Newcastle Hospitals - Home - TRUST BOARD of... · 2020-06-09 · Miss Kate Elizabeth Carney, MBChB Edinburgh 2007, BSc (Hons) Edinburgh 2004, MRCS Edinburgh 2010. ChM General Surgery

Agenda item A8(i)a

TRUST BOARD

Date of meeting 31st January 2019

Title Consultant Appointments

Report of Andy Welch, Medical Director

Prepared by Jane Padget, Assistant HR Officer

Status of Report Public Private Internal

☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information

☐ ☐ ☒

Summary The content of this report outlines recent Consultant Appointments.

Recommendations The Board of Directors is asked to note for information the decisions of the Appointments Committee.

Links to Corporate Objectives

Putting patients first; maintaining financial viability/stability

Links to Strategy and Clinical Risks

N/A

Impact

Tick yes or no as appropriate Yes No

Quality and Safety X

Legal X

Financial X

Human Resources X

Equality and Diversity X

Engagement and communication X

Sustainability X

If yes, please give additional information: N/A

Reports previously considered by

Consultant Appointments are submitted for information in the month following the Appointments Panel.

1

Agenda item A8(i)a

____________________________________________________________________________________________________ Consultant Appointments Trust Board 31

st January 2019

CONSULTANT APPOINTMENTS

1. APPOINTMENTS COMMMITTEE – CONSULTANT APPOINTMENTS 1.1 An Appointments Committee was held on 14 December 2018 and interviewed one

candidate for the post of Consultant Urological Surgeon.

By unanimous resolution the Committee was in favour of appointing Dr Andrew David Moon. Dr Moon holds MBBS (University of Newcastle) 2009, MRCS (Edinburgh) 2012 and FRCS Urol (Edinburgh) 2017. Dr Moon is currently employed on behalf of the Lead Employer Trust, based at the Freeman Hospital.

Dr Moon is expected to take up the post in March 2019.

1.2 An Appointments Committee was held on 19 December 2018 and interviewed one

candidate for the post of Consultant Clinical Geneticist.

By unanimous resolution the Committee was in favour of appointing Dr Richard Martin. Dr Martin holds MBChB (Queens University) 2007, MRCP (Edinburgh) 2012 and a Diploma in Clinical Education (Newcastle University) 2013. Dr Martin is currently working as a Locum Consultant Clinical Geneticist with the Trust.

Dr Martin is expected to take up this post as soon as possible.

1.3 An Appointments Committee was held on 19 December 2018 and interviewed one

candidate for the post of Consultant Chemical Pathologist

By unanimous resolution the Committee was in favour of appointing Dr Purba

Banerjee. Dr Banerjee holds MB BS (Bangalore) 2000, MRCP (UK) 2009 and FRCPath

(UK) 2017. Dr Banerjee is currently employed as a Consultant Chemical Pathologist

with North Cumbria University Hospital.

Dr Banerjee is expected to take up the post of Consultant Chemical Pathologist in

March 2019.

1.4 An Appointments Committee was held on 10 January 2019 and interviewed one

candidate for the post of Consultant Interventional Neuroradiologist.

By unanimous resolution the Committee was in favour of appointing Dr Chee Gan. Dr

Gan holds MB BCh (University of Wales) 2007, FRCR (UK) 2012 and EDiNR (European

Board of Neuroradiology) 2016. Dr Gan is currently working as a Consultant

Interventional Neuroradiologist at the University Hospital of Wales.

Dr Chee is expected to take up the post of Consultant Interventional Neuroradiologist

in March 2019.

2

Agenda item A8(i)a

____________________________________________________________________________________________________ Consultant Appointments Trust Board 31

st January 2019

2. RECOMMENDATION 1.1 – 1.4 – For the Board to receive the above report.

Report of Andy Welch Medical Director 16 January 2019

3

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Agenda item BRP A8(i)a

TRUST BOARD

Date of meeting 31st January 2019

Title Honorary Consultant Appointments

Report of Andy Welch, Medical Director

Prepared by Andy Welch, Medical Director

Status of Report Public Private Internal

☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information

☐ ☐ ☒

Summary The content of this report outlines recent requests for Honorary Consultant Contracts.

Recommendations The Board of Directors is asked to note the award of/ extension to the Honorary Consultant Contracts.

Links to Corporate Objectives

Continue to recruit and retain the very best staff.

Links to Strategy and Clinical Risks

Putting patients first and providing care of the highest standard focusing on safety and quality. Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.

Impact

Tick yes or no as appropriate Yes No

Quality and Safety

Legal

Financial

Human Resources

Equality and Diversity

Engagement and communication

If yes, please give additional information: Award of Honorary Consultant Contracts

Reports previously considered by

Honorary Consultant Appointment requests are submitted for information as and when requests are received.

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HONORARY CONSULTANT APPOINTMENTS

1. HONORARY CONSULTANT APPOINTMENT REQUESTS 1.1 Dr Nithya Ratnavelu Dr Nithya Ratnavelu, MB BCh BAO, Belfast 1997 - 2003, BSc (Hons) Biochemistry, Belfast 2000 - 2012, is currently employed by Gateshead Health NHS Foundation Trust as a Consultant Gynaecological Oncologist. An Honorary Contract for Dr Ratnavelu is requested so that a joint operating service for 16-18 year olds in the Newcastle area can be provided. There will be no financial implication to the Trust. 1.2 Dr Christopher Duncan

Dr Christopher Duncan, BSc Med Sci Aberdeen 2001, MB ChB (with Hons) Aberdeen 2003, MRCP UK 2005, DTM&H 2007, DPhil Oxford 2014, MRCP (ID) 2016, currently has an Honorary Contract with the Trust as a Clinical Intermediate Fellow/ Honorary Consultant in Infectious Diseases until 28 February 2019 Dr Duncan has recently been awarded a Clinical Research Fellowship which has been added to his current post and this will take his post up to 4th November 2021. There is no cost to the Trust for the extension of his Honorary Contract. 1.3 Professor Stephen Jones Professor Stephen Jones, BMedSci, Newcastle 1987, MBBS Newcastle 1990, MRCP 1993, Dip BMedSci Newcastle 1994 FRCP 2006. Newcastle University has requested an Honorary Consultant Contract be awarded to Professor Stephen Jones. A Selection Committee held on 19th September 2018 resolved that Professor Jones be appointed Honorary Clinical Senior Lecturer (Consultant) in Dental Services. The Trust was represented on the Selection Committee by Mr B Cole, Clinical Director Dental Services. Professor M Thomason and Mr J Durham who supported the appointment. The post is fully funded by the University.

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1.4 Miss Kate Elizabeth Carney Miss Kate Elizabeth Carney, MBChB Edinburgh 2007, BSc (Hons) Edinburgh 2004, MRCS Edinburgh 2010. ChM General Surgery Edinburgh 2015, FRCS Edinburgh 2016, is currently employed by Northumbria Healthcare NHS Foundation Trust as a Consultant Colorectal Surgeon. An Honorary Contract has been requested to allow Miss Carney to assist with patients from both Trusts on a regular basis. There is no financial implication to the Trust. 2. RECOMMENDATIONS The Board is asked to note:

1.1 Dr Nithya Ratnavelu will receive an Honorary Contract as a Consultant

Gynaecological Oncologist with immediate effect and for the duration of her involvement in the joint operating service.

1.2 Dr Christopher Duncan will receive an extension to his Honorary Contract as a Consultant in Infectious Diseases until 4th November 2021.

1.3 Professor Stephen Jones will receive an Honorary Contract as a Consultant Physician with immediate effect and for the duration of his post with the University.

1.4 Miss Kate Elizabeth Carney will receive an Honorary Contract as a Consultant Colorectal Surgeon with immediate effect. This should be reviewed in 2021.

Report of Andy Welch Medical Director 23rd January 2019

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Agenda item A8(ii)a – BRP AD JD Nov18 appendix

Executive Chief Nurse

Maurya Cushlow

Associate Director of

Midwifery

Elaine Blair

Associate Director of AHPs

Stella Wilson

Nurse specialists IM&T

Professional lead OPD/Dental

Procurement

Deputy Chief Nurse

Elizabeth Harris

Chief Nursing - Information

Officer

Associate Director of Nursing

Lisa Guthrie

(RVI)

Clinical Standards

Deteriorating patient

Clinical assurance Tool

Environmental

standards/PLACE

HCAI

Sepsis

Falls

Pressure Ulcers

Safety Thermometer

CAT

Tissue Viability

SAFER

Nutrition

Dementia

Care planning

Continence Care


Ian Joy

(FRH)

Workforce & Practice Development

Workforce strategy

E Roster

Safe Staffing

Escalation

Succession Planning

Preceptorship

Competency Frameworks

New role development

Education

Research

Advanced practice & NP

development

SNCT development

Carter efficiency work

International Recruitment


Peter Towns

(Community)

Prevention, Health promotion,

out of hospital care

Prevention & well being

Medicines management

Nurse consultants

Public Health

Out of hospital care

Clinical supervision

Parity of esteem

Diversity & inclusion

End of Life Care

Patient experience –

complaints/Patient

Involvement

OHS (operational)

Chaplaincy


Helga Charters

(Trustwide) Children & Young People

Professional responsibility for nursing teams in designated children’s areas

Lead responsibility for children and young people cared for in adult areas across Trust.

Children and young people focused involvement alongside ADN adult posts – - Clinical Standards - Workforce & Practice Development - Prevention, Health promotion, out of

hospital care. NISR • Learning Disabilities

NISR

Hospital at night

Trustwide transformation/CIP/Business Planning (with LH)

H

9



Nursing

Prevention, Health

promotion, out of hospital

care


Nursing

Clinical Standards


Nursing

Workforce & Practice

Development

Matron Infection

Prevention and Control

Nurse Consultant –

Continence Care

Nurse Consultant

Tissue Viability

Nurse consultant

vulnerable older adults

Falls and Pressure Ulcer

Improvement Lead

Data Manager - Patient

Services

Associate Nurse

Consultant Vulnerable

Older Adults

Senior Nurse N&M

Staffing

Lead for Nursing

Midwifery & AHP

Research & Practice

Development

Senior Nurse - Practice

Development

Nursing Models of

Education Project

Manager

Senior Nurse -

International

Recruitment

Senior Nurse -

Specialist Palliative

Care/End of Life

Nurse Consultant

Cancer Services

Macmillan Lead

Head of Patient

Experience

Chaplaincy

Clinical service manager

OHS

Equality and Diversity

Lead

Nurse Consultant for

Paediatric Immunology

Senior Nurse - Hospital

at Night


Nursing

Children and Young People

10


Lisa Guthrie

Royal Victoria

Infirmary Base

Matrons

Internal and Older Peoples

Medicine

Angela McNab, Chris Bill, Linda

Morgan, Barbara Goodfellow

EPOD

Sue Cook, Julie Graham

Neurosciences

Cheryl Teasdale

Clinical Research

Aileen Burn

Peri-Op and Critical Care (RVI)

Lisa Squires, Dawn Turley,

Lesley Scott

Women’s Services

Angela Barnes

Ian Joy

Freeman Hospital

Base

Matrons Community District Treacey Kelly Nursing (DN East, DN Central, DN West, ENNS), Care Home Support Team Alison Deagle Walk in Services (Molineux, Ponteland Road, Westgate Road, Lemington), Newcroft Sexual Health CRRT, Chronic Disease Monitoring, Community TB Service Kath Robinson Health Visiting (HV East, HV West, HV Central) School Health (SH West, SH East, SH Central)

Peter Towns

Community

Base

Matrons

Cardiothoracic

David Kinnersley, Fiona

Hindhaugh, Amanda Vickers,

Andrea Russell

Urology/Renal/IOT

Sally Ridley, Julia Ibbotson,

NCCC

Vacant Post

Surgery

Sam Rutherford, Diane

Henaghan

Orthopaedics

Ruth Saunders

Peri-Op and Critical Care

(FH)

Alison Gray, Sharon

Thompson, Emma McCone

Helga Charters

C&YP Lead

Matrons GNCH Jenny Palmer, Claire Riddell Louise Raine, Emma Willey, Vacant Post Cardiothoracic Rachel Patterson

Neonates Yve Collingwood

Site & Professional Leadership (Nursing)

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12

Agenda Item A8(ii)b – BRP

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

SAFEGUARDING COMMITTEE QUARTER 3 UPDATE 2018/19

1. INTRODUCTION

This paper provides a Quarter 3 update from the Safeguarding Committee to inform the

Board of Directors of implications emerging from new statutory national guidance, emerging

issues, and local practice developments.

Safeguarding activity for Quarter 3 in 2018/2019 evidences 1340 “Cause for Concerns” (CFC)

/ referrals across the safeguarding teams; 238 case discussions in the MASH by the

Children’s Nurse Advisor’s; 166 deprivation of liberty safeguards (DoLS) applications and 479

contacts with the LD team for advice and support.

