Trust Board papers 7th September 2011 - Barking Havering and ...

TRUST BOARD MEETING 

Wednesday, 7 September 2011 at 1.00 pm 

Board Room, Trust Headquarters 

Queen’s Hospital 

A G E N D A 

1. Apologies for Absence 

2. Minutes of the meeting held on 6 July 2011 (Attachment A) 

3. Matters Arising and Actions 

4. QUALITY AND PATIENT STANDARDS 

4.1 Quality & Patient Standards Performance Report – July 2011 (Attachment B) 

(AD/DCW/RMcA) 

4.2 Emergency Care Report on July 2011 Performance (MS) (Attachment C) 

4.3 Maternity Services Update – July 2011 Monthly Report (CD) (Attachment D) 

4.4 Infection Prevention & Control Annual Report 2010/2011 (DCW) (Attachment E) 

4.5 Quality & Safety Committee Escalation Report (SB) (Attachment F) 

5. FINANCE, WORKFORCE AND ACTIVITY 

5.1 Finance Report – Month 4 (July) 2011/12 (DIW) (Attachment G) 

5.2 Workforce Key Performance Indicators – July 2011, including (Attachment H) 

Summary Report on the Workforce Committee meeting held on 

8 August 2011 (RMcA) 

5.3 Activity Report – August 2011 (NM) (Attachment I) 

6. GOVERNANCE: 

6.1 Care Quality Commission Action Plan Update (SB) (Attachment J) 

6.2 Board Assurance Framework – Quarter 1 (April-June) 

2011/12 (SB) (Attachment K) 

7. INFORMATION 

Matters for Noting: 

7.1 Interim Chair and Chief Executive’s Report (Attachment L) 

7.2 Cancer Services Management Board Annual Report (Attachment M) 

7.3 Minutes of the Quality & Safety Committee meeting held on (Attachment N) 

the 14 June 2011 

7.4 Draft Agenda for November Trust Board Meeting and Rolling (Attachment O) 

Programme for 2011 

8. Any Other Business 

Date of Next Meeting: The next public meeting will be held on Wednesday, 2 November 2011 

at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s Hospital 

9. Questions from the Public 

10. Exclusion of the Public and Press In accordance with the Public Bodies Admission to Meetings 

Act), to resolve to exclude members of the public and press from the remainder of the meeting. 

Trust Board Agenda – 7 September 2011 1

1 

BARKING, HAVERING AND REDBRIDGE UNIVERSITY 

HOSPITALS NHS TRUST 

Minutes of the Part I Trust Board Meeting held on the 6 July 2011 

in the Board Room, Trust Headquarters, Queen’s Hospital 

Present: Mr Edwin Doyle Interim Chair 

Mrs Averil Dongworth Chief Executive 

Mr Stephen Burgess Medical Director 

Mr William Langley Non-Executive Director 

Mr Keith Mahoney Non-Executive Director 

Mrs Ruth McAll 

Director of Human Resources & OD 

Mr Neill Moloney 

Director of Planning & Performance 

Mr Robert Royce 

Director of Strategy 

Prof Anthony Warrens Non-Executive Director 

Ms Deborah Wheeler Director of Nursing 

Mr Michael White 

Non-Executive Director 

Mr George Wood 

Non-Executive Director/Vice Chair 

Mr David Wragg 

Director of Finance 

Ms Caroline Wright Non-Executive Director 

In Attendance: Mrs Carol Drummond Divisional Director, Women & Children’s Division 

Dr Ian Grant 

Divisional Director, Cancer, Diagnostics & 

Therapeutics Division 

Ms Imogen Shillito Director of Communications 

Mrs Sue Williams 

Executive Assistant/Trust Board Secretary 

The Interim Chair started the meeting by welcoming two visitors; Ms Ann Douse, Clinical Governance 

Manager for NHS London and Ms Katy Steward from the King’s Fund, who was providing feedback to the 

Board on process, behaviour and engagement of its members. 

Mr Doyle also welcomed two new Non-Executive Directors who had commenced recently with the Trust, 

Ms Caroline Wright and Professor Anthony Warrens from Queen Mary, University of London. The Interim 

Chair had asked Ms Wright to join the Quality & Safety Committee and to take a special interest in 

communications and along with Mr White, an interest in the Trust’s relationship with patients and the public 

in the development of the Trust’s membership for Foundation Trust status. Mr Doyle had also asked 

Professor Warrens to join the Quality & Safety Committee and with his background to take a special 

interest in Education and Research and the challenges the Trust faced in the emergency pathway through 

the hospital. Professor Warrens was also going to take an interest in the work going on around ‘London 

Cancer’. 

