause: Slow process means that the time to recruit new members of
staff into the organisation has elongated.
Effect: Vacancy gaps within teams.
Impact: Services working with a reduced workforce for longer than they
would ordinarily do so impacting on morale and quality of care.
Increased agency spend as the staffing shortfall is managed in the short
term.
4
4
3-6 Months
Monthy
Risk to operational delivery as vacancies are not filled in a timely
06/01/2016 manner.
Target Impact
SG2
Corporate
Workforce
Directorate
Workforce &
Development
Direct
11/11/2014
Effective
07
Safe
All vacancies notified to
Director of Workforce to
rapidly identify trends.
Target Likelihood
16
New Deputy to Director of
Workforce to commence
in post.,
Lead Director
4
(PMO Work stream - Workforce)
Director Of Workforce And Deve
4
Date Entered : 19/01/2016 14:32
3
Director Of Workforce And Deve
Lead Officer
15
Lead Manager
There is currently a 3 month
monitoring period in operation
that is due for completion end
of March 2016. Fill rate is
currently 18 weeks with a target
fill rate of 14 weeks to be
achieved by the end of March
2016
5
Director Of Workforce & Development
Three month monitoring
period to commence
following implementation of
all improvement measures
(end of December 2015)
3
Associate Director Of Training & Transformation
New process has been
launched and feedback will be
provided to Workforce Matters
Committee at the end of
February 2016
Director Of Workforce & Development
Information obtained through
the new exit interview process
is to be collated and sorted by
Division, themes etc. A report
will be prepared and
presented to the Workforce
Matters Committee in
February 2016
Associate Director Of Human Resources
Wellbeing and Engagement
Group - has been on hold
until new Deputy to
Director of Workforce in
post.
Action Progress
Residual Rating
1 5 Regular monitoring
through EMT and
Workforce Matters
Committee
Actions Planned
Current Impact
5
Details of Risk Control
Current Likelihood
3
Initial Risk Rating
Monthy
Inability to sustain staffing levels in the Trust due to turnover of staff.
06/01/2016
Cause: Increased turnover of staff - with particular focus on district
nursing and ward based nursing staff.
Effect: Increased number of vacancies and/or skills gaps within
operational teams. Low staff morale.
Impact: Compromise to patient care and safety, less able to deliver to
contract specifications. Breach of contract delivery - penalties/fines.
Staff support systems compromised, e.g. appraisals.
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
Corporate
Workforce
Directorate
Workforce &
Development
Direct
Added to Register
Division,
Direcotrate,
Department
11/11/2014
CQC Domain
SG2 Strategic Objective
06
Safe
Number
Risk Register - Corporate Risks
Improvement Work
stream: Director Led
Project Group and Project
Plan
New Deputy to Director of
Workforce to commence
in post.,
All vacancies notified to
Director of Workforce to
rapidly identify trends.
Weekly conference calls to
internal Recruitment Team
Date Printed: 21/01/2016
Page 4 of 8
12
4
2
8
Risk Proximty
Target Risk Rating
16
3
3-6 Months
4
4
0-3 Months
4
Target Impact
On the divisional risk register Corporate risk, deviation
templates were completed and
agreed for all AHP services with
the exception of OT. No cost
pressures or inefficiencies have
resulted for the changes made
to the teams and all teams now
have an agreed skill mix to work
towards with no additional cost
pressures.
OT remains outstanding current
cost pressure £500k. Workforce
model and required
establishment now modelled
with finance
OT budget/establishment
remains outstanding Output of
WPT does not reflect the skill
mix required within the Team.
Transformation of Social Care
and Care Act have increased
demand on the team.
20
Target Likelihood
Awaiting amendments agreed
to be applied to individual
budgets concerned. Potential
for small cost pressure (initial
estimate £25k) on SLT budget
but will confirm once budgets
rectified.
Potential work force model
described to be implemented
as vacancies arise.
5
Lead Director
2 0 North and South
Implementation Groups reporting to Workforce
Planning and Information
(sub of Workforce
Matters).
4
Deputy Chief Executive Officer
Discussed at Senior
Management Team meeting and
no change or update at this
time
Director Of Operations
Business planning workshops
to were held during
November and following
these a CIP engagement
session for each division will
take place between January
2016 and March 2016.
Lead Officer
2 0 CIP Scrutiny Panel in place
reporting to FIP on a
monthly basis.
Monitoring of progress
against targets - escalated
to FIP Committee
Process undertaken to
identify and allocate
projects to Directorates.
Targets and initial project
plans sign off process in
place.
Lead Manager
Action Progress
Residual Rating
Actions Planned
Current Impact
Details of Risk Control
Current Likelihood
Initial Risk Rating
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
Division,
Direcotrate,
Department
Added to Register
CQC Domain
Strategic Objective
Number
Risk Register - Corporate Risks
5
4
Cause: Insufficient programmes identified to deliver the full CIP target.
In addition failure of CIP programmes to deliver against the targets
identified
Effect: Trust will be in a position of overspend.
Impact: Failure to deliver will mean that the Trust is unable to deliver a
breakeven at year end.
Corporate
Operations
Directorate
01/02/2015
SG2
11
Responsive
(PMO Work stream - CIP)
Monthy
Potential delay to implement findings and potential solutions of the
11/01/2016 Toolkit for AHP's
Cause: Inability (capacity and skills gap) of some operational managers
to implement the toolkit
Effect: Services not operating as efficiently as they could
Impact: Significant impact on CIP Delivery (approx. costing savings of
£2.5m not achieved/gap)
4
5
CIP Scrutiny Panel
Jan 16: Ongoing work to
address OT issues
Date Entered : 14/01/2016 11:07
Director Of Operations Director Of Operations & Service Transformation
Monthy
Risk of non-delivery of the CIP Target for 15/16. Target for health set at
13/01/2016 a minimum of 13.7 million (approx. 6% of Trust health budget). In year
risk.
Director Of Operations Director Of Operations & Service Transformation
Corporate
Transformation
Directorate
Financial
Management
01/01/2015
SG5
09
Well-Led
Use of Bank staff. Staff
being asked if they wish to
join the Bank on
induction.
Date Entered : 21/01/2016 08:29
Date Printed: 21/01/2016
Page 5 of 8
Target Impact
Target Risk Rating
Risk Proximty
3
2
6
0-3 Months
16
Target Likelihood
4
Lead Director
4
Director Of Workforce And Deve
Jan 16: Work ongoing in
relation to implementation of
toolkit
Lead Officer
We have not made any progress
re AHP toolkit .
Exception reports been
completed by division and
professional lead . This will
mean deviation form the toolkit
recommendations
Lead Manager
Templates need to be
presented to WPIG. Division
not currently in a position to
safely progress.
Associate Director Of Training & Transformation
Action Progress
Residual Rating
Actions Planned
Current Impact
Details of Risk Control
Current Likelihood
Initial Risk Rating
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
Division,
Direcotrate,
Department
Added to Register
CQC Domain
Strategic Objective
Number
Risk Register - Corporate Risks
Date Entered : 14/01/2016 10:41
Monthy
Risk of non-compliance with appraisals and mandatory training, in
06/01/2016 accordance with Trust guidance
Cause: Uptake of appraisals has reduced primarily due to 1) capacity
within the workforce and 2) changes to reporting periods to reflect
increments, although the quality of appraisals has improved
Effect: Less face2face time between managers and staff for staff
dialogue. Negative impact on planning for training and development.
Impact: Negative impact on staff morale and team
understanding/ownership. Reduced awareness of individual's role in
the organisational context. Potential compromise to patient care
This risk has a co-dependency with Risks CRR 6 staff turnover, and CRR
7 timely filling of vacancies.
Date Printed: 21/01/2016
4
4
1 6 Workforce Matters and
EMT
Priority work stream
Monthly dashboard with
performance data.
Monitoring of
re-registration
Feedback on process
through staff opinion
survey.
Ongoing monitoring of
mandatory training
compliance (likely to drop in
January due to winter
pressures and no mandatory
training sessions being
scheduled).
Implementation plan for Trust
wide appraisal process being
developed
No further update at this time.
Date Entered : 06/01/2016 11:56
Director Of Workforce & Development
Corporate
Workforce
Directorate
Workforce &
Development
Direct
01/01/2015
SG3
14
Safe
Risk discussed at WIPG 18
January 2016. There are
significant financial
implications attached to this
process. A deviation template
needs to be presented and
discussed at EMT 19 January
2016
Page 6 of 8
2
6
0-3 Months
4
1
4
Risk Proximty
Target Risk Rating
3
0-3 Months
16
Target Impact
4
Target Likelihood
4
Lead Director
15
Chief Operating Officer - Spec
5
Director Of Nursing And Qualit
Contract monitoring
bimonthly with three Local
Authority providers.
Lead Officer
Jan 16: Confirmed date
required for commencement
of new IT roll out
3
Lead Manager
Few minor issues are being
addressed and tested. Roll out
to commence in February 2016
but no confirmed date as yet.
Computers out of stock and
therefore only able to provide
20 computers at a time (approx.
60 computers need replacing)
and therefore roll out may take
some time depending on how
quickly new computers can be
obtained
Senior Programme Manager
Trial of new IT system to be
completed
Strategic Sexual Health Service Lead
Contracts with IT providers
- not supporting the
service delivery
Action Progress
Residual Rating
Cause: The IT system is provided by three different providers therefore a
very complex system. IT investigation carried out but no system
improvements.
Effect: Telephony system with intermittent cut out (or no phone system
at all at times), limits access to clinical system, stress to staff/low
morale, ad hoc use of a paper based system
Impact: Unable to report against contract KPIs. Patient experience due
to delays - complaints. Short term risk to clinical care and patient
safety due to move to paper based system as and when required. Issue
has been cited in some staff turnover.
1 5 Contract with activity
levels and KPIs
Actions Planned
Current Impact
5
Details of Risk Control
Current Likelihood
3
Initial Risk Rating
Monthy
Risk that the computer system will compromise the delivery of the LLR
04/12/2015 Sexual Health services against contract
Initial Impact
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
Initial Likelihood
Specialist Services
Division
Sexual Health
City of Leicester,
Leics and R
Added to Register
Division,
Direcotrate,
Department
01/03/2014
CQC Domain
SG5 Strategic Objective
15
Well-Led
Number
Risk Register - Corporate Risks
Date Printed: 21/01/2016
4
4
1 6 Adult Safeguarding team
and Professional Leads
Social worker available for
advice and support.
Briefings distributed to all
staff
Limited number of taught
sessions available to staff
Drafting of the MCA policy
Provision of additional taught
sessions
Updating the Training needs
analysis
Uploading an updated
ELearning package
Additional staff to be
identified to deliver MCA
training
Training needs analysis updated
and sent to the training
department
The MCA presentation
(Safeguarding Board Approved)
has been sent to the training
team and is awaiting upload as
an ELearning package.
Date Entered : 23/12/2015 15:10
Head Of Adult Safeguarding
Monthy
There is a risk that some staff are not fully competent and not applying
18/01/2016 the principles of the Mental Capacity Act in practice.
Cause: Lack of full provision of training and policy guidance available to
staffEffect: There are some staff that haven't received the necessary
training on MCAImpact: There may be some patients/service users that
havent received the appropriate assessments.
Director Of Nursing & Quality
23/12/2015
SG1
Corporate
Nursing And
Quality
Adult
Safeguarding
Caring
Safe Effective
Date Entered : 14/01/2016 10:57
608
Page 7 of 8
Date Entered : 21/01/2016 11:32
Target Impact
Target Likelihood
Target Risk Rating
Risk Proximty
4
2
8
0-3 Months
Lead Director
16
Director Of Nursing And Qualit
4
Lead Officer
4
Lead Manager
Weekly actions continue to be
monitored through the
operational delivery group with
escalations identified by the
steering group to Executive
Management Team. Progress
towards the delivery of actions
together with assurance testing
of outcomes is on track for
delivery.
Director Of Nursing & Quality
Ongoing work to complete
actions identified in detailed
action plan
Residual Rating
2 0 Detailed action plan in
place to address areas of
non-compliance. Action
plan reviewed and
updated weekly at Steering
Group meeting and
Operational Delivery Group
meetings and any slippage
escalated to EMT weekly
Action Progress
Current Impact
4
Actions Planned
Current Likelihood
5
Initial Risk Rating
Initial Impact
Initial Likelihood
Monthy
Non compliance issues have been identified by the Care Quality
19/01/2016 Commission which, if not addressed, could lead to possible
enforcement action
Cause: CQC did not receive adequate assurance in all areas during an
inspection in November 2015Effect: Non-compliance issues
identifiedImpact: Possible enforcement action if non-compliance
issues not addressed
Details of Risk Control
Associate Director Of Quality And Nursing
Responsive
Safe
Well-Led
Date Printed: 21/01/2016
Added to Register
Corporate
Nursing And
Quality
Review Cycle Description of Risk
and Last
Updated
Cause
Effect
Impact
19/01/2016
CQC Domain
Caring
SG1 Strategic Objective
625
Division,
Direcotrate,
Department
Effective
Number
Risk Register - Corporate Risks
Page 8 of 8
Enc 05
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 27 JANUARY 2016
Enclosure:
Enc 05
Subject:
Safe Nurse Staffing in Community Hospitals
Strategic Goal:
(tick as applicable)
X
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
Our organisation will develop and deliver sustainable, innovative services that
support independence
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Rose Goodwin - Director of Nursing & Quality (Interim)
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
This paper provides an overview of nurse staffing levels in the Community Hospitals of the
Partnership NHS Trust during November 2015 and December 2015.
KEY POINTS:
The nurse staffing levels summary is attached for both November 2015 (Appendix 1) and
December 2015 (Appendix 2).
November 2015
• Safe staffing has been maintained throughout November 2015 across all 4 Community
Hospitals operated by the Partnership Trust.
• Day time fill rate for registered nurses has increased by 2% to 98.1%; care worker fill rate
remains unchanged.
• The number of shifts being characterised as being of professional concern (red) has fallen
from 16 to 10.
• The number of shifts with only 1 RN on duty has fallen to 6 from 18.
• Ward 2 at Cheadle remains an outlier against registered nurse to patient ratios (day time
shifts). There have been no patient safety issues reported on the ward related to staffing.
• The number of shifts with additional care worker on duty continues to rise in response to the
need to carry out close supervision and monitoring for those at risk of falls.
Page 1 of 8
Enc 05
•
•
Vacancies have increased within the service. There are challenges in recruitment due to
interest in the roles and poor calibre of applicants at interview.
Staff sickness for care workers has risen to 6.81% from 3.92% (October 2015) and can be
attributed to seasonal illness and pre-existing health problems requiring surgical
interventions.
December 2015
• Safe staffing has been maintained throughout December 2015 across all 4 Community
Hospitals operated by the Partnership Trust.
• Day time fill rate for registered nurses has fallen slightly (1%) to 97.4% and for care workers
to 99.3%. Night time fill rate remains unchanged.
• The number of shifts being characterised as being of professional concern (red) has risen
from 10 (November 2015) to 16, which is a return to October 2015’s position. There have
been no patient safety issues as a result of staffing.
• The number of shifts with only 1 RN on duty has risen from 6 to 16 (in line with October’s
position) and includes four shifts for Scotia Ward where bed occupancy was low (4 and 5
patients) that it was deemed safe to have only one registered nurse on duty.
• Wards 1 and 2 at Cheadle Hospital are reporting day time registered to patient ratios in
excess of national best practice guidance, (1:9 and 1:10 respectively). There have been no
patient safety issues reported on the ward related to staffing.
• The number of shifts with additional care worker on duty has fallen by 4% in December
2015 but additional staff continue to be needed to undertake close supervision and
monitoring of those at risk of falls.
• Vacancies remain relatively unchanged during December 2015.
INTER DEPENDENCIES:
Legal and/or Risk
It is a requirement of NHS England to provide monthly updates on safe
staffing levels. Failure to comply will risk reputational damage with the
public.
Clinical
The link between safe nurse staffing levels is clear. Ensuring that the right
staff are on duty to deliver care in a timely manner is a priority for the
Partnership Trust
Financial
There are no direct financial implications associated with this paper
however there are additional costs associated with temporary staff usage.
HR
On-going recruitment and management of staff sickness is reliant upon
HR support. The Staffing Establishment has been approved by and
supported by the Board
Staff and Trade
Union involvement
actions
undertaken/planned
Support from staff side colleagues is essential in managing staff absence
and supporting safe recruitment practices.
Social Care
This paper relates to safe nurse staffing levels in Community Hospitals
only.
Patient & Public
Involvement
There has been no direct involvement of public groups in the development
of this paper. Safe staffing information is available to the wider public
through NHS Choices and the organisations website.
Equality Impact
Safe nurse staffing levels has an impact on all users of service regardless
of culture or ethnicity. This paper describes how a safe staffing profile is
monitored and this is available to the public via the organisations website.
Information exempt
None. This paper will be published on the Partnership Trust website to
Page 2 of 8
Enc 05
from Disclosure
allow public scrutiny.
Requirement for
further review
Safe nurse staffing levels will continue to be monitored on a monthly basis
RECOMMENDATIONS / ACTION REQUIRED:
The Trust Board is requested to:
1. Note the report content and be assured that the organisation is compliant with safe nurse
staffing level guidance for both November and December 2015.
Page 3 of 8
Enc 05
Report on Safe Nurse Staffing in Community Hospitals –November 2015
Safe Nurse Staffing
Safe staffing has been maintained during November 2015 across the community hospital in-patient
wards.
Fill Rate
NHS England requires all NHS organisations to provide information relating to ‘Fill Rate’ for both day
and night time shifts. The term ‘Fill Rate’ relates to the total planned hours (staff scheduled to work
on roster) versus actual hours worked and not to the number or skill mix required in agreed shift
establishment.
The fill rate during day time shifts for registered nurses in November 2015 is reported at 98.1%
(96.0% in October 2015) and 101.3% for care workers, which is unchanged from October 2015.
Night time fill rate has increased slightly for registered nurses from 98.7% in October to 99.1% in
November 2015. At night the fill rate for care workers has also risen to 102.5% (October 2015 –
100.7%) and reflects the additional staff used to support care for those at risk of falls.
RN to Patient Ratio
The overall registered nurse (RN) to patient ratio remains within acceptable parameters (1:7 - day
time and 1:10 - night time). A ratio of one registered nurse to nine patients (day time) has been
reported at on Ward 2 at Cheadle Hospital on three successive occasions from September to
November 2015. The ward has a relatively high vacancy factor (5.19WTE) for registered nurses, has
staff on maternity leave as well as an above average rate of sickness for both care workers and
registered nurses. The Hospital Matrons and Community Hospitals Manager are working with HR
colleagues in the active recruitment to these and posts across the service.
Night time shifts are staffed so as to ensure a minimum of two registered nurses on duty and
therefore the night time patient to registered nurse ratio will vary from ward to ward, with the average
ratio for night time being reported as 1:10 across the service. There are no wards during November
which have exceeded the agreed standard for each ward at night.
The number of shifts where there is only one registered nurse on duty has fallen from eighteen
(October 2015) to six in November 2015; all of these shifts were night shifts. On 1 November 2015
severe fog affected the area and was cited as a reason as to why three registered nurses failed to
report for duty, resulting in only one registered nurse being available. It was fortunate that additional
care staff were on duty to support individuals at risk of falls, thus reducing some of the risk
associated with only one registered nurse being on duty.
Number of Shifts Deviating from Agreed Staffing Levels
Each ward has a staffing establishment and skill mix developed from safe staffing reviews which is
based on patient acuity. The number of instances where the shift by shift establishment is deviated
from is reported as part of the summary dashboard.
The number of shifts falling below agreed staffing for registered nurses was 289 in November
(24.7%) a slight fall from October’s figure (28.8%) and for care workers this figure was 36 (3.07%)
which is unchanged from October’s figure (3.22%).
The number of shifts above agreed establishment for registered nurses was 62 (5.29%) which is an
increase compared to the October percentage (3.06%). The reported increase can be attributed to
Page 4 of 8
Enc 05
issues with supply and demand for temporary staff. There have been a number of occasions during
November 2015 where requests have been made to the internal Bank for care workers but none
could be provided for the dates/shifts required, there was however registered nurse availability and
these staff were utilised, despite a lower band being required, so as not to impact safety. Additional
care workers continue to be utilised across the service and there has been a further rise in the
number of shifts above the agreed establishment for this staff group to 57.09%. These staff have
been utilised to support individuals who, due to cognitive impairment and increased frailty, are at
increased risk of falls and harm and to fill gaps in registered nurse rota’s where this staff group
cannot be sourced.
Professional Concerns
There were ten shifts reported as being of professional concern during November 2015 a fall from
October (16). The majority (9 shifts) of these shifts were night shifts and one was a late shift. Three
of the night shifts related to temporary staff failing to report for duty due to inclement weather (fog).
Five of the shifts where professional concern was raised were shifts with only one registered nurse
on duty. The short notice absence coupled with high patient demand put additional pressure on the
teams; in the majority of cases there were no patient safety incidents although there were a small
number of no harm falls where staffing levels were considered a factor. In the remaining instances
concerns related to increased care needs of those on the wards. Mitigation of risk has been
achieved by reprioritising work activities and support provided by other staff on site.
The number of ‘amber’ shifts reported has fallen slightly to 21.88% (256 shifts) from 22.41% in
October 2015 and those classed as been of no concern (green) have correspondingly increased to
77.26% from 76.26% in October 2015.
Agency Staff Usage
Agency usage has remained relatively unchanged during November 2015; registered nurse agency
staff – 8% (9% in October 2015), care worker – 11% (10% in October 2015). Wards are required to
utilise the internal Bank to supply temporary staff in the first instance before agency resources can be
considered. Where agency staff are used senior manager agreement is required.
Care workers form the majority of agency staff usage so as to support individuals at risk of falls.
There are some wards where registered nurse agency use is high and reflects vacancy and sickness
in this staff group.
Recruitment
The number of registered nurse and care worker vacancies within the Community Hospitals service
(hands on care) has increased to 32.77WTE (RN – 26.62 WTE and HCSW – 6.15WTE) from 28.73
WTE. Recruitment continues, however suitable candidates both in number and suitability for the
position offered continues to be a challenge.
Sickness
The average percentage sickness absence in November 2015 remains relatively unchanged for
registered staff (2.69% - Nov/ 2.77% - Oct) and has increased for care workers (6.81% – Nov/ Oct –
3.92%). The majority of sickness relates to short term illness, often associated with the time of year
however there are a number of staff awaiting surgery and are precluded from work as a result of their
health needs.
Page 5 of 8
Enc 05
Report on Safe Nurse Staffing in Community Hospitals –December 2015
Safe Nurse Staffing
Safe staffing has been maintained during December 2015 across the community hospital in-patient
wards.
Fill Rate
NHS England requires all NHS organisations to provide information relating to ‘Fill Rate’ for both day
and night time shifts. The term ‘Fill Rate’ relates to the total planned hours (staff scheduled to work
on roster) versus actual hours worked and not to the number or skill mix required in agreed shift
establishment.
The fill rate during day time shifts for registered nurses in December 2015 is reported at 97.4%
(98.1% in November 2015) and 99.3% for care workers, which is a slight fall from November 2015
where care worker fill rate (day) was reported at 101.3%. Night time fill rate remains relatively