Safeguarding training is a priority and continues to be delivered weekly at Trust Induction

for all new staff. Supplementary training is mandatory and is provided in line with national

requirements with additional bespoke safeguarding training on request. Safeguarding

supervision is provided to a range of staff across acute and community services. The teams

continue to review policies and complete audits to provide assurance regarding

safeguarding processes; they also contribute to a number of serious case reviews with our

local authority colleagues and support the work of both local Safeguarding Boards. Almost

50% of the work across the teams relates to out of area service users.

The Trust’s safeguarding teams continue to deliver a high quality service that serves to

promote the safety and well-being of adults at risk and vulnerable children. They are

extremely responsive to staff, providing advice and support to meet the demands of a

motivated and vigilant workforce. The teams respond to national guidance to improve

practice developments, undertake significant work to review processes to provide assurance

processes are robust and identify areas for development. The work of the safeguarding

teams continues to increase in relation to case numbers, complexity, training expectations

and the need to provide assurance; there are a number of risks they are working to

mitigate. This paper will summarise these issues, which have been raised and discussed with

the Safeguarding Committee.

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NATIONAL REPORTS AND REGULATORY UPDATE

The ‘Decision-making and mental capacity NICE guideline was published on 3rd October

2018 nice.org.uk/guidance/ng108 . This guideline covers decision-making in people 16 years

and over who may lack capacity now or in the future. It aims to help practitioners support

people to make their own decisions where they have the capacity to do so and to keep

people who lack capacity at the centre of the decision-making process.

The Care Quality Commission (CQC) estimates that around 2 million people may lack the

capacity to make certain decisions for themselves at some point due to illness, injury or

disability. The Mental Capacity Act 2005 was designed to empower and protect individuals

in these circumstances. However, the CQC identified serious issues with the practical

implementation of the Act.

It is in this context that the Department of Health commissioned this guideline, which makes

recommendations for best practice in assessing and supporting people aged 16 years and

older with decision-making activities. It helps to ensure that people are supported to make

decisions for themselves when they have the mental capacity to do so, and where they lack

the mental capacity to make specific decisions, they remain at the centre of the decision-

making process. The guideline supports the empowering ethos and principles introduced by

the Mental Capacity Act 2005 and explained in the Code of Practice. These are:

A person must be assumed to have capacity unless it is established that he lacks

capacity.

A person is not to be treated as unable to make a decision unless all practicable steps to

help him to do so have been taken without success.

A person is not to be treated as unable to make a decision merely because he makes an

unwise decision.

An act done, or decision made, under this Act for or on behalf of a person who lacks

capacity must be done, or made, in his best interests.

Before the act is done, or the decision is made, regard must be had to whether the

purpose for which it is needed can be as effectively achieved in a way that is less

restrictive of the person's rights and freedom of action.

The guideline focuses on:

advance care planning

supporting decision-making

assessment of mental capacity to make specific decisions at a particular time

The guideline does not cover:

decision-making activities and support for children under 16 years

the issue of deprivation of liberty and the Deprivation of Liberty Safeguards processes.

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The principles within this NICE Guidance are actively promoted throughout the Trust in

terms of advice and guidance to staff and MCA training to support clinical practice and

decision-making.

2. PRACTICE DEVELOPMENTS

There are a number of areas of safeguarding practice being developed, either to enhance

patients’ experience and ensure patient safety or to develop best practice especially in

relation to multi-agency working. Examples are outlined below.

i) SARC1 and CSE Mental Health Referral Pathway

A task and finish group has been set up to consider how children who have been subjected

to sexual abuse or sexual exploitation can have appropriate and timely access to mental

health services. The scope of this work will include areas covered by Northumberland,

Durham and Cleveland police forces. Provider services vary across the region and

commissioning arrangements are very complex. This often prevents timely access to

psychological support following trauma for children and young people who have

experienced sexual abuse. A second meeting is planned for January 2019.

iii) Learning Disability Champions

There was a meeting held in November with four consultants who expressed interest in the

opportunity to become a learning disability champion. A further two also expressed interest

but were unable to attend the meeting. It was agreed that all would become ambassadors

for LD and provide support to the LD nursing team by participating in mortality reviews,

chairing the quarterly mortality review meeting and to chair the LD Steering Group. This will

be reviewed after 6 months but it is very refreshing to have some key individuals who are

committed and motivated to provide this corporate leadership role.

iv) NHSI Learning Disability National Benchmarking Survey

The Trust has participated in a Learning Disability National Benchmarking Survey by NHSI. 80

consent forms were sent out to adult service users; 8 were returned within the time frame

and only 1 individual completed the survey. 20 staff surveys were distributed &

organisational data was submitted although there were some gaps due to the structure of

the survey. It is understood that NHSI will take the learning from this inaugural national

survey and consider how improvements can be made, as responses across the country have

generally been poor. Feedback from the survey will be shared at the National Learning

Disability Conference in March 2019.

1 Sexual Assault Referral Centres (SARC)

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v) Review of arrangements to use Special Care Baby Unit as a Place of Safety

A meeting has been held with CCG and Children’s Social Care to consider the issues of

utilising the special care baby unit (SCBU) as a place of safety for babies who are born where

the protection plan is for them to be discharged into foster care. Issues discussed:

Well babies being placed in SCBU as a place of safety until ICO (Interim care Order) is

obtained

Availability of court hearing dates for CSC to apply for ICO

Increased cot pressures for babies in SCBU

Inappropriate practice of placing well babies in SCBU as a place of safety

Cases where well babies have had to be transferred to local SCBU unit as place of

safety as RVI have no capacity to accommodate

Option of obtaining police protection order after delivery to place babies with foster

carer until ICO granted

A further meeting is being planned to include Northumbria Police and Legal Services to consider how a robust system can be established that ensures the safety of babies on a Child Protection Plan who cannot be cared for by the mother on postnatal ward until an Interim Care Order is obtained

vi) Children’s Social Care (CSC) and Maternity Services

A meeting has been held with CCG and CSC to address current issues in relation to maternity

services not receiving safeguarding information in a timely manner, iin particular:

Difficulties speaking to allocated social workers and not receiving a return call

Not receiving feedback regarding outcome of CSC referral

Birth plans not being completed and forwarded to RVI at an appropriate gestation

Delays in arranging pre-discharge meetings and obtaining ICO (interim care order)

No CSC representation at safeguarding forum meeting for last few months

Actions agreed:

The Safeguarding Core Group will complete the birth plan at the first meeting after

viability of the pregnancy has been reached and will send a copy to RVI. This content will

be reviewed at each subsequent core group.

CSC to identify birth plan templates currently in use and remove old versions.

CSC to identify two social workers to attend maternity safeguarding forum on

alternative months.

CSC to review the process for sending out letter to referrer to inform of outcome of

referral submitted.

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vii) Safeguarding Communication Forums

Safeguarding Communication Forums are well established across the Trust and have been in

place for a number of years. They take place quarterly and alternate across the Freeman

and RVI sites. The forums are well attended by a cross section of staff from a range of

different clinical and non-clinical roles. For 2019, the safeguarding Teams are going to

increase the number of forums and will hold them 6 times per year. Each forum will be

delivered on both sites within the same week where possible. This will enable more people

to attend the forums and for a range of external speakers to be invited. In February, a

speaker from the Rape Crisis service will deliver a presentation about sexual violence and

trauma; in April, another speaker from Community Safety will present a discussion about

substance misuse and drugs issues affecting our local communities.

viii) Human Rights in Health Care Conference

The Safeguarding Adults Team is leading on a Human Rights in Health Care Conference that

will take place on the 19 September 2019. The focus will be on the following articles with an

interwoven theme relating to the mental capacity act.

Article 2: Right to life

Article 3: Freedom from torture and inhuman or degrading treatment

Article 4: Freedom from slavery and forced labour

Article 5: Right to liberty and security

Article 8: Respect for your private and family life, home and correspondence Zoe Lodrick who is a well renowned expert in Sexualised Trauma has agreed to be a keynote speaker at the conference. Further information will follow in due course. viiii) Routine Enquiry for Domestic Abuse in Sexual Health The Adult safeguarding Team are undertaking a piece of work with Sexual Health Services to audit how routine enquiry for domestic abuse is undertaken in practice. An initial scoping exercise has been undertaken and a full audit will be completed by the end of June 2019.

3. INTERNAL ASSURANCE / POLICY COMPLIANCE

The Trust Safeguarding Committee has met quarterly as planned to ensure appropriate

scrutiny, challenge and assurance is in place.

Policies revised to date in Q3 2018/2019:

Prevent Policy (V1.0) approved at Safeguarding Committee November 2018

Safeguarding Clinical Supervision for Nurses, Midwives and Allied Health Professionals

who work with Children (V4.0) approved at Safeguarding Committee November 2018

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Was not Brought (at Hospital Out Patients appointments for Children) – V3.0

Restraint Policy (Adults) V7.0 approved at Safeguarding Committee November 2018

Audits completed to date in Q3 2018/2019:

Safeguarding Supervision for 0-19 service – presented to Safeguarding Committee

November 2018

Audits are reported to the Trust’s Safeguarding Committee and provide assurance that

policies and processes are being monitored and reviewed regularly.

4. TRAINING

Trust wide compliance with Safeguarding Mandatory Training is as follows:

Safeguarding Mandatory Training Compliance 2018/2019

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Safeguarding Adults Level 1 95.7% 97.6% 87.1% 87.38% 87.30%

Safeguarding Children Level 1 95.7% 97.6% 87.1% 86.72% 86.65%

Safeguarding Adults Level 2 77.0% 83.2% 80.6% 82.56% 82.13%



TOTAL Prevent : 15.3% 40.2% 55.4% 64.85% 69.75%

BPAT n/a n/a 57.2% 66.00% 70.30%

WRAP n/a n/a 53.4% 63.60% 69.10%

Progress towards the 85% target for WRAP

training has slowed despite weekly

advertising and additional sessions for face-

to-face training across Freeman and RVI.

There have been multiple sessions offered in lecture theatres with very limited uptake.

Prevent training is advertised every week in ‘In Brief’ and reminders are also sent out to

Directorate Managers and Clinical Directors to disseminate across teams and services.

There has been a national issue with eLearning on ESR that was identified towards the end

of December that affected individual competencies to be pulled through to staff profiles on

completion of eLearning. This has still not been fully resolved and staff are temporarily

being advised not to complete eLearning by Workforce and Development.

Target Red Amber Green

end of Q1 40% 0-29% 30-39% 40%+

end of Q2 80% 0-69% 70-79% 80% +

end of Q3 90% 0-79% 80-90% 90% +

end of Q4 95% 0-84% 85-95% 95% +

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The same process for providing Directorate Managers with Prevent training data will be

implemented for the other levels of safeguarding training from January 2019.

The Trust is compliant with NHS England national requirement for the submission of

PREVENT assurance data. Quarter 3 data was submitted on the 08 January 2019.

The safeguarding trainer has worked with the safeguarding teams to review the training

matrix for mandatory safeguarding and Prevent training. This is in line with a Trust-wide

review of training needs. It has been a complicated process given the range of mandatory

safeguarding training and the publication of the Adult Safeguarding Roles and Competencies

for Health care Staff (2018). The latest version is attached (appendix 1) and will be discussed

at the January Safeguarding Committee for formal ratification. This document was

distributed across the Trust to Directorate Managers, Clinical Directors, Matrons, Clinical

Educators and a range of other staff. The feedback has been very positive in terms of how

easy the document is to follow.

The next stage of the process is to review the job roles in ESR to allocate the appropriate

level of training to each job role. Once completed, this will be sent to workforce

Development for them to amend ESR so that each individual member of Trust staff will be

able to clearly identify the level of training they require. For some staff, this may mean the

level of training will change, but it will prevent duplication and save time as staff that

currently have to complete level 1 or level 2 training will have the requirement to complete

level 1 removed. This has been warmly received and supports the recommendations within

the intercollegiate documents for both children and adults.

5. SAFEGUARDING ACTIVITY

Key points for the Safeguarding Committee to note in relation to activity up to the end of

Quarter 3 2018/19:

i) Women’s Services Safeguarding Activity

Safeguarding Maternity

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of cause for

concerns received 908 879 231 182 218

Number of FGM cases reported 56 28 9 13 10

Babies born on child protection

plans 260 108 19 25 22

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Babies discharged into foster care 52 52 7 15 6

Number of safeguarding

supervision sessions delivered 45 59 9 16 20

ii) Adult Safeguarding Activity

Safeguarding Adults

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total cause for concerns

received from staff 2094 2081 524 629 626

Case discussion 168 343 110 105 92

Discriminatory 1 4 0 1 1

DoLS Enquiry 192 87 11 24 29

Domestic abuse 317 311 76 107 113

Exploitation 14 * * * *

Financial abuse 93 94 24 25 35

Institutional 248 17 4 1 0

MARAC 48 55 8 15 18

MCA Enquiry 83 85 22 21 10

Modern Slavery 7 34 2 1 3

Neglect 141 367 112 105 123

Physical abuse 63 89 20 40 39

Psychological/

emotional 48 55 11 17 11

Radicalisation 5 7 1 4 3

Self-neglect 314 438 102 132 125

Sexual abuse 72 95 21 31 24

MAPPA Notifications 153 84 26 24 30

Violent Patient Notifications 59 72 11 25 27

The safeguarding adults’ team continue to be the single point of contact (SPoC) for Multi

Agency Risk Assessment Conference (MARAC) and MAPPA (multi-agency public protection

arrangements), PREVENT and violent patients on behalf of the Trust.

