Agenda and supporting papers - Plymouth Hospitals NHS Trust

Trust Board
Friday 5 July 2013, 9.00 am – 1.00 pm
Board Room, Derriford Health & Leisure Centre
Agenda
Section 1
Standing Items
1 Welcome, apologies and declarations of interest Chairman Verbal
2 Questions for the Board pertinent to the agenda Chairman Verbal
3 Minutes of the meeting held on 7 June 2013
Approve the previous minutes and discuss any matters arising
Chairman
Paper
4 Review of outstanding actions Chairman Paper
Setting the context for the Board
5 Chairman’s introductory remarks Chairman Verbal
6 Why we are here … Learning Stories for the Board
The learning and changes in practice resulting from patient stories
since September 2012, with recommendations on how the Board
develops this regular agenda item
7 Chief Executive’s Report
Highlighting the topical external issues affecting the Trust
Director of
Nursing/
Director of
Governance
Chief
Executive
Presentation
Verbal
BREAK: 10.30 am – 10.45 am
Section 2
Our Current Performance
8 Safety and Quality Report
Quarterly report on the work and activities of the Healthcare
Governance Team and wider organisation
8a
Serious Patient Safety Incidents and Complaints
Common themes and improvement programmes in place to avoid
further harm
9 Performance Report
Performance to the end of May 2013, with in-depth focus on key issues
affecting our Governance Risk Rating
10 Finance Report
Review of Month 2 position
Director of
Nursing/
Medical
Director
Director of
Nursing/
Medical
Director
Chief
Executive
Director of
Finance
Paper
Paper
Report
and
Dashboard
Paper
BREAK: 12.15 – 12.20 pm

Trust Board
Section 2 (continued)
Our Current Performance
11 Quarterly update on acute hospital standards for people with
Learning Disabilities
Quarterly review of declaration of compliance
Associate
Director of
Nursing
Paper
12 Equality and Diversity update
Integrating and embedding equality and diversity strategically at Board
level and as part of the core business of the Trust
Section 3
Governance
13 Information Governance
Quarterly update on assurance by the Senior Information Risk Owner
14 Trust Seal
Quarterly report in accordance with Standing Orders
Director of
Human
Resources &
OD
Director of
Planning &
Site Services
Board
Secretary
Paper
Paper
Paper
Assuring Committee Chairs’ Reports and meeting minutes. The following items will be reviewed
‘in the round’. Issues will be discussed only if not covered as part of the earlier Performance
Review or if Board members require additional assurance to be sought.
15 Safety & Quality Committee
Report of assurances from June meeting and review of June minutes
16 Finance, Performance & Investment Committee
Review of May minutes
17 Human Resources & Organisational Development Committee
Report of assurances from the June meeting and review of June
minutes
18 Audit Committee
Chair’s Report and review of May minutes
Closing items
Committee
Chair
Committee
Chairman
Committee
Chair
Committee
Chair
Paper
Paper
Paper
Paper
19 Any other business Chairman Verbal
20 Date of next meeting
Friday 27 September 2013 at 9.00 am
Chairman
Verbal

Members of Plymouth Hospitals NHS Trust Board of Directors have declared the following interests:
Name Position Declared Interest
Richard Crompton Chairman None
Kevin Baber Chief Operating Officer None
Lee Budge Director of Governance None
Greg Dix Director of Nursing None
Ian Douglas Non‐Executive Director Managing Director and owner, Blackdown Consulting
Director, Mango Evolution Ltd
Director, Challenge‐X Ltd
Ann James Chief Executive Trustee, Exeter Royal Academy for Deaf Education
Health and Medical Champion, Chamber of Commerce
Member, Plymouth Council Growth Board
Director, South West Peninsula Academic Health
Science Network
Terence Lewis Non‐Executive Director Honorary Life President, Heartswell South West
Chairman, Plymouth Marine Laboratory
Governor, Plymouth University
Chairman, Plymouth University Peninsula Schools of
Medicine and Dentistry Medical School Board
President, Plymouth Heartbeat
House of Hope, Nepal – family orphanage
Alex Mayor Medical Director Shareholder in Serco plc
Elizabeth Raikes Non‐Executive Director Trustee, Fortescue Garden Trust
Hein Scheffer
Director of Human
Resources &
Organisational
Development
Director, Wavelengths 106 (Pty) Ltd
Trustee, Boherwald Trust
Margaret Schwarz Non‐Executive Director Director, Cornwall Care
Governor of Plymouth University (from 1 July 2013)
Joe Teape
Director of Finance &
Strategy
Former Branch Chairman and Branch Committee
member of the Healthcare Financial Management
Association
Henry Warren
Denis Wilkins
Associate Non‐Executive
Director
Associate Non‐Executive
Director
Governor and member of Finance Committee of
Plymouth University
Chairman and Director of Tradewind Turbines Ltd
Chairman and Director of Fluvial Innovations Ltd
Director of J&S Ltd
Chairman, Council for St John (Ambulance) Cornwall
Governor of Plymouth University (from 1 July 2013)
Mike Williams Non‐Executive Director No commercial interests to declare.
Honorary research fellow with South Devon Healthcare
NHSFT.
My department at Exeter University has research grants
from South Devon Healthcare NHSFT and Open
Innovation to conduct research in South Devon Health
and Social Care services.

Item 3
Plymouth Hospitals NHS Trust
Minutes of the Trust Board meeting Part 1
9.00 am on Friday 7 June 2013
Board Room, Derriford Health & Leisure Centre
Present:
Apologies:
Richard Crompton, Chairman
Kevin Baber, Chief Operating Officer
Greg Dix, Director of Nursing
Ian Douglas, Non-Executive Director
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Ann James, Chief Executive
Terence Lewis, Non-Executive Director
Alex Mayor, Medical Director
Elizabeth Raikes, Non-Executive Director
Joe Teape, Director of Finance & Strategy
Henry Warren, Associate Non-Executive Director
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Denis Wilkins, Associate Non-Executive Director
Mike Williams, Non-Executive Director
Hein Scheffer, Director of Human Resources & Organisational
Development
A
Margaret Schwarz, Vice-Chair
Rob Sneyd, Dean, Plymouth University Peninsula Schools of
Medicine & Dentistry
In attendance: Martin Bamber, Deputy Director of Human Resources
Lee Budge, Director of Governance
Gill Hunt, Board Secretary
‘Governors’ in
attendance
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Brian Jones, Associate Director of Finance
Amanda Nash, Head of Communications
Steve Spencer, Commanding Officer, MDHU
Nick Thomas, Director of Planning & Site Services
Sally Wilson, Chief Financial Accountant
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Marina Taylor, Public ‘Governor’, Plymouth constituency
Action
101/13 Welcome, apologies and declarations of interest
The Chairman welcomed members of the public in attendance.
Apologies had been received on behalf of Hein Scheffer, Margaret
Schwarz and Rob Sneyd.
Commander Steve Spencer, MDHU, was attending his last Board
meeting on stepping down from his command to take up an overseas
posting. The Chairman thanked Commander Spencer for his
contribution and wished him well. The Chairman welcomed Lt
Commander Tim Jones, who would be taking up his appointment as
MDHU Commander in July 2013 and attended the meeting as an
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observer.
The Chairman required those present to declare any interests they
may have pertaining to the matters listed on the agenda. There were
no declarations of interest.
102/13 Questions to the Board pertinent to the agenda
A member of the public
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wished to place on record her appreciation of
the care that her husband, currently a patient on Braunton Ward, had
received since his admission one week ago. Her husband had been a
patient on the same ward three years previously and it was apparent
to both her and her husband that standards were much improved.
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Referring to recent local media reporting of the recruitment of
additional nursing staff and an increase in the Trust’s bed base, a
member of the public queried how, given the Trust’s financial position,
this would be funded. Ms James stated that this would be discussed
as part of agenda items 8 and 10.
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The Board Secretary read a written question from shadow ‘governor’
Mrs Vera Mitchell. Mrs Mitchell noted the pressures nationally on
emergency access and suggested the Department of Health had a
role to play in influencing the irresponsible lifestyles that contributed to
disease and trauma. She asked what the Board would do, in
partnership with stakeholders, to encourage healthy and responsible
lifestyles. In response,
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Dr Mayor stated that there was a clear
commitment from the Board to contribute to the local public health
agenda. He highlighted the smoke-free Trust initiative, the Trust’s
involvement in the Plymouth Alcohol Strategy, and its role, through Dr
Paddy English and his colleagues, in tackling health problems
associated with obesity.
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The Board Secretary read a second written question from Mrs
Mitchell. Mrs Mitchell enquired whether the Board would continue its
rigorous support to maintain and extend the work of the Infection
Prevention and Control team. Mr Dix affirmed that the Board would
do so; in addition to the team’s work with the Peninsula College of
Medicine and Dentistry to develop and deliver a Master’s programme
in Infection Prevention and Control, the Trust’s new organisational
structure would facilitate improved practice at service line level.
There were no further questions.
103/13 A Learning Story for the Board
Dr Ian Higginson, Consultant in Emergency Medicine, related his own
experiences in January 2013 during a 28 hour inpatient stay. Dr
Higginson described all aspects of his assessment, diagnosis and
surgery as highly efficient and was of the view that the good nursing
care he had received had facilitated his prompt discharge.
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The Board discussed the learning points and matters arising from Dr
Higginson’s experience:
• The Surgical Assessment Unit had been very crowded and the
patient experience would be improved by reducing the number
of beds per bay.
• The area was pervaded by the lingering smell of hospital food.
• Rear opening gowns eliminated any sense of patient dignity.
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• Staff were not aware of two-way claves and how to connect
them.
• Ward managers must have control of ward stock lists.
• A patient had been kept in a bed whilst awaiting diagnostics but
could have been discharged and called back as an outpatient,
freeing up the bed. The wider issue was medically fit patients
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detained in beds awaiting diagnostics.
• Delayed discharges waiting for TTAs. Dr Higginson had spent
15% of his entire hospital stay waiting for medications.
• He had been prescribed and provided with TTA drugs that he
did not require,
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resulting in unnecessary costs to the Trust.
• The benefits of the Enhanced Recovery programme in
engaging patients in goals for their discharge. This programme
was currently practiced in the Trust in surgery but not yet in
medicine.
• The known variations in clinical outcomes according to time
and day of admission,
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recently the subject of national media
reporting.
The Chairman requested an update on the issues arising from Dr
Higginson’s story at the next Board. The next scheduled Board
walkround to the ED and SAU would focus on the issues raised. On
behalf of the Board, the TChairman thanked Dr Higginson for attending.
Dr Higginson left the meeting.
104/13 Minutes and matters arising from the meeting held on 3 May 2013
DoN/DoG
The minutes of the meeting held on 3 May 2013 were agreed as a
true and accurate record. There were no matters arising.
105/13 Review of Action List
95/13 Quality Improvement Strategy
Dr Mayor updated the Board. The points made at the Board on 3 May
had been incorporated into the implementation plan led by the Deputy
Director of Nursing and Assistant Medical Director Paul McArdle. The
plan was due to be reviewed at the Senior Management Team
meeting on 24 June and by the Safety & Quality Committee in July.
71/13 Review of performance data presented to the Board to ensure
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Board oversight of contributing or underlying issues.
Noted as outstanding.
[Post meeting note: Board Secretary to follow up with Medical
Director and NED Mike Williams].
BS
The Board noted the action list.
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In setting the context for the day, the Chairman referred to recent
media attention on the Trust and the overriding requirement to focus
on the needs of the patient. For some months now Board members
had stressed the requirement to get the basics of care right and, in so
doing, produce a compelling
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strategy to set the organisation’s future
path. Today the Board would focus on both these important
requirements. It would be asked to approve proposals to improve
emergency target performance, together with an associated bed
programme to increase bed availability and aid patient flows, and the
Chief Executive would be presenting the Board’s strategy and vision
for the Trust.
A
106/13 Chairman’s introductory remarks
The new clinical leadership structure was vital to service delivery and
placed clinicians at the heart of the Trust. In return, the Board must
expect this new framework to pay dividends in terms of quality,
performance and efficiency. Finance remained a significant challenge
and the Board required
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assurance that this would be effectively
tackled at the pace to effect success.
107/13 Chief Executive’s Report
The Senior
Management Team had had challenging but productive discussions
with the local press and had been clear on their commitment to work
with the public and with staff as the Board launched its strategic
vision. To support this, details of the new clinical leadership team
would be announced to staff next week; these were key individuals
whose work would support the delivery of the Trust’s overarching
strategy, At the Heart of Health in the Peninsula.
Ms James supported the Chairman’s remarks.
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Ms James gave a presentation to support the strategy launch. The
approach adopted in developing this vision had been open and
transparent and had involved clinicians and stakeholders. The
document gave a clear sense of the Trust’s future direction and set
out the approach to creating new partnerships with patients, staff and
the health community. Ms James referred to debate concerning the
Trust’s future positioning as either a ‘district general hospital’ or a
specialist service provider. It was her view that it should, and could,
be both and that doing so need not be complex.
The strategy detailed the core services that the Trust would continue
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to deliver and articulated a firm commitment to continue to develop
specialist services and build on existing areas of excellence in cancer,
specialist surgery, major trauma, neonatal care and obstetrics.
Feedback from clinical commission groups and specialist
commissioners on the document’s tone, style and ambition had been
positive.
Ms James highlighted the requirement to sustain partnerships with
commissioners and
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local health providers, with the MDHU, with
Plymouth University and private sector partners, and to promote the
growth of clinical research through the Peninsula Academic Health
Science Network. The strategy set out how staff would be engaged in
its delivery and how, through strengthening clinical leadership and
demonstrating responsiveness to patients’ needs, service quality
would improve. In summary,
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Ms James highlighted the strategy’s
strong patient focus and the importance of being confident in our
ambitions - the local population deserved this. She commended the
strategy to the Board.
The Chairman invited discussion. The main points were:
A
• Acknowledgement that the launch provided the opportunity for
the Board’s greater involvement in local partnership working
and in influencing key external clinicians. The Board must not
be the recipient of change but drive it. The commitment to
patients and to the health community was welcome and would
be an important
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factor in strategy implementation.
• Dr Williams sought to understand the position on local
community-based services. Ms James stated that locally the
pressures on hospitals were recognised, not only in terms of
the demand for urgent care but also in the increased acuity of
patients. There
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was a will to consider commissioning services
in other ways. The Trust could provide different models of care
and this was an opportunity to pursue and influence the
transformation agenda.
• The requirement to review the strategy in six months in terms
of the broader strategic goals and future service provision.
Specifications for National Specialist Commission had just
been released and the Senior Management Team would
consider this in the context of strategy refinement.
• Commander Spencer highlighted the onus on the Trust Board
to present a compelling narrative to staff and to engage them in
delivery. To aid this, the inclusion of a site plan to bring the
document to life was agreed. Ms James, Mr Teape and the
Director of Planning & Site Services would agree the process
and timescale to achieve this. Ms James stated that there may
be a requirement for external assistance and she would update
CE
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the Board next month.
• The document must link to Annual Business Plan and set more
detailed timescales for delivery.
The Board noted the Chief Executive’s Report and welcomed the
launch of the strategy document.
108/13
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Emergency Access Target Recovery and Bed Programme
Mr David Brown, Assistant Director of Operations, and Ms Sophie
O’Brien, Service Improvement Lead, attended for this item and gave a
presentation which described
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the national context behind current
emergency access performance and the local actions being taken to
improve performance to 95%. These actions included changes to the
Trust’s bed base.
There was a break between 10.25 am and 10.40 am.
Emergency Access Target Recovery
A
The presentation identified three overarching causes for the failure to
deliver the four hour standard:
• Failure to process patients in a timely way.
• Failure to respond to requests for specialist support in a timely
way.
• Failure to admit patients in a timely way (no bed available).
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Mr Brown’s report described actions to improve performance against
these three root causes. Mr Baber had communicated to senior
medical staff the new expectations for the ED; this had provoked
some specialties to put forward pathway initiatives to improve flow.
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The Board discussed the proposed actions. The main points were:
• Assurance was sought, and given, that medical staff supported
a nurse-led ED.
• Understanding the importance of specialist support, the
interface between the ED and specialist services and the
agreement of internal professional standards.
• The ongoing debate concerning generalist v specialist and the
Trust’s ability to contribute to this debate.
• The broader context of workforce planning and the Trust’s
ability to meet its own needs at a time of national change.
• Mr Baber stated that the health-community Urgent Care Forum
were content with the Trust’s plans. He explained the role of
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the Forum in targeting winter funding.
Bed Programme
The aim of the Bed Programme was to deliver the appropriate bed
base for the Trust’s patient flow by:
• Ensuring patients were cared for in the most appropriate
setting.
• Preventing the
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cancellation of surgical patients.
• Operating at a manageable occupancy rate across medicine
and surgery to provide personal, high quality, safe care.
The Bed Programme identified the difference between current and
optimal capacity as 56 beds. It proposed the establishment of:
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• 20 short stay medical beds driven by the known increase in
patients who stay 0-2 days.
• 26 Healthcare of the Elderly beds on Monkswell ward.
• 10 in-ward escalation beds.
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The cost of this investment in the current year was £2.246m for the
additional 74.05WTE staff, with a full year effect of £3.388m. In
addition, capital costs associated with relocating services, including a
further relocation of the Preoperative Assessment Unit, totalled £665k.
The main risks associated with delivery were:
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• Recruitment.
• Internal professional standards.
Mr Brown drew the Board’s attention to the risks to delivery and to
their mitigations set out in the presentation and in the accompanying
report. Mr Brown suggested
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that the most significant risk was the
failure to deploy the enhanced community workforce to support
patients in an alternative environment when winter pressures hit. Dr
Williams stated that there was no reason why the Trust should not be
proactive in this regard. Mr Baber agreed, staff could function outside
of the footprint of the hospital; other organisations did so with a
significant positive impact on bed availability.
The Board considered the proposals. In so doing, the main points of
discussion were:
• Uncertainty as to whether 26 beds was sufficient to cope with
the variation in demand and whether this number would meet
changing local demographics. Ms O’Brien stated the Trust
would require thirteen additional beds to cope with future
demand and a work stream was reviewing this.
• Mr Wilkins queried the degree of clinical involvement in these
proposals. Mr Baber stated that the Care Group Directors had
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Item 3
been involved and there was service line support. Mr Brown
stated that the proposals had been routed through the relevant
clinical groups to ensure support.
• Dr Williams stated that the Board could not be sure that these
proposals would save money and be better for patients.
Success would be dependent on a tight grip on the associated
operational issues. The discharge element, which was
dependent on
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other parties, was crucial and there was limited
assurance that this would be delivered in the short term.
• Mr Teape identified the requirement for a clear audit trail for
admissions/discharges to be shared with commissioners. Mr
Teape and Mr Baber would shape this.
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• Mrs Raikes asked whether this investment would add to the
existing CIP programme. Mr Teape stated that it would not and
that the costs were included in the £5m ‘investment for quality’
projects discussed at the May Board.
• Successful nurse
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recruitment was crucial to the plan’s success,
both operationally and financially. Mr Dix stated that nurse
recruitment was just keeping pace with internal turnover and it
was likely that it would be necessary recruit internationally.
Whilst Ms James agreed in principle, she felt there was more
that could be done in local advertising and this should be
pursued.
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Concluding the Board’s discussions, Ms James stated that the Senior
Management Team must develop range of KPIs for Board level
oversight. Agreement of these proposals would send confirmation to
staff that the Board had listened and acted on two of their concerns:
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• The importance of minimising patient and staff moves to meet
operational imperatives.
•
The Board:
The importance of supporting staff to deliver the consistently
high levels of care that they would wish.
• Noted the internal actions being taken to support
improvements within the ED pathway and improve
hospital-wide support for patients within the ED.
• Noted the community-wide actions required to support
hospital based Emergency Care in the longer term.
• Approved the actions described within the Bed
Programme and the associated investment necessary to
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109/13 Performance Report
Finance and Efficiency
A contract value of £353.2m had been agreed with commissioners.
The contract would operate on a managed Payment by Results (PbR)
basis which assumed that full PbR would be operated but both parties
would work together to
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deliver all contractual commitments within the
funding envelope available. Mr Teape drew the Board’s attention to
the variable elements of the contract, including cardiac activity, set out
in his report. Dr Williams asked whether there was confidence that a
PbR contract would enable cardiac to deliver at the required level. Mr
Teape stated that focused support was being given to this team. Two
additional ring fenced
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beds had been provided as an immediate
measure.
Noting the ISTC provision, locally, of cataract surgery, Dr Williams
asked whether this had been built in to budget assumptions. Mr
Teape confirmed that it had; about £0.5m had been taken out of the
ophthalmology budget
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and the service line had been asked to produce
a capacity plan with sensitively analysis.
Mr Teape stated the intention to include in future reports key contract
issues, including activity variations, as well as contract penalties and
CQUIN achievements to raise the profile of these issues at Board
level.
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Operational Performance
Mr Baber stated that May had seen a significant decrease in
cancellations but performance remained unacceptable. The
Chairman queried progress
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with driving theatre efficiency. Mr Baber
stated that authority had been given to surgeons/anaesthetists to get
lists under way. A Service Line Director for Theatres had been
appointed and would drive this.
Cancelled Operations
Accident & Emergency Department 4 hour target
May performance had been 94.75%, with 97.74% to date in June.
Year to date performance was 93.53% and the quarter may yet be
recovered.
Follow-up Backlog
Dr Williams was concerned that the follow-up backlog remained static
at 23,000 and the Board was not assured that the actions in place
would deliver the required improvement. Dr Mayor stated that he had
asked Assistant Medical Director Paul McArdle to undertake a full risk
assessment on all patients on the follow-up list and Mr Baber
explained the approach to appropriately prioritising patients and to
remove those with no ongoing clinical need. Commander Spencer
asked whether there was confidence that the backlog was not
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continuing to build. Mr Baber stated that this was being addressed as
part of the waiting list policy.
Referral to Treatment (exception report)
The report set out actions to address under-performance. The Trust
would fail this target in Quarter 1 but the planned actions facilitated
the speediest resolution of long patient waits. Mr Baber expected to
reach a sustainable position by October.
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The Board noted performance ahead of target in April.
The Trust failed the target in April and performance had further
deteriorated in May.
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Mr Baber stated that an options paper would be
submitted to commissioners on the Trust’s overall capacity; this would
include additional staffing and the outsourcing of some activity.
Mrs Raikes queried whether the actions to achieve stroke and cancer
performance, reported
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in February and March respectively, remained
relevant as performance had not reached the required targets. Mr
Baber stated that the issue with stroke concerned admittance to the
ASU but beds had been ring fenced, compounded by a peculiarity
around the appropriateness of some of the targets when there were
overriding clinical reasons not to admit to the ASU. Exception reports
on cancer and stroke
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would be included in next month’s report to the
Board.
The Board were pleased to note performance at 85% for April. Mr Dix
stated that the quality of the responses had improved; the next step to
improve quality would
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be to survey complainants’ satisfaction with the
Trust’s process. A recently published report on NHS governance of
complaints handling had been circulated to Board members; this
would inform an internal review of complaints due to be reported in
July.
Fractured Neck of Femur
Diagnostics and surveillance
Cancer and Stroke
Complaints
COO
Friends and Family Test Response
The Trust has failed this target in April and May. Mr Dix had reviewed
performance by ward in order to focus effort where necessary.
Discretionary Pay
Mrs Raikes queried the high level of discretionary pay reported in
April. Mr Teape acknowledged that the Senior Management Team’s
focus had not yet had the required impact. The Board agreed that a
seminar on understanding and mitigating discretionary pay would be
incorporated in the Board development schedule.
Workforce
Mr Bamber stated that the scoping of a new framework for non-
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medical appraisal was complete and he expected to bring a proposal
to the Senior Management Team to review in July. The Board
discussed the inclusion in appraisal documentation of key clinical
competencies by staff grade. Mr Bamber stated that the Trust applied
the Agenda for Change Knowledge and Skills Framework but Mr Dix
acknowledged that the identification of key clinical competencies
across all wards and specialties was inconsistent. There was
agreement that the broader issue was for appraisal documentation to
facilitate the alignment of personal objectives with Trust objectives.
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The twelve month average sickness absence rate had reduced to
4.49%. Focus on progress towards achieving the Trust target of 3.8%
was being applied through robust management, with additional
training for managers.
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Monitor’s Governance Risk Rating
The Board noted the RAG rating of red for April. Professor Lewis
queried the underlying reason for failing the cancer screening service
referral and Mr Baber would provide this information outside the
meeting.
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In concluding the Board’s discussions, it was agreed that the Senior
Management Team would review the presentation and content of the
performance narrative to ensure that it provided oversight of KPIs
associated with the implementation of the Winter Plan, the Annual
Business Plan and the Board-specific KPIs agreed earlier in the year.
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The Board noted the Performance Report.
110/13 Infection Prevention and Control Annual Report 2012/13
Dr Peter Jenks, Director of Infection Prevention and Control, and Ms
Claire Haill, Lead Nurse
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Infection Control, attended for this item.
Dr Jenks presented highlights from his report and drew the Board’s
attention to key achievements in 2012/13. Overall, he was pleased to
report a significantly improved position since he was last invited to
report to the Board in September 2012. He acknowledged the
contribution of the Chief Executive in this regard, and of Julie
Richards, Associate Director of Planning, and Stuart Windsor, Facility
Operations Manager in their work with Serco. Looking forward, new
and inexperienced staff would be joining the Trust in the next few
weeks and the infection control team must prepare for their arrival and
continue to lead on minimising infections associated with medical
devices.
COO
SMT
The Chairman asked how the Trust could ensure a consistently
rigorous focus on infection control. Dr Jenks suggested encouraging
a culture keen to demonstrate best practice. Mr Dix agreed; the nurse
preceptorship period was vital in embedding best practice and
supporting relevant training. Noting the number of bed days lost due
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to Norovirus, Professor Lewis queried new developments that may
mitigate this. Dr Jenks stated that early warning to admitting staff of
community-based occurrences was vital.
The Board noted the Infection Control Annual Report.
Dr Jenks and Nurse Haill left the meeting.
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Mr Teape stated that following the Board’s agreement of the budget
strategy, a £13m deficit budget, after planned CIPs of £24m, had been
agreed and submitted to the Trust Development Authority.
Discussions continued with the TDA to agree additional support during
the year. They would
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require the production of a robust three year
programme to achieve a sustainable position. He referred the Board
to paragraph 3.14 of his report, which set out the actions and
timescales to develop this by September 2013.
Against a planned deficit of £941k in month 1, an actual deficit of
£913k had been recorded,
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£28k better than planned. Mr Teape stated
that improvements to controls were monitored by the Finance,
Performance & Investment Committee (FPIC), alongside mobilisation
of service line implementation from June. A review of CIPs, by
Directorate, was in progress for review by FPIC in June. In reviewing
the report, Dr Williams suggested the inclusion of actual activity and
the deployment of reserves
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to meet this. Mr Teape expected the
quality of reporting to improve from next month following changes to
Finance monthly close arrangements.
Ms James updated the Board on discussions with the TDA. Whilst the
Trust’s planned deficit was among the highest reported, overall the
Trust’s ambition was
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considered good. There had been no written
response from the TDA following the ‘Board to Board’ in February but
they had accepted the Trust’s budget. She expected external support
to commence in the next few weeks.
111/13 Finance Report: Month 1 Financial Results
Mr Warren stated that during his induction he had picked up on a
prevailing attitude amongst staff that financial issues were always,
somehow, satisfactorily resolved and suggested that the Board
reflected on this. Mr Teape acknowledged this; staff had been
informed of the financial situation in the current year but there would
doubtless be a level of scepticism that the Senior Management Team
would need to tackle, particularly given the context of media
announcements of spending on additional staff and beds.
In concluding the Board’s discussions, the Chairman stated that the
Board expected pace in the development of the financial recovery
plan.
The Board:
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• Noted the financial position of the Trust as at 30 April
2013.
• Approved a deficit budget of £13m for 2013/14.
There was a break between 1.05 pm and 1.10 pm.
D
Mr Teape’s report set out the proposed capital programme for
2013/14. The programme had been subject to extensive review by
the Investment Panel, the Capital Steering Group and the FPIC, all of
which included clinical representation. Mr Teape stated that it would
be unwise to approve
R
individual elements of the programme at the
expense of others and recommended that the Board approved the full
plan with the expectation that cash flow would be tightly managed.
The Trust’s Scheme of Delegation defined those individual elements
within the overall plan that must come back to the Board for approval.
Progress with the capital plan delivery was reported monthly to the
Board and was subject
A
to FPIC oversight.
112/13 Capital Budget Report 2013/14
Mr Budge noted the Medical Equipment Rolling Replacement
Programme budget of £1.7m and queried the criteria used to assess
the risks and whether the Board could be assured that equipment for
patients would not fail. Dr Mayor explained the risk assessment
employed by the Medical
F
Devices Strategy Group and expressed his
confidence in their decision making process.
Mr Teape referred the Board to section 6 of the report which set out
where capital spend would be focused if additional resources were
available. After reviewing the details the Board took the view that it
was not for Board members
T
to second guess others’ best informed
decisions. They should instead seek assurance of the integrity of the
process in bringing forward these recommendations and that the
investments proposed were strategically and clinically important. Mr
Douglas stated that FPIC had reviewed the proposed programme
twice. There were risks associated with it but there was also
contingency and FPIC supported the programme proposed.
Dr Williams queried the degree to which leasing arrangements were
available. Mr Teape stated that FPIC had previously reviewed this but
it would be picked up as part of the longer term procurement strategy.
Echoing earlier discussions, the Board noted that:
• Linking the capital plan with the site development plan to be
developed as part of the strategy implementation would be
welcome.
13

Item 3
• Careful communication of the spending associated with the
plan was important given the mixed messages to staff and
public that could arise.
The Board:
• Approved a capital programme of £15m consisting of precommitments
of £4.1m and additional proposed schemes
of £11.4m on
D
the understanding that £0.5m of slippage
would be identified as the year progressed.
• Agreed that this approval would be kept under review in
recognition that affordability was dependent on the Trust’s
cash position.
R
• Noted the table of reserve bids in the event that additional
funding could be secured.
• Noted that all other schemes would come back to the
Board as Full Business Cases on the basis that they were
loan funded.
A
113/13 Theatre Safety Improvement Plan
This report set out actions to minimise risk to patients following five
Never Events which occurred between November 2012 and March
2013. In addition to the immediate actions described, Dr Mayor
explained the remit of the Surgical Safety Improvement Programme to
F
disseminate medium and long term interventions to improve patient
safety. Dr Williams queried the initiatives within teamwork
interventions. Dr Mayor cited the introduction of formal theatre
debriefing sessions associated with the WHO checklist and Human
T
Factors training.
Mr Dix outlined the key changes resulting from the Theatre Safety
Improvement Plan under the domains of resources, communication,
Five Steps Safe Surgery and training and education. The report
detailed the changes expecting during the coming month. The Trust
would be subject to national expert review at the end of June with
recommendations reported in July. Whilst there had been some
overall slippage with the Plan, he was confident that the Trust’s new
organisational structure, including the appointment of a service line
lead for Theatres, would bring this back on track.
The Board welcomed the external involvement detailed in the report
and requested periodic reports on progress.
The Board noted the report.
14

Item 3
114/13 Quality Account 2012/13
Dr Mayor presented the Quality Account to the Board for approval.
He assured the Board that appropriate consultation had been, and
continued to be, undertaken and that the document supported the
Trust’s overall clinical strategy. The Quality Account had been
reviewed by the Safety & Quality Committee prior to submission to the
Trust Board.
D
Dr Williams raised the following queries:
• Page 37 – the 42% completion rate for observation charts was
lower than expected. Dr Mayor stated that the methodology
had changed from previous years and performance would be
re-audited to ensure improvement.
R
• Page 6 – include the ‘fifth’ Trust value for consistency with
other documents.
• Page 7 – over use of acronyms in this public facing document.
115/13
A
Annual Accounts for the year ended 31 March 2013
Mr Teape presented for approval the accounts and associated
documentation for the ended 31 March 2013. These had been
completed to the timescale
F
required by the Department of Health and
to an exacting standard, by Sally Wilson. Mr Teape wished to place
on record his thanks to Ms Wilson and to Brian Jones, also present,
for their hard work.
Subject to these amendments, the Board approved the Quality
Account.
The Audit Committee had reviewed the accounts and associated
documentation at their
T
meeting on 31 May and recommended them to
the Trust Board for approval. In doing so, the Committee had agreed
that the accounts had been prepared on a going concern basis.
Mr Teape drew the Board’s attention to the external auditor’s draft
Audit Findings report, and to the qualified Value For Money conclusion
based on the Trust’s inability to achieve the original forecast £1m
budget surplus for 2012/13 and its failure to set a balanced budget for
2013/14.
There were no questions.
The Board:
• Approved the annual accounts for the year ended 31
March 2013 and authorised their signature by the Chief
Executive and the Director of Finance.
15