Mr Doyle announced that following the departure of Mrs Liggins at the end of June, Mr George Wood had 

been appointed the Trust’s new Vice Chair. In this role, he would became the Chair of the Trust’s 

Remuneration Committee. 

2011/022 APOLOGIES FOR ABSENCE 

All Trust Board members present. 

2011/023 MINUTES OF THE PART II MEETING HELD ON 18 MAY 2011 

The minutes of the meeting were noted as a true record and signed by the Interim Chair, with one 

amendment. Mr Langley asked the Board to record that in agenda item 2011/017 he had not asked if the 

Trust had any property that it did not know about, but if the Trust had any property empty or under utilised 

that it could do something with, but had a cost associated with it. Mr Wragg confirmed that the Trust did 

not have any property that fitted this scenario. 

Trust Board Minutes (Part I) 6 July 2011

2 

Agenda item 2010/105 was now discharged. It was agreed that Ms Wheeler would send out an update on 

agenda item 2011/008 to all Board members. 

Agenda item 2011/015: Mr Royce confirmed that a further review of the capital programme had been 

undertaken, prioritisation had been completed, but it was not yet finalised. The Board agreed that the 

update would be presented at the next Finance & Programme Management Committee meeting. 

2011/016: The Chief Executive reported that the Director of HR had started some work on this in 

preparation for the August Trust Board Seminar, where she would cover the whole staff engagement 

strategy in its development session. Some smaller targeted survey work had already started, particularly 

in the Women & Children’s Division and three key questions had been included, which provided more 

clarity in terms of the feedback received. HR Advisors had also completed some questionnaires with 

fifteen questions based on job satisfaction and had randomly selected staff groups. This data would all be 

fed back to the Staff Survey Action Group to be taken forward by them. 

Action: Deborah Wheeler 15.7.11 

Robert Royce 26.7.11 

2011/024 MATTERS ARISING 

No matters arising. 

2011/025 INTERIM CHAIR & CHIEF EXECUTIVE’S REPORT 

Report provided to the Trust Board for information. Following a point raised by the Interim Chair in relation 

to ProCure21+, Mr Wragg informed the Board that this provided a list of national framework conditions and 

guidance on the best way to procure capital projects and also provided a template to review against in 

relation to the Trust’s estate strategy. It was noted that the deadline for submission of nominations to take 

part in the London Torch Relay had now passed. A major impact on the Trust in relation to the Olympic 

Games in 2012 was the unavailability of staff who would be encouraged to assist with marshalling activities 

whilst still being paid by the Trust. It was agreed by the Board that this issue should be referred to the 

Workforce Committee for them to consider. 

The Trust Board noted the report. 

Action: Ruth McAll 8.8.11 

2011/026 HEALTH4NEL UPDATE 

Mr Royce confirmed that the Trust had provided all the evidence requested to the Independent 

Reconfiguration Panel (IRP). A number of staff had been involved in providing this evidence, particularly 

the Chief Executive, Medical Director and Director of Finance, as well as the Divisional Director for Women 

& Children in relation to maternity services. A large number of documents had been supplied over the last 

few weeks, particularly in relation to workforce information, maternity services modelling, emergency care 

and implementation timescales for the Health4NEL changes and their capital consequences. The Board 

noted that the report by the IRP was expected to be forwarded to the Secretary of State by 22 July 2011 

and the Trust awaited the outcome. 

The Trust Board noted the update. 