The team also attend safeguarding adult meetings and support the work of the Newcastle

Safeguarding Adults Board and sub-groups.

The Adult safeguarding Team would like to highlight some of the current safeguarding

concerns that are emerging in adults. These include:

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Homelessness, drug use – exploitation and assault

Concerns relating to self-neglect which can be profound and include risk of death

Increasing concerns about County Lines and Cuckooing

For further information, please follow these links:

http://www.nationalcrimeagency.gov.uk/publications/832-county-lines-violence-

exploitation-and-drug-supply-2017/file

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_

data/file/756031/Protecting_children_from_criminal_exploitation_human_trafficking_mod

ern_slavery_addendum_141118.pdf

iii) Learning Disability

Learning Disability

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of electronic alerts

present in patient records 2116 2298 * * 2624

Adults 1850 1984 * * *

Transition * * *

Young people 266 314 * * *

Referrals received for advice and

support

Adults

Transition

Young people

2055 1708

518

333

23

178

489

288

30

171

479

325

33

121

Inpatient episodes for people identified

with a learning disability 719 816 243 236 254

Day case attendances by people

identified as having an LD 540 513 120 118 93

Outpatient attendances by people

identified as having an LD 4961 5339 1508 1435 1454

Emergency Department attendances

involved a person with an LD. 786 974 251 209 225

People with LD who died whilst

receiving Trust care 16 10 10 3 0

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iv) Deprivation of Liberty Safeguards

Trust applications for Deprivation of Liberty Safeguards (DoLS) 2018/2019

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of DoLS applications

made by the Trust 581 400 121 131 166

RVI 331 202 66 67 83

Freeman 192 142 39 62 83

CAV 58 56 16 5 N/A N/A

There has been a notable increase in the number of Deprivation of Liberty applications

made during December and this has continued into January. We would like to attribute this

improvement to the briefings to senior clinical staff, matrons and medics and the

programme of ward based audits to review patients who should have a DoLS application in

place. Additional training sessions will continue and there has been a meeting held to

discuss how a condensed 30 minute training could be implemented to target medical staff

specifically. This will continue to be monitored monthly in the Safeguarding Teams and by

the Trust’s MCA Steering Group / Safeguarding Committee.

v) Children’s Safeguarding Activity

Safeguarding Children

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of cause for

concerns received 2872 2446 643 714 496

Information sharing 1252 1171 284 292 185

Overdose/ alcohol or

substance misuse by

young person

313 326 106 95 55

Referrals to children’s

Social Care by Trust staff 204 224 67 92 71

Child protections medicals

were completed 148 130 47 30 36

Forensic medicals

completed 196 213 38 53 46

MASH case discussions 1284 816 328 323 238

22


6. RISKS AND RISK MITIGATION

There are a number of identified risks:

i) Safeguarding Mandatory Training including Prevent has been added to the Patient

Services Risk Register. The Trust did not meet the national target of 85% for staff

requiring WRAP (PREVENT) training by the end of March 2019; this remains a key

challenge. Compliance with all other levels of safeguarding training is below the target

of 90% by the end of Q3.

ii) Deprivation of Liberty Safeguard applications have been added to the Patient Services

Risk Register as the reduction in deprivation of liberty applications across the Trust

increases the risk the potential for unlawful detention of patients. This is being

scrutinised and ongoing audit and education is being progressed.

iii) Electronic record keeping and data management within the safeguarding teams is

reliant on storing documents and excel spreadsheets securely on shared drives. The

safeguarding teams need access to electronic record keeping systems to facilitate

improved documentation and data management.

iv) The Audit Cycle for the Safeguarding Teams is behind schedule for 2018/19 and this

will be subject to the development of an action plan for 2019/20 to ensure robust

review of practice and a continuous cycle of improvement is maintained within the

teams.

v) It is important that safeguarding is continuously embedded as “Everyone’s Business”

through training, education and sharing lessons learnt from case feedback to prevent

vulnerable children or adults at risk from being missed.

vi) The accumulative impact of these risks increases pressure on the Trust’s Safeguarding

Team to meet key performance requirements including audit, review of policies and

professional practice.

Work is ongoing to address these risks as detailed above.

23


7. SUMMARY

The safeguarding teams are wholly committed and strive to ensure Trust staff are fully

supported to fulfil their safeguarding responsibilities to promote the safety and well-being

of all patients who access Trust services. This update provides assurance that the Trust’s

Safeguarding Teams are pro-actively leading and contributing to work in response to a range

of complex and challenging issues.

8. RECOMMENDATION

To (i) note the content of this report (ii) support the on-going work of safeguarding teams

within the Trust to protect children and vulnerable adults (iii) note risks and risk mitigation.

Jo Gamble

Head of Safeguarding

11 January 2019

24


Level

Staff Groups

Safeguarding Requirement

Method & Frequency

Prevent Requirement

Method & Frequency

1

All non-clinical staff (e.g. board level execs and non-execs, admin staff, caterers, domestics, counter staff, senior managers/strategic professionals with no patient contact) All clinical staff who have NO patient contact (e.g. laboratory staff, technicians, healthcare scientists etc.) Clinical staff Bands 1, 2, 3 & 4 with patient contact (e.g. housekeepers, theatre orderlies, health care assistants, associate practitioners). Volunteers (all roles)

Adults Level 1

eLearning – every 3 years

000 Preventing Radicalisation - Basic Prevent Awareness


Children Level 1


2

Clinical staff - Bands 5 and above with any patient contact (adults and/or children) (e.g., radiographer/radiologist, allied health professionals, chaplains, registered nurses, medical staff, dental staff including consultants). + B4 dental nurses and B4 nursery nurses

Adults Level 2


000 Preventing Radicalisation - Awareness of Prevent (Level 3)


Children Level 2


Mandatory Safeguarding Adults & Children and Prevent Training Requirements

Appendix 1

25


3

adult

Clinical staff Bands 5 and above with primarily adult patient contact who would assess and evaluate the needs of adults where there are safeguarding concerns. (e.g., District nurses, Community Staff Nurses, Mental Health Practitioners working with adults, registered nurses, AHP’s or medical staff with a lead role in adult protection as appropriate to their role).

Adults Level 3

eLearning or Face to face – annually



Children Level 2


3

children

Clinical staff Band 5and above who work primarily with children who would assess and evaluate the needs of children / young people where there are safeguarding or child protection concerns (E.g. paed staff nurses, paed surgeons/ paed anaesthetists & intensivists/ dentists/ community children’s’ nurses, looked after children nurses, forensic nurses, mental health Practitioners working with children, radiologists/ radiographers, paed allied health professionals, paed specialist nurses, nursery managers etc.). Consultant Paediatric staff will receive training from the Named / Designated Doctor delivered by a series of lectures throughout the year.

Adults Level 2




Children Level 3

Face to face – annually + eLearning option

26


3

combined

Clinical staff Bands 5 + who frequently work with children on a Child Protection Plan or CIN basis (e.g. health visitors, school nurses, midwives, safeguarding nurses, learning disability nurses, , lead professionals for safeguarding and child protection, psychologists, sexual health staff, substance misuse services, ED staff and Walk-in Centre staff etc.)

Adults Level 3

eLearning or Face to face – annually



Children Level 3

Face to face – annually + eLearning option

+ additional non-mandatory learning e.g. FGM / Domestic Abuse / Sexual Exploitation / Neglect / Self-neglect etc.

All staff are encouraged to attend multi-agency / multi-professional training relevant to their role in addition to the Trust’s core mandatory training as described above.

27


28

Nursing Information DashboardThis report combines metrics from a number of sources to build an overall picture of each ward/clinical area. A key to each metric isbelow. This report should not be used to make judgements in isolation.

RN & Care Staff Fill Rates – actual nursing hours for the month as a percentage of the planned nursing hours for Registered Nurses andCare Staff. This includes day and night shifts. Fill rates above 100% indicate that more nursing hours were worked during the monththan was planned.

Funded establishment – the agreed nursing budget provided by Finance, expressed as whole-time equivalent.

SNCT establishment – using the Safer Nursing Care Tool methodology, this establishment has been calculated by taking the number ofpatients at each care level (as defined in the tool) and applying a multiplier. There is a lot of room for subjectivity in this measure,depending on who collected the data.

Registered Nursing Ratio (on shift) – the skill mix of the workforce on a ward that was Registered Nurse, expressed as a percentage ofthe overall nursing workforce. This is based on the actual hours input via the Nurse Day Count. Wards using HCA ‘specials’ will havelower RN ratios than planned.

Ward occupancy – the bed occupancy of the ward, occupied bed days expressed as a percentage of the available bed days.

Red flags – the number of nursing red flags (as defined by NICE) for each day and night shift. Most of these are for when the shortfall ofplanned vs. actual staffing is more than 15%.

Staff turnover – this is a 12-month figure showing the nursing workforce turnover, with the number of leavers for the period expressed asa percentage of the number of staff still in post at the end of the period. This was defined by HR.

Sickness absence – the whole time equivalent days lost to sickness absence as a percentage of the total available whole timeequivalent days. This figure is received once a month but is not currently updated to reflect any corrections made or late entries.

Vacancy rate – the whole time equivalent vacancies for all nurses (RNs and HCAs) expressed as a percentage of the budget whole timeequivalent.

Band 5 vacant Wte - the whole-time equivalent vacancies for Band 5 nurses.

Band 5 vacancy rate – as above, for Band 5 nurses only.

Bank fill rate – the number of filled bank/agency nursing shifts expressed as a percentage of the total number of shifts requested.

Bank & overtime – the whole time equivalent usage that was bank, agency or overtime, expressed as a percentage of the nursingestablishment.

C. difficile – the number of cases of C. difficile identified post-72 hours of admission to the Trust.

Datix staffing incidents – the number of Datix reports submitted because of shortages in nursing staff.

Fall per 1,000 bed days – the number of patient slips, trips and falls (all severities) expressed as a rate per 1,000 (occupied) bed days.

Pressure ulcers per 1,000 bed days – as above, for all Trust-acquired pressure ulcers.

Falls & Pressure Ulcers - the total number of falls and pressure ulcers added together.

Friends & Family Test response rate – the number of patients responding to the Friends & Family Test expressed as a percentage of thetotal number of patients who were eligible to respond.

SBR Sister – indicates whether the ward currently has a Sister/Charge Nurse who was recruited using the Strengths-Based Recruitmentprocess.

29

CreeD

Typewritten Text

CreeD

Typewritten Text

CreeD

Typewritten Text

Agenda Item A8(iii) BRP

RN & Care Staff Fill Rates – actual nursing hours for the month as a percentage of the planned nursing hours for Registered Nurses andCare Staff. This includes day and night shifts. Fill rates above 100% indicate that more nursing hours were worked during the monththan was planned.

Funded establishment – the agreed nursing budget provided by Finance, expressed as whole-time equivalent.

SNCT establishment – using the Safer Nursing Care Tool methodology, this establishment has been calculated by taking the number ofpatients at each care level (as defined in the tool) and applying a multiplier. There is a lot of room for subjectivity in this measure,depending on who collected the data.

Registered Nursing Ratio (on shift) – the skill mix of the workforce on a ward that was Registered Nurse, expressed as a percentage ofthe overall nursing workforce. This is based on the actual hours input via the Nurse Day Count. Wards using HCA ‘specials’ will havelower RN ratios than planned.

Ward occupancy – the bed occupancy of the ward, occupied bed days expressed as a percentage of the available bed days.

Red flags – the number of nursing red flags (as defined by NICE) for each day and night shift. Most of these are for when the shortfall ofplanned vs. actual staffing is more than 15%.

Staff turnover – this is a 12-month figure showing the nursing workforce turnover, with the number of leavers for the period expressed asa percentage of the number of staff still in post at the end of the period. This was defined by HR.

Sickness absence – the whole time equivalent days lost to sickness absence as a percentage of the total available whole timeequivalent days. This figure is received once a month but is not currently updated to reflect any corrections made or late entries.

Vacancy rate – the whole time equivalent vacancies for all nurses (RNs and HCAs) expressed as a percentage of the budget whole timeequivalent.

Band 5 vacant Wte - the whole-time equivalent vacancies for Band 5 nurses.

Band 5 vacancy rate – as above, for Band 5 nurses only.

Bank fill rate – the number of filled bank/agency nursing shifts expressed as a percentage of the total number of shifts requested.

Bank & overtime – the whole time equivalent usage that was bank, agency or overtime, expressed as a percentage of the nursingestablishment.

C. difficile – the number of cases of C. difficile identified post-72 hours of admission to the Trust.

Datix staffing incidents – the number of Datix reports submitted because of shortages in nursing staff.