Item 3
• Approved the writing off of losses and special payments
made during the year ended 31 March 2013.
• Authorised the Chief Executive to sign the Letter of
Representation.
116/13 Safety & Quality Committee Chair’s Report
D
The Board noted the Chair’s report of the May meeting and noted the
minutes of the April and May Committee meetings. No further
assurances were sought.
117/13 Finance, Performance & Investment Committee Chairman’s
Report
R
The Board noted the Chairman’s report of the May meeting and noted
the minutes of the April Committee meeting. No further assurances
were sought.
118/13 Any Other Business
A
Commander Steve Spencer wished to record his appreciation of the
Board’s support for MDHU staff and its recognition of their
commitment to the wider organisation. During his tenure as CO,
engagement between the Trust and the MDHU had increased
immeasurably. Commander Spencer had enjoyed his time with the
Trust and wished the Board
F
well for the future.
119/13 Date of next meeting
T
There was no other business and the meeting concluded at 1.55 pm.
Friday 5 July 2013 at 9.00 am.
Signed
____________________________________
Dated
____________________________________
16

Updated: prior to July Board Item 4
Outstanding Actions
Plymouth Hospitals NHS Trust
Action List for Trust Board Part 1
Date Ref Action Lead Comments
03.05.13 86/13,
page 3
Learning Disabilities Service
Quarterly Declaration of
Compliance: Director of Nursing to
liaise with Deputy Director of
Nursing to ensure evidence of
learning from patient story to May
Board is included in next scheduled
report in July 2013.
DoN/
DDoN
Scheduled for July
2013 and included
on agenda.
Associate Director
of Nursing to give
verbal update
when paper
presented.
07.06.13 103/13,
page 3
Learning from Patient Story: Board
to receive update on
implementation of key learning
issues.
[Post meeting note: at Chief
Executive’s request, action
subsequently extended to reflect
learning from all patient stories
since September 2012 to be led by
Director of Nursing/Director of
Governance].
DoN/DoG
Included on July
Board agenda at
item 5.
07.06.13 107/13,
page 6
Inclusion of site plan in strategy.
Chief Executive, Director of Finance
& Strategy and Director of Planning
& Site Services to agree process
and timescale, including any
requirement for external assistance,
and Chief Executive to include
update in her report to the July
Board.
CE
Scheduled for July
2013.
07.06.13 109/13,
page
11
Senior Management Team to
review content and narrative of
performance report to include
oversight of KPIs for Winter Plan,
Annual Plan and previously agreed
Board-specific KPIs.
SMT
Timescale not set
and no lead
nominated.
Completed actions will be shown for one month only. 1

Updated: prior to July Board Item 4
Actions referred by the Board to Board Committees to progress
Date Ref Committee and Action Lead Comments
12.04.13 71/13,
page 7
Safety & Quality Committee
Review performance data
presented to the Board to ensure
Board oversight of contributing or
underlying issues.
The action from the April Board
was:
Dr Mayor reminded Board members
that the HSMR and the SHMI were
only two performance measures:
they should not be considered in
isolation but as part of a broader
suite of performance metrics.
Professor Lewis queried whether
the underlying data was reviewed
by the Safety & Quality Committee.
[…] Dr Williams stated that the
Committee did not review data
below the level presented to the
Board and relied on the Medical
Director to give assurance on
underlying data and to identify any
areas requiring a more detailed
analysis. Professor Lewis
suggested that, under these
circumstances, the Committee
should review below the line. The
Board requested Dr Mayor and Dr
Williams, who would be chairing the
Safety & Quality Committee from
June, to review data presentation to
ensure that the Board was sighted
of the contributing, or underlying,
issues. It was agreed that the
Safety & Quality Committee would
review the last three months’ data in
depth.
MD/MW
Outstanding.
Board to have
visibility of
outcome via
Chair’s Report and
meeting minutes.
On 13.06.13
Board Secretary
clarified action
with Medical
Director and NED
Mike Williams.
Agreed that they
would discuss on
day of June Safety
& Quality meeting.
Verbal update at
July meeting.
Completed actions will be shown for one month only. 2

Updated: prior to July Board Item 4
Completed Actions
Date Ref Action Lead Comments
12.04.13 70/13,
page 6
Human Resources &
Organisational Development
Committee
South West Pay, Terms &
Conditions Consortium Report:
HR&ODC to agree action plan and
process for pursuing ‘optimisers’
within identified, prompt, timescales.
DoHR
&OD
Included in
HR&ODC’s Chair’s
Report to the July
Board and minutes
of the June
meeting.
Completed.
12.04.13 74/13,
page
12
Human Resources &
Organisational Development
Committee
National Staff Survey 2012: agree
2/3 issues for immediate focus to
secure step change and identify
measures to confirm good, credible
progress of delivery.
DoHR
&OD
Included in
HR&ODC’s Chair’s
Report to the July
Board and minutes
of the June meeting
2013.
Completed.
03.05.13 95/13,
page
11
Quality Improvement Strategy:
additions to be made, as set out on
page 12 of May Trust Board
minutes. Medical Director to give
verbal update at June Board.
MD
Update given at
June Board, as
scheduled.
Completed.
03.05.13 95/13,
page
12
Quality Improvement Strategy: At
request of Chair of HR&ODC,
Deputy Director of Human
Resources to review HR&OD
Strategy to ensure it supports
above. HR&ODC to review at its
June 2013 meeting.
DDofHR
Update included in
HR&ODC’s Chair’s
Report to the July
Trust Board.
Completed.
07.06.13 109/13,
page
10
Exception reports on cancer and
stroke performance to be included
in the Performance Report to the
July Board.
COO
Scheduled for July
2013 and included
in Performance
Report narrative.
Completed.
Completed actions will be shown for one month only. 3

Updated: prior to July Board Item 4
07.06.13 109/13,
page
11
Performance Dashboard, p.22.
Chief Operating Officer to identify
underlying reasons for failure in
April of target for NHS cancer
screening service referral and
advise Professor Lewis.
COO
Completed.
Completed actions will be shown for one month only. 4

Item 8
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Safety & Quality Report
Deputy Director of Nursing, Patient Experience Manager, Patient Safety &
Effectiveness Manager
Director of Nursing and Medical Director
Director of Nursing and Medical Director
Purpose
To provide a quarterly quality report on the work and activities of the
Healthcare Governance Team and wider organisation.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
This report provides a quarterly update to the Trust Board on Quality; it replaces the quarterly
Healthcare Governance report. Healthcare governance activity is reported monthly to the
Safety & Quality Committee. This report provides an overview for the quarter 1 April 2013 to 15
June 2013. The report includes an analysis of trends, hotspots, themes, issues and resulting
improvement.
•
Patient Safety & Clinical Effectiveness highlights the following areas of notable performance:
days since last never event; reduction in harm rate evidenced through global trigger tool and a
significant reduction in inpatient falls over the past two months. In addition some areas have
been highlighted as areas of concern as follows: an increase in the proportion of patients
harmed measured using the safety thermometer.
Personal experience report details progress against a number of areas including, PALS,
complaints, local inpatient survey programme and the ‘friends and family test’ (FFT)
The complaints response rate target of 80% has been achieved for 3 consecutive months,
leading to agreement of a stretched target of 90% by October 2013. PALs figures continue to
remain stable and have identified issues with access and waiting for our patients. Work to
improve REI signage was as a result of information received through PALS. Plans to survey
complainants to Plans to survey complainants once the complaints process is complete are
now in place and will commence from July.
314 inpatients were surveyed during April and May, using the Meridian system delivered by our
volunteers.
FFT response rates continue to improve although the 15% target has not been achieved to
date, further work to raise awareness with the public is underway with additional posters and
banners emphasising the importance of feedback from our patients.

Item 8
Quality Impact Assessment
Paper includes key patient safety, clinical effectiveness and patient experience data, providing
assurance regarding high level clinical outcomes, management of adverse events, complaints,
PALS, patient feedback and NICE guidance.
Financial Impact Assessment
Potential loss of income if Trust fails to meet CQC requirements and safety obligations.
Regulatory Impact Assessment
The Trust is required to demonstrate compliance with CQC requirements, potential litigation if
incidents and complaints are not managed.
Key Recommendations
The Trust Board is asked to note the content of the report.
Next Steps
The Safety & Quality Committee will continue to receive monthly reports on healthcare
governance activities. The Trust Board will continue to receive detailed quarterly reports,
supplemented by summary reports monthly.
2

Item 8
DETAILED REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Safety & Quality Report
Deputy Director of Nursing, Patient Experience Manager, Patient Safety &
Effectiveness Manager
Director of Nursing
Director of Nursing
1. Purpose
The purpose of this report is to provide the Trust Board with an update on Safety and Quality
activities within the Trust.
2. Background
The Trust recognises the importance of continually enhancing its healthcare governance
arrangements for the benefit of our patients. Significant progress has been made in
introducing a revised framework to support the delivery of safe, effective and personal care.
The Trust has a dedicated Integrated Healthcare Governance Team which seeks to support
clinical teams in the provision of safe, effective and personal care.
3. Clinical Effectiveness
3.1 Hospital Standardised Mortality Rate (HSMR)
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that
measures and compares the expected rate of death in the Trust with the actual rate of death.
The graph illustrates that the PHNT mean is consistently below the national average of 100
and that this position is stable. In addition, there are now 7 consecutive data points below the
mean indicating that the mean could potentially be reset to a lower value. It should be noted
that HSMR is just one quality marker amongst many and the drive for improvement must
continue.

Item 8
3.2 Quarterly Summary Hospital-Level Mortality Indicator (SHMI)
SHMI is a hospital-level indicator which reports mortality at trust level across the NHS in
England using standard and transparent methodology. This indicator is being produced and
published quarterly by the Health and Social Care Information Centre. As with the HSMR
values, the Trust has now reported 7 consecutive data points below the mean and there is
the option to reset the mean to drive continuous improvement.
4. Patient Safety
4.1 Monthly Incident Reporting Rate
Incident Reporting Rate per 100 Admissions
(May 11 - May 13)
12
Incident Reporting Rate per 100 Admissions
10
8
6
4
2
0
6.1
Jul-11
6.7
Aug-11
7
Sep-11
5.8
Oct-11
6.4 6.5
Nov-11
Dec-11
5.6
Jan-12
7.3
Feb-12
6.3
Mar-12
7.5
Apr-12
7.8 8.15 7.95
May-12
Jun-12
Jul-12
8.71
Aug-12
7.92
Sep-12
8.48 8.87 9.69
Oct-12
Nov-12
Dec-12
10.54
9.33 9.4
8.94
Jan-13
Feb-13
Mar-13
Apr-13
Month / Year
Incident Reporting Rate per 100 Admissions UCL LCL Mean
The Trust continues to improve the incident reporting rate reflecting an open culture of
reporting and learning which is essential in the drive for continuous improvements in patient
safety. The control limits have now been reset to encourage continuing improvement. The
Safe Care Group are currently reviewing the detailed information within this data and are
expected to set a revised definition and trajectory in order to maintain the focus on patient
safety incidents.
4

Item 8
4.2 Monthly Proportion of Incidents Resulting in Harm
Percentage of Incidents Resulting in Patient Harm
(April 2010 - May 2013)
50%
45%
% of Incidents Resulting in Patient Harm
40%
35%
30%
25%
20%
15%
10%
5%
0%
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Month / Year
% of Incidents Resulting in Harm UCL LCL Mean
This indicates that the current monthly variation is due to natural causes and part of a stable
system - the Safe Care Group will review this data and investigate potential interventions to
reduce this figure sustainably. Every reported incident is classified based on whether there
was any harm to the patient and, if so, the extent of that harm. The previous graph (4.1)
illustrates an increasing reporting rate which, when combined with the above graph, again
suggests that the proportion of incidents resulting in harm to patients is stable in spite of
increasing reporting. Harm is defined as any unintended physical or psychological outcome
for the patient.
4.3 Days Since Last Never Event
300
Number of Days Since Last Never Event
(April 2010 to May 2013)
No of Days Since Last Never Event
250
200
150
100
50
0
01/04/2010
01/05/2010
01/06/2010
01/07/2010
01/08/2010
01/09/2010
01/10/2010
01/11/2010
01/12/2010
01/01/2011
01/02/2011
01/03/2011
01/04/2011
01/05/2011
01/06/2011
01/07/2011
01/08/2011
01/09/2011
01/10/2011
01/11/2011
01/12/2011
01/01/2012
01/02/2012
01/03/2012
01/04/2012
01/05/2012
01/06/2012
01/07/2012
01/08/2012
01/09/2012
01/10/2012
01/11/2012
01/12/2012
01/01/2013
01/02/2013
01/03/2013
01/04/2013
01/05/2013
Date
There are no reported Never Events this quarter. The last Never Event was reported on 20 th
March 2013 under the category of Wrong Implant.
5

Item 8
4.4 Monthly Proportion of Patients Harmed (NHS Safety Thermometer)
18
NHS Safety Thermometer
% of Patients Harmed
Apr 12 ‐ May 13
16
14
% Patients Harmed
12
10
8
6
4
2
0
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Mar‐13
Apr‐13
May‐13
% Patients Harmed UCL LCL Mean
Month / Year
The NHS Safety Thermometer is a tool for measuring, monitoring and analysing the
proportion of patient harm and ‘harm-free’ care at a given point in time against four particular
‘types’ of harm. Each month, a snapshot audit is undertaken on every inpatient on a single
day. The audit records the prevalence of 4 different types of harm events:
• Pressure Ulcers
• Catheter Associated Urinary Tract Infections
• DVT and PE
• Falls
The audit also records whether the harm event happened prior to or during admission. PHT
is consistently submitting audits for the majority of inpatients and is recognised regionally for
this. The graph illustrates that the prevalence of patient harm events remains relatively
stable.
4.5 Monthly Proportion of Patients Harmed (Global Trigger Tool)
GTT: % of Patients Harmed
(Jan 09 - Dec 12)
45%
40%
35%
% of Patients Harmed
30%
25%
20%
15%
10%
5%
0%
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Nov-11
Jan-12
Mar-12
May-12
Jul-12
Sep-12
Nov-12
Month / Year
% Patients Harmed Mean UCL
6

Item 8
The Trust uses the IHI Global Trigger Tool methodology to conduct retrospective reviews of
patient records using ‘triggers’ to identify possible adverse events. A clinical team review 20
sets of patient notes per month. The graph indicates that from March onwards the majority of
the data points were below the 15% mean. The mean and upper control limits have been
recalculated accordingly.
4.6 Hospital Acquired Pressure Ulcers (Datix)
The Trust target is a 50% reduction in grade 3 and grade 4 hospital acquired pressure ulcers
per month using the P2 measure on National Safety Thermometer
At the Safe Care Group meeting in May 2013 the group reviewed the frequency in
occurrence of hospital acquired pressure ulcers (HAPU) (grade 3 and 4) and agreed that
hospital acquired pressure ulcers would be monitored monthly by the group. It was also
agreed that the current plan to reduce the numbers of HAPU would be reviewed and an
improvement programme implemented to reduce the frequency in line with the CQUIN plan
for 2013/2014.
4.7 Inpatient Falls (Datix)
200
Number of Reported Patient Falls (Datix)
by Month and Severity
180
160
140
120
100
80
60
40
20
0
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Mar‐13
Apr‐13
May‐13
None Minor Moderate Severe/Catastrophic Death caused by the incident
7

Item 8
Inpatient falls are currently monitored by the Nursing and Midwifery Board. April and May
have seen a significant reduction in the number of inpatient falls which is likely to be
attributable to an increase in nursing staffing on the wards. Work continues to further
improve this number. The Trust target is to reduce the number of falls to less than 50 per
month.
5 Patient Experience
5.1 Patient Advice and Liaison Service (PALS)
PALS team provide an on demand service with the aim of resolving patient issues at an early
stage, to avoid situations developing into formal complaints.
The Trust received a total of 847 PALS enquiries for the period 01 Apr 2013 to 17 Jun 2013.
PALS enquiries listed by directorate are detailed below.
8

Item 8
PALS enquiries are broken down in the 5 themes / subjects as detailed below.
• Information, Communication and Choice - 277
Communication issues 86
Information provision 40
Staff attitude 21
• Access and Waiting - 168
Outpatient delays 55
Inpatient delays / 18ww 47
9

Item 8
REI signage
PALS were contacted by the husband of a patient who is severely visually impaired and who
recently attended the REI at Derriford for the first occasion. Following the appointment, the
patient’s husband e-mailed PALS to express concerns regarding the poor signage to the REI
from the car parks at the rear of the hospital site. He suggested a review of the current
signage from the rear of the hospital and the route through the building from Level 6 to Level
3 and also came up with a number of innovative ideas for the Trust’s consideration.
In discussion with the patient and her husband and the Head of Site and Environmental
Services, arrangements are being made to carry out a walk around the site with a view to
determining what can be done to provide a safer/more patient friendly environment. There
are plans to include patient representatives, a member of the RNIB and other interested
parties.
Update
Further to the concerns expressed by a patient with severe visual impairment and her
husband late in April, a site walk around was conducted at the end of May. The patient
attended with her husband and her Guide Dog. Also present were the Trust Leads for
Environment and Sustainability and Hotel Services and representatives from the Royal
National Institute for the Blind South Devon and Cornwall Institute for the Blind and a
member of the PALS team.
The site visit incorporated a review of the bus stop area near the main entrance of the
hospital, the new blue badge parking site that will commence work later this month (adjacent
to the Chest Clinic) and signage to and from both areas.
Signage within the main building as well as at the REI main base on level 3 was reviewed
and reviewed the safety and quality of signage to the pedestrian crossings near the main
entrance and on level 3. A number of required improvements were noted and although the
works are on-going the patient representatives felt the visit was informative and were
reassured that the Trust is listening and acting on what our patients are saying to us. It was a
very positive afternoon which has forged good links with the visually impaired community.
Breaking Bad News
There has been a gradual increase in the number of reports and concerns raised by relatives
and carers in relation to the approach used when breaking bad news notably the
environment in which these conversations take place. In a number of cases these
conversations were held in corridors or on an open ward. Families feel they have not been
given the time and space to absorb sad news. Whilst we appreciate space is at a premium
there is a significant impact on family members many of whom are left with unresolved
questions and a sense that the Trust does not care or respect their feelings.
Awareness training will be reviewed to ensure it considers the environment when breaking
bad news. Information relating to similar cases will be considered by ward area to identify
any areas where the lack of privacy is a particular issue.
5.2 Complaints
The chart below details the number of complaints received between May 2012 and May
2013.
10

Item 8
Continued effort to monitor performance against the complaints response target has
significantly improved the number of complaints responded to within agreed timeframes.
Plans to survey complainants once the complaints process is complete are now in place.
Commencing from July complainants will be sent a satisfaction survey asking them for their
views of the process and whether they felt their issues were fully resolved and their concerns
addressed.
Following the success achievement of the 80% complaints performance target the Director of
Nursing has agreed a revised target of 90% from 1 st October 2013.
11

Item 8
Complaints received listed by directorate.
Complaints
received broken down in the 5 themes / subjects as detailed below.
12

Item 8
5.3 Learning and improving
The following table summarises current themes and improvement actions that have been
identified from all Healthcare Governance activity including complaints and PALS.
Theme Actions / Improvement Lead Timeframe
Major project aiming to improve overall
healthcare administration functions
including:
Sam Sheridan Mar 2014
• Self Check-In and Electronic Outcome
Forms
• Digital dictation
• Review of the clinical office
Clinical
Administration
• Electronic document management
systems
Review • Review of health records
• Ward administration
• Managed mail
• Enhanced telephony
• Appointments, booking and prep
• Internal Communication Environment
(ICE) – improved information links with
primary care
Outpatient
Follow Up
Delay
• Issues pertaining to the follow up
backlog and subsequent delays in
outpatient appointments at the REI are
managed through Task & Finish Group
chaired by the Assistant Medical
Director. Work is progressing to reduce
the backlog including validation of all
patients and appointments
Paul McArdle
Ongoing
Parking –
disabled
spaces
Parking &
signage – REI
• Improved availability for members of
public requiring disabled spaces.
Working Group in place including
members of the public and LINK.
• Walk round of the new REI area to
identify future improvements to signage.
Patient representatives, member of
RNIB and other interested parties
involved in walk round on 28 May 13.
Action plan agreed.
Andrew Davies Start date
Jun 13
Andres Davies
Liz McGuffog
30 Jun 13
5.4 Patient Feedback
The Trust programme for gathering feedback from our inpatients began in October 2010 and
covers all wards except intensive care, critical care, high dependency and paediatric areas,
to date 5824 patients have been surveyed.
Local inpatient ward satisfaction surveys are undertaken using iPads on an ongoing basis by
a number of volunteers. A selection of wards, grouped by Matron is targeted each month on
a rolling programme using the Meridian System. The survey report based on the findings is
available to the matron, sister/manager and ward management to review through the
Meridian system. Actions and learning are subsequently developed and sent to the Patient
Experience
Manager for ongoing management.
13

Item 8
The graphs below illustrate responses provided from the updated Local Adult
Survey between 01 July 2012 – 31 May 2013, when 2903 patients were surveyed.
Inpatient
For the period 01 April 2013 to 31 May 2013 413 patients were surveyed.
Would you recommend Plymouth Hospitals NHS Trust to your family and friends?
How would you rate the care you are receiving?
Do you think the hospital staff do everything they can to help control your pain?
14

Item 8
Do you feel that staff involve you in decision about your care and treatment?
In your opinion how clean is the hospital room or ward you are staying on?
On the ward you are staying on, are you treated with dignity and respect?
Plans to introduce a Patient Experience Committee, chaired by the Director of Nursing have
been agreed and will include members of the public, clinical and management staff. The first
meeting will take place in July 2013. The committee will drive forward the patient experience
strategy and develop an annual plan of work. An action plan to address a number of the key
patient experience issues and concerns will be produced and monitored through the Patient
Experience Committee.
15

Item 8
5.5 Friends and Family Test
From 1 st April 2013, all organisations providing NHS funded services are required by the
Department of Health to ask the Friends and Family question. A similar question is used in
the private sector to give a headline figure that shows overall customer satisfaction, generally
known as the ‘Net Promoter’ score.
The implementation plan agreed in November 2012 is now complete. Further work is now
required to ensure the Trust is fully compliant with the Friends and Family Test, including
improving performance to achieve the 15% response rate required to achieve the CQUIN
targets. Further roll out to Maternity Services by October 2013 is planned.
Continued efforts throughout May resulted in an increase in response rates from 11.5% to
13.5% for inpatients in May and 5.3% to 8.4% for Emergency Department. Further work to
raise awareness for both staff and members of the public will include information stands
throughout the remainder of June and July, posters and banners reminding patients of the
importance of returning their completed questionnaires. Targeted support from the Patient
Services Team will be given to those areas where results are particularly disappointing.
May 2013 Results
Acute Inpatient
Total number of people eligible to respond - 2953
Extremely
Likely
Likely
Neither
Likely nor
Unlikely
Unlikely
Extremely
Unlikely
Don’t Know
Total
Responses
265 112 10 10 5 4 398
Emergency Department
Total number of people eligible to respond – 4511
Extremely
Likely
Likely
Neither
Likely nor
Unlikely
Unlikely
Extremely
Unlikely
Don’t Know
Total
Responses
241 94 23 11 4 4 377
16

Item 8
FFT scores are calculated on a monthly basis using the following equation:
Proportion of respondents who would be extremely likely to recommend (response category:
“extremely likely”)
MINUS
Proportion of respondents who would not recommend (response categories: “neither likely
nor unlikely”, “unlikely” & “extremely unlikely”)
Figures detailing FFT rates for all acute Trusts will be published by the Department of Health
at the end of July, thereby providing a benchmark to measure progress against.
6. Patient Opinion
Over the past 12 months 108 comments have been posted, all of which have been
responded to. The top three areas for concern relate to attitude of staffing, communication,
and lack of information provided regarding care. In the past three months there has been a
notable increase in the number of compliments posted in the website, 58 of the postings
have been positive feedback. An example of a recent compliment from a gentleman who
was admitted as an emergency is shown below.
As arthritic sufferer, aged 73, I am most grateful for the reception, check, interest and respect taken
throughout by all the staff. Given the recent virulent criticisms of the NHS, I can only say a massive
"Thank You" to Derriford Hospital. Head of A&E can be proud of their team, and I Ieft feeling
comforted and re-assured.
7. Ward Audits
The Trust programme for audting all wards using the Meridian tool began in December 2011.
This report will now focus on the following Nursing Quality Indicators, the charts below
showing performance in the last year. The next quarter will see considerable changes to
questions as a result of triangulation.
17

Item 8
1. Pressure Ulcers (EoC)
2. Falls (EoC)
3. Hydration & Nutrition (EoC)
4. Observations - completeness and escalation (EoC)
5. Cleanliness
7.1 Essence of Care (EoC)
16255 individual patient audits have been completed up to 18 June 2013.
Pressure Ulcers
The essence of care audit assesses the following:
• Compliance with Waterlow assessment
• Compliance with up-to-date EPUAP assessment
Analysis/Action – this assures us that assessments are being undertaken. However, there
are two themes from our RCA’s; inaccurate assessment and inaction/wrong action following
assessment. The Safe Care Group will consider a paper in July proposing a revised
approach to measurement (outcome focussed) and a re-launch of intentional rounding.
18

Item 8
Falls
The essence of care audit assesses the following:
• Compliance with Morse assessment
• Compliance with up-to-date EPUAP assessment
Analysis/Action - This suggests that assessments of risks of falls are being undertaken on a
reliable basis. However, if does not tell us how these risk assessments have informed the
care plan or if the correct preventative measures have been put in place to reduce the risk of
falls in hospital. The Safe Care Group will consider a paper in July proposing a revised
approach to measurement (outcome focussed) and a re-launch of the Falls reduction
package across our wards.
Nutrition & Hydration
The essence of care audit assesses the following:
• Compliance with MUST assessment
• Where needed has a food chart been completed?
Analysis/Action - The newly formed Nutrition task and finish will review all feedback
regarding nutrition and develop an improvement plan to address patient feedback results,
reduce patient complaints and improve use of MUST assessment. The question in the local
inpatient survey will also be revised to ensure that vulnerable patients are being asked the
question; the current results indicate that the wrong patients are being asked if they received
help and thus the giving false assurance.
19

Item 8
Observations
The essence of care audit assesses the following:
• Have observations been performed at the required frequency
• Has there been a red trigger in the last 24hrs?
• What is recorded about escalation actions trigger?
Analysis/Action – these results would suggest that Observations are being done when
required and that triggers are being escalated. However, a recent spot audit undertaken on
one day suggested concerns about a lack of escalation. That said, different measures were
used during the spot audit and as a consequence, a review is underway. and a further spot
audit undertaken in July.
7.2 Cleanliness Audits
1951 audits have been completed up to 18 June 2013. The environment audit addresses a
number of cleanliness issues; the key issue being the cleanliness of commodes as part of
infection prevention and control. These audits include regular ‘Peer review’.
20

Item 8
Commodes
Analysis/Action – Whilst the position has improved over the past twelve months there
continues to be sporadic failures from both the meridian audit and the internal audit process
(latter improved recently). Meridian now sends a real time alert direct to a specified group
when a commode inspection fails; if any ward fails the commodes audit, they are
automatically monitored on a daily basis until the Matron is assured that the issues are
addressed (i.e. as evidenced by consistent non-failure of commode inspections).
21

Item 8a
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Serious Patient Safety Incidents and Complaints - Summary Review
June 2012 – May 2013
Patient Safety & Effectiveness Manager, Patient Experience Manager
Medical Director
Medical Director and Director of Nursing
Purpose
To provide the Board with a summary of serious incidents, serious and
significant complaints for June 2012 – May 2013, including common themes
and improvement programmes in place to avoid further harm.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
The Trust reported 64 serious incidents in the reporting period (June 2012 – May 2013) shown
in Annex 1. These have been categorised by type to provide assurance that themes and trends
have been identified and that improvement programmes are in place.
During the same period the Trust received 36 serious and significant complaints, shown as
Annex 2.
Quality Impact Assessment
This report provides assurance that progress is being made in meeting the Trust’s objective of
providing safe, effective and personal care to patients.
Financial Impact Assessment
Potential loss of income if Trust fails to meet CQC requirements and safety obligations.
Regulatory Impact Assessment
Applicable to all CQC regulations relating to Safety & Quality.
Key Recommendations
The Board are asked to note the contents of the report.
Next Steps
The Trust Board will continue to receive quarterly reports.
•
•

Annex 1
Item 8a
SURGICAL ERROR
• 4 Serious Incidents Reported (+ 3 surgical never
events in March 2013
• Common themes identified during investigation:
• Team working, culture and behaviour
• Lack of standardised process
• Surgical Safety Improvement Programme established
• Accountable Lead: Greg Dix
• Reporting to Safety & Quality Committee
VENOUS THROMBOEMBOLISM
• 2 Serious Incidents Reported
• Common themes identified during investigation:
• Failure to act on risk assessment
• Failure to administer prescribed prophylaxis
• VTE Improvement Workstream established
• Accountable Lead: Alex Mayor
• Reporting to Safe Care Group
DELAYED DIAGNOSIS/FAILURE TO ACT ON DIAGNOSTIC RESULTS
• 5 Serious Incidents Reported
• Common themes identified during investigation:
• Inadequate system to ensure results reviewed / acted on
• Inadequate failsafe to highlight un‐reviewed reports
• Radiology Improvement Workstream established
• Accountable Lead: Peter Macnaughton
• Reporting to Safe Care Group
UNEXPECTED DEATH OF ADULT
• 2 Serious Incidents Reported
• Common themes identified during investigation:
• None‐ remain under investigation
• Completed RCAs to be reviewed by Safe Care
Group to identify learning and required actions
Confidential Information Leak, 1
Venous Thromboembolism, 2
Delayed diagnosis or failure to act
on diagnostic results, 5
Unexpected death of adult, 2
Surgical Error (Retained foreign
object or wrong site surgery), 4
Maternity Incident, 2
Ward Closure / Infection Control
Incident, 10
Serious Patient Safety Incidents
Summary Review of Reported SIRIs
June 2012 – May 2013
Serious Incidents Reported by PHNT
Other, 3
WARD CLOSURE/INFECTION CONTROL
• 10 Serious Incidents Reported
• Common themes identified during investigation:
•
• Improvement Workstream established:
• Accountable Lead: Peter Jenks
• Reporting to Infection Control Committee
Unexpected death of child, 2
Inpatient fall, 3
Drug Incident (Insulin), 1
Follow Up Appointment Delay, 1
Hospital Acquired Pressure Ulcer
(3/4), 28
INPATIENT FALLS
• 3 Serious Incidents Reported
• Common themes identified during investigation:
• Failure to complete risk assessment
• Failure to act on risk assessment
• Safety Improvement workstream established
• Accountable Lead: Kevin Marsh
• Reporting to Nursing and Midwifery Board
UNEXPECTED DEATH OF CHILD
• 2 Serious Incident Reported
• Investigation ongoing
• Safe Care Group to review completed investigation
report and identify learning and necessary actions
HOSPITAL ACQUIRED PRESSURE ULCERS (3/4)
• 28 Serious Incidents Reported
• Common themes identified during investigation:
• Failure to complete risk assessment
• Failure to act on completed risk assessment
• Safety Improvement Workstream established
o Accountable Lead: Kevin Marsh
o Reporting to Safe Care Group
DRUG INCIDENT (INSULIN)
• 1 Serious Incidents Reported
• Common themes identified during investigation:
• Failure to follow Hyperkalaemia treatment
guidelines
• Safe Use of Insulin Improvement Workstream
established
• Accountable Lead: Daniel Flanagan
• Reporting to Safe Care Group
FOLLOW UP APPOINTMENT DELAY
• 1 Serious Incidents Reported (Ophthalmology)
• Common themes identified during investigation:
• Waiting lists not prioritised by clinical risk
• Inadequate capacity to meet demand
• Follow Up Backlog Improvement Workstream
established
• Accountable Lead: Paul McArdle
• Reporting to Safety & Quality Committee

Annex 2
Item 8a
Summary of Serious and Significant Complaints (June 2012 – May 2013)
Serious and Significant Complaints by Sub‐type
Adverse outcome of
Operation/Surgery, 3
Weekend Discharge,
1
Aspects of Clinical
treatment, 6
Clinical Review , 1
Communication to
Patient/Relatives, 2
Conflicting Clinical
Decisions, 1
Incorrect diagnosis
(where no
treatment), 7
Breakdown of Complaints by Grading
Number of Serious Complaints = 11
Number of Significant Complaints = 24
Number of Significant Professional Complaints = 1
Breakdown of Complaints by Directorate
Clinical Support Services = 2
Ophthalmology = 1
Emergency Services = 9
Medical Specialties = 3
Orthopaedics & Rheumatology = 2
General
impoliteness/indiffer
ence, 1
Clinical Review, 3
Pain Control, 1
Outpatient delay, 2
Inpatient Delays, 1
Incorrect Diagnosis,
1
Drug error/incident,
3
Slips, Trips and Falls,
2
Inappropriate
Discharge, 1
Gastroenterology, Surgery and Renal = 10
Oncology & Blood Services = 1
Head & Neck Surgery = 2
Neurosciences = 2
Reproductive Health, Neonatal & Women's
Services = 2
Children & Young People's Health = 1
Anaesthetics, Theatres & Pain = 1

