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Trust Board Papers
Isle of Wight NHS Trust
Board Meeting in Public (Part 1)
to be held on
Wednesday 26th March 2014
at
09.30am - Conference Room—Level B
St. Mary’s Hospital, Parkhurst Road,
NEWPORT, Isle of Wight, PO30 5TG
Staff and members of the public are welcome
to attend the meeting.
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Meeting in public on 26th March 2014 Isle of Wight NHS Trust
Board – Page 1
Please note Change of Venue
The next meeting in public of the Isle of Wight NHS Trust Board
will be held on Wednesday 26th March 2014 commencing at 09:30hrs.at
the INNOVATION CENTRE, ST CROSS BUSINESS PARK, NEWPORT, Isle of
Wigh, Staff and members of the public are welcome to attend the
meeting. Staff and members of the public are asked to send their
questions in advance to [email protected] to ensure that as
comprehensive a reply as possible can be given.
AGENDA Indicative Timing
No. Item Who Purpose Enc, Pres or Verbal
09:30 1 Apologies for Absence, Declarations of Interest and
Confirmation that meeting is Quorate
1.1 Apologies for Absence: Andy Heyes, Interim Director of
Planning, ICT & Integration.
Chair Receive Verbal
1.2 Confirmation that meeting is Quorate Chair Receive Verbal No
business shall be transacted at a meeting of the Board
of Directors unless one-third of the whole number is present
including:
The Chairman; one Executive Director; and two Non-Executive
Directors.
1.3 Declarations of Interest Chair Receive Verbal 09:35 2
Patients Story 2.1 Presentation of this month's Patient Story CEO
Receive Pres 09:55 3 Minutes of Previous Meetings
3.1 To approve the minutes from the meeting of the Isle of Wight
NHS Trust Board held on 26th February 2014 and the Schedule of
Actions.
Chair Approve Enc A
3.2 Chairman to sign minutes as true and accurate record Chair
Approve Verbal 3.3 Review Schedule of Actions Chair Receive Enc
B
10:05 4 Chairman’s Update 4.1 The Chairman will make a statement
about recent activity Chair Receive Verbal 10:10 5 Chief
Executive’s Update
5.1 The Chief Executive will make a statement on recent local,
regional and national activity.
CEO Receive Enc C
5.2 Employee Recognition of Achievement Awards CEO Receive Pres
5.3 Employee of the Month CEO Receive Pres
10:20 6 Quality and Performance Management 6.1 Performance
Report EDNW Receive Enc D 6.2 Update on Data Quality Underpinning
KPIs EDF Receive Enc E 6.3 Minutes of the Quality & Clinical
Performance Committee held
on 19th March 2014 QCPC Chair
Receive Enc F
6.4 Minutes of the Finance, Investment & Workforce Committee
held on 19th March 2014
FIWC Chair
Receive Enc G
6.5 Board Walkabouts Action Tracker EDNW Receive Enc H 6.6 Staff
Story EDNW Receive Pres 11:20 COMFORT BREAK 11:30 7 Strategy and
Business Planning 7.1 Business Case -Endoscopy EDNW Approve Enc
I
7.2 Workforce Strategy EDNW Approve Enc J 7.3 Operating Plan
2014/15 & 2015/16 inc Corporate Objectives
2014 (Vision, Objectives & Critical Success Factors) CEO
Approve Enc K
7.4 Formal Approval of Financial Budgets for 2014/15 EDF Approve
Enc L
7.5 FT Programme Update FTPD Receive Enc M 7.6 FT Self
Certification FTPD Approve Enc N
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Meeting in public on 26th March 2014 Isle of Wight NHS Trust
Board – Page 2
12:20 8 Governance and Administration
8.1 Board Assurance Framework (BAF) Monthly update Comp Sec
Approve Enc O
8.2 Standing Orders, Scheme of Delegation, Standing Financial
Instructions Update
Comp Sec
Approve Enc P
8.3 Health & Safety Policy EMD Approve Enc Q
8.4 Notes of the FT Programme Board held on 25th February 2014
CEO Receive Enc R 8.5 Minutes of the Charitable Funds Committee
held on 11th March
2014 Chair CFC
Receive Enc S
12:55 9 Matters to be reported to the Board Chair 9.1 10 Any
Other Business Chair 11 Questions from the Public Chair To be
notified in advance 12 Issues to be covered in private. Chair
The meeting may need to move into private session to discuss
issues which are considered to be ‘commercial in confidence’ or
business relating to issues concerning individual people (staff or
patients). On this occasion the Chairman will ask the Board to
resolve:
'That representatives of the press, and other members of the
public, be excluded from the remainder of this meeting having
regard to the confidential nature of the business to be transacted,
publicity on which would be prejudicial to the public interest',
Section 1(2), Public Bodies (Admission to Meetings) Act l960.
The items which will be discussed and considered for approval in
private due to their confidential nature are:
Earl Mountbatten Hospice (EMH) 2014/15 contract Isle of Wight
NHS Trust Contracting Strategy 2014/15 and beyond Shared Business
Service – Contract renewal Hip, Knee & Trauma Prosthesis –
Ratification Report IDAS Re-tender Strategic Estates Partner -
Update Reports from Serious Incidents Requiring Investigation
(SIRIs) Safeguarding Update Employee Relations Issues Notes of the
Audit & Corporate Risk Committee Annual
Performance Review meeting held on 11th March 2014
The Chairman or Chief Executive will indicate if there are any
other issues which may be discussed in private without entering
into detail about them. Members of the public, the press and
members of staff will then be asked to leave the room.
13:00 13 Date of Next Meeting: The next meeting of the Isle of
Wight NHS Trust Board to be held in public is on Wednesday 30th
April 2014 in the Conference Room at St. Mary’s Hospital,
Newport, Isle of Wight, PO30 5TG.
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 1
Minutes of the meeting in Public of the Isle of Wight NHS Trust
Board
held on Wednesday 26th February 2014 in the Conference Room, St
Mary’s Hospital, Newport, Isle of Wight
PRESENT: Danny Fisher Chairman Karen Baker Chief Executive (CEO)
Mark Pugh Executive Medical Director (EMD) Chris Palmer Executive
Director of Finance (EDF) Alan Sheward Executive Director of
Nursing & Workforce (EDNW) Nina Moorman Non Executive Director
Charles Rogers Non-Executive Director (Senior Independent
Director) Peter Taylor Non-Executive Director Sue Wadsworth
Non-Executive Director
In Attendance: Jessamy Baird Designate Non-Executive Director
David King Designate Non-Executive Director Mark Price FT Programme
Director & Company Secretary Andy Shorkey Foundation Trust
Programme Management Officer
(for item 14/071) Jackie Skeel Assistant Director for
Organisational Development (for
item 14/068) Keith Morey Civil Contingencies Manager (for item
14/070) Brian Johnston Head of Corporate Governance & Risk
Management
(for item 14/074) Sally Bailey Midwife Sonographer (for item
14/063) Pamela George Sister NICU (for item 14/063) Monika
Driscoll-Abbasi Midwife (for item 14/063) Carole Hewison Midwife
(for item 14/063) Joyce Brooks Midwife (for item 14/063) Yvonne
Harris Clinical Lead/Midwife (for item 14/063) Sarah Cox
Housekeeper, Rehabilitation Team (for item 14/064) Natalie Mew
Sister, Rehabilitation Team (for item 14/064) Marie Gasior Matron,
Rehabilitation/Stroke (for item 14/064) Sarah Hayward Business
Manager, Planned Directorate (for item
14/063) Martin Robinson Associate Director, Planned Directorate
(for item 14/063) Richard Knowles Head of Prison Healthcare (for
item 14/063) Diane Adams Radiology & Cancer Manager (for item
14/063) William King Consultant Radiologist (for item 14/063) Lisa
Street Project Manager (for item 14/063) Observers: Chris Orchin
Health Watch Nancy Ellacott Patient Council Emma Topping
Communications & Engagement Manager Alison Toney Communications
& Engagement Officer Caroline Chipperfield Director, Thames
Valley & Wessex Leadership
Academy Sarah Goodson Senior Consultant, Kings Fund Minuted by:
Lynn Cave Trust Board Administrator
Members of the Public in attendance:
There were two members of the public present
Enc A
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 2
Minute No.
14/057 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND
CONFIRMATION THAT THE MEETING IS QUORATE
The Chairman welcomed everyone to the meeting. Apologies for
absence were received from Andy Heyes – Interim Director of
Planning, ICT & Integration and Jane Tabor, Designate
Non-Executive Director. Apologies were also received from Andrew
Turner MP, Cllr Lora Wilcox and Cllr Gordon Kendall There were no
declarations of interest. The Chairman announced that the meeting
was quorate.
14/058 PATIENT STORY The Chief Executive introduced the patient
story. She advised that there was no film this
month as the planned audio recording was not of suitable audio
quality to broadcast. Therefore, the story would be covered using a
slide presentation. The Executive Director of Nursing &
Workforce explained that the patient concerned had been on
Alverstone Ward and had provided the following feedback:
∑ Mixed experience – good and bad ∑ “Flexible visiting times” on
the ward – but not in their experience! ∑ Wanted to see my husband
when I came back from theatre but was not allowed ∑ Issues with
access to side rooms and privacy and dignity ∑ Some staff need to
smile more – come across abrupt / rough ∑ Healthcare assistants
good ∑ Food is good
The response as a result of this Patient Story is as
follows:
• Open visiting not in place due to admission and theatre times
– but ward does try to accommodate a flexible approach to visiting
for patients with a specific need, as in this ladies case.