unchanged for registered nurses, 98.1% in December and 99.1% in November 2015, and care
workers, 103.9% in December and 102.5% in November 2015. ‘Overfill’ rates (above 100%) reflect
the additional care worker staff utilised to fill gaps in the rota where registered nursing staff cannot be
sourced and to support care for those at risk of falls, thus mitigating risk.
RN to Patient Ratio
The overall registered nurse (RN) to patient ratio remains within acceptable parameters (1:7 - day
time and 1:10 - night time). A day time ratio of one registered nurse to nine patients has been
reported on Ward 1 and a ratio of one registered nurse to ten patients reported for Ward 2 both
wards are at Cheadle Hospital. Night time ratios (registered nurse to patient) on these wards are
within normal parameters (1:10). Staff sickness and registered nurse vacancies are all key
contributors to an inability to meet the ratios recommended nationally. In addition the hospital’s rural
location, away from public transport links means attracting temporary staff to fill registered nurse
gaps in the rota is difficult. Recruitment options continue to be pursued but the future transfer to
University Hospital of North Midlands is seen by prospective candidates as a detractor and reducing
interest in available posts. The hospital manager and matrons are working closely to reallocate
staffing from other sites to improve cover however the ability to achieve this is hampered by
absences on other wards and sites.
Night time shifts are staffed so as to ensure a minimum of two registered nurses on duty and
therefore the night time patient to registered nurse ratio will vary from ward to ward, with the average
ratio for night time being reported as 1:10 across the service.
The number of shifts where there is only one registered nurse on duty has risen during December
2015 from 6 to 16. The majority of shifts where there was only one registered nurse on duty were
night shifts (13). Four of these shifts relate to Scotia Ward, as a result of staff sickness and
additional registered nurse cover could not be sourced; ward occupancy was low, four and five
patients, and following a risk review it was determined by operational managers that the remaining
staffing levels were sufficient to maintain safety, particularly with the available support from wards on
site on these occasions. Nine of the instances where there was one registered nurse on duty were
classed as being of professional concern. Four of these were night shifts, one early shift and one
late shift and were of concern due the lateness that staff were made aware that registered nurse
cover would be diminished. There were no patient safety incidents as a result of staffing on any of
the wards reporting professional concern or reduced registered nurse cover.
Number of Shifts Deviating from Agreed Staffing Levels
Each ward has a staffing establishment and skill mix developed from safe staffing reviews which is
based on patient acuity. The number of instances where the shift by shift establishment is deviated
from is reported as part of the summary dashboard.
Page 6 of 8
Enc 05
The number of shifts falling below agreed staffing for registered nurses was 336 in December 2015,
an increase compared to November’s data (289/24.7%), and represents 27.8% of all shifts; for care
workers this figure was 59 (4.9%), again an increase from November 2015 (36/3.07%). No
excessive annual leave was taken in December 2015 and the fall in shifts below agreed staffing
levels is thought to relate to a reduction in availability from temporary staff (Bank and Agency) due to
the Christmas and New Year holiday period.
The number of shifts above the agreed establishment for registered nurses has remained relatively
unchanged at 66 shifts (5.4%) for December 2015 (62/5.29% in November 2015). There have been
a number of shifts where care worker cover was required but availability was limited to registered
nursing staff; in these instances the more qualified individual was utilised to ensure safety rather than
accept a gap in the service. For care workers there were 645 shifts (53.3%) where additional staff
were utilised, which is a slight reduction on November’s figure of 57.09%. This staff group have
supported additional care needs, particularly those at risk of falls and also to mitigate risk where
registered nurse cover cannot be sourced.
Professional Concerns
There were sixteen shifts reported as being of professional concern during December 2015
compared to ten shifts in November 2015 but this figure is equal to that reported in October 2015.
The majority of these shifts (11) were night shifts; four were late shifts and one an early shift. The
majority of shifts were deemed as being of professional concern as a result of short notice absence,
either sickness or failure of temporary staff to report for duty, or where patient care needs exceeded
nursing capacity. There were no patient safety incidents relating to staffing on these shifts but
nursing staff felt pressured and as they continued to strive for high quality care with reduced
resources.
The number of ‘amber’ shifts has increased from 256 (21.88% - November 2015) to 380 (31.4%) in
December 2015. This change is a reflection in the increased activity associated with the winter and
holiday period and associated increase in patient acuity. It is important to note that an amber shift is
one where there is a disparity between agreed and actual staffing numbers/skill mix or between
demand and capacity however the concern or disparity concern has been resolved or appropriate
mitigation in place to maintain safety.
Agency Staff Usage
Agency usage for December 2015 is reported as 8% for registered nursing staff, which is no change
from previous months and 12% for care worker staff, a slight increase (Nov – 11%, Oct – 10%) from
previous months and reflects the need to provide support for those at risk of harm whilst in an
inpatient area. Use of Agency staff is agreed through the operational management team for the
hospitals and can only be considered when all other avenues have been exhausted.
Recruitment
The number of vacancies for both registered nursing and care worker staff has remained relatively
unchanged (RN: Nov – 26.62WTE & Dec – 25.15WTE and HCSW: Nov – 6.15WTE & Dec –
4.66WTE). A rolling programme of recruitment continues however perceived uncertainty about the
future of this service and the impending transfer of some services to University Hospitals of North
Midlands has resulted in a low level of interest in available posts.
Sickness
The average percentage sickness absence for December 2015 is reported at 39.68WTE (7.27%) for
care workers and 5.5WTE (2.82%) for registered staff. The overall small increase in sickness
amongst care workers is a likely reflection of seasonal illnesses e.g. colds, flu like symptoms and
winter vomiting. There are some ward areas that are reporting high levels of sickness absence again
due to seasonal health problems but also long term health issues, some of whom require surgery
before they are able to return to work.
Page 7 of 8
Enc 05
Recommendations
The Trust Board is requested to:
1. Note the report content and be assured that the organisation was compliant with safe nurse
staffing level guidance for both November and December 2015.
Page 8 of 8
Safe Staffing (Community Hospitals)
Nov-15
Professional Judgement
Monthly Fill Rate (NHS Choices)
No of shifts RAG rated by nurse in charge
Actual V Rostered Staffing (Hours)
Staffing Ratios
Establishment
Low Staffing
High Staffing
Agency Staff
Vacancies and Leave
Average RN to Patient Ratio
Ward Establishment
(WTE)
Number of shifts BELOW agreed
establishment
Number of shifts ABOVE
agreed establishment
Average % of Actual Staffing
Agency Staff
WTEs vacant or not filled due to sickness/maternity leave
Professional Assurance
Ward
Bed Numbers
Green
Amber
Red
RN - Day
HCSW - Day
RN - Night
HSCW - Night
Day
Night
RN
HCSW
RN
HCSW
Only 1 RN on
Shift
RN
HCSW
RN
HCSW
Vacancies - RN
Vacancies HCSW
Posts
appointed to
but not yet
started
Maternity
Leave
Bennion
21
54
35
1
96.3%
97.7%
98.2%
100.9%
1:6
1:11
16.85
14.80
33
3
1
0
66
5%
5%
0.73
0.00
0.00
0.00
2.05 - HSCW Safe staffing has been maintained throughout November 2015. There was only
one shift (Night) which was of professional concern and also resulted in one
(11.88%)
RN on duty. A Bank member of staff failed to report for duty due to adverse
0.07 - RN
weather (fog). A near miss event (fall without injury) occured on this shift and
(0.41%)
staffing was thought to be a contributing factor.
Oak
21
81
9
0
100.1%
98.1%
101.9%
100.0%
1:7
1:10
15.14
14.24
2
7
0
2
2
1%
1%
1.77
0.00
0.00
0.00
1.32 - HSCW
(10.49%)
0.06 - RN
(0.41%)
0.00
1.15 - HSCW shifts with only one RN on duty or where professional concern was raised. The
ward is unable to meet the RN staffing levels set out as part of the D2A project
(6.11%)
and where gaps in RN provision cannot be filled, care worker staff have been
1.25 - RN
utilised to mitigate risk. Additional care worker staff have also been used to
(8.00%)
support close supervision and monitoring of those individuals at risk of falls.
0.00
4.52 - HSCW
(9.49%)
1.38 - RN
(2.94%)
0.00
0.07 - HSCW
(0.48%)
0 - RN
(0.00%)
1.00
2.65 - HSCW one shift (Night) which was of professional concern and also resulted in one
RN on duty. An Agency member of staff failed to report for duty due to adverse
(13.72%)
weather (fog). Mutual aid was provided from the adjacent ward and there were
0.69 - RN
no patient safety issues relating to staffing reported. Additional care worker
(4.47%)
staff have also been used to support close supervision and monitoring of those
1.00
2.72 - HSCW
(7.10%)
0.69 - RN
(2.24%)
0.00
0.87 - HSCW
(7.06%)
0.6 - RN
(5.23%)
0.00
0.88 - HSCW the night shifts resulting in only one RN on duty. All shifts where concern was
(7.84%)
raised resulted from late notice absence, making sourcing additional staff
challenging. The majority of absences related to sicknes but one shift was
0.17 - RN
challenged
due to poor weather and the Agency nurse did not report for duty as
(1.52%)
Hospital
Bradwell
Sickness
Professional Assurance Statement
Safe staffing has been maintained throughout November 2015. There were no
shifts with only one RN on duty or where professional concern was raised.
Safe staffing has been maintained throughout November 2015. There were no
Sycamore
22
58
32
0
98.7%
100.0%
100.0%
100.0%
1:6
1:11
18.56
17.51
31
2
0
0
31
1%
2%
3.65
0.00
0.00
There have been no patient safety incidents relating to staffing.
Total
Bradwell
Ward One
64
24
193
84
76
6
1
0
98.2%
95.3%
98.6%
97.8%
100.0%
100.0%
100.5%
100.0%
1:6
1:8
1:10
1:12
50.55
15.14
46.55
14.24
66
12
12
6
1
0
2
20
99
72
2%
3%
3%
18%
6.15
0.00
0.00
0.00
0.00
0.00
Cheadle
Safe staffing has been maintained throughout November 2015. There were no
shifts with only one RN on duty or where professional concern was raised.
Additional staff have been utilised to provide close monitoring and supervision
for those individuals at risk of falls. There have been instances where care
worker staff could not be sourced and RN's were available; in these instances
they were redeployed to another ward area, with RN gaps.
Safe staffing has been maintained throughout November 2015. There was only
Ward Two
24
46
43
1
98.0%
98.8%
98.3%
100.0%
1:9
1:12
18.56
16.51
57
0
1
0
60
17%
7%
5.19
0.00
0.00
individuals at risk of falls.
Total
Cheadle
Cottage
48
19
130
68
49
21
1
1
96.5%
98.8%
98.3%
99.1%
99.2%
100.0%
100.0%
96.8%
1:8
1:8
1:12
1:9
33.70
15.14
30.75
11.82
69
37
6
1
1
0
20
1
132
38
10%
7%
13%
1%
5.19
3.65
0.00
1.60
0.00
0.00
Safe staffing has been maintained throughout November 2015. There were no
shifts with only one RN and only one shift (Night) where professional concern
was raised. Short notice sickness absence from the care worker staff and an
inability to find alternative cover placed additional pressure on the team, whilst
caring for patients with complex care needs. There were no patient safety
issues relating to staffing. Additional care worker staff have been used to
support close supervision and monitoring of those individuals at risk of falls and
to mitigate risk where RN gaps cannot be filled.
Leek
Safe staffing has been maintained throughout November 2015. There were four
shifts where professional concern was raised (1x Late and 3 x Night) with two of
Saddler
17
59
27
4
100.0%
99.6%
96.8%
97.2%
1:8
1:9
15.14
10.82
52
1
2
0
55
6%
9%
4.58
0.00
0.00
a result. There were two instances of no harm falls on these shifts and staffing
was thought to be a contributing factor.
Leek
36
127
48
5
99.4%
99.4%
98.4%
97.0%
1:8
1:9
30.28
22.64
89
2
2
1
93
6%
5%
8.23
1.60
0.00
0.00
1.75 - HSCW
(7.45%)
0.77 - RN
(3.38%)
Broadfield
23
55
35
0
88.4%
108.6%
100.0%
125.0%
1:8
1:11
16.01
22.65
29
7
1
7
52
2%
17%
0.00
2.00
2.00
1.00
0.37 - HSCW shifts where professional concern was raised and one shift (Night) with only one
(2.17%)
RN on duty due to failure of an Agency nurse failing to report for duty. Gaps in
RN provision were filled by additional care worker staff when RN's could not be
1.43 - RN
sourced. Additional care worker staff were also utilised to reduce risk of harm
(9.16%)
0.00
2.2 - HSCW
(14.51%)
0.8 - RN
(6.36%)
Safe staffing has been maintained throughout November 2015. There were no
shifts with only one RN on duty or where professional concern was raised.
Additional care workers were utilised to provide close monitoring for those at
risk of falls.
Safe staffing has been maintained throughout November 2015. There were no
shifts with one RN on duty and two shifts (Night) where professional concern
was raised. Late notice sickness absence resulted in RN gap's not been filled
adding additional pressure on to the team, caring for individuals with complex
health needs. There were no patient safety incidents relating to staffing
reported onthese shifts. Additional care workers were utilised to provide close
monitoring for those at risk of falls. Where care workers were requested and
none available but a RN was sourced these staff were utilised on wards with RN
gaps in the rota.
Total
Safe staffing has been maintained throughout November 2015. There were no
amongst individuals with unpredictable and risky behaviours.
Chatterley
21
64
26
0
94.3%
99.1%
100.0%
99.0%
1:7
1:12
16.85
15.80
26
0
0
5
85
37%
27%
4.19
0.00
0.00
Grange
32
83
5
2
105.3%
109.1%
96.6%
103.3%
1:6
1:10
22.54
19.22
5
3
0
18
75
23%
26%
0.00
0.00
0.00
1.78
2.46 - HSCW
(11.08%)
1.54 - RN
(7.25%)
Jackfield
20
78
11
1
98.8%
97.7%
98.3%
98.8%
1:6
1:10
15.14
14.24
5
0
1
8
88
2%
15%
0.86
1.55
0.00
0.00
0.35 - HSCW Safe staffing has been maintained throughout November 2015. There was one
shift (Night) with only one RN on duty and where professional concern was
(2.61%)
raised as a result of late notice sickness. Additional care workers were utilised
0.02 - RN
to provide close monitoring for those at risk of falls and those who require the
(0.16%)
support of more than 2 members of staff to move safely.
Scotia
10
90
0
0
100.0%
99.3%
100.0%
100.0%
1:4
1:4
11.89
6.12
0
0
0
0
5
0%
0%
1.00
0.00
0.00
0.00
Sneyd
20
84
6
0
100.5%
108.7%
100.0%
114.1%
1:6
1:10
17.01
14.23
0
6
0
1
39
0%
11%
1.00
1.00
0.00
0.00
Haywood
126
454
83
3
98.3%
104.0%
99.0%
105.4%
1:6
1:9
99.44
92.26
65
16
2
39
344
11%
16%
7.05
4.55
2.00
2.78
274
904
256
10
98.1%
101.3%
99.1%
102.5%
1:7
1:10
246.11
218.64
289
36
6
62
668
8%
11%
26.62
6.15
2.00
3.78
Haywood
Total
Overall
Total
0.8 - HSCW
(12.38%)
0 - RN
(0.00%)
1.3 - HSCW
(8.69%)
0.02 - RN
(0.14%)
7.48 - HSCW
(8.57%)
3.81 - RN
(3.85%)
16.47 - HSCW
(6.81%)
6.65 - RN
(2.69%)
Safe staffing has been maintained throughout November 2015. There were no
shifts with only 1 RN on duty or where professional concern was raised
Safe staffing has been maintained throughout November 2015. Safe staffing
has been maintained throughout November 2015. There were no shifts with
only 1 RN on duty or where professional concern was raised. Additional care
workers were utilised to provide close monitoring for those at risk of falls.
Safe Staffing (Community Hospitals)
Dec-15
Monthly Fill Rate (NHS Choices)
Staffing Ratios
Establishment
Low Staffing
High Staffing
Agency Staff
Vacancies and Leave
Actual V Rostered Staffing (Hours)
Average RN to Patient Ratio
Ward Establishment
(WTE)
Number of shifts BELOW agreed
establishment
Number of shifts ABOVE
agreed establishment
Average % of Actual Staffing
Agency Staff
WTEs vacant or not filled due to sickness/maternity leave
Ward
Bed Numbers
Green
Amber
Red
RN - Day
HCSW - Day
RN - Night
HSCW - Night
Day
Night
RN
HCSW
RN
HCSW
Only 1 RN on
Shift
RN
HCSW
RN
HCSW
Vacancies - RN
Vacancies HCSW
Posts
appointed to
but not yet
started
Bennion
21
48
45
0
92.8%
102.2%
100.0%
100.0%
1:6
1:10
16.85
14.80
40
3
0
0
62
3%
5%
0.73
0.00
0.00
Hospital
Maternity
Leave
Sickness
Professional Assurance Statement
0.00
1.49 - HSCW
(8.49%)
0.42 - RN
(2.60%)
Safe staffing has been maintained throughout December 2015. There were no
shifts with only one registered nurse on duty or where professional concern was
raised. Acuity of patients remains high and additional staff are being utilised to
reduce risk of falls in those at risk. Additional care worker staff were utilised to fill
gaps in the roster where registered nursing staff could not be sourced and to
support individuals at risk of falls.
Safe staffing has been maintained throughout December 2015. There was one
shift (Night shift) with only one registered nurse on duty as a result of late notice
sickness. Bed capacity was slightly reduced (2 empty beds) and measures
were taken to reduce risk. Support was provided from colleagues on site and
reprioritising work activities reduced risk. There was one shift (Night Shift)
where professional concern was raised due to increased demand following
deterioration in a patient's health. There were no patient safety incidents as a
result of staffing concerns. Additional staff have been used to support close
supervision and monitoring of those at risk of falls.
Safe staffing has been maintained throughout December 2015. There were was
one shift (Night shift) with only one registered nurse on duty which was also of
professional concern. Short notice sickness and increased patient care needs
were key factors on this shift. There were no patient safety incidents as a result
of staffing concerns. Where gaps in registered nursing cover cannot be filled
additional care workers have been sourced to maintain patient safety.
Oak
21
64
28
1
95.8%
100.5%
98.4%
100.0%
1:6
1:11
15.14
14.24
15
2
1
0
15
8%
9%
1.77
0.00
0.00
0.00
Sycamore
22
45
47
1
99.0%
98.5%
98.4%
96.7%
1:7
1:11
18.56
17.51
49
4
1
1
43
2%
4%
3.65
0.00
0.00
0.00
1.23 - HSCW
(6.90%)
0.06 - RN
(0.41%)
Bradwell
64
157
120
2
95.8%
100.4%
98.9%
99.0%
1:7
1:11
50.55
46.55
104
9
2
1
120
5%
6%
6.15
0.00
0.00
0.00
5.12 - HSCW
(11.02%)
0.64 - RN
(1.38%)
Ward One
24
57
36
0
90.3%
97.4%
100.0%
106.4%
1:9
1:12
15.14
14.24
28
5
0
11
72
6%
23%
0.00
0.00
0.00
0.00
0.77 - HSCW
(5.95%)
0.35 - RN
(2.65%)
Safe staffing has been maintained throughout December 2015. There were no
shifts with only one registered nurse on duty or where professional concern was
raised. Additional care worker staff were utilised to fill gaps in the roster where
registered nursing staff could not be sourced and to support individuals at risk of
falls.
Safe staffing has been maintained throughout December 2015. There was only
one shift (Night shift) with only one registered nurse on duty, which was also of
professional concern. Short notice staff sickness and an inability to source
allternative cover contributed to increased pressure onthose on duty.
Reprioritisation of work activities and mutual aid from colleages on the other
ward on site mitigated risk. There were no patient safety incidents. Additional
care worker staff have been used to support close supervision and monitoring of
those at risk of falls as well as filling registered nursing gaps when they could
not be sourced.
Cheadle
Total
Ward Two
24
30
62
1
99.3%
99.4%
98.4%
96.3%
1:10
1:12
18.56
16.51
61
0
1
0
72
7%
8%
5.19
0.00
0.00
1.00
2.93 - HSCW
(15.15%)
0.64 - RN
(4.17%)
Cheadle
48
87
98
1
94.3%
98.4%
99.2%
100.6%
1:9
1:12
33.70
30.75
89
5
1
11
144
7%
15%
5.19
0.00
0.00
1.00
3.7 - HSCW
(10.55%)
0.99 - RN
(3.41%)
0.00
1 - HSCW
(8.31%)
0.6 - RN
(5.04%)
Safe staffing has been maintained throughout December 2015. There were
three shifts where proffessional concern was raised (Night shifts) and all of these
shifts also had only oneregistered nurse on duty as a result of failure of staff
reporting for duty. Staff on the preceding shift offered additional support with
key activities, reprioritisation of workload and support from colleagues on site
maintained safety. There were no patient safety incidents as a result of staffing
reported. Gaps in RN provision have been filled by care workers where
registered nurse staff could not be sourced. Additional staff have been used to
support close supervision and monitoring of those at risk of falls.
Safe staffing has been maintained throughout December 2015. There were two
shifts (1 x Early and 1 x Late) where professional concern was raised both of
which resulted in only one registered nurse on duty. There was a further shift
(Late) where there was only one registered nurse on duty as a result of short
notice sickness. Both shifts where concerns were raised related to short notice
sickness and high levels of patient dependency, which added additional
pressure to those on duty. There were no patient safety incidents resulting from
staffing. Gaps in registered nurse provision have been filled by care workers
where registered nurse staff could not be sourced. Additional staff have been
used to support close supervision and monitoring of those at risk of falls.
Cottage
19
66
24
3
94.2%
102.9%
95.2%
100.0%
1:8
1:10
15.14
11.82
43
1
3
1
42
10%
5%
2.69
0.00
1.00
Leek
Saddler
17
45
46
2
95.8%
101.9%
100.0%
104.5%
1:8
1:8
15.14
10.82
52
2
3
0
62
12%
24%
3.27
0.00
1.00
0.00
0.08 - HSCW
(0.75%)
0.32 - RN
(2.94%)
Leek
36
111
70
5
95.0%
102.4%
97.6%
102.6%
1:8
1:9
30.28
22.64
95
3
6
1
104
11%
14%
5.96
0.00
2.00
0.00
1.08 - HSCW
(4.53%)
0.92 - RN
(3.99%)
Broadfield
23
56
37
0
92.5%
91.1%
96.7%
111.4%
1:8
1:10
16.01
22.65
31
21
1
14
29
3%
9%
0.00
2.00
1.00
1.29
0 - HSCW
(0.00%)
1.88 - RN
(12.02%)
Safe staffing has been maintained throughout December 2015. There was one
shift (Night shift) with only one RN on duty, as the agency member of staff
failed to report for duty and no shifts where professional concern was raised.
Gaps in nurse staffing have been supported by additional care workers and
support has been recieved from the wider MDT working on the ward.
Safe staffing has been maintained throughout December 2015. There were
three shifts (2x Night shifts and 1 X Late shift) where professional concern was
raised, with both night shifts having only one registered nurse on duty as a
result of short notice sickness. Increased patient care needs exceeding staffing
capacity prompted professional concerns on the third shift. No safety issues
arose as a result of this increase in care needs but the ward staff were under
additional pressure to meet patient needs and maintain safety. Additional care
workers have been utilised on all late and night shifts to support and monitor
those at risk of falls.
Total
Chatterley
21
84
6
3
100.0%
98.8%
96.8%
100.0%
1:8
1:13
16.85
15.80
3
9
2
13
57
33%
27%
4.19
0.00
0.00
0.00
2.12 - HSCW
(13.14%)
0.8 - RN
(6.08%)
Grange
32
82
8
3
103.2%
102.3%
97.8%
107.5%
1:7
1:10
22.54
19.22
4
0
0
9
64
15%
19%
0.00
0.00
1.00
1.78
1 - HSCW
(4.37%)
0 - RN
(0.00%)
Safe staffing has been maintained throughout December 2015. There were no
shifts with only one registered nurse on duty and three shifts (2 Night shifts and
1 x Late shift) where professional concern was raised. High patient care needs
on these shifts due to deteriorating health problems increased pressure on staff
to meet patient needs and maintain safety. There were no patient safety issues
arising from staffing. Additional care workers have been utilised on all late and
night shifts to support and monitor those at risk of falls.
Safe staffing has been maintained throughout December 2015. There were no
shifts with only one registered nurse on duty and two shifts (1 x Late and 1 X
Night) where professional concerns was raised. Both shifts experienced
increased patient care demands which exceeded capacity placing additional
pressure on those on duty. There were no patient safety incidents relating to
staffing. Additional care workers have been utilised on all late and night shifts to
support and monitor those at risk of falls and those who require the support of
more that two members of staff to move safely.
Haywood
Total
Professional Assurance
2.4 - HSCW
(17.68%)
0.16 - RN
(1.12%)
Bradwell
Total
Professional Judgement
No of shifts RAG rated by nurse in charge
Jackfield
20
71
20
2
101.3%
92.5%
100.0%
94.4%
1:6
1:10
15.14
14.24
3
2
0
13
76
0%
11%
0.86
0.86
2.00
0.00
2.63 - HSCW
(19.11%)
0.32 - RN
(2.26%)
Scotia
10
84
9
0
100.0%
96.2%
93.5%
100.0%
1:4
1:5
11.89
6.12
4
3
4
0
6
0%
0%
1.80
1.80
0.00
0.00
0.8 - HSCW
(12.38%)
0 - RN
(0.00%)
Safe staffing has been maintained throughout December 2015. There were four
shifts with only one registered nurse on duty due to sickness absence and due
to low patient numbers (4 and 5 patients) a risk review determined it was safe to
have one registered nurse on duty. There were no patient safety incidents as a
result of staffing. There were no shifts where professional concern was raised.
Sneyd
20
81
12
0
99.6%
111.8%
100.0%
131.5%
1:6
1:10
17.01
14.23
3
7
0
4
45
0%
19%
1.00
0.00
0.00
0.00
0.6 - HSCW
(4.01%)
0 - RN
(0.00%)
Safe staffing has been maintained throughout December 2015. There were no
shifts with only one registered nurse on duty or where professional concern was
raised.Additional care workers have been utilised on all late and night shifts to
support and monitor those at risk of falls.
Haywood
126
458
92
8
99.7%
98.4%
97.5%
108.3%
1:6
1:10
99.44
92.26
48
42
7
53
277
8%
14%
7.85
4.66
4.00
3.07
7.15 - HSCW
(8.84%)
3 - RN
(3.39%)
274
813
380
16
97.4%
99.3%
98.1%
104.0%
1:7
1:10
246.11
218.64
336
59
16
66
645
8%
12%
25.15
4.66
6.00
4.07
39.68 - HSCW
(7.27%)
5.55 - RN
(2.82%)
Overall
Total
Enc 06
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD
TO BE HELD ON: 27 JANUARY 2016
Enclosure:
Enc 06
Subject:
Quality Scorecard
Strategic Goal