Item 9
SUMMARY REPORT
Trust Board 5 July 2013
Subject Performance Report (Month 2)
Prepared by
Approved by
Presented by
Purpose
Advanced Performance Analyst
Deputy Head of Performance
Chief Executive and Executive Leads
This paper highlights and summarises the key performance issues that have
arisen during May 2013, describes the mitigating actions and provides an
assessment of the future projected performance risk.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
• • • •
Executive Summary
This is the integrated performance report for May 2013 and formally reports much of the data
that was covered verbally at the June 2013 Board.
As with previous reports, performance against key indicators is mixed with a number of areas of
positive performance for example VTE risk assessment. In some cases such as achievement
of the ED 4 hour target performance has improved markedly on April and continues to improve
in June 2013. This is also the case with cancelled operations where performance has
improved significantly in recent weeks.
Of concern is the deterioration of performance against the 6 week diagnostic target and this is
largely explained by failure in one area and a further verbal update will be given at Board
regarding action to resolve. Exception reports for Stroke, cancer 62 day and cancelled
operations are included at annex 2, 3 and 4.
Quality Impact Assessment
The safety and quality section of the report highlights positive performance against a range of
indicators and this will be explored further in the quarterly quality report to this Board.
Financial Impact Assessment
The financial position of the Trust is on plan at month 2 although significant actions are required
to ensure the achievement of the cost improvement programme.
The contract position at month 2 is significantly under achieving from a financial perspective as
a result of a lower case mix, lower activity in key areas and contract fines. Emergency activity is
already above plan. Whilst the financial impact is mitigated in 2013-14 due to the nature of the
contract signed the recurring impact if this continues is of significant concern and action is
required to understand the position in more detail.
Regulatory Impact Assessment
This paper addresses the performance of the Trust against its statutory financial and performance
duties and against Trust Development Authority and Monitor financial standards.
•
•
1

Item 9
Key Recommendations
The Trust Board is asked to:
1. Note the monthly position and update of the Trust on performance for Month 2.
2. Review the summary of performance exception reports for stroke, cancer 62 day and cancelled
operations detailed in Annex 1-4.
Next Steps
The Board will be provided with monthly updates on our performance.
2

Item 9
DETAILED REPORT
Trust Board June 2013
Subject Performance Report (Month 2)
Prepared by
Approved by
Presented by
1 Introduction
Advanced Performance Analyst
Deputy Head of Performance
Chief Executive and Executive Leads
This paper summarises Trust performance against the key national and local targets up to
end of May 2013. Mitigating actions are described where underperformance is identified.
This report accompanies the detailed Performance Dashboard for May 2013.
2 Safety & Quality
The below diagram provides headlines on current performance across the safety and
quality domain.
Safe
Care
The Trust remains top performer in the South‐West for HSMR and benchmarks well for SHMI
Incident reporting rate remains in the national upper quartile demonstrating a positive reporting culture
% of incidents resulting in harm remains above internally set threshold
Effective
Care
The Trust's readmission rate is ~4% better than expected
Despite positive performance against expected levels, the Trust does not benchmark well vs other SW Trusts
SAFETY
&
QUALITY
Patient
Experience
% of complaints responded to in timeframe remains above target
Zero non‐clinically justified single sex breaches this year
Friends and family test response rates are below suggested levels of 15%
Number of cancelled operations and associated 28‐day breaches remains high
Infection
Control
Zero cases of hospital apportioned MRSA this year
Number of hospital apportioned C‐Diff cases remains below trajectory
No ward closures for Norovirus
Other
>95% of eligible patients risk assessed for VTE in April and May
Hip fracture and stroke targets failed in April and May
Follow‐up backlog continues to grow
Safe Care (Section B1 of Performance Dashboard)
2.1 The Trust continues as the South-West’s top performer for HSMR and performs
approximately 5% better than expected for the SHMI measure. These areas remain
under scrutiny via the Clinical Effectiveness Group.
2.2 The Trust’s incident reporting rate of 9.7 incidents per 100 admissions remains within
the national upper quartile and demonstrates a positive reporting culture. Conversely,
the data demonstrates a harm rate above the internal threshold set at 28%.
2.3 Surgical safety checklist compliance remains high (98% in May) however the data
shows that particular specialties continue to underperform in this area. A review of the
data is underway to ensure that instances where only a partial checklist is required
are not counting against the service lines inappropriately.
3

Item 9
Effective Care (Section B2 of Performance Dashboard)
2.4 The Trust’s readmission rate remains ~3% lower than expected resulting in a
benchmarked South-West position of 12 th from 18 Trusts.
Patient Experience (Section B3 of Performance Dashboard)
2.5 The friends and family test was introduced to the Trust in April and has started to
feedback information about patient opinion. Although we are yet to reach the
recommended response rate of 15% for both cohorts (A+E and inpatients) the data
shows a gradual improvement in the number of A+E attendees recommending our
service but conversely a reduction in the number of inpatients who would recommend
the Trust.
2.6 61 operations were cancelled on the day of admission for non-clinical reasons in May
representing 1.27% of all elective admissions. This is a significant improvement on
April which saw 130 operations cancelled on the day (2.65% of all elective
admissions). The availability of general beds continues to be the most prevalent
reason for cancellation. See Annex 3 for exception report.
Infection Control (Section B4 of Performance Dashboard)
2.7 The Trust has reported no cases of hospital apportioned MRSA this year whilst the 4
cases of hospital apportioned C.Difficile are in line with the trust’s trajectory of no
more than 2 cases per month.
2.8 Patient level MRSA screening for elective admissions has reduced to 91% in May,
5% lower than this time last year. This drop in performance has been escalated at the
Matrons meeting and individual pockets of poor performance are being addressed.
2.9 The Trust has reported no ward closures due to Norovirus in 13/14.
Other Quality and Safety Measures (Section B5 of Performance Dashboard)
2.10 The Trust continues to achieve the national VTE risk assessment standard with 95%
of eligible patients being risk assessed. Work continues to focus on those areas
where non-compliant patients are identified whilst qualitative audits are also
underway to ensure the procedure is being carried out effectively.
2.11 The Trust has failed to operate on at least 85% of fractured neck of femur patients
within 36hrs of admission in April and May. Of the 13 May patients who failed to get to
theatre within the required timeframe, 8 were medically unfit.
2.12 Despite an improvement on April’s performance (59%), the Trust has failed to deliver
the stroke target in May with only 67% of stroke patients spending 90% or more of
their stay on the acute stroke unit. See Annex 1 for exception report.
2.13 As at the 31 st May, the follow-up backlog had risen to 24,305 patients, an increase of
767 patients from April.
4

Item 9
3 Access and Activity
The below diagram provides headlines on current performance across the access & activity
domain.
A&E
A+E 4hr wait target failed in April and May
30‐min ambulance handover target failed in April and May
Cancer
Year‐to‐date failure of 62‐day urgent referral and screening cancer targets
Remaining seven cancer targets remain on target in‐month and YTD
ACCESS
&
ACTIVITY
RTT
April and May failure of incomplete pathways and admitted pathways 18‐week RTT targets
Decision‐to‐treat and non‐admitted RTT backlogs continue to grow
Admitted backlog reduction remains on plan
Diagnostics
173 patients (2.8% of total list) were waiting over 6 weeks for a diagnostic test at end of May
Other
Non‐elective activity remains below plan
Average medical outlier occupancy has reduced in May
Small reduction in medical and surgical length of stay in May
Access to rapid access chest pain clinic, GUM and primary PCI remain above target
Medical Admissions remain greater than plan
Accident and Emergency (Section B1 of Performance Dashboard)
3.1 A&E 4hr wait performance improved significantly in May but fell just short of the 95%
national standard at 94.8% (402 patients waited longer than 4hrs). Performance
continues to improve throughout June and although current trajectory suggests we
can expect an in-month performance in excess of 97%, performance for the quarter is
likely to fall short of the 95% target. This will impact our Monitor governance risk
rating detailed later in this report.
3.2 We continue to report ambulance handover delays of greater than 30 minutes.
Despite this, performance in May did improve significantly with just 36 breaches
reported compared to 64 in April, resulting in a May performance of 1.2%.
Cancer (Section C3 of Performance Dashboard)
3.3 All cancer targets have been met both in-month and year-to-date with the exception
of the 62-day urgent referral standard which failed in April and May, and the 62-day
screening target which is below target year-to-date after a particularly poor April
performance. There was no common cause relating to the screening target failure
although in 4 cases the patient chose to delay by a number of days whilst considering
treatment options.
5

Item 9
Description
31 days from 'decision to treat' (%)
62 days from urgent GP referral (%)
62 days from screening referral to treat (%)
62 days from consultant upgrade to treat (%)
31 days ‐ DTT to subsequent ‐ surgery (%)
31 days ‐ DTT to subsequent ‐ drugs (%)
31 days ‐ DTT to subsequent ‐ rad'th'py (%)
2 weeks for breast symptom referral (%)
2 weeks from urgent GP referral (%)
Apr May YTD Target RAG
O,A,Q,M 98.2% 99.2% 98.7% 96% Green
O,A,Q,M 81.9% 84.4% 83.1% 85% Red
O,A,Q,M 79.2% 92.7% 85.4% 90% Red
O,Q 100.0% 92.6% 95.7% 85% Green
O,A,Q,M 96.7% 94.4% 95.6% 94% Green
O,A,Q,M 99.1% 99.3% 99.2% 98% Green
O,A,Q,M 98.0% 97.5% 97.8% 94% Green
O,A,Q,M 95.7% 96.1% 95.9% 93% Green
O,A,Q,M 93.2% 95.1% 94.1% 93% Green
The Trust reported 20.5 breaches of the 62-day urgent referral standard in May, of
which 9 were outside of the Trust’s control (i.e. due to patient choice or for medical
reasons associated with tertiary referral). Of the remaining 11.5, 9 were due to delays
in diagnostic tests or treatment planning.
Year-to-date performance for the 62-day screening target is still suffering from the 5
breaches reported in April. The trust reported only 1.5 breaches in May.
See Annex 2 for exception report.
Due to recent internal process changes we have seen a significant improvement in
the number of urgent 2 week wait referrals who have been seen within 10 days. The
table below shows the detail of the improvement:
Oct ‐ Dec 2012 Jan‐13 Feb‐13 Mar‐13
Apr‐13
May‐13 Jun‐13
Cancer Site
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Num
Seen
% in 10
days
Grand Total 4174 38.05% 1287 52.21% 1272 45.36% 1331 45.83% 1383 50.98% 1406 61.81% 509 57.96%
Referral to treatment (Section C4 of Performance Dashboard)
3.4 Admitted and incomplete pathways 18-week standards have failed for the second
consecutive month due to a continued and planned clearance of the admitted backlog
(backlog reduced by 211 patients to 1215 as at 17 th June).
Detailed specialty level recovery plans have been developed that include recovery
trajectories spanning 13/14. Due to the complex nature of the actions required and
the size of the backlog, these plans indicate that certain areas will be unable to
recover to a sustainable position until January 2014. As reported at the last Board
this target will be failed during quarter 2 due to the continued and planned clearance
of the backlog.
6

Item 9
Diagnostics & surveillance (Section C6 of Performance Dashboard)
3.5 Diagnostic wait performance has deteriorated in May with 2.8% of the total waiting list
(173 patients) waiting longer than 6 weeks for a diagnostic test at the end of May.
Of the 173 breach patients, the majority (79) were waiting for an Echocardiogram. A
number of options are being considered to address the capacity issues identified by a
review of this modality. These options include employing external cardiology
technicians to carry out tests using our facilities although this additional support would
not be available until August. In the meantime, the department are putting on
additional lists to provide extra capacity.
31 patients were waiting for an Endoscopy due to a complex mix of issues ranging
from patient choice to staff availability for specialist paediatric and general
anaesthetic cases.
52 patients were waiting for Imaging - 12 MRI scans and 14 CT scans were delayed
due to staff availability for specialist cases and breakdown of the Alliance scanner
whilst 26 ultrasound delays were due to unusual levels of staff unavailability.
A more detailed report on diagnostic delays is being developed with the service line
and will be made available to the Board when complete.
4 Finance & Efficiency –
4.1 A separate report on the Trust’s financial position is being presented to the Trust
Board by the Director of Finance.
4.2 This section of the report will provide the Board with an update on key contract issues
including activity variances as well as full details on contract penalties and CQUIN
achievement.
4.3 Contract Position
4.4 If the Trust was on a fully variable contract it would, at Month 2 owe commissioners
£1.4m. Key issues to highlight from this high level analysis are the continuing
significant underperformance on elective care, and the level of contractual penalties
incurred.
4.5 Elective activity is underperforming at Month 2 by 126 spells (1.2%) under plan and
£1m under on income. This income underperformance is significant being 8% below
plan. Key specialties with underperformance are cardiac surgery (£189k) where they
are still suffering cancellations. In April, 43 theatre slots were lost, and in May 25 slots
were lost. ITU capacity was a key issue, but staffing levels have now been addressed
so performance should improve back to contract level in future. However, if the lost
capacity from the first few months is not recovered through future over-performance
the Trust will continue to under-perform for the year. In Neurosurgery the activity is
only slightly under plan but the income variance is £275k under plan due to case mix.
Neurosurgery has capacity gaps that are being addressed through extended days
and more formalised weekend working. Plastic Surgery is continuing to underperform
(£221k) with reduced theatre capacity and under-utilisation of the plastics trauma
theatre. Waiting lists are beginning to rise slightly. Further work is being done to
understand the picture more fully.
7

Item 9
4.6 Non Elective Activity is overall 455 spells under plan and £181k under the income
plan. Within this, Obstetric activity is underperforming (120 spells under for birth
HRGs year to date) as is Neonatology. This underperformance masks the fact that
emergency activity is over performing by 228 (3%) spells and £641k income. This
over-performance on emergency activity continues to impact on the Trust’s elective
capacity. The Trust therefore needs to continue to work with commissioners on
reducing emergency demand, otherwise it will continue to impact upon elective work.
4.7 A&E remains fairly close to plan, though there is a continuing shift towards a more
complex case mix.
4.8 Outpatients are over performing on first outpatients, but this is offset by an
underperformance on outpatient procedures. Further effort is required to work down
the follow up backlog. Wherever possible, this needs to be done by alternatives to
face to face contacts, with minimal resource required. An active discussion with the
CCG is on-going.
4.9 There are further contractual financial penalties in 2013-14 compared with 2012/13.
The Trust has incurred £427k of contractual penalties to Month 2. The key figures
within this are for RTT £260k, Diagnostic Waits £47k and Cancelled Operations £52k.
RTT is being intentionally breached over the first part of this year, to ensure backlogs
are cleared and to put the Trust in a sustainable RTT position moving forward. Under
the Managed PbR arrangements, penalties are returned to the Trust to invest in
corrective action.
4.10 As the Board will be aware the Trust’s contract will operate on a managed payment
by results (PbR) basis. For month 2 this means that the variance to date of £1.4m is
significantly mitigated as only the variable and semi variable elements of the contract
have an impact on the Trust’s financial position in 2013-14. The variance after return
of fines and the managed PbR adjustment is £0.136m with the significant adverse
variance being cardiac surgery offset by stem cell transplant activity.
4.11 Although the financial variance is significantly mitigated due to the contract agreed
the early signs are of concern and the overall contract position to date will need
further review and close monitoring to ensure that we have a full understanding of the
issues as well as having mitigating actions in place.
4.12 In respect of CQUIN (Quality payments) measures for the year these are at the final
stages of agreement and we expect to be able to start reporting these at the end of
quarter 1.
5 Workforce
Month 2 has seen a small increase in establishment with a similarly small rise in staff
in post. There have also been sharp reductions in discretionary pay and sickness
absence.
Key variances are:
Staff in post (Section E1 of Performance Dashboard)
5.1 The budgeted establishment has increased in Month 2 by 7 WTE to 5,754, WTE and
staff in post has increased in Month 2 by 6 WTE to 5,398.
8

Item 9
Discretionary pay (Section E1 of Performance Dashboard)
5.2 Discretionary pay has reduced by £373k in Month 2 to £1.38m. This is principally due
to a large reduction in nursing bank and agency.
Training and Appraisals (Section E2 of Performance Dashboard)
5.3 The completion of mandatory essential skills training has remained static in Month 2
at 95%. Child protection has also remained static at 97%. Manual handling and basic
life support have both decreased slightly by 1% to 92% and 87% respectively.
Appraisal completion rates (for non-medical staff) have remained static in Month 2 at
82%.
Sickness Absence (Section E3 of Performance Dashboard)
5.4 Sickness absence has decreased in Month 2 from 4.34% to 3.63%, with the 12 month
average sickness absence rate also continuing to decrease to 4.44%.
In terms of sickness absence rates within staff groups, the staff groups with combined
short and long term absence of more than 4% are Estates (5.42%) and Additional
Clinical Services (6.13%).
More robust management of poor attendance is being implemented alongside a
range of prevention and wellbeing initiatives.
A number of interventions have been put in place to support the health and wellbeing
of staff and increase their resilience. The Occupational Health and Wellbeing
Department’s Employee Assistance Service provide counselling, mediation, mental
health advice and a range of education and training including:
• Preventing Stress
• Understanding Stress
• Promoting Positive Manager Behaviour (which is run for managers)
• Building Resilience (which is available for all staff, as well as a group intervention)
• Self-Care course (to help staff focus on their own individual health and wellbeing).
Alongside the implementation of a new Sickness Absence Policy, the contracts of
employment of 17 individuals having been terminated in the past 6 months, following
persistent absence associated with health issues.
6 Compliance with Monitor’s Requirements
Governance Risk Rating (Section F1 of Performance Dashboard)
Continued failure of the A&E 4 hour target and 62 day cancer standards in addition to
the failure of RTT admitted and incomplete pathways have resulted in a ‘Red’ rating
for May. We anticipate a final Q1 position of 4.0 (Red), with the same four standards
failing the quarter.
9

Item 9
Summary of performance exception reports Annex 1
Performance Area Previous report Forecast and performance summary Further report?
A&E 4 Hour Standard June 2013 91.7% in April, improved to 94.8% in May. June performance currently above 97% but
unlikely to save the standard for Q1.
Referral to Treatment
(Admitted patients)
June 2013
Target failed at 88.3% in April and May. This is a planned failure to allow clearance of a
large backlog of patients. Trust-wide compliance with target expected during Q3 whilst
recovery of certain service-lines will take until year-end.
Cancelled operations June 2013 We previously reported actions being taken to achieve a 0.8% sustainable position.
May performance at 1.27%, a significant improvement on April (2.65%). This is linked to
the bed base proposals as reported to the June Board.
Diagnostics February 2013 Performance has deteriorated in May to 2.8% from 1.6% in April.
We forecast failure of this target in June due to capacity issues for Cardiac
Echocardiogram. Additional capacity not available until July.
Stroke February 2013 We previously said we would achieve the target of 80%.
April and May have both failed at 59% and 67% respectively.
Cancer
(62 day standards)
March 2013 We previously said this would be fully achieved by April 2013.
62-day screening target has improved in May but is still failing year-to-date.
62-day urgent referral has failed in April and May (81.9% and 84.4% respectively)
The attached exception report details two key actions that will allow the Trust to achieve
the target from September 2013.
Annex 4
A further detailed
analysis of this area
will be completed for
the next Board
Annex 2
Annex 3
Follow-up backlogs February 2013 Backlog continues to grow with an extra 767 added in May bring total to 24,305. A further detailed
report agreed via
IPAM will come to
Board when complete
10

Item 9
9 Performance Exception Report Annex 2
Stroke patients who spend at least 90% of their time in Hospital on a
Stroke Unit based on Days
Performance summary
Performance from May was 66.7%, an improvement on the April position but still below the
national standard of 80%.
Update on previous actions
Burrator has been ring-fenced throughout May to be used only for neurosciences. The
intention is that this will lead to an increase in the bed availability for acute stroke patients to
be admitted directly from the emergency department. The impact of this can be seen in the
reduction in the number of patients who were identified as a stroke within the ED but were
not directly admitted to the stroke unit due to bed availability from a volume of 10 patients in
April breaching for this reason to 3 patients in May (2 patients in June so far)
Further planned action
Action Lead Deadline
Continuous review patients who were not assessed in the
emergency as query stroke but who subsequently were
diagnosed with a stroke later in their journey
Establishment of clear patient flows to ensure any
patients admitted to Burrator who are not stroke patients
can be moved in a timely manner.
Review potential for establishment of a high care nursing
area within Burrator to allow for escalated levels of care
for patients who currently are admitted to ICU or MAU lvl
1
David Alao
Davina Finch
Davina Finch
Monthly
review
End July
End July
11

Item 9
Ensure that all patients admitted through ambulatory care
are appropriately recorded as outpatients during their
ambulatory care episode
Review care pathways for patients coded as breaching
due to a short length of stay to identify actions to address
Identification of best performing Trusts to compare
working practices and additional actions to deliver
sustainable change.
Forecast
Donna Clewer
Edna Piper
Donna
Clewer/Rachel
Bottell
Expected impact of improvements to be achieved by September 2013
Mid July
Mid July
Mid July
12

Item 9
Performance Exception Report Annex 3
62 Day "GP Urgent referral to Treatment"
Performance summary
May Performance was 84.4% and 83.1% year to date.
Of the 20.5 breaches in May, 11 were deemed to be influenced by reasons under the control
of the trust. 9 Diagnostic delay breaches, 1 Insufficient Outpatient Capacity and 1 Insufficient
Inpatient Capacity.
Update on previous actions
The High level Cancer Action Plan contains 20 specific actions,
9 are flagged as Green, 7 are flagged as Amber and 4 as Red.
Red – Plans in place but concerns about delivery
Amber – Plans in place and action progressing
Green – Plans complete or in place
Further planned action
Action Lead Deadline
Urology - Implement pre biopsy MRI for high risk patients
Urology - Implement active surveillance for low risk
patients
Lung - One stop shop. Resolve consultant capacity
Paul Hunter-
Campbell/Jemma
Edge
Paul Hunter-
Campbell/Jemma
Edge
Lee Johns/Tim
Howells
July 2013
July 2013
July 2013
13

Item 9
Forecast
Significant progress has been made to implement a new pathway within lung and urology.
However due to the patients currently in the system it is unlikely this will be realised until
September. It is anticipated with all the changes small but steady sustainable progress will
be made. However once changes have been embedded it is recognised that continued
progress with all sites is required to ensure all patients where appropriate are treated within
the 62 day standard.
14

Item 9
Performance Exception Report Annex 4
Cancelled Operations
Background
Performance Summary
During 2012/13 the trust struggled to achieve a low level of Cancelled operations. During
the second half of the year this was principally due to excessive medical outliers occupying
surgical beds. In cardiac high rates were seen and the key identified caused was ITU
occupancy. The key performances are highlighted in tables 1-4 below.
Table1. Trust cancelled ops
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
53 93 61 69 55 75 71 62 70 89 94 108
1.2% 1.7% 1.3% 1.3% 1.1% 1.6% 1.4% 1.2% 1.6% 1.8% 2.0% 2.2%
Table2. Medical outliers
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
33 17 18 10 14 10 22 46 54 64 60 60
Table3. Cancelled elective cardiac cases
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TOTAL
69 83 72 86 83 80 87 84 86 89 78 82 979
5 7 2 7 8 7 9 10 8 11 17 12 103
7.2% 8.4% 2.8% 8.1% 9.6% 8.8% 10.3% 11.9% 9.3% 12.4% 21.8% 14.6%
* Note: Total cardiac activity was 1149 cases including ‘white board’ patients.
10.5%
It is clear that although a trust decision to expand cardiac ICU beds was taken – the reality
was that staff availability and agency availability did not meet expectation (increase of
11WTE needed) to allow this.
15

Item 9
Update on previous actions
Current Actions
Key actions taken in April and May include:
• ‘Winter ward’ Monkswell remains open – this has significantly improved the start of
lists and cancellations in May and June.
• Redefinition of list starts to enable theatres to start on time. This has greatly
improved in May and June. Theatres now have a ‘green light’ to start first case as
long as trust is not at ‘black’ status. (Subject to HDU and level1 patients detailed
planning). This is actively addressing lost time and overruns.
• Gradual increase in staff In CICU – although we predict this will take to October to be
fully established.
Table 4. Trust cancelled ops
April May June (25 th )
130 61 30
2.6% 1.3% 0.6%
•
Further Planned Action
Action Lead Deadline
Re-Establishment of patient call 3-4 days before surgery
( Trust target)
Opening of additional short stay ward in Autumn –
should have 20+ bed impact on reduction of medical
outliers. ( Trust target)
Relocation of SAU and ring fencing from medicine
(reduce medical outliers)
Re fresh of clinical ownership for list contents (increased
commitment and confidence in list make up) Trust target.
Increase of Main ITU bed compliment (probably not until
Q3). Both targets.
Modelling of detailed LOS splits in main and Cardiac
ITU. (To understand variability on LOS and whether
predictable groupings). Both targets.
Forecast
It is expected that the Trust target will achieve the 0.8% target going forward. Clearly the
whole occupancy model for both ITU’s into winter will affect the overall result and may need
more modelling. It is expected that Cardiac cancellations will improve post October to be in
line with other centres at 8%
16

Trust Board Performance Report
Report on performance to the end of May 2013

Contents
EXECUTIVE SUMMARY D FINANCE & EFFICIENCY
A1 Summary performance dashboard D1 Income & Expenditure
D2 Cost Improvement Plan (CIP)
B SAFETY & QUALITY D3 Capital expenditure
B1 Safe care D4 Cash management
B2 Effective care D5 CQUIN & Contract Penalties
B3 Patient experience
B4 Infection control E WORKFORCE
B5 Other safety & quality metrics E1 Staffing numbers
E2 Training & appraisals
C ACCESS & ACTIVITY E3 Sickness absence
C1 Accident & Emergency
C2 Non-Elective Activity F EXTERNAL ASSESSMENTS
C3 Cancer services F1 Monitor's Governance Risk Rating
C4 Referral to treatment (RTT) F2 Monitor's Financial Risk Rating
C5 Elective and Outpatient Activity
C6 Other access & activity metrics
Rationale for Inclusion
The following key indicates the source of the metrics included on pages B1 - F2
O - National Operating Framework, A - SHA Acute Performance Framework, CQ - National or locally agreed CQUIN target,
M - Monitor Governance Framework, Q - NHS Contract Quality Requirement

OTHER
ACCESS & ACTIVITY
Acting Chief Operating Officer
WORKFORCE
Human Resources Director
SAFETY & QUALITY
Medical Director & Acting Chief Nurse
FINANCE & EFFICIENCY
Acting Director of Finance
A1
Summary performance dashboard - May 2013
Status Ranking Page Metric Status Page
Safe Care
Income & Expenditure
Hospital Standardised Mortality Ratio (HSMR Relative Risk) 83.0 YTD 1/17 (SW YTD) £000s variance from plan (Month) (26)
Summary Hospital-Level Mortality Indicator (SHMI ) 95.5 YTD 6/17 (SW YTD) £000s variance from plan (Year To Date) (54)
D1
% Surgical safety checklist completion 98.0% M2
B1
Cost Improvement Programme
Incidents Reporting Rate (per 100 admissions) 9.70 M2 Full year forecast variance from target (£000s) 1,700
% incidents leading to harm, loss or damage 32% M2 CIPs Delivered (£000s) 6,048
Effective Care
CIPs Forecast as Green Risk (£000s) 10,937 D2
Readmissions (13 Month Avg Relative Risk) 97.0 YTD 12/17 (SW YTD) B2 CIPs Forecast as Amber Risk (£000s) 7,274
Patient Experience
CIPs Forecast as Red Risk (£000s) 1,441
Friends and Family Test Response Rate (Inpatient) 13.7% M2
Capital Expenditure
Friends and Family Test Response Rate (ED) 8.4% M2 % of capital programme spent 12% D3
Complaints closed within target (%) 85% M2
B3
Cash Management
Non-clinically justified mixed sex breaches (No.) 0 M2 Revised Planned Closing Cash Balance (£'000s) 3,226
Cancelled operations (% of elective FFCEs) 1.96% YTD Actual Closing Cash Balance (£'000s) 8,761
Infection Control
Cleared Balances (£'000s) 9,409
MRSA cases (hospital apportioned) 0 YTD 8 / 17 (SW YTD) BPPC - NHS Volume (% within target) 97% D4
B4
C-Diff cases (hospital apportioned) 4 YTD 4 / 17 (SW YTD) BPPC - NHS Value (% within target) 98%
Other key safety & quality metrics
BPPC - Non-NHS Volume (% within target) 95%
% stroke patients >90% of time on stroke unit 62.6% YTD BPPC - Non-NHS Value (% within target) 90%
B5
Follow-up backlog - actual (no.of patients) 24305 YTD
Contract Penalties
Accident & Emergency
Contract Penalties - Year-to-Date (£000's) 427 D5
% of A&E patients waiting 30 mins) 1.7% YTD C1
Discretionary Spend (£000s) 1380
Delayed transfers of care (delayed days as % of occupied days) 1.7% YTD Vacancy % - Nursing 5.52%
Cancer Services
Vacancy % - Medical 7.07% E1
31 days from 'decision to treat' (%) 98.7% YTD 102/168 (Nat Q3) Vacancy % - Admin & Managers 6.60%
62 days from urgent GP referral (%) 83.1% YTD 153/167 (Nat Q3) Vacancy % - Other Staff 6.47%
62 days from screening referral to treat (%) 85.4% YTD 133/145 (Nat Q3)
Training & Appraisals
62 days from consultant upgrade to treat (%) 95.7% YTD 64/154 (Nat Q3) Basic Life Support (% completed) 87%
31 days - DTT to subsequent - surgery (%) 95.6% YTD 140/162 (Nat Q3) C3
Manual Handling (% completed) 92%
31 days - DTT to subsequent - drugs (%) 99.2% YTD 4/152 (Nat Q3) Essential Skills (% completed) 95% E2
31 days - DTT to subsequent - rad'th'py (%) 97.8% YTD 69/78 (Nat Q3) Child Protection (% completed) 97%
2 weeks for breast symptom referral (%) 95.9% YTD 43/143 (Nat Q3) Appraisals (% completed) 82%
2 weeks from urgent GP referral (%) 94.1% YTD 150/170 (Nat Q3)
Referral To Treatment (RTT)
18 weeks - Admitted patients (%) 88.3% M2 160/174 (Nat M12)
18 weeks - Non-admitted patients (%) 95.9% M2 195/207 (Nat M12)
18 weeks - Audiology Direct Access (%) 97.3% M2
C4
% Incomplete pathways within 18 weeks 90.3% M2 187/206 (Nat M12)
Other key access & activity metrics
% patients waiting >6 weeks for diagnostic test 2.8% M2 C6
Sickness Absence
Trust Sickness Absence Rate (Average %) 3.63% E3
External Assessments
Monitor's Governance Risk Rating
Monitor's Financial Risk Rating
Red 0% (4.0)
2
F1
F2
3

B1
Safe care
Description
Hospital Standardised Mortality Ratio (HSMR Relative Risk)
Summary Hospital-Level Mortality Indicator (SHMI Relative Risk)
% Surgical safety checklist completion
Incidents Reporting Rate (per 100 admissions)
% incidents leading to harm, loss or damage
Never Events
Overdue safety alerts
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
85 83 83.0 100.0 Green R > 100 G < 100
95 96 95.5 100.0 Green R > 100 G < 100
96.8% 98.0% - 95% Green R < 92% G > 95%
9.8 9.7 - 7.5 Green R < 6.00 G > 7.50
33% 32% - 28% Red R > 28% G < 28%
Q 0 0 0 0 Green R > 0 G < 1
3 3 - 0 Red R > 0 G < 1
120
100
80
60
Mortality (HSMR)
(13 - Month Avg for Feb 12 - Feb 13)
Actual
Lower is better
ANALYSIS OF KEY PERFORMANCE INDICATORS
National Average
120
100
80
60
Summary Hospital Mortality Indicator (SHMI)
(13 - Month Avg for Jan 12 - Jan 13)
Lower is better
COMMENTARY
Mortality
The Trust continues to perform well in respect of
HSMR (17% better than expected) and the SHMI (4%
better than expected). The mortality data presented
is approx 4/5 months in arrears due to the lag time
required for all UK Trusts to submit to the National
database and results to be analysed. Individual
diagnosis / procedure groups flagged as a concern
are reviewed via the Clinical Effectiveness Group.
40
20
-
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Surgical safety checklist completion
100%
Higher is better
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
40
20
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Incident Reporting Rate per 100 admissions
12.0
10.0
Higher is better
8.0
6.0
4.0
2.0
-
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Incident Reporting
Our reporting rate sits firmly within the national
upper quartile with a rate of 9.7 incidents per 100
admissions reported in May 2013. This reporting rate
is significantly above the national average of ~7.5
and provides evidence that we have a good culture
of openly reporting incidents.
4

Readmissions Relative Risk
B2
Effective care
Description
Readmissions (13 Month Avg Relative Risk)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
96.4 97.0 97.0 100.0 Green R > 100 G < 100
ANALYSIS OF KEY PERFORMANCE INDICATORS
COMMENTARY
Hospital Readmissions (Source : HED)
The readmission relative risk is a statistical
calculation that measures the overall rate of
readmissions within a hospital, compared with a
national benchmark.
The ‘all diagnoses’ readmission rate for Plymouth
Hospitals NHS Trust for the 13 month period to Jan
2013 was 97.0, a readmission rate 3% better than
expected.
The Trust's Clinical Effectiveness Group continues to
monitor any diagnosis or procedure groups which
flag as a readmission 'alert'.
The latest SW SHA benchmarking position is provided
in the bottom graph.
5

Response Rate
Recommender Score
B3
Patient experience
Description
Friends and Family Test Response Rate (ED)
Friends and Family Test Response Rate (Inpatient)
Friends and Family Test Result (ED)
Friends and Family Test Result (Inpatient)
Complaints closed within target (%)
Complaints Backlog (i.e. past their 'reply by' date)
Non-clinically justified mixed sex breaches (No.)
Cancelled operations (% of elective FFCEs)
28 day rebooking breaches (% of cancelled ops)
Friends and Family Test
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Friends and Family Test Response Rate (ED)
Friends and Family Test Response Rate (Inpatient)
Friends and Family Test Result (ED)
Friends and Family Test Result (Inpatient)
Reasons for Cancellations
Anaesthetist Sick/Unavailable
Anaesthetist On Leave
Surgeon Sick/Unavailable
Surgeon On Leave
No General Bed Available
No Critical Care Bed Available Post Operatively
Equipment Missing/Failure
No Space On Theatre List/Emerg Took Priority
Theatre List Overran
Lack Of Theatre Staff
Other
Total
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
5.3% 8.4% 5% 15% Red R < 15% G > 15%
11.5% 13.7% 12% 15% Red R < 15% G > 15%
52.1 54.4
66.2 63.1
85% 85% - 80% Green R < 60% G > 80%
11 12
O,A,Q - - - - Green R > 10 G < 0
Q 2.65% 1.27% 1.96% 0.8% Red R > 1.5% G < 0.8%
Q 3.8% 9.8% 5.8% 5.0% Red R > 5% G < 5%
ANALYSIS OF KEY PERFORMANCE INDICATORS
COMMENTARY
Complaints closed within target (%)
Friends and Family Test
Complaints
Complaints Backlog (i.e. past their 'reply by' date)
From April 2013, all patients will be asked a simple
70 100%
100
question to identify if they would recommend a
60
particular A&E department or ward to their friends
95%
80
and family. Trusts are expected to reach a minimum
50
15% response rate to ensure an adequate sample
90%
60
size. Recommender scores are also provided.
40
85%
40
30
Complaints
80%
20 The Trust responded to 85% of complaints within
20
target during May. The complaints backlog is 12
10
75%
0 overdue cases.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 YTD
2
77 27
19 7
2 4
5 6
19 14
3
3 3
130 61
0
Cancelled Operations
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Lower is better
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD
6
Mixed Sex Accommodation
There were no instances of non-clinically justified
mixed sex accommodation in May.
Cancelled Operations
During May, 61 operations were cancelled on the day
of admission or later due to non-clinical reasons - a
breakdown of the cancellation reasons can be found
in the table below. Of these, 6 were not rebooked
within 28 days as per the national standard.