• On return from theatre it is essential to ensure that the
patient is settled and comfortable and observations taken prior to
allowing the relative at the bedside.
• Minimal side rooms are available which are allocated dependent
on clinical need. • Side rooms do have blinds on the door and
windows. Ward Sister is considering
the purchase of ‘engaged signs’ for the side rooms • Patient did
not raise any concerns at the time with the Ward Sister, but did
speak
at length to Matron. • Patient and her husband has been asked
back to relay their experience to the
ward staff directly. The Executive Director of Nursing &
Workforce explained that a “Welcome to the Ward” booklet was being
introduced which would provide information to the patient on a
range of areas including who to talk to if they have any concerns.
Peter Taylor raised the question of the suitability of the Diabetic
options within the patients menu choices. The Executive Director of
Nursing & Workforce confirmed that the dieticians would be
asked to review the current choices. Jessamy Baird also confirmed
that this had been discussed at the Quality & Clinical
Performance Committee at which an update from the Executive
Director of Nursing & Workforce was pending. Action Note: The
Executive Director of Nursing & Workforce to follow up with the
dieticians and report back on the outcome of the review of diabetic
patient meal options.
Action by: EDNW
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 3
Peter Taylor also asked about the patient information boards
above the beds and could these have the consultants name and lead
nurse shown. The Executive Director of Nursing & Workforce
confirmed that these were in place in some areas and that the
remaining areas would be completed shortly. Action Note: The
Executive Director of Nursing & Workforce to update the Board
on the progress of the installation of patient information
boards.
Action by: EDNW Sue Wadsworth asked for an update on the Ward
Information Boards. The Executive Director of Nursing &
Workforce confirmed that the format of these was being trialled on
Appley Ward and the final touches were being made to the monthly
performance notice by the PIDS team. They would then be rolled out
across the Trust. Charles Rogers stated that he was pleased to see
that the patient would be returning to give direct feedback to the
ward team. The Chief Executive stated that it was important to note
that the patient had received excellent clinical treatment but that
the patients experience should also be about excellent customer
care and good communication which is something that the Trust is
striving to promote. Sue Wadsworth commented on how useful it was
that the Action Plan had been shown on screen and requested that
this be done for all future Patient Stories brought to the Board.
Action Note: The Executive Director of Nursing & Workforce to
arrange for a summary slide to be prepared for all Board Patient
Stories.
Action by: EDNW The Isle of Wight NHS Trust Board received the
Patient Story
14/059 MINUTES OF PREVIOUS MEETING Minutes of the meeting of the
Isle of Wight NHS Trust Board held on 29TH January 2014
were approved. Jessamy Baird asked that for clarity it should be
noted that Min No 14/037(v) is an extension of Action No. TB/054
and should be read in conjunction with the updates shown in the
Action Plan. Proposed by Peter Taylor and seconded by Charles
Rogers The Chairman signed the minutes as a true and accurate
record.
14/060 REVIEW OF SCHEDULE OF ACTIONS
a) TB/054 – Discharge Summaries – The Executive Medical Director
confirmed that in January 2014 100% of discharge summaries had been
completed by the required date and it was planned for all patients
to leave hospital with their discharge summary. Peter Taylor
commented that this problem had been ongoing for some considerable
time and queried if there should be a specific Key Performance
Indicator (KPI) within the Performance report to show this. The
Executive Medical Director advised that there was a KPI for the
clinical directorates and this was monitored at the monthly
meetings. The Chairman stated that it was important to note that
considerable improvements had been made over the period and the
critical factor was having full electronic records in place.
b) TB/055 – Safe Staffing Levels – The Executive Director of
Nursing & Workforce confirmed that these would all be completed
by the end of March.
c) TB/058 – Funding for the Covered Walk from Helipad – The
Executive Director of Finance confirmed that £58k had been agreed
for this project.
d) TB/059 – Flu Incentives - The Executive Director of Nursing
& Workforce confirmed that the HR team were working on the
scheme at present.
e) TB/061 – Board Walkabout Action Tracker – this item is due
for 30th April Board meeting.
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 4
f) TB/069 – Long Term Financial Model (LTFM) –The Executive
Director of Finance confirmed that the final document would be
taken to the next Finance, Investment & Workforce Committee in
March.
g) TB/071 – Palliative Care/Earl Mountbatten Hospice – it was
confirmed that this would be discussed with the Designate
Non-Executive Directors after Board.
h) TB/073 – Patient Story Action Tracker – this item is due for
30th April Board meeting.
The Isle of Wight NHS Trust Board received the Review of
Schedule of Actions
14/061 CHAIRMAN’S UPDATE The Chairman reported on the following
items:
a) Care Quality Commission (CQC) visit – The Chairman confirmed
that the CQC
inspection was likely to take place in early June. He stated
that the organisation should be ready to be inspected at any time
and that it should be business as usual rather than a special
occasion.
b) Members – The Chairman reported that there had been a
successful Medicine for
Members event which had received good attendance from members
and also that the first newsletter had been published. The aim now
is to keep members interested and engaged.
c) Peter Taylor – The Chairman advised that it was with sadness
that he had to
advise the Board of Peter Taylor’s retirement as a Non-
Executive Director. He confirmed that Peter would continue all his
current duties until after the 2013/14 accounts had been approved
in early June.
d) Non-Executive Director recruitment – The Chairman stated
following advice
from the Trust Development Authority the post vacated by Peter
Taylor’s departure will be filled by a candidate with good
financial experience. He confirmed that it would go out to
advertisement this week with a closing date of 24th March.
Interviews would be held on 10th April.
The Isle of Wight NHS Trust Board received the Chairman’s
Update
14/062 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented
her report. Areas covered were:
National
• Mental health crisis care concordat • care.data update
Local • Care Quality Commission inspection • Health watch
inspections published • Isle of Wight Children’s Trust • Our future
workforce given careers advice • Awards
Peter Taylor pointed out that the Outside Gym had been funded by
Charitable Funds. He also congratulated the Chief Executive on her
effort to promote cycling amongst staff. The Isle of Wight NHS
Trust Board received the Chief Executive’s Update
14/063 EMPLOYEE RECOGNITION OF ACHIEVEMENT AWARDS The Chief
Executive presented Employee Recognition of Achievement Awards:
This
month under the Category:
a) Quality Care & Innovation – Dr William King b) Going the
Extra Mile – Lisa Street & Sarah Hayward c) Long Service –
Richard Knowles, Monika Driscoll-Abbasi, Sally Bailey, Joyce
Brooks, Carole Hewison and Pamela George
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 5
The Chief Executive congratulated all recipients on their
achievements. The Isle of Wight NHS Trust Board received the
Employee Recognition of Achievement Awards
14/064 EMPLOYEE OF THE MONTH • The Chief Executive presented the
Employee of the Month award to Sarah Cox
who is a Housekeeper within the Rehabilitation team. She
confirmed that Sarah had been nominated for her excellent work by
patients who felt she should be recognised for her work. The Chief
Executive congratulated her. The Isle of Wight NHS Trust Board
received the Employee of the Month Award
QUALITY AND PERFORMANCE MANAGEMENT
14/065 PERFORMANCE REPORT The Executive Director of Finance
presented the Performance report for December.
Highlights
∑ Operational performance is again very good with no Red rated
categories ∑ All Cancer indicators maintaining year to date
position ∑ Emergency Care 4 hour standard performance remains above
target ∑ No grade 4 pressure ulcers reported in hospital during
January ∑ No of C.Diff cases on track to achieve year end stretch
target
Lowlights
∑ 2nd Hospital acquired MRSA bacteraemia case identified YTD ∑
Staff absenteeism due to sickness remains above target. ∑ Formal
complaints show rise in January ∑ VTE assessment recording below
plan ∑ CIP targets remain challenging
Key Points:
a) Patient Safety, Quality & Experience: Areas of particular
focus regarding patient safety, quality and experience include:
Pressure ulcers: We continue to under achieve our planned
reduction across all grades of pressure ulcers, both in the
hospital setting and the wider community. A range of actions
continues to support hospital and community staff.
Venous Thrombo-Embolism (VTE) risk assessment: The recorded
percentage of patients that have a VTE risk assessment increased
slightly but remains below target for January (90.8%). The system
upgrade to enforce compliance has now been completed and improved
results are expected to be reflected in February.
Health Care Acquired Infection (HCAI): We are currently within
both our nationally set threshold and our local stretched target
for Healthcare Acquired Clostridium Difficile infection, remaining
at 6 YTD, with no cases reported during January. There was 1 case
of Healthcare Acquired MRSA bacteraemia identified in January, 2
YTD.
b) Operational Performance: Performance against our key
operational performance indicators is again mainly green for the
month with only 2 amber indicators.
We achieved 93% again this month against our stretched target of
95% for high risk TIA fully investigated and treated within 24
hours. Although still under achieving, we consistently exceed the
national target of 60%.
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 6
All cancer targets are again green for year to date, although
the provisional figures indicate 1 amber (Subsequent Drug Treatment
within 31 days) for January. This breach was due to patient choice.
Across all cancer measures, 18 of the 23 breaches this month were
patient led. A range of actions continue to maintain the
performance of these indicators.
c) Workforce: The total pay bill for January (£9.86m) is above
plan (£9.54m). The number of FTEs in post is also currently higher
than plan. The HR Directorate are closely monitoring and supporting
the Clinical directorates with their workforce plans, in particular
their control over their spend on variable hours.