We will provide high quality and safe services which provide an
excellent experience and best possible outcomes
We will work with users and carers to deliver integrated services,
simply and effectively
Our organisation will develop and deliver sustainable, innovative
services that support independence

Our workforce will be empowered and supported to deliver care in
a way that is consistent with our values
We will make excellent use of our resources and improve levels of
efficiency across our services
Director Lead:
Rose Goodwin, Interim Director of Nursing & Quality
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
The report provides the Trust Board with a concise quality scorecard. The scorecard provides the
performance, experience, safety, and effectiveness data of service users and carers during
November 2015.
KEY POINTS:
•
•
•
•
Of the 39 indicators with agreed target, there are 7 red rated indicators. Explanation and
actions are detailed on the front page of the scorecard. Escalated actions will be developed
with operational teams and signed off through Divisional Business Meetings.
The Quality Team is coordinating the development of agreed targets and RAG rating
thresholds for applicable remaining indicators
Further work to develop metrics will be aligned with the development of the Trust Quality
Priorities for 2016/17
The Scorecard was received at the Quality Governance Committee on 13 January 2016
INTER DEPENDENCIES:
Legal and/or Risk
The Quality Scorecard provides the Board with assurance that
mechanisms are in place to manage and monitor quality and identify when
any concerns may emerge.
Clinical
All staff have a responsibility for the experience, safety, and quality of the
services they provide.
Page 1 of 2
Enc 06
Financial
Potential savings linked to better monitoring, reduced risk and prompt
action.
HR
Training/Development – Rolling programme of key governance/quality
messages and responsibilities through staff induction.
Social Care
Social Care data is incorporated in this report for the Trust Service User /
Carer Experience work programmes.
Patient & Public
Involvement
User, Carer and Parent feedback along with suggestions of service
improvement is included in the User/Carer experience work programmes.
Equality Impact
A equality impact assessment has been implemented throughout the
development of the Quality Framework and associated work programmes.
Information exempt
from Disclosure
None
Requirement for
further review
Monthly
RECOMMENDATIONS:
The Board is recommended:
• To discuss and note the quality indicators in the scorecard and the mitigation for November
2015.
Page 2 of 2
Quality Scorecard
November 2015
Safety
7
1
2
26
Effectiveness
1
0
0
9
Experience
10
0
1
13
Performance
9
3
4
8
Lead
Indicator
DIRECTION*
2014/15
Average
MONTH
TARGET
RAG
EXPLANATION AND ACTIONS
84.09%
>95%
Red
Key factor is old harm present on transfer into our
care
14
(YTD)
10
(annual
tolerance)
Red
Infection Control team are now reviewing patients
daily. New patients with loose stools are screened
regardless of risk factors. Infection Control are
reviewing lists of patients prior to transfer into the
Trust. NB 12 out of 14 cases were deemed
unavoidable to the Trust.
85.0%
90%
Red
D04a: % receiving reablement in the year,
Gary
where the immediate outcome was no
Stubbs
support or low level support
-
72.0%
Red
67.3%
Comprehensive Improvement Plan in Place - Owner
Ed Finnemore
D06b: % older people at home and needing
Gary
no on-going Social Care services 91days
Stubbs
following receipt of reablement
-
55.0%
Red
54.8%
Comprehensive Improvement Plan in Place - Owner
Ed Finnemore
Gary i02b(i): The proportion of people using social
Stubbs care who receive direct payments - snapshot
-
27.5%
Red
24.6%
Comprehensive Improvement Plan in Place - Owner
Ed Finnemore
J01d: Proportion of clients in receipt of long
Gary
term support who had a review (rolling 12
Stubbs
months)
-
70.0%
Red
58.3%
Comprehensive Improvement Plan in Place - Owner
Ed Finnemore
Exceptions
Caroline
Llewelly Safety Thermometer - Harm Free Care
n
Carrie
Clostridium Difficile Cumulative YTD
Felgate
Marie
Allen
Patient feedback on the Quality of Care
2014/15
total 10
A variety of actions have been put into place to
improve quality in response to the feedback received.
*Sparklines provide a general direction indicator only, and should be read along with the numerical data
Quality Scorecard
18/01/2016
Page 1
Quality Scorecard
Lead
November 2015
Safety
Indicator
MONTH
TARGET
RAG
>95%
Red
>95%
Green
N/A
-
N/A
-
N/A
-
N/A
-
>950
Green
DIRECTION*
2014/15
Average
EXPLANATION AND ACTIONS
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Safety
Hospitals Safety Thermometer - Harm Free
Care
Hospitals Safety Thermometer - No New
Caroline Llewellyn
Harms
Caroline Llewellyn
Caroline Llewellyn Hospitals Key Harms - Pressure Ulcers (All)
Caroline Llewellyn
Hospitals Key Harms - CAUTI (All)
Caroline Llewellyn
Hospitals Key Harms - Falls with harm
Caroline Llewellyn
Hospitals Key Harms - VTE (New)
Duncan Kett
Total incidents reported
84.09%
97.73%
13.26%
1.89%
1.58%
0.00%
1192
72 6.25 + 25%
Key factor is old harm present on
transfer into our care
90.92% 92.76% 90.90% 90.86% 89.75% 87.88% 87.75% 84.09%
96.42% 97.70% 96.78% 96.71% 96.62% 97.73% 98.02% 97.73%
9.86% 11.92% 12.29% 10.67% 13.74% 10.23% 10.94% 13.26%
Quality Priority 5
1.30%
0.88%
0.82%
0.92%
1.28%
0.76%
1.58%
1.89%
0.70%
0.32%
1.06%
0.53%
0.88%
1.14%
1.19%
1.58%
0.37%
0.55%
0.24%
0.34%
0.25%
0.00%
0.00%
0.00%
875
1040
1082
1128
967
1105
1206
1192
Duncan Kett
Number of 'near misses' reported
20
21
93
92
59
61
86
72
Duncan Kett
Total incidents reported applicable to the
Partnership Trust Care
822
N/A
-
605
755
781
749
704
738
825
822
Duncan Kett
Total incidents identified at POA
370
N/A
-
270
285
301
379
263
367
381
370
18
N/A
-
29
18
24
25
26
14
32
18
<3.47%
Green
4.79%
2.38%
3.07%
3.34%
3.69%
1.90%
3.88%
2.19%
-
-
2.6
3.7
3.5
3.1
2.7
3.56
4
4.25
-
-
17.7
23.1
24
25.40
21.30
26.3
25.1
22.4
74
N/A
-
58
64
59
49
52
79
68
74
2
<12
-
3
0
2
1
2
1
3
2
9.16
N/A
-
0
Green
-
-
Duncan Kett
Number of Serious Incidents (SI's)
Duncan Kett
Percentage of reported incidents classified
as serious incidents
Duncan Kett
Incidents per 1000 community contacts
4.25
Incidents per 1000 bed days
22.4
Duncan Kett
Duncan Kett
Total Falls Incidents
Duncan Kett
Total Falls Serious Incidents
Duncan Kett
Falls per 1000 bed days
Duncan Kett
Number of Never Events
2.19%
0
Green
6.25
Quality Priority 5
3.47%
Quality Priority 5
6.59
6.86
6.47
5.71
5.84
0
0
0
0
0
9.6
0
8.2
0
9.16
0
Pressure Ulcers
Sue Mason
Community Grade 3 & 4 Report
Sue Mason
Community - Avoidable and Attributable
grade 3 & 4
Sue Mason
Hospitals - Grade 3 & 4 Report
16
YTD 20
0
Pending
RCA
<23
Amber
-
-
Zero tolerance action plan,
including 'react to red'
programme with roll-out to
community.
1 PU reported in October is
pending RCA
23
15
29
22
25
23
21
16
4
5
2
2
3
1
3
1
0
1
1
0
0
1
0
174
20
4
Sue Mason
Hospitals - Avoidable and Attributable PUs
0
-
0
0
0
0
0
0
Sue Mason
Deep Tissue
34
-
-
23
23
27
26
14
18
30
34
Sue Mason
Grade 1 Report
3
-
-
1
2
0
2
1
4
0
3
13
Sue Mason
Grade 2 Report
90
-
-
80
112
78
85
62
83
97
90
687
Sue Mason
Grade 3 Report
16
-
-
22
14
28
21
21
22
21
16
165
Sue Mason
Grade 4 Report
0
-
-
2
1
2
2
4
1
1
0
13
Quality Scorecard
18/01/2016
0
195
Page 2
Lead
Indicator
MONTH
TARGET
RAG
DIRECTION*
2014/15
Average
EXPLANATION AND ACTIONS
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Infection Prevention and Control
Carrie Felgate
Clostridium Difficile Cumulative YTD
Carrie Felgate
Clostridium Difficile per 100k bed days
14
Infection Control team are now
reviewing patients daily. New
patients with loose stools are
2014/15 total screened regardless of risk factors.
Infection Control are reviewing lists of
10
patients prior to transfer into the
Trust. NB 12 out of 14 cases were
deemed unavoidable to the Trust.
2
5
7
9
10
13
-
22.70
32.70
23.31
23.31
11.20
36.60
10
Red
N/A
14
14
Carrie Felgate
Mortality related to CDI (7 days)
0
N/A
-
0
0
0
0
0
0
0
0
Carrie Felgate
Mortality related to CDI (30 days)
0
N/A
-
0
0
0
0
0
0
0
0
Carrie Felgate
Mortality related to CDI (90 days)
0
N/A
-
Carrie Felgate
E Coli - Number of Incidents
1
N/A
-
100.00%
95%
Green
0
0
Green
0
N/A
-
Carrie Felgate
Carrie Felgate
Carrie Felgate
MRSA Screening on Admission (% screened
on elective admission)
MRSA Bacteraemia day of admission +1
(Community hospitals)
MSSA (number of cases) (Hospital Acquired)
2014/15 total
11
0
0
0
0
0
1
0
0
1
2
2
0
2
1
1
1
100.00% 99.00% 99.50% 99.72% 100.00% 99.34% 99.76% 100.00%
2014/15 total 1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
*Sparklines provide a general direction indicator only, and should be read along with the numerical data
Quality Scorecard
18/01/2016
Page 3
Quality Scorecard November 2015
Lead
Effectiveness
Indicator
Corporate Governance
Number of Coroners Regulation 28
Elaine
received (Previously Coroner Rule
Mullington
43's)
Third Provider infromation from
CDH
Robin
Medium
Sasaru
Robin
High
Sasaru
NICE
TARGET
RAG
0
N/A
-
N/A
DIRECTION*
2014/15
EXPLANATION AND ACTIONS
Average
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Feb
Mar
YTD
0
0
0
0
0
0
-
24
23
24
25
38
40
61
235
N/A
-
14
15
15
16
12
18
14
104
-
N/A
-
-
Metric in development
71%
N/A
-
-
Metric in development: Currently
showing compliance with
Previous Years Guidance (April
13 onwards)
55%
58%
64%
64%
66%
70%
71%
71%
100%
100%
Green
100%
100%
100%
100%
100%
100%
100%
100%
100%
8
N/A
-
-
15
7
4
4
0
2
4
2
Number of Quality Visits
0
-
-
No visits in Nov 2015 due to the
CQC inspection
1
2
2
2
3
2
4
0
Cumulative Assurance Rating
-
-
-
Metric in development
NICE Guidelines high-risk noncompliance (number of guidance)
Robin
Sasaru
NICE Guidelines Compliance
Audit
Julianne
National Audit participation
Brightman
Julianne
Local Audit projects completed
Brightman
Quality Visits
awaiting
SCC data
awaiting
SCC data
0
0
Jan
0
Robin
Sasaru
Robin
Sasaru
MONTH
0
*Sparklines provide a general direction indicator only, and should be read along with the numerical data
Quality Scorecard
18/01/2016
Page 4
Quality Scorecard
Lead
November 2015
Indicator
Experience
MONTH
TARGET
RAG
DIRECTION*
2014/15
Average
EXPLANATION AND
ACTIONS
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Complaints
Wendy Dale
Wendy Dale
Wendy Dale
Number of formal complaints
received - Health
Number of formal complaints
received - Social Care
Number of formal complaints
received Total
Wendy Dale
Number of compliments received
(customer services & ASC only)
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Wendy Dale
Quality Scorecard
11
N/A
-
16
N/A
-
27
N/A
-
90
N/A
-
Complaints Closed within
Timescales in Accordance with
the National NHS Complaint
Regulations
100.0%
N/A
Green
Complaints referred to the LGO
0
N/A
-
3
N/A
-
0
N/A
-
0
N/A
-
Complaints referred to the LGO
and Ongoing
Complaints referred to the LGO
and Upheld
Complaints referred to the LGO
not upheld
Complaints referred to the PHSO
and Ongoing
Complaints referred to the PHSO
and Upheld
Complaints referred to the PHSO
not upheld
Number of complaints reviewed
by independent panel
4
N/A
-
0
N/A
-
1
N/A
-
3
20
-
2014/15 total
202
2014/15 total
149
2014/15 total
351
2014/15 total
2022
Quality Priority 2
16
14
29
20
17
16
11
136
11
5
13
9
13
11
8
16
86
24
21
27
38
33
28
24
27
222
61
171
103
172
203
163
128
90
1091
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100%
2014/15 total
12
2014/15 total
49
2014/15 total
8
2014/15 total
19
2014/15 total
19
2014/15 total
0
2014/15 total
1
2014/15 total
17
13
Quality Priority 2
18/01/2016
2
1
0
1
0
1
0
0
5
4
3
2
2
2
2
3
3
21
2
2
0
1
0
1
0
0
6
4
0
0
0
0
0
0
0
4
4
4
4
4
5
5
4
4
34
0
0
0
0
0
0
2
0
2
0
0
1
0
0
0
0
1
2
3
3
3
2
2
2
0
3
18
Page 5
Lead
Indicator
MONTH
TARGET
RAG
DIRECTION*
2014/15
Average
EXPLANATION AND
ACTIONS
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
User and Carer Experience
Marie Allen
FFT Total captured feedback
3832
N/A
-
2546
3033
3547
3726
3316
3398
3401
3832
26799
Marie Allen
Total FFT Sample
3457
1500+
Green
2336
2893
3384
3543
3314
3240
3184
3457
25351
Marie Allen
Total FFT Sample Score
98%
90%
Green
97%
97%
97%
97%
98%
98%
96%
98%
Marie Allen
FFT Service User Sample
2770
1300+
Green
1850
Quality Priority 2
1907
2312
2671
2843
2444
2381
2559
2770
Marie Allen
FFT Service User Score
97%
90%
Green
97%
Quality Priority 2
98
97
97
97
97
97
96
97
Marie Allen
FFT Carer Sample
687
200+
Green
Quality Priority 2
429
581
713
702
690
859
625
687
Quality Priority 2
98%
97%
98%
98%
98%
98%
97%
99%
Quality Priority 2
85%
84%
83%
85%
84%
85%
83%
85%
Marie Allen
Carer Score
99%
95%
Green
Continuity of care (no information
given on am & pm slot availability
is given, and different numbers of
staff are providing care on a dayto-day basis) - case mgt has been
reviewed, and rotas are being
shared with service users.
Preferred appt times are allocated
where possible, with advanced
allocation implemented in Stoke
Sexual Health services
appointment waiting times for
'clinic in a box' - Service is
reviewing appointments to reduce
waiting times, and including
additional clinics, and developing
a service leaflet for waiting times.
Community Hospitals- Standards
of care - staffing increase on day
and night shift. Reminders to staff
to ensure that buzzers and
personal belongings are kept
within reach
CYP- Continuity of care for Stoke
Children's Continuing Healthcare,
(staffing levels, allocated case
manager & appointments). New
rota with advanced allocations for
continuing healthcare in place.
North & South have given a rota to
service users so they know what
staff be seeing them.
Marie Allen
Patient feedback on the Quality of
Care
85%
90%
Red
Marie Allen
Information
92%
90%
Green
Quality Priority 2
90%
91%
89%
92%
94%
91%
92%
92%
Marie Allen
Listened to
95%
90%
Green
Quality Priority 2
95%
95%
96%
96%
95%
94%
96%
95%
Quality Priority 2
97%
97%
96%
98%
97%
96%
97%
96%
Marie Allen
Being Involved
96%
90%
Green
5286
*Sparklines provide a general direction indicator only, and should be read along with the numerical data
Quality Scorecard
18/01/2016
Page 6
Quality
Scorecard
Lead
November 2015
Performance
Indicator
MONTH
TARGET
RAG
DIRECTION
2014/15
Avg
EXPLANATION AND ACTIONS
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Comprehensive Improvement Plan
in Place – For details please contact
Barrie Knox / Ed Finnemore
56.2%
61.4%
60.2%
62.1%
62.9%
62.9%
62.9%
62.4%
89.6%
86.2%
86.4%
85.8%
86.0%
86.0%
86.2%
85.4%
56.3%
53.4%
53.0%
51.5%
50.0%
49.6%
50.3%
49.9%
Social Care ('Fin Yr to Date' unless otherwise stated)
Gary
Stubbs
D04a
% receiving reablement in the year, where the immediate
outcome was no support or low level support
-
72%
Red
67.3%
Gary
Reablement
Stubbs
D06a
% older people at home 91 days after discharge from
hospital into reablement
-
85%
Green
87.9%
Gary
Stubbs
Gary
Stubbs
Gary
Stubbs
Gary
Stubbs
Gary
Stubbs
D06b
Timeliness
E03
Carers
E11
Safeguarding
F05
Personal Budgets
i02a(i)
i02b(i)
Gary
Direct Payments
Stubbs
Gary
Permanent Long
Stubbs
Stay Residential
Gary Admissions
Stubbs
Gary
Reviews
Stubbs
% older people at home and needing no on-going Social Care
services 91days following receipt of reablement
Waiting time from assessment start to assessment
completion: percentage completed within 4 weeks
% carers assessed or reviewed in the year out of the total
number of carers 'on the books
55%
Red
54.8%
Comprehensive Improvement Plan
in Place – For details please contact
Barrie Knox / Ed Finnemore
-
75%
Green
73.3%
75.1%
72.4%
73.6%
73.6%
75.3%
75.7%
76.4%
76.5%
-
70%
Amber
60.7%
86.9%
87.2%
89.8%
88.3%
80.1%
75.1%
70.3%
68.9%
% cases where the risk of harm has been reduced
-
94%
Amber
92.1%
92.8%
93.0%
92.9%
92.9%
92.6%
92.7%
92.4%
93.0%
% using social care who receive self-directed
support (personal budget or direct payment) - snapshot
-
84%
Amber
73.4%
Increasing - now only 1.2% off 84%
target
76.0%
79.7%
80.3%
77.3%
75.9%
78.1%
80.8%
82.8%
The proportion of people using social care who receive direct
payments - snapshot
-
27.5%
Red
24.6%
Comprehensive Improvement Plan
in Place – For details please contact
Barrie Knox / Ed Finnemore
24.3%
24.5%
25.4%
24.3%
24.3%
24.1%
23.9%
24.1%
i03a(ii) Younger adults 18-64 (per 100,000 population)
-
6.5
Green
6.6
6.0
5.4
5.2
5.2
5.6
6.1
5.9
5.6
i03b(ii) Older people aged 65+ (per 100,000 population)
-
525.0
Green
538
508.8
509.4
510.5
517.9
520.8
513.2
515.0
509.0
57.9%
57.5%
57.3%
54.5%
55.5%
55.6%
55.7%
57.7%
J01d
Proportion of clients in receipt of long term support who had a
review (rolling 12 months)
58.3%
Comprehensive Improvement Plan
in Place – For details please contact
Barrie Knox / Ed Finnemore
70%
Red
84.2%
18 weeks
-
100.0% 100.0% 100.0% 100.0%
93.9%
Diabetes North Staffs
100.0%
18 weeks
-
100.0% 100.0% 100.0% 100.0%
100.0%
Geriatics - Falls
100.0%
18 weeks
-
100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0%
Geriatics - Parkinsons
95.5%
18 weeks
-
94.1%
100.0% 100.0% 100.0%
100.0% 100.0%
Heart Failure - South
95.2%
18 weeks
-
100.0%
92.1%
96.0%
100.0%
98.5%
Non-admitted Completed Pathways
99.5%
95%
-
99.6%
99.6%
99.8%
99.8%
99.8%
99.5%
99.7%
99.5%
Admitted Completed Pathways
99.4%
90%
-
98.4%
99.1%
99.4%
99.5%
98.7%
98.5%
98.9%
99.4%
Completed Pathways
99.0%
92%
-
99.4%
99.7%
99.7%
99.6%
99.4%
99.3%
99.1%
99.0%
Cannock Chase CCG
100.0%
95%
Green
100.0%
99.0%
100.0%
99.0%
98.0%
99.0% 100.0% 100.0%
East Staffordshire CCG
100.0%
95%
Green
95.0%
98.0%
100.0%
98.0%
100.0% 100.0% 100.0% 100.0%
SES and Seisdon CCG
100.0%
95%
Green
99.0%
100.0%
99.0%
99.0%
100.0%
99.0% 100.0% 100.0%
Stafford and Surrounds CCG
100.0%
95%
Green
100.0% 100.0%
99.0%
100.0%
100.0%
99.0% 100.0% 100.0%
98.9%
95%
Green
99.2%
99.7%
99.8%
99.8%
Referral to Treatment - Long Term Conditions
Ian
Porter
Ian
Porter
Ian
Porter
Ian
Porter
Ian
Porter
Diabetes Stoke
94.9% 100.0%
84.2%
92.9% 100.0% 100.0%
98.5%
94.1%
100.0%
95.5%
95.2%
Referral to Treatment -All Consultant- led Services
Ian
Porter
Ian
Porter
Ian
Porter
Referral to Treatment - Allied Health Professional
Ian
Porter
Ian
Porter
Ian
Porter
Ian
Porter
Ian
Porter
North Staffordshire and Stoke on Trent CCG
*Sparklines provide a general direction indicator only, and should be read along with the numerical data
99.9%
99.8%
99.4%
98.9%
Dec
Jan
Feb
Mar
Enc 07
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD
TO BE HELD ON: 27 JANUARY 2016
Enclosure:
07
Subject:
Integrated Performance Report – Month 9
Strategic Goal
(tick as appropriate):