Fall per 1,000 bed days – the number of patient slips, trips and falls (all severities) expressed as a rate per 1,000 (occupied) bed days.

Pressure ulcers per 1,000 bed days – as above, for all Trust-acquired pressure ulcers.

Falls & Pressure Ulcers - the total number of falls and pressure ulcers added together.

Friends & Family Test response rate – the number of patients responding to the Friends & Family Test expressed as a percentage of thetotal number of patients who were eligible to respond.

SBR Sister – indicates whether the ward currently has a Sister/Charge Nurse who was recruited using the Strengths-Based Recruitmentprocess.

30

Nursing Information Dashboard - December 2018

Business and Development

Area MonthRN FillRate

CareStaffFill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff

TurnoverSicknessAbsence

VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate

Bank &AgencyFill Rate

Bank &Overtime

C.difficile

DatixStaffingIncident

s

Falls per1,000beddays

PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Park Suite - RVI

Oct 2018 96.78% 59.85% 13.30 3.96 87.03% 59.88% 11 9.1% 4.8% 27.8% 2.37 25.5% 93.75% 12.41% 0 0 0.00 0.00 0 0.00% No

Nov 2018 100.22% 29.98% 13.30 4.55 93.26% 61.29% 6 9.1% 11.6% 27.8% 2.37 25.5% 100.00% 5.94% 0 0 0.00 0.00 0 0.00% No

Dec 2018 98.68% 68.18% 13.30 4.75 84.85% 32.12% 6 9.1% 3.7% 27.8% 2.37 25.5% 100.00% 6.39% 0 0 0.00 0.00 0 0.00% No

Page 131


Cancer Services


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 33 -Freeman

Oct 2018 100.69% 100.62% 25.57 25.56 78.94% 93.14% 10 14.8% 0.8% 0.0% 0.00 0.0% 100.00% 10.25% 0 0 6.13 2.04 4 13.64% No

Nov 2018 100.27% 92.52% 25.57 21.82 80.23% 90.78% 12 16.0% 3.6% 11.7% 2.00 10.8% 92.31% 0.31% 1 0 8.64 2.16 5 23.68% No

Dec 2018 88.01% 110.54% 25.33 23.14 74.73% 95.01% 25 20.8% 6.8% 10.9% 0.76 4.4% 100.00% 0.59% 0 0 6.06 0.00 3 12.90% No

Ward 34 -Freeman

Oct 2018 90.25% 87.95% 30.01 31.73 68.86% 86.69% 16 3.7% 3.8% 13.1% 0.94 5.0% 63.04% 14.23% 0 0 7.17 1.43 6 19.83% Yes

Nov 2018 92.39% 95.67% 29.77 28.74 67.52% 77.44% 13 11.1% 4.4% 15.8% 1.70 9.7% 71.05% 3.43% 0 1 9.93 1.66 7 44.30% Yes

Dec 2018 86.97% 93.06% 29.77 28.69 66.68% 80.02% 20 7.4% 5.3% 16.9% 2.02 11.5% 48.57% 8.67% 0 0 4.65 1.55 4 6.30% Yes

Ward 35 -Freeman

Oct 2018 98.70% 92.93% 27.80 26.72 66.37% 76.86% 4 10.3% 8.6% 1.0% 0.00 0.0% 32.35% 12.73% 1 0 8.18 1.64 6 12.41% Yes

Nov 2018 95.09% 88.37% 27.25 21.72 66.60% 76.41% 8 10.7% 11.0% 2.6% 0.00 0.0% 67.61% 6.09% 0 0 11.74 1.68 8 17.91% Yes

Dec 2018 92.31% 86.89% 27.25 25.83 65.96% 75.19% 13 10.7% 9.6% 2.6% 0.00 0.0% 54.00% 4.81% 0 0 6.70 0.00 4 9.26% Yes

Page 232


Cardiothoracic Services


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

PICU -Freeman

Oct 2018 98.06% 116.06% 98.12 92.69% 80.94% 26 3.7% 5.0% 2.5% 1.01 1.4% N/A 0.00% 0 0 0.00 0.00 0 N/A No

Nov 2018 93.89% 125.51% 98.12 N/A 91.82% 82.30% 38 3.7% 6.7% 2.7% 1.23 1.7% N/A 0.85% 0 0 0.00 3.58 1 0.00% No

Dec 2018 92.80% 106.45% 98.19 92.90% 85.81% 44 3.7% 8.0% 3.2% 3.62 5.0% N/A 0.35% 0 0 0.00 0.00 0 0.00% No

Ward 21 -Freeman

Oct 2018 92.24% 100.42% 130.92 92.53% 62.17% 43 12.4% 8.7% 2.8% 3.26 3.2% N/A 3.02% 0 0 0.00 7.08 3 N/A No

Nov 2018 96.02% 97.78% 130.92 N/A 92.97% 75.76% 34 11.6% 7.7% 2.7% 3.10 3.1% 100.00% 1.96% 0 0 0.00 6.00 3 N/A No

Dec 2018 94.27% 90.65% 130.92 93.28% 63.78% 39 10.9% 8.9% 0.2% 0.00 0.0% 66.67% 5.29% 0 0 0.00 13.79 6 N/A No

Ward 23 -Freeman

Oct 2018 93.10% 85.65% 48.45 30.48 78.76% 74.95% 52 1.8% 4.8% 0.0% 0.00 0.0% N/A 0.56% 1 0 0.00 0.00 0 27.69% No

Nov 2018 98.16% 95.02% 48.45 23.22 77.87% 68.82% 32 1.8% 5.2% 0.0% 0.00 0.0% N/A 1.09% 0 0 2.76 0.00 1 38.60% No

Dec 2018 93.20% 78.29% 48.45 27.92 80.69% 69.02% 37 1.8% 2.5% 1.7% 0.69 2.2% N/A 0.87% 0 0 0.00 0.00 0 0.00% No

Ward 24/24A -Freeman

Oct 2018 96.10% 63.40% 53.68 27.71 90.19% 72.49% 11 7.0% 4.4% 10.1% 1.09 3.3% 75.00% 6.86% 0 0 4.61 1.54 4 61.83% No

Nov 2018 96.29% 61.16% 53.68 24.63 90.47% 71.31% 14 7.3% 4.1% 11.3% 1.76 5.3% 91.67% 1.88% 0 0 1.62 3.23 3 0.00% No

Dec 2018 90.42% 42.01% 53.68 26.78 92.89% 66.94% 29 7.4% 4.7% 15.0% 3.76 11.3% 95.65% 3.99% 0 0 1.75 0.00 1 0.00% No

Ward 25 -Freeman

Oct 2018 97.52% 84.74% 24.80 21.41 68.16% 79.32% 11 12.0% 10.6% 5.8% 1.40 10.8% 82.46% 13.95% 0 0 0.00 2.05 1 23.94% Yes

Nov 2018 99.71% 95.17% 24.80 18.04 66.19% 75.33% 5 7.7% 6.5% 7.4% 0.79 6.1% 91.30% 3.23% 0 0 13.27 4.42 8 33.33% Yes

Dec 2018 96.84% 86.96% 24.58 18.35 67.73% 72.74% 4 7.7% 6.2% 6.9% 1.65 12.0% 81.82% 1.91% 0 0 4.43 2.22 3 42.42% Yes

Ward 27 -Freeman

Oct 2018 95.08% 88.92% 25.52 29.00 69.69% 81.82% 7 3.7% 2.5% 0.1% 0.00 0.0% 100.00% 4.78% 0 0 0.00 0.00 0 11.35% No

Nov 2018 89.33% 84.27% 25.52 31.10 69.56% 89.71% 13 7.7% 6.3% 0.1% 0.00 0.0% 100.00% 4.08% 0 0 0.00 0.00 0 37.33% No

Dec 2018 88.57% 73.46% 25.67 36.45 72.73% 76.59% 9 3.8% 6.8% 4.0% 0.00 0.0% 100.00% 5.88% 0 0 4.37 0.00 1 19.29% No

Ward 29 -Freeman

Oct 2018 94.64% 95.52% 31.36 32.11 59.32% 90.91% 28 9.4% 6.4% 23.5% 3.36 21.5% 62.89% 10.84% 0 1 10.00 3.75 11 1.12% No

Nov 2018 95.88% 99.66% 31.36 28.32 58.62% 88.81% 7 6.1% 3.2% 21.5% 2.36 15.1% 70.00% 4.94% 0 0 2.62 0.00 2 0.53% No

Dec 2018 90.66% 93.12% 31.36 33.58 58.49% 85.34% 24 6.1% 3.9% 18.3% 1.36 8.7% 71.19% 7.81% 0 0 6.13 1.23 6 2.30% No

Ward 30 -Freeman

Oct 2018 91.68% 132.21% 31.77 28.42 66.23% 76.59% 19 9.1% 5.6% 0.3% 0.00 0.0% 69.23% 3.43% 0 1 5.43 2.72 6 13.91% No

Page 333



CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 30 -Freeman

Nov 2018 89.06% 122.37% 31.77 25.36 67.29% 70.75% 22 9.4% 11.0% 0.3% 0.00 0.0% 75.00% 5.60% 0 0 7.60 1.52 6 22.22% No

Dec 2018 83.90% 94.69% 31.77 22.25 69.34% 59.73% 30 9.7% 9.8% 5.1% 0.61 3.4% 72.73% 5.76% 0 0 1.74 0.00 1 4.76% No

Ward 49 - RVI

Oct 2018 90.71% 98.39% 30.31 35.22 55.23% 85.87% 11 7.1% 8.1% 19.6% 2.08 14.9% 78.90% 25.57% 0 0 12.95 7.77 16 17.98% No

Nov 2018 95.52% 98.84% 30.31 29.62 56.44% 84.94% 4 9.7% 6.9% 9.7% 0.08 0.6% 84.78% 6.17% 0 0 6.77 4.06 8 0.00% No

Dec 2018 90.81% 100.71% 30.31 35.30 55.04% 88.54% 13 6.9% 10.0% 13.0% 1.08 7.7% 60.00% 7.39% 0 0 5.51 8.26 10 0.00% No

Ward 50 - RVI

Oct 2018 92.22% N/A 23.05 8.74 100.00% 70.43% 1 4.3% 1.0% 7.5% 1.00 8.7% 96.88% 12.45% 0 0 15.27 7.63 3 N/A No

Nov 2018 92.67% N/A 23.65 9.63 100.00% 68.89% 0 4.3% 2.3% 9.9% 1.00 8.7% 92.31% 2.66% 0 0 16.13 0.00 2 N/A No

Dec 2018 93.83% N/A 23.65 8.38 100.00% 82.80% 2 0.0% 1.9% 5.6% 1.00 8.7% 83.87% 4.52% 0 0 0.00 6.49 1 N/A No

Page 434


Childrens Services


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 10 - RVI

Oct 2018 98.30% 103.11% 23.43 30.41 70.42% 83.01% 0 4.0% 12.2% 1.9% 0.00 0.0% 81.82% 17.07% 1 3 0.00 0.00 0 1.88% Yes

Nov 2018 98.31% 102.69% 23.43 30.07 70.51% 88.22% 0 3.8% 20.7% 0.0% 0.00 0.0% 93.75% 11.18% 0 1 0.00 0.00 0 0.00% Yes

Dec 2018 94.80% 94.43% 23.43 26.39 71.46% 68.03% 5 3.8% 17.1% 0.0% 0.00 0.0% 84.38% 5.63% 0 0 0.00 0.00 0 0.00% Yes

Ward 11 - RVI

Oct 2018 96.27% 85.91% 24.93 32.38 81.83% 76.37% 13 3.7% 1.8% 3.7% 0.33 2.0% 100.00% 0.92% 0 0 0.00 0.00 0 1.58% No

Nov 2018 93.01% 89.45% 24.93 32.51 80.61% 76.44% 16 3.7% 2.6% 3.7% 0.33 2.0% 100.00% 1.36% 0 0 0.00 0.00 0 0.00% No

Dec 2018 90.03% 87.44% 24.93 30.48 79.93% 66.07% 26 3.8% 3.1% 3.7% 0.33 2.0% 100.00% 2.17% 0 0 0.00 0.00 0 0.00% No

Ward 12 - RVI

Oct 2018 99.69% 98.62% 83.79 91.37% 84.16% 9 4.3% 6.4% 0.0% 0.00 0.0% N/A 0.74% 0 0 0.00 0.00 0 N/A No

Nov 2018 104.58% 101.21% 83.79 N/A 90.46% 96.56% 5 4.3% 6.3% 0.0% 0.00 0.0% N/A 0.97% 0 0 0.00 2.54 1 N/A No

Dec 2018 97.96% 97.55% 83.79 90.81% 72.21% 15 5.6% 3.4% 0.0% 0.00 0.0% N/A 4.00% 1 1 0.00 0.00 0 N/A No

Ward 1A - RVI

Oct 2018 92.61% 52.74% 34.76 34.87 93.15% 88.41% 25 0.0% 1.6% 11.5% 1.37 5.2% 60.00% 3.08% 1 0 0.00 0.00 0 39.13% No