B4
Infection Control
Description
MRSA cases (hospital apportioned)
C-Diff cases (hospital apportioned)
MSSA cases (hospital apportioned)
MRSA Screening -Elective
MRSA Screening -Non Elective
Wards closed due to norovirus
Number of days wards closed due to norovirus
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG
O,A,Q 0 0 0 3 Green
O,A,Q 2 2 4 25 Green
2 5 7
93% 91% 95%
94% 95% 94%
0 0
0 0
RAG Thresholds
See graph below
See graph below
ANALYSIS OF KEY PERFORMANCE INDICATORS
MRSA Year To Date Target Upper Threshold
Clostridium Difficile
7
6
40
35
5
30
4
25
20
3
15
2
10
1
5
- - - - - - - - - - -
-
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
6
5
MSSA Cases
Actual cases in month
Ward Closures due to Norovirus
30
Wards closed due to norovirus
25
Number of days wards closed due to norovirus
COMMENTARY
MRSA
The Trust reported no cases of hospital apportioned
MRSA bacteraemia in May.
Clostridium Difficile
The Trust reported 2 cases of hospital apportioned
Clostridium Difficile in May.
The rate per 100,000 bed days and SW benchmark
are currently unavailable whilst the SHA performance
website is migrated to reflect the new CCG structure.
Ward Closures
No ward closures were reported during May due to
Norovirus.
4
20
3
15
2
10
1
5
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
0
0 0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
7

B5
Other safety & quality metrics
Description
% of eligible patients VTE risk assessed
% of hip fracture patients operated on within 36 hrs
% stroke patients >90% of time on stroke unit
Follow-up backlog - actual (no.of patients)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
O,A,CQ 95% 95% 95% 90% Green R < 95% G > 95%
Q 81% 76% 78% 85% Amber R < 70% G > 85%
Q 59% 67% 63% 80% Red R < 75% G > 80%
23,538 24,305
ANALYSIS OF KEY PERFORMANCE INDICATORS
VTE Risk Assessment Actual Target
Hip Fractures
120%
90%
COMMENTARY
VTE Risk Assessment
95% of patients admitted in May who required a VTE risk
assessment recieved it on admission.
100%
80%
80%
70%
60%
Hip Fractures
During May 76% of FNOF patients were operated on within
36 hours of admission.
60%
40%
50%
40%
30%
Stroke
During May 67% of stroke patients spent >90% of their stay
on the stroke unit.
20%
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
20%
10%
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Follow-Up Backlog
As at the end of May, the follow-up backlog had risen to
24,305 patients.
Stroke Patients
90%
80%
70%
60%
50%
40%
30%
20%
10%
Follow-up Backlog
30,000
25,000
20,000
15,000
10,000
5,000
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
-
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
8

C1
Accident & Emergency
Description
% of A&E patients waiting 30 mins)
Delayed transfers of care (delayed days as % of occupied days)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
O,A,M,Q 91.7% 94.8% 93.3% 95.0% Red R < 95% G > 95%
Q 61 66 64 60 Red R > 60 G < 60
Q 2.2% 1.2% 1.7% 0.0% Red
A,Q 3.0% 3.3% 1.7% 3.5% Green R > 5% G < 3.5%
ANALYSIS OF KEY PERFORMANCE INDICATORS
A&E 4 Hour Standard Actual Target
100.0%
98.0%
96.0%
94.0%
92.0%
90.0%
COMMENTARY
A&E Performance
A&E 4 hour wait performance was below target (95%)
at 94.8% in May.
Arrival to Definitive Treatment Time
Median duration was 66 mins for May.
Ambulance Handover Times
During May, 1.2% of patients experienced a handover
time of over 30 minutes. The Trust is working closely
with SWAST on daily liaison.
Delayed transfers of care
3.3 % of the total occupied bed days in May were
delayed days. Daily escalation and meetings with our
wider partners in health and social care continue in
order to minimise these delays. Discussing rehab
capacity in Plymouth and Cornwall with
commissioners.
88.0%
86.0%
91.7%
94.8%
93.3%
84.0%
82.0%
80.0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD
9

C2
Non-Elective Activity
Description
Inpatient activity vs plan (variance in spells)
Inpatient activity vs 12/13 actual (variance in spells)
Marginal Rate Emergency Threshold Adjustment vs plan (000's)
All Admissions
MAU Admissions
From GP
All Admissions
SAU Admissions
From GP
All Admissions
Ambulatory care Admissions
From GP
Surgical inpatient length of stay
Medical inpatient length of stay
Medical Outliers - Average Daily Occupancy Rate
13/ 14 Non-elective Inpatient Activity vs Plan Actual Plan
5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
3,000
2,500
2,000
1,500
1,000
500
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All Admissions to SAU, MAU and Ambulatory Care
MAU (ALL) SAU (ALL) Ambulatory Care (ALL)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG
-223 -232 -455 0
-144 -320 -463 0
Available from Mnth 4
£0 0
1,453 1,419 2,872
376 384 760
543 619 1,162
298 342 640
242 243 485
193 182 375
6.93 6.85
9.36 9.35
61 54 -
ANALYSIS OF KEY PERFORMANCE INDICATORS
£1
£1
£1
£1
£0
£0
£0
3,000
2,500
2,000
1,500
1,000
500
Marginal Rate Emergency Threshold Adjustment
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
GP Admissions to SAU, MAU and Ambulatory Care
MAU (GP) SAU (GP) Ambulatory Care (GP)
70
60
50
40
30
20
10
0
Medical Outliers - Average Daily Occupancy Rate
RAG Thresholds
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
COMMENTARY
13/14 Inpatient Activity vs Plan and vs 12/13
As at the end of Month 2 we were 455 spells (non-elective inpatient stays) below plan for the year and have seen 463 fewer non-elective inpatients than the same period in 12/13. N.B Due to a change in recording practice, 2500 non-elective Obstetrics patients
need to be removed from the 13/14 inpatient plan.
Marginal Rate Emergency Threshold
The National contract and PBR rules state that any non-elective inpatients treated above and beyond the levels of a nationally set baseline (the levels seen in 08/09) will only attract 30% of the tariff. The amount shown here represents the amount of income lost
each month through non-elective inpatients volumes above and beyond the 08/09 levels. N.B Figures will be available from Month 4 onwards
Medical Outliers
These numbers represent the average daily volume of medical patients outlied on surgical wards.
MAU, SAU and Ambulatory Care Admissions
These graphs show the overall number of admissions to these three locations and the proportion of which are GP admits.
10

C3
Cancer services
Description
31 days from 'decision to treat' (%)
62 days from urgent GP referral (%)
62 days from screening referral to treat (%)
62 days from consultant upgrade to treat (%)
31 days - DTT to subsequent - surgery (%)
31 days - DTT to subsequent - drugs (%)
31 days - DTT to subsequent - rad'th'py (%)
2 weeks for breast symptom referral (%)
2 weeks from urgent GP referral (%)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
O,A,Q,M 98.2% 99.2% 98.7% 96% Green R < 96% G > 96%
O,A,Q,M 81.9% 84.4% 83.1% 85% Red R < 85% G > 85%
O,A,Q,M 79.2% 92.7% 85.4% 90% Red R < 90% G > 90%
O,Q 100.0% 92.6% 95.7% 85% Green R < 85% G > 85%
O,A,Q,M 96.7% 94.4% 95.6% 94% Green R < 94% G > 94%
O,A,Q,M 99.1% 99.3% 99.2% 98% Green R < 98% G > 98%
O,A,Q,M 98.0% 97.5% 97.8% 94% Green R < 94% G > 94%
O,A,Q,M 95.7% 96.1% 95.9% 93% Green R < 93% G > 93%
O,A,Q,M 93.2% 95.1% 94.1% 93% Green R < 93% G > 93%
COMPARISONS WITH THE NATIONAL AVERAGE
Performance Against 62 Day Target Compared with National Average - Analysis of Breaches
Q1 2012/13
England
Q2 2012/13
England
Average Last Two
Quarters
Performance in
Month
Variance from
Average
Brain & CNS
86.2%
86.2% 86.2% 100.0%
13.8%
Breast
98.0% 97.8% 97.9% 100.0% 2.1%
Gynaecological 85.3%
85.2% 85.3%
100.0% 14.8%
Haematological (excluding Acute Leukaemia) 83.3% 83.5% 83.4% 100.0% 16.6%
Head & Neck
76.4% 75.8% 76.1%
58.8%
-17.3%
Lower Gastrointestinal 77.3% 79.0% 78.2%
80.0% 1.9%
Lung 83.0% 80.4% 81.7%
66.7%
-15.0%
Other
80.8% 81.3% 81.1% 100.0%
19.0%
Sarcoma
78.3% 83.9%
81.1% 100.0%
18.9%
Skin 97.8%
97.9%
97.9%
97.5%
-0.3%
Upper Gastrointestinal 80.7%
81.0%
80.9%
50.0%
-30.9%
Urological (excluding Testicular)
84.4% 83.0% 83.7%
81.5%
-2.2%
Rare Cancers (Testicular, ACL & Childrens)
93.5%
92.9%
93.2%
100.0%
6.8%
TOTAL 87.3% 87.2% 87.3%
85.1%
-2.2%
BREACHES IN THE MONTH
Total Number % of Trust
% of Total Total Trust % of Trust
Total Breaches
Treated Treatments
Breaches Breaches Breaches
Brain & CNS
0
0.0%
0
0.0%
0.0
0.0%
Breast
13
10.0%
0
0.0%
0.0
0.0%
Gynaecological
2
1.5%
0
0.0%
0.0
0.0%
Haemotological (excluding Acute Leukaemia)
6
4.6%
0
0.0%
0.0
0.0%
Head & Neck
8.5 (0.5)
6.5%
3.5 (0.5)
17.9%
1.0
8.3%
Lower Gastrointestinal
10
7.7%
2
10.3%
2.0
16.7%
Lung
15
11.5%
5
25.6%
5.0
41.7%
Other
1
0.8%
0
0.0%
0.0
0.0%
Sarcoma
1
0.8%
0
0.0%
0.0
0.0%
Skin
40
30.7%
1
5.1%
0.0
0.0%
Upper Gastrointestinal
6 (1)
4.6%
3
15.4%
1.0
8.3%
Urological (excluding Testicular)
27
20.7%
5
25.6%
3.0
25.0%
Rare Cancers (Testicular, ACL & Childrens) 1
0.8%
0
0.0%
0.0
0.0%
TOTAL
130.5 (1.5) 100.0%
19.5 (0.5)
100%
12.0
100%
COMMENTARY
Cancer Standards
Performance is above target for all cancer standards with
the exception of:
62 Day GP Urgent Referral (In-Month & Year-to-date)
There were 20.5 breaches in May. 9 of these were outside
of the Trust’s control - due to either patient choice or for
medical reasons.
62 days from screening referral to treat (%) (Year-to-date)
This standard achieved in May but YTD performance is still
below target due to April's poor performance ( 5 breaches
with only 1 out of Trust control)
Tertiary Breaches
Pathway improvement being pursued with other acute
trusts.
Comments
11

C4
Referral To Treatment (RTT)
Description
18 weeks - Admitted patients (%)
18 weeks - Non-admitted patients (%)
18 weeks - Audiology Direct Access (%)
% Incomplete pathways within 18 weeks
Backlog - Admitted patients (No.)
Backlog - Non-admitted patients (No.)
Backlog - Decision to Treat (No.)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar - Target RAG RAG Thresholds
O,A,Q,M 88.3% 88.3% 90% Red R < 90% G > 90%
O,A,Q,M 95.6% 95.9% 95% Green R < 95% G > 95%
Q 98.4% 97.3% 95% Green R < 95% G > 95%
O,A,M 89.7% 90.3% 92% Red R < 92% G > 92%
1,426 1,273 420 Green See Graph for Trajectory
285 314 200 Red R > 300 G < 200
576 562 400 Red R > 500 G < 400
ANALYSIS OF KEY PERFORMANCE INDICATORS
Admitted Patients Actual Target
Non-admitted Patients
100%
98%
100%
98%
96%
96%
94%
94%
92%
92%
90%
90%
88%
88%
86%
86%
84%
84%
82%
82%
80%
80%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
COMMENTARY
RTT
The Trust failed to meet the 18-weeks admitted and
incomplete pathway RTT standards in May due to the
planned clearance of the admitted backlog.
RTT Backlogs
As at the end of May, the number of patients waiting
more than 18 weeks for treatment in a non-admitted
setting or awaiting a decision to treat was above
trajectory whilst the admitted backlog was below
planned levels for May.
Audiology Direct Access
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Decision to treat
Non-admitted patients
Backlog
Admitted Patients
Admitted Backlog Plan
2500
2000
1500
1000
500
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
12

C5
Elective & Outpatient Activity
Description
Referrals vs plan (variance in referrals ; GP and non-GP)
Elective activity vs plan (variance in spells)
Outpatient activity vs plan (variance in attendances)
Length of stay vs 12/13 (variance in days)
Day Case Rates
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD
978 -1039 -61 0
-18 -108 -126 0
937 291 1228 0
0.00 0.12 - 0
78.0% 74.9% -
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Referrals vs Plan
13/14 Actual Referrals
13/14 Planned Referrals
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Referrals vs plan
The Trust has received 61 fewer referrals than planned as at the end of Month 2.
ANALYSIS OF KEY PERFORMANCE INDICATORS
13/14 Elective Actual
Elective Activity vs Plan
13/14 Elective Plan
6,000
5,000
4,000
3,000
2,000
1,000
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
COMMENTARY
Outpatient Actual
Outpatient Activity vs Plan
Outpatient Plan
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Elective activity vs plan
The Trust has admitted 126 fewer elective inpatients than planned as at the end of Month 2.
Outpatient activity vs plan
The Trust has seen 1228 more outpatients than planned as at the end of Month 2.
13

C6
Other access & activity metrics
Description
% patients waiting >6 weeks for diagnostic test
% IP/DC planned patients waiting longer that 'treat by' date
Suspended patients as % of total waiting list (%)
Rapid Access Chest Pain - % patients seen within 2 weeks
% pPCI - 150 min call to first balloon inflation
% GUM patients offered to be seen within 48 hrs
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
O,A,Q 1.6% 2.8% - 1% Red R > 1% G < 1%
6.5% 6.9% - 5% Amber R > 15% G < 5%
4.7% 5.0% - 5% Green R > 10% G < 5%
Q 100.0% 100.0% 100% 100% Green R < 98% G > 99%
Q 50.0% 100.0% 81% 75% Green R < 75% G > 75%
Q 100.0% 100.0% 100% 100% Green R < 98% G > 99%
3.0%
2.5%
2.0%
1.5%
ANALYSIS OF KEY PERFORMANCE INDICATORS
Diagnostic Waits Actual Target
COMMENTARY
Diagnostic Waits
As at 31st May 2013, 2.8% of patients (173 patients)
on a diagnostic waiting list were waiting over 6 weeks
for their test against a National Operating Framework
target of 1%.
Reperfusion Waiting Times
In-month performance against the new pPCI standard
in May was 100% (81% year-to-date) against an
annual target of 75%.
GUM Clinic
In May, 100% of those patients attending the GUM
clinic were offered an appointment within 48 hours.
1.0%
Lower is better
0.5%
0.0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
14

£m
D1
0.0
(2,000.0)
(4,000.0)
(6,000.0)
(8,000.0)
Income & Expenditure
OVERALL SUMMARY
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
COMMENTARY
At the end of the second month of the new financial year, the Trust’s position is some £54k better
than the £2.45 million planned deficit, at an actual position of £2.40 million deficit. Overall, this
represents a £254k underspend against operational budgets and a £200k under-delivery of CIP
targets.
Income is £242k behind plan in Month 2 before CIPs as a result of under-performance against cardiac
and non-contracted activity within the variable element of the contract and low levels of Private
Patient, Education and Research income.
Pay is underspent by £668k to Month 2 before CIPs with savings from vacancies exceeding
discretionary pay costs in the majority of areas.
(10,000.0)
(12,000.0)
(14,000.0)
Actual
Plan
Non Pay expenditure is overspent by £154k before CIPs. Drug expenditure remains higher than plan,
with 50% of the excluded drugs overspend being re-imbursed by Commissioners. Medical and Surgical
Supplies expenditure is lower than plan reflecting lower than planned activity levels in some high cost
areas.
DETAILED ANALYSIS
PLAN Plan Actual Variance MONTH PERFORMANCE Budget Actual Variance
Variance Variance
DIRECTORATE
Apr-12 (941) (913) (28) Income (34,011) (33,210) 801
in-month YTD
May-12 (2,455) (2,401) (54) Pay expenditure 21,116 20,389 (727) Cardiothoracics 43 (97)
Jun-12 (3,580) Non-pay expenditure 12,580 12,439 (141) Children & Young People's Health 23 52
Jul-12 (4,683) Depreciation and interest 1,829 1,869 40 Emergency Services 26 39
Aug-12 (5,869) NET DEFICIT/(SURPLUS) 1,514 1,488 (26) Gastro, Surgery and Renal Services 119 184
Sep-12 (7,052) Head & Neck Surgery 60 81
Oct-12 (8,132) YTD PERFORMANCE Budget Actual Variance Medical Specialties 153 222
Nov-12 (9,040) Income (67,945) (66,906) 1,039 Neurosciences 12 30
Dec-12 (9,923) Pay expenditure 41,978 40,859 (1,119) Ophthalmology 50 68
Jan-13 (11,043) Non-pay expenditure 24,764 24,775 10 Oncology & Blood (51) 286
Feb-13 (11,581) Depreciation and interest 3,658 3,674 16 Orthopaedics & Rheumatology (11) 126
Mar-13 (13,000) NET DEFICIT/(SURPLUS) 2,455 2,401 (54) Reproductive Health and Womens Srvs 97 142
Anaesthetics Pain and Critical Care (24) (62)
Pharmacy (37) 9
Health Science & Technology (42) (45)
Clinical Support Services 95 94
Chief Executive (2) 29
Information and Planning (15) (54)
Director of Finance (53) (72)
Director of Human Resources (40) (88)
Site Services 126 169
Medical Director (36) (92)
Trust Wide (490) (1,077)
All figures are recorded in £000s Research and Development (30) 3
TOTAL (26) (54)
15

D2
Cost improvement programme (CIP)
3,500,000
3,000,000
2,500,000
2,000,000
Red
Amber
Green
Delivered
Plan
OVERALL SUMMARY
COMMENTARY
Plans have been developed in order to deliver up to £25.7m of savings. Following the decision by the
Board to allow non-recurring CIPs only in exceptional cases, £1.6 million of Non-Recurring Directorate CIPs
have been removed from the position reported at Month 1. At present, £23.1m of the plans are for
recurring schemes, with a full year effect of £26.8million. The risk assessed value of schemes is currently
£19.7million and additional schemes will be required to ensure achievement of the target for the year.
Further work is underway to assess progress with delivery of schemes and to review forecasts of delivery
at a more detailed level.
1,500,000
1,000,000
500,000
0
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
DETAILED ANALYSIS
FORECAST
Plan Delivered Green Amber Red PROGRAMME SUMMARY Target Forecast Variance
Apr-13 1,154,016 1,212,409 Directorate Schemes - Clinical 11,731,000 5,421,149 (6,309,851)
May-13 1,256,484 998,339 0 Directorate Schemes - Corporate 1,346,000 1,101,857 (244,143)
Jun-13 1,228,018 432,257 872,317 291,983 117,933 Outpatient Efficiency 451,000 451,000 0
Jul-13 1,722,667 370,503 866,056 315,529 122,759 Clinical Administration 1,294,000 1,201,860 (92,140)
Aug-13 1,751,560 378,063 898,765 231,954 122,759 Medicines Management 1,300,000 1,299,999 (1)
Sep-13 1,752,583 379,492 898,765 446,239 122,759 Theatre Efficiency 360,000 360,000 0
Oct-13 2,502,879 379,492 1,390,264 984,521 159,093 Beds 0 0 0
Nov-13 2,510,179 379,491 1,149,164 991,910 159,093 Workforce 4,340,000 3,680,498 (659,502)
Dec-13 2,512,768 379,489 1,149,164 999,299 159,093 Medical Job Planning 500,000 500,000 0
Jan-14 2,517,768 379,489 1,149,164 1,007,042 159,093 Non NHS Income 1,280,000 1,279,999 (1)
Feb-14 2,567,890 379,489 1,154,289 1,002,042 159,093 Non Pay 2,000,000 2,000,000 0
Mar-14 2,523,189 379,566 1,409,484 1,003,263 159,097 Finance Solutions 1,500,000 2,224,720 724,720
TOTAL 24,000,000
6,048,079 10,937,435 7,273,783 1,440,770 Reserve Slippage 7,000,000 6,178,985 (821,015)
25,700,067
Adjustment for stretch targets (9,102,000) 0 9,102,000
TOTAL 24,000,000 25,700,067 1,700,067
16

D3
16,000
14,000
12,000
10,000
Capital expenditure
OVERALL SUMMARY
Actual
Plan
COMMENTARY
The Capital plan of £15 million was approved at the June meeting of the Board.
Expenditure to date totals £1.8 million, principally on the Stem Cell ward and other
projects carried forward from the previous year. The remainder of schemes are
underway or in planning in order to deliver the entirety of the programme by yearend.
8,000
6,000
4,000
2,000
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
DETAILED ANALYSIS
MONTH Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar CAPITAL SCHEME Plan Actual %
Plan 1,262 491 2,027 1,543 1,057 1,591 1,209 1,083 1,143 906 1,060 1,649 Stem Cell Ward upgrade 600 356 59%
Actual 1,262 574 LINAC C replacement 450 18 4%
VARIANCE 0 83 Radiopharmacy 1,000 34 3%
% OF PLAN 100% 117% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 5th Endoscopy Room 40 14 35%
Other Planning Schemes 1,706 70 4%
CUMULATIVE Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Estates Backlog Maintenance 2,958 220 7%
Plan 1,262 1,753 3,780 5,323 6,380 7,971 9,180 10,263 11,406 12,313 13,372 15,022 IM&T systems and infrastructure 2,980 698 23%
Actual 1,262 1,836 Rolling Equipment Replacement programme 1,400 0 0%
VARIANCE 0 83 Imaging Replacement Programme
% OF PLAN 100% 105% Directorate equipment/minor works 2,826 403 14%
Transformational Change enabling mesures 522 22 4%
Contingency 540
Donated assets
Over commitment
TOTAL 15,022 1,836 12%
17

D4
Cash Management
Description
Revised Planned Closing Cash Balance (£'000s)
Actual Closing Cash Balance (£'000s)
Cleared Balances (£'000s)
BPPC - NHS Volume (% within target)
BPPC - NHS Value (% within target)
BPPC - Non-NHS Volume (% within target)
BPPC - Non-NHS Value (% within target)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
5,362 3,226 3,226
Not applicable
5,846 8,761 8,761
Not applicable
8,416 9,409 9,409
Not applicable
96% 97% 97% 95% Green R < 80% G > 95%
95% 98% 98% 95% Green R < 80% G > 95%
94% 95% 95% 95% Green R < 80% G > 95%
86% 90% 90% 95% Amber R < 80% G > 95%
£000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
ANALYSIS OF KEY PERFORMANCE INDICATORS
COMMENTARY
The original cash plan anticipated receipt of cash
support in June. The revised cashflow forecast
reflects indications that the support will be provided
in a number of smaller issues when necessary
through the year to avoid cash deficits. The actual
timings and values of these payments have yet to be
confirmed.
The cash balance is higher than plan at the end of
May as a result of timing differences in the payment
of Capital and Revenue creditors. The forecast
balance at the end of June is close to the revised plan
at £2.2m.
The Trust’s Better Payments Practice Code (BPPC)
performance improved against all measures in the
month. Performance at Month 2 against all measures
was at or above the 95% target, with the exception of
Non-NHS invoices by value.
0
Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-142007/08
Mar-14
Actual Plan Revised Cash Forecast
18

£
D5
Contract Penalties & CQUIN
Description
Never Events
Eliminating Mixed Sex Accommodation
Cancer (62 days)
Cancer (31 days)
Cancer (2 Week Waits)
RTT 18-week standards
RTT 52-week waiters
Diagnostic Waits
A&E
Ambulance Handovers
Cancelled Ops 28-day breaches
Cancelled Ops Multiple Breach Patients
C-Diff
250,000
200,000
150,000
100,000
50,000
-
TOTAL
CONTRACT PENALTIES
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG
- - -
- - -
5,852 4,993 10,845
- - -
- - -
105,239 104,599 209,839
25,000 25,000 50,000
23,925 23,371 47,296
15,401 16,450 31,850
16,800 8,200 25,000
768 25,584 26,351
4,856 20,761 25,616
-
RAG Thresholds
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
197,840 228,957 0 0 0 0 0 0 0 0 0 0 426,797
COMMENTARY
Contract Penalties
As at the end of May, contract penalties have been applied in 9
C-Diff
out of the 13 areas totalling over £426k, over half of which has
Cancelled Ops Multiple Breach Patients been related to RTT - failure against the National 18-week RTT
Cancelled Ops 28-day breaches
standards and reporting of 52+ week waiters.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Ambulance Handovers
A&E
Diagnostic Waits
RTT 52-week waiters
RTT 18-week standards
Cancer (2 Week Waits)
Cancer (31 days)
Cancer (62 days)
Eliminating Mixed Sex Accommodation
Never Events
19

E1
Staffing numbers
Description
Establishment (WTE)
Contracted Staff in Post (WTE)
Vacancies (WTE)
Discretionary Spend (£000s)
Vacancy % - Nursing
Vacancy % - Medical
Vacancy % - Admin & Managers
Vacancy % - Other Staff
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Current Target RAG RAG Thresholds
5,747 5,754
Not applicable
5,392 5,398
Not applicable
355 356
1,753 1,380 - - Red R > 1300 G < 1000
5.65% 5.52% 5.52% - Amber R > 10% G < 3%
6.90% 7.07% 7.07% - Amber R > 10% G < 5%
6.11% 6.60% 6.60% - Amber R > 10% G < 5%
6.25% 6.47% 6.47% - Amber R > 10% G < 5%
Establishment
Vacancies (WTE) Contracted Staff in Post (WTE)
7,000
6,000
5,000
4,000
3,000
2,000
1,000
-
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
ANALYSIS OF KEY PERFORMANCE INDICATORS
Discretionary Pay Spend
Discretionary Spend (£000s)
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
-
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Vacancy Rates Vacancy % - Nursing Vacancy % - Medical Vacancy % - Admin & Managers Vacancy % - Other Staff
8%
COMMENTARY
Overall Establishment
The budgeted establishment has increased in Month
2 by 7 WTE to 5,754 WTE. Staff in post has increased
in Month 2 by 6 WTE to 5,398.
Discretionary Pay
Discretionary pay has reduced by £373k in Month 2
to £1.38m. This is principally due to a large
reduction in nursing bank and agency.
Turnover
Annual turnover for Month 2 is 8.50% in comparison
to 9.35% in the same period in the previous year.
7%
6%
5%
4%
3%
2%
1%
0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
20

E2
Training & appraisals
Description
Basic Life Support (% completed)
Manual Handling (% completed)
Essential Skills (% completed)
Child Protection (% completed)
Appraisals (% completed)
PERFORMANCE INDICATORS
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds
88% 87% 87% 95% Amber R < 85% G > 95%
93% 92% 92% 95% Amber R < 85% G > 95%
Q 95% 95% 95% 95% Green R < 85% G > 95%
Q 97% 97% 97% 95% Green R < 85% G > 95%
Q 82% 82% 82% 95% Red R < 85% G > 95%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Training Actual Gap from Target
Child Protection Essential Skills Manual Handling Basic Life Support
ANALYSIS OF KEY PERFORMANCE INDICATORS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Appraisals
Appraisals
COMMENTARY
Mandatory Training
The completion of mandatory essential skills training
has remained static in Month 2 at 95%. Child
protection has also remained static at 97%. Manual
handling and basic life support have both decreased
slightly by 1% to 92% and 87% respectively.
Appraisal
Appraisal completion rates (for non-medical staff)
have remained static in Month 2 at 82%.
21

E3
Sickness absence
PERFORMANCE INDICATORS
Description
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG
RAG Thresholds
Trust Sickness Absence Rate (Average %)
4.3% 3.6% - 3.5% Amber R > 4.2% G < 3.5%
National Benchmark 18 / 41 32 / 41
Comparator group is all large acute Trusts (41)
Add Prof Scientific and Technical
4.3% 3.9%
Additional Clinical Services
7.2% 6.1%
Administrative and Clerical
4.0% 3.3%
Allied Health Professionals
2.1% 2.8%
Estates and Ancillary
6.6% 5.4%
Healthcare Scientists
3.7% 2.5%
Medical and Dental
1.4% 1.1%
Nursing and Midwifery Registered
4.7% 3.7%
ANALYSIS OF KEY PERFORMANCE INDICATORS
Sickness Absence Rate
Actual Target
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Sickness Absence
COMMENTARY
Sickness absence has decreased in Month 2 from
4.34% to 3.63%, with the 12 month average sickness
absence rate also continuing to decrease to 4.44%.
In terms of sickness absence rates within staff groups,
the staff groups with combined short and long term
absence of more than 4% are Estates (5.42%) and
Additional Clinical Services (6.13%).
Long and Short Term Sickness Absence Rates by Staff Group
Nursing and Midwifery Registered
1.82%
1.92%
Medical and Dental
0.60%
0.54%
Healthcare Scientists (e.g. clinical scientists and biomedical scientists)
1.57%
0.94%
Estates and Ancillary
3.33%
2.09%
Allied Health Professionals (e.g. physios, OT, dieticians, radiographers)
Administrative and Clerical
1.98%
2.05%
0.85%
1.20%
Additional Clinical Services (e.g. HCAs and AHP helpers)
2.85%
3.28%
Add Prof Scientific and Technical (e.g. pharmacists, ATOs, ODPs)
1.48%
2.38%
0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%
Sickness Rates - Long Term (28 Days Plus)
Sickness Rates - Short Term (Under 28 Days)
22

F1
Monitor's Governance Risk Rating
Description
Target
Weighting
Quarter 1 Quarter 2
Quarter 3 Quarter 4
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4
Clostridium Difficile - Meeting the C Diff Objective
Met 1.0 Met Met
MRSA - Meeting the MRSA Objective
Met 1.0 Met Met
All cancers: 31 day wait
for second or
subsequent treatment
comprising either:
Surgery 94% 96.7% 94.4%
Anti cancer drug treatments 98% 1.0 99.1% 99.3%
Radiotherapy 94% 98.0% 97.5%
All cancers: 62 day wait
for first treatment
comprising either:
From urgent GP referral to
treatment
From NHS cancer screening
service referral
85% 81.9% 84.4%
1.0
90% 79.2% 92.7%
All cancers: 31 day wait from diagnosis to first
treatment
96% 0.5 98.2% 99.2%
Cancer: two week wait
from referral to date
first seen comprising
either:
All cancers 93% 93.2% 95.1%
Symptomatic breast patients 93% 95.7% 96.1%
0.5
Total time in A&E (% within 4 hrs)
95% 1.0 91.7% 94.8%
Max 18 week referral to treatment - admitted
90% 1.0 88.3% 88.3%
Max 18 week referral to treatment - non admitted
Max 18 week referral to treatment - incomplete
pathways
Does the Trust meet requirements relating to access
to healthcare for people with learning disabilities?
95% 1.0 95.6% 95.9%
92% 1.0 89.7% 90.3%
Met 0.5 - - - Met - - - Met - - - Met - - - Met
Green=

Risk Rating
F2
Monitor's Financial Risk Rating
OVERALL SUMMARY
COMMENTARY
The Trust’s Financial Risk Rating remains at 2, in accordance with the plan for the year.
5
4
3
2
1
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
OVERALL SCORE Plan Actual Forecast PERFORMANCE VALUES Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Apr-13 2 2 EBITDA margin 2.6% 1.9%
May-13 2 2 EBITDA % Achieved 100.4% 105.8%
Jun-13 2 Return on assets employed -0.5% -1.2%
Jul-13 2 I&E Surplus Margin -2.7% -3.6%
Aug-13 2 Liquidity Ratio 22 22
Sep-13 2
Oct-13 2
Nov-13 2 SCORING REGIME
Dec-13 2 EBITDA margin
Jan-14 2 EBITDA % Achieved
Feb-14 2 Return on assets employed
Mar-14 2 I&E Surplus Margin
Liquidity Ratio
DETAILED ANALYSIS
Scoring
11=5
100=5
3=5
3=5
60=5
CURRENT SCORE
2
PERFORMANCE SCORES Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
EBITDA margin 2 2
EBITDA % Achieved 5 5
Return on assets employed 3 2
I&E Surplus Margin 1 2
Liquidity Ratio 4 3
24

Item 10
SUMMARY REPORT
Trust Board 5 th July 2013
Subject
Prepared by
Approved by
Presented by
Month 2 Financial Results
Director of Finance
Director of Finance
Director of Finance
Purpose
The purpose of this paper is to provide the Board with a summary of the Trust’s
financial performance to the end of May 2013 (Month 2).
This report accompanies the detailed performance dashboard for May 2013 with
the finance section included at D1 to D5.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
At the end of the second month of the new financial year, the Trust’s position is some £54k better
than the £2.45 million planned deficit, at an actual position of £2.40 million deficit.
The annual cost improvement target is £24m. There are currently £25.7m of schemes identified.
The risk assessed value of schemes is currently £19.7million which is £4.3million below the target.
The Board will note from this that there remains significant risk in delivering a £24m savings
programme and actions are on-going to address this.
•
•
Quality Impact Assessment
Each of the Trust’s proposed savings is subject to a formal Quality Impact Assessment, which is
signed off by the Medical Director and Director of Nursing and monitored by the Programme
Management Office and Executive Management Team.
Financial Impact Assessment
This paper updates the Board on the overall financial performance of the Trust.
Regulatory Impact Assessment
This paper addresses the performance of the Trust against its statutory financial duties and against
Trust Development Authority and Monitor financial standards.
Key Recommendations
The Trust Board is asked to:
1. Note the financial position of the Trust as at 31st May 2013.
2. Endorse and discuss the actions set out at 5.3 of the report.
Next Steps
Carry out a review of progress and forecast delivery of cost improvement schemes. Implement
improved financial controls. Develop a medium to long term financial recovery plan.