Sickness absence increased slightly in January (3.86%) and
remains above plan. Specific problem areas are identified and
challenged at directorate performance review meetings.
d) Finance & Efficiency:
Overall we have slightly over-achieved our financial plans for
January and based on the new measure, the Continuity of Service
Rating, introduced by Monitor on 1st October 2013, our overall
rating is 4.
Despite recognising forward banked CIP schemes of £681k and
Trustwide Transformation schemes of £1,479k, the YTD CIP target of
£6,830k has not been achieved by £662k. In order to mitigate any
carry forward of CIP into 14/15 recurrent savings of £1,776k still
need to be identified.
The following areas were raised in discussion:
i. Pressure Ulcers – Peter Taylor requested an update on planned
action to reduce the number of ulcers. The Executive Medical
Director confirmed that the Tissue Viability team were going out
into the community to ensure competency of NHS staff, with
community nurses providing similar assessments in other areas. The
Executive Director of Nursing & Workforce stressed the need to
ensure that when staff visit a patient at home, that a full
assessment is carried out on all potential risk elements instead of
just attending to the specific area covered by the visit. He
confirmed that work was being undertaken with the local authority
and other providers. David King asked if this was being extended
into the private sector and the Executive Director of Nursing &
Workforce advised that this was not happening as yet but the plan
was to cover the entire island with a standard process. Charles
Rogers asked how progress would be reported, and Mark Price asked,
on behalf of Jane Tabor, if a deep dive on the area would be
covered. It was advised that this would be covered in depth by the
Quality & Clinical Performance Committee. Jessamy Baird stated
that patient education on the prevention of pressure ulcers was
important as was gaining their co-operation in notifying health
visitors if they have any concerns. The Executive Medical Director
advised that it was important to record any specific instructions
given to patients and to check their understanding before leaving
in order to effectively gain their compliance.
ii. Stroke/TIA Patients Declined Appointments – Sue Wadsworth
asked if having
a transportation problem should be a reason for declining an
appointment. She wondered why more flexibility was not available in
these incidences. The Executive Medical Director advised that if a
patient was unable to attend due to transportation issues this
would be included within the data and he stressed that nationally
we were in the top 10% and were doing very well within this
area.
iii. Benchmarking Update – David King asked why the percentage
of patients
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 7
admitted through A&E was higher than the national average.
The Executive Medical Director explained that it was due to the way
in which A&E was used. The data would include patients waiting
to be assessed and discharged within the day as well as those who
remain within the hospital for longer periods. He explained that
having the Beacon centre on site helped to filter these short term
patients down but did not exclude them completely. The Executive
Director of Nursing & Workforce confirmed that improved
ambulatory pathways to assess patients before they arrive could
help in reducing the numbers being admitted to MAU for less than
one day. He advised that within the new A&E unit there were two
spaces for ambulatory trolleys and also the refurbished MAU would
have a further 5 spaces which would assist in reducing the level of
admissions via A&E.
iv. Risk Register – David King asked for an update on why the
Safeguarding
Children Training was still on the register. The Executive
Medical Director advised that discussions with other local
providers were in progress to increase the level of face to face
training opportunities. Sue Wadsworth asked why this could not be
done via eLearning. The Executive Director of Nursing &
Workforce confirmed that level 1 training was via eLearning but
that level 2 training and above required face to face sessions. He
confirmed that a further 10 training sessions had been arranged and
discussions were in place with other Trusts to develop an eLearning
programme for level 2.
Jessamy Baird stated that some of the description of the risks
were very generic and could result in a permanent position on the
risk register. She asked if these could be reviewed. The Executive
Medical Director advised that when staff-assess a risk it is on a
local level which to them will seem a high risk but at Board level
it may not rate as high. The Executive Director of Nursing &
Workforce advised that the directorates had been asked to review
these more rigorously to ensure that appropriate risk scores were
made. Peter Taylor stated that he felt that this part of the
performance report needed further development. David King agreed
and stated that it should be showing the strategic imperative of
each to Board against operational and strategic risk. The Executive
Director of Finance confirmed that the Capital Investment Group did
undertake a full risk review on capital schemes. Peter Taylor
stated that an additional area showing the actions approved by the
Capital Investment Group would be helpful. Action Note: The
Executive Director of Finance to review possible additional data to
be included for future reports.
Action by: EDF Sue Wadsworth requested that an update on the
Ophthalmic Case note risk be brought to the Quality & Clinical
Performance Committee. Action Note: Executive Director of Nursing
& Workforce to arrange for a report to be presented at the
Quality & Clinical Performance Committee.
Action by: EDNW
v. Sickness Absence – Jessamy Baird asked if details of seasonal
variation could be shown in future reports. Charles Rogers advised
that these were reviewed at Finance, Investment & Workforce
Committee meetings and took into consideration the previous 3 years
statistics.
vi. KPI Finance – David King challenged the green rating for
Capital. He stated that in his experience he had not seen so much
money still to spend and so little time in which to achieve it. The
Executive Director of Finance agreed that the rating should perhaps
be amber, but assured the meeting that all the capital spend would
be achieved by the end of the financial year. Peter Taylor reminded
the meeting that the capital plan had changed mid-year and the
Executive Director of Finance agreed that this had caused some
delay. The Board agreed that the risk rating should be amber.
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 8
The Company Secretary tabled a question from Jane Tabor which
asked if next year’s capital spend report could show planned spend
by month or by quarter. The Executive Director of Finance confirmed
that the capital plan was already being prepared and would be
presented to the Finance, Investment & Workforce Committee. A
discussion took place surrounding how the capital plan would be
shown and how it would link to the Long Term Financial Model and
the Clinical Strategy, and it was agreed that capital spend would
be brought back to Board Seminar for more discussion. Action Note:
The Executive Director of Finance to prepare a presentation with
the Interim Director of Planning, ICT & Integration for Board
Seminar on the capital plan.
Action by: EDF/IDPII
vii. QIPP Programme Monitoring – Jessamy Baird asked if the use
of the work Senility was appropriate. The Executive Medical
Director confirmed that this was still used as an ICD101 coding
criteria.
viii. Falls - Charles Rogers asked if falls which fall outside
the category of “resulting in significant injury” could be shown.
The Chairman confirmed that this was a category which was included
within the Board Walkabout questionnaire and Sue Wadsworth
confirmed that these were also looked at in detail at the Quality
& Clinical Performance Committee (QCPC). The Executive Director
of Nursing & Workforce advised that a total review of the
annual total number of falls would be added to the agenda of the
QCPC. Action Note: Executive Director of Nursing & Workforce to
arrange for a full report on Falls to be presented at the QCPC
committee.
Action by: EDNW ix. Compliments – The Company Secretary asked on
behalf of Jane Tabor, if in
future the level of compliments could be added to the report.
The Executive Director of Finance confirmed that this was in hand
and would appear in the next report. Action Note: The Executive
Director of Finance to ensure that the level of compliments be
added to the performance report.
Action by: EDF The Isle of Wight NHS Trust Board received the
Performance Report
14/066 MINUTES OF THE QUALITY & CLINICAL PERFORMANCE
COMMITTEE Sue Wadsworth reported on the key points raised at the
last meeting held on 19th
February 2014.
a) Min No.14/052 - Special Measure Process Paper: The Deputy
Director of Nursing explained how special measures would work in
future and highlighted the issues and challenges identified by the
risk review
b) Min No.14/057 – Audit Results of Non-Medical Prescribing
Assessment: The Committee received an update on the results and
will receive this information annually
c) Min No.14/061 - Outpatient Appointments and Records Unit :
The Committee received an update on auto-discharge issues
d) Min No. 14/068 – Joint Safeguarding Steering Group Report:
The Committee received an update on the current status for Adult
and Children’s safeguarding including an overview of open
cases.
e) Min No. 14/073 – Health watch Visits – Summary Report: The
Committee received the summary report following the visits and
noted there were recommendations
1 The National Clinical Coding Standards ICD-10
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 9
f) Min No. 14/075 – TDA2 Self Certification: The Committee
challenged Board Statement 13 regarding the management capacity in
place but after debate concluded it could support compliance.
The Isle of Wight NHS Trust Board received the minutes of the
Quality & Clinical Performance Committee
14/065 MINUTES OF THE FINANCE, INVESTMENT & WORKFORCE
COMMITTEE Charles Rogers reported on the key points raised at the
last meeting held on 19th February
2014
a) Min No 14/026 – Workforce: The Committee received the draft
Workforce Strategy.
b) Min No 14/026 – Workforce: Overspend on pay through Bank
staff, Locums and overtime.
c) Min No. 14/027 - Financial Performance: The Committee
received assurance that based on the Month 10 position the end of
year surplus will be met.
d) Min No. 14/028 - Contracts Update: The Committee received a
detailed Contract Status report and timetable to provide assurance
that the Contracts/Heads of Terms would be signed by 28th February
deadline.
The Isle of Wight NHS Trust Board received the minutes of the
Finance, Investment & Workforce Committee
14/066 BOARD WALKABOUT ACTION TRACKER The Executive Director of
Nursing & Workforce presented the report and advised that
this
programme of Board visits had now been in operation for a year.
At the time of reporting, 177 visits have taken place (141
Clinical, 36 non-clinical), from these 170 actions have been
identified:
∑ 143 are complete, ∑ 11 are still within timescale, ∑ 16 remain
overdue against the original date for completion set, with 1
showing as
overdue against both board and directorate revised timescale,
these actions are progressing.