2011/027 CARE QUALITY COMMISSION 

Mr Burgess informed the Board that the Care Quality Commission (CQC) had announced on the 29 June 

2011 that they would be carrying out a whole hospital review, the first major whole Trust review of services 

undertaken by them. They were expected to be in the organisation for approximately eight weeks. The 

Board noted the Terms of Reference, which included reviewing an emergency care pathway, an elective 

pathway and the maternity services pathway. Through the pathway investigations they would also be 

looking at the effectiveness of governance structures, risk, training and equipment (a very wide ranging 

review). The Board noted that Robert Royce was the Senior Responsible Officer and Executive Lead. He 

was currently coordinating the first tranche of evidence that had been requested by the CQC Team. Mr 

Royce would keep the Board updated, but if anyone had any issues to raise in-between Board meetings, 

then they should contact Mr Royce directly. The Board fully supported the process and would assist in any 


3 

way possible. Professor Warrens questioned the benchmark for the process and that they were looking at 

appropriate processes in place, rather than outcomes. The Interim Chair requested that the two new Non- 

Executive Directors should receive copies of the two Warning Notices regarding Maternity previously 

received from the CQC. 

The Board agreed that it was important for staff to be fully briefed on the Review and to make sure that a 

communication was sent out to all staff advising them that they were looking at process rather than 

outcomes. 

Following a question raised by Mr Langley in relation to the Trust’s communication strategy for handling the 

Review, it was confirmed that Mr Royce would be working closely with the Director of Communications in 

order to keep staff fully informed of what was happening. An internal and external communications plan 

was already in place and an office had been set up to coordinate everything. The Director of 

Communications would arrange for the communications plan to be circulated to all Board members. The 

Board noted that the Trust had had to put in additional resources to coordinate and manage the Review. 

Action: Sue Williams 15.7.11 

Imogen Shillito 15.7.11 

2011/028 QUALITY ACCOUNT 2010/11 

Mr Burgess presented the final version of the Quality Account 2010/11, following input from local 

stakeholders. He confirmed that this was now available on the Trust’s Website and Intr@net. Mr Burgess 

informed the Board that some of the responses from stakeholders had been received after the deadline, 

when the Quality Account had already been published. Some of these responses had been very positive 

and it was agreed that arrangements would be made for a link to these comments to be included on the 

Website and Intr@net. Notification of the Quality Account’s publication would be circulated to all staff 

through this month’s Team Brief. 

The Trust Board noted the final Quality Account 2010/11. 

2011/029 EMERGENCY CARE REPORT 

Mr Moloney informed the Board that against the target of 95% for type 1 attendances, the Trust had 

achieved 93.99% for May at King George Hospital and 82.23% at Queen’s Hospital. The Board noted that 

a significant improvement had been made in the last three weeks with Queen’s performing at 95% on 

average and King George 98% (average for the Trust had been in excess of 98%, which was an excellent 

improvement). May’s performance had been affected by the lack of bed flow and reduced discharges over 

the two bank holidays. The Board noted that there had been an overall improvement in performance 

against the new A&E quality indicators. 

Mr Moloney informed the Board that ambulance handover times at the Trust had been some of the longest 

in London, with Queen’s performance at the end of May being 21.6 minutes and 17 minutes at King 

George, against a target of 15 minutes. He confirmed that a range of actions had been put in place to 

improve the process, but he also reported that there had been 18 black breaches at Queen’s, which had all 

been reported to NHS London as Serious Incidents (black breaches meant that patients had waited over 

60 minutes to be offloaded). A joint action plan had been agreed between the London Ambulance Service 

(LAS) and the Trust and a Summit with LAS was being arranged within the next two weeks to ensure the 

action plan was sufficiently robust. The Board noted that both the Medical Director and the Divisional 

Director for Medicine/Emergency Care were leading a process to review progress in the A&E department, 

to ensure a safe service was maintained at all times. The reintroduction of the Jonah system was having 

an impact on patient flow and the Trust was seeing some very good results from this work on the wards. 

Project management support was currently being added to, in order to roll it out to the rest of the 

organisation. 

Mr Wood highlighted that some of the completion dates on the Emergency Care Programme Action Plan 

had been missed and that the Trust should be able to address these quicker. Mr Moloney confirmed that 

all risks and issues were being escalated through to the Emergency Care Programme Board and the 


4 

Executive Team was supporting the Divisions where necessary and the appropriate level of escalation was 

in place if a deadline was missed. 