Nov 2018 77.93% 44.31% 34.76 35.14 93.14% 93.24% 51 0.0% 4.5% 11.5% 1.37 5.2% 85.71% 2.13% 0 0 0.00 0.00 0 0.00% No

Dec 2018 77.27% 93.00% 34.76 26.85 86.83% 82.47% 101 7.4% 5.9% 11.7% 1.37 5.2% N/A 2.59% 0 0 0.00 0.00 0 0.00% No

Ward 1B - RVI

Oct 2018 97.24% 138.57% 23.60 28.05 83.09% 96.28% 7 4.0% 1.7% 7.7% 1.79 10.5% 92.59% 9.62% 0 0 7.73 0.00 3 0.00% No

Nov 2018 99.52% 188.84% 23.60 29.00 78.67% 97.44% 5 4.2% 1.1% 6.6% 0.56 3.3% 100.00% 1.23% 0 0 0.00 0.00 0 0.00% No

Dec 2018 98.92% 177.42% 23.60 28.42 79.60% 90.82% 2 4.2% 1.2% 6.2% 0.79 4.6% 97.06% 2.42% 0 0 0.00 0.00 0 0.00% No

Ward 2 - RVI

Oct 2018 90.99% 63.63% 33.89 33.26 86.18% 76.31% 32 14.7% 5.4% 7.2% 0.87 3.4% 80.00% 13.13% 0 0 2.22 0.00 1 0.00% No

Nov 2018 95.14% 72.31% 33.89 37.68 85.38% 81.12% 29 14.7% 2.8% 3.7% 0.66 2.6% 100.00% 7.94% 0 0 0.00 0.00 0 0.00% No

Dec 2018 96.19% 80.94% 33.89 31.77 84.66% 77.23% 15 21.9% 4.3% 6.2% 1.51 5.9% 100.00% 5.43% 0 0 0.00 0.00 0 2.38% No

Ward 3 - RVI

Oct 2018 82.40% 91.35% 43.28 22.26 78.30% 88.71% 91 16.7% 0.0% 8.7% 1.53 6.5% 100.00% 9.43% 0 2 0.00 0.00 0 0.00% No

Nov 2018 83.60% 94.69% 43.28 21.84 77.93% 89.00% 95 15.0% 2.8% 8.7% 1.53 6.5% 81.08% 6.79% 0 0 0.00 0.00 0 0.00% No

Dec 2018 85.75% 89.25% 43.28 21.48 79.35% 89.03% 117 15.0% 0.9% 6.4% 0.53 2.3% 93.55% 3.93% 0 0 0.00 3.62 1 0.00% No

Ward 4 - RVI Oct 2018 89.79% 96.60% 46.73 35.19 87.97% 78.71% 29 10.9% 2.7% 4.3% 0.39 1.2% 100.00% 3.51% 0 0 0.00 0.00 0 0.00% No

Page 535



CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

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Registered Nurse

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WardOccupan

cyRed

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Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 4 - RVI

Nov 2018 91.18% 69.83% 46.73 36.09 91.13% 88.24% 26 10.9% 3.0% 5.2% 0.84 2.5% 100.00% 1.48% 0 0 0.00 0.00 0 0.00% No

Dec 2018 89.33% 63.75% 46.73 38.44 91.68% 84.49% 41 11.1% 4.2% 7.0% 0.92 2.8% 62.50% 1.67% 0 0 0.00 0.00 0 0.00% No

Ward 6 - RVI

Oct 2018 N/A N/A 70.58 N/A 100.72% 10.4% 5.8% 10.8% 3.27 7.4% 80.00% 5.45% 0 3 0.00 0.00 0 2.58% No

Nov 2018 N/A N/A 70.58 N/A N/A 99.21% 9.1% 6.6% 9.1% 1.27 2.9% 86.21% 4.68% 0 0 0.00 0.00 0 0.00% No

Dec 2018 N/A N/A 70.58 N/A 92.35% 7.8% 5.9% 10.5% 2.27 5.1% 94.44% 3.10% 0 1 0.00 0.00 0 0.00% No

Ward 8A - RVI

Oct 2018 90.88% 95.45% 14.70 70.70% 70.04% 12 14.3% 1.3% 16.7% 2.38 27.4% 63.33% 22.31% 0 1 0.00 0.00 0 2.54% No

Nov 2018 102.43% 100.00% 14.70 72.31% 64.89% 2 14.3% 5.5% 16.7% 2.38 27.4% 76.19% 5.44% 0 0 0.00 0.00 0 0.00% No

Dec 2018 96.78% 65.85% 14.70 77.48% 42.59% 4 14.3% 7.9% 16.7% 2.38 27.4% 35.71% 4.08% 0 0 0.00 0.00 0 0.00% No

Ward 9 - RVI

Oct 2018 85.38% 126.40% 34.32 32.45 81.17% 93.35% 36 16.7% 1.0% 18.0% 3.96 15.8% 95.83% 11.36% 0 0 0.00 0.00 0 50.57% No

Nov 2018 81.95% 141.75% 34.32 33.98 79.18% 92.71% 44 16.7% 2.2% 18.0% 3.96 15.8% 83.87% 3.58% 0 0 0.00 0.00 0 0.00% No

Dec 2018 80.34% 129.53% 34.32 31.99 81.21% 91.13% 49 16.7% 4.4% 18.0% 3.96 15.8% 70.00% 4.84% 0 0 0.00 0.00 0 20.37% No

Page 636


EPOD


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

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cyRed

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Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 10 -Freeman

Oct 2018 95.39% 101.16% 34.85 46.76 71.46% 70.54% 5 0.0% 3.7% 18.1% 3.03 14.1% 83.53% 12.05% 0 0 4.19 0.00 3 13.58% Yes

Nov 2018 92.01% 98.71% 34.85 38.85 71.22% 63.49% 10 0.0% 3.3% 23.2% 3.80 17.6% 100.00% 2.64% 0 0 6.54 3.27 6 12.93% Yes

Dec 2018 89.16% 101.12% 34.85 40.98 70.05% 58.96% 12 0.0% 2.7% 23.2% 3.80 17.6% 92.00% 3.47% 0 0 10.14 3.38 8 15.99% Yes

Ward 20 - RVI

Oct 2018 97.04% 77.72% 28.27 22.95 77.04% 59.76% 0 10.0% 4.9% 19.6% 1.12 6.4% 73.44% 8.03% 0 0 2.82 0.00 1 8.84% No

Nov 2018 98.75% 85.03% 28.51 24.07 76.04% 48.70% 0 10.3% 8.0% 22.6% 2.79 16.0% 81.13% 3.05% 0 0 0.00 0.00 0 0.00% No

Dec 2018 92.46% 85.43% 28.51 13.45 75.00% 49.65% 4 10.3% 2.9% 19.1% 2.79 16.0% 70.77% 4.35% 0 0 0.00 0.00 0 0.00% No

Ward 37 - RVI

Oct 2018 96.56% 39.81% 22.27 9.92 90.03% 0.00% 0 0.0% 6.7% 10.9% 0.42 2.9% N/A 6.06% 0 0 0.00 0.00 0 N/A No

Nov 2018 95.39% 56.49% 22.27 87.03% N/A 14 0.0% 4.1% 10.9% 0.42 2.9% N/A 0.00% 0 0 0.00 0.00 0 N/A No

Dec 2018 88.86% 37.99% 22.27 90.29% N/A 13 0.0% 3.3% 10.9% 0.42 2.9% N/A 0.31% 0 0 0.00 0.00 0 N/A No

Ward 47 - RVI

Oct 2018 91.41% 76.20% 33.08 25.60 79.35% 72.52% 25 3.4% 4.0% 15.1% 4.46 20.0% 75.00% 1.12% 0 0 4.94 1.65 4 8.43% No

Nov 2018 95.69% 78.17% 33.08 28.19 79.50% 79.88% 18 7.1% 0.8% 15.1% 3.46 15.5% 85.00% 0.48% 0 0 3.09 1.55 3 0.00% No

Dec 2018 90.88% 80.22% 33.08 25.85 78.17% 73.33% 24 7.1% 0.4% 16.6% 3.46 15.5% 72.73% 0.42% 0 0 1.63 4.89 4 0.00% No

Ward 5 - RVI

Oct 2018 96.77% 46.13% 16.01 N/A 87.24% 87.63% 0 0.0% 3.6% 13.6% 2.00 18.4% 100.00% 5.62% 0 0 3.07 3.07 2 0.88% No

Nov 2018 82.51% 51.87% 16.01 13.01 86.76% 89.44% 29 0.0% 3.7% 7.3% 1.00 9.2% 77.78% 0.00% 0 0 3.11 6.21 3 0.00% No

Dec 2018 98.00% 43.55% 16.01 8.51 90.26% 65.86% 1 11.8% 10.0% 7.3% 1.00 9.2% 80.00% 0.44% 0 0 0.00 4.08 1 18.57% No

Page 737


Institute of Transplantation


CareStaff Fill

Rate

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ment

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C.difficile


s


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per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 38 -Freeman

Oct 2018 94.32% 105.16% 44.24 28.97 81.40% 85.77% 22 2.3% 2.6% 5.6% 2.47 8.3% 79.61% 14.15% 0 0 3.28 1.64 3 44.44% No

Nov 2018 95.22% 89.68% 44.49 26.61 83.85% 85.36% 14 2.3% 6.9% 6.2% 2.72 9.1% 77.78% 1.53% 0 0 3.47 0.00 2 0.00% No

Dec 2018 94.21% 93.88% 44.49 25.85 83.26% 80.65% 15 2.3% 3.9% 6.2% 2.72 9.1% 66.36% 0.27% 0 0 3.50 1.75 3 0.00% No

Page 838


Internal Medicine


CareStaff Fill

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Falls &Pressure

Ulcers

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ResponseRate

SBRSister

AssessmentSuite - RVI

Oct 2018 79.58% 127.02% 74.53 82.93 61.85% 69.81% 78 15.5% 4.8% 7.0% 1.55 4.4% 79.31% 10.16% 0 0 7.39 3.70 12 5.60% No

Nov 2018 90.92% 123.48% 74.63 79.62 65.58% 65.27% 48 15.5% 4.0% 0.0% 0.00 0.0% 78.70% 7.26% 0 0 7.15 4.09 11 0.00% No

Dec 2018 91.11% 107.44% 74.63 82.31 68.69% 66.97% 55 15.3% 5.4% 0.0% 0.00 0.0% 84.29% 4.46% 0 0 9.63 3.85 14 4.05% No

Cherryburn -CAV

Oct 2018 86.66% 93.70% 41.34 38.23 54.36% N/A 28 N/A N/A 22.1% 2.02 11.1% N/A 16.52% 0 0 0.00 0.00 13 N/A No

Nov 2018 83.73% 97.11% 41.34 39.40 52.57% N/A 28 N/A N/A 19.6% 2.02 11.1% N/A 2.49% 0 0 0.00 9 N/A No

Dec 2018 N/A N/A 41.34 38.67 N/A N/A N/A N/A 19.6% 2.02 11.1% N/A 3.82% 0 0 0.00 6 N/A No

Ward 13 -Freeman

Oct 2018 92.36% 129.75% 40.03 27.73 43.86% 87.08% 36 3.2% 7.6% 27.8% 4.90 30.6% 95.45% 12.34% 1 0 1.83 0.00 1 0.00% No

Nov 2018 100.12% 139.99% 40.03 26.21 43.98% 75.79% 19 3.0% 7.5% 27.8% 3.90 24.4% 100.00% 3.80% 0 0 9.51 3.80 7 0.00% No

Dec 2018 105.03% 142.62% 40.03 36.07 44.70% 94.69% 17 2.9% 5.6% 21.8% 2.90 18.1% 94.44% 7.77% 0 0 9.80 2.80 9 0.00% No

Ward 14 -Freeman

Oct 2018 80.16% 158.14% 41.87 35.31 39.57% 87.74% 32 10.0% 7.7% 27.8% 2.00 12.9% 96.10% 19.78% 0 0 2.45 3.68 5 0.00% No

Nov 2018 81.25% 163.90% 41.87 34.37 39.03% 91.77% 24 9.7% 6.1% 30.2% 2.00 12.9% 96.97% 2.58% 0 0 8.48 3.64 10 0.00% No

Dec 2018 83.89% 137.90% 41.87 37.80 44.00% 93.33% 25 6.7% 9.2% 30.2% 4.00 25.8% 96.69% 2.99% 0 0 8.06 4.61 11 0.00% No

Ward 15 -Freeman

Oct 2018 86.98% 155.75% 39.20 44.88 41.87% 97.74% 46 5.9% 4.7% 16.3% 1.79 12.3% 80.00% 14.92% 0 0 12.10 1.10 12 56.67% No

Nov 2018 90.27% 156.07% 39.20 41.61 42.73% 96.44% 29 5.9% 3.8% 15.3% 2.99 20.6% 88.10% 4.34% 0 0 17.28 2.30 17 17.86% No

Dec 2018 81.66% 169.46% 39.20 45.18 38.33% 95.81% 44 3.0% 8.3% 17.8% 3.99 27.5% 74.69% 5.28% 0 0 14.59 5.61 18 25.00% No