The Executive Director of Nursing & Workforce confirmed that
a number of the open actions were linked to the capital plan and
the work was currently being undertaken. He also advised that from
April the walkabout questionnaires would be based on the KLOE3
criteria for CQC4 inspections The Isle of Wight NHS Trust Board
received the Board Walkabout Action Tracker
14/067 PATIENT STORY ACTION TRACKER The Executive Director of
Nursing & Workforce confirmed that following discussion it
had
been agreed to withdraw this item from the agenda for this
meeting.
14/068 STAFF STORY The Executive Director of Nursing &
Workforce introduced the Assistant Director for
Organisational Development who would be presenting her story.
The Assistant Director for Organisational Development outlined her
development from leaving school with limited qualifications, to
joining the NHS via the staff bank in 2000. She outlined how,
through hard work and undertaking a range of qualifications, she
developed her teaching and management skills which she has used to
develop a wide range of learning opportunities for other staff, as
well as progressing professionally to her
2 Trust Development Authority 3 Key Lines Of Enquiry 4 Care
Quality Commission
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 10
current role. She stated that she hoped that her story would be
an inspiration to others to show that although they may not start
out with the best opportunities and qualifications, it is possible
to develop yourself to achieve greater attainment than would
originally have been predicted. Peter Taylor suggested that this
story might be useful to pass onto the schools as a role model for
what can be achieved. The Isle of Wight NHS Trust Board received
the Staff Story
STRATEGY AND BUSINESS PLANNING
14/069 2012 – 2013 REFERENCE COSTS The Executive Director of
Finance presented the outcome of the 2012/13 Reference Cost
Index which had been received from the Department of Health. She
explained that these figures were assessed on data a year in
arrears. She outlined how the index scores were arrived at and the
implication for the Island. She highlighted that there had been a
considerable amount of work carried out over the year to improve
the accuracy of the data to ensure that the index score was as
accurate as possible. Peter Taylor stressed how important Service
Line Reporting (SLR) was and the need for accurate input. The
Executive Director of Finance stated that SLR had been available
for the past 2 years and was now in the position to be able to be
used for decision making to a limited extent. The Company Secretary
asked, on behalf of Jane Tabor, if it would be possible for more
consideration to be given to this subject in a seminar. The Board
agreed this proposal. Action Note: The Company Secretary to arrange
for a seminar on Service Line Reporting and Reference Costs to be
added to the Board Seminar Forward Planner.
Action by: CS The Executive Director of Finance confirmed that
the Trust would be working closely with the Commissioners and other
outside bodies. The Isle of Wight NHS Trust Board received the
2012-13 Reference Costs
14/070 INCIDENT RESPONSE PLAN (EMERGENCY PREPAREDNESS, RELIANCE
& RESPONSE ASSURANCE ASSESSMENT)
The Civil Contingencies Manager presented the Incident Response
Plan and explained that this was a statutory requirement. He
outlined where there would be joint working with other agencies
including the Police and Fire Service. The Company Secretary
confirmed that this item had been covered in more depth at the
previous Board Seminar. It was confirmed that the full plan would
be added to the intranet for reference once approved by Board.
Proposed by Peter Taylor and seconded by Charles Rogers The Isle of
Wight NHS Trust Board approved the Incident Response Plan
14/071 BUSINESS PLANNING PROCESS The Foundation Trust Programme
Management Officer confirmed that the business
planning process was required by the Trust Development Authority
to be approved by the Board. This document lays out the processes
which will be used to develop the Operating Plan 2014/15 &
2015/16, and the full Integrated Business Plan (IBP) and its
supporting strategies. Proposed by Peter Taylor and seconded by Sue
Wadsworth The Isle of Wight NHS Trust Board approved the Isle of
Wight NHS Trust Business Planning Process
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 11
14/072 FT PROGRAMME UPDATE The FT Programme Director presented
the monthly update:
a) Timeline
∑ Chief Inspector of Hospitals visit will take place in June
2014 ∑ FT status achievable by March 2015
b) IBP/LTFM work ongoing to deliver draft for 4 April submission
∑ Detailed feedback received from TDA
c) Membership Recruitment campaign ∑ Current Membership at 3754.
∑ The membership data based has been reviewed and cleansed. ∑
“Medicine for Members” repeated 31 January 2014 ∑ Governor
development day held 10 February 2014
Nina Moorman stressed the importance that any anxiety the senior
management teams may have surrounding the Chief Inspector of
Hospitals inspection should not be transferred to the staff. The
Chief Executive stated that support would be given to staff to
prepare for this visit. The Executive Director of Nursing &
Workforce confirmed that it should be business as usual and this is
just what we do on a daily basis. The Isle of Wight NHS Trust Board
received the Foundation Trust (FT) Programme Update.
14/073 FT SELF CERTIFICATION The FT Programme Director presented
the monthly update stating that there was a slight
correction to Appendix 1B Condition G4 - change date from 31
January 2014 to 31 March 2014. Proposed by Charles Rogers and
seconded by Sue Wadsworth The Isle of Wight NHS Trust Board
approved the FT Self Certification
GOVERNANCE & ADMINISTRATION
14/074 BOARD ASSURANCE FRAMEWORK (BAF) DASHBOARD & SUMMARY
REPORT Head of Corporate Governance & Risk Management presented
the report and advised
that there were now no principal risks rated as Red, and 6 new
risks had been introduced in January. The Company Secretary asked,
on behalf of Jane Tabor, if risk CSF8.2 should remain as Amber
instead of the recommended upgrade to Green. A discussion to place
and it was agreed that this item would stay as Amber. Action Note:
CSF8.2 should remain as Amber instead of the recommended upgrade to
Green.
Action by: HCG Proposed by Sue Wadsworth and seconded by Peter
Taylor The Isle of Wight NHS Trust Board approved the Board
Assurance Framework (BAF) Dashboard & Summary Report
14/075 MINUTES OF THE AUDIT & CORPORATE RISK COMMITTEE
Peter Taylor reported on the key points raised at the last
meeting held on 4th February 2014
a) Min No. 14/007 - Annual Report & Quality Account
Timetable 2013/14: The editor when appointed should drive the
co-ordination of the Report with the respective committees to
ensure that production of the Report is aligned with Annual
Accounts and that a substantial draft Annual Report be available
for the Board Seminar on the 13th May 2014. A timetable slip would
be unacceptable this
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 12
year. b) Min No. 14/008 - Budget Setting Framework 2014/15: The
purpose of the
Budget Setting Framework is to ensure a sound and consistent
approach to budget setting and that realistic and deliverable
budgets are set and delivered.
c) Min No. 14/010 - Statement on Going Concern 2013/14:
Assurance could be provided to the Trust Board and External Audit
that the Going Concern concept had been reviewed and agreed that it
was appropriate for the Accounts to be prepared on that basis.
d) Min No. 14/016 - Internal Audit Service: Assurance could be
provided to the Trust Board on the continuity of the internal audit
service following the sale of Deloitte & Touche Public Sector
Internal Audit Limited to Mazars Limited.
The Isle of Wight NHS Trust Board received the minutes of the
Audit & Corporate Risk Committee
14/076 RECOMMENDATIONS FROM THE AUDIT & CORPORATE RISK
COMMITTEE
Peter Taylor presented the recommendations raised at the last
meeting held on 4th February 2014
a) Min No. 14/017 - Internal Audit Report – Payroll Workforce
Transactions – Limited Assurance: As a result of the continuing
concern over procedures within the HR Department, the Committee
recommend that a Risk Summit is undertaken on the HR
Department.
b) Min No. 14/021 - Consolidation of Charitable Fund Accounts:
The Committee
recommended not to consolidate Charitable Fund Accounts in the
2013/14 Trust Accounts for presentation to the Trust Board for
approval
c) Min No. 14/023 - Board Assurance Framework (BAF): The
Committee
recognised that significant improvement had been achieved during
the year and recommended that the in-year targets within the BAF be
used as the framework for the content of the Trust’s Annual
Report
The Executive Director of Nursing & Workforce advised that
in respect of recommendation a) shown above, a repeat audit would
be carried out by internal audit with an option of carrying out a
risk summit if deemed necessary. He had discussed this with the
Audit Committee members after their meeting on 4th February and
this had been agreed. It was confirmed that the internal audit
visit would be unannounced. Proposed by Nina Moorman and seconded
by Sue Wadsworth The Isle of Wight NHS Trust Board approved the
recommendations of the Audit & Corporate Risk Committee with
the caveat to (a) described in the minute above.
14/077 CONSOLIDATION OF CHARITABLE FUNDS ACCOUNTS
The Executive Director of Finance outlined the need for this
measure and formally requested that this be approved. Proposed by
Peter Taylor and seconded by Charles Rogers. The Isle of Wight NHS
Trust Board approved the recommendation NOT to consolidate the
2013/14 Charitable Funds Accounts within the 2013/14 IW NHS Trust
Annual Accounts.
14/078 VICE CHAIRMAN OF CHARITABLE FUNDS COMMITTEE The Chairman
asked that formal approval be given for Sue Wadsworth to be
appointed
Vice Chairman of the Charitable Funds Committee. Proposed by
Charles Rogers and seconded by Peter Taylor. The Isle of Wight NHS
Trust Board approved the appointment of Sue Wadsworth as the Vice
Chairman of the Charitable Funds Committee
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IOW NHS Trust Board Meeting Pt 1 26th February 2014 13
14/079 MATTERS TO BE REPORTED TO THE BOARD None
14/080 QUESTIONS FROM THE PUBLIC There were no questions
received from the public.