Item 10
DETAILED REPORT
Trust Board 5 th July 2013
Subject
Prepared by
Approved by
Presented by
Month 2 Financial Results
Director of Finance
Director of Finance
Director of Finance
1. Purpose
1.1 The purpose of this paper is to provide the Board with a summary of the Trust’s
financial performance to the end of May 2013 (Month 2).
1.2 This report accompanies the detailed performance dashboard for May 2013 with the
finance section included at D1 to D5.
2. Background
2.1 For 2013-14 the Trust has a planned deficit of £13m after assuming savings of £24m.
2.2 The month 2 detailed financial results have been subject to review at the Finance and
Investment Committee meeting of the 26 th June 2013. Any issues from the Finance
Committee review will be reported to the Board.
3. Overall Position Month 2
3.1 At the end of the second month of the new financial year, the Trust’s position is some
£54k better than the £2.45 million planned deficit, at an actual position of £2.40
million deficit. Overall, this represents a £254k underspend against operational
budgets and a £200k under-delivery of cost improvement programme (CIP) targets.
3.2 The overall position to date is shown against plan below: -

Item 10
3.3 The Income and Expenditure variances to the end of May are shown in Table 1:
Table 1 – Operational Performance Month 2
OPERATIONAL
PERFORMANCE
Budget
M2
Actual
M2
Variance
M2
Budget
YTD
Actual
YTD
Variance
YTD
INCOME
£'000 £'000 £'000 £'000 £'000 £'000
Provision of healthcare
30,053 29,665 (388) 60,038 59,778 (260)
Education, training and 2,007 1,950 (57) 4,013 3,910 (103)
research
Other Income 1,545 1,595 50 3,097 3,218 121
Income CIPs 406 0 (406) 797 0 (797)
TOTAL INCOME 30,053 29,665 (388) 67,945 66,906 (1,039)
EXPENDITURE
Pay (21,056) (20,389) 666 (41,526) (40,859) 667
Pay CIP (61) 0 61 (452) 0 452
Non-pay (12,490) (12,439) 51 (24,621) (24,775) (154)
Non-pay CIP (90) 0 90 (144) 0 144
TOTAL EXPENDITURE (33,696) (32,829) 868 (66,742) (65,634) 1,108
NET
315 381 66 1,203 1,273 70
SURPLUS/(DEFICIT)
(Before depreciation
and interest)
Depreciation and interest (1,829) (1,869) (40) (3,658) (3,674) (16)
NET
(DEFICIT)/SURPLUS
(1,514) (1,488) 26 (2,455) (2,401) 54
CIP MEMO 1,256 998 (258) 2,411 2,211 (200)
3.4 Income is £242k behind plan in Month 2 before CIPs as a result of underperformance
against cardiac and non-contracted activity within the variable element
of the contract and lower than planned levels of private patient, education and
research income. In addition, income CIPs are £797k behind plan with the failure to
deliver the planned additional cardiac surgery income and delays in receiving
additional private patient income.
3.5 Pay is underspent by £667k to month 2 before CIPs with savings from vacancies
exceeding discretionary pay costs in the majority of areas. Pay CIPs are a further
£452k over-achieved largely as a result of the recognition of pay CIPs from delays
against cost pressures and investments held in reserves.
3.6 Non Pay expenditure is overspent by £154k before CIPs with a contribution from nonpay
CIPS and delays in spending reserves of £144k, reducing the overall variance to
£10k.
3.7 Overall CIP delivery has fallen behind plan in the month. As in Month 1, a significant
element of CIP delivery reflects delayed commitment of reserves. Further focus on
the implementation of planned schemes will be required to rectify this situation.
Reserves are being tightly managed by the Director of Finance in order to offset
delays in delivery of Cost Improvement Plans.

Item 10
4. Key Issues for the Board
4.1 If the Trust was on a fully variable contract it would, at Month 2 owe commissioners
£1.4m due to significant income underperformance on elective care (126 cases but
accounting for £1m), and the level of contractual penalties incurred (£0.4m). The key
areas of elective under performance are neurosurgery, cardiac surgery and plastic
surgery. A greater understanding of the elective under performance is required and
work is on-going to review this.
4.2 Within this net financial under performance emergency activity is over performing by
228 patient spells (3%). This over-performance on emergency activity continues to
impact on the Trust’s elective capacity. The Trust therefore needs to continue to work
with commissioners on reducing emergency demand, otherwise it will continue to
impact upon elective work.
4.3 The Trust has incurred £427k of contractual penalties to Month 2. The key figures
within this are for referral to treatment (RTT) £260k, diagnostic waits £47k and
cancelled operations £52k. RTT is being intentionally breached over the first part of
this year, to ensure backlogs are cleared and to put the Trust in a sustainable RTT
position moving forward. Under the Managed PbR arrangements, penalties are
returned to the Trust to invest in corrective action.
4.4 As the Trust is operating a managed PbR contract in 2013-14 (with only certain items
variable) the variable contract included within the month 2 results (after return of
penalties) is £0.136m under plan. The key area of concern in this month 2 variable
position is the under-performance on cardiac surgery.
4.5 All pay budgets at a summary level are under spent. Discretionary pay has reduced to
£1.38m in the month although this includes the benefit of the reversed accrual from
month 1 of £150,000. After allowing for this one off benefit this is still the lowest
spending since October 2012 although too early to confirm that this improvement can
be sustained.
4.6 The cost improvement programme at month 2 has achieved £2.2m against a target of
£2.4m. However, £1.5m of this sum has been achieved through delayed commitment
of reserves and urgent work is on-going via Trust Wide programmes and Care
Groups to ensure operational delivery. A more detailed CIP update is set out at
section 5 below.
4.7 The cash flow forecast for the year has been updated reflecting indications from the
Trust Development Authority that the £13m requested cash support will be provided
in a number of smaller issues when necessary through the year to avoid cash deficits.
The actual timings and values of these payments have yet to be confirmed. Current
cash levels remain acceptable without adverse impact on creditor payments.
4.8 In respect of the capital programme there is a £15m plan presently approved. Of this,
£13.7 million of schemes are in planning or underway. £1.3 million has been held
back until later in the year in order to assist with cash issues and/or additional
contingencies should they arise. At the present time, the capital programme remains
flexible should the Trust’s cash position give cause for concern.
5. Cost Improvement Programme (CIP)
5.1 The agreed CIP target for the year is £24.0m. Against this, plans have been
developed in order to deliver up to £25.7m of savings. Following the decision by the
Board to allow non-recurring CIPs only in exceptional cases, £1.6 million of non-

Item 10
recurring Directorate CIPs have been removed from the position reported at Month 1.
At present, £23.1m of the plans are for recurring schemes, with a full year effect of
£26.8million.
5.2 The risk assessed value of schemes is currently £19.7million set out in the graph
below. The risk assessed value is £4.3million below the target. Further work is
underway with the Programme Management Office to assess progress with delivery
of schemes and to review forecasts of delivery at a more detailed level and this work
will be completed following the month 3 financial close.
5.3 The Board will note from the above that there remains significant risk in delivering a
£24m savings programme and actions on-going include: -
5.3.1 Implementation of new financial controls guidance. A new ‘Financial Controls
Guidance’ document has been issued to all budget holders, giving detailed practical
guidance on the implementation of effective financial controls on recruitment,
discretionary pay and non-pay expenditure across the organisation.
5.3.2 Establishment of an Executive Review Panel which meets weekly to give approval to
a number of high cost items including specific recruitment activity, outsourcing and
additional clinical capacity sessions.
5.3.3 Establishment of Financial Performance Reviews in addition to the overall
performance reviews. These will initially operate at a care group level but will move to
a Service Line level in Month 3 once financial and operational data is available to
match the newly established service lines.
5.3.4 Development of a financial recovery plan with the aim of both securing delivery in
2013-14 as well as developing robust plans for 2014-15 and 2015-16. At the time of
writing we are in the process of recruiting an external partner to support us with
additional capacity to develop a detailed financial recovery plan. A further update will
be provided to the Board.
6. Conclusion and recommendations
6.1 The Board is asked to note the financial position of the Trust as at 31 st May 2013.
6.2 The Board is asked to endorse and discuss the actions at 5.3

Item 11
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Quarterly update on acute hospital standards for people with Learning
Disabilities
Prepared by
Approved by
Presented by
Purpose
Associate Director of Nursing/Nurse Consultant Older People
Director of Nursing & Midwifery
Associate Director of Nursing/Nurse Consultant Older People
To report to the Board the outcomes of a recent review Learning Disabilities
Liaison service, including outcomes of recent complaints.
To provide an update on compliance with national standards.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
People with Learning Disabilities have an equal right to healthcare. It is important, therefore,
that the Trust has services, staff and support which enable people with Learning Disabilities to
use our services. The Trust needs to ensure that our healthcare services provide a high
standard of care and treatment to people with Learning Disabilities – which meet national
requirements and standards. Care and treatment of individuals must take into consideration
and make reasonable adjustments where necessary, for their complex needs and disabilities.
The Learning Disabilities (LD) Liaison service was established three years ago, to provide
support to clinical teams across the Trust in the care and treatment of people with LD. The
team, its scope of practice and ways of working have recently been reviewed. This has
involved external stakeholders and has led to the review of the operational protocol and
development of Standard Operating Procedure for the team. The outcomes of recent
complaints regarding the care of people with Learning Disabilities have also informed the new
SOP. The focus of the Learning Disabilities Liaison team is to work with clinical teams across
the hospital, community settings and primary care to facilitate and promote high quality of care
to people with Learning Disabilities, as they access Trust services.
Progress continues to be made towards the national standards, as laid out in the Monitor
framework and Care Quality Commission; the Trust continues to provide high quality care to
people with Learning Disabilities, which is compliant with national standards.
Quality Impact Assessment
This report provides assurance of compliance with CQC standards - Outcomes 1, 4, and 7.
The Trust has a legal duty to ensure equality of service provision and to meet requirements from the
Equality Act (2010).
Financial Impact Assessment
No direct impact
Key Recommendations
The Trust Board is asked to:
1. Confirm commitment to the Getting It Right Charter (Annex 1).
2. Note the outcomes of the review of Learning Disabilities Liaison team (Annex 2 & 3).
•

Item 11
3. Review the Trust’s continued position and satisfy itself that the Trust is able to declare
continuing compliance towards the Monitor Compliance framework (Annex 4).
Next Steps
The Standards Operating Procedure will be presented to Personal Care Group for approval; it will
then be published for use across the Trust and to replace the Joint Working Protocol (current
operational procedure)
The Trust Board will continue to receive reports on progress towards the national standards for
people with Learning Disabilities (quarterly).

Item 11
DETAILED REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Quarterly update on acute hospital standards for people with Learning
Disabilities
Associate Director of Nursing/Nurse Consultant Older People
Director of Nursing & Midwifery
Associate Director of Nursing
Purpose
People with Learning Disabilities have an equal right to healthcare. It is important, therefore,
that the Trust has services, staff and support which enable people with Learning Disabilities
to use our services. This report details the work undertaken to review the working of the
Learning Disabilities Liaison team, the scope of practice for this team and to improve how
people with Learning Disabilities are supported as they use Trust services.
The Trust needs to ensure that our healthcare services provide a high standard of care and
treatment to people with Learning Disabilities, which takes into consideration and makes
reasonable adjustments for their complex needs and disabilities. The Trust is committed to
supporting the Getting It Right Charter - ensuring that we focus on the needs of individuals;
to see the person not the disability (Annex 1).
The Trust Board is required to review compliance with the national Monitor framework for
standards of care for people with Learning Disabilities - this report provides detail of the work
towards compliance (Annex 4)
Background
People with learning disabilities often have specific health needs, in addition to the general
health needs which the rest of the population face throughout life. However, for various
reasons, they often struggle to access the same level of healthcare services – both in terms
of primary and secondary care. The range of specific needs people with Learning
Disabilities have included:
• Communication – abilities to read and write, verbal communication, sensory needs.
• Memory – ability to tell the time, remember everyday facts, medication compliance.
• Social – ability to forge relationships, deal with people, organise themselves, manage
financial and domestic affairs, risk awareness, unemployment.
• Physical needs may be linked to their learning disabilities e.g. immobility, obesity,
swallowing difficulties, incontinence.
• Challenging behaviours in a small number of cases.
• Medical/health conditions often related to learning disabilities e.g. dental care,
diabetes, epilepsy, coronary heart disease, respiratory disease, hypothyroidism,
Gastro-Intestinal conditions and cancers, mental health issues.
(Royal College of Nursing 2006 – Meeting the health needs of people with learning disabilities)
The Death by Indifference report by Mencap (2007) highlighted the fact that people with
learning disabilities receive poor care and treatment from healthcare services. The report
concluded that:

Item 11
• People with learning disabilities are seen to be a low priority.
• Many healthcare professionals understand little about learning disabilities.
• Many healthcare professionals do not properly consult and involve the families and
carers of people with learning disabilities.
• Many healthcare professionals do not understand the law around capacity and
consent to treatment.
• Health professionals rely inappropriately on their own estimates of a person’s quality
of life.
• The complaints system within NHS services is often ineffectual, time-consuming and
inaccessible for people with learning disabilities.
(Death by Indifference, Mencap March 2007)
The report claimed that many people with learning disabilities die in hospital due to the
widespread ignorance and indifference throughout healthcare services, towards their needs
and those of their families and carers. Mencap claim that the inequitable service afforded to
those with learning disabilities by hospitals and other healthcare services amounts to
institutional discrimination.
Earlier this year, a Confidential Inquiry which reviewed the 247 deaths of people with
Learning Disabilities over a two year period concluded that 42% deaths reviewed were
premature; the reasons for premature deaths being delayed investigations or treatment,
inadequate response to changing needs of individuals and inappropriate care for complex
and ongoing health needs.
(Confidential Inquiry into the premature deaths of people with Learning Disabilities 2013)
In January 2013, concerns raised through a Coroner’s inquest (heard December 2012; case
two years old), via a Rule 43 letter, were reported to the Trust Board. The concerns raised
were in respect of adherence to our own operational policy for managing patients with
Learning Disabilities in hospital; in particular around the support of individuals with consent to
treatments and care.
Since then, there have been concerns raised by families of two people with Learning
Disabilities, regarding the lack of consideration of individuals’ complex needs with clinical
decision-making; concerns were raised that staff were not focusing on the needs of
individuals, rather were distracted by their profound disabilities.
As a result of this, a review of the Learning Disabilities Liaison service and the Trust’s Joint
working protocol (2009) was commenced, at that time by the Acting Director of Nursing.
Following an internal review, a preliminary report was reported to the Trust Board in April
(Annex 2).
A Review of the Learning Disabilities Liaison Team with external stakeholders
In order to continue with the good multi-agency working established by the LD Liaison team
and to involve (new) local commissioners in the development of the LD Liaison service, a
review involving a range of external stakeholders has been completed. This included:
• Consideration of the outcomes/findings of the internal review of the LD liaison team
structure, working practices/relationships and implementation of the Joint operational
protocol.
• Feedback from commissioners, community providers and other partners, with respect
to the relationships with the LD liaison team, impact to patients, families and other
service providers.

Item 11
• Challenge in respect of the ‘Getting it Right’ Charter.
• Review of numbers of people with Learning Disabilities supported in hospital over the
past three years.
• Joint agreement on the areas of the operational protocol which needed revising.
• Evaluation of the LD Liaison team structure, with discussions regarding further
support/resources needed to extend the service and establish seven-day working
• Agreement on further review/feedback processes.
A summary of the feedback and agreed actions from this review is presented in Annex 3.
The partnership working, commitment to continuous improvement and desire to develop
further the LD liaison team were commended by the commissioners. Working with
community LD services across Plymouth, Devon and Cornwall services is a challenge - but
there was commitment from both NEW Devon and Kernow CCG LD commissioning
managers to facilitate better involvement, breaking down of barriers and improvement in
working relationships between primary care, community services and secondary care.
Scope of practice of the Learning Disabilities Liaison team
The Learning Disabilities Liaison Service was established in November 2009 to provide
support to clinical teams across the Trust in the care and treatment of people with LD. The
LD liaison team forms part of the wider Derriford liaison team, supporting clinical teams
across the Trust in the management of patients with complex needs. Derriford liaison team
includes specialist liaison nurses for mental health, learning disabilities, alcohol and
vulnerable adult services. The LD liaison team has recently undergone organisational
change: a team leader has been appointed with two other Clinical Nurse Specialists; the
Clinical Nurse Specialist for vulnerable adults in the Emergency Directorate also forms part
of the team and supports patients through the urgent care pathway. This newly configured
team has now established an extension to the working hours/days to provide an evening and
weekend service.
Following the review of service and the operational protocol, a Standard Operating
Procedure for the working of the LD liaison team has been developed. The roles of the
Learning Disabilities liaison team are to facilitate the meeting of individual healthcare needs
for people with Learning Disabilities with complex needs and support clinical teams to best
meet the needs of individuals. This involves liaising with the community learning disability
teams, community providers, families and acute hospital clinical services and co-ordinating
support, planning and treatment delivery for referrals of people with Learning Disabilities,
who may require help to access acute services. The LD Liaison team will:
• Facilitate and co-ordinate of patient care – focusing on needs of the individuals and
incorporating Hospital Passport information and ensuring that reasonable
adjustments are made to take into consideration the individual’s complex needs.
• Ensure appropriate assessments and information are made available to inform the
patient care plan.
• Provide assurance that legal requirements are met re clinical decision making, under
Mental Capacity Act.
• Develop effective working relationships – between clinical teams, relatives,
providers/carers involved with the individual, community services.
• Ensure good governance is maintained and national standards are met - with respect
of care planned and delivered, communications, patient information and involvement.
• Promote staff awareness, education and training re need of people with Learning
Disabilities.
• Provide leadership in the developments and approach to care for people with LD.

Item 11
The review of the Learning Disabilities liaison team has been very encouraging in terms of
the positive feedback from users, community providers and local commissioners. The
structure of the team and its scope of practice will be enhanced, once commissioners have
agreed increased resources, to manage the increase in numbers of patients being supported
and to accommodate weekend working.
Lessons from recent experiences of people with Learning Disabilities
An internal review has been undertaken of a longstanding complaint made last year. The
parents of the individual felt that they had not been fully involved in the clinical decisionmaking
over a period of some months; they were also concerned that clinicians had focused
on their son’s disabilities rather than his clinical needs.
In an informal complaint, made when the CQC undertook its regular unannounced
inspection, concerns were raised by parents of a lady with Learning Disabilities with regards
to the utilisation of the Liverpool Care Pathway for the Dying. The decision-making and
involvement of the family were reviewed as part of the investigation into the concerns raised.
Both of these incidents had similarities with the findings of Mencap (2007 and 2009) and the
CIPOLD (2013) – that people with Learning Disabilities can be disadvantaged in the
processes of clinical decision-making; that clinicians can focus on the person’s disabilities
rather than their clinical needs.
The investigations for both of these incidents identified:
• Good family involvement in all clinical decisions – with regular discussions with
family recorded.
• Compliance with the Mental Capacity Act, with appropriate Best Interest decisions
made regarding plans for treatment.
• No evidence that clinicians focused solely on the person’s disabilities - rather
considered the impact of their long-term condition on any current treatment plans,
clinical interventions and prognosis.
• Good teamwork between clinical teams – this allowed regular review of decisions
and discussions; so that clinical decisions could be changed according to patient
recovery and parent involvement.
However, as with any investigations, there were lessons learned from both incidents. Mostly
for the form of communication clinical teams have with families, terminology used and the coordination
of discussions. It was clear in both cases that the Learning Disabilities liaison team
needed to be more active, get involved earlier and be more proactive in their support for
individuals and their families.
The lessons learned have been incorporated into the revised SOP for the Learning
Disabilities Liaison team
Derriford User Group (DUG)
This is a user/patient group, established in 2011, of people with Learning Disabilities. DUG
is a sub-group of the Health Sub-Group of the Learning Disabilities Board (Plymouth City
Council). Members of the group are supported by Trust staff and with advocacy from People
First from the Highbury Trust, to provide feedback on patient experiences, a perspective on
various Trust services from people with Learning Disabilities and a partnership working for
the LD Liaison team.

Item 11
Over the past two years, members of DUG have been supported to promote initiatives such
as Annual Health Assessments (primary care), development of their own Hospital Passports,
consideration of Organ Donation and Staying Healthy campaign. They have also worked
closely with Trust staff to contribute to the following:
• Recruitment of staff to the LD Liaison team.
• Signage across the hospital.
• Secret Shopper feedback.
• Webpage for Learning Disabilities on the Trust’s website.
• Patient mealtimes and menus.
Following discussion with the Trust Chairman and Chief Executive, at recent DUG meeting,
members of DUG will be supported to continue work towards advising on signage and other
aspects of the hospital environment and involved in improving the language and presentation
of patient letters to people with Learning Disabilities.
There are plans to extend the user group to include people with Learning Disabilities from
both Devon and Cornwall local authority areas; also to include DUG in the wider patient/user
feedback planned by the Patient Services team as part of the Patient Experience work.
National Standards for People with Learning Disabilities in Hospital
Progress continues to be made towards the national standards as laid out in the Monitor
framework and Care Quality Commission and is reported in Annex 4. The Trust continues to
provide high quality care to people with Learning Disabilities:
• Reasonable adjustments are made to care plans/care pathways for people with
Learning Disabilities, through the involvement of LD liaison team and
communication with community services.
• Clinical teams which care for people with Learning Disabilities on a regular basis,
have active LD Link nurses. These provide leadership and support to other
colleagues for the particular care needs for individuals and to promote the use of
reasonable adjustments.
• The role and scope of the LD liaison team in supporting people with complex
needs has recently been reviewed and revised. The team provide important
liaison with community services, advice to clinical teams and support to
individuals and their families.
• Discharges are well planned and communicated with community services,
facilitated by the LD liaison team.
• There is regular training and education for staff, to raise awareness of the specific
needs of people with LD and those who are vulnerable adults.
• Support is provided to carers as they work with clinical teams to meet the needs
of patients in hospital. This is particularly relevant to parents of people with LD,
some of whom have their own health and care issues – as they often spend long
periods of time in hospital supporting patients.
• Incidents and complaints involving patients with LD are flagged, to allow the
involvement of the LD liaison nurses in the investigation and resolution of
complaints/incidents.
• The Meridian ‘Essence of Care’ audit system is used to review/audit to standards
of care for patients identified with LD.

Item 11
Conclusion and recommendations
Further progress towards standards of care in hospital for people with Learning Disabilities
has been made since the last update report. The review of the LD liaison team has been very
useful and encouraging; it has enabled a focused revision of the Standard Operating
Procedure for the management of patients with Learning Disabilities in hospital and a review
of the team structure. Issues and concerns raised through patient experiences have also
been addressed as part of this review and revised operational procedure.
The Trust Board is asked to:
1. Confirm commitment to the Getting It Right Charter.
2. Note the outcomes of the review of Learning Disabilities Liaison team.
3. Review the Trust’s continued position and satisfy itself that the Trust is able to
declare continuing compliance towards the Monitor Compliance framework.

Item 11
Getting it Right Charter Annex 1
How is it for you? Your feedback?

Item 11
Outcome of Internal review of LD Liaison team service Annex 2
Intervention
Review of the Trust’s operational protocol for
people with LD.
Progress (further updates in italic)
Internal review completed – Review with
external stakeholders now also completed
Evaluate weekend working.
Support the LD Liaison team to work in a key
worker/case manager way to ensure the care plan
for people with LD is fully facilitated and coordinated
Undertake mortality reviews of any hospital deaths
of people with LD, to review the planning of care,
involvement of patient/carers and to review clinical
decision-making processes
Ensure involvement of the LD team in any patient
who is cared for on the Liverpool Care Pathway –
this will be implemented as a strict policy
requirement
Review the care management of people with LD
who have highly complex needs to ensure objective
review and learning.
Review the operational leadership to of the team.
Review the team structure
Revise Action plan re National Standards
Complete – interim arrangement for weekend
service is in place whilst Team Leader post is
being recruited.
Discussed with commissioners, need for
additional staff in team to maintain weekend
service - weekend working currently
suspended. Limited value of service, due to
other providers, services etc not available.
Limited planned treatments at weekends
currently
Completed
Meridian template completed – first reviews in
progress.
Process for Mortality reviews by Medical Lead
agreed
Completed
In progress – process of multi-agency
involvement in care management to be agreed
via external review.
Operational policy reviewed – to be presented
to Personal Care Group
Completed – B7 stepping into B6 vacant post,
B7 to national advert. B7 recruited
Complete – for further discussion at external
review (support may be available for further
resource via commissioners) Commissioners
identified need to fund additional post to
extend scope of team and also provide admin
support
Completed – pending agreement & adaptation
via external review External stakeholders
pleased with progress and plans

Item 11
Outcome of review with external stakeholders Annex 3
Intervention
Update and extend use of RAPA - to alert team on
patient movement (admissions, transfers,
discharges)
Update on Progress
LD Liaison Team working with IT managers to
maximise use of RAPA system – extend to
outpatient appointments ;
Community LD team planning to utilise RAPA
to alert patient activity and identify need to
support patients
Improve support to those caring for people with
Learning Disabilities - involvement of carers
(family carers and formal carers) in hospital care
Carers’ policy utilised as standard for carers of
people with Learning Disabilities
LD liaison team to facilitate involvement of
carers in hospital care plan
Need to include Carers’ feedback and
experience
Promote use of Hospital Passport
LD Liaison team to work closely with users,
carers, community services and providers re
development of Hospital Passports
Team to ensure Hospital Passports fully
utilised to inform care plan in hospital
Improve patient experience feedback
Local Patient survey now includes inpatients
with Learning Disabilities on regular basis
Derriford User Group (DUG) enhanced and
involved in range of service planning; further
develop role of DUG in general patient
feedback and involvement
Routine Mortality reviews instigated – to review
death in hospital of any patient with Learning
Disabilities
Prioritise LD Liaison team working - to manage
increase in patient numbers (particularly inpatients)
Joint operational protocol currently being
revised; focus on facilitation of complete care
plan, support with clinical decision-making,
involvement in Best Interest Decisions, liaison
with families and provider services
Continue with staff awareness training and
development of LD Link staff
Link staff working well in key
specialities/clinical areas
Continue with delivery of clinical training at
ward/department level
Continue with formal training – to junior
doctors, preceptees, Healthcare Assistants
Support Clinical Educators and Clinical Nurse
Specialists

Item 11
Develop formalised care pathway for Children with
Learning Disabilities re transition to adult services;
LD liaison team working with Children’s’
services and LD Community team to agree
transition arrangements, pathways, support
Safe Places Scheme
LD Liaison team working with departments – to
raise awareness and ensure facilities in place
for Safe Places within hospital
Extend information for people with Learning
Disabilities
Continue with progress on Easy Read
information
Develop further the Web-page, for use by
patients, families, carers and staff
Develop LD Liaison team
New Team leader appointed
Agreement with commissioners re need for
more funding for extended service
Weekend working planned once additional
staff funded
Role of team to extend to include people on
transition from children’s services, Autism &
Aspergers - once additional staff funded
Need for administrative support identified -
role defined.
Wider Partnership working to continue
Regular review of service against national
standards and requirements
Trust represented at Learning Disabilities
Board; Safeguarding Adults Boards
LD liaison team continue with involvement in
HealthSub Group
Established close working with Patient
advocacy groups, service providers,
Community LD service
Continue with wider network (regional)
Regular report to Trust Board
Review of National Confidential Enquiry into
Premature deaths of People with Learning
Disabilities (2013) – to include in update
operational protocol
Review of compliance with CQC standards on
regular basis

Item 11
Learning Disabilities National Standards Action plan Annex 4
Framework Requirement/Measure Rating Actions
Monitor (2)
Standards with Actions Outstanding
Does the NHS Trust provide readily available and
comprehensible information to patients with learning
disabilities about the following criteria?: treatment
options/complaints/procedures/appointments.
(1-4)
PHT = 3
Continue to
develop easy read
information - focus
on specific
treatments in
common use; Easy
Read information
available on Trust
website.
Review on
Quarterly basis
Ongoing action
Peer
Review
1.5
Clear, accessible and timely information about medication
and specific treatments and procedures is available to
people with learning disability and carers.
(1-3)
PHT - 2
Being developed
with LD Link nurses
for specific
treatments.
Involvement of LD
Liaison team in all
decisions re LCP
Review on
Quarterly basis
Ongoing action
Standards with ongoing actions to maintain compliance
Monitor (2)
Does the NHS Trust have protocols in place to encourage
representation of people with learning disabilities and their
family carers
(1-4)
PHT = 4
Derriford User
Group (DUG)
involved in local LD
Partnership Board,
Health Sub-group.
DUG involved in
local LD events and
in regular feedback
to the Liaison team
Representation of
DUG to be
extended
Review on
Quarterly basis
Ongoing action
Monitor (2)
Does the NHS Trust have protocols in place to regularly
audit its practices for patients with learning disabilities and to
demonstrate the findings in routine public reports?
(1-4)
PHT = 4
Regular reviews of
care for people with
LD – via Essence
of Care (Meridian)
Undertake Mortality
Reviews of people
with LD who have
died in hospital
Review LD Liaison
team complete
Updated LD Liaison
team SOP –

Item 11
Peer
Review
2.2
Peer
Review
6.2
Peer
Review
7.1
Patients with learning disability and their carers receive
appropriate information about nutrition and hydration during
admission.
Recording of and learning from other incidents involving
people with learning disability, including complaints /Patient
advice and Liaison Service feedback etc.
Patient safety issues are identified proactively and patients
receive a high standard of fundamental care.
(1-3)
PHT - 3
(1-3)
PHT - 3
(1-3)
PHT - 3
revised with
external
stakeholders
Review on
Quarterly basis
Ongoing action
Serco have
developed Easy
Read information re
menus - these
have been
reviewed by DUG.
DUG have worked
with Serco to give
feedback on menus
from people with
LD
Review on
Quarterly basis
Ongoing action
Datix flag in place
to identify incidents
for people with LD.
Incidents reviewed
and reported
through
Safeguarding
Steering Group.
Review on
Quarterly basis
Ongoing action
Meridian Essence
of Care filter in use
– to be reviewed for
all LD patients;
Complaints for
people with LD
highlighted and
reviewed by LD
team
Review on
Quarterly basis
Ongoing action
Completed Actions
Peer
Review
1.3
All Hospital departments have access to and use a wide
range of resources to help in the production of easy read
documents for assessments, care plans etc.
(1-3)
PHT - 3
Resources and
support available to
specialities re Easy
Read information
Peer
Review
2.4
All hospitals reflect the reasonable adjustments required for
people with learning disability in their Single Equality
Scheme and its associated action plan.
(1-3)
PHT - 3
Audit of reasonable
adjustments to care
plans of people
with LD.
Review and update
of protocol for
people with LD in

Item 11
Peer
Review
2.5
Peer
Review
2.7
Peer
Review
3.3
Patients with learning disability are discharged home safely. (1-3)
PHT - 3
Training and education regarding learning disability, health
inequalities and communication is provided to all hospital
staff.
Family carers and other care providers are involved as
partners, planning the care of a patient with a learning
disability where possible.
(1-3)
PHT - 3
(1-3)
PHT -3
hospital
Review of roles of
LD Liaison Team
LD Liaison team
involved in
discharge planning.
Readmissions
identified through
RAPA system;
Feedback from
clinical teams in
community –
evidence of good
discharge planning
Wide range of LD
awareness training
achieved;
Safeguarding adult
training now in
induction &
mandatory
programme for all
clinical staff.
Link staff supported
by LD Liaison team
Trust Carers’ Policy
published.
Recommendations
from Patients
Association Survey
(2012)
implemented
Reviewed the care
management of LD
patient with
complex needs

Item 12
SUMMARY REPORT
Trust Board
5 th July2013
Subject
Prepared by
Approved by
Presented by
Equality & Diversity Update
Equality & Diversity Leads
Director of HR & OD
Director of HR & OD
Purpose
The purpose of this report is to initiate the work required to integrate and
embed equality and diversity strategically at Board level and as part of the
core business of the Trust. The report will also inform the Board about the
proposals for the implementation of the Board Inclusion Programme and
request support with this.
Decision
Approval
Information
Assurance
•
•
•
Corporate Objectives
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
• • • •
Executive Summary
This report offers detail on the current position of Equality and Diversity in the organisation. It
identifies examples of good practice and how it can impact on patient and staff experiences. It
demonstrates areas where there are obstacles to progress, i.e. where equality processes are
not integrated into core business, as in the case of the equality assessments.
It recommends that Equality and Diversity becomes part of core business which in turn
facilitates compliance with the Equality Act 2010 and Public Sector Duty. The recently
established Equality and Diversity Steering Group (EDSG) requires commitment from the
senior management team to support delivery of the Equality Delivery System (EDS).This
includes proposals for a Board Inclusion Development Programme, supported by the Plymouth
Way, to further develop a common culture of quality care.
Quality Impact Assessment
Fulfilling our equality obligations will ensure all patients can access consistent quality care
Financial Impact Assessment
Litigation costs
Regulatory Impact Assessment
Compliance with the Equality Act 2010 and Public Sector Duty
Key Recommendations
The Trust Board is asked to:
1. Support the principal of equality & diversity becoming part of the Trust’s core business.
2. Support proposals for a Board Inclusion Development Programme
3. Support the utilisation of Trust surveys, complaints and incidents to identify trends and
the interventions required
4. Support the Plymouth Way in embedding the values in the Trust and allowing the
appropriate challenge of behaviours and attitudes
1

Item 12
Next Steps
1. Conversation between the providers of the Board Inclusion Programme and the Chair of
the HR&OD Committee
2. Meeting of the Chairman, the Chief Executive, the Director of HR&OD and the providers
of the Board Inclusion Programme
3. Board Inclusion Development Programme to commence Quarter 3 13/14.