We will provide high quality and safe services which provide an excellent
experience and best possible outcomes

We will work with users and carers to deliver integrated services, simply and
effectively

Our organisation will develop and deliver sustainable, innovative services that
support independence

Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values

We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Jonathan Tringham, Director of Finance and Resources
Recommendation:
For Approval &
Assurance
X
For Discussion
For Information
PURPOSE OF THE REPORT:
The purpose of this report is to provide a concise integrated view of performance across the
organisation for December 2015. The report comprises of a summary of integrated performance
including Operational, Quality, Finance and Workforce indicators, incorporating trends and
benchmarks where appropriate in line with the performance framework that has been adopted by the
Partnership Trust.
KEY POINTS:
Annex 1 - Provides an executive summary and overview of the Partnership Trust’s performance.
Annex 2 - Details performance against the full suite of the Partnership Trust’s Board indicators.
Annex 3 - Illustrates the quality assessment of services provided by the Partnership Trust. The
selected indicators have been grouped into safety, effectiveness and experience.
Annex 4 - Demonstrates the Trust’s Board self certification statement response to the TDA for
November 2015.
Annex 5 – Detailed analysis by exception.
Page 1 of 4
Enc 07
Key Performance Messages
Overall, of the 59 Partnership Trust’s Board performance indicators with targets attached, 37 are
green, 7 are amber and 15 are red.
The RAG status has changed for 4 indicators in December:
•
•
1 indicator improved from “Amber” to “Green”
1 indicator improved from “Red” to “Amber”
•
•
1 indicator dropped from “Green” to “Amber”
1 indicator dropped from “Amber” to “red”
Annex 1
General Updates:
•
This end of quarter report incorporates detailed analysis of underperforming areas. In
response to feedback from, FIP and Board, we have introduced the following improvements in
the Q3 report:
o Included the population size for Operations KPIs in order provide additional context
o Estimated improvement trajectories
o Assessed in detail data quality drivers for KPIs causing concern (we are currently
reviewing DQ % scores methodologies, and these will be added again in the January
report). Note that DQ % scores will be lower than the average score of the individual
DQ drivers (combined impact of multiple factors).
Page 2 of 4
Enc 07
Key Areas of Strong Performance Improvement include:
•
The proportion of social care clients receiving self-directed support has followed a steady
improvement trend since August (75.9%), and for the first time reached performance levels
above target in December (84.9%). This is consistent with the high proportion survey
respondents who report feeling that their support is directed by them and responsive to their
needs (97%).
Key Performance Concerns:
•
•
The percentage of Harm Free Care in the Safety Thermometer, currently at 91.3% against its
95% target, remains the only area of non-compliance in the Quality Assessment.
Social Care indicators remain a source of concern:
o Delayed transfers of care attributable to social care (60.0) notably exceed their target
(37.5). The delayed days indicator (1,579) is also notably higher than its target (1,015).
o The carers assessments indicator has rapidly deteriorated in the year from a peak in
June (89.8%) to its current level (66.1%), making it Red for the first time in the year.
Detailed analysis and improvement plan are now under development.
o Reablement indicators remain below target with no sign of decisive improvement.
o The proportion of customers receiving self-directed support through direct payments
remains static at 24% below the 27.5% target.
o The reviews indicator has started to show signs of improvement, and it currently
stands at 63.4% against its 70% target. There will be a huge emphasis on reviews on
Q4, as this has been identified as the single most important area of performance by
the Commissioner for that period.
INTER DEPENDENCIES:
Legal and/or Risk
Clinical
Financial
HR
Staff and Trade
Union involvement
actions
undertaken/planned
The performance information included in the attached report is dependent
on the quality of the source data which is taken from a number of
information systems. If data consists of poor quality there is a risk that
decisions could be made based on flawed performance information, and a
risk of adverse audit judgements.
It is essential that the performance scorecard continues to include Clinical
Quality and Safety related indicators to drive continuous improvement.
The financial pressures facing the Partnership Trust over the coming
years necessitate the development of further ‘value for money’ indicators
to include in the monthly scorecard.
Managing performance outcomes is dependent on its workforce for
example training, appraisal and sickness levels.
Performance information is shared with staff at all levels of the
organisation, and a JSP agreed data input policy requires all staff to input
activity within 5 working days.
Social Care
The report includes key Social Care performance indicators.
Patient & Public
Involvement
The inclusion of service user feedback in performance reporting is
essential for Trust Board assurance.
Equality Impact
The use of good Data Quality to inform decision making / service delivery
is key in ensuring vulnerable groups are not discriminated against.
NA
Information exempt
from Disclosure
Requirement for
Routine reports are provided to the Trust Board, Finance, Investment and
Performance Committee and Operational management meetings to
Page 3 of 4
Enc 07
further review
update on performance issues.
RECOMMENDATIONS / ACTION REQUIRED:
The Trust Board are asked to note the content of the executive summary and performance
scorecard.
The Committee are asked to approve the Self-Certification Return to the NTDA for November. The
Committee is also asked to review the declaration for December against Statements 2 and 5 in
light of the warning notice from the CQC and to consider whether it continues to report compliance
against Statements 1, 6, 7, and 10.
Page 4 of 4
ANNEX 2: Section 1 - Quality & Safety - Lead Director - Rose Goodwin - Director of Nursing and Quality - Performance Indicators - 2015 / 2016 - December Data - Month 9
Strategic Objective
Data
Quality
Indicator
Type
L
L
Number of Formal Complaints Received
Health / Social Care
L
Number of Compliments Received
N
% of Complaints Acknowledged Within 72 Hours of Receipt
Health / Social Care
N
We Will Work with
Partners, Users and
Carers to Deliver
Integrated Services
Outturn
2014/15
Indicator
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
210
13
16
14
29
20
17
16
11
18
147
11
5
13
9
13
11
8
16
10
96
2152
1071
1673
1570
1594
1743
2005
1564
1685
1335
14240
Direction of
Travel
Performance
Vs. Benchmark
Group
154
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
N
Complaints Closed within Timescales in Accordance with the National NHS
Complaint Regulations
100%
L
Social Care Complaints Escalated to the Local Government Ombudsman
8
2
2
0
1
0
1
0
0
0
6
L
Social Care Complaints Escalated to the Local Government Ombudsman and
Upheld ( # awaiting outcome)
2
#
2
0
1
0
1
0
0
0
4
L
Health Complaints Escalated to the Parliamentary and Health Service
Ombudsman
2
0
0
1
0
0
0
1
0
0
2
L
Health Complaints Escalated to the Parliamentary and Health Service
Ombudsman and Upheld (# awaiting outcome)
3
0
0
#
0
0
0
2
0
0
2
60%
64%
52%
62%
68%
66%
73%
65%
71%
70
113
105
206
209
230
164
234
196
93%
95%
93%
94%
92%
96%
96%
92%
97%
110
155
199
331
285
331
259
336
262
98%
97%
97%
97%
97%
98%
96%
98%
97%
2336
2312
2671
2843
2444
3240
3184
3457
3240
25727
Customer Overall Satisfaction (Extremely satisfied at all times) with the Care and
SC
Support Experience with Social Care?
72%
*
Sample received - Customer Overall Satisfaction (Extremely satisfied at all times)
SC
with the Care and Support Experience with Social Care?
*
1527
Do you feel that you have care and support which is directed by you and
SC
responsive to your needs?
90%
*
Sample Received - Do you feel that you have care and support which is directed
SC
by you and responsive to your needs?
We Will Provide High
Quality and Safe
Services Which Provide
an Excellent Experience
and Best Possible
Outcomes
*
*
L
Net Promoter Score (NPS)
L
Net Promoter Score (NPS) Number of people responding
97%
*
24222
1300
2268
L
Number of Serious Incidents
254
29
18
24
25
26
14
32
18
21
207
L
Total Incidents Reported Applicable to the Partnership Trust Care
7028
605
763
785
749
709
745
832
822
702
6712
L
Percentage of reported incidents classified as serious incidents 3.61%
4.67%
2.32%
3.06%
3.33%
3.67%
1.88%
3.84%
2.19%
2.99%
154,503
149,489
162,117
158,787
154,576
148,550
152,232
150,555
138,959
L
Number of Total Face to Face Contacts
TDA
Number of Serious Incident Pressure Ulcers Reported (STEIS)
171
23
16
21
24
22
10
29
15
14
174
TDA
Number of Serious Incident Pressure Ulcers Deemed Avoidable Following Root
Cause Analysis (RCA) Review Panel ( # awaiting outcome)
31
4
5
2
#
#
#
#
#
#
11
TDA
Number of Serious Incident Pressure Ulcers Deemed Unavoidable Following Root
Cause Analysis (RCA) Review Panel ( # awaiting outcome)
78
11
7
14
#
#
#
#
#
#
32
TDA
Serious Incident Falls Reported Through National Reporting System Resulting in
Severe Injury or Death
17
3
0
2
1
2
1
3
2
4
18
TDA
Falls per 1000 Inpatient Occupied Bed Days
8.19
6.59
6.86
6.47
5.71
5.84
9.64
8.16
9.16
7.61
9.64
TDA
Outstanding Alerts (more than 3 months old reported through the Central Alerting
System)
0
0
0
0
0
0
0
0
0
0
0
0
N
Mixed Sex Accommodation: Single Sex Number of Breaches
0
0
0
0
0
0
0
0
0
0
0
0
N
Number of Never Events
0
0
0
0
0
0
0
0
0
0
0
0
C
Clostridium Difficile - number of avoidable incidents cumulative (INDICATOR
AMENDED FROM PREVIOUS MONTHS WHERE INCLUDED UNAVOIDABLE) #
awaiting panel
2
<=8
0
0
0
1
0
0
1
0
2#
2
C
Methicillin-Resistant Staphylococcus Aurous (MRSA) Bacteraemia (number of
incidents within 1 month / Hospital associated)
1
0
0
0
0
0
0
0
0
0
0
0
1,915,961