14/081 ANY OTHER BUSINESS
a) Chemotherapy/Haematologist Consultant Vacancy - The Chairman
invited Nancy Ellacott, Vice Chair of the Patient Council, to
speak. She asked for an update on succession planning for the
Consultant Haematologist. The Executive Director of Nursing &
Workforce confirmed that suitable locum support had been arranged
whilst the substantive post was being recruited to. He also
confirmed that partnership working in this area with other local
Trusts was being actively explored.
b) CQC Training Event – The Executive Medical Director confirmed
that the training
event on 27th February would be held in the Education
Centre.
c) Sub Committee attendance – The Company Secretary advised that
a TDA induction event for new Non-Executive Directors would be held
on 19th March which coincided with the main Board sub- committee
meeting day. He requested that all remaining Non-Executive Members
involved in these meetings confirm their attendance as soon as
possible to ensure that a quorum is achieved.
14/082 DATE OF NEXT MEETING The Chairman confirmed that next
meeting of the Isle of Wight NHS Trust to be held in
public is on Wednesday 26th March 2014 in the Conference Room,
St Mary’s Hospital, Newport, Isle of Wight. The meeting closed at
12:40 Signed…………………………………. Chair Date:…………………………………….
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20/03/20141 of 3
ISLE OF WIGHT TRUST BOARD Pt 1 (Public)ROLLING SCHEDULE OF
ACTIONS TAKEN FROM THE MINUTES
Date of Meeting
Minute No. Action No. Action Lead Update Due Date Forecast Date
Progress RAG Date Closed Status
27-Nov-13 13/261 & 14/037(v)
TB/054 Discharge Summaries - Sue Wadsworth also reported that
she had attended the Directorate Performance Review meeting on 22nd
November which had resulted in her being concerned about the level
of outstanding discharge summaries. The Executive Medical Director
assured her that these were being monitored closely and
improvements would be seen once the JAC system was fully
operational. He noted that there had been a data spike in August
when the new doctors had joined the Trust. He also noted that ISIS
programme had had teething problems which had also resulted in a
data spike. He confirmed that he would be monitoring this area.
EMD Executive Medical Director to update the Board on the levels
of outstanding discharge summaries. 16/12/13 - Discharge summary
completion rates are part of the directorate performance updates
20/01/14 There continues to be a level of non completed discharge
summaries by the cut off date for payment, although these are all
completed eventually. EMD in discussion with Acute Directorate to
move to patients not leaving hospital unless the summary is
completed. 29/01/14 - Item raised again under minute 14/037(v).
26/02/14 - The Executive Medical Director confirmed that in January
2014 100% of discharge summaries had been completed by the required
date and it was planned for that all patients to leave hospital
with their discharge summary. Also confirmed was that there was a
KPI for the clinical directorates and this was monitored at the
monthly clinical directorate meetings.
26-Feb-14 Completed 26-Feb-14 Closed
27-Nov-13 13/264 TB/055 Safe Staffing Levels - The Deputy
Director of Nursing confirmed that a report onSafe Staffing Levels
would be presented every 6 months to the QCPC. She alsoconfirmed
that if the principles were approved today then a detailed plan
wouldbe drawn up with the Transformation and Quality Improvement
team to movethe project forward with an update report in February.
The Executive Director ofFinance requested that the Executive
Director of Nursing and Workforce bringthis report to the FIWC at
the appropriate time.
EDNW Executive Director of Nursing and Workforce bring update
report on Safe Staffing Levels and the costs involved to FIWC.
16/12/13 - reporting going to FIWC for 22 Jan 2014. 21/01/14 -
Going to QCPC & FIWC in March. 26/02/14 - The Executive
Director of Nursing & Workforce confirmed that these would all
be completed by the end of March. 19/03/14 - will be a Board
Seminar agenda item on 8 April 2014
29-Jan-14 26-Mar-14 Completed 19-Mar-14 Closed
08-Jan-13 13/283e TB/058 Funding for Covered Walk from Helipad:
The Executive Director of Finance wished to clarify the funding
position mentioned in this minute. She confirmed that an offer of
funding had been made for the covered walk to the helipad but
stated that to date no funding had been requested by the Trust. The
Chairman stated that as this was the case could the Chief Executive
to pursue the funding.
IDPII Chief Executive to formally pursue the funding to allow
the creation of the covered walk to the helipad. 13/02/14 - CEO
advised that this has been passed to the Interim Director of
Planning, ICT & Integration to progress. 26/02/14 - The
Executive Director of Finance confirmed that £58k had been agreed
for this project.
26-Feb-14 26-Mar-14 Completed 26-Feb-14 Closed
08-Jan-13 13/288vi TB/059 Flu Incentives: The Executive Director
of Nursing & Workforce commented that Hull Trust used
incentives to get staff to take up the vaccine and had almost 100%
staff covered. He stated that if staff have 0% sickness absence,
all mandatory training completed and flu vaccine they get the
incentive which he wanted to explore.
EDNW The Executive Director of Nursing & Workforce to
explore staff incentives linked to flu vaccination. 21/01/14 - DDW
reviewing this suggestion. 26/02/14 - The Executive Director of
Nursing & Workforce confirmed that the HR team were working on
the scheme at present.
26-Feb-14 26-Mar-14 Progressing Open
08-Jan-13 13/293 TB/061 Board Walkabouts Action Tracker: Annual
report requested. EDNW The Executive Director of Nursing &
Workforce to arrange for an annual report be submitted to Board in
April 2014.
30-Apr-14 30-Apr-14 Progressing Open
29-Jan-14 14/037-ix TB/069 Long Term Financial Model (LTFM) –
Peter Taylor requested that the revised version of this document be
presented to the Finance, Investment & Workforce Committee.
EDF The Executive Director of Finance confirmed that once the
LTFM has been updated this would happen. 19/02/14 - confirmed that
this will return to FIWC once produced. 26/02/14 - The Executive
Director of Finance confirmed that the final document would be
taken to the next Finance, Investment & Workforce Committee in
March.
26-Mar-14 26-Mar-14 Progressing Open
29-Jan-14 14/041 TB/070 Mortality Data - Peter Taylor asked if
it was possible to break down the mortality data by age and
benchmark the Island’s figures nationally. The Executive Medical
Director agreed to look into this for his next quarterly
report.
EMD Executive Medical Director to review age trends for next
quarterly report.
30-Apr-14 30-Apr-14 Progressing Open
Designate Non Executive Directors: David King (DK) Jane Tabor
(JT) Jessamy Baird (JB)
Executive Medical Director (EMD) Executive Director of Nursing
& Workforce (EDNW) Deputy Director of Nursing (DDN)
Non Executive Directors: Danny Fisher (DF) Sue Wadsworth (SW)
Peter Taylor (PT) Charles Rogers (CR) Nina Moorman (NM)
Key to LEAD: Chief Executive (CE) Executive Director of Finance
(EDF)
Foundation Trust Programme Director/Company Secretary (FTPD/CS)
Trust Board Administrator (BA) Head of Communication (HC) Executive
Director of Finance Deputy (EDF Dep)
Interim Director of Planning, ICT & Integration (IDPII) Head
of Governance & Assurance (HOG)
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Date of Meeting
Minute No. Action No. Action Lead Update Due Date Forecast Date
Progress RAG Date Closed Status
29-Jan-14 14/041 TB/071 Palliative Care - it was suggested that
the new Designate Non- Executive Directors visit the hospice and
also the clinical coding department to better understand the
process.
CS The Company Secretary to arrange a visit for the new
Designate Non- Executive Directors to be arranged to the Hospice
and also Clinical Coding Department. 11/02/14 - Hospice visit to be
arranged. Clinical Coding to be included on Board walkabout
programme for March. 26/02/14 - it was confirmed that this would be
discussed with the Designate Non-Executive Directors after Board.
19/03/14 - Company Secretary requested a visit. Dates to fit in
with Board walkabout schedule.
26-Mar-14 26-Mar-14 Completed 19-Mar-14 Closed
29-Jan-14 14/044 TB/073 Patient Story Action Tracker - These
were reviewed by the Quality & Clinical Performance Committee
monthly and an end of year report would be made to the Board.
EDNW The Executive Director of Nursing & Workforce to
present the End of Year Patient Story report at the April Board
meeting. 19/03/14 - Patient Story action Tracker to be reviewed to
ensure it encompasses the actions taken, and a year end position
will be submitted to Board.
30-Apr-14 30-Apr-14 Progressing Open
26-Feb-14 14/058 TB/074 Diabetic Meal Choices - Peter Taylor
raised the question of the suitability of theDiabetic options
within the patients menu choices. The Executive of Nursing
&Workforce confirmed that the dieticians would be asked to
review the currentchoices. Jessamy Baird also confirmed that this
had been discussed at theQuality & Clinical Performance
Committee at which an update from theExecutive Director of Nursing
& Workforce was pending.
EDNW The Executive Director of Nursing & Workforce to follow
up with the dieticians and report back on the outcome of the review
of diabetic patient meal options. 20/03/14 - Menu choices are
assessed by Dieticians for there suitability, and diabetic patients
are able to choose from the main menu. Additional items have been
added to the menu some of which are suitable for Diabetics. The
patient menu has been the subject of review from the speech and
language service and it has been agreed to review the menu with the
input of SALT, Dietetics and catering.