Mr Burgess updated the Board on the safety aspect and confirmed that they were currently developing high 

level triggers; five at present, including access to resuscitation, being able to be seen within 15 minutes to 

assessment and unloading patients from ambulances. This was the first piece of work and they would 

expand on this to include specialist opinions from Consultants and access to investigations, but they would 

need more time to achieve a position the Trust was satisfied with. Mr Langley felt that there was a lot of 

activity mentioned in the report, but it did not give him comfort, particularly around recruitment and he was 

keen to understand what actions were taking place behind the report to make sure the Trust achieved the 

improvement it required within the timeframe. The Director of HR confirmed that the SHO posts in the 

department had been recruited to, in fact the Trust had over recruited and was making significant progress 

in this area. Fixed term contracts had been offered to three out of the eight vacant Consultant posts (two 

had accepted and one was pending) and five middle grades had been offered contracts. The nurses 

recruited for A&E were in post and the Trust SHO Doctors appointed were coming on stream from this 

month. It had been identified at the Workforce Committee that it was not an easy recruitment campaign 

and focus would continue in this area throughout the year. It was also agreed that the Trust should look at 

how to retain staff once they were recruited. 

Mr Mahoney made the point that the Queen’s building was not conducive to informal communication. The 

Trust had seen robust plans, but they did not seem to materialise and this should be reviewed. The Interim 

Chair reiterated his previous comments at Board meetings that Team Briefing and face to face 

communication was the most powerful communication tool and the Board agreed that there should be 

renewed effort around ensuring this happened. Ms Wright raised the point that when reading through the 

paper, reference had been made to ambulance handovers and the LAS Summit, but in future she felt that 

this should include what the Trust was trying to achieve from such a meeting. Reference to reasons for 

the decline in performance was over a period of more than a year, including the poor patient flow, and she 

felt it would be helpful to know what the Trust was doing to improve this. It was agreed that Mr Moloney 

would pick this up with her at their induction meeting next week. 

Mr White did not feel that in overall project management terms the ‘rag’ ratings of red, amber and green 

gave an accurate picture of what was happening. He referred to the Nottingham Spoke monitoring and 

that a number of other Trusts were moving towards this system and BHRUT should take this on board. It 

was agreed that the Chief Executive would look at this and report back to the Board. 

The Board noted that KPMG was currently undertaking a Review and a Project Management Office was in 

the process of being established to assist the Executive Team to deliver the Cost Improvement 

Programmes. The Trust was hoping that the Challenged Trust Board (CTB) would contribute towards the 

cost of this. It was agreed that Mr White would be the Non-Executive Lead for this area and provide 

support to the Executive Team, as he had years of experience and skills in this field. 

The Chief Executive proposed that now the Trust had a full complement of Non-Executive Directors, it 

would be beneficial to hold a development session on length of stay and the Jonah system at the August 

Trust Board Seminar. 

The report did not reflect the work that the Chief Executive, Medical Director and Divisional Director for 

Medicine/Emergency Care were doing with the Medicine Division, A&E Department and Radiology in 

talking to clinicians about their role in delivering the improvements required. The Trust was starting to see 

a response, reflecting in the improvements in the patient flow. Culture and behaviour of staff was also 

beginning to change. 

Action: Averil Dongworth 3.8.11 

2011/030 MATERNITY SERVICES UPDATE 

Mrs Drummond highlighted the key areas, identified through the scorecard and the Maternity Services 

Improvement Plan and presented the new format for the Action Plan, which had been put together in 

partnership with ONEL Sector and representatives of NHS London. Following the sign-off of the Action 

Plan, it had been agreed that there would be fortnightly meetings with the Sector and monthly meetings 


5 

with NHS London. Mrs Drummond presented the first Maternity Services Weekly Performance Report. 

This contained a lot more valuable information and enabled the department to analyse and improve some 

of the ways in which women flowed through the service and staff were deployed. The Board noted the 

balanced scorecard and the three new KPIs around the number of women referred into the obstetric unit, 

emergency caesareans and also the time taken for women to be seen when they first arrived in triage. Mrs 

Drummond reported that there was now 80% attendance from Consultants at MDTs and Consultants were 

more on board with this process. The Interim Chair stated that the Board would expect 100% attendance 

and did not find it acceptable if someone did not attend a meeting that they were required to attend and this 

should be conveyed to the relevant people. Three SI’s had been reported in May. She also informed the 

Board that the Maternity Escalation Policy had not been robustly utilised, but this was now fully in place 

and being followed. Part of the action plan and one of the key performance indicators, was to ensure 

100% of leavers had an exit interview, in order for the reasons for leaving to be tracked. It was agreed that 

in respect of all reports received by the Board, there should be a clear narrative against variances reported, 

so it was clear what the Trust was doing to address these and the steps being taken to bring performance 

back up to target/trajectory. 