96.1%

8.3
1,369,768
C
Methicillin-Resistant Staphylococcus Aurous (MRSA) Screening on Admission (%
screened on elective admission)
C
TDA
99.9%
100%
99.0%
99.5%
99.7%
100%
99.3%
99.0%
100%
100%
Methicillin-Resistant Staphylococcus Aurous (MRSA) Screening on Admission No screened on elective admission / No required screening
371/371
381/385
449/451
355/356
300/300
302/304
411/412
354/354
426/426
Methicillin-Sensitive Staphylococcus Aureus (MSSA) (No of cases hospital
associated)
0
0
0
0
0
1
0
0
0
1
0.43%
95%
TDA
Complicated Urinary Tract Infection (CUTI) Percentage
TDA
Complicated Urinary Tract Infection (CUTI) - Number with new CUTI / Number of
patients
TDA
E Coli - Number of Incidents
11
SC
Compliance with Vulnerable Adults Quality Standards (quarterly) (SC44)
86%
SC
Compliance with Vulnerable Adults Quality Standards (quarterly) (SC44) - Number
of people included in the population sample size
2536
SC
Compliance with Vulnerable Adults Quality Standards (quarterly) (SC44) Total
number of audits due / Total number of audits completed
170/164
SC
Percentage of Cases Where the Risk of Harm has been Reduced (F05)
0.57%
92.1%
0.70%
0.46%
0.34%
0.39%
0.69%
0.48%
0.21%
0.32%
0.27%
15/2148
10/2170
7/2078
8/2068
14/2039
10/2073
4/1916
6/1871
5/1857
1
2
2
0
2
1
0
1
0
92%
80%
94% Q3
92.8%
93.0%
88%
92.9%
92.9%
92.6%
89%
92.7%
92.4%
93.0%
Percentage of Cases Where the Risk of Harm has been Reduced (F05) - Total Risk
/ Risks Reduced
99.7%
9
88%
93.0%
93.0%
688/640
SC
Adult Protection Case Closures Open Over 3 Months
2711
SC
Adult Protection Case Closures Open Over 6 Months
1381
83
86
59
96
93
60
59
52
55
643
L
Percentage of Deaths (all inpatient deaths)
7.4%
7.2%
7.3%
8.6%
7.7%
9.0%
12.2%
8.2%
9.3%
7.1%
8.0%
L
Ordinary Finished Consultant Episodes (FCEs)
340
382
388
386
300
321
334
322
338
C
Prison Healthcare: Deaths in Custody
0
0
0
0
0
1
0
0
2
5
189
185
160
145
152
89
106
87
91
Indicator Type - N - National L - Local C - Contractual TDA - Trust Development Authority SC - Social Care ACFT - Aspiring Community Foundation
* The population size for the Health & Social Care local survey could not be identified
To be noted - following feedback from the Trust Board in November 2015 additional metrics have been added to provide context to performance indicators - these metrics have been shaded grey to show for informative purposes only and are not counted towards the overall RAG rated quadrant
1204
3
ANNEX 2: Section 2 Operations - Lead Director - Kieron Murphy - Director of Operations - Performance Indicators - 2015 / 2016 - December Data - Month 9
Strategic Objective
We Will Provide High Quality and
Safe Services Which Provide an
Excellent Experience and Best
Possible Outcomes
Data
Quality
Indicator
Type
Indicator
C
Outturn
2014/15
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
YTD
Delayed Transfers of Care Community Hospitals within the Trust (percentage
of occupied bed days) - Overall Trust Percentage
3.4%
3.9%
4.2%
9.4%
10.7%
6.7%
6.4%
6.9%
7.3%
6.4%
Delayed Transfers of Care Community Hospitals within the Trust - Overall
Trust Patients
302
354
375
810
951
549
533
561
622
5057
C
Delayed Transfers of Care Community Hospitals within the Trust - Staffs
Patients
114
72
123
218
222
209
295
258
237
1748
C
Delayed Transfers of Care Community Hospitals within the Trust - Stoke on
Trent Patients
188
250
241
592
729
340
238
303
385
3266
Occupied Bed Days / Beds Available
8800/9450
9178/9765
8962/9450
8579/9579
8596/8959
8196/8370
8329/8649
8077/8370
8538/8649
SC
Number of Social Care and Joint Delayed Transfers of Care (average no. of
people delayed on snapshot dates) (average per month) (E07)
51.2
37.5
47.00
54.50
54.30
56.00
57.40
60.00
63.90
60.00
SC
Number of Social Care and Joint Delayed Transfers of Care Days (average per
month) (E08)
1311
1015
1393
1442
1439
1514
1571
1579
1666
1579
L
Average Length of Stay (ALOS) (Community Hospitals Mean)
24.1
24.7
23.7
24.2
21.2
25.6
27.2
22.1
23.7
24.6
24.0
C
Average Length of Stay (ALOS) (Community Hospitals Median)
17
23 days
19
17
16
15
17
18
14
16
18
17
N
Percentage of Patients Seen Within 4 Hours in MIU/Walk-in Centres
99.8%
95%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
N
Number of Patients Seen Within 4 Hours in MIU/Walk-in Centres - Patients Seen
/ Total Patients
1173/1173
1184/1184
1155/1155
1241/1241
1073/1073
1141/1141
1076/1076
1010/1010
1033/1033
N
Percentage of Admitted Patients Meeting the 18 Week Consultant Led Referral
to Treatment Target
98.4%
99.1%
99.4%
99.5%
98.7%
98.5%
98.9%
99.4%
98.5%
N
Number of Admitted Patients Meeting the 18 Week Consultant Led Referral to
Treatment Target - Admitted 18 Week Clock Stops / Total Admitted 18 Week
Clock Stops
253/257
231/233
168/169
210/211
154/156
195/198
175/177
170/171
129/131
N
Percentage of Non-Admitted Patients Meeting the 18 Week Consultant Led
Referral to Treatment Target
99.6%
99.6%
99.8%
99.8%
99.8%
99.5%
99.7%
99.5%
99.6%
N
Number of Non-Admitted Patients Meeting the 18 Week Consultant Led
Referral to Treatment Target - Non-admitted 18 Week Clock Stops / Total Non admitted 18 Week Clock Stops
4890/4912
4878/4899
5406/5418
5146/5156
4309/4317
4793/4818
4851/4864
5070/5093
4522/4541
N
Percentage of Patients on Incomplete Consultant-Led Pathways Waiting Less
Than 18 Weeks
99.4%
99.7%
99.7%
99.6%
99.4%
99.3%
99.1%
99.0%
98.5%
N
Number of Patients on Incomplete Consultant-Led Pathways Waiting Less
Than 18 Weeks - 18 Week Incomplete Pathways / Total patients on Pathway
3810/3834
4040/5051
3953/3963
3830/3942
3942/3966
3911/3940
3995/4033
3699/3735
3506/3559
L
Number of Consultant-Led Patients Reported as Waiting 26 Weeks or Over
(completed pathways)
190
8
4
3
2
1
4
0
6
5
33
N
Number of Consultant-Led Patients Reported as Waiting 52 Weeks or Over
(completed pathways) (national target in place 2013/14)
0
0
0
0
0
0
0
0
0
0
0
0
C
Therapies - Percentage of Patients Treated Within 18 Weeks from Referral to
Treatment
97.6%
95%
99.5%
99.6%
99.6%
99.8%
99.8%
99.6%
99.6%
99.8%
99.8%
99.7%
C
Therapies - Number of Patients Treated Within 18 Weeks from Referral to
Treatment - Treatment Within < 18 Weeks / All Therapy Patients with a Clock
Stop
8503/'8548
8083/8113
9348/9386
9079/9101
8019/8037
8138/8171
8239/8268
8776/8797
8167/8186
C
Speech and Language Therapy - First Appointment Within Local Waiting
Targets (North only)
97.4%
100%
98.5%
100%
100%
100%
100%
100%
100%
C
Speech and Language Therapy - First Appointment (North only) - Patient Seen
in Local Timescale / Total Number of Patients
112/115
132/132
130/132
154/154
141/141
148/148
144/144
148/148
108/108
C
Occupational Therapy - First Appointment Within Local Waiting Targets (North
only)
97.5%
99.0%
99.8%
99.6%
99.8%
100%
100%
99.8%
99.6%
C
Occupational Therapy - First Appointment (North only) - Patient Seen in Local
Timescale / Total Number of Patients
867/889
674/681
492/493
556/558
431/432
506/506
549/549
463/464
478/480
C
Physiotherapy - First Appointment Within Local Waiting Targets (North only)
87.7%
85.7%
90.7%
91.0%
80.4%
90.2%
93.3%
93.9%
98.2%
C
Physiotherapy - First Appointment (North only) - Patient Seen in Local
Timescale / Total Number of Patients
1818/2072
1443/1684
1984/2184
1760/1928
1294/1610
1613/1788
2164/2320
2038/2170
2092/2130
C
Podiatry - First Appointment Within Local Waiting Targets Full Compliance with
Routine, Urgent and Intermediate (North only)
359
374
392
363
271
271
406
363
316
4.5%
4.3%
4.3%
4.6%
4.8%
4.7%
4.6%
4.3%
4.2%
98.2%
98.8%
97.3%
92.5%
97.5%
81.2%
90%
95%
92%
95%
95%
90% - Q2
C
Percentage of Patients that DNA Their Outpatient/Community Appointment (All
Services)
4.5%
7.5%

25
98.9%
99.7%
99.3%
99.6%
99.3%
90.6%
90%
Podiatry - First Appointment Full Compliance with Routine, Urgent and
Intermediate (North only) - number of Patients seen
Performance
Direction of Travel Vs. Benchmark
Group
4.4%
 98.6% ACFT
Sep 13
C
Patients that DNA Their Outpatient/Community Appointment (All Services) Patients that DNA / All Contacts Including DNA
N
Percentage Patients Receiving a Diagnostic Scan Within 6 Weeks of Referral
N
Patients Receiving a Diagnostic Scan Within 6 Weeks of Referral - Scan Within
6 Weeks / Total Number of Scans
SC
Waiting time from assessment start to assessment completion: percentage
completed within 4 weeks (E03)
SC
Waiting time from assessment start to assessment completion Number
completed within 4 weeks (E03) - Number of Clients Assessment Completed
within 4 weeks / Total number of clients Assessed
SC
Proportion of carers assessed or reviewed in the year out of the total
number of carers 'on the books (E11)
SC
Number of carers assessed or reviewed in the year out of the total
number of carers 'on the books (E11) - Year to date average forecast / Total
Carers
N
Prison Healthcare Services: Hepatitis B - Percentage vaccinated within 31 days
of reception including those already vaccinated (data collected quarterly)
8220/181443 7566/177571 8309/190260 8633/188594 7178/162290 7931/172886 7763/175207 7050/166348
99.2%
73.3%
>99%
75%
Long stay residential care permanent admissions - Younger adults 18-64 (I03a
ii)
100%
100%
100%
100%
100%
100%
100%
100%
100%
235/235
210/210
189/189
72/72
327/327
237/237
251/251
254/254
224/224
74.9%
72.8%
73.4%
73.6%
75.1%
75.0%
75.6%
76.5%
76.5%
60.7%
70%
86.9%
87.2%
89.8%
88.3%
80.1%
75.1%
70.3%
68.9%
76.5%
80%
6.6
6.5
79.1%
77.0%
81.8%
76.6%
80.4%
80.1%
85.3%
79.9%
180/85/335
162/102/343
181/107/352
148/133/367
177/97/341
169/108/346
227/116/402
180/107/359
6.0
5.4
5.2
5.2
5.6
6.1
5.9
5.6
538
525.0
508.8
509.4
510.5
517.9
520.8
513.2
515.0
509.0
SC
Percentage of people receiving reablement in the year, where the
immediate outcome was no support or low level support (D04a)
SC
Number of people receiving reablement in the year, where the
immediate outcome was no support or low level support (D04a) - Clients with
no needs identified / Total clients
SC
Percentage of Older People still at home 91 days after discharge from
hospital into reablement (D06a)
SC
Number of Older People still at home 91 days after discharge from
hospital into reablement (D06a) - Clients at home with no or low services / Total
Clients
SC
Older people still at home and needing no on-going Social Care services
91days following receipt of reablement services (D06b)
SC
Older people still at home and needing no on-going Social Care services
91days following receipt of reablement services (D06b) - Clients at home with
no services / Total Clients
SC
The proportion of people using social care who receive self-directed
support (personal budget or direct payment) - snapshot (i02ai)
SC
The proportion of people using social care who receive self-directed
support (personal budget or direct payment) - snapshot (i02ai) - Target Clients /
Total Clients
SC
The proportion of people using social care who receive direct payments snapshot (i02bi)
SC
The proportion of people using social care who receive direct payments snapshot (i02bi) - Target Clients / Total Clients
SC
Percentage of clients receiving long-term support at any point in the
reporting period who have had any kind of review in the last 12 months (J01d)
L
66.1%
79.9%
6.0
6.0
493.0
493.0
1015
69.1%
72%
56.2%
61.4%
60.2%
62.1%
62.9%
62.9%
62.9%
62.4%
Bed Occupancy Inpatients Percentage
63.0%
63.0%
Eng :74.9%
WM: 68.7%
Shires: 77.0%
84.9%
Eng: 80.7%
WM: 80.0%
Shires: 81.3%
(unvalidated)
579/919
87.9%
85%
89.6%
86.2%
86.4%
85.8%
86.0%
86.0%
86.2%
85.4%
84.9%
883/1040
54.8%
55%
56.3%
53.4%
53.0%
51.5%
50.0%
49.6%
50.3%
49.9%
49.0%
49.0%
510/1040
73.4%
84%
76.0%
79.7%
80.3%
77.3%
75.9%
78.1%
80.8%
82.8%
84.9%
84.9%
4620/5442
24.6%
27.5%
24.3%
24.5%
25.4%
24.3%
24.3%
24.1%
23.9%
24.1%
24.0%
24.0%
1307/5442
58.3%
70%
57.9%
57.5%
57.3%
54.5%
55.5%
55.6%
55.7%
57.7%
Percentage of clients receiving long-term support at any point in the
reporting period who have had any kind of review in the last 12 months (J01d) Total Clients with long term support / Total Clients
We Will Make Excellent Use of
Our Resources and Improve
Levels of Productivity Across
Our Services
66.1%
34
Long stay residential care permanent admissions (ASCOF definition): Older
people aged 65+ (I03b ii)
SC
Our Organisation Will Develop
and Deliver Sustainable,
Innovative Services That Support
Independence
75.6%
4340/6564
SC
SC
100%
4862/6314
Prison Healthcare Services: Hepatitis B Numbers vaccinated within 31 days of
reception - Number of patients already vaccinated / Number of patients
vaccinated within 31 days / Numbers in prison healthcare
SC
1807/23322
63.4%
63.4%
7013/11,054
93.0%
93.1%
94.0%
94.8%
89.6%
99.4%
97.9%
96.3%
96.5%
98.7%
94.4%
88.1%
ANNEX 2: Children's Services - Lead Director - Kieron Murphy - Director of Children's Services - Performance Indicators - 2015 / 2016 - December Submission - Month 9
The RAG ratings have been reviewed with the service for new birth visits and reviews based on performance rates over the past twelve months and in comparison with other NHS Trusts regionally and nationally, where benchmarking information has shown that the Partnership Trust out-performs its peers, and therefore an assessment has been made that an amber rating
would provide the appropriate context should performance fall within a 90-94% range
Strategic Objective
We Will Provide High Quality and
Safe Services Which Provide an
Excellent Experience and Best
Possible Outcomes
Data
Quality
Score
Indicator
Type
Indicator
C
Percentage of Births that Receive a Face to Face New Birth Visits within 10-14
Days by a Health Visitor (data collected quarterly) Data delayed due to
changes in national reporting requirements
C
Number of Births that Receive a Face to Face New Birth Visits within 10-14
Days by a Health Visitor - Total number of face-to-face New Birth Visits (NBV)
undertaken between 10-14 days, by a Health Visitor with mother and father /
Total number of population based births, in the geographical area of provider's
responsibility
C
Percentage of Children who Received a 12 month review within 15 months
(data collected quarterly) Data delayed due to changes in national reporting
requirements
C
Number of Children who Received a 12 month review within 15 months - Total
number of children who received a review, by the age of 15 months of age,
based on the month when the child reached 12 months of age / Total number
of children aged 12 months, in the appropriate month
C
Percentage of Children who Received a 2 - 2.5 Year Review (data collected
quarterly) Data delayed due to changes in national reporting requirements
C
Number of Children who Received a 2 - 2.5 Year Review - Total number of
children who received a review, between the ages of 2-2.5 years of age, based
on the month when the child reached 2-2.5 years of age / Total number of
children aged 2-2.5 years, in the appropriate month
C
Percentage of Infants for whom Breastfeeding Status is Recorded at the 6 - 8
Week Check (data collected quarterly)
C
Number of Infants for whom Breastfeeding Status is Recorded at the 6 - 8 Week
Check - Number of infants where feeding status has been recorded at 6-8wk
check / Total number of infants receiving 6-8wk check
Outturn
2014/15
Target
90.60% 95% / 98%
96.30% 95% / 98%
90.30% 95% / 98%
90.60% 95% / 98%
Apr
May
Jun
Jul
Aug
Sep
Oct
93.20%
93.30%
91.20%
93.70%
94.90%
95.50%
94.90%
884/949
936/986
915/1003
1001/1068
929/979
962/1007
999/1053
94.80%
93.60%
95.50%
97.10%
96.80%
95.30%
97.00%
943/995
967/1033
963/1008
980/1009
1003/1036
1001/1050
1031/1063
91.10%
89.60%
91.70%
90.50%
997/1095
1041/1162
987/1076
1004/1109
90.50%
1004/1109
77.40%
79.80%
2225/2873
2358/2955
92.20%
1034/1122
Nov
Dec
Jan
91.60%
Feb
Mar
YTD
94.90%
97.00%
91.60%
953/1040
Indicator Type - N - National L - Local C - Contractual TDA - Trust Development Authority SC - Social Care ACFT - Aspiring Community Foundation Trust
To be noted - following feedback from the Trust Board in November 2015 additional metrics have been added to provide context to performance indicators - these metrics have been shaded grey to show for informative purposes only and are not counted towards the overall RAG rated quadrant
79.80%
Direction of Travel
Latest
Performance
Vs. Benchmark
Group
ANNEX 2: Section 3 - Finance - Lead Director - Jonathan Tringham - Director of Finance and Resources - Performance Indicators 2015 / 2016 - December Data - Month 9
Strategic Objective
We Will Make Excellent Use
of Our Resources and
Improve Levels of
Productivity Across Our
Services
Data
Quality
Indicator
Type
Indicator
N
Outturn
2014/15
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Financial Performance vs. Planned Performance (favourable
performance in brackets)
Nil
254
28
638
1,012
1,002
76
806
2,320
3,115
L
Percentage of Cost Improvement Programme (CIP's) Delivered (Against
YTD Plan)
100%
13%
26%
25%
46%
53%
115%
130%
126%
113%
97.2%
ACFT
Better Payment Practice Code by Volume
95%
90%
89%
91%
87%
87%
86%
86%
86%
87%
90.1%
ACFT
Better Payment Practice Code by Value
95%
93%
94%
95%
87%
86%
87%
87%
86%
90%
85.6%
ACFT
Liquidity Ratio Days Metric
4
4.0
4.0
3.0
3.0
3.0
3.0
3.0
3.0
Capital Servicing Capacity Metric
3
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
ACFT
Continuity of Service (CoS) Score
4
2.5
2.5
2.0
2.0
2.0
2.0
2.0
2.0
ACFT
Non-NHS Payables > 90 Days %
5%
10%
10%
18%
25%
18%
15%
20%
13%
17%
ACFT
Non-NHS Receivables > 90 Days %
5%
17%
14%
24%
31%
33%
29%
35%
34%
33%
Indicator Type - N - National L - Local C - Contractual TDA - Trust Development Authority SC - Social Care ACFT - Aspiring Community Foundation Trust
Jan
Feb
Mar
YTD
Performance
Direction of Travel Vs. Benchmark
Group
Target
3.8
ANNEX 2: Section 4 - Workforce - Lead Director - Julie Tanner - Director of Workforce - Performance Indicators - 2015 / 2016 - December Data - Month 9
Strategic
Objective
Our Workforce
Will be
Empowered and
Supported to
Deliver Care in a
Way That is
Consistent With
Our Values
Performance Vs.
Benchmark
Group
Data
Quality
Indicator
Type
Indicator
Outturn
2014/15
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
99% TDA
Workforce Sickness Rate Culmative (%)
4.98%
4.67%
4.55%
4.49%
4.44%
4.45%
4.48%
4.45%
4.40%
4.45%
4.46%
95%
TDA
Workforce Sickness Rate (%) - Monthly
4.02%
4.67%
4.55%
4.43%
4.34%
4.49%
4.59%
4.30%
4.07%
4.40%
4.29%
95% ACFT
Sickness Absence Rates - Short Term (less than 28 days)
1.58%
1.37%
1.41%
1.17%
1.34%
1.19%
1.35%
1.53%
1.73%
1.36%
2.39% as @
March 2015
95% ACFT
Sickness Absence Rates - Long Term (more than 28 days)
3.39%
3.17%
3.02%
3.17%
3.15%
3.40%
2.95%
2.55%
2.67%
2.93%
2.72% as @
March 2015
100% L
Percentage of Staff Having 'In-Date' Appraisal
59.08%
95%
62.80%
63.45%
62.48%
59.45%
64.90%
70.18% 73.65% 72.21%
71.50%

77.38%
100% N
Statutory & Mandatory Training Compliance
80.52%
90%
79.85%
78.69%
78.80%
77.85%
79.87%
81.43% 83.29% 83.71%
84.39%

87.1%
97%
L
Staff Turnover Cumulative (excluding bank/fixed term)
9.63%
<10%
0.79%
1.74%
2.81%
3.73%
4.74%
5.53%
6.35%
7.28%
8.04%
100% TDA
% Registered Nurses
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Indicator Type - N - National L - Local C - Contractual SHA - Strategic Health Authority SC - Social Care ACFT - Aspiring Community Foundation Trust
* Data Completeness included from Month 9
Jan
Feb
Mar
YTD
Direction of Travel

4.30%
Annex 3 - Quality Assessment - Lead Director - Rose Goodwin - 2015 / 2016 - December Data - Month 9
Indicator
Domain
Percentage of Reported Incidents Classified as Serious Incidents
2.99%
Compliance with Vulnerable Adults Quality Standards (Quarter 3)
89%
80%

Number of incidents (causing harm or otherwise) per 1,000 direct / face-toface contacts
5.05
ACFT Benchmark 3.99 @ Sep 13
Serious Incident Falls Reported (STEIS) Resulting in Severe Injury or Death
4
Target in development
7.61
Target in development
Safety Thermometer - Percentage of no New Harms (Community Hospitals /
Community Services)
96.8%
> 95%

Safety Thermometer - Percentage of Harm Free Care (Community Hospitals /
Community Services)
91.3%
> 95%

0
0

2 / 2#
<=8

Number of Never Events
0
0

MRSA Bacteraemia (Hospital associated) YTD
0
0

MRSA Screening on Admission (% screened on elective admission in month)
100%
95%

Venous Thromboembolism (VTE) Screening
100%
100%

Compliant
Compliant

0
0

NHS Litigation Authority – Failure to maintain, or certify a minimum published
CNST level of 1.0 or have in place appropriate alternative arrangements
Compliant
Compliant

WHO Surgical Checklist Compliance
Compliant
Compliant

Certification Against Compliance With Requirements Regarding Access to
Healthcare for People With a Learning Disability
Compliant
Compliant

Mixed Sex Accommodation (Single sex number of breaches)
Clostridium Difficile Number of avoidable incidents cumulative (# awaiting
panel) YTD
CQC Compliance with no major impact actions identified
Number of Coroners Regulation 28 received (Previously Coroner Rule 43's)
NICE Guidelines Compliance
Participation in National Audit Programme
Experience
Compliant
Target in development
Falls per 1,000 inpatient occupied bed days
Effectiveness
Target / Tolerance
14
Number of Serious Incident Pressure Ulcers Reported (STEIS)
Safety
Months Performance
There were 116 new NICE guidelines issued in 2015/16. Since March 2013 there
are 31 pieces of guidance that are relevant but partially complaint. A monthly
report is sent to the Divisional Business Meetings that details the non-compliance
for each Division, the current actions and expected compliance date so it can be
monitored at these committees.
Compliant
Compliant

SSOTP Re-admission Rates (excluding daycases)
5.3%
Net Promoter Score
97%
97%

Complaints closed within timescales in accordance with the National NHS
Complaint regulations
100%
100%

Do you feel that you have care and support which is directed by you and
responsive to your needs?
97%
90%