26-Mar-14 30-Apr-14 Progressing Open
26-Feb-14 14/058 TB/075 Patient Information Boards - Peter
Taylor also asked about the patient information boards above the
beds and could these have the consultants name and lead nurse
shown. The Executive Director of Nursing & Workforce confirmed
that these were in place in some areas and that the remaining areas
would be completed shortly.
EDNW The Executive Director of Nursing & Workforce to update
theBoard on the progress of the installation of patient
informationboards. 19/03/14 - The Patient Information boards are
beingreviewed and work is progressing in ensuring that all areas
have aboard in place that identifies the Consultant and Lead
nursenamed.
26-Mar-14 26-Mar-14 Progressing Open
26-Feb-14 14/058 TB/076 Patient Story Action Plan Slide - Sue
Wadsworth commented on how useful itwas that the Action Plan had
been shown on screen and requested that this bedone for all future
Patient Stories brought to the Board.
EDNW The Executive Director of Nursing & Workforce to
arrange for asummary slide to be prepared for all Board Patient
Stories.19/03/14 - completed - patient story action slide provided
forboard on 26th March 2014.
26-Mar-14 26-Mar-14 Completed 19-Mar-14 Closed
26-Feb-14 14/065 (iv) TB/077 Risk Register Definitions - Jessamy
Baird stated that some of the description of the risks were very
generic and could result in a permanent position on the risk
register. She asked if these could be reviewed. The Executive
Medical Director advised that when staff-assess a risk it is on a
local level which to them will seem a high risk but at Board level
it may not rate as high. The Executive Director of Nursing &
Workforce advised that the directorates had been asked to review
these more rigorously to ensure that appropriate risk scores were
made. Peter Taylor stated that he felt that this part of the
performance report needed further development. David King agreed
and stated that it should be showing the strategic imperative of
each to Board against operational and strategic risk. The Executive
Director of Finance confirmed that the Capital Investment Group did
undertake a full risk review on capital schemes. Peter Taylor
stated that an additional area showing the actions approved by the
Capital Investment Group would be helpful.
EDF The Executive Director of Finance to review possible
additionaldata to be included for future reports.
Progressing Open
26-Feb-14 14/065 (iv) TB/078 Ophthalmic Case note risk - Sue
Wadsworth requested that an update on theOphthalmic Case note risk
be brought to the Quality & Clinical PerformanceCommittee.
EDNW The Executive Director of Nursing & Workforce to
arrange for areport to be presented at the Quality & Clinical
PerformanceCommittee.
19-Mar-14 19-Mar-14 Completed 19-Mar-14 Closed
26-Feb-14 14/065 (vi) TB/079 Capital Plan - A discussion took
place surrounding how the capital plan would be shown and how it
would link to the Long Term Financial Model and the Clinical
Strategy, and it was agreed that capital spend would be brought
back to Board Seminar for more discussion.
EDF/IDPII The Executive Director of Finance to prepare a
presentation with the Interim Director of Planning, ICT &
Integration for Board Seminar on the capital plan. 19/03/14 - This
has been scheduled for 13 May Board Seminar.
13-May-14 13-May-14 Completed 19-Mar-14 Closed
26-Feb-14 14/065 (viii) TB/080 Falls - Charles Rogers asked if
falls which fall outside the category of “resulting in significant
injury” could be shown. The Chairman confirmed that this was a
category which was included within the Board Walkabout
questionnaire and Sue Wadsworth confirmed that these were also
looked at in detail at the Quality & Clinical Performance
Committee (QCPC). The Executive Director of Nursing & Workforce
advised that a total review of the annual total number of falls
would be added to the agenda of the QCPC.
EDNW The Executive Director of Nursing & Workforce to
arrange for a full report on Falls to be presented at the QCPC
committee.
18-Apr-14 18-Apr-14 Progressing Open
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Date of Meeting
Minute No. Action No. Action Lead Update Due Date Forecast Date
Progress RAG Date Closed Status
26-Feb-14 14/065 (ix) TB/081 Compliments – The Company Secretary
asked on behalf of Jane Tabor, if in future the level of
compliments could be added to the report. The Executive Director of
Finance confirmed that this was in hand and would appear in the
next report.
EDF The Executive Director of Finance to ensure that the level
of compliments be added to the performance report.
Progressing Open
26-Feb-14 14/069 TB/082 Reference Costs & Service Line
Reporting - The Company Secretary asked, onbehalf of Jane Tabor, if
it would be possible for more consideration to be givento this
subject in a seminar. The Board agreed this proposal.
CS The Company Secretary to arrange for a seminar on Service
LineReporting and Reference Costs to be added to the Board
SeminarForward Planner. 19/03/14 - This has been scheduled for 8
JulyBoard Seminar.
08-Jul-14 08-Jul-14 Completed 19-Mar-14 Closed
26-Feb-14 14/074 TB/083 CSF8.2 - The Company Secretary asked, on
behalf of Jane Tabor, if risk CSF8.2 should remain as Amber instead
of the recommended upgrade to Green. A discussion to place and it
was agreed that this item would stay as Amber.
HOG SF8.2 should remain as Amber instead of the recommended
upgrade to Green.
26-Mar-14 26-Mar-14 Completed 19-Mar-14 Closed
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REPORT TO THE TRUST BOARD (Part 1 - Public) ON 26TH MARCH
2014
Title Chief Executive’s Report Sponsoring Executive Director
Chief Executive Officer
Author(s) Head of Communications and Engagement Purpose For
information Action required by the Board: Receive P Approve
Previously considered by (state date): Trust Executive Committee
Mental Health Act Scrutiny
Committee
Audit and Corporate Risk Committee
Nominations Committee (Shadow)
Charitable Funds Committee Quality & Clinical Performance
Committee
Finance, Investment & Workforce Committee
Remuneration Committee
Foundation Trust Programme Board
Please add any other committees below as needed Board Seminar
Other (please state) Staff, stakeholder, patient and public
engagement: This report is intended to provide information on
activities and events that would not normally be covered by the
other reports and agenda items. Executive Summary: This report
provides a summary of key successes and issues which have come to
the attention of the Chief Executive over the last month. For
following sections – please indicate as appropriate: Trust Goal
(see key) All Trust goals Critical Success Factors (see key)
All Trust Critical Success Factors
Principal Risks (please enter applicable BAF references – eg
1.1; 1.6)
None
Assurance Level (shown on BAF)
Red Amber Green
Legal implications, regulatory and consultation requirements
None
Date: 19 March 2014 Completed by: Andy Hollebon
Enc C
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NATIONAL NHS Pay It is disappointing that the Government have
rejected advice and decided that NHS staff this year will receive
either their annual increment where appropriate or a one per cent
rise but not both. This does recognise the difficult financial
times faced by all public sector organisations but at the same time
it doesn’t feel as if we are being appreciated fully for what we do
although I know that we are all committed to ensuring that patients
receive the best possible care. NHS Change Day 2014 is the second
year that a national NHS Change Day has been promoted. This is a
frontline led campaign with a mission to inspire us all to do
something better together to improve care for people. This national
initiative works by individuals and teams making a simple pledge to
make a change that matters in every day practice. As an Executive
Team, we pledged to the organisation that: We are committed to
improving two-way communication between staff at all levels in
order to help reduce their daily working life stress levels. You
can still get involved in NHS Change Day - you have until 31 March
to make your pledge by visiting www.changeday.nhs.uk. LOCAL CQC
Inspection Preparation In June we expect the Care Quality
Commission to undertake a large inspection of services at the
Trust. As part of our preparation for this important event we have
held the first peer review-style pseudo inspection of services
across the Trust Our mock inspectors identified many areas of good
practice and some areas that need work. The process will help us
all to achieve our aim, together, of creating an excellent
organisation that gives excellent patient care. This is a real
opportunity to genuinely improve our services, not just for the CQC
inspection this June, but beyond. My Life a Full Life News – Spring
2014 The My Life a Full Life programme is a collaboration between
the Clinical Commissioning Group (CCG), Isle of Wight NHS Trust,
Isle of Wight Council and the Voluntary Sector. It aims to deliver
a more coordinated approach to health and social care services for
people needing care and support on the Island. The fourth edition
of the My Life a Full Life quarterly newsletter is now available.
It contains lots of information about the changes taking place on
the Island which are already making a difference to people’s lives
such as Better Care funding, improving information sharing, local
integrated working, helping people to support and care for
themselves and more. The newsletter can be downloaded at
www.iwight.com/My-Life-a-Full-Life. Norovirus Outbreak As this
report is written St. Mary’s Hospital is continuing to face very
serious challenges with patients and staff experiencing Norovirus
which causes diarrhoea and vomiting. Over 40 patients have been
directly affected and 20 per cent of the Trust’s 236 hospital beds
are affected. The main areas affected by the Outbreak have
been:
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3
∑ Appley Ward ∑ Colwell Ward ∑ General Rehabilitation Unit ∑
Stroke Neuro Unit
∑ Whippingham Ward ∑ Medical Assessment Unit (MAU) ∑ St. Helens
Ward
The Trust has taken a range of measures to enable more resources
to be diverted into resolving the issue, including:
∑ All visiting to the main hospital (not just to the wards
closed to new admissions) is restricted to essential visiting only
and a time to visit must be agreed with the Ward Manager. Wards
should be contacted via the Hospital Switchboard.