Ward 16 -Freeman

Oct 2018 91.50% 163.43% 39.50 37.00 41.83% 94.62% 6 14.3% 6.2% 24.3% 4.74 29.6% 85.58% 24.10% 2 0 3.41 1.14 4 0.00% No

Nov 2018 87.34% 158.06% 39.50 37.41 40.50% 93.18% 13 10.0% 18.0% 22.7% 4.90 30.6% 84.07% 3.04% 0 0 6.31 0.00 5 105.10% No

Dec 2018 90.93% 154.27% 39.50 21.95 38.91% 79.69% 10 10.0% 20.6% 25.0% 4.83 30.2% 76.45% 2.76% 0 0 5.39 1.80 4 0.00% No

Ward 18 -Freeman

Oct 2018 82.93% 177.77% 36.67 42.99 34.29% 96.89% 56 6.5% 1.8% 27.9% 3.29 25.7% 93.37% 25.69% 0 0 9.51 7.13 14 48.15% Yes

Nov 2018 86.76% 171.02% 36.67 43.40 36.70% 95.83% 21 6.1% 1.1% 25.1% 3.29 25.7% 95.58% 4.25% 0 0 8.70 9.94 15 32.61% Yes

Dec 2018 99.47% 161.22% 36.67 42.66 39.56% 93.32% 5 5.7% 2.2% 22.4% 3.29 25.7% 97.56% 3.95% 0 0 7.41 7.41 12 82.76% Yes

Ward 19 - RVI Oct 2018 135.50% 100.98% 24.65 15.95 69.88% 93.38% 1 8.7% 0.0% 10.0% 0.85 7.8% 40.00% 5.72% 0 0 2.62 2.62 2 67.86% Yes

Page 939



CareStaff Fill

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cyRed

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Rate


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s


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Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 19 - RVI

Nov 2018 105.84% 92.41% 24.65 23.45 66.42% 89.93% 1 8.7% 1.4% 5.9% 0.05 0.5% 69.23% 9.78% 0 0 10.37 0.00 5 0.00% Yes

Dec 2018 102.79% 99.96% 24.65 19.30 63.83% 87.28% 3 8.7% 2.0% 5.9% 0.05 0.5% 55.00% 0.57% 0 0 8.21 0.00 4 0.00% Yes

Ward 30 - RVI

Oct 2018 76.34% 99.52% 36.25 31.67 52.92% 96.13% 55 5.6% 2.4% 9.1% 4.87 25.4% 100.00% 4.44% 0 0 1.12 7.83 8 14.93% Yes

Nov 2018 78.82% 103.36% 36.25 31.18 52.79% 95.44% 47 5.6% 6.0% 3.6% 2.87 14.9% 94.29% 1.96% 0 0 11.64 1.16 11 0.00% Yes

Dec 2018 77.63% 101.11% 36.25 31.96 53.13% 92.47% 49 11.4% 5.1% 1.7% 2.20 11.5% 93.55% 0.61% 0 0 15.12 2.33 15 0.00% Yes

Ward 31 - RVI

Oct 2018 94.18% 63.35% 40.32 38.52 63.85% 97.78% 4 N/A N/A 26.0% 0.76 4.8% 98.36% 8.93% 0 0 11.38 6.83 16 16.67% Yes

Nov 2018 91.00% 63.69% 40.32 29.51 62.93% 97.70% 6 N/A N/A 29.0% 1.76 11.0% 93.22% 2.90% 1 0 10.59 8.24 16 0.00% Yes

Dec 2018 86.72% 64.86% 40.32 35.74 61.37% 93.55% 14 N/A N/A 26.6% 1.80 11.3% 92.73% 4.56% 0 0 14.27 2.38 14 0.00% Yes

Ward 41 - RVI

Oct 2018 79.15% 106.84% 43.35 34.40 59.70% 75.68% 48 5.6% 5.3% 21.5% 8.09 32.2% 92.31% 11.00% 0 1 4.92 4.92 6 11.19% No

Nov 2018 77.21% 119.43% 43.35 27.05 56.39% 69.10% 51 5.4% 9.3% 16.8% 6.09 24.2% 93.22% 6.37% 1 0 5.57 0.00 3 0.00% No

Dec 2018 79.56% 107.31% 43.35 26.96 59.72% 66.38% 51 8.1% 5.3% 14.5% 5.09 20.2% 89.06% 4.57% 0 0 0.00 1.87 1 0.00% No

Ward 48 - RVI

Oct 2018 96.40% 167.90% 40.69 33.93 40.18% 97.22% 0 8.3% 0.0% 27.9% 2.00 12.5% 100.00% 13.37% 0 0 8.01 1.14 8 33.68% No

Nov 2018 98.38% 160.82% 40.69 34.19 41.70% 92.83% 0 10.5% 0.7% 29.1% 3.00 18.8% 100.00% 3.64% 0 0 9.96 7.47 14 0.00% No

Dec 2018 94.23% 176.37% 40.69 37.62 38.39% 91.09% 2 7.9% 3.1% 24.2% 4.00 25.0% 100.00% 7.37% 0 0 6.11 3.67 8 0.00% No

Ward 51 - RVI

Oct 2018 81.87% 148.59% 11.60 9.31 69.00% 83.84% 35 0.0% 4.5% 0.9% 2.10 24.4% 85.92% 33.36% 0 0 12.05 18.07 5 0.00% No

Nov 2018 94.97% 129.14% 11.60 8.91 75.09% 77.25% 9 0.0% 1.0% 0.9% 1.10 12.8% 96.36% 1.21% 0 0 6.85 0.00 1 0.00% No

Dec 2018 98.33% 110.21% 11.60 8.91 76.89% 77.25% 6 0.0% 0.3% 0.9% 1.10 12.8% 79.37% 0.86% 0 0 0.00 0.00 0 0.00% No

Ward 52 - RVI

Oct 2018 101.06% 136.25% 41.54 42.79 56.50% 91.90% 3 4.5% 4.9% 0.0% 1.44 6.2% 91.67% 6.11% 0 0 3.04 3.04 6 6.73% No

Nov 2018 96.25% 125.04% 41.54 37.72 57.39% 88.67% 5 4.7% 6.9% 0.0% 2.64 11.2% 93.10% 2.05% 0 0 6.44 1.07 7 0.00% No

Dec 2018 98.05% 129.03% 41.54 44.16 56.98% 91.61% 6 0.0% 7.5% 0.0% 2.64 11.2% 94.00% 2.89% 0 0 3.02 4.02 7 0.00% No

Ward 9 -Freeman

Oct 2018 96.99% 123.67% 38.86 45.89% 93.14% 7 5.4% 8.0% 27.8% 3.58 25.6% 88.31% 16.01% 0 0 0.00 0.00 0 50.00% No

Nov 2018 91.89% 133.75% 38.86 42.63% 96.19% 12 5.4% 8.8% 25.2% 3.58 25.6% 94.94% 3.24% 0 0 0.00 0.00 0 27.27% No

Dec 2018 87.44% 85.76% 38.86 50.49% 95.05% 33 5.6% 6.4% 21.1% 3.58 25.6% 95.70% 7.10% 0 0 0.00 0.00 0 15.79% No

Page 1040


Musculoskeletal Services


CareStaff Fill

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cyRed

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Rate


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C.difficile


s


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per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 19 -Freeman

Oct 2018 93.23% 90.75% 31.56 28.72 56.77% 66.38% 9 0.0% 6.5% 7.9% 1.80 11.1% 69.57% 15.30% 0 0 1.43 1.43 2 5.07% No

Nov 2018 98.43% 95.34% 31.56 21.91 56.90% 46.27% 3 0.0% 7.4% 7.9% 2.00 12.1% 100.00% 2.31% 0 0 0.00 0.00 0 7.63% No

Dec 2018 92.87% 89.23% 31.56 29.06 57.15% 52.94% 6 0.0% 4.7% 12.1% 2.92 17.7% 85.71% 1.36% 0 0 1.79 1.79 2 12.82% No

Ward 20 -Freeman

Oct 2018 93.12% 75.02% 21.20 15.13 64.83% 47.66% 2 11.1% 9.1% 15.7% 3.11 28.8% 86.60% 12.97% 0 0 4.68 0.00 2 4.46% Yes

Nov 2018 89.60% 82.21% 21.20 14.45 61.84% 43.06% 13 11.1% 0.7% 20.4% 3.11 28.8% 90.32% 1.65% 0 0 16.13 0.00 6 28.23% Yes

Dec 2018 89.39% 83.62% 21.20 15.84 61.63% 34.55% 11 11.1% 2.8% 20.4% 3.11 28.8% 89.89% 1.27% 0 0 6.83 3.41 3 7.85% Yes

Ward 22 - RVI

Oct 2018 81.24% 113.49% 40.50 33.20 54.25% 75.50% 40 17.2% 11.1% 26.9% 7.32 34.3% 78.15% 37.43% 0 0 2.52 13.84 13 21.59% Yes

Nov 2018 86.24% 121.78% 40.50 37.74 53.98% 74.53% 30 16.7% 8.0% 24.4% 6.32 29.6% 87.77% 4.05% 0 0 6.60 6.60 10 0.00% Yes

Dec 2018 83.96% 110.07% 40.50 40.82 55.82% 68.13% 39 16.7% 5.6% 24.2% 5.32 24.9% 86.15% 2.81% 0 0 12.64 7.02 14 0.00% Yes

Ward 23 - RVI

Oct 2018 87.81% 97.08% 37.92 29.02 57.80% 73.03% 33 2.9% 10.0% 8.6% 1.07 5.7% 70.27% 24.02% 0 1 2.87 1.44 3 15.09% Yes

Nov 2018 92.34% 98.19% 37.92 5.86 58.75% 71.08% 27 6.1% 3.9% 6.0% 1.07 5.7% 88.24% 4.80% 0 0 12.10 3.03 10 0.00% Yes

Dec 2018 94.57% 87.13% 37.92 21.47 60.14% 56.58% 21 6.1% 5.9% 13.9% 1.07 5.7% 79.41% 5.72% 0 0 11.07 9.23 11 0.00% Yes

Ward 42 - RVI

Oct 2018 108.44% 102.10% 35.37 18.61 58.96% 55.32% 0 2.9% 1.8% 7.3% 2.28 12.7% 100.00% 8.09% 0 0 4.32 2.16 3 19.23% Yes

Nov 2018 104.98% 110.33% 35.37 17.42 56.23% 56.88% 1 2.9% 0.8% 7.3% 1.28 7.2% 73.68% 1.05% 0 0 4.36 0.00 2 0.45% Yes

Dec 2018 96.75% 104.06% 35.37 13.75 55.35% 38.85% 9 3.0% 2.5% 7.3% 1.28 7.2% 83.33% 1.19% 0 0 0.00 3.09 1 3.05% Yes

Page 1141


Neurosciences


CareStaff Fill

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Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 15 - RVI

Oct 2018 87.54% 83.03% 43.49 32.90 58.52% 89.75% 22 14.3% 2.3% 3.7% 0.90 4.0% 88.71% 12.26% 0 0 13.22 2.40 13 3.30% Yes

Nov 2018 94.41% 80.88% 43.49 35.98 61.10% 86.10% 7 14.3% 3.6% 8.3% 0.00 0.0% 92.98% 5.17% 0 0 5.17 1.29 5 0.00% Yes

Dec 2018 88.21% 77.03% 43.49 36.27 60.85% 81.27% 22 14.6% 1.1% 10.6% 0.90 4.0% 97.56% 1.89% 0 2 17.22 1.32 14 0.00% Yes

Ward 16 - RVI

Oct 2018 94.98% 131.42% 35.56 37.77 50.06% 94.80% 7 8.6% 4.7% 2.0% 0.64 3.5% 82.07% 19.66% 0 0 13.17 2.20 14 20.20% No

Nov 2018 99.57% 146.41% 35.56 40.17 48.55% 92.04% 0 5.9% 3.2% 8.4% 2.84 15.4% 88.81% 5.12% 0 0 0.00 3.50 3 0.00% No

Dec 2018 96.46% 133.78% 35.56 37.27 50.01% 88.24% 6 2.9% 1.9% 8.4% 2.84 15.4% 100.00% 2.17% 1 0 9.43 1.18 9 0.00% No

Ward 43 - RVI

Oct 2018 87.10% 124.02% 30.52 22.23 49.04% 73.30% 25 7.1% 1.7% 16.7% 2.02 14.7% 90.10% 18.61% 0 0 8.62 0.00 4 36.59% No

Nov 2018 96.54% 112.64% 30.52 19.77 54.06% 68.67% 9 14.3% 0.4% 12.4% 1.71 12.5% 95.45% 4.62% 1 0 16.55 0.00 7 0.00% No

Dec 2018 91.22% 116.74% 30.52 22.72 52.09% 70.62% 14 14.3% 0.3% 15.6% 2.24 16.3% 98.44% 6.65% 0 0 2.24 2.24 2 0.00% No