Quality Account Maintenance & Development
Quality Account Development - The account is available on the
Trust's website
ANNEX 5 - Self Certification Board Statement - Lead Director - Stuart Poynor - Chief Executive - November Submission - Month 8
The Partnership Trust Board is required to submit a self-assessment for each of the below 14 statements to confirm Trust compliance to the TDA on a monthly basis
Assessment
Full
Compliance
1
The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model
(supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any
further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and
continually improving the quality of healthcare provided to its patients
Yes
2
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration
requirements.
Yes
3
The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust
have met the relevant registration and revalidation requirements
Yes
4
The board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in
force from time to time.
Yes
Reference
Comment (Where criteria is not met)
For Clinical Quality that:
For Governance that:
5
The board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS
Constitution at all times.
Yes
6
All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external
audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner.
Yes
7
The board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate
evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued
compliance
Yes
8
The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in
place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented
satisfactorily
Yes
9
An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements
that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).
Yes
10
The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets as set out in the NTDA
oversight model; and a commitment to comply with all known targets going forward
No
11
The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit.
Yes
12
The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that
there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any
vacancies.
Yes
13
The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge
their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management
capacity and capability
Yes
14
The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating
plan; and the management structure in place is adequate to deliver the annual operating plan.
Yes
The Trust is currently in discussion with the TDA to agree a
financial outturn that will ensure it is complaint with TDA
requirements. 31st March 2016
Annex 5 - Detailed analysis by exception
5.1. Delayed Transfers of Care – SSOTP Community Hospitals
5.2. Delayed Transfers of Care – Social Care
5.3. Reablement Outcomes
5.4. Reviews
5.5. 6-8 Weeks Breastfeeding Coverage
5.6. Hepatitis B Vaccination Rates
5.1 Delayed Transfers of Care – SSOTP Community Hospitals
Division
Specialist & Children’s
Service
Hospitals
Service Lead
Sue Pointon
Performance Indicator / Issue
Performance Lead
Matthew Beardmore
Current
Performance
The percentage of occupied bed days occupied by
patients that are a Delayed Transfer of Care (DToC).
RAG
Status
Causing
Concern?
R
Y
Consequences
Clinical

Reputational
Contract
ual

Background
No contractual target has been agreed for 2015/16. The TDA monitors the Partnership Trust against a Community Trust
target of 7.5%. The specialist division monitors against a nominal 5% target.
The DToC rate has risen in December. The monthly rate is 7.3% which equates to 622 DToC days (an increase of 10.9%
on November’s figure of 561 days).
Of the 622 days, 385 days related to Stoke-on-Trent patients and 237 days related to Staffordshire patients.
Statistical Analysis
The following two tables provide detail of the levels of delays caused by the top 4 reasons. The first table
splits the current month (December) by Stoke and Staffordshire. The second table provides a three month
trend. This demonstrates the increase in delays is due to care packages, completion of assessments and
further non acute NHS care.
Fig. 1: Top 4 reasons for DToC days (December 2015)
Patient Choice
Awaiting Completion of Assessment
Awaiting Care Package in Own Home
Further non acute NHS care
Total
SOT
119
38
98
61
316
Staffs
70
52
65
34
221
Fig. 2: Top 4 reasons for DToC days – three month trend
Patient Choice
Awaiting Completion of Assessment
Awaiting Care Package in Own Home
Further non acute NHS care
Total
Oct-15
Nov-15
Dec-15
230
28
88
89
435
221
60
74
41
396
189
90
163
95
537
Fig. 3 provides detail on the attributable agency for all delays in month.
Fig. 3: Attributable agency for all DToC days (December 2015)
SOT
NHS
Social Care
Both
Total
Staffs
228
143
14
385
124
82
31
237
Fig. 4: Delays as a percentage of occupied bed days (chart and table)
Delays as a % of OBD's
12%
10%
7.3%
6.9%
6.4%
4.2%
3.9%
2%
3.4%
4%
6.7%
9.4%
6%
10.7%
8%
0%
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
2015/16
DTOC Days
Bed Days
Apr
302
8800
May
355
9178
Jun
375
8962
Jul
810
8579
2014/15
Aug
951
8909
Sep
549
8196
Oct
533
8329
Nov
561
8077
Dec
622
8538
Data Quality Assessment
Data Quality: Overall assessment of data completeness and accuracy
based on the data quality drivers below:
Data Quality
QI
DE
MC
UT
BP
SD
Data Quality Drivers
Data Quality Assessment (Full)
Data Quality
Assessment - DTOC.xl
Systems Design (SD):
The extent to which the system fit for the purpose of the service
Business Processes (BP):
The extent to which there are robust processes in place to enable data to be
recorded accurately and consistently
Understanding of requirements by front line staff (UT):
The extent to which training is sufficient to ensure staff fully understand the
use of and why data is being collected
Management checks and feedback as part of episode closure (MC):
The extent to which managers quality assure the work of practitioners and
feedback to them
Data extraction and analysis tools (DE):
The extent to which data extraction tools and reports reflect an accurate
picture of the information contained in the IT system
Quality Indicators (QI):
The extent to which the service the indicator relates to has embedded
measures of data quality
Key Issues Impacting on Performance
Issues
Impact
I1: Care package delays
During December the number of care package delays has fluctuated but remains high
rd
th
with a peak in the 3 and 4 weeks of the month approaching the Christmas period.
These delays did reduce at the end of the month. There were a higher percentage of
these delays attributed to Stoke local authority as opposed to County.
Some capacity has been made available for Stoke patients with AMG agency to
address this issue but this has not been consistently available to reduce community
hospital delays and has been limited in capacity. The county authority continues to use
their LIS service to support those with long waiting times for care packages or those
only requiring simple packages.
Both authorities have utilised interim placements for those waiting for care packages
where appropriate e.g. Amberley Hs and Brighton House. However availability of these
interim placements has also been limited. Prior to Christmas the teams did undertake
the ‘empty hospitals’ exercise to maximise the resources available for discharge prior
to the holidays. This involved additional presence on the wards of senior staff from
both health and social care. Acuity of the patients in the hospital beds remains high
meaning that most care package requests are for complex packages e.g. X4 double
care calls.
The number of choice delays fell during December. The daily patient flow conference
calls continue and these call focus on agreeing actions to resolve the choice delays. If
these actions do not resolve issues then they are escalated to the Service Managers
for support and advice.
Service Managers and Social Care Team leaders continue to meet with patients/
families when these delays are escalated to them or when choice letters are issued as
per policy. Discharge facilitators and Patient Flow Coordinators support this process.
Individual cases are referred to the legal team for their support when required.
This has become necessary on occasions when families refuse to look for alternative
accommodation when their home of choice has no capacity or when families cannot
agree on a home of choice. Court of protection has had to be instigated for 2 cases in
order to move forward to discharge; however this is a lengthy process.
I2: Choice delays
13: EMI Stay at Home
scheme
14: Intermediate care at
home
I5: Provider availability/
capacity and
assessment
I6: CHC funded patients-
17:Awaiting completion
of social care
assessment
I8: Other delays
During the first few weeks of December there was an increase in delays due to
capacity within the EMI S@H scheme. In order to reduce these delays patients waiting
were considered for interim placement in the EMI assessment beds e.g. Amberley
House. However their capacity also diminished during December. There has been
and increased demand for this service due to the increase in the number of patients
with dementia needs in the community hospitals.
During the run up to Christmas there was an increase in delays waiting for Intermediate
Care Services in their own home. Capacity within the service was poor at this time.
There remain a number of patients in December who have chosen a care home but are
on a waiting list for availability in that home of choice. Some patients are on waiting
lists for a multiple homes. Both health and social care teams work closely with families
to signpost them to homes that have availability.
However their capacity can change quickly. Availability of placements is particularly
challenging for those with complex needs e.g. EMI nursing. Commissioners did initiate
in December a scheme to reward care homes who came to assess and accepted
patients into their care within 24 hours of assessment. However there remained some
delays waiting for provider assessments.
In December there remained a number of patients waiting for care home placements or
care packages who have full Continuing Healthcare funding in October. These patients
are often near the end of life or have complex needs hence the impact of delays is high
on both the patient and can be stressful for their families.
Families often have a particular care home in mind in these circumstances if capacity is
not available this has to be approached sensitively to minimise distress. Care homes
with the ability to manage end of life care are also limited.
Any patient waiting for a care package at the end of life is treated as a priority for
capacity. The care home procurement system (ADAM) for those with CHC funding will
st
be introduced on February 1 .
There has been an increase in the number of delays attributed to social care
assessment during December. There is a high demand for social care assessment in
the community hospitals and the capacity to complete these assessments within the
72hrs agreed in the New Care Act is challenging. These issues are escalated to social
care team managers daily and resources are re-assigned where appropriate. We have
agreed to re- look at our local processes in light of this.
There remain ad-hoc cases of housing or equipment delays. These are monitored
closely and issues escalated so that prompt support can be obtained e.g. housing
agencies. These delays are usually of short duration.
Key Improvement Actions
Owner
Sue Pointon
Actions
Issues
addres
sed
Delivery
status
Deadline
A1: Escalate care package delay issues to
senior managers and commissioners when
required to facilitate care agency provision
I1
A2: Daily patient flow conference calls to
ensure that choice delays are closely
monitored and agreed actions allocated to a
named individual
A3: Service Managers and Social Care Team
leaders continue to meet with patients/
families when these delays are escalated to
them or when choice letters are issued as per
policy
A3: Health and Social Care teams work
closely with families to signpost them to
homes that have availability
A4: Proposed introduction of Matrix Dynamic
Procurement System for CHC funded
patients
All
Issues are raised when
required. This process enabled
AMG provision to be provided
in October which has helped
reduce the number of delays
In place
I2
In place
B
I3
In place
B
I4
A5:Review of local processes for
referral/notification to social care
17
Delay in implementation of the
Matrix system now planned for
January 2016.Update - now
agreed for implementation on
st
Feb 1 . System is called
ADAM. Training for our staff
th
booked for 28 January.
Earlier identification of the
need for social care
intervention
On-going
RAG
G
B
January16
G
February
2016
R
Improvement Trajectory
Not applicable. The Partnership Trust remains below the nominal TDA target level of 7.5%
Remaining Risks
Owner
Lisa Hulme
Risk
Impact
Related
issues
R1: Increasing inability to match capacity of care packages in the community to demand
for patients in community hospitals
High
I1, I4
5.2 delayed Transfers of Care – Social Care
Division
Trust
Service
Adult Social Care (ASC)
Delayed Transfers of
Care (DToC)
Performance Indicator / Issue
Service Lead
Area Managers
(North & South
Divisions)
Current
Performance
RAG
Status
DToC KPIs:
E07 - % Number of Social Care and Joint Delayed
Transfers of Care EPISODES: Average Per Month
E07b - % as E07 Where Reason for Delay Was
'Completion of Assessment'
E08 - % Number of Social Care and Joint Delayed
Transfers of Care DAYS: Average Per Month
E08b - % as E08 Where Reason for Delay Was
'Completion of Assessment'
Background
Causing
Concern
?
Performance Lead
Barrie Knox
Consequences
Clinical
Reputational
Contract
ual


Red
Red

Yes
Red
Red
Delayed Transfers of Care (DToC) represent a considerable burden on the combined health and
social care economies. Patients are unable to be supported in their most suitable care
package/environment owing to capacity restraints. The movement is from admitted to community
based care. Excess emergency activity within health/social care economies, often experienced
during situations of Winter pressures, exacerbate DToC occurrence by creating surges of demand.
Statistical Analysis
E08 - % Number of Social Care and Joint Delayed Transfers of Care DAYS:
Average Per Month
E07 % Number of Social Care and Joint Delayed Transfers of Care EPISODES:
Average Per Month
80
1800
70
1600
1400
60
1200
50
1000
40
800
30
600
20
400
10
200
0
0
Apr
May
Jun
Jul
Target
Aug
Sep
Oct
Nov
Dec
Desired Improvement
Actual Performance
Jan
Feb
Apr
Mar
May
Jun
Target
Realistic Trajectory
Jul
Aug
Sep
Actual Performance
Oct
Nov
Dec
Desired Improvement
Jan
Feb
Mar
Realistic Trajectory
E08b - % as E08 Where Reason for Delay Was 'Completion of Assessment'
E07b - % as E07 Where Reason for Delay Was 'Completion of Assessment'
600
50
45
500
40
35
400
30
300
25
20
200
15
10
100
5
0
0
Apr
May
Jun
Target
Jul
Aug
Actual Performance
Sep
Oct
Nov
Desired Improvement
Dec
Jan
Realistic Trajectory
Feb
Mar
Apr
May
Jun
Target
Jul
Aug
Actual Performance
Sep
Oct
Nov
Desired Improvement
Dec
Jan
Realistic Trajectory
Feb
Mar
Current KPI Performance (as at November 2015 – reports are one month in arrears):
E07:
Target
Actual
14/15 Outturn
E07b:
Target
Actual
14/15 Outturn
37.5
64.9
51.2
E08:
14.0
25.1
14.8
E08b:
Target
Actual
14/15 Outturn
1,015
1,691
1,311
Target
Actual
14/15 Outturn
300
545
301
Due to the difficulty in materially impacting performance due to market conditions, the intention is to stabilise
performance rather than expect to make significant improvement in the short term across these indicators.
Key Issues Impacting on Performance
Issues
Impact
I1 Capacity Restraints within Health & Social Care
Provision
With growing demand from demographic and acuity
factors, the capability to meet demands is stretched
over time. Where appropriate provision is unavailable
DToCs will occur.
The 2012 Health & Social Care Act heralded new
standards for reporting DToC. These standards
represented a change in reporting for SSoTP.
I2 Care Act Compliant Reporting
Key Improvement Actions
Owner(s)
Area Managers
Actions
Issues
addressed
Delivery
status
A1 ASC Reviews Project
I1
A2 Emergency Planning
I1
A3 Reporting Updates
I2
Reviews audit to ensure alignment of
need and provision within ASC.
Identified areas for reduced provision
will free up capacity for more care
packages to be brokered and for LIS
team resources to be redirected
towards reablement, thus reducing
pressure within ASC which will prevent
DToCs from taking place.
Substantial work with health and social
care commissioners has been
undertaken to put in place
emergency/Winter pressures schemes
to provide additional capacity to
prevent blockages. Additional funding
has been earmarked to support these
schemes, though its scale relative to
likely demands is limited.
Work has been undertaken internally
to update community hospital reporting
to be compliant with Care Act
requirements. In parallel, SSoTP has
been liaising with SCC around data
compliance to ensure that
Deadline
RAG
January
2016
Amber
March 2016
Amber
November
2015
Amber
responsibilities and causation for
DToCs can be identified.
Following preliminary investigations in
partnership with SCC, SSOTP is
undertaking an extending analysis to
standardise implementation to ensure
that reporting is accurate and
compliant.
Remaining Risks
Owner(s)
New date
March 2016
Area Managers
Risk
Impact
Related
issues
R1 Reviews Project – potential for unmet need to be identified rather than
streamlining of existing packages thereby generating additional demands
within the present funding/capacities.
R2 Winter Pressures – unusually severe weather patterns will create
additional emergency pressures which will overcome planned
resources/schemes.
Medium
I1
Medium
I1
5.3 Reablement Outcomes
Division
Trust
Service
Adult Social Care
(ASC) Reablement
Performance Indicator / Issue
Reablement KPIs
D04a - % immediate outcome no/low level support
D06b - % at home w/o on-going social care > 91 days
Background
Service Lead
Area Managers
(North & South
Divisions)
Current
Performance
RAG
Status
Red
Red
Causing
Concern
?
Yes
Performance Lead
Edward Finnemore
Consequences
Clinical

Reputati
onal
Contract
ual


The reablement of social care clients is a key deliverable within the Trust’s ASC strategy, being the
major component to maintain and enhance individual capabilities in meeting their own social care
needs. Successful reablement can therefore offset demands for social care provision.
KPIs established with Staffordshire County Council (SCC) have sought to measure that success, in
the case of D04a and D06b through the rates of clients receiving no/low support following
reablement, and the numbers capable of staying at home after three months (91 days). Reablement
performance has proved challenging to deliver over many years, and the performance levels for
D04a and D06b have both experienced declining trends in recent months within 2015/16.
Statistical Analysis
D04a: Percentage of people receiving reablement in the year, where the immediate outcome was no support
or low level support. (ASCOF 2D)
Target
72.0%
Actual
63.0% (represents 579 service users of a total population of 919)
14/15 Outturn
69.1%
D06b: Older people still at home and needing no on-going Social Care services 91 days following receipt of
reablement services.
Target
55.0%
Actual
49.0% (represents 510 service users of a total population of 1,040)
14/15 Outturn
54.8%
Data Quality Assessment
Systems Design (SD):
The extent to which the system fit for the purpose of the service
Business Processes (BP):
The extent to which there are robust processes in place to enable data to be recorded
accurately and consistently
Understanding of requirements by front line staff (UT):
The extent to which training is sufficient to ensure staff fully understand the use of and
why data is being collected
Management checks and feedback as part of episode closure (MC): The extent to
which managers quality assure the work of practitioners and feedback to them
Data extraction and analysis tools (DE):
The extent to which data extraction tools and reports reflect an accurate picture of the
information contained in the IT system
Quality Indicators (QI):
The extent the service the indicator relates to has embedded measures of data quality
Overall DQ for Social Care Reablement is rated, as of January 2016, at 2.5 (of 5) which gives it an overall
amber rating. The attached document provides the underlying assessment for ASC reviews across the six
elements contained within the DQ analysis.
Social Care Data
Quality Assessment - R
Key Issues Impacting on Performance
Issues
Impact
I1 Client Scope
Efficiency requirements inherent within the ASC
contract require greater focus on reablement. More
service users will therefore be supported through
reablement however there will be an increasing trend
for this group to require a level of support (increasing
co-morbidities) to enable them to remain at home.
Operational response and with reference to the Social
Care Act has been to maximise opportunity for service
users to undertake reablement program . This has the
consequence that more service users will benefit from
enablement opportunity however they may have the
outcomes of community services at home – with
reduction on reliance of care placements or the
outcome of a care placement. The operational
preference to optimise overall outcomes rather than to
restrictively pursue indicator performance impacts on
performance.
I2 Separation Inpatient Enablement Services
I3 Internal Service Demarcation – Health/Social Care/
Divisional
I4 LIS Reablement Focus
Key Improvement Actions
Issue is to ensure who is included in the cohort sample
– hospital discharge to enablement program not respite
and assessment population.
Remaining difficulties across health and ASC teams
within the Trust. Specifically accessing therapeutic
professional skills (especially physiotherapy). Need to
breakdown barriers between Enablement and
Intermediate Care teams in order to achieve improved
results/sharing professional knowledge. Operational
feel that North and South economies operate in parallel
rather than concord, with opportunities for shared
learning and potential efficiencies lost.
2015/16 operational pressures have resulted in LIS staff
supporting maintenance packages rather than focusing
purely on reablement.
Owner(s)
Area Managers
Actions
Issues
addressed
Delivery
status
Deadline
RAG
A1 Hospital Discharge
Information
I1, I3
March 2016
Amber
A2 ASC Reviews Project
I1, I4
March 2016
Amber
A3 Client Expectation
I2
January
2016
Completed
A4 Staff Communication
across Community Services
I3
Improvements to discharge information
being implemented. Impacts on ability
to identify most appropriate patients for
enablement. Working well with
Discharge to Assess (D2A) – completing
health screen information within CD.
Extracted data regarding hospital
screening being reviewed for accuracy
during January 2016. Service user
opportunities for Reablement access to
be reviewed by management.
An analysis of ASC reviews will be
undertaken in Autumn 2015 with a view
to identifying potential package care
provision reductions. Such a reduction
will benefit both LIS Teams in being able
to refocus back towards reablement,
and the wider private marketplace in
freeing provision capacity to be made
available to other clients. Private sector,
Able2, has been brought in to provide
reviews capacity – need to review
quality and impact of the additional
resource during Jan-Feb 2016.
Operational need to continually ensure
client expectations upon entering into
reablement, to minimise potential for
disengagement when exposed to full
care clients. Brighton House service
user expectation being managed
through implementation of new
admission information to clarify process
and ensure full consent to reablement
programme.
Implementing co-location of
Intermediate Care and Enablement staff
at Brighton House to bring together staff
skills and promote joint working.
Scheduled to start October 2015.
Would benefit from being extended to
ILCT/LIS staff, though the Trust estate is
a practical restriction on implementation.
November
2015
Completed
Remaining Risks
Owner(s)
Area Managers
Risk
Impact
Related
issues
R1 Best Practice Learning Across Trust – operationally feels as though there
are significant gaps between North and South Divisions – silo working.
Understanding across Areas within Division, but not between Divisions.
R2 Continuing Capacity Restraints – prevent release of staff to reablement
from maintenance packages.
Medium
I1, I3
Medium
I4
5.4 Reviews
Division
Trust
Service
Adult Social Care
(ASC) - Reviews
Performance Indicator / Issue
ASC Reviews:
J01d Percentage of long-term clients receiving any
review (incorporates both J01d(i) community and
J01d(ii) residential).
Service Lead
Christine Wheeler
Performance Lead
Edward Finnemore
Current
Performance
RAG
Status
Causing
Concern?
Red
Yes
Consequences
Clinical