∑ All scheduled in-patient operations, apart from some for
urgent care such as cancer and orthopaedics, have been cancelled
until 22/3/14. The operations will be rescheduled as soon as
possible.
∑ Access to the main hospital for patients and visitors is only
via the main entrance. It is
therefore better to park closer to the main entrance if you have
mobility issues or arrange to be dropped at the main entrance
before cars are parked.
∑ Visitors and patients are asked to ensure they cleanse their
hands on entering and leaving
the hospital and entering and leaving clinical areas.
∑ No more than two visitors per patient.
∑ Children under the age of 16 and elderly or vulnerable adults
should not visit unless necessary.
∑ Anyone who has had symptoms, such as vomiting and diarrhoea,
must not come into the
hospital until they have been clear of those symptoms for at
least 48 hours.
∑ Patients visiting the Beacon Health Centre and Emergency
Department should only be accompanied by one other person if
possible.
Where possible the Trust has tried to ensure that day surgery,
outpatient appointments or clinics remain unaffected and patients
were asked to attend as normal. The team managing the outbreak are
meeting twice a day and the outbreak has been designated an
‘Internal Incident’ to ensure that resources are redeployed to
manage the issue. We have also been working with and are grateful
for the support of partner agencies including Isle of Wight Council
(adult social care, public health and education), General Practice
and our colleagues in the nursing and residential care home sector.
I would like to apologise for the inconvenience this is causing
patients and visitors at St. Mary’s but I hope everyone will
understand the need for us to get this nasty bug under control.
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Allergy and Asthma Centre I’ve been inspired by the work of the
Asthma and Allergy Centre. We have as part of our organisation one
of only 6 centres across the country doing cutting edge research
and service provision in this area. The passion of the team and the
opportunities they provide us with are incredible. Hospital Porters
raise money for Cancer Clinical Nurse Specialists Well done to 14
Porters at St Mary’s Hospital who have raised £600 after letting
their moustaches run wild throughout November 2013, during the
Movember campaign which helps raise awareness among men of the
warning signs of prostate cancer. The hospital porters however
wanted to donate locally and donated to the Cancer Clinical Nurse
Specialists (CNS) for education and equipment. After collecting all
of their sponsorship, the porters presented the cheque to Lead
Cancer Nurse, Anne Snow.
Karen Baker Chief Executive Officer 19 March 2014
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Title
Sponsoring Executive Director
Author(s)
Purpose
Action required by the Board: XPreviously considered by (state
date):
Quality & Clinical Performance Committee
Isle of Wight NHS Trust Board Performance Report 2013/14
Chris Palmer (Executive Director of Finance) Tel: 534462 email:
[email protected]
Iain Hendey (Assistant Director of Performance Information and
Decision Support) Tel: 822099 ext 5352 email:
[email protected]
To update the Trust Board regarding progress against key
performance measures and highlight risks and the management of
these risks.
Receive Approve
Trust Executive Committee Mental Health Act Scrutiny
Committee
Nominations Committee (Shadow)
19/03/2014
Audit and Corporate Risk Committee
Charitable Funds Committee
Assurance Level (shown on BAF)
Legal implications, regulatory and consultation
requirements
Trust Goal (see key)
Critical Success Factors (see key)
Principal Risks (please enter applicable BAF references – eg
1.1; 1.6)
For following sections – please indicate as appropriate:
Quality, Resilience,Productivity & Workforce
CSF1, CSF2, CSF6, CSF7, CSF9
Staff, stakeholder, patient and public engagement:
Executive Summary:
This paper sets out the key performance indicators by which the
Trust is measuring its performance in 2013/14. A more detailed
executive summary of this report is set out on page 2.
Remuneration Committee
Quality & Clinical Performance Committee
19/03/2014Charitable Funds Committee
Finance, Investment & Workforce Committee
Foundation Trust Programme Board
19/03/2014
Other (please state)
Please add any other committees below as needed
None
Date: Thursday 20th March Completed by: Iain Hendey
���� Green���� Amber���� Red
Page 1 of 28
Enc D
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Executive Summary
Patient Safety, Quality & Experience:
Pressure ulcers: We continue to under achieve our planned
reduction across all grades
of pressure ulcers, both in the hospital setting and the wider
community. A range of
actions continue to support improvements in this area.
VTE: Risk assessment figures from 4th February show an
underperformance (94% vs
95% target), this figure is based on the final month of manual
data capture. Pharmacy
are now confident that the new upgrade to their system during
February has eliminated
previous data collection problems and we are now achieving 100%,
exceeding both the
local and national targets of 95%.
HCAI: We are currently within both our nationally set threshold
and our local stretched
target for Healthcare Acquired Clostridium Difficile infection,
remaining at 6 YTD, with
no cases reported during February.
Workforce:
The total pay bill for February (£9.83m) is above plan (£9.55m).
The number of FTEs in
post is also currently higher than plan (10). The HR Directorate
are closely monitoring
and supporting the Clinical directorates with their workforce
plans, in particular their
control over their spend on variable hours.
Sickness absence increased again in February (4.65%) and remains
above plan at
3.77% YTD. Specific problem areas are being identified for
investigation and are
challenged at directorate performance review meetings.
HCAI:
no cases reported during February.
There were no cases of Healthcare Acquired MRSA bacteraemia
identified in February,
remaining at 2 YTD.
Mental Health:There was a single breach in Child &
Adolescent Mental Health but the
extremely low numbers have an exaggerated impact on
percentages.
Operational Performance:
Performance against our key operational performance indicators
is again mainly green
for the month, the only red flag being referral to treatment
times for non-admitted
patients. TIA reporting figures are not yet available for
February (as at 19/3).
All cancer targets are again green for month and year to date.
Provisional figures
indicate that 40% of breaches during February were due to
capacity issues.
From April 2014 this Performance report will be revised to
include a wider range of
measures and a clearer reporting structure for Acute, Community
and Mental Health
and Ambulance services which will give a more balanced
reflection on our performance
as the only fully integrated Trust in the country.
Finance & Efficiency:
Overall we have slightly over-achieved our financial plans for
February by £214k and
based on the new measure, the Continuity of Service Rating,
introduced by Monitor on
1st October, our overall rating is 4.
The target YTD CIP target of £7,547k has been under-achieved by
£1,151k, and
recurrent savings of £1,478k still need to be identified.
However, there is an increasing
risk that this carry forward figure is significantly higher.
Directorates are continuing to
review opportunities to mitigate this balance with a view to
eliminating any carry forward
into next financial year.
Page 2 of 28
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Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Balanced scorecard
GRR
ref:Patient Safety, Quality & Experience
Annual
TargetYTD
Performance
Month TrendSparkline
Year end
forecastWorkforce
In
Month YTD
Performance
Month Trend YTD plan
Quality Acct #1 Summary Hospital-level Mortality Indicator
(SHMI)* Jul-12 - Jun-13 1.00 1.1160 Q3 N/A � 1.105 Total workforce
SIP (FTEs) 2,670.0 2,680 Feb-14 n/a �
Quality Acct #1Hospital Standardised Mortality Ratio (HSMR)
Jul-12 - Jul-13 100 103.47 Q3 N/A � 102.90 Total pay costs (inc
flexible working) (£000) £9,545 £9,831 Feb-14 £106,411 �
£103,987
Quality Acct #2 Patients admitted that develop a grade 4
pressure ulcer 0 2 Feb-14 16 � 17 Variable Hours (FTE) 139 186.00
Feb-14 1,590 � 1541
Quality Acct #2 Patients admitted that develop a grade 2 or 3
pressure ulcer 60 12 Feb-14 93 � 102 Variable Hours (£000) £87 £615
Feb-14 £6,139 � £675
Quality Acct #3 Reduction in communication complaints/concerns
150 15 Feb-14 151 � 165 Staff sickness absences 3% 4.65% Feb-14
3.77% � 3%
Quality Acct #4 Amber care bundle (now implemented - no audited
results as yet) - - - - - Staff Turnover 5% 0.61% Feb-14 8.96%
�
Child & Adolescent Mental Health (CAMHS) seen within 18
weeks referral to treatment 100% 95% Feb-14 98% � 98% Mandatory
Training 80% 77% Feb-14 74% �
VTE (Assessment for risk of) >95% 94% Feb-14 90% � 90%
Appraisal Monitoring (cumulative) 100% 63.9% Feb-14 63.9% �
MRSA (confirmed MRSA bacteraemia) 0 0 Feb-14 2 � 2 Employee
Relations Cases 0 40 Feb-14 149 (live)
14 C.Diff (confirmed Clostridium Difficile infection - stretched
target) 8 0 Feb-14 6 �� 6
Clinical Incidents (Major) resulting in harm (confirmed &
potential, includes falls & PU G4) 48 2 Feb-14 53 � 55
Clinical Incidents (Catastrophic) resulting in harm (confirmed
& potential) 8 2 Feb-14 9 � 10
Falls - resulting in significant injury 11 1 Feb-14 8 � 9
Delivering C-Section 70% 74% Feb-14 68% � 68%
Breast Feeding at Delivery (Target reduced February 2014)
>80% 72% Feb-14 75% � 75%
Formal Complaints 1% 2.16% Feb-14 2.16% �
High risk TIA fully investigated & treated within 24 hours
(National 60%) 95% 93% Jan-14 83% �� 82% Liquidity ratio days
=>15 39 Feb-14 39 �
8b Symptomatic Breast Referrals Seen
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Highlights
All Cancer indicators maintaining year to date position
Emergency Care 4 hour standard performance remains above
target
No of C.Diff cases are on track to achieve year end stretched
target
Reduction in formal complaints during FebruaryReduction in
formal complaints during February
Marked improvement in VTE risk assessment recording
Page 4 of 28
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Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Lowlights
Drop in Admitted 18 weeks referral to treatment time for
January
Staff absenteeism due to sickness remains above target
Pay costs/variable hours remain challenging
CIP targets remain challengingCIP targets remain challenging
Drop in Non-admitted 18 weeks RTT for February.