Item 12
DETAILED REPORT
Trust Board 5 th July 2013
Subject
Prepared by
Approved by
Presented by
Equality & Diversity Update
Equality & Diversity Leads
Director of HR&OD
Director of HR&OD
Purpose
The purpose of this report is to initiate the work required to integrate and embed equality and
diversity strategically at Board level and as part of the core business of the Trust. The report
will also inform the Board about the proposals for the implementation of the Board Inclusion
Programme and request support with this.
Background
Following a period of change within the organisation, the lines of responsibility and reporting
for the equality and diversity work programme were unclear. The Director of HR & OD has
taken on the role of executive lead for this work and the Equality and Diversity Steering
Group (EDSG) has been established to replace the previous equality delivery group.
Following the introduction and implementation of the Equality Delivery System (EDS), the
Trust assessed its performance against the EDS outcomes. This produced equality
objectives as required by the Public Sector Equality Duty.
The EDS is a national framework, developed by the Department of Health, in conjunction
with the Equality and Diversity Council. It has 18 outcomes defined under 4 goals. The goals
are:
1. Better health outcomes for all;
2. Improved patient access and experience;
3. Empowered, engaged and well supported staff; and
4. Inclusive leadership at all levels.
These grades and objectives were agreed and published at the beginning of 2012 and can
be found in annex 1.
Equality & Diversity
1. Equality & Diversity Steering Group
The EDSG, was established in October 2012 and is a sub-committee, reporting to the
HR&OD Committee. The purpose of the group is to develop and oversee the equality and
diversity work programme, including, the Trust’s equality objectives and the EDS. It will
ensure work is co-ordinated across the Trust with the involvement and ownership of relevant
stakeholders whilst providing assurance to the Committee that the equality and diversity
agenda is placing the patient at the heart of what we do, whilst meeting legislative
requirements, CQC standards and statutory duty.
The group will also support the Trust in developing a culture that values staff, improves
patient experience while putting equality, diversity and human rights at the heart of all of its
business.
3

Item 12
2. Board Inclusion Development Programme
Following the Board’s review in 2012 and though the EDS assessment an area of priority that
was identified, which required action was the positioning of equality strategically at Board
and senior management level. Methods to address this were investigated and a programme,
provided in conjunction with the NHS Leadership Academy was found.
This programme is the Board Inclusion Development Programme provided by Diversity
Practice. The programme is being offered free of charge to the Trust but would usually have
a cost of £21000.
Following a small selection process, the Director of HR&OD and the Director of Governance
met with Diversity Practice, during April 2013, who is the preferred service provider. They
delivered a detailed presentation on the value of the programme to staff and patients and
made recommendations in terms of the next steps for the Trust’s consideration.
The aim of the programme is to support the Board in developing the critical connection
between the organisational culture, Equality, Diversity and Inclusion (EDI) and the Trust’s
core business. It will also identify our current position, identify any gaps and what needs to
be done to ensure that the Trust delivers an equitable service to all its delivers stakeholders.
It is essential that the programme is aligned to the Plymouth Way, the Trust Strategy which
incorporates Safety and Quality, and the Quality Strategy. It will support the objectives of
improving patient experience, staff engagement and meeting our financial obligations
The EDSG will support and facilitate the programme, providing an advice and challenge
function with mutual accountability with the HR&OD Committee and will update the Trust
Board, to give visibility and assurance of progress and outcomes of the programme.
The EDSG had a meeting in June 2013 which was chaired by the Director of Governance.
The meeting was attended by Diversity Practice, who is the provider of the programme and
Yvonne Coghill, from the NHS Leadership Academy who will support the Trust through this
programme. A number of recommendations were made at this meeting which will be
progressed over the coming weeks; these include conversations with the chair of the HR &
OD Committee, Chief Executive and the Trust Chairman.
3. Good practice
There are areas of good practice across the Trust where equality and diversity is having a
positive impact on staff and patients, these include:
• Project Search – Work rotation opportunities for 19 – 24 year olds with learning
disabilities;
• Flexible Retirement – giving people the option to change the intensity or hours of
their work as they approach retirement which helps the Trust retain experienced,
valued employees with a range of skills;
• Valuing people statement in all Trust policies;
• Learning Disability Service – liaison nurses providing additional, specialised
support for patient with Learning Disabilities;
• Meal time support for patients as required;
• Bespoke ‘valuing people’ training including dignity in care and recommendations
from the Francis report;
• Equality & diversity included in the revised plan for induction; and
• Equality and Diversity Leads are part of the CQC Leads Forum to integrate
equality and diversity into the assurance that we collect for each CQC outcome.

Item 12
4. Current risks and concerns
The top risks and concerns for PHNT have been identified as:
• Equality impact assessment process is not integrated robustly into business
practice. This is a legislative requirement to ascertain how the way we provide our
services affects our patients and staff;
• Lack of equality information around complaints and incidents;
• Engagement with issues arising from the staff and patient surveys;
• Lack of disclosure in workforce data; and
• Poor quality patient data.
Conclusion
By embedding equality and diversity into the day to day business of the organisation, with
clearly defined objectives, we will ensure that we become an employer and service provider
of choice.
The Board Inclusion Development Programme, aligned to the Plymouth Way and Quality
Strategy, will be a first step to developing an improved equality and diversity strategy and
infrastructure, impacting positively on our patients and staff.
This will enable us to show, over time, that all our patients have equal access to services
which are open and approachable to all. In addition it will let us demonstrate that we deliver
high quality outcomes in partnership with others, are responsible and accountable for what
we do, showing to our staff that we value their contributions whilst developing their potential.
Recommendations
The Trust Board is asked to:
1. Support the principal of equality & diversity becoming part of the Trust’s core
business;
2. Support proposals for Board Inclusion Development Programme;
3. Support the utilisation of Trust surveys, complaints and incidents to identify trends
and the interventions required and
4. Support the Plymouth Way in embedding the values in the Trust and allowing the
appropriate challenge of behaviours and attitudes

Item 12
EDS Grades and E & D Objectives Annex 1
Plymouth Hospitals – Equality Objectives
• To enable the Trust to analyse patient outcomes and experiences by protected characteristic
and as a result, identify and initiate improvements as required. To do this we will:
• Improve patient data collection to allow the monitoring of all required protected
characteristics in line with the public sector duty requirements. This will include
improving the facilities to collect patient data on our systems
• Continue to collect and expand the collection of equality information on the local patient
surveys.
• Develop and deliver a programme of awareness/education to ensure staff have the
knowledge and skills to collect this information in appropriate ways
• On-going monitoring and analysis of patient/carer feedback, complaints, untoward
incidents and patient survey results will be undertaken on a monthly basis, and
outcomes fed back to the appropriate assurance leads to enable them to develop and
implement actions as required
• The annual review of the equality objectives will demonstrate an improvement in the
patient data collected, and its use.
• To improve the discharge experience for all patients and their relatives/carers regardless of
their protected characteristics by ensuring that:
• The discharge process is completed in a timely fashion
• Clear information is provided in an appropriate format about any medications and ongoing
care requirements.
• On-going monitoring and analysis of patient/carer feedback, untoward incidents,
complaints and patient survey results will be undertaken on a monthly basis, and
outcomes fed back to the appropriate assurance leads to enable them to develop and
implement actions as required .
• The annual review of the equality objectives with the local interests groups will monitor
the implementation of actions and assess the resulting improvements
• Ensure information provided to patients regarding their care/treatment is provided
• Within appropriate timescales
• In an appropriate, understandable format.
• Monitoring and analysis of patient/carer feedback, complaints and patient survey results
will be undertaken on a monthly basis, and outcomes fed back to the appropriate
assurance leads to enable them to develop and implement actions as required.
• The annual review of the equality objectives with the local interests groups will monitor
the implementation of actions and assess the resulting improvements
• Ensure Equality & Diversity learning and development programmes, specifically around
attitudes and behaviours, are attended by all staff on an annual basis. Monitor and analyse
attendance by staff group via the Oracle Learning Management system (OLM) and the
Electronic Staff Record (ESR). Development of an assessment tool needs to be undertaken to
assess the skills and competencies of staff gained from the learning and how positive
outcomes are produced in the work area.
• Ensure the Board can define and position equality & diversity as a strategic opportunity
• To improve access and quality in healthcare and reduce health inequalities. Monitoring
and analysis of patient/carer feedback, complaints and patient survey results will be
undertaken on a monthly basis, and outcomes fed back to the appropriate assurance
leads to enable them to develop and implement actions as required
• To use the NHS constitution as an opportunity to ensure comprehensive services to
patients from all protected characteristics. Monitoring and analysis of patient/carer
feedback, complaints and patient survey results will be undertaken on a monthly basis,
6

Item 12
and outcomes fed back to the appropriate assurance leads to enable them to develop
and implement actions as required
• To embed equality & diversity into all mainstream business
• Increase leadership competence and capability in equality & diversity using the
principles of the NHS Leadership Framework and EDS Leadership Competency
Framework.
• To understand the impact of equality and diversity on staff and patients through regular
reports to the Trust Board.
7

Item 12
Plymouth Hospitals Trust – EDS Self-Assessment Grades
Goal Outcomes Status
Undeveloped Developing Achieving Excelling
1 Better
health
Outcomes for
all
1.1 Services are commissioned, designed and procured to
meet the health needs of local communities. The
health needs of local communities, promote well-being,
and reduce health inequalities
1.2 Individual patients needs are assessed and resulting
services provided in appropriate and effective ways
1.3 Changes across services for individual patients are
discussed with them and transitions are made
smoothly
1.4 The safety of patients is prioritised and assured. In
particular, patients are free from abuse , harassment,
bullying and violence from other patients and staff, with
redress being open and fair to all
1.5 Public Health, vaccination and screening programmes
reach and benefit all local communities and groups
2 Improved
patient
access and
experience
2.1 Patients, carers and communities can readily access
services and should not be denied access on
unreasonable grounds.
2.2 Patients are informed and supported to be as involved
as they wish to be in their diagnosis and decisions
about their care and to exercise choice about
treatments and place of treatment
8

Item 12
2.3 Patients and carers report positive experiences of their
treatment and care outcomes and of being listened to
and respected and how their privacy and dignity is
prioritised
2.4 Patients and carers complaints about services and
subsequent claims for redress should be handled
respectfully and efficiently
3 Empowered,
engaged and
well
supported
staff
3.1 Recruitment and selection processes are fair, inclusive
and transparent so that the workforce becomes as
diverse as it can be within all occupations and grades
3.2 Levels of pay and related terms and conditions are
fairly determined for all posts with staff doing equal
work and work rated as of equal value being entitled to
equal pay
3.3 Through support, training, personal development and
performance appraisal, staff are confident and
competent to do their work so that services are
commissioned or provided appropriately
3.4 Staff are free from abuse, harassment, bullying and
violence from both patients and their relatives and
colleagues with redress being fair and open to all
3.5 Flexible working options are made available to all staff,
consistent with the needs of the service and the way
people lead their lives.
9

Item 12
3.6 The workforce is supported to remain healthy, with a
focus on addressing major health and lifestyle issues
that affect individual staff and the wider population
4 Inclusive
leadership at
all levels
4.1 Boards and senior leaders conduct and plan their
business so that equality is advanced and good
relations fostered within their organisations and beyond
4.2 Middle managers and other line managers support and
motivate their staff to work in culturally competent ways
within a work environment free from discrimination
Excelling – Purple
Achieving - Green
Developing – Amber
Undeveloped – Red
4.3 The organisation uses the competency framework for
Equality and Diversity Leadership to recruit, develop
and support strategic leaders to advance equality
outcomes
10

Item 13
SUMMARY REPORT
Trust Board 5 th July 2013
Subject
Prepared by
Approved by
Presented by
Information Governance
Head of Clinical Systems Governance
Director of Planning and Site Services (Senior Information Risk Owner)
Director of Planning and Site Services (Senior Information Risk Owner)
Purpose
The Senior Information Risk Owner (SIRO) provides the Board with a quarterly
update on Information Governance; highlighting key progress, risks, incidents and
management action.
The case note improvement project is being reported to the Safety and Quality
Committee at each meeting. The evidence for Care Quality Commission Outcome
21 (Records) was presented to the May 13 Audit Committee.
Decision
Approval
Information
Assurance
•
•
Corporate Objectives
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
Whilst Information Governance is part of everyone’s role within the Trust, work is being carried out by
key teams to improve the overall Information Governance Framework. This is informed by the
Information Governance Toolkit requirements, new incident reporting criteria, Care Quality Commission
& NHS Litigation Authority (NHSLA) feedback and national Data Quality benchmarking on the Secondary
Uses Service (SUS) dashboards.
This report highlights the work carried out by the four steering groups reporting to the Records and
Information Governance Forum.
Quality Impact Assessment
An effective Information Governance framework is essential to ensure that all members of staff manage
information for the benefit of patients.
Financial Impact Assessment
• Information Governance Breaches can attract financial penalty from the Information
Commissioner.
• Effective corporate document management is essential for NHLSA Assessment and will affect
premiums.
• Whilst the primary reason for accurate information is for patient care, this information assists with
running an efficient service.
Regulatory Impact Assessment
• The Information Commissioners Office regulates the use and access to personal and official
data. The main laws being the Data Protection Act and the Freedom of Information Act.
• The Care Quality Commission regulates:
Records standards under Outcome 21.
Transferring information to other providers under Outcome 6
• The Health & Social Care Information Centre oversee the Secondary Use Service (SUS).
1

Item 13
Key Recommendations
The Trust Board is asked to note:
1. Work being overseen by the Records and Information Governance forum and the Records
Strategy work being reported to the Safety and Quality Committee.
2. The Medical Director taking the role of Chief Clinical Information Officer.
3. The recruitment of a dedicated FOI Manager to address the FOI backlog.
Next Steps
1. Follow up action for Outcome 21 issues raised by CARE QUALITY COMMISSION initial
feedback.
2. The “Development and Management of Trust Wide Documents” Policy is being significantly
changed and will be brought to a future Board meeting for ratification.
3. The IG team will submit V11 baseline IG Toolkit by 31 st July 13.
4. The IG team will produce figures for incidents recorded using new categories on Datix for next
Board report.
5. The Caldicott Guardian to update the executive team on the implications of the recent IG report
from Dame Fiona Caldicott known as Caldicott2.
2

Item 13
DETAILED REPORT
Trust Board 5 th July 2013
Subject
Prepared by
Approved by
Presented by
Information Governance
Head of Clinical Systems Governance
Director of Planning and Site Services (Senior Information Risk Owner)
Director of Planning and Site Services (Senior Information Risk Owner)
Purpose
1. The purpose of the report is to provide an update on Information Governance; highlighting key
progress, risks, incidents and management action.
Background
2. Information Governance is overseen by the Records & Information Governance Forum (RIGF)
which is chaired by the SIRO. The following sub groups report into this Forum:
Key Highlights
• Caldicott Information Governance Group (CIGG)
• Data Quality Steering Group (DQSG)
• Health Records Steering Group (HRSG)
• Corporate Records Management Steering Group (CRMSG)
Information Governance
3. The Care Quality Commission’s initial feedback following the last routine investigation highlights
three Information Governance issues under Outcome 21:
Outcome 21 Issues raised by CARE
QUALITY COMMISSION
Physical Security of Casenotes.
• On some wards records were
accessible to patients and visitors.
• In some areas case note cupboards
were not locked and some had the
key pad access number available on
the cupboard.
• In one ward, the locks were no longer
suitable to lock the cupboard doors.
Electronic check in.
• In some areas information such as
patients' names, addresses and
dates of birth, was easily visible to
other people in the waiting area.
Initial Management Response
• Standard lockable trollies have been
introduced onto all wards as part of
the Records Management Action
Plan.
• This is being reported to the Safety
and Quality Committee by the Interim
Records Strategy Lead.
• Action for the Director of Nursing to
Introduce Audits of the use of these
trollies.
• Audits will be reported to the Health
Records Steering Group.
• The Clinical Admin Programme has
raised these concerns and will be
addressing them directly with Intouch
at a contract implementation review
meeting on 27 th June.
• The first priority will be to adapt the
screens to improve confidentiality.
3

Item 13
Telephone conversations.
• On some wards telephone
conversations made by staff about
patients could be clearly heard by
patients and visitors in seating areas.
• The Head of Clinical Systems
Governance will review procedures on
wards with Nursing management and
the Caldicott Guardian.
• The correct procedures will be
communicated to ward staff and
overseen by the Caldicott Group
4. The Information Governance Toolkit (IGT) is now being overseen by the Health and Social Care
Information Centre (HSCIC) which replaced Connecting for Health. The HSCIC released Version
11 in early June13 without any significant change to the 45 requirements. The IG team are
preparing for the Baseline Submission at the end of July 13.
5. In tandem with the release of V11 of the IGT, the HSCIC have published new guidance on the
way that Trusts should report, manage and investigate Information Governance Serious Incidents
Requiring Investigation (SIRIs). From June 13 all Organisations processing health and adult
social care personal data are required to use a new online IG Incident Reporting Tool to report IG
SIRIs to the Department of Health, Information Commissioners Office (ICO) and other regulators
as appropriate.
6. The algorithm used to decide if an IG incident is a SIRI has altered. The Information Governance
Team is learning the new system. It is recognised that there is no simple definition of a serious
IG incident. What may at first appear to be of minor importance may, on further investigation, be
found to be serious and vice versa. Plymouth Hospitals Trust last reported an IG SIRI to the ICO
in January 2012. In the 2012/13 financial year the IG team dealt with 354 IG incidents none of
which were categorised as SIRI’s.
7. The IG Team now record all incidents that they deal with on Datix and are currently reviewing the
categories used to reflect the new HSCIC guidance. Figures will be available for the next Board
update. In addition, the team continue to scan the Datix system and flag those incidents with an
IG element.
8. Dame Fiona Caldicott has published the report of the recent review of Information Governance.
This is known as Caldicott2. The Caldicott Guardian will present the implications of this review to
the Executive team.
9. The original Caldicott report was written in 1997 when the health services were more paternalistic
and much less patient centred, now the public are a lot more concerned about what happens to
their information. Caldicot2 states that a re-balancing of sharing and protecting information is
urgently needed in the patients’ and service users’ interest.
10. The original Caldicott Principles still stand but have been updated with a 7 th principle being
added: “The duty to share information can be as important as the duty to protect patient
confidentiality”. Appropriate sharing of information is seen as important as maintaining
confidentiality.
11. The following Subject Access Requests have been made under the Data Protection Act for 2013
(as at 14/06/2013)
No of requests Disclosed after 40 Cumulative Total
days
January 24 3 24
February 16 5 40
March 13 3 53
April 13 4 66
May 25 None as at 14/06/13 91
4

Item 13
Corporate Documents
12. Accessing Trust wide policies and procedures will soon be through the new intranet site being
rolled out by the Communications Team. This will replace the current network shared folder. This
is in line with the vision of the Healthnet replacement being the main portal for staff to access
information.
13. The Information Governance (IG) team have continued to target out of date policies. Currently 24
of the 161 policies are out of date. Of this number there is a residual group of 10 policies that
have remained out of date for over 12 months. All of the Ratifying Leads are aware and have
been emailed a list of the policies that they are responsible for.
14. The “Development and Management of Trust Wide Documents” Policy is undergoing a significant
review following feedback from the last NHSLA visit and on-going learning. The updated policy
will need to be ratified by the Trust Board. One key issue that needs to be decided is how local
as opposed to Trust wide documents will be governed.
15. The Trust has noted that it has become increasingly difficult to sustain compliance within the 20
working day deadline for Freedom of Information requests. The number of requests has now
stabilised, however, the number of questions being asked within each request and the case
complexity has increased. We have acted to address this matter by recruiting a fixed-term FOI
Manager with a view to reviewing and improving our practices in this regard and providing
additional resource and focus on this important area
16. Current FOI metrics are as follows:
2009 2010 2011 2012
As at
21/05/13
Open cases that are still within 20 working
day limit
0 0 0 0 22
Open case past the 20 working day limit
(Excluding any previous year open cases)
0 0 0 4 25
Number of cases answered on time 172 138 111 117 49
Number of cases not answered on time 38 64 113 103 37
Data not available 9 32 11 7 2
Total number of Freedom of
Information cases
219 234 235 231 135
Percentage of compliance 79% 68% 50% 53% Pending
Health Records (Casenotes and the move to eNotes (electronic notes)
17. Progress on the Records Management Programme and Casenote Improvement Programme
continues to be reported to the Safety and Quality(S&Q) Committee. The Interim Records
Strategy Lead attended the June 13 meeting to update on the actions.
18. The Director of Planning and Site Services and Interim Records Strategy Lead met with the
Medical Director on 10 th June 13 to discuss Professional Clinical Leadership for Health Record
keeping and the Records Strategy The Medical Director agreed to take on the role of Chief
Clinical Information Officer which is a Board level clinician who leads on electronic health
records. The need for this role was highlighted in the DH Information Strategy; “The power of
information”.
5

Item 13
19. The Medical Director has written to all Service Line Clinical leads instructing them to:
• Ensure that all doctors have access to record keeping training.
• Audit Clinical Record Keeping Standards and present to departmental Clinical
Governance meetings.
• To provide assurance to the Safety and Quality Committee.
The Medical Director will review these actions through performance meetings.
20. In preparation for the transition to eNotes the Interim Records Strategy Lead is reviewing how
Clinical Letters are stored across the Trust. These documents must be captured in order to store
an accurate historic record on the patient’s electronic notes.
21. The Director of Planning and Site Services and Interim Records Strategy Lead presented to the
Medical Education Committee (MEC) in May 13 to update on the eNotes strategy. This was well
received by the clinicians with offers of support.
Information Security
22. There has beeen a standardisation of External Storage Devices. All future purchases of USB pen
drives and external hard drives will be limited to a product range featuring always-on encryption
which negates the risk of staff purposefully or inadvertently disabling data encryption. The
devices also offer greater compatibility and are easier to use.
26. Plymouth ICT Shared Service are now deploying the AirWatch Mobile Device Management
solution to Trust issued iPads and mobile devices. Mobile Device Management is essential to
enable the secure use of consumer devices in business and clinical settings. It will also act as an
enabler for any future ‘Bring Your Own Device’ initiative which the Trust may wish to explore.
AirWatch is part of the longer term ICT strategy to provide flexibility to choose devices best suited
to the intended task and enable mobile access to clinical and business applications.
Data Quality of Electronic Patient Records
23. The Data Quality Steering Group benchmarks the quality of the data submitted to the Secondary
Use Service (SUS) using the national SUS Data Quality Dashboard. Patients should be
identified using their NHS number; with varying compliance targets based on national
achievement for 3 different categories. The Trust continues to achieve these targets in 12/13.
NHS Number Categories National Target – Month
12
Trust Achievement – Month
12
Admitted Planned Care 99.1% 99.1%
Outpatient 99.3% 99.3%
ED 94.9% 97.1%
24. Similarly, the recording of a patient’s GP Practice must meet national targets, which the Trust is
currently exceeding in all areas with the exception of the ED, but the Data Quality team are
implementing a plan to achieve this. The Trust is achieving the Outpatient Attendance Outcomes
target, but further improvement will be delivered when the eOutcomes solution is released by the
Clinical Admin Programme.
25. The one outstanding indicator is the population of the Patient Pathway Identifier, when this is
populated on SUS, PHNT have the potential to be top of the Data Quality ratings for all Trusts in
the old South West SHA area. This improvement is on the list of priorities for the Software
Development team.
26. A draft Data Quality strategy has been created and will be implemented alongside the Clinical
Administration Review. The implementation of the strategy will ensure that the responsibility and
accountability for data quality is understood and built into the new roles. Alongside this,
appropriate administration training will be delivered and the Data Quality function will provide ongoing
support and performance monitoring of Data Quality indicators.
6

Item 13
Recommendations
27. The Board is asked to note:
Conclusion
• The work being overseen by the Records and Information Governance Forum and the
records strategy work being reported to the Safety and Quality Committee.
• The Medical Director will take over the role as Chief Clinical Information Officer and a
dedicated Freedom of Information Manager has been appointed to address the backlog
of Freedom of Information requests.
28. Work is being carried out by all areas holding key Information Governance roles. The CARE
QUALITY COMMISSION report following the recent routine inspection has highlighted immediate
issues to be addressed. Operational Information Governance incident reporting is being
revamped. Metrics for Subject Access and Freedom of Information requests are now being
reported. The implications of the Caldicott2 report are being considered. A long term Health
Record Strategy is now in place with a vision to move to eNotes. Clear clinical leadership for
Health Record Keeping has been established.
7

Item 14
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Trust Seal
Board Secretary
Director of Governance
Board Secretary
Purpose
The purpose of this report is to update the Board on the use of the Trust’s
Seal.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
In accordance with the Trust’s Standing Orders, the Trust Board receives regular quarterly
updates on the use of the Trust’s Seal. The last report covered the three months ended 27
March 2013. No documents were signed and sealed in the period 28 March 2013 to 26 June
2013.
•
Quality Impact Assessment
None.
Financial Impact Assessment
None.
Regulatory Impact Assessment
None but this report demonstrates good governance and compliance with Standing Orders.
Key Recommendations
The Trust Board is asked to note this report.
Next Steps
Not applicable.

Item 15
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Safety and Quality Committee Chair’s Report
Dr Mike D Williams, Safety & Quality Committee Chair
Dr Mike D Williams, Safety & Quality Committee Chair
Dr Mike D Williams, Safety & Quality Committee Chair
Purpose
This report highlights key issues considered at the Safety and Quality
Meeting on the 17 June 2013 to provide assurance to the Trust Board that
safety and quality governance arrangements are in place.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
The main issues discussed at the meeting were:
•
•
1. Theatre Safety
Following the CQC communication about Theatre safety, the committee received
assurance from the Chief Executive and Director of Nursing that the Theatre Safety
Improvement Plan had been subject to rigorous external review by the Trust
Development Authority. Further actions are in hand to ensure the implementation of the
plan, particularly around the scheduling of theatre lists.
2. Outpatient backlog
The Committee considered a report detailing the work done to risk assess the outpatient
backlog in ophthalmology. Further actions have now been requested to ensure that a
similar risk assessment is undertaken for other specialties. It is apparent that there is
insufficient capacity in a number of specialties to meet both the current demand and
eliminate the backlog of patients. The risks associated with this situation need to be
considered by the Trust Board in partnership with commissioners.
3. Maternity services
The Committee received assurance from the Royal College of Obstetricians and
Gynaecologists’ Report on patterns of maternity care in English hospitals.
4. Mortality data
The Committee took assurance from the hospital standardised mortality ratio, which
provides data about hospital mortality, that the current rate remains at around 20% less
than it could be expected. Similarly, the Committee received assurances from the
hospital mortality indicator, which provides data on deaths up to 30 days following
hospitalisation, that the rate is around 7% less than could be expected. However, the
Committee requested that consideration be given as to how to reduce further the
mortality rate, especially for patients admitted over the weekend.
5. Serious incident W33081/W33105 – action plan report
The Committee considered a range of issues resulting from this report. The general
learning point was made about the necessity for the terms of reference for serious

Item 15
incident investigations to be clearly established and timeframes set to ensure issues are
addressed more rapidly than had been in this case.
6. Health Records Action Plan
The Committee received a detailed report about actions being undertaken to meet the
required standards, which provided limited assurance. It is recognised that the
complexity of some of the issues means that full implementation of the plan will require
further work.
The minutes of the meeting are attached at Annex 1.
Quality Impact Assessment
All issues discussed have potential to negatively impact on the quality of care provided.
Financial Impact Assessment
To be considered, where relevant.
Regulatory Impact Assessment
Relevant to all essential standards and outcomes.
Key Recommendations
The Trust Board is asked to:
1. Take assurance that suitable governance arrangements are in place for safety and quality
issues addressed by the Committee.
2. Decide how to assess and except a degree of risk relating to the outpatient backlog with
commissioners.
Next Steps
The Committee will continue to provide the Board with regular reports on its activities to provide
assurance that we are providing safe, effective and personal care to our patients.