Reputational
Contract
ual


Background
The performance indicators covering Reviews are split as follows:
-
J01d(i) – percentage of long-term community-based clients receiving any review
J01d(ii) – percentage of long-term residential-based clients receiving any review
J01d represents the Trust’s business as usual (BAU) objective for client reviews. Within the Q4 remainder of
2015/16 the Trust has been asked by Staffordshire County Council (SCC) to focus on the priorities of the
Reviews Project which is being jointly undertaken between SSoTP and SCC. This focus will be prioritised
over its BAU norm at least until March 2016, pending future re-evaluation of ASC review performance within
Staffordshire.
Statistical Analysis
Client Reviews are currently below target in the Trust for the latter element only and RAG rated as Red:
• J01d(i) – December YTD Trust wide is currently 58.3% (represents 4,854 service users of a 7,446 total
population).
• J01d(ii) – December YTD Trust wide is currently 56.4% (represents 2,159 service users of a 3,608
total population).
• Please see overleaf for latest position shown graphically (December 2015 data).
•
The current trajectory for both elements of Reviews suggest that the Trust will not achieve its target
this year. As a result, an action plan has been formulated to ensure that the direction of travel
improves to reach the required number of client reviews before the year end as well as contributing to
local financial recovery plans.
Key contributors to achieving this target include staff within the ILCTs and the CIS. For that reason, both
Neighbourhood Managers and ISMs are operationally tasked with driving the required continuing
improvements. For example, within the North Division, Newcastle has reorganised its staffing in all teams due
to the Care Act and the demands on each team. It became apparent that annual reviews were not being
completed in a timely way by the ILCTs and the Community Hospital teams. The reasons for this was due to
the ILCTs holding complex cases whereby case work was prioritised based on risk and the pressure the
hospital team face to ensure there is patient flow through the system.
The other key issue is correct recording within Care Director. For numerous reasons, staff are still not
completing this correctly and key areas have been supported by Performance to drill down into the detail to
find solutions to this problem.
The current Trust Performance for Reviews on a 12 month rolling basis, as of December 2015, measured as
per indicator J01d, all long-term clients with any review, is 63.4%. This represents 7,013 reviews within a
total service user count of 11,054. The above graph shows the YTD performance which is now starting to
move ahead of the established target threshold (70%), however, with SCC’s focus on reviews there is now a
working target of 100% of clients being reviewed. This is being delivered according to a set of review
prioritisation criteria agreed with the Council.
Data Quality Assessment
Social Care Data
Quality Assessment - R
Systems Design (SD):
The extent to which the system fit for the purpose of the service
Business Processes (BP):
The extent to which there are robust processes in place to enable data to be
recorded accurately and consistently
Understanding of requirements by front line staff (UT):
The extent to which training is sufficient to ensure staff fully understand the
use of and why data is being collected
Management checks and feedback as part of episode closure (MC):
The extent to which managers quality assure the work of practitioners and
feedback to them
Data extraction and analysis tools (DE):
The extent to which data extraction tools and reports reflect an accurate
picture of the information contained in the IT system
Quality Indicators (QI):
The extent to which the service the indicator relates to has embedded
measures of data quality
Overall DQ for Social Care Reviews is rated, as of January 2016, at 1.7 (of 5) which gives it an overall red
rating. The attached document provides the underlying assessment for ASC reviews across the six elements
contained within the DQ analysis.
Key Issues Impacting on Performance
Issues
Impact
1. Demand and Capacity Pressures
Current demand exceeds capacity. Although staff have
been transferred to the Review team there have been
high levels of sickness and, in addition, two of the
permanent staff members have been seconded to the
Independent Review team.
It was originally planned that the Review team would
concentrate on the scheduled reviews where the case
has been closed with services and the ILCT teams
would focus on their key worked cases ensuring these
are reviewed.
If timely reviews are not held then service users may
not be receiving the correct support required to meet
their eligible needs.
This reduces the reported figures and doesn’t reflect the
work completed by the teams, which in turn making it
difficult to action areas of poor performance and
recognise good areas for positive outcomes.
2. Highly prescriptive recording systems (Care Director)
which does not lend itself for staff to correctly and
intuitively action the right areas, and produces
performance indicators which lack accuracy and
confidence.
Key Improvement Actions
Owner
Christine Wheeler
Actions
Issues
addres
sed
Delivery
status
Deadline
RAG
1. Ensuring that review performance data on
Care Director is captured correctly by all staff
within the ILCT and CIS teams. It has
become apparent that when completing
reviews staff are entering the date into the
required field for the next annual review date
but are omitting to complete the information
screen on Care Director which stipulates
when the actual date of the review has
occurred.
I2
It has been discussed with all
staff on the ILCTs that this field
must be completed. They have
been tasked a deadline date of
9/12/15 to review all of their
open cases and ensure that the
cases which they have reviewed
have the field review date
completed. This will increase the
number of reviews completed by
130 for the district.
10/1/2016
A
20/12/15
A
Ongoing
G
Christine Wheeler is to meet
with the Team leaders in CIS to
ensure that the staff on their
teams also complete this field.
Ensuring that the data has been
captured will form part of the pre
closure checklist send to admin.
2. It has been identified that there are over
250 authorised Service Provisions that do not
have a completed review date and a further
23 cases whereby the incorrect field has
been completed and not the actual review
date.
I2
3. Additional Review Team Recruitment and
I1
The list of these cases has been
obtained and all of the cases will
have the correct actual review
date inputted on to the
information screen on Care
Director by the Team Attached
Clerk.
The Review team have clear
Productivity
4. All members of the ILCTs to bring their list
of key-worked cases to supervision. They
need to demonstrate if the service user has
been reviewed that, all of the correct fields
have been completed in Care Director.
I1, I2
If they have not reviewed the care received,
then a plan needs to be agreed with the
supervisor as to when they will be completed.
This is to be a set agenda item in each
person’s supervision session.
5. Minimum Reviews Staff Target
I1, I2
5. Independent Review Team Monitoring and
Engagement
I1, I2
6. Monthly Monitoring of all reviews
I1
7. Appointing additional Agency resource
under Sandra Daniels to carry out targeted
reviews between November and March 2016
I1
individual targets. A full time
staff member should complete
40 reviews per calendar month.
This is reviewed in monthly
supervision sessions. The Team
Attached clerk will record on a
dedicated spreadsheet which
reviews have been allocated
and will update the spreadsheet
once the review is completed
and correctly recorded in Care
Director.
Monthly performance meetings
are held with the Area Manager,
Neighbourhood Managers,
Team Leaders and Advanced
Practitioners. Clear guidance
has been given to all who
supervise Social care staff about
what is expected from
supervision sessions in relation
to performance issues.
All team members to be
allocated five reviews by the
Team Attached clerks. These
reviews will be kept on a
spreadsheet which will be
updated once the review has
been completed and correctly
recorded in Care Director.
Target productivity for full time
dedicated reviews staff to be 2
reviews per day, or 10 for the
whole week.
Monthly discussions with Wendy
Snell to see what is being found
in the areas where the pilot is
taking place.
To be on all meetings agenda in
each team meeting, locality
meeting and supervision
sessions
Project initiation and planning
phase
Remaining Risks
Owner
31/12/15
A
30/01/16
A
Ongoing
G
31/10/15
G
01/11/15
G
Sandra Daniels
Risk
Impact
Related
issues
1. Service users/patients require crisis management rather than a managed
review due to lack of capacity.
High
1
5.5 6-8 Weeks Breastfeeding Coverage
Division
Specialist & Children’s
Service
Health Visiting
Service Lead
Pauline Evans
(UNICEF Lead)
Current
Performance
Performance Indicator / Issue
Breastfeeding data coverage 6-8 weeks after birth
(breastfeeding status of mother to be recorded at 6-8 week visit
by health visitors).
Accurate completion and return of 6-8 week breastfeeding data
by health visitors (HV’s) to child health to reach minimum target
of 95% (NHS England target).
Current performance data suggests that no teams within South
Staffordshire are achieving this coverage rate, and performance
is falling each quarter.
RAG
Status
Causing
Concern?
Red

Performance Lead
Matthew Beardmore
Consequences
Clinical
Reputational
Contract
ual


Background
GP’s are commissioned to undertake a 6-8 week check of all new born babies, and the recording of the breastfeeding
status is one of the questions in this 6-8 week check.
The Health Visitor service is commissioned to help maintain the percentage of mums that are fully or partially
breastfeeding between the Primary Visit and the 6-8 week check. This is measured by comparing the data at Primary
Visit (collected by the Health Visitor) with the data collected by the Health Visitor on behalf of the GP at the 6-8 week
check. Historically the 6-8 week data collection has not been formally put into a GP contract so Health Visitors have been
tasked with collecting the data and returning to child health.
The directive given to Health Visitors across the Partnership Trust is that when they complete height/weight
measurements as part of the 6-8 week check, they are also requested to complete the breastfeeding status questions.
In the North area (Stoke-on-Trent and North Staffordshire), this information is then directly input onto Trust information
systems by Health Visitors. In Southern Staffordshire, the information is removed from the infant’s red book and sent to
the Health Informatics Service to input onto the Child Health system.
1
Statistical Analysis
The following chart and table outline current performance for the Partnership Trust as a whole, and then by CCG area (as
a proxy for Health Visiting teams).
Fig. 1: Breastfeeding Coverage Rate (Summary)
Breastfeeding Coverage Rate by by Quarter
(2013/14 and 2014/15 YTD)
100.0%
20.0%
79.8%
77.4%
89.6%
89.4%
91.8%
90.7%
88.4%
89.5%
40.0%
90.6%
60.0%
91.4%
80.0%
0.0%
Target
Total
Number of Infants with
Breastfeeding Data
Recorded
Total Infants
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Q2
14/15
Q3
14/15
Q4
14/15
Q1
15/16
Q2
15/16
2,639
2,759
2,749
2,562
2,717
2,761
2,699
2,511
2,225
2,358
2,890
3,048
3,075
2,901
2,996
3,007
3,018
2,802
2,873
2,955
Fig. 2: Breastfeeding coverage rate by CCG (rolling 5 quarters)
CCG
Cannock Chase
East Staffordshire
North Staffordshire
Seisdon Peninsula
South East Staffs
Stafford and Surrounds
Stoke-on-Trent
Total
Target
Q2
2014/15
83.1%
84.9%
100.0%
88.8%
82.7%
86.7%
100.0%
91.8%
95.0%
Q3
2014/15
87.3%
75.1%
100.0%
87.1%
71.1%
87.8%
100.0%
89.4%
95.0%
Q4
2014/15
85.4%
75.4%
100.0%
86.8%
74.9%
87.7%
100.0%
89.6%
95.0%
Q1
2015/16
61.9%
58.0%
100.0%
60.3%
65.3%
58.9%
100.0%
77.4%
95.0%
2
Q2
2015/16
64.3%
61.7%
100.0%
71.2%
58.7%
68.5%
100.0%
79.8%
95.0%
Data Quality Assessment
Data Quality: Overall assessment of data completeness and accuracy
based on the data quality drivers below:
Data Quality
QI
DE
MC
UT
BP
SD
Data Quality Drivers
Data Quality Assessment (Full)
Data Quality
Assessment - Breastfe
Systems Design (SD):
The extent to which the system fit for the purpose of the service
Business Processes (BP):
The extent to which there are robust processes in place to enable data to be
recorded accurately and consistently
Understanding of requirements by front line staff (UT):
The extent to which training is sufficient to ensure staff fully understand the
use of and why data is being collected
Management checks and feedback as part of episode closure (MC):
The extent to which managers quality assure the work of practitioners and
feedback to them
Data extraction and analysis tools (DE):
The extent to which data extraction tools and reports reflect an accurate
picture of the information contained in the IT system
Quality Indicators (QI):
The extent to which the service the indicator relates to has embedded
measures of data quality
Key Issues Impacting on Performance
Issues
Impact
I1: Process for submission and coding of forms not
working in South Staffordshire
Health Visiting teams are clear that they are sending all
their forms through to the Health Informatics Service
(HIS) and the HIS are clear that they are coding all
forms they receive. However, performance rates
suggest that this process is not working
Therefore the process for coding needs to be reviewed
Health Visiting teams in South Staffordshire are reliant
on the HIS to input breastfeeding data on their behalf
and therefore have no direct control over the data they
collect being recorded on the Child Health system
Breastfeeding status reports are set up and available at
GP practice level, but do not provide individual staff
member detail
I2: Lack of direct control over data input for Health
Visitors
I3: Teams do not have staff-level reports to enable any
performance issues to be investigated
3
Key Improvement Actions
Owner
Pauline Evans
Actions
Issues
addressed
Delivery
status
Deadline
A1: Assess feasibility of adding SNOMED
codes to Lorenzo to enable direct input of
breastfeeding data by Health Visitors
I1, I2
A2: Assess whether an e-process could be
introduced to transfer information
I1, I2
A3: Team leaders to check existing
breastfeeding status reports and investigate
all instances where children do not have
their breastfeeding status recorded with
individual staff
I3
A4: Performance team to assess feasibility
of setting up breastfeeding status reports to
individual staff member level
I3
Meeting took place on 5
October at which this was
discussed.
th
This was followed up on 6
November – awaiting
confirmation from IM&T of
feasibility of SNOMED codes
If A1 is deemed not to be
feasible, this action will be
explored. A similar issue was
experienced in the community
hospitals, and an e-process
introduced, which could be
adapted by Health Visitors
Reports are in place at GP
practice level to enable Team
Leaders to do this. Team
leaders receive a reminder
email each month to check
their data.
We have a current list of staff
members aligned to GP
practices but due to switch to
geographical working awaiting
new staff lists to set up
reports. If status is directly
input onto Child Health system
via SNOMED or local codes,
reports could be set up this
way.
th
4
RAG
30/11/2015
A
31/12/2015
(if required)
A
In place
B
31/12/2015
New date
30/01/2016
A
Improvement Trajectory
Based on the actions listed above, the graph below charts progress towards achieving the 95% data coverage
target. Taking into account whichever process is used will be introduced during Q4, it is anticipated that it will
not be fully embedded until Q2 2016/17, although improvements should be seen during Q4 2015/16 and Q1
2016/17.
Fig. 3: Improvement trajectory for Breastfeeding data coverage
100.0%
90.0%
80.0%
Process fully embedded
by Q2 2016/17
70.0%
Commencement of new
process during Q4
2015/16
60.0%
50.0%
Actual
Trajectory
Target
Remaining Risks
Owner
Ian Turner
Risk
Impact
Related
issues
R1: Until a resolution is found, performance will continue to be poor. The Health
Visiting service moved from NHS England to Local Authority commissioned in October.
High
I1, I2
5
5.6 Hepatitis B Vaccination Rates
Division
Specialist & Children’s
Service
Offender Healthcare
Service Lead
Maggie Whitmore/
Nikki Black
Performance Indicator / Issue
Current
Performance
RAG
Causing
Percentage of Hepatitis B vaccinations given within 31
Status Concern?
days of reception
A
Y
Background
Performance Lead
Matthew Beardmore
Consequences
Clinical
Reputati
onal
Contract
ual



The Hepatitis B vaccination rate was slightly below target in November at 79.9%. Had another two patients had a
vaccination in-month, the target would have been achieved.
This is the first time since July 2015 that the 80% target has not been achieved. The main issues this month have been at
Brinsford and Werrington. In the case of the former establishment, there are challenges around the remand environment
which means that offenders are not always within prison long enough to have the full course of vaccinations.
At Werrington the drop in figures this month relates to a few people declining vaccination, but also a number of patients
agreed but were transferred very quickly before injections could be given. Based on performance for the year to date it is
anticipated that this is a one-off issue.
Vaccination rates continue to be maintained or improve at all other establishments. Drake, Featherstone and Stafford, all
achieved 80% or more in-month.
The table in fig. 1 outlines the current vaccination rates with the number of patients applicable each month since April
2015.
Based on overall performance over the past few months, and that all actions at each establishment have been
implemented, and all other issues are outside control of the service, it is recommended that this improvement plan is
closed.
Statistical Analysis
Fig. 1: Breakdown of Hep B achievement by month
Number of new/transferred
prisoners
Number of new/transferred
prisoners vaccinated with 31 days
Number of prisoners already
vaccinated
Hepatitis B vaccine coverage for all
new/transferred prisoners
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
335
343
352
367
341
346
402
359
85
102
107
133
97
108
116
107
180
162
181
148
177
169
227
180
79.1%
77.0%
81.8%
76.6%
80.4%
80.1%
85.3%
79.9%
Fig. 2: Breakdown of Hep B achievement by month (April 2014 onwards)
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Overall
Target
Data Quality Assessment
Data Quality: Overall assessment of data completeness and accuracy
based on the data quality drivers below:
Data Quality
QI
DE
MC
UT
BP
SD
Data Quality Drivers
Data Quality Assessment (Full)
Data Quality
Assessment - Hepatitis
Systems Design (SD):
The extent to which the system fit for the purpose of the service
Business Processes (BP):
The extent to which there are robust processes in place to enable data to be
recorded accurately and consistently
Understanding of requirements by front line staff (UT):
The extent to which training is sufficient to ensure staff fully understand the
use of and why data is being collected
Management checks and feedback as part of episode closure (MC):
The extent to which managers quality assure the work of practitioners and
feedback to them
Data extraction and analysis tools (DE):
The extent to which data extraction tools and reports reflect an accurate
picture of the information contained in the IT system
Quality Indicators (QI):
The extent to which the service the indicator relates to has embedded
measures of data quality
Key Issues Impacting on Performance
Issues
Impact
HMP Featherstone
I1: Low numbers of permanent staff to carry out Hep B
vaccinations
I2: Any new staff recruited may require training to carry
out vaccinations
I3: Training needed for all members of staff in one
session to give maximum effect on waiting lists
I4: E-training not accessible on Trust website as the site
was being updated and therefore not available until
September
I5: New staff to SSOTP need face to face vaccine
training instead of e-training as per infection control
policy
HMP Brinsford
I6: A significant number of patients arriving at HMYOI
Brinsford decline Hep B vaccination when offered at
secondary screening
Recruitment and retention of nurses was very poor over
a long period of time therefore agency staff were used
in the department to ensure safe staffing levels. Agency
staff were not up to date or trained in vaccinating
patients so clinic waiting list for Hep B increased
Permanent staffing levels increased however new staff
did not vaccinate in previous roles therefore needed
training in SSOTP vaccination procedures.
Clinics had to be cancelled due to only 1 permanent
member of staff available to vaccinate patients
Experienced permanent staff need mandatory annual
updates which they can usually access on-line. As they
could not access e-training due to the website being
closed for several months, their ability to vaccinate was
removed and therefore clinic waiting lists increased as
clinics had to be cancelled.
As new nurses to SSOTP need to have face to face
training instead of e-training, clinics had to be cancelled
until face to face training could be arranged.
Causes compliance issues as this impacts on the
percentage of hep B vaccinations carried out
Key Improvement Actions
Owner
Action
HMP Featherstone
A1: 6 new staff recruited from May to July
A2: Training issues identified
A3: Vaccination trainer identified
th
A4: Date of training arranged for the 11
August
A5: All staff advised to come in on days off
for training to ensure all staff trained on the
day
Maggie Whitmore/
Nikki Black
Issues
addres
sed
Delivery
status
Deadline
I1
Completed
I2, I3,
I4, I5
I3, I4, I5
Completed
Completed
I1, I2, I3
Completed
I3, I5
Completed
31 July
2015
rd
3 August
2015
rd
3 August
2015
rd
3 August
2015
rd
3 August
2015
st
RAG
B
B
B
B
B
Improvement Trajectory
Based on the actions listed above – and those from previous iterations of the plan, the graph below charts
progress towards achieving the 95% data coverage target:
Fig. 3: Improvement trajectory for Hepatitis B vaccination coverage
100.0%
95.0%
Training issues fully
resolved at Featherstone
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
Data recording
issues resolved
at Werrington
Drop in figures at Werrington
due to a number of patients
being transferred very quickly
before injections could be given
60.0%
Actual
Remaining Risks
Trajectory
Target
Owner
Carol Adams
Risk
Impact
Related
issues
R1: HMP Brinsford continues to have challenges related to the remand environment which
can mean that patients can be transferred from the establishment prior to the full set of
vaccinations being given
High
I2, I3
Enc 08
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST
TRUST BOARD MEETING
TO BE HELD ON: 27 JANUARY 2016
Enclosure:
Enclosure 08
Subject:
Finance Report For Period Ending 31 December 2015 (Quarter 3)
Strategic Goal:
(tick as applicable)
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
Our organisation will develop and deliver sustainable, innovative services that
support independence
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values

We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Jonathan Tringham
Recommendation:
For Approval & Assurance