Page 5 of 28
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Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Pressure Ulcers
Analysis: Quality Account Priority 2 - Prevention &
Management of Pressure UlcersCommentary:
General:There has been a change in the reporting process whereby
numbers are
reviewed for both the current and previous month and there may
be changes to
previous figures once validated. These figures are also included
within the clinical
incident reporting and where any rise is also reflected.
Hospital acquired:There were 2 x grade 4 pressure ulcers
reported in the hospital
during February, showing a YTD position of 16 against 21 at the
same point last
year. Grade 2 numbers stand 89 YTD against 103 for the same
period with grade 3
numbers at 4 YTD against 15 in 2012/13.
Community acquired: There has been marked improvement in grade 4
incidence
over recent months despite an initial increase on the baseline
from last year. Both
grade 2 and 3 pressure ulcers numbers have reduced from 2012/13,
with the
reduction in grade 3s achieving the 50% decrease required of the
target. 2
4
6
8
10
12
14
16
18
Nu
mb
er r
ep
orte
d
G2 Community Acquired Pressure ulcer incidence
2012.13 2013.14
Target 3/12 average
1
2
3
4
5
6
Nu
mb
er r
ep
orte
d
G3 Community Acquired Pressure ulcer incidence
2012.13 2013.14 Target 3/12 Average
1
2
3
4
5
Nu
mb
er r
ep
orte
d
G4 Community Acquired Pressure ulcer incidence
2012.13 2013.14 Target 3/12 Average
0
1
2
3
4
5
6
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Nu
mb
er r
ep
orte
d
Month
G3 Hospital Acquired Pressure ulcer incidence
2012.13 2013.14 Target 3/12 average
0
2
4
6
8
10
12
14
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Nu
mb
er r
ep
orte
d
Month
G2 Hospital Acquired Pressure ulcer incidence
2012.13 2013.14 Target 3/12 average
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Nu
mb
er r
ep
orte
d
Month
G3 Hospital Acquired Pressure ulcer incidence
2012.13 2013.14 Target 3/12 average
Explanation of RAG Rating
Red=Any G4 or 2 G3 or 5 any in rol ling 3 month period
Amber=1G3 or increase/no change in G2 in rol ling 3 month
period
Green=No G3 or G4 and decrease in G2 or 2 or less of any grade
(1&2) in roll ing 3 month period
Status:Date:
The Clinical Nurse Specialist continues to support the wards
with management of complex wounds
and assessment of Pressure Ulcer Competency standards across all
front-line staff within the trust. Executive Director of Nursing
& Workforce/ Tissue Viability Specialist Nurse Mar-14 In
progress
Action Plan: Person Responsible:
Work continues to raise awareness and improve prevention.
A 'deep-dive' exercise has reviewed all Community grade 4's over
the past months. One area of
concern is patient compliance. Action plans are being discussed
and developed from this. Executive Director of Nursing &
Workforce/ Tissue Viability Specialist Nurse Mar-14 In progress
The Clinical Nurse Specialist & Director of Nursing are
working with Communication & Engagement to
develop a Pressure Ulcer Campaign across the wider healthcare
economy. Executive Director of Nursing & Workforce/ Tissue
Viability Specialist Nurse Spring 14 In progress
Issues have been highlighted,relating to the use of appropriate
care plans and this will form part of the
ward accountability process. Matrons are working to summarise
care delivery standards for patients
at risk, in order to streamline analysis of PUs once
identified.
In progressMar-14Executive Director of Nursing & Workforce/
Tissue Viability Specialist Nurse
0
2
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Month
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Month
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Month
Page 6 of 28
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Patient Safety
Commentary: Analysis: Clostridium Difficile infections against
national target
Clostridium difficile
There were no Healthcare Acquired Clostridium Difficile (C Diff)
cases in February
(YTD = 6) and we remain within our planned control total for the
national threshold
of 12 for the year.
We are currently working towards a locally stretched target of
8. This threshold is
weighted across the year to take account of the historically
expected winter
increase. We have entered this winter period and remain within
our stretched
trajectory.
Methicillin-resistant Staphylococcus Aureus (MRSA)
There have been no cases of Healthcare Acquired MRSA bacteraemia
in the Acute
hospital during February.
The Action Plan for MRSA is progressing and work continues on
the Healthcare
Associated Infection agenda.
All cases continue to be subject to root cause analysis to
identify actions necessary to ensure the
trajectory remains achieved.
Executive
Director of Nursing &
Workforce
Mar-14 Ongoing
An external Healthcare Acquired Infection expert (currently
working with the Trust Development
Authority) visited during February to oversee our current
policies & procedures to offer advice on
improvement. The report has yet to be received.
Executive
Director of Nursing &
Workforce
Mar-14 Report expected
A risk register entry for this target is under development by
the Director of Infection Prevention &
Control (DIPC) in conjunction with the Infection Prevention
& Control Team.
Executive
Director of Nursing &
Workforce
Mar-14 In progress
Status:
Associated Infection agenda.
Action Plan: Person Responsible: Date:
Page 7 of 28Page 7 of 28
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Formal Complaints
Analysis: Complaints Commentary:
There were 17 formal Trust complaints received in February
2014 (24 previous month) with 256 compliments recieved by
letters and cards of thanks across the same period. There
were
over 21,400 consultant led contacts during February.
Across all complaints and concerns in February 2014:
Top areas complained about were:
- Orthopaedics (8)
- Medical services (7 )
- Ambulance services (6)
Across all complaints and concerns in February 2014:
Top subjects complained about were:
- Clinical care (28)
- Out-patient appointment delay/cancellation (27)
- Communication (10)
80
29
69
4
20
7
9
0
20
40
60
80
100
120
Acute Community Planned Corporate
Complaints received April 13 to date
including those returning
dissatisfied
Original Number received Returners
Clinical Care 4 12 11 -1 �Nursing Care 3 2 1 -1 �Staff Attitude
1 1 0 -1 ����Communication 1 3 2 -1 �Outpatient Appointment Delay/
Cancellation 0 2 1 -1 �Inpatient Appointment Delay / Cancellation 0
0 1 1 �Admission / Discharge / Transfer Arrangements 0 0 0 0
����Aids and appliances, equipment and premises 0 1 0 -1
����Transport 0 0 1 1 �Consent to treatment 0 0 0 0 ����Failure to
follow agreed procedure 0 0 0 0 ����Hotel services (including food)
0 0 0 0 ����Patients status/discrimination (e.g. racial, gender) 0
0 0 0 ����Privacy & Dignity 0 0 0 0 ����Other 1 3 0 -3 ����
RAG
rating
Primary Subject December 2013
January
14
February
14CHANGE
Quality Account Priority 3 - Improving communications
Date:
- Communication (10)
Quality Account Priority 3 - Improving Communication
The target of a 20% reduction in both complaints &
concerns
across the year regarding communication is being monitored.
This is currently achieved for Year to Date complaints
although
concerns continue to exceed the planned trajectory. This
could
be due to increased awareness and accessibility addressing
concerns before reaching conversion to formal complaint level.
Individual months are colour rated for their achievement of the
target for that month. The Year to Date figure for 2013/14 shows
the cumulative position against the equivalent YTD position for
2012/13
Status:Action Plan: Person Responsible:
Following the review of complaints, recommendations have been
made
relating to complaints management. Resources will be allocated
to Clinical
Directorates to assist them in owning their complaints and
managing them
closer to the point of care. Resource to be identified through
organisational
change.
Executive Director of Nursing & Workforce / Business Manager
-
Patient Safety; Experience & Clinical EffectivenessApr-14
Planned
Other 1 3 0 -3 ����
Links to The NHS Outcomes Framework Domain 4 – Ensuring That
People Have A Positive Experience Of Care
KPI Description Target
(cumulative)
Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total
YTD
Reduction in complaints relating to
communication �20%
2012/13 3 4 6 3 4 6 8 7 1 7 5 2 56
2013/14 4 1 3 5 2 2 3 2 4 5 5 36
Reduction in concerns relating to
communication �20%
2012/13 20 19 12 14 8 10 11 6 6 10 8 8 132
2013/14 17 12 8 8 7 5 18 10 11 9 10 115
Page 8 of 28Page 8 of 28
-
Isle of Wight NHS Trust Board Performance Report 2013/14February
14
Litigations
NPSA Category
Q4 12/13 Q3 13/14 Q4 13/14 Change RAG
Access, Appointment, Admission, Transfer, Discharge 1 3 0 -3
����
Accident that may result in personal injury 0 0 0 0 ����
Consent, Confidentiality or Communication 0 0 0 0 ����
Infrastructure or resources (staffing, facilities, environment)
0 0 0 0 ����
Medication 0 0 2 2 ����
Implementation of care or ongoing monitoring/review 2 4 1 -3
����
Q4 Isle of Wight NHS Trust Claims Dashboard
Cur