Page 1242


Periop and Crit Care


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 18 - RVI

Oct 2018 95.70% 171.67% 109.46 90.94% 80.79% 20 14.7% 4.3% 5.4% 4.09 5.1% 80.17% 6.79% 0 0 1.81 9.07 6 N/A No

Nov 2018 96.20% 92.90% 109.46 N/A 94.91% 79.55% 26 15.7% 3.4% 6.0% 4.32 5.4% 76.36% 4.30% 1 0 0.00 7.62 4 N/A No

Dec 2018 109.68% 82.61% 109.46 95.98% 82.99% 26 14.0% 2.6% 7.9% 6.32 7.9% 81.37% 3.06% 0 0 1.77 1.77 2 N/A No

Ward 37 -Freeman

Oct 2018 93.50% 116.09% 116.60 87.88% 80.06% 54 7.0% 4.0% 0.0% 0.00 0.0% N/A 2.02% 0 0 0.00 16.48 9 N/A No

Nov 2018 91.43% 104.89% 116.60 N/A 88.69% 67.58% 50 6.2% 7.1% 0.0% 0.00 0.0% N/A 1.66% 0 0 2.24 11.21 6 N/A No

Dec 2018 94.35% 123.14% 116.60 87.34% 72.43% 42 7.1% 7.4% 0.0% 0.00 0.0% N/A 1.23% 0 0 0.00 12.15 6 N/A No

Ward 38 - RVI

Oct 2018 87.79% 59.35% 108.88 90.96% 80.81% 59 12.9% 4.5% 0.4% 0.00 0.0% N/A 1.36% 0 0 0.00 19.96 10 N/A No

Nov 2018 87.80% 69.33% 108.88 N/A 89.60% 67.00% 57 12.1% 4.3% 0.9% 0.00 0.0% N/A 1.32% 0 0 0.00 7.46 3 0.00% No

Dec 2018 90.79% 65.78% 108.88 90.37% 76.61% 54 11.3% 5.3% 0.0% 0.00 0.0% N/A 0.59% 0 0 0.00 16.84 8 N/A No

Page 1343


Surgical Services


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 36 - RVI

Oct 2018 90.18% 107.04% 30.00 23.67 70.16% 86.45% 61 7.1% 0.0% 8.2% 2.39 12.5% 100.00% 5.90% 0 0 3.73 3.73 4 25.84% No

Nov 2018 91.12% 104.75% 30.00 19.14 70.58% 80.20% 51 7.1% 0.0% 8.2% 2.39 12.5% 95.65% 0.00% 1 0 2.09 2.09 2 0.00% No

Dec 2018 93.57% 100.90% 30.59 24.06 71.19% 78.39% 31 3.6% 1.5% 10.0% 1.00 5.6% 100.00% 0.23% 0 0 4.12 2.06 3 0.00% No

Ward 44 - RVI

Oct 2018 107.14% 90.92% 29.24 22.69 65.01% 65.22% 2 20.0% 6.4% 16.1% 1.50 9.3% 81.93% 18.19% 0 0 2.02 0.00 1 5.43% No

Nov 2018 106.22% 87.33% 29.24 25.93 65.72% 61.66% 4 20.0% 6.8% 19.5% 1.50 9.3% 89.36% 3.56% 0 0 3.84 1.92 3 0.00% No

Dec 2018 108.37% 96.10% 29.24 18.09 63.85% 58.59% 3 15.4% 5.3% 19.5% 1.50 9.3% 91.43% 2.26% 0 0 0.00 3.83 2 0.00% No

Ward 45 - RVI

Oct 2018 N/A N/A 16.52 N/A N/A 0.00% 0 5.9% 8.3% 4.6% 0.76 8.2% N/A 0.61% 0 0 0.00 0.00 1 15.24% No

Nov 2018 N/A N/A 16.52 N/A N/A 0.00% 0 5.9% 1.7% 4.6% 0.76 8.2% N/A 0.24% 0 0 0.00 0.00 0 26.62% No

Dec 2018 N/A N/A 16.52 N/A N/A 0.18% 0 5.9% 2.0% 4.6% 0.76 8.2% N/A 0.00% 0 0 0.00 0.00 0 36.68% No

Ward 46 - RVI

Oct 2018 94.64% 94.82% 33.58 34.69 66.34% 90.63% 14 0.0% 4.2% 3.0% 1.00 5.0% 100.00% 6.28% 1 0 4.87 0.00 4 86.21% No

Nov 2018 94.09% 86.39% 33.58 32.82 67.95% 88.20% 13 0.0% 5.3% 8.4% 2.80 13.9% 100.00% 5.00% 0 0 0.00 0.00 0 0.00% No

Dec 2018 89.62% 95.54% 33.58 35.08 63.89% 68.98% 24 0.0% 3.7% 8.4% 2.80 13.9% 86.67% 4.47% 0 0 7.97 0.00 5 0.00% No

Ward 5 -Freeman

Oct 2018 73.34% 105.57% 30.46 23.68 57.72% 97.74% 46 7.4% 0.5% 24.1% 4.99 28.6% 92.86% 12.80% 1 0 1.65 0.00 1 23.26% No

Nov 2018 80.59% 110.13% 30.46 24.38 60.23% 86.99% 35 7.1% 0.4% 18.2% 3.19 18.3% 95.65% 6.93% 0 0 0.00 1.68 1 32.61% No

Dec 2018 80.44% 115.79% 30.46 36.92 59.65% 87.07% 37 11.1% 0.7% 18.2% 3.19 18.3% 95.65% 8.93% 0 2 1.46 0.00 1 16.33% No

Ward 6 -Freeman

Oct 2018 101.16% 103.51% 29.17 31.37 59.36% 82.25% 3 8.0% 2.1% 8.0% 2.22 13.5% 74.29% 16.35% 0 0 1.46 0.00 1 44.44% Yes

Nov 2018 99.98% 97.44% 29.17 26.87 60.90% 72.82% 3 7.7% 3.2% 8.0% 2.22 13.5% 89.47% 6.00% 0 0 0.00 0.00 0 52.56% Yes

Dec 2018 98.48% 90.95% 29.17 28.68 63.34% 70.67% 10 7.7% 3.9% 4.5% 1.22 7.4% 93.18% 6.96% 0 0 0.00 0.00 0 39.76% Yes

Ward 7 -Freeman

Oct 2018 83.25% 157.36% 26.04 32.82 60.38% 88.71% 38 15.0% 0.2% 16.2% 4.19 24.6% 97.40% 28.99% 2 0 5.59 4.20 7 0.00% Yes

Nov 2018 85.48% 172.51% 26.04 29.17 59.25% 82.56% 37 15.0% 0.2% 20.0% 5.19 30.5% 97.06% 6.72% 0 0 4.66 0.00 3 65.43% Yes

Dec 2018 83.70% 171.90% 26.04 31.08 59.40% 84.04% 36 14.3% 0.0% 20.0% 5.19 30.5% 93.75% 10.71% 0 0 1.44 2.88 3 36.92% Yes

Ward 8 -Freeman

Oct 2018 93.37% 88.66% 30.98 27.70 54.16% 86.55% 7 8.3% 8.9% 31.6% 7.78 47.4% 70.64% 19.24% 0 0 8.97 1.49 7 73.02% Yes

Page 1444



CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Ward 8 -Freeman

Nov 2018 104.40% 94.74% 30.98 27.26 57.62% 79.26% 8 8.3% 9.5% 22.0% 4.82 29.4% 90.38% 10.33% 0 0 17.21 1.72 11 54.29% Yes

Dec 2018 83.00% 121.51% 30.98 30.39 55.29% 73.41% 36 8.3% 6.3% 22.0% 4.82 29.4% 98.70% 5.36% 0 0 14.17 3.15 11 53.62% Yes

Page 1545


Urology and Renal Services

Area Month

RNFill

Rate

CareStaffFill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

EAS - Freeman

Oct 2018 N/A N/A 14.10 N/A 37.79% 11.1% 4.1% 9.4% 1.09 11.8% 70.59% 10.14% 0 0 0.00 0.00 0 N/A No

Nov 2018 N/A N/A 14.10 N/A N/A 30.95% 11.1% 1.9% 2.3% 0.09 1.0% 66.67% 4.26% 0 0 0.00 0.00 0 N/A No

Dec 2018 N/A N/A 14.10 N/A 16.59% 17.6% 3.1% 2.3% 0.09 1.0% 75.00% 0.00% 0 0 0.00 0.00 0 N/A No

Urology Clinic -Freeman

Oct 2018 N/A N/A 12.54 N/A N/A 7.7% 14.5% 16.9% 1.80 25.9% N/A 2.95% 0 0 0.00 0.00 0 N/A No

Nov 2018 N/A N/A 12.54 N/A N/A N/A 7.1% 13.6% 8.9% 0.80 11.5% N/A 4.55% 0 0 0.00 0.00 0 N/A No

Dec 2018 N/A N/A 12.54 N/A N/A 6.7% 9.5% 8.9% 0.80 11.5% N/A 1.83% 0 0 0.00 0.00 0 N/A No

Ward 1 -Freeman

Oct 2018 08.28% 85.58% 14.80 13.54 73.29% 49.33% 0 33.3% 0.0% 0.0% 0.00 0.0% 100.00% 7.50% 0 0 0.00 0.00 0 8.72% No

Nov 2018 02.37% 86.08% 14.80 17.39 71.51% 33.19% 0 33.3% 5.1% 11.7% 1.32 15.5% N/A 1.01% 0 1 0.00 0.00 0 11.11% No

Dec 2018 07.49% 101.36% 14.80 16.71 69.63% 59.17% 1 33.3% 0.8% 11.7% 1.32 15.5% N/A 0.88% 0 0 14.08 0.00 1 6.16% No

Ward 2 -Freeman

Oct 2018 01.60% 97.61% 31.38 27.42 61.56% 77.74% 2 3.3% 0.2% 6.4% 0.50 3.0% 85.19% 2.36% 0 0 5.53 0.00 4 24.14% Yes

Nov 2018 94.56% 101.24% 31.38 21.39 59.04% 72.61% 8 3.2% 4.0% 6.4% 0.50 3.0% 64.00% 0.22% 1 0 7.67 1.53 6 24.04% Yes

Dec 2018 96.49% 91.69% 31.38 24.70 62.04% 63.38% 5 3.3% 1.3% 1.7% 1.50 8.9% 50.00% 1.85% 0 0 8.94 0.00 5 28.65% Yes

Ward 32 -Freeman

Oct 2018 90.53% 72.57% 48.99 40.04 81.64% 96.11% 26 4.2% 4.8% 7.0% 4.02 12.0% 100.00% 9.57% 0 0 4.76 2.38 6 0.00% Yes

Nov 2018 89.07% 99.40% 48.99 35.30 76.14% 94.92% 30 4.2% 7.2% 7.0% 4.02 12.0% 93.88% 2.74% 0 0 9.95 0.00 8 13.75% Yes

Dec 2018 85.89% 88.01% 48.99 37.65 77.75% 82.62% 34 8.7% 8.4% 7.0% 4.02 12.0% 71.43% 3.65% 0 0 11.14 1.39 9 5.05% Yes

Ward 3 -Freeman

Oct 2018 89.64% 92.95% 30.74 24.99 59.67% 78.03% 15 30.8% 11.6% 14.8% 2.64 15.7% 75.86% 11.68% 0 2 1.39 0.00 1 12.50% No

Nov 2018 91.31% 99.51% 30.74 27.64 56.96% 70.94% 8 29.6% 10.6% 14.8% 2.64 15.7% 93.85% 1.24% 0 1 3.32 0.00 2 12.29% No

Dec 2018 91.59% 101.92% 30.74 25.15 57.38% 76.66% 12 30.8% 5.1% 17.8% 4.29 25.6% 96.97% 1.89% 0 0 2.99 0.00 2 8.92% No

Page 1646


Womens Services


CareStaff Fill

Rate

FundedEstablish

ment

SNCTEstablish

ment

Registered Nurse

Ratio (onshift)

WardOccupan

cyRed

FlagsStaff


VacancyRate

Band 5Vacant

Wte

Band 5Vacancy

Rate


Bank &Overtime

C.difficile


s


PressureUlcers

per 1,000bed days

Falls &Pressure

Ulcers

Friends &Family

ResponseRate

SBRSister

Birthing Centre- RVI

Oct 2018 91.41% 99.39% 21.62 82.78% 50.54% 23 4.3% 3.8% 7.4% N/A 42.86% 2.54% 0 0 0.00 0.00 0 1.75% No

Nov 2018 96.03% 101.52% 21.62 N/A 83.18% 46.39% 15 4.3% 3.4% 10.2% N/A 45.24% 0.93% 0 0 0.00 0.00 0 104.21% No

Dec 2018 91.61% 101.17% 21.62 82.56% 39.25% 24 4.3% 5.3% 10.2% N/A 42.86% 0.93% 0 0 0.00 0.00 0 75.79% No