For Discussion
For Information
PURPOSE OF THE REPORT:
The purpose of the report is to present to the Partnership Trust Board the Partnership Trust’s financial
performance at 31 December 2015 (Quarter 3), and to consider the financial outlook arising from this.
KEY POINTS:
The Partnership Trust is reporting an actual deficit of £6.651m at the end of Quarter 3, representing an
adverse variance of £5.057m against an internal budgeted deficit to date of £1.595m.
This compares to the planned financial position submitted to the Trust Development Authority (TDA) of
£3.546m deficit at Quarter 3. Following two consecutive months of “run-rate” deficits in excess of £1m,
Month 9 has shown anticipated improvement with an “in-month” deficit of £0.6m.
The latest forecast outturn based upon the performance at Quarter 3, and status of recovery actions, would
continue to give rise to a “best case” outcome of £4.1m, with a “most likely” scenario in the region of
£6.1m.
Page 1 of 10
Enc 08
The Partnership Trust has now received formal confirmation from the TDA that the “capital to revenue”
funding proposition referred to the Partnership Trust Board last month will be transferred non-recurrently to
the Partnership Trust, and will improve the financial position in accordance with “discussions with the TDA
Business Director”. In essence, there will be an expectation that the Partnership Trust now achieves a
£0.2m surplus (i.e. the “best case” £4.1m operating deficit less the £4.3m non-recurrent funding transfer”).
It is imperative, therefore, that every opportunity is taken to maximise cost reduction / income maximisation
in light of the remaining downward trend required to achieve this target, and contractual risks that may
emerge over the final quarter.
INTERDEPENDENCIES:
Legal and/or Risk
Clinical
Financial
The key financial risks are identified within the report.
The Partnership Trust’s budgets need to support the delivery of Clinical
Services.
Failure to deliver within budget will result in deterioration in the Partnership
Trust’s financial position and resilience going forwards.
HR
The Partnership Trust will need to ensure that all staff with budget
responsibility have the relevant training and support to discharge the duties
delegated to them.
Social Care
This financial performance covers the whole of the Partnership Trust’s
activities.
Staff and Trade Union
involvement actions
undertaken/planned
This report is for information.
Patient & Public
Involvement
The budget supports the delivery of Services provided by the Partnership
Trust, and where necessary these plans will have had Patient and Public
Involvement.
Equality Impact
The budget supports the delivery of Services provided by the Partnership
Trust, and where necessary these plans will have had an Equality Impact
Assessment.
Information exempt from
Disclosure
Requirement for further
review
This report is for information.
Financial performance will be reviewed on a monthly basis.
RECOMMENDATIONS:
The Partnership Trust Board is asked to consider the financial performance of the Partnership Trust at the
end of December 2015 (Quarter 3), the financial prospects for the remainder of the year, and note the
approval of the “capital to revenue” transfer by the TDA.
Page 2 of 10
Enc 08
POSITION OVERVIEW
EBITDA
• The Partnership Trust's Earnings before
Interest, Taxation, Depreciation and
Amortisation (EBITDA) for the quarter
ending 31 December 2015 shows a deficit
of £2.146m (0.8%).
•
This is £3.294m behind the revised plan of
£1.148m surplus submitted to the NHS
Trust Development Authority (TDA) to take
account of the stretch target of £2.015m.
Actual vs Plan Forecast vs Plan
EBITDA


Deficit


Cash






Continuity of Service
CIP Delivery

INCOME & EXPENDITURE (I&E) POSITION
• The Partnership Trust's financial position
at Quarter 3 is an actual deficit of
£6.651m, representing
an adverse
variance of £5.057m against the internal
YTD budget of £1.595m deficit.
•

The Quarter 3 planned deficit submitted to
the TDA represented £3.356m.
CASH
• The Partnership Trust has a cash balance
of £11.5m at the end of December.
•
This is a £4.0m shortfall against the year
to date plan of £15.5m.
•
The Partnership Trust is currently scoring
a 3 for liquidity as per the Continuity of
Services rating.
CONTINUITY OF SERVICES RATING
• The Partnership Trust's overall Continuity
of Services rating at Quarter 3 is 2.0, and
remains in line with the target set out in
the Annual Plan.
COST IMPROVEMENT PLAN (CIP)
• The Partnership Trust has set an internal
savings programme for Health services of
£13.7m for 2015/16, with a planning
estimate of £9.9m represented in the plan
submitted to the TDA. The profile of CIP
delivery is demonstrated in Appendix 1,
and is compared to the TDA plan.
Up to 5% favourable variance

On target

Up to 5% adverse variance

•
>5% favourable variance
>5% adverse variance
The delivery of cash-releasing efficiency,
along with the management of demand in
Adult Social Care (ASC), have featured as
the most critical factors in the financial
prospects of the Partnership Trust. The
deficit of £6.651m at Quarter 3 is
attributable to demand and price
pressures in Adult Social Care (ASC) of
£3.4m, and a combination of CIP and
demand pressures (£3.3m) manifesting in
the Health position, particularly in
community hospitals.
TEMPORARY STAFFING EXPENDITURE
• The Partnership Trust has spent
£13.516m on temporary staff at the end of
Quarter 3, comprising £10.990m agency
staffing, and £2.526m bank staffing.
Agency costs peaked between April and
August, attributable in the main to the reopening of wards in community hospitals.
However temporary staffing costs remain
higher than levels experienced last year
due to medical demand in Community
Hospitals.
Page 3 of 10
Enc 08
CONTINUITY OF SERVICES RATING
Year to 31
December 2015
Rating
Weight
Weighted
Score
Target
3.0
3.0
50%
1.5
Actual
3.0
3.0
50%
1.5
Target
Capital Service
Capacity (Times) Actual
1.0
1.0
50%
0.5
1.0
1.0
50%
0.5
METRIC
Liquidity Ratio
(Days)
Risk Rating
•
Target
2.0
2.0
Actual
2.0
2.0
The weighted score of 2.0 falls in line with
the TDA plan score of 2.0, reflecting
performance against the capital service
capacity rating.
ACCOUNTABILITY FRAMEWORK
• These metrics give an indication of
whether there are financial risks within the
Partnership Trust. They do not have a
bearing on the Continuity of Service rating
but are an element of the Partnership
Trust's overall RAG rating.
•
At Quarter 3, the Partnership Trust is rated
as Red risk overall.
•
The Partnership Trust at Quarter 3 is
reporting an actual deficit of £6.651m
representing an adverse variance of
£3.115m against the TDA planned position
of £3.536m deficit.
•
Higher
Score
Lower
Score
n/a
(7)
>1.25
n/a
The CIP is ahead of the revised TDA plan
at Quarter 3, and accordingly is rating
Green in this context.
Accountability Framework M07 M08 M09
Forecast Outturn, Compared
to Plan
Year to Date, Actual
compared to Plan
Actual Efficiency Year to
Date, Compared to Plan
Forecast Efficiency,
Compared to Plan
Forecast Underlying Surplus /
(Deficit) Compared to Plan
Forecast Year End Charge to
Capital Resource Limit
Public Dividend Capital
Accessed for Liquidity
Purposes
Forecast Achievement of
Stretch Financial
Performance Target
Page 4 of 10
Enc 08
STATEMENT OF COMPREHENSIVE INCOME TO 31 DECEMBER 2015
£m
Budget
Actual
Variance
Activity Income
- Health
156.6
160.7
4.1
- Adult Social Care
113.5
112.9
(0.6)
3.9
5.2
1.2
274.1
278.8
4.7
Pay Expenditure
(130.5)
(135.7)
(5.2)
Non-Pay Expenditure
(140.6)
(145.2)
(4.6)
Operating Expenditure
(271.1)
(280.9)
(9.8)
2.9
(2.1)
(5.1)
EBITDA %
1.1%
(0.8%)
Depreciation
(2.5)
(2.5)
0.0
0.0
0.0
(0.0)
Interest Payable (PFI)
(1.3)
(1.3)
0.0
Dividend
(0.7)
(0.7)
0.0
Retained Surplus / (Deficit)
(1.6)
(6.7)
(5.1)
(0.6%)
(2.4%)
Other Income
Operating Income
EBITDA
Interest Received
I&E Surplus / (Deficit) %
INCOME
• Overall, income at Quarter 3 is £4.7m in
excess of the Partnership Trust’s YTD
budget, mostly attributable to short term
funding streams in relation to system
resilience together with “pass through”
funding.
EXPENDITURE
• Performance against operating budgets
demonstrates not only the impact of the
factors set out above, but reflects the
tangible signs of stress in delivery of
efficiency savings, and prevailing demand
pressures across the health and social
care landscape.
I&E POSITION
• The Partnership Trust's I&E financial
position at Quarter 3 shows an actual
deficit of £6.651m, representing a
£5.057m adverse variance against the
YTD internal budget of £1.595m deficit.
•
The position is heavily influenced by
performance
against
the
cost
improvement plan (CIP), and increasingly
as a result of pressures in the Adult Social
Care contract and community hospitals
particularly.
Page 5 of 10
Enc 08
YEAR TO DATE SUMMARY
•
EBITDA
•
This financial year has been difficult for
most NHS bodies and local authorities
nationally in facing up to public spending
constraint and demographic pressures.
Locally, it is a very challenging economy.
The Partnership Trust has achieved an
EBITDA margin deficit of 0.8% for the
period to 31 December 2015 against the
TDA planned surplus of 0.4%.
FORECAST SUMMARY
•
•
•
The financial risks for the Partnership
Trust, and direction of travel in
performance, were highlighted early in the
financial cycle, and this has allowed
financial recovery action to make a
significant improvement in prospects.
Following two consecutive months of “runrate” deficits in excess of £1m, Month 9
has shown anticipated improvement with
an “in-month” deficit of £0.6m.
Pay spend has reduced, supported by
assertive intervention in the procurement
and governance of temporary staffing. In
Adult Social Care (ASC), demand and
market pressures remain a strong theme,
and whilst non-recurrent actions have
been developed to recover the position in
2015/16, the underlying “run-rate” remains
a significant forward challenge for the
partnership.
Elsewhere,
financial
pressures continue to be characterised by
strong demand and cost pressures,
hardest felt in community hospitals.
•
A review of the position at Quarter 3 has
considered the direction of travel in
pressures described earlier, progress in
the development and delivery of further
cash-releasing measures through the Cost
Improvement Programme (CIP), financial
recovery regime, and Adult Social Care
(ASC) services.
•
As highlighted earlier, performance at
Quarter 3 has shown some anticipated
improvement in recent “run-rates” with an
“in-month” deficit of £0.6m.
•
Financial prospects are considered more
fully in the next section.
However,
achievement of a £4.1m deficit (prior to
the “capital to revenue” funding now
approved by the TDA of £4.3m) remains
dependent upon delivery of “best case”
scenarios in relation to financial recovery,
and containment of contractual risks and
underlying demand pressures, particularly
in ASC services and community hospitals.
CASH
STATEMENT OF FINANCIAL POSITION
•
At 31 December 2015 the Partnership
Trust had £11.5m of cash.
•
The cash position is £4.0m behind the
plan at Quarter 3. This is predominantly
due to Creditors which were £5.8m lower
than plan, partially offset by Capital Spend
£2.5m behind plan, relating to slippage on
Project Evolve.
SUMMARY
•
Net assets as at the end of Quarter 3 are
£51.1m.
Page 6 of 10
Enc 08
STATEMENT OF FINANCIAL POSITION AS AT 31 DECEMBER 2015
£m
31 December 2015
Land, Buildings and Equipment
87.5
0.2
Trade and Other Receivables (>1yr)
Total Non-Current Assets
87.7
Inventories
0.6
Trade and Other Receivables (<1yr)
17.8
Cash and Cash Equivalents
11.5
Total Current Assets
29.9
Trade and Other Payables (<1yr)
(33.2)
Provisions (<1yr)
(0.1)
Borrowings (<1yr)
(0.8)
Total Current Liabilities
(34.2)
Creditors (>1yr)
0.0
Provisions (>1yr)
0.0
Borrowings (>1yr)
(34.8)
Total Non-Current Liabilities
(34.8)
Net Assets
48.6
Public dividend capital
1.4
Revaluation reserve
17.6
Retained Earnings
29.6
Total Taxpayers' Equity
48.6
CAPITAL PROGRAMME
CAPITAL PROGRAMME AS AT 31 DECEMBER 2015
£k
Plan
Estates & Equipping
Actual
782
(124)
Information Tech
5,348
2,841
(2,507)
Total
6,254
3,623
(2,631)
•
The forecast position for Project Evolve
accounts is £2.2m, IT Infrastructure £1.9m
and Estates £0.9m.
•
Capital spend for the remainder of the
year is under close scrutiny to ensure
accurate forecasting and delivery of spend
in line with our CRL.
•
Due to the change in go-live of Evolve a
significant amount of spend has slipped
into 2016/17.
Variance
906
•
•
Following approval by the Department of
Health the Partnership Trust is transferring
£4.3m of capital resource to revenue to
support the I&E position.
The Capital Resource Limit (CRL) for
2015/16 therefore has been reduced by
£4.3m to £5.0m. This has been possible
due to slippage in both Project Evolve and
Estates schemes.
Page 7 of 10
Enc 08
FINANCIAL PROSPECTS
•
•
A financial risk of up to £8.8m was
articulated at Quarter 1, and initiated the
development and leadership of a
programme of financial recovery and risk
containment.
Prospects for further
improvement from the current trajectory
remain dependent upon delivery of “best
case” scenarios in that programme of CIP
savings, financial control and governance
measures, maximisation of risk-share
funding
through
negotiation,
and
exploitation of all financial flexibility
available.
•
To deliver the best case scenario would
require a positive outcome in relation to
“step-up / step-down” negotiations with
North
Staffs
commissioners
and
safeguarding of funding relating to the
valuable winter resilience schemes
(discharge to assess) approved in
2014/15. The Partnership Trust is clear
this represented a recurrent commitment,
but CCGs are yet to confirm this in
payment and remains subject to their
internal investigation.
•
Previous experience tells us that further
contractual pressures will inevitably
materialise over the final stages of the
financial year, and this, together with
persistence in demand pressures for ASC
and
community
hospitals,
some
uncertainty regarding risk-share funding,
and the variable impact of financial
recovery actions in the ASC area, reflects
the spread in the forecast outcome at this
stage.
•
The table below provides a high level
summary of the challenge.
The latest forecast outturn based upon the
performance at Quarter 3, and status of
recovery actions, would continue to give
rise to a “best case” outcome of £4.1m,
with a “most likely” scenario in the region
of £6.1m.
Page 8 of 10
Enc 08
SSOTP Financial Prospects - Movement & Analysis of Forecast
Best case Forecast £4.1m
Health
£m
Q3 Headline Projection Before Action
6.0
ASC
£m
Most Likely Forecast £6.1m
Total
£m
Health
£m
4.5
10.5
6.0
(4.5)
(4.5)
(0.3)
(0.3)
(0.3)
(1.0)
ASC
£m
Total
£m
4.5
10.5
(3.5)
(0.3)
(0.3)
(0.3)
(1.0)
(3.5)
(0.3)
(0.3)
(0.3)
(1.0)
0.0
1.0
1.0
4.1
5.1
Financial Recovery:ASC Efficiency & Risk Share
CIP Cash-Releasing
Prescriptive Control of Discretionary Spend
Agency Workforce Intervention
Consolidation of Accounting Practice
(0.3)
(0.3)
(0.3)
(1.0)
Contract Income Pressures:Contract / Income Pressures
4.1
NATIONAL CAPITAL TO REVENUE FUNDING
OPTION
•
Given the performance nationally, the TDA
recently wrote to Trusts with a proposition
for transferring any slippage in their capital
resource limit (CRL) into revenue funding,
on the basis that this would result in a
“pound for pound” improvement in their
Income & Expenditure positions. Given
the current slippage in the capital
programme of the Partnership Trust, this
presented an opportunity of just under
£4.3m.
0.0
1.0
6.1
•
The Partnership Trust has now received
formal confirmation from the TDA that this
funding will be transferred non-recurrently
to the Partnership Trust, and will improve
the financial position in accordance with
“discussions with the TDA Business
Director”. In essence, there will be an
expectation that the Partnership Trust
achieves a £0.2m surplus (i.e. a “best
case” £4.1m operating deficit less the
£4.3m non-recurrent transfer”.
•
It is imperative that every opportunity is
taken to maximise cost reduction / income
maximisation in light of the remaining
downward trend required, and the
contractual risks emerging
Page 9 of 10
Enc 08
APPENDIX 1: CIP PLAN v ACTUAL
Cumulative CIP Plan Vs Actual CIP Delivery
10,000,000
9,000,000
8,000,000
Amount £000's
7,000,000
6,000,000
5,000,000
Cumulative Actual
Original TDA Cumulative Plan
Revised TDA Cumulative Plan
4,000,000
3,000,000
2,000,000
1,000,000
April
May
June
July
August
September
October
Month
November
December
January
February
March
Page 10 of 10
Enc 09
REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: Wednesday 27th January 2016
Enclosure:
Subject:
Responsible Officer Report – Medical Appraisal Compliance and
Revalidation Recommendations
Quarter 3 (October – December 2015)
Strategic Goal
(tick as appropriate):
√
We will provide high quality and safe services which provide an excellent
experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and
effectively
Our organisation will develop and deliver sustainable, innovative services that
support independence
√
Our workforce will be empowered and supported to deliver care in a way that is
consistent with our values
We will make excellent use of our resources and improve levels of efficiency
across our services
Director Lead:
Dr James Shipman, Medical Director
Recommendation:
For Approval &
Assurance
For Discussion
For Information
x
PURPOSE OF THE REPORT:
To provide the Partnership Trust Board with a quarterly update on medical appraisal compliance
and Revalidation Recommendations
KEY POINTS:
This reporting process maintains quarterly communications between Responsible Officers at
the local level and their higher-level Responsible Officers (NHS England), to whom they are
linked, enabling a picture of high-level indicators (including appraisal rates) to be built up over
the year, so that any problems can be identified and resolved at an early stage.
The Annual Organisational Audit (AOA) will supersede the need for a quarterly report in the
final quarter.
Page 1 of 3
Enc 09
INTER DEPENDENCIES:
Legal and/or Risk
This is a legal requirement for the Partnership Trust to
comply with the Medical Profession (Responsible
Officers) Regulations 2010.
Clinical
Ensuring that doctors employed by the ‘Trust’ meet the
General Medical Council’s fitness to practice standards
provides a safe clinical environment within the services
of the Partnership Trust.
Financial
Failure to maintain high professional standards of care
may result in significant financial liability to the
Partnership Trust in terms of legal claims and
settlements.
HR
The systems and processes to meet the legal
requirements are managed through HR working with the
Responsible Officer.
Social Care
No specific inter dependencies
Staff and Trade Union involvement
actions undertaken/planned
No specific involvement
Patient & Public Involvement
No specific involvement
Equality Impact
No negative impacts identified
Information exempt from Disclosure
None
Requirement for further review
Quarterly/Annual reporting
RECOMMENDATIONS:
The Partnership Trust Board is asked to review and accept the report.
Page 2 of 3
Enc 09
Staffordshire and Stoke on Trent Partnership NHS Trust
Medical Appraisal Compliance and Revalidation Recommendations
Quarter 3 – October to December 2015
Name of designated body: Staffordshire and Stoke-On-Trent Partnership NHS Trust
Responsible Officer:
Dr James Shipman, Medical Director
No of doctors in the designated body as at 31 December 2015:
46
No of doctors due to hold appraisal meeting:
6
No of doctors who had appraisal meeting:
6
No of doctors who had deferment to next quarter:
0
No of doctors RO accepts postponement is reasonable:
0
No of doctors who had revalidation date due this quarter:
5
No of doctors who had revalidation recommendation:
5
No of doctors who had positive revalidation:
4
No of Doctors who had a recommendation to defer:
1
No of Doctors who had a recommendation of non-engagement:
0
Page 3 of 3
Evaluation of the Partnership Approach to Leadership
Presentation to Trust Board on
Wednesday 27th January
Background
• Newly formed Partnership Trust wanted a bespoke
•
•
•
•
model of leadership development
There was requirement to design an approach that
aligned to the Partnership Trusts vision, values and
behaviours framework
Sustainable internal leadership model that supported
capacity and capability of all managers
Project initiated to develop the leadership approach that
the staff wanted
Evaluation has been undertaken 12 months on to
show what difference it has made
The ‘Partnership Approach’ Implementation
• Gateway launched April-August 2014
• 548 managers attended
• 10 Masterclasses designed developed and delivered by
•
•
•
•
internal staff across the Trust
To date 820 staff attended the Gateway
Delivery now on a monthly basis
Leadership and Management essential 5 day
programme
12 Master Classes are now in operation, and over 60
sessions currently scheduled for 2016
Level 4 what do staff say?
Approximately one year since attending the Gateway, 98% of respondents
are still using the models, tools and ideas in practice either some, a little
or a lot
‘We have more
coaches now, if
the environment
was not right a
good coach or
counsellor would
recognise that’
‘It seems like a long
time ago now, but I
am now really in a
team of one (due to
my role). I felt the
gateway followed on
with what I had done
with the king’s fund in
terms of compassion,
it does not always
happen due to work
pressures but it is
what we should be
aspiring to.’
‘The biggest thing I took
from the day was that you
have to think about
yourself and remember
you are the leader but
think about yourself
(position 1.2.3). We are all
stressed and overworked
and I do reflect back and
think to take a step back,
to think about things and
to go again. Staff are
struggling and you are
the one to keep things
buoyant.’
Conclusion
• The evaluation demonstrates much positive feedback with the majority of
•
•
•
colleagues advising that they are utilising the models, tools and ideas learnt
on the Gateway.
The Gateway gives clear expectations of how the Trust aspires to effective
leadership behaviour. It gives a knowledge base to work from, and confirms
leaders are managing staff according to the Trust Values.
The Focus Group feedback has demonstrated that service users are always
at the heart of the services and regardless of how staff may be feeling and
they remain professional at all times.
The Gateway will be reviewed to ensure it meets the diverse needs of the
workforce and addresses the health and social care economy changes.
Sustainability
•
The evaluation of the leadership programme has evidenced that we need to continue
with a Trust wide programme that embraces current and new managers.
•
The ‘Partnership Initiative’ our resource centre for Organisational Health, will be the
showcase for all Leadership Activity and will allow delivery of all Trust Strategies.
•
All managers who have been recognised as ‘Purple Person’ in the Talent
Management framework, will automatically be put forward for all elements of the
leadership Development programme.
•
Operations and Corporate partners as part of Matrix working will be encouraged to
support design, development and delivery of Masterclasses, ‘Learn bites,’ and future
leadership development interventions.
•
Every team operations and corporate will be offered a team away day to
identify training and development interventions that can support delivery of the
business objectives