Safety & Quality Committee
Item 15, Annex 1
Monday 17 th June 2013
Maternity Seminar Room, Level 5
Draft Minutes
Chair: Mike Williams (MW) Non-Executive Director – Chairman
Present: Lee Budge (LB) Director of Governance
Greg Dix (GD)
Chief Nurse
Ann James (AJ)
Chief Executive
Alex Mayor (AM)
Medical Director
Margaret Schwarz (MS) Non-Executive Director
Denis Wilkins (DW)
Non-Executive Director
In Attendance: Richard Best (RB) Deputy Director of Operations
Jayne Glynn (JG)
Patient Experience Manager
Debs Hounsome (DH) Acting Officer Commanding Nursing
Invited members: Kylie Glynn (KG) (Minutes) Healthcare Governance Facilitator
Kevin Marsh (KM) (Item 10) Deputy Chief Nurse
Sue Stock (SS) (Item 11) Head of Midwifery
Anne Bussell (AB) (Item 12) Health Records Advisor
1. Welcome and Apologies Action
The Chair welcomed Committee members to the meeting.
The Committee noted apologies from Kevin Baber, Amelia Brooks, Clare Cotter, Sue
Kelley, Paul McArdle and Julie Morgan.
Richard Best attended the meeting on behalf of Kevin Baber.
2. Minutes and Matters Arising
Minutes of the previous meeting were agreed as a true and accurate record.
The Chair asked if the Personal, Safe and Effective Care Groups were going to be
merged and whether a single report would be presented at future meetings.
LB explained the groups would not be merging imminently as there are significant work
streams being reported through them and the detail needs to be discussed at subcommittee
level. When service lines have been agreed the quality governance meeting
structures will be reviewed again. GD highlighted concerns regarding the removal of the
sub-committee care groups as governance frameworks within the directorates and
service lines is currently very poor therefore, adequate assurance of action could not be
provided.
LB informed the Committee that additional discussions have taken place around
combining the Safe and Effective Care Group, which would then be chaired by AM and
then have a Patient Experience Forum chaired GD. need to be clear about what we need
these groups to do. AJ highlighted the importance of clarifying what the roles of these
groups would be and what the Committee would like them to focus on.
AM explained that in the past directorates have depended on the overarching
governance structure and the culture must change so that they understand they are
responsible for implementing actions and providing assurance. The Chair noted the
Committee can be used to hold relevant leads to account.
S&Q Draft Minutes June 13 Page 1 of 7

Item 15, Annex 1
3. Review of Action Table
Assurance Framework – VTE Risk Assessment
Update on VTE risk assessment figures included within Safe Care report. Action closed.
Safe Care Report – Additional Information
Breakdown of serious, significant and moderate incidents included within report. Detail
regarding themes to be included from July 2013.
AB
Follow-up Backlogs – IPAM Report
Update regarding follow-up backlogs presented to the IPAM meeting on 30 th May 2013.
Action closed.
Follow-up Backlogs – Coding System
Meeting with final directorate at the end of the week to discuss the coding systems.
Issues to be dealt with separately by the relevant leads. Action closed.
Review of Consultant Clinical Practice
Relevant paper reviewed and disseminated to Non-Executive Directors. Action closed.
4. Messages from the Board and Sub-Committees
The Chair informed the Committee that the Board would like clarity on the patient safety
measures that will be used throughout the organisations and how these will link to the
overarching quality strategy, improvement plan and governance arrangements. Although
these plans will evolve with time the Committee must ensure that governance
arrangements link with improvement. There needs to be assurance that continual
improvements are being made as well as the right boxes being ticked.
AJ explained that GD, AM and KM are currently reviewing the structure of the quality
team to ensure it aligns with service improvement. Clear accountability will also be
identified. There needs to be a step change as there are strong reporting mechanisms in
place however processes for implementing timely changes need to be established. The
Chair added that the pressure to demonstrate improvements has increased significantly
since the publication of the Francis report.
The Committee noted that the Trust had received a draft report from the CQC visit
conducted in April 2013 and the findings were currently being considered.
Implementation of the updated theatre safety action plan has continued to ensure the
concerns that have been raised as a part of the informal feedback are addressed. AJ
explained that a warning notice on surgical safety had been issued to the Trust on Friday
14 th June 2013. GD had met with the TDA to explain the detailed action plan in place and
AJ would be meeting with key staff members to ensure operating list scheduling issues
were resolved rapidly.
5. Weekend Mortality Rates
The Chair highlighted concerns regarding the difference in the mortality rate between
week days and weekends within the Trust. Data has been presented on page two of item
6, appendix 1. Although this is not uncommon within Trusts across the country it is an
issue that should be considered so that improvements can be made.
AM explained that the rates reflect how working systems are currently set-up within the
Trust for example, the workforce planning profile focuses on elective services which are
performed during weekdays. This is currently being reviewed to ensure senior
consultants and surgeons are in the Trust during the weekend. Lack of senior clinical
support is a problem in all areas across the Trust and is not prevalent within any one
particular department however; this may cause more issues within emergency services.
Work is also ongoing with services in the community and peninsula to ensure patients
who are unwell are not transferred to hospital because services in the community are not
currently available at the weekend.
S&Q Draft Minutes June 13 Page 2 of 7

Item 15, Annex 1
RB noted that whilst 7 day working for consultants is currently being considered other
changes can be made to improve the mortality rate at the weekends. For example, if
phlebotomy services coincided with ward rounds there would not be a 24 hour delay in
obtaining results, during which time patients can deteriorate rapidly.
The Chair asked the Committee to consider what changes to drive improvements can be
made within the next 6-12 months. Although this issue cannot be resolved in its entirety
within this timeframe particular elements can be focused on. These can then be included
within the Trust’s safety improvement plan.
AM
6. Effective Care Report
The Committee noted the content of the report which focuses on the follow-up backlogs
and compliance with NICE Guidance. Capacity for clinical audit within the Trust was
highlighted as being particularly small for an organisation of this size. As a result AM and
GD are discussing how this can be incorporated within the governance quality team.
Follow-up Backlogs
The Chair informed the Committee the Non-Executive Directors were particularly
disappointed with lack of progress in reducing the outpatient follow-up backlog. It would
appear that significant time is being spent trying to complete risk assessments within
each directorate and there is not enough focus on resolving the backlog.
RB explained there are significant capacity problems as additional funds to clear the
backlog of patients are not available within the commissioning contract. This is trying to
be done in addition to delivering a normal service. Changes to pathways need to be
made to prevent this from being an ongoing issue in the future. We must ensure the
correct patients are being added to the follow-up waiting lists for the right reason.
The Chair explained risk assessments, as completed within Ophthalmology, need to be
in place within all directorates and a review of which patients are being added to the
waiting lists needs to be completed. AJ added that a specific plan for each specialty
needs to be put in place as each backlog will need to be addressed in different ways.
Issues within one area may not be relevant for another.
The Chair noted that Ophthalmology remains the biggest concern particularly given the
risk for some of these patients. RB assured the Committee that patients who have been
identified as high risk are being dealt with as a priority and this has been incorporated
within the capacity planning for this specialty.
LB highlighted it was still not clear within the report where the high risk areas lie in other
specialties within the report. AM explained that Paul McArdle is working with directorates
to ensure a breakdown of the risk, as included within appendix 2 for Ophthalmology, is
available for all directorates. Report on progress to be brought to the next meeting
The Chair summarised that there appear to be continual issues in reducing the follow-up
backlog due to the lack of capacity however; high risk patients within all directorates will
be identified so that these can be treated as a priority. In addition, service line leads will
need to develop local action plans to demonstrate how the overall backlog can be
reduced and how pathways for adding patients to follow-up waiting lists will be reviewed.
PMc
KB
7. Personal Care Report
GD presented the Personal Care Report to the Committee and highlighted the following
key points –
• Publication of results for key performance measures will be reviewed so that the
trend analysis for each measure can be reviewed and provide additional assurance
• PALS and complaint rates have remained relatively stable during the past five
months except for the spike in the number of complaints received in April 2013
GD/JG
S&Q Draft Minutes June 13 Page 3 of 7

Item 15, Annex 1
• Top three issues raised through PALS remain as communication, inpatient delays
and outpatient delays. Although communication remains a top theme there are no
particular areas of concern that could be addressed which would show an
improvement in the overall figures of these issues
• A particular piece of work in relation to communication is being completed with those
who are visually and hearing impaired so that feedback can be used to drive
improvements for these care pathways. AJ suggested doing the same with patients
who suffer with learning difficulties
• The FFT response continues to improve and run charts will be included within the
report from next month. The Trust is currently achieving a response rate of 13.5%.
Some wards have achieved a 40-50% response rate whilst others have only
achieved 4%. Implementation of FFT within good performing areas will be shared to
ensure the response rates are increased.
The Chair noted that a significant number of the PALS and complaints received within
the Trust relate to the Gastroenterology, Surgery and Renal directorate. JG explained the
key issues within this area relate to patient access to treatment for example, a number of
patients are informed they will be reviewed within 4-6 weeks but the waiting list within the
directorate is 12 weeks at that stage. RB noted that there is a strong correlation to the
follow-up backlog as this directorate account for half of the admitted follow-up backlog.
The Committee took assurance from the content of the report and asked that actions
were taken to reduce the PALS and complaint levels in Surgery.
JG
8. Safe Care Report
AM presented the Safe Care Report to the Committee and highlighted the following key
points –
• The HSMR and SHMI data demonstrates the Trust is maintaining good rates
• In February 2013 VTE cases were identified and each patient had received the
appropriate treatment, although 93% of these cases received the appropriate risk
assessment
• The four yearly GTT report shows there has been a continual reduction in harm
caused to patients. Areas identified consistently with top three areas of harm are
wound infections, pressure ulcers and hospital acquired pneumonia. All of these are
currently being addressed through ongoing work programmes
The Chair asked whether specific improvement areas from the Regional Patient Safety
Initiative will be incorporate within the overarching quality improvement action plan. AM
explained that service line leads will be expected to lead on particular improvements
however, Trust wide issues will be monitored at sub-committee or committee level. GTT
is an indicated of where the efforts of the Trist must be focused.
The Chair highlighted inpatient falls as a particular issue and explained that a particular
piece of work regarding intentional rounding was completed at RD&E Hospital and this
appeared to have a significant impact on the number of falls. GD added that the
implementation of intentional rounding was re-launched at Taunton hospital as it became
a tick box exercise. Within two years of this re-launch there was a 30% reduction in the
number of inpatient falls. The Chair emphasised the importance of ensuring this is
implemented properly within the Trust and that there is culture change. For this to
happen within the hospital there needs to be clear leadership. GD and DH are working
on getting intentional rounding used within the Trust which will reduce falls and improve
nursing care.
GD/DH
9. Assurance Framework
LB presented a new Quality Assurance Framework to the Committee and asked for their
comments and whether any risks were felt to be missing.
The Committee asked that the following comments and risks were incorporated within
the framework –
S&Q Draft Minutes June 13 Page 4 of 7
LB

Item 15, Annex 1
• Include additional columns to show what evidence would need be provided to
demonstrate assurance that risks were being adequately managed
• Consider how complexity of resolving issues and associated risks can be
incorporated
• Diagnostic reporting to be included as a key risk
• AJ asked that sharing of information reported on Datix and STEIS with Executive
Directors is considered for inclusion
Inclusion of medical staffing was discussed however, AM assured the Committee that
this issue was being addressed with service line leads.
The Chair explained that the overall risk assessment and assurance framework is due to
be presented to SMT and the Board in July 2013 and once agreed this will determine the
focus of the Committee.
The Committee agreed to the content of the Assurance Framework subject to the
suggestions listed above.
10. Serious Incident W33081 / W33105 – Action Plan Report
KM presented the serious incident action plan to the Committee following an
independent review of the case. The following key points were highlighted –
• The external investigation looked into the process behind the internal investigation,
access to relevant notes, IT support within the community and reporting mechanisms
surrounding Glucose Tolerance Test (GTT) results
• Of the 22 recommendations made, 20 have been implemented and the remaining 2
will take some time as they depend on IT support. 12 of the 33 areas in which care is
provided within the Community have poor IT access therefore, if this cannot be
improved the locations will be changed
• Evidence of the recommendations implemented has been provided. The way in
which this has been done will be used for all RCA reports completed within the Trust
• The first RCA report that was completed focused on the delivery and resuscitation of
the infant however, the key issues related to the reporting of GTT results
• GP surgeries were found to be reporting GTT results differently therefore SS worked
to have this standardised and the PCT have confirmed that set parameters are now
in place
• Two band 2 posts within maternity would provide the support required to manage
GTT results within the Trust however, recent funding for this roles was removed but
discussions to address this are ongoing
• Considerable learning from the case has been highlighted and shared with the
relevant teams
• Terms of reference for investigations, including external, will be put in place to ensure
all staff involved in the case receive the appropriate support
• The case had been referred to the NMC and following a review they do not feel there
are any additional issues that need to be followed-up
• Case will be presented to the Child Death Panel and the initial RCA report, external
investigation report and action plan report will be presented
The Chair asked what the timeframes were surrounding this case. KM explained the
incident occurred approximately two years ago. There were significant delays in finalising
the investigation report and issues regarding GTT had not been identified. Lessons about
how the investigation was set up and conducted had been learnt. SS added this
investigation was completed outside of the specialty therefore a number of elements had
to undergo an additional review. All incident and complaint investigations are now
completed within the directorate by those who are independent of the specific case.
AJ highlighted the importance of clarifying who will be responsible for completing an
investigation, within what timeframe, with the involvement from whom and what the brief
is. It is essential these elements are included within the Terms of Reference.
S&Q Draft Minutes June 13 Page 5 of 7

Item 15, Annex 1
The Chair asked SS to ensure timeframes for looking for alternative solutions to the IT
issues is agreed so that progress can be made if the initial recommendations cannot be
implemented. Further update regarding these timeframes and evidence of imbedded
actions to be discussed at the Safe Care Group in six months’ time.
SS
11. RCOG Report on Patterns of Maternity Care in English Hospitals
SS presented the RCOG report to the Committee and explained this is the first issue of
the report. Although the first report for all Trusts has been anonomised this will be
changed for future reports so that results can be compared and used for bench marking.
The following key points were highlighted –
• 11 areas of practice were chosen for the review and there were 19 relevant criteria
• The Trust was performing above the mean in 17 of these criteria
• Format of data clarified. Both lower and higher scores can be positive results
• The key issues related to the disparity in management of a patient on the same care
pathway. These pathways have been refined and clear standards have been put in
place therefore improvements should be reflected within future reports
• Areas of disparity that have been addressed will be audited to ensure the changes
have been imbedded
• The Trust’s caesarean section rate is consistently 4-5% lower than the national
average however, research that is now available suggests that if a midwifery lead unit
was available this could be improved even further as patients who deliver in an
obstetric led unit are four times more likely to undergo a caesarean section
AM asked how this information triangulates with other data that is available. SS
explained that when the data is reviewed in line with best practice set by other
organisations it helps clarify how the Trust should be performing. For example 2.1% of
patients who deliver at Derriford Hospital suffer a third or fourth degree tear however,
best practice suggests that a rate below 4% could demonstrate that these tears are not
being identified and therefore patients are not receiving the adequate treatment.
The Committee noted the content of the report.
12. Health Records Action Plan
AB presented the Health Records Update Report to the Committee and highlighted the
following key points –
• Meeting held with AM and he has now been identified as the clinical lead for records
• Letter sent to all service line leads explaining their responsibilities including the need
for annual case note training and audits
• A new working group has been established to discuss how improvements can be
made to the paper records
• A presentation regarding electronic notes was presented to the MEC and a significant
amount of support has been offered. Currently awaiting approval of funding before
this can be progressed any further
• Significant progress has been made in relation to the transportation of notes.
Maternity have not yet identified a space where blue boxes can be delivered and
stored however, if this not agreed by the end of June 2013 all notes will be delivered
to the level 3 storage room
• MAU looking to use a fixed storage space for notes on the ward as opposed to
lockable trolleys due to space issues. Lynher ward have also opted to store notes in
lockable office
S&Q Draft Minutes June 13 Page 6 of 7

Item 15, Annex 1
• Concerns raised via ‘ask Ann’ regarding departments not tracing notes. This will now
be included as a performance indicator for each directorate to ensure poor
performing directorates are addressed
• Case note training is ongoing and 140 members of staff have been trained. The
training has been followed-up by an audit and it has demonstrated that the training
has had the impact required
• 50,000 pieces of loose notes have now been filed which is approximately 25% of all
filing that needs to be completed
• A pilot for sending paper to filing service at Bush Park will be piloted by Neurology in
July 2013
LB highlighted that concerns regarding overheard discussions of patient information and
notes left on the nurses’ station were raised by the CQC. AB explained that issues
regarding discussions on the telephone will be picked up through training being provided
by the information governance team by demonstrating scenarios and use of lockable
should improve issues relating to notes left at the nurses’ stations.
The Committee took assurance that progress that had been made and recognised the
hard work it had taken to achieve this and the challenges that remain.
13. Communication
The Chair listed the following key points for onward communication to the Trust Board –
• Updated Theatre Safety Action Plan has continued to be implemented as planned
• Risk assessment for follow-up backlog within Ophthalmology will be completed for all
directorates so that high risk patients can be dealt with as a priority
• The Trust continues to maintain a good mortality rate however, the difference in the
rate between week days and weekend will be reviewed in further detail
• A number of key learning points from external review regarding investigation
processes will be incorporated within investigation terms of reference
• RCOG report shows Maternity unit within the Trust is performing above the mean rate
within 17 of the 19 relevant criteria considered
• Good progress made with implementation of the health records action plan and
Committee noted particularly difficult implementation points within the plan
14. Review and Learning
The Chair informed the Committee that meetings will be held on a bi-monthly from July
2013.
LB suggested that performance reports regarding key issues should be included on the
agenda for review.
Date and time of next meeting
Monday 15 th July 2013 – 12:30, Maternity Seminar Room (Lv 5)
S&Q Draft Minutes June 13 Page 7 of 7

Item 16
COMMITTEE MINUTES
Finance, Performance & Investment Committee (FPIC)
Date 22 nd May 2013
Location Room 2 DHLC
Attendees
Ian Douglas, (Chairman)
Keith Chapman, Assistant Director of Operations (ADoO)
David Cooper, Project Accountant (PA)
Annie Cornelius, Senior Matron (SM)
Phil Hughes, Assistant Medical Director (AMD)
Brian Jones, Associate Director of Finance (AsDoF)
David Killoran, Interim Deputy Director of Finance (IDDoF)
Elizabeth Raikes, NED (ER)
Dan Stevens, Deputy Head of Performance (DHoP)
Joe Teape, Director of Finance (DoF)
Nick Thomas, Director of Planning & Site Services (DoPSS)
Henry Warren, Associate NED (HW)
Jenny Waycott, Contract Manager (CM)
Michelle Smith, Executive Office Team Leader (MS) – minutes
Corporate & Committee Affairs
44/13 Welcome and apologies
The apologies were noted as above.
Apologies
Kevin Baber, Chief Operating Officer (COO)
Richard Best, Director of Operations (DoO)
David Brown, Assistant Director of Operations
(ADoO)
Lee Budge, Director of Governance (DoG)
Greg Dix, Director of Nursing (DoN)
Ann James, Chief Executive (CE)
Alex Mayor, Medical Director (MD)
The Chairman introduced Henry Warren to the Committee, who had recently joined the Trust
as an Associate Non-Executive Director.
45/13 Minutes and matters arising from the previous meeting
The minutes of the last meeting were agreed as a true and accurate record. There were no
matters arising.
46/13 Action update
• Business planning 13/14
Further update to be provided to the Trust Board via finance paper but this was likely to
attract some media interest.
• Contract Penalties
No formal response had been received from the Commissioners but as the contract had
been agreed and signed and both organisations had submitted accounts it would be
assumed that there was no liability.
• Budgetary control policy
Update due next meeting but the DoF updated the Committee on plans to introduce a
comprehensive developmental programme both for the finance team and the wider
organisation, encouraging a culture of financial management throughout.
• DV Valuation
The DoF tabled an update from the Financial Management Accountant which outlined
the methods and processes used in the valuation of assets. The DoF would provide a
further update on the challenges and the effect of annual dividend at the next meeting of
the Committee. The DoF and DoPSS would also look at ways of improving the
relationship with the District Valuer.
• Assurance Framework
This item did not feature on the agenda as the framework was currently being updated
by the DoG, but updates noted at the previous Committee meeting would be
incorporated into the new version.
• Best Practice Tariffs
DoF/
DoPSS
1

Although it was agreed at the last meeting of the Committee that a paper would be
received instead a contact update had been presented, with more information on Best
Practice Tariffs to be presented in June.
47/13 Messages from the Board and other Committees
There were no messages from the Board or other Committees.
48/13 Review of Investment Panel minutes
The May meeting of the Investment Panel had taken place the previous day so minutes were
not yet available. The DoPSS highlighted the key issues discussed as the capital
programme, the e-prescribing project and the replacement gamma cameras. He also
reported that the terms of reference and membership of the group had been reviewed in light
of the implementation of the Care Group Structure, and the newly appointed Care Group
Directors would be invited to attend future meetings.
Finance & Performance
49/13 Operational Performance Review
The full performance report was not yet available for review but the DHoP tabled the
Monitor Governance Risk Rating scorecard for month 1, and highlighted key areas for
discussion:
• The Monitor Governance Risk Rating was 4 (red) for month 1.
• 62 day cancer – both failed in M1 and screening target failed in last 7 out of 8
quarters, meaning that Monitor could choose to apply an override.
• A&E 4 hour – failed in M1 due to difficulties with flow.
• C-Difficile – Monitor target set at 25 for the year, although this would again be
straight-lined. The DHoP believed that no cases were reported in M1.
• RTT – Admitted and Incomplete pathway targets both failed. The DHoP highlighted
that any failure of the incomplete pathway target would result in the failure of the
entire quarter. Therefore there was an opportunity to focus on treating the longest
waiting patients first which would hopefully bring performance to a sustainable
position for quarter 2.
The ADoO highlighted the reasons for failure including cancellation of elective surgery due
to an increase in non-elective activity and also noted the work of the DoO with the cancer
teams to improve performance, particularly in 3 sub-specialties. The Committee discussed
the impact of GP working patterns which could result in a notable increase in pressure on
emergency services, and ER felt that this should be noted/diarised so that the
Commissioners could be challenged accordingly.
Item 16
The DoF agreed to discuss with the COO formalising a monthly response from the Trust to
the Commissioners and for the purpose of audit trail. Also the DoF and COO, with the
support of senior performance team, would discuss the development of a plan to address
the RTT issues that would include a clear correlation between waiting lists, activity and the
finances required each month to deliver, and when it would be expected to achieve. This
plan would be agreed by FPIC before approval by the Trust Board
DoF
DoF
50/13 Financial Performance Review
The AsDoF presented the financial update for month 1. Key areas discussed were as
follows:
• Annual and income and expenditure plans were reviewed and the month 1 position
was noted to be slightly better than planned.
• The Committee noted the overspend in month 1 and ER expressed concern that
there was no detail on how much of this was planned or unplanned. The DoF and
IDDoF explained that a meeting had been arranged for later in the week to review
existing arrangements and plan a more formalised process, ensuring a greater level
of detail and visibility for future meetings.
• The AsDoF updated the Committee on the performance of the variable contract, in
particular Neuro and Cardiac Surgery. He outlined the current positions of income,
2

Item 16
pay and staffing, highlighting that medical agency/locum spend was still of concern,
in the main due to junior doctor cover issues. The Committee expressed concern
that junior doctor movements/changeover had not been planned for when they were
expected at this point in the year. The DoF agreed to discuss with the MD who was
already undertaking work on this, and an update would be requested for the Trust
Board to include the scale of the problem, the options available and the potential
impact on patients if not addressed.
• The Committee also noted the current position of Private Patients, Research and
Development and non-pay expenditure. The DoF noted the agreement with
Commissioners that any over or under spend on drugs would be split 50% with the
Trust. This had not been anticipated so the full year impact had not been included
in the plan. The DoF confirmed that he would be
• The Committee discussed the current discretionary spend and the actions in place
to reduce it. The DoF reported that there was a reserve of £4m for discretionary pay
but spend from this would only be approved by well managed areas in exceptional
circumstances. Directorates had been asked to map out workforce plans for the
year and alongside the controls plan in place, it was expected that spend would
come down.
• The AsDoF presented the month 1 CIP summary, outlining the actual and planned
savings, although these had not been risk assessed. It was expected that once risk
assessed, planned savings would be between £19-22m, so further work was
required to reach the target of £24m. Currently £12m of this could be comfortably
achieved. The Committee discussed the importance of finding recurrent savings.
The DoF advised that only one off large items would be accepted as non-recurrent
and other savings identified previously such as slipped vacancies would instead be
classed as underspend. The AsDoF reported that the policy was still in the process
of being implemented and the forecast would be refreshed once this was in place,
with some CIPs reclassified as underspend.
The Chairman requested that future updates included a split of planned recurrent
and non-recurrent savings. The Committee endorsed the approach and agreed to
review the CIP savings programme in detail at next month’s meeting.
• The AsDoF concluded his presentation by briefly updating the Committee on the
cash position and the Capital Programme. The Committee noted that the Monitor
financial risk rating was 2 and was likely to remain so for the year which would
impact on the Trust’s Foundation Trust application as a minimum of 3 was required.
DoF
DoF
51/13 2013/14 Contract update
The CM updated the Committee on key developments of the existing contract deal with the
Commissioners and the planning for 2014/15:
• The agreed contract value was improved on the previous year at £353.2m.
• A managed PbR contract had been agreed, removing almost all significant financial
risk to the Trust. Never events, single sex accommodation breaches and MRSA
bacteraemias could still attract penalties but these were not felt to be high risk. The
Committee discussed the benefits of a managed PbR contract and the other types
of contracts available, and the contracting process.
• The CM outlined the variable elements of the contract and highlighted successful
investments.
• Major sticking points in negotiations were non-elective activity, follow up backlog,
the definition of admission/consultant to consultant referrals and CQUINs. The CM
explained that the Trust felt that CQUIN should be paid on the whole contract value
including pass-through. National guidance was being sought and if successful this
could mean an additional £1m from commissioners. The Committee noted that the
CQUIN milestones were still to be confirmed.
• Work was underway to forward plan for the 2014/15 contracting process, although
the CM highlighted that there were outside influences beyond the Trust’s control
which would need to be accounted for later.
• The implementation of the new Care Group structure would be key as teams would
be able to develop strategic aims, highlight issues and work with the contracting
teams to negotiate with commissioners. The Committee discussed engagement
3

Item 16
and involvement of clinicians, which had been patchy in the past.
• The Committee recognised the challenge of the whole health community and the
need to take cost out of the system and ensure that it is sustainable. However the
Chairman highlighted the importance of ensuring the Trust negotiates the best deal
possible.
• The CM highlighted the importance of retaining specialist services and ensuring
stability through maximum take during 2013/14. The Committee discussed the
involvement of the Specialised Commissioning Group which made up around 30%
of the contract value.
• There were some issues with the system that collected data on activity which
needed to be resolved.
• The Committee noted the contract deal for 2013/14. The Committee requested a
further update at the July Committee on the resolution of outstanding issues, and
process for planning for the 2014/15 contract.
• HW to meet with the CM to review the contract with the Commissioners and also
the Commercial Contract Manager to discuss how the Trust’s commercial contracts
could be strengthened.
CM
CM/HW
52/13 Reference Costs
The AsDoF outlined the requirement for the Trust to submit an annual return, and the
national process introduced which required Committee/Board approval before the return
could be submitted. It was expected that the submission will be ready for review by the
accountants and directorate teams in around 2 weeks, with the submission due on 16 th
July.
Due to data collection issues in some areas the Trust was currently reporting a low silver
standard on the MAQ scoring system. However it was expected that the implementation of
the Care Group structure would improve the engagement of clinicians. Also the
introduction of some new IT systems would increase the data available. The Trust’s index
was favourable against the national average.
The Committee discussed the disconnect between a favourable reference cost index and
the financial position and the potential reasons for this such as varying marginal rates,
direct access income and educational funding arrangements. It was agreed that further
work was required to understand this in more detail and the DoF would give thought to
types of assurance available such as internal/external audit and peer review.
The Committee agreed to receive the submission by email for virtual approval as it was
unlikely that it would be available for the June Committee meeting.
DoF
AsDoF
Closing Issues
53/13 Any other business
The DoPSS highlighted that, due to concerns regarding the speed of retrieval of ‘prior’
images, the PACS Board had made the decision to defer the go live date of the final phase
of the project by 3 months. There will now be a series of commercial discussions with the
suppliers regarding remediation. A further briefing would be brought back to the committee
as those discussions develop.
54/13 Communication
The Chairman listed items for inclusion in the Chair’s report for the Trust Board:
• Peninsula Pathology Partnership
• District Valuation
• Operational Performance – 18 week work due June FPIC/July Trust Board
• Finance – CIP performance, comfortable on delivery of £12m against target of
£24m, with a focus on recurrent savings.
• Cover for Junior Doctor gaps
• Contact update 213/14 – update to be brought back in July on progress against Q1
objectives
• Reference Costs – exercise to be undertaken to provide assurance
4

Item 16
• PACS contract – likely deferral of go-live date due to issues with migration of
existing data.
55/13 Next Meeting: 26 th June 2013, 0930 Conference Room DHLC
5

Item 17
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Human Resources & Organisational Development Committee Chair’s
Report
Deputy Director of HR&OD
NED HR&OD Committee Chair
NED HR&OD Committee Chair
Purpose
To summarise the key issues discussed and assurances received at the Human
Resources and Organisational Development Committee (HR&OD) meeting held
on 14 June 2013.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
• •
Executive Summary
•
The key issues and assurances considered by the Committee are outlined below.
HR & OD Strategy
The Committee received an update on the HR&OD Strategy and confirmation that it supported the
Quality Improvement Strategy. In light of the new Trust Strategy, “In the Heart of Health in the
Peninsula” having been approved at the June Trust Board, it was agreed that the HR&OD Strategy
would be further reviewed against this and the Trust’s corporate objectives. The Committee
received assurance that progress was being made with recruiting to ward vacancies but sought
additional assurance on issues of retention and the position regarding medical workforce staffing
levels.
Staff Survey
The Director of HR&OD updated the Committee that the Executive Team had agreed from the Staff
Survey results, three key areas of immediate focus, in addition to directorate actions in response to
the Staff Survey results. These relate to Communication; the Trust as a place to work; and the Trust
as a place to be treated. The Committee accepted these were the right areas of focus and
requested a more detailed update on how this would be achieved at the next meeting.
Francis Report
The Committee received a report on the key HR&OD implications arising from the Francis Report,
and the associated workstreams of the Trust’s HR&OD Strategy. The Committee received
assurance that the HR&OD Strategy and delivery plan had appropriate workstreams in place to
respond to the recommendations. It was also acknowledged that cultural change was key, in
ensuring that patients are placed at the heart of everything we do, particularly during the current
time of financial challenge. The Committee agreed that the key issues were for a culture of
openness to be strengthened, leadership development, correct staffing levels and retention, and
that lessons learnt are effectively shared to embed learning.

Item 17
Terms and Conditions of Employment
The Workforce QIPP Programme Manager updated the Committee on the Foundation Trust
Network Optimisers, and how these had been systematically reviewed and were being implemented
within the Trust.
It was noted that whilst some of the Optimisers did not show significant savings in the current year,
this was because many of the possible actions were already being implemented and included in the
Trust's existing Workforce CIP schemes. These are subject to formal monitoring through the
Programme Management Office. Other elements of the Optimisers required work this year to lead
to savings in the next financial year.
The Committee noted that the medical staff Optimisers were being led separately by the Medical
Director, and sought assurance at a future meeting on how these were being progressed,
particularly given the scale of possible savings. It was noted that it would be important to consider
any unintended consequences as a result of implementing the optimisers, and engaging effectively
with staff and the trade unions.
Leadership Development
The Committee was concerned over the potential risk to the delivery of the planned Leadership
Development Programme, due to the financial position of the Trust. The Director of HR&OD
confirmed that alternative plans are being considered.
Assurance on the Trust’s Leadership Development and OD capability was sought, by means of a
Skills Review, which the Director of HR&OD will undertake.
Equality and Diversity
The Committee received an update on progress being made over the delivery of the Equality
Delivery System. It was noted that membership of the Equality Delivery Steering Group required
stronger clinical staff representation to help ensure that the EDS objectives are delivered.
The Committee supported the proposed recommendations in relation to the Board Inclusion
Development Programme, which would help ensure equality and diversity is better considered in
day to day decision making.
The minutes of the meeting are attached at Annex 1.
Quality Impact Assessment
Implementation of the HR&OD Strategy will have a positive impact on quality of care.
Financial Impact Assessment
Increased productivity will support achievement of CIP savings.
Regulatory Impact Assessment
Compliance with CQC Outcomes 12,13, and 14, and Equality Objectives.
Key Recommendations
The Trust Board is asked to receive this report and consider if any further assurances are required.
Next Steps
The Committee will progress its Forward Work Programme and the emerging issues to be referred
to other Board Committees will be communicated through this report.