Delivery Suite -RVI

Oct 2018 99.44% 111.76% 156.45 82.01% 49.31% 20 3.3% 5.1% 2.0% 0.74 13.4% 38.60% 1.78% 0 0 0.00 0.00 0 0.00% No

Nov 2018 98.90% 110.89% 156.45 N/A 82.03% 43.57% 18 3.3% 5.5% 2.7% 0.74 13.4% 24.66% 2.99% 0 0 0.00 0.00 0 0.00% No

Dec 2018 93.86% 112.11% 156.45 80.97% 40.90% 38 1.7% 6.1% 2.6% 0.74 13.4% 18.75% 1.04% 0 0 2.82 0.00 1 0.00% No

Ward 32/33 -RVI

Oct 2018 97.97% 104.12% 54.43 49.01% 120.97% 16 6.6% 7.2% 10.9% N/A 53.25% 5.79% 0 0 0.63 0.00 1 0.00% No

Nov 2018 98.04% 99.69% 54.43 50.12% 114.37% 17 8.3% 10.2% 10.9% N/A 56.12% 0.04% 0 0 0.00 0.00 0 0.00% No

Dec 2018 96.05% 94.06% 54.43 51.10% 96.39% 14 8.6% 11.4% 10.5% N/A 38.89% 0.50% 0 0 0.00 0.00 0 0.00% No

Ward 32 - RVINov 2018 N/A N/A 0.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 0 0.00 0.00 0 N/A No

Ward 33 - RVINov 2018 N/A N/A 0.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 0 0.00 0.00 0 N/A No

Ward 34 - RVI

Oct 2018 99.43% 45.25% 20.64 81.95% 69.59% 1 0.0% 12.2% 6.3% N/A 73.47% 7.56% 0 0 0.00 0.00 0 N/A No

Nov 2018 97.73% 44.87% 20.64 N/A 81.84% 70.48% 4 0.0% 10.0% 5.9% N/A 61.70% 0.63% 0 0 0.00 0.00 0 N/A No

Dec 2018 91.02% 42.35% 20.64 81.82% 70.05% 0 0.0% 20.2% 10.7% N/A 41.79% 0.19% 0 0 0.00 0.00 0 N/A No

Ward 35 - RVI

Oct 2018 90.31% 77.34% 114.44 91.83% 83.32% 51 4.9% 3.4% 6.5% 6.99 9.4% 100.00% 1.55% 0 0 0.00 0.00 0 N/A No

Nov 2018 95.36% 75.04% 114.44 N/A 92.44% 85.73% 49 5.7% 6.2% 2.4% 2.26 3.0% 100.00% 2.80% 0 0 0.00 0.00 0 N/A No

Dec 2018 91.87% 70.37% 114.44 92.63% 83.35% 42 5.8% 5.5% 2.2% 2.08 2.8% 100.00% 1.72% 0 2 0.00 0.00 0 N/A No

Ward 40 - RVI

Oct 2018 98.42% 118.51% 41.73 15.05 68.35% 52.20% 9 8.9% 2.0% 12.4% 3.53 17.3% 90.00% 15.67% 0 0 0.00 2.81 1 10.53% No

Nov 2018 98.13% 126.55% 41.73 21.16 66.88% 43.03% 8 6.5% 1.8% 11.0% 2.53 12.4% 89.91% 4.43% 0 0 3.52 0.00 1 2.58% No

Dec 2018 92.67% 116.92% 41.73 21.92 67.55% 35.92% 11 6.5% 3.5% 11.0% 2.53 12.4% 80.77% 3.45% 0 0 0.00 0.00 0 3.80% No

Page 1747


48

Appendix i

December 2018

Healthcare-Associated Infections Report

49

Healthcare-Associated Infection Report December 2018

0

10

20

30

40

50

60

70

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

MRSA Yearly Trend

0

1

2

3

4

5

6

7

8

9

10

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

MRSA Bacteraemia - Cumulative Performance April 2018 to March 2019

Cumulative Actual

0

10

20

30

40

50

60

70

80


C. difficile - Cumulative Performance April 2018 to March 2019

Cumulative Local Objective Cumulative ActualCumulative Contract

Objective: ≤76

0

100

200

300

400

500

600

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

C. difficile Yearly Trend

0.00

5.00

10.00

15.00

20.00

25.00

30.00


C.difficile Monthly Incidence Rates Per 100,000 Bed Days December 2018

HA C.diff per 100,000 Bed Days National Average/Trust Target

0

5

10

15

20

25


Gram Negative Bacteraemia Month on Month Performance December 2018

E. coli Klebsiella Pseudomonas

0

10

20

30

40

50

60

70

80

90

100

110


MSSA Bacteraemia - Cumulative Performance Against Trajectory December 2018

2017/18 Cumulative 2018/19 Cumulative Local Target

0

5

10

15

20

25

30

35

40


C. difficile - Medicine December 2018

Medicine 2017/18 Medicine 2018/19

0

5

10

15

20

25


MSSA Bacteraemia - Cardiothoracic December 2018

Cardiothoracic 2017/18 Cardiothoracic 2018/19

Objective: zero tolerance

Page (1)

50

Agenda item: A8(iv)

IPC indicators (reported to DH)

MRSA Bacteraemia - non-Trust 0 0 0 0 0 0 2 0 1 3

MRSA Bacteraemia - Trust-assigned (objective 0) 0 n 0 n 1 n 0 n 1 n 0 n 0 n 0 n 0 n 2 n

MRSA HA acquisitions 3 5 4 4 4 4 2 4 2 32

MRSA Elective Screening Compliance (%) - - - - - - - - - -

MRSA Emergency Screening Compliance (%) - - - - - - - - - -

MSSA Bacteraemia - post-48 Hours Admission 15 n 10 n 5 n 9 n 6 n 12 n 9 n 3 n 7 n 76 n

E coli Bacteraemia - post-48 Hours Admission 20 20 18 16 9 14 10 13 19 139

Klebsiella Bacteraemia - post-48 Hours Admission 6 7 13 8 4 7 9 6 10 70

Pseudomonas Bacteraemia - post-48 Hours Admission 6 3 1 4 3 1 3 1 2 24

C.diff - Hospital Acquired (objective 76 or fewer) 5 n 4 n 6 n 8 n 10 n 7 n 11 n 7 n 2 n 60 n

C.diff - cases appealed 0 1 0 3 6 1 2 3 0 16

C.diff - appeals successful 0 1 0 3 6 1 2 3 0 16

C.diff related death certificates 1 0 0 0 0 0 0 0 0 1

Part 1 1 0 0 0 0 0 0 0 0 1

Part 2 0 0 0 0 0 0 0 0 0 0

Periods of Increased Incidence (PIIs)

MRSA Periods of Increased Incidence (PIIs) - - - 1 - - - 1 - 2

Patients affected - - - 4 - - - 2 - 6

C.diff Periods of Increased Incidence (PIIs) 1 - - 1 3 - 3 - - 8

Patients affected 5 - - 4 6 - 6 - - 21

Other Organisms Periods of Increased Incidence (PIIs) - - - - - - - - - 0

Patients affected - - - - - - - - - 0

Outbreaks

Norovirus Outbreaks 2 - - - - - - 2 4 8

Patients affected (total) 26 - - - - - - 24 20 70

Staff affected (total) 8 - - - - - - 11 11 30

Bed days losts (total) 138 - - - - - - 60 155 353

Other Outbreaks 4 2 - - - 1 - - - 7

Patients affected (total) 3 13 - - - 3 - - - 19

Staff affected (total) - 6 - - - 0 - - - 6

Bed days losts (total) 0 77 - - - 4 - - - 81

C.diff Transit and Testing Times Target <18hrs

Trust Specimen Transit Time 11:07 12:55 11:13 11:31 12:45 11:39 10:19 10:23 13:30 11:42

Laboratory Turnaround Time 03:02 03:52 05:01 05:03 04:50 04:15 03:58 02:37 02:53 03:56

Total to Result Availability 14:09 n 16:47 n 16:14 n 16:34 n 17:35 n 15:54 n 14:17 n 13:00 n 16:23 n 96.52% n

Hygiene Indicators/Audits (%)

CAT Trust Total N/A 96.50% n N/A 96.74% n N/A 96.29% n N/A 96.53% n N/A 96.52% n

Hand Hygiene Opportunity N/A 98.82% n N/A 99.88% n N/A 98.92% n N/A 99.40% n N/A 99.26% n

Hand Hygiene Technique N/A 98.58% n N/A 99.28% n N/A 98.44% n N/A 98.20% n N/A 98.63% n

Cleanliness audits N/A 97.57% n N/A 98.22% n N/A 97.45% n N/A 97.31% n N/A 97.64% n

Infection Control Mandatory Training (%)

Infection Control 83% n 83% n 84% n 86% n 87% n 87% n 88% n 88% n 89% n 86% n

Aseptic Non Touch Technique Training (%)

ANTT (M&D staff only) 26% n 26% n 33% n 34% n 36% n 35% n 47% n 48% n 49% n 37% n

Jan Feb Mar Cumulative

Feb Mar Average

Average

Feb

Feb

Cumulative

Sept Oct Nov Dec JanApril May June July Aug

June

MayApril

April

Healthcare-Associated Infection Report December 2018

June

June

April May June

May

May

June

April

July

JulyApril May

April May

July

June

Aug Sept Oct Nov

Oct

Sept Oct

Sept

Cumulative

Cumulative

Average

Jan

Nov

Nov

JanNov

Feb MarJan

Feb

Feb

Mar

Mar

Dec

Aug

Aug

DecSept

DecOct

Oct

Sept

July Aug JanDec MarNovSept

July MarJan

Dec

Dec

July

Nov

Oct

Aug

Aug

Page (1)

51

Pages included WRES

APPENDIX Agenda item A10

52

Pages included Raising Awareness | Staff awareness sessions during 2017 - 2018

LGBT History Month | February 2017 – Staff and patient engagement points, Emotional Intelligence, Film

screening Losses sessions

Transgender Day of Visibility | March 2017– used social media too

raise awareness

Equality and Diversity Week 2017 | May

2017 – staff network drop in session, Bullying and Harassment Awareness Session, rainbow Flag raised, staff/patient engagement points

IDAHOBIT | May 2017, rainbow flag raised

Newcastle Pride| July

2017 – stall in the Market Place

Trans Lives Matter Conference | May 2017

–developed in partnership with local organisations supporting

trans people with the aims of creating partnerships across

Public Sector organisations to address trans inequalities.

53


Black History Month | October 2017 – Multicultural ‘Lunch & Learn’ with the LGBT Fed – ‘How would it Feel?’,

Talk by Ranjana Bell, member of an Employment Tribunal and Chair of the CPS Scrutiny Panel for Racist and Religious hate

crime, screening of Hidden Figures and offered Tackling Racism Training by Show Racism the Red Card.

Transgender Day of Remembrance | November 2017 – Cannon Rachel Mann – ‘Respecting

Transgender People in a Prejudiced World’

UK Disability History Month | December 2017 – Screening of ‘Unrest’ and

talk by Professor Julia Newton about ME.

LGBT History Month | February 2018 – Count your

Losses sessions

Transgender Day of Visibility | March 2018

– ‘Say What?’ A session by Lewis Latimer on the use of

language, Trans Flag raised

International Day for the Elimination of

Racial Discrimination | April 2018 – Multicultural

‘Lunch & Learn’ and bullying and harassment awareness session.

54


Equality and Diversity Week 2018 | May 2018 – Bullying and Harassment in the Workplace, Gender

Identity Awareness, HIV Awareness, Show Racism the Red Card – LGBT Hate Crime, Positive Prospective of Disability in the

Workplace, Multilingual Progressive Muscle Relaxation, staff engagement

Time to Change| May 2018 – Pledged to change the

way we think and act about mental health at work signed

Gender Identity Training for Senior

Mangers| June 2018 – facilitated by Be North providing an

overview of gender diverse people and communities and the

contemporary issues they face within the context of health care

Newcastle Pride| July 2018 – stall in the Market Place

.

IDAHOBIT | May 2018, rainbow flag raised

Black History Month | October 2018 – Chi Onwurah – BAME

Leadership Talk, Lyn Cole Challenges

and Reflections for minority ethnic

people working in England, staff

engagement points

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LGBT History

Month | February 2019 –

Count your Losses sessions, A

Day in the Life of a Chaplain,

Rainbow Flag, Role models

Better Health at Work| November 2018 –

Continuing Excellence Assessment

International Day of People with

Disabilities| engagement points for staff and patients

Trans Lives Matter Conference | November 2018 – 2nd Trans Lives Conference in partnership

with other NHS and third sector partners

Transgender Day of Visibility | November 2018 –

use of social media to promote and staff engagement points

Hate Crime Awareness Conference| October 2018 – representatives

attended the event organised by Northumbria Police

Medical School EDI Leads Conference| October 2018 – member of

the staff network presented date relating to WRES

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Newcastle Hospitals - Home - TRUST BOARD of... · 2020-06-09 · Miss Kate Elizabeth Carney, MBChB Edinburgh 2007, BSc (Hons) Edinburgh 2004, MRCS Edinburgh 2010. ChM General Surgery

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