Item 17, Annex 1
MINUTES OF THE HR & OD COMMITTEE
HELD ON FRIDAY 14 TH JUNE 2013 1000-1200
BOARD ROOM, DHLC
Attendees
Chair Elizabeth Raikes Non-Executive Director (ER) Chair
Martin Bamber Deputy Director of HR (MB)
Carolyn Bruce- Shadow Governor
(CBS)
Spencer
Hiu Lam Director of Medical Education (HL)
Kevin Marsh Deputy Director of Nursing (KM)
Anna Orrock Care Group General Manager (CSS) (AO)
Sharon Russell OD Manager (SR)
Hein Scheffer Director of HR & OD (HS)
Nick Varney Workforce QIPP Programme (NV)
Manager
Sophia Wrigley Chair, HMSC (SW)
Mike Williams Non-Executive Director (MW)
In Attendance: Leah Brooks Equality & Diversity Lead (Service) (LB)
Jayne Middleman OD Facilitator (JM)
Gillian Pothecary Minutes (GP)
No. Item Action Timescale
28/2013 Welcome and Apologies
Apologies were received and noted from:
Ann James, Chief Executive
Greg Dix, Director of Nursing
Alex Mayor, Medical Director
Lee Budge, Director of Governance
Amanda Nash, Head of Communications
Laura Cottey, Junior Doctor Representative
Nick Thomas, Director of Site Services and Planning
Martyn West, LNC Chairman
• ER commented in relation to attendance, that the Board
had reviewed governance and committee structures and it
is intended that the HR&OD Committee will focus on the 4
core workforce corporate objectives. The Terms of
Reference will be reviewed at the next meeting.
• Congratulations were noted in relation to the Celebration
Awards, and ER thanked the Awards Steering Group for
all their hard work to organise what was a very successful
event.
1

Item 17, Annex 1
29/2013 Minutes and Matters Arising from the Previous Meeting
The notes of the meeting held on 10 th April 2013 were agreed as
an accurate record.
SV 16/8/2013
HS highlighted that the rolling action table would in future be fully
completed with comments on progress.
30/2013 HR&OD Strategy
The Committee received an update on the HR&OD Strategy and
confirmation that, following a review, it supported the Quality
Improvement Strategy. It was agreed that the HR&OD Strategy
would be further reviewed against the new Trust Strategy, “In the
Heart of Health in the Peninsula” and the Trust’s corporate
objectives.
MB 16/8/2013
HS provided an update on actions since the last meeting. Key
points included:
Recruitment and ward staffing
• As of 30 March 2013, the total clinical and non-clinical
nurse vacancies are 179.18 WTE, including an additional
36 WTE for the staffing of Monkswell. 130.15 WTE of
these vacancies are currently at post-interview stage.
• Steady progress was being made on recruitment,
particularly for HCA’s, but it was noted that retention was
also critical.
• MW highlighted the need to also focus on reviewing plans
to ensure adequate medical staffing levels. HS agreed,
and confirmed he had arranged to meet with Yvonne
Linley-Shaw, Medical Workforce Business Partner, to
discuss this issue.
• It was acknowledged that there is a risk when opening
additional beds that medical staffing is not reviewed
robustly in addition to nursing staffing levels. HL agreed,
and stated that the junior doctor workforce should be
reviewed within each service line. HL added that Alex
Mayor, Medical Director, and Emma Rayment, Business
Manager, are leading a project on junior doctor staffing
levels.
Mandatory Training and Appraisal
• It was noted that a paper on the content and delivery of
mandatory training would be discussed at the next
HR&OD Committee meeting. The paper would also
highlight proposed changes to mandatory training
reporting, where for example, historically, Junior Doctors
are not included in the mandatory training figures reported.
• HL stated that reports were produced in relation to JD
2

Item 17, Annex 1
mandatory training data, and that it should therefore be
possible to incorporate them in the dashboard.
Appraisal
• Feedback from the Plymouth Way sessions on appraisal,
show that some staff question the value and impact of the
current appraisal experience. Issues raised included the
time available to undertake appraisals and their impact.
HS reported on the current work on a new electronic
appraisal process, which can be linked with the KSF and
development plans, and a stronger link to organisational
objectives.
• AO requested any new appraisal process was subject to
consultation with a different staff groups.
• MW added that it is also very important to reflect in the
appraisal process the Trust’s strategy and objectives. This
will help to embed the new culture and strategy.
Leadership Development
• HS stated that due to the financial position of the Trust,
there was a real risk that the planned Leadership
Development Programme might be deferred and
alternative plans are being considered.
• ER asked when the OD and leadership development skills
audit feedback would be available. HS agreed this would
be ready for the August meeting.
Staff Survey and Temperature Check
• The Director of HR&OD confirmed that the Executive
Team had agreed from the Staff Survey results, three key
areas of focus, in addition to directorate actions in
response to the Staff Survey results. These relate to
Communication; the Trust as a place to work; and the
Trust as a place to be treated. The Committee accepted
these were the right areas of focus and requested a more
detailed update on progress at the next meeting.
HS
SR
16/8/2013
16/8/2013
• The local temperature check staff surveys are continuing,
and feedback on a monthly basis will be provided to staff.
KM enquired if more analysis on the results could be
undertaken. For example, in relation to how staff feel about
family members being treated at PHNT, and a breakdown
of the results to staff groups and departments. SR said
she would confirm the level of breakdown possible from
the results and discuss this with KM.
Sickness Absence
• The new sickness absence policy has now been
implemented, additional training is being provided to
managers, and a wide range of well-being and ill health
prevention initiatives were also being made available to
3
SR
16/8/2013

Item 17, Annex 1
31/2013 Francis Report
• MB presented a paper on the key HR&OD implications
arising from the Francis Report, and the associated
workstreams of the Trust’s HR&OD Strategy. It was noted
that the HR&OD Strategy covered the key workforce
aspects of the Francis Report. The Committee
acknowledged that cultural change and leadership
development were crucial.
• MB highlighted that the Whistleblowing Policy has been
reviewed and renamed as the “Raising Concerns Policy’.
Summary guidance would also be shortly shared with staff
in support of the new policy.
• MW discussed research around effective teams and the
impact of team working on the quality of care and patient
outcomes.
32/2013 Terms and Conditions Review
• NV presented a report on the Foundation Trust Network
Optimisers and how each optimiser had been reviewed
and was being implemented.
• It was noted that some of the Optimisers were already
included in the existing Workforce CIP schemes and
savings were not shown against these again in the report
tabled, to avoid double counting of savings.
• Due to the significant potential savings from medical
workforce optimisers which were being led separately by
the Medical Director, it was agreed that a report on
progress with the medical optimisers should be presented
by David Edwards to the Committee at a future meeting.
DE 16/8/2013
• KM asked that all workforce optimisers are carefully
considered to avoid any unintended consequences, such
as staff reverting to agencies to work additional hours, as
has happened amongst the nursing staff group in the past.
• ER asked how the proposed changes are being
communicated with staff. MB confirmed that these would
continue to be subject to Staff Side engagement through
the JSNC, and wider communication with staff through
team brief and Vital Signs. HS added that the CEO had led
a series of presentations to staff across the Trust in the
past few months about the Optimisers and SWPC, with
questions raised in the sessions shared with staff.
33/2013 Equality and Diversity Update
• JM and LB provided the Committee with an update on
progress in delivering the Trust’s EDS objectives and a
4

Item 17, Annex 1
recent meeting with Diversity Practice.
• JM stated that an area that was highlighted as requiring
action during the EDS assessment and the setting of
equality objectives, was that of the positioning of equality
strategically at Board and senior management level.
• The Committee supported the recommendation in relation
to the Board Inclusion Development Programme.
• It was noted that the membership of the Equality and
Diversity Steering Group would need to be reviewed with
stronger clinical representation required.
• In response to a question from ER about the reported lack
of equality information on patient complaints, LB
responded that the process for collection of ethnicity
information was currently not robust enough.
34/2013 Health and Safety Committee
• The Committee was unclear as to why the Health and
Safety Committee minutes were presented at the HR&OD
Committee meeting. HS explained that there had been
some previous discussion over which Committee these
minutes should report in to, and agreed to discuss with
Executive Director colleagues and clarify.
HS 16/8/2013
35/2013 Communication
ER confirmed the key issues that would be included in feedback
to the Trust Board included:
• Recruitment
• Training
• The Francis Report
• Equality and Diversity
In terms of learning, it was agreed it had been a productive
meeting, which had covered a number of important issues. ER
asked that moving forward we are clearer on the purpose of
reports submitted to the Committee.
36/2013 Any Other Business
The meeting closed at 11:30hrs
39/2013 Date and Time of Next Meeting
The next meeting will be held Friday 16 th August 1000-1200 in the
Board Room DHLC.
5

Item 18
SUMMARY REPORT
Trust Board 5 July 2013
Subject
Prepared by
Approved by
Presented by
Audit Committee Chair’s Report
Board Secretary
Margaret Schwarz, NED Chair
Margaret Schwarz, NED Chair
Purpose
This paper provides a summary of assurances received and issues or
concerns that the Audit Committee feels should be brought to the attention
of the Trust Board, or to other Board Committees, resulting from the Audit
Committee meeting on 31 May 2013.
Corporate Objectives
Decision
Approval
Information
Assurance
Quality Care Inspired People Healthy Organisation Innovate & Collaborate
•
Executive Summary
The Committee received internal management, Internal Audit and External Audit reports.
CQC Outcome Review
In accordance with its forward work plan, at each meeting the Committee tests the
adequacy of assurance and the process for testing compliance of a CQC outcome. The
Committee assessed Outcome 21 Records, an issue of longstanding concern. The review
had been scheduled as a result of known focus by the Care Quality Commission. The
Director of Planning & Site Services reported on evidence of compliance, gaps in assurance
or areas where evidence of compliance could be strengthened and the actions in place to
address these issues. Three issues identified by a CQC inspection in 2012 remain a
concern:
• Security of case notes on wards.
• Updating case notes in a timely manner.
• Treatment Escalation Plans not being completed consistently in respect of DNAR.
The Committee received limited assurance that the planned actions would achieve
compliance and no assurance on the timescale for achieving compliance. Health
records was again raised as a concern in verbal feedback from the CQC following a recent
inspection and the Committee noted that their written report of their findings was imminent.
The Safety & Quality Committee would continue to oversee this issue.
Bevan Brittan Risk update
This covered key points from the Francis Report, focusing on the requirement for NHS trusts
to consider the Report’s recommendations and to decide how, and to what extent, to apply
them to their respective organisations. Key advice for the Board was to avoid complacency
through over-reliance on positive feedback from patient surveys. More generally, in terms
of the Board’s responsibility to ensure the provision of safe patient care, the advice was for
the Board to be mindful of the pressure in the wider health system and to ensure that its
decisions were based on reliable data.
Annual Reports
The Committee reviewed three annual reports for the year 2012/13; Counter Fraud, Internal
•
1

Item 18
Audit and the Committee’s own review of its activities.
Annual Accounts 2012/13
With regard to financial reporting for the year ended 31 March 2013, the Committee
received good assurance on the systems and processes to finalise these by the
requisite deadline.
• Draft accounts had been submitted to the DoH by the 22 April 2013 deadline,
supported by good quality working papers with no material errors.
• The Head of Internal Audit Opinion was, once again, one of ‘significant assurance’.
The Committee’s attention was drawn to weaknesses in controls, identified as health
records management, data protection and financial control.
• External Audit’s draft Audit Findings Report set out their expectation to issue an
‘except for’ qualified Value for Money conclusion based on the failure to achieve the
original planned surplus budget and the failure to set a balanced budget for 2013/14.
Their audit did not identify any significant control weaknesses that they wished to
bring to the Committee’s attention.
• The Committee scrutinised and approved the draft Letter of Representation and the
schedule of losses and special payments.
• The Committee scrutinised the accounts for the year ended 31 March 2013 and
agreed that these had been properly prepared on a going concern basis and
recommended them to the Board for approval.
Management of External Assessments
The Committee received good assurance of the process to respond to recommendations
and requirements arising from external assessments. The number of external assessments
has now increased to 101; the management of the register is shifting to a more pro-active
approach to drive the discipline required to ensure that action plans are developed,
implemented, monitored and followed up.
PACS Replacement
Further to Internal Audit’s concerns at the previous Audit Committee meeting, the Director of
Planning & Site Services was asked to update the Trust Board in April. At the May Audit
meeting Internal Audit again expressed their concerns on the risks to this project. The
Director of Planning & Site Services confirmed that the go-live date had been deferred for
three months with a consequential financial exposure, assessed at a maximum of £60k, to
the Trust. The complicated contractual arrangements were compounded by the nonidentification,
at that time, of a commercial negotiator for the Trust. The Finance,
Performance & Investment Committee will keep this issue under review.
The minutes of the meeting are attached at Annex 1.
Quality Impact Assessment
None directly.
Financial Impact Assessment
None directly.
Regulatory Impact Assessment
The Audit Committee scrutinises the risks and controls affecting all aspects of the Trust’s
business and is central to the organisation’s governance.
Key Recommendations
The Board is asked to note this report.

Item 18
Next Steps
The Audit Committee will progress its Forward Work Programme and the emerging issues to be
referred to other Board Committees will be communicated through this report.

Item 18, Annex 1
Plymouth Hospitals NHS Trust
Draft minutes of the Audit Committee meeting
12.30 pm on Friday 31 May 2013
Conference Room, Derriford Health & Leisure Centre
Present:
Margaret Schwarz, Non-Executive Director, Committee Chair
Ian Douglas, Non-Executive Director
Terence Lewis, Non-Executive Director
Elizabeth Raikes, Non-Executive Director
D
Henry Warren, Associate Non-Executive Director
Denis Wilkins, Associate Non-Executive Director
Mike Williams, Non-Executive Director
In
attendance:
Apologies:
R
Peter Barber, Audit Lead, Grant Thornton
Kevin Baber, Chief Operating Officer
Martin Bamber, Deputy Director of Human Resources
David Bray, Audit Manager, Grant Thornton
Lee Budge, Director of Governance
Greg Dix, Director of Nursing
Mark Glover, Audit Manager, Audit South West
Gill Hunt, Board Secretary
A
Alex Mayor, Medical Director
Jenny McCall, Director of Audit, Audit South West
Joe Teape, Director of Finance
Nick Thomas, Director of Planning & Site Services
Sally Wilson, Chief Financial Accountant
F
Richard Best, Director of Operations
Ann James, Chief Executive
Hein Scheffer, Director of Human Resources & Organisational
Development
Tracy Wheeler, Local Counter Fraud Specialist
T
40/13 Welcome, apologies and declarations of interest
Action
Mrs Schwarz noted the apologies listed above and required those
present to declare any interests they had pertaining to the matters
listed on the agenda. There were no declarations of interest.
41/13 Minutes and matters arising
The minutes of the meeting held on 10 April 2013 were agreed as a
true and accurate record subject to the following amendment:
Combined Cost Improvement Programme, Business Planning and
Budgetary Control Review
Page 5, final bulleted point to read “[…] of an experienced Deputy
Director of Finance.”
1

Item 18, Annex 1
Matters arising
4/13 and 19/13 Counter Fraud Work Plan
The Committee noted that any consequences for SFIs arising from the
risk based approach to this work in 2013/14 had been covered by the
Director of Finance’s paper on financial controls presented to the May
Trust Board.
42/13 Review of Action List
D
The Committee noted that there were no outstanding actions.
In order to facilitate the attendance of visitors to the meeting, the Chair
took papers in a different order to that set out on the agenda.
R
43/13 Bevan Brittan Risk Update
Mr Simon Lindsay, partner, Bevan Brittan, attended to give a risk
update to the Committee.
Mr Lindsay gave a
A
presentation on key points from the Francis
Report, focusing on the requirement for NHS trusts to consider the
Report’s recommendations and to decide how and to what extent to
apply them to their respective organisations. He explored in depth
three themes:
F
• Constitution and standards.
• Candour and complaints.
• Nursing care.
Mr Lindsay summarised the Government’s response to the Report
focusing on:
T
• Clear, enforced standards.
• Professional regulation.
• Patient centred leadership.
• Provision of accurate, useful information.
Mr Lindsay stated that it was incumbent on NHS Trust Boards not to
delay their responses and, in formulating them, to avoid complacency
through over-reliance on positive feedback from patient surveys.
Dr Williams stated that a significant number of the Report’s
recommendations did not apply to hospital trusts and, in the absence
of guidance on this point, how should Boards respond? Mr Lindsay
stated that this was a matter for individual trusts to address; however,
to not respond to recommendations which did apply to their
organisation would be unacceptable. Drawing on his experience of
other organisations’ approach to this issue, Mr Budge stated that a
robust way forward would be for provider organisations to identify and
2

Item 18, Annex 1
evidence those recommendations which were believed to apply and to
respond appropriately. He confirmed that Trusts were co-operating
and sharing their individual approaches, which was helpful for all.
Mr Lindsay briefed the Committee on two inquest case studies and
the key issues arising from these. The Committee discussed these, in
broad terms. In the context of operational and staffing pressures, Mr
Wilkins queried the point at which a service may be withdrawn in the
interests of patient safety
D
and the legal position of doing so. Mr
Lindsay stated that there was no guidance or definitive answer to this
difficult question and it would depend on the circumstances. However,
conscientious monitoring and an ability to audit actions and evidence
careful decision-making would be crucial. The broader point was the
pressure in the system going forward and Trust Boards must be
cognizant of this.
R
44/13 Review of CQC Outcome 21: Records
A
In setting the context for this review, Mrs Schwarz stated that health
records had been an issue of longstanding concern to the Audit
Committee and to the
F
Safety & Quality Committee, which was
currently overseeing progress with compliance. The review being
undertaken today had been scheduled as a result of known focus by
the Care Quality Commission (CCQ) and as part of the Committee’s
rolling programme to review the process to test assurance of
outcomes declaring compliance. The current status of this outcome
was compliance but with
T
moderate concern.
Mrs Schwarz thanked Mr Lindsay for attending and he left the
meeting.
Penny Taylor, Head of Clinical Systems Governance, attended for this
item.
Mr Thomas stated that that this standard was very broad and covered
more than health records. An inspection in 2012 by the CQC and a
subsequent mock inspection in March 2013 had identified concerns
with the security of case notes on wards, updating notes in a timely
manner and with Treatment Escalation Plans (TEP) not being
completed consistently in respect of DNAR. Dr Williams asked Mr
Thomas how confident he was that the actions in place would ensure
compliance. If the CQC inspected today, would they find the Trust
compliant? Assurance could not be given on this point and Mr Budge
stated that the CQC had been asked if they were able to identify other
similar organisations who exhibited best practice. Mrs Raikes asked
when the Trust would be compliant. Mr Budge stated that when the
CQC submitted the formal report of their inspection it was likely that
the Trust would be given between thirty and sixty days to comply.
Some of the issues were not unique to the Trust and whilst they were
features of working in a busy environment, they also concerned
culture, which took longer to shape. Overall, the actions would take
3

Item 18, Annex 1
time to embed and Mr Budge would ensure that the Head of
Assurance undertook a further review.
Mrs Schwarz queried progress with DNAR recording. Dr Mayor stated
that it was challenging to ensure this conversation was undertaken
sensitively and comprehensively. Dr Williams acknowledged this
could be an issue in MAU but it must be comprehensively resolved in
the subsequent patient pathway. Dr Mayor was meeting with junior
doctors to ensure that
D
patient notes were clearly annotated when the
conversation had not been had. Mr Budge suggested that the Safety
& Quality Committee set a timescale for a further audit and then track
progress. Dr Mayor stated that TEP was an issue for the wider health
community to address and that, overall, the solution lay outside the
Trust. Mr Baber suggested seeking and adopting best practice from
other trusts who had complied with this standard.
R
There were no further questions.
The Committee noted the assessment of compliance with moderate
concern and the limited assurance provided by the actions identified.
The Board would receive updates via the Safety & Quality Committee.
A
Penny Taylor left the meeting.
45/13 Counter Fraud Annual Report 2012/13
46/13
The Committee noted
F
this document. There were no questions.
Internal Audit Annual Report 2012/13
Mr Glover gave an overview of the report and is contents. The
Committee discussed two issues of concern, the delay to the PACS
project implementation
T
and the deferral of the Joint Advisory Group on
Gastrointestinal Endoscopy (JAG) accreditation inspection.
PACS
Mr Thomas updated the Committee on developments at the PACS
Project Board which had taken place the previous day. On the
Committee’s recommendation it had been decided to defer the
scheduled go-live date for three months and to extend the existing
provider’s contract for the same timescale as there was insufficient
assurance on the speed at which historical images could be
accessed. The maximum financial exposure to the Trust would be
c£60k plus costs associated with extending the life of the Project
Board.
Dr Williams queried the degree of confidence Mr Thomas had that a
delay of three months would be sufficient to solve the problem. Mr
Thomas explained the size and complex nature of the project and
contractual arrangements, which involved dealing with sub-contractors
under Connecting for Health (C4H). The situation was aggravated by
4

Item 18, Annex 1
existing terms and conditions negotiated under C4H. At this stage Mr
Thomas was not clear about the Trust’s contractual position and
recompense arrangements. The financial benefits of the new system
would not now be realised as early as had been anticipated. Dr
Williams asked who was responsible for the commercial negotiations.
Mr Thomas stated that the SMT had not yet had this discussion.
Professor Lewis asked whether Mr Thomas intended to overlap the
two PACS systems.
D
Mr Thomas stated that it had been intended to
pursue a soft roll out but the Trust was aware that other organisations
had experienced problems with implementation. The Trust would roll
out to other users prior to Radiology. Professor Lewis sought, and
received, assurance that contingency plans were in place. Updates
on this issue would be reported to the Board via the Finance,
Performance & Investment RCommittee (FPIC).
Dr Williams queried progress in resolving this issue. Mr Baber stated
that the JAG review was scheduled for September and he would be
meeting with the relevant Care Group Director and service line
manager to receive an
A
update on progress. Dr Williams queried the
risks to the Trust of failing to achieve accreditation. Dr Mayor stated
that should this be the case, the risk would be the loss of the
screening service. Due to the size of the facility, meeting EMSA was
challenging and he suggested that there appeared to have been an
underestimate that the size of the facility required to match increased
demand for the service.
F
Endoscopy Suite Review
The Committee considered the executive summaries of Internal Audit
reports issued since the previous meeting:
Tenders & Quotes
Mrs Schwarz queried
T
whether FPIC would overview progress with this
report’s recommendations. Mr Teape stated that they formed part of
the wider approach to controls on non-pay in the programmes being
led by the Head of Procurement, Andy McMinn. Mr McMinn would
appraise FPIC of progress.
Recruitment Processes
For the avoidance of doubt, Mr Glover stated that the report covered
only non-medical recruitment, which was in accordance with the
original briefing. Professor Lewis asked why medical recruitment had
not been covered. Mrs Schwarz stated that the purpose of the audit
had been to establish whether recruitment processes were sufficiently
slick to respond at a time when the Trust was urgently seeking to
recruit additional nurses. In responding to Professor Lewis’s question,
Mr Bamber stated that the learning from this report had been applied it
to medical recruitment. The Committee noted that the CQC, having
focused on recruitment, had not expressed concerns during their
recent inspection.
5

Item 18, Annex 1
Payroll & Expenses
No comments were made.
Serco Hygiene Compliance Reporting
Noting the report’s conclusion that Internal Audit could not provide full
assurance that (a) Serco were fully compliant with the hygiene
requirements of the Trust and (b) Serco inspections were reported
accurately, Mrs Schwarz queried who was responsible for leading
delivery of the recommendations.
D
Mr Thomas stated that this was the
Facility Operations Manager but he could not confirm whether the
report’s recommendations had been implemented.
Dr Williams noted that the report stated that Serco were compliant
with the requirements of the National Specification for Cleanliness in
the NHS. However, Internal
R
Audit’s conclusions were at odds with this
assertion. The results of audits undertaken between April 2011 and
March 2012 were set out in the report but these were inconsistent and
historic. It was therefore difficult to form a view given the conflicting
statements presented. Mrs Raikes was concerned that there was
insufficient traction on resolving this important issue and whilst
Internal Audit’s attention
A
had identified the anomaly, she had limited
assurance of delivery. Noting that a combined audit tool was likely to
be rolled out in June 2013, Mrs Schwarz stated that the Committee’s
concerns would be addressed as part of Internal Audit’s follow-up
process.
F
Mr Budge briefed the Committee on the reasons why this report had
been commissioned and stated his intention to provide a copy to the
individual who had raised the matter in the first instance.
Neonatal Transport Contract Review
Hygiene Inspection
Whilst there were no comments
T
on the report, Mr Glover passed on to
the Committee feedback from the Audit team member who had
undertaken the inspection. In her experience staff had been
responsive, well-engaged and keen to ensure high standards of
cleanliness across all wards. Mr Dix would convey these sentiments
at the appropriate forum.
Head of Internal Audit Opinion (HOIAO)
Ms McCall referred the Committee to pages 7 to 16 of the Annual
Report and specifically to page 8, which detailed Internal Audit’s
overall opinion of ‘significant assurance’ that there was a generally
sound system of internal control within the Trust and to the basis for
forming that opinion. Ms McCall drew the Committee’s attention to
the identified weaknesses in controls, which were detailed as health
records management, data protection and financial control. Ms
McCall referred the Committee to the two Third Party Assurance
Reports confirming the opinion of effective controls for the Electronic
Staff Record and Shared Business Services.
6

Item 18, Annex 1
Five of the seven Non-Executive Directors present had been
appointed since the close of the previous financial year and in seeking
to develop a more informed understanding of the respective roles of
internal and external audit, including the processes and evidence
used by both audit functions to determine their respective end of year
opinions, a broad discussion developed. Non-Executive Directors
used this as an opportunity to triangulate their own knowledge and
observations of the Trust’s performance with the arguments presented
to them by internal and
D
external audit and to share their perspective,
as Board Directors with corporate responsibility, of audit’s findings. In
general terms the discussion covered:
• Understanding the roles of internal and external audit and their
respective focus on process/controls and on outcomes.
R
• The requirement of the Trust Board, via the Audit Committee,
to have earlier visibility of the inconsistent application of
controls when this could lead to serious risks, for example
controls around discretionary pay. Professor Lewis sought
clarification on the costs included within discretionary pay. Mr
Teape stated
A
that service lines had been asked to prepare
workforce plans which included substantive and discretionary
pay for the full year. Temporary and agency staff, overtime and
waiting list initiative payments all contributed to discretionary
pay costs. Professor Lewis highlighted the importance of
ensuring that workforce and activity were aligned.
F
• The longer term intention to devolve autonomy to service lines
within the current imperative to apply strict financial controls to
ensure that the Trust’s overall financial position did not
deteriorate further. After the last Audit Committee meeting
Non-Executive Directors had received copies of the Trust-
T
commissioned PWC report on financial controls. Mr Teape
placed PWC’s work into context for the Committee. Their
recommendations had been incorporated into an action plan,
the implementation of which would be overseen by FPIC.
• Understanding why the known problems of bed capacity had
not emerged as part of internal and external audits’ focus. Mr
Barber stated that this was covered in the review of resources
and his firm had commented on this. For the last three years
the focus of his firm’s Value for Money (VFM) conclusion had
shifted from generic to financial resilience. In 2010/11 his firm
qualified its conclusion. An improvement was noted in 2011/12
and the Trust delivered in a challenging environment and
therefore their opinion had not been qualified in 2011/12. The
position had deteriorated in 2012/13 in the area of financial
resilience and the evidence for this was set out in his firm’s
report.
7

Item 18, Annex 1
The Committee noted Internal Audit’s Annual Report and the HOIAO.
47/13 Audit Committee Annual Report 2012/13
The Committee reviewed and approved this Annual Report.
48/13 External Audit: Financial Resilience Report (draft)
D
Mr Barber presented this report which summarised the financial
resilience element of his firm’s VFM conclusion on their audit work for
2012/13. The report RAG-rated the Trust’s arrangements on:
• Key indicators of financial performance.
• Strategic financial planning.
• Financial governance.
• Financial controls.
R
Mr Barber drew the Committee’s attention to the Executive Summary
and to high level risk assessments of red for key indicators of financial
performance and strategic financial planning and to amber for
financial governance
A
and financial control. These ratings contributed
to a qualified VFM conclusion.
Mr Douglas drew Mr Barber’s attention to page 7 of the report and
stated that there was, in fact, clinical representation on all the Board’s
Committees.
F
Dr Williams suggested that the Trust’s financial challenges resulted
from whole system problems. Did Mr Barber’s firm audit other health
organisations, thereby facilitating an holistic view? Mr Barber stated
that his firm audited other NHS organisations and would submit to the
Department of Health on overall performance report, although within
this individual organisations Twould not be named. In this context his
firm played a role in taking forward topical debates nationally.
Professor Lewis queried whether Mr Barber’s firm had a conflict of
interest. Mr Barber stated that there was not because his firm audited
individual organisations and was not involved in contract negotiations.
Mr Warren sought to clarify a definition of ‘Value for Money’. Mr Bray
explained that the Audit Commission, in their Code of Audit Practice,
set out the relevant criteria. This Code, followed by all auditors for
consistency, was approved by Parliament every five years.
The Committee noted the draft report.
49/13 External Audit: Audit Findings Report (draft)
Mr Barber stated that this report had been issued on 29 May and his
firm’s deadline to comment on the financial statements fell on 10
8

Item 18, Annex 1
June. However, work was well ahead and had not identified any
areas of concern. There had been a small number of trivial errors.
Mr Barber wished to record his thanks to Mr Teape, Mrs Wilson and to
their team, who had produced comprehensive working papers and
with whom they had worked to produce a very positive outcome. This
outcome confirmed his audit planning assumptions that the Trust was
a low risk organisation.
D
Mr Barber stated that he was satisfied that the Trust had in place
arrangements to secure economy, efficiency and effectiveness, with
the exception of Financial Resilience. For this reason it was intended
to issue a qualified ‘except for’ conclusion on the Trust’s
arrangements for securing economy, efficiency and effectiveness in its
use of resources. His
R
firm had been proposing to issue an ‘emphasis
of matter’ conclusion in recognition of the Trust Board setting a deficit
budget for 2013/14. However, confirmation had been received from
the Trust Development Authority of their willingness to underwrite the
deficit and there was now no longer any requirement to issue an
‘emphasis of matter’ conclusion.
A
Mr Barber confirmed that his firm would report on the outcome of their
external assurance work on the Trust’s Quality Account prior to
issuing their opinion on the financial statements and issuing their VFM
conclusion for the year.
50/13
F
Annual Accounts for the year ended 31 March 2013
The Committee noted the draft report.
Mr Teape presented the Annual Accounts (Annex 1) to the Committee
for scrutiny, together with a statement of comprehensive income for
2012/13, showing movement from 2011/12 (Annex 2), a Going
Concern Review (Annex 3) and draft Letter of Representation.
T
Mr Douglas queried whether there had been any significant changes
to format, style or content this year and Mrs Wilson confirmed that
there had not. Since circulating the accounts there had been some
minor amendments to the narrative but these were not of a material
nature.
Mr Warren queried whether the financial statements aligned with the
management accounts. Mr Teape and Mrs Wilson confirmed that this
was the case. Mr Warren sought, and received, clarification of the
information set out in section 9.4 of the accounts. Mr Teape stated
that the Trust did not make payments outside contractual terms.
The Committee reviewed and approved the Annual Governance
Statement set out on pages 3 to 10 of the accounts.
There were no other queries on the financial statements.
9

Item 18, Annex 1
Going Concern Review
Mr Teape reminded the Committee of its responsibility to obtain
assurance that the accounts had been prepared on a going concern
basis. Referring to page 5 of Annex 3, Dr Williams sought to
understand the statement that “Income for the year has been agreed
with Commissioners on a managed PbR basis.” Mr Teape stated that
there was a joint commitment across the health community to ensure
the Trust would deliver
D
the contract value. The contract had been
‘split’ into three themes: block, variables and a risk-share element.
The contract had been signed and there was good assurance of its
integrity.
Mr Baber would circulate to NEDs the summary briefing recently
issued by commissioners
R
to GPs.
Professor Lewis sought assurance that the Trust would be
appropriately recompensed for winter pressures this year. Mr Baber
stated that the Trust was involved in discussions and there may be
some additional funding to support additional activity and there was
optimism that this would
A
be forthcoming.
Mr Warren strongly argued that the Trust was a going concern given
its unique purpose and funding arrangements and Committee
members welcomed his perspective.
COO
The Committee endorsed
F
the assessment of the Trust as a going
concern and recommended to the Trust Board the approval of the
assessment as the basis for preparation of the Trust’s financial
statements.
Letter of Representation
The Committee reviewed
T
this and recommended to the Trust Board
that they approve it and that they authorise the Chief Executive and
Director of Finance to sign it.
51/13 Losses and Special Payments for the year ended 31 March 2013
The Committee reviewed the schedule and noted that the total, £298k,
was lower than 2011/2012 and that the total number of bad debts
written off had reduced. The Committee remained concerned,
however, by the increase, both in terms of incidence and payments
made, in respect of the loss of patients’ property.
The Committee noted the report and recommended to the Trust Board
that they approve the formal write-off.
52/13 Management of External Assessments
Mr Budge presented the half yearly review of progress in responding
to recommendations and requirements arising from external
10

Item 18, Annex 1
assessments. Mr Budge explained the process by which issues of
concern arising from external assessments were elevated, via the
Assurance Framework, to the Trust Board.
There were no questions and the Committee noted the report.
53/13 Safety and Quality Committee
Minutes of the April 2013
D
meeting were noted by the Committee.
54/13 Finance, Performance & Investment Committee
Minutes of the April 2013 meeting and minutes of the ‘commercial-inconfidence’
section of the April 2013 meeting were noted by the
Committee.
R
55/13 Human Resources & Organisational Development Committee
Minutes of the April 2013 meeting were noted by the Committee.
56/13 Audit Chair’s Report
A
to the Board
It was agreed that this would cover:
• CQC Outcome 21 review.
• Bevan Brittan risk update.
F
• Approval of the accounts and associated documentation review
and recommendations to the Board.
57/13 Review and Learning
As agreed at the May meeting, this item featured a discussion to
extract learning from
T
a topical issue and on this occasion it was the
Committee’s relationship with Internal Audit. Prior to the meeting
there had been a Board session to agree Internal Audit’s work plan for
2013/14. The Committee reflected on the following questions:
• Does the Audit Committee understand its relationship with
Internal Audit?
• How are we assured that reports are thorough?
• Is the Audit Committee sufficiently proactive?
• Could we use what they tell us more efficiently?
• How can we improve triangulation?
The Committee agreed that its understanding of its relationship with
Internal Audit had improved as a result of the pre-meeting session and
particularly through questioning during the meeting. The Committee
gained assurance on thoroughness through challenge and audit
scope and agreed that there was a requirement for significant
management attention at the start of the process. It would be helpful
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Item 18, Annex 1
if Internal Audit more proactively highlighted their upcoming work to
the Committee.
Dr Williams asked whether the Committee’s focus was prepared for
the change to service line reporting. Whilst it was agreed that this
was the long term goal, the new structure was not yet sufficiently
developed to support this. However, just as Directorates had the
opportunity to request Internal Audit support, so would service lines.
In the meantime, audit
D
activity would focus at care group level, with
more in-depth activity at service line level, when necessary.
It was agreed that at the next meeting Review and Learning activity
would focus on nurse staffing levels.
R
There was no other business and the meeting closed at 3.30 pm.
58/13 Any Other Business
59/13 Date of next meeting
A
12.30 – 3.30 pm Friday 9 August 2013.
F
T
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