The number of midwife vacancies at the end of June totalled 55.5WTE; during May and June there had 

been 26 new recruits and 30WTE starters with job offers and 21 interviews planned for next week, which 

would be mapped into the 55.5WTE vacancies. The Division had established an Associate Head of 

Midwifery for Governance and Quality to lead the Education and Clinical Governance processes. A stricter 

regime around performance management had been established and during May three midwives had been 

suspended and one disciplinary hearing held resulting in a final written warning. Mrs Drummond informed 

the Board that she had agreed with the new Non-Executive Director leading on Maternity, Ms Wright, that 

she would forward her the Weekly Performance Reports on a regular basis. 

It was recognised by the Board that no other Maternity Service had been asked to provide this level of 

reporting and consideration was being given to rolling this out to other units, in order to provide 

benchmarking data. Ms Wheeler had spoken to the Chief Nurse at NHS London and she had confirmed 

that she would share it at future meetings in the Autumn. Due to the length of the Action Plan, it had been 

agreed that the review meetings would go through it in four parts to enable detailed monitoring of progress 

and this would be reflected in future Board update reports. 

The Board acknowledged the huge progress that had been made in maternity services. The Board noted 

that the Minister Anne Milton was visiting the unit on the 7 July and the Chief Executive, Director of Nursing 

and Divisional Director for Women & Children looked forward to showing her the progress that had been 

made. 


2011/031 REVIEW OF THE CHRONIC FATIGUE SYNDROME SERVICE 

The review of the Chronic Fatigue Syndrome Service was presented by Mr Moloney. He informed the 

Board that demand for this service had declined and the Trust currently had two inpatients. Funding had 

become more difficult and the Trust’s Local Commissioners had confirmed that they were not interested in 

funding inpatient services in the future. The Lead Consultant had recently retired and an attempt to recruit 

associate specialists had not succeeded. Low utilisation of these beds and the reduction in demand over 

the last year had made it difficult for economies of scale. A full Consultation had been undertaken with 

patients, patient representatives, Commissioners, staff and other interested parties and all comments had 

been taken into account. The overwhelming view was that the inpatient service should be discontinued 

once the current two patients had been discharged and the Trust would continue to provide an outpatient 

service. 

Professor Warrens asked about the data on the effectiveness of this service and Mr Moloney informed the 

Board that the Commissioners had not always been convinced by the information available and formed the 

view that there was a lack of evidence base. The Board noted that one of the Trust’s Consultant 

Neurologists was going to take clinical and professional responsibility for the outpatient service, through 

which he would assess and make recommendations back to GPs for OT, or counselling services to be 

provided by the Trust once funding had been agreed. The retiring Consultant had an international 


6 

reputation, but there did not seem to be anyone else in the country with his level of expertise. The Trust 

had received quite a lot of feedback from patients and campaign groups and whatever decision the Board 

took, this would need careful communication handling, as there was likely to be further media interest. If 

the Trust was going to limit itself to an outpatient service, Mr Langley asked if there was another local Trust 

who also provided this service and it was agreed that the Medical Director would check if the Royal London 

had a service in place. 

The Trust Board agreed that the inpatient service would discontinue after the two patients had been 

discharged and the Trust would continue to provide an outpatient service. The Director of Communications 

would prepare a communications engagement plan. 

Action: Stephen Burgess 22.7.11 

Imogen Shillito 22.7.11 

2011/032 QUALITY AND PATIENT STANDARDS PERFORMANCE REPORT – MAY 2011 

Mr Moloney highlighted the key areas from the Quality and Patient Standards Performance Report for May 

2011. There had been one MRSA case in May, taking the Trust’s total for the year so far to 3, against an 

annual target of not more than 8 cases. Mr Moloney also reported that the Trust had not had a case of 

MRSA bacteraemia since 3 May this year. He reported 45 same sex breaches, which were all related to 

the step down of patients from critical care areas into general wards. These breaches occurred when 

patients of opposite sexes were not able to be transferred to a single sex area within a six hour timeline 

from the time the decision was made to transfer. Actions had been put in place now and patients were 

being identified much earlier, so that preparations could be made in advance. There had been no material 

change in readmission rates within 30 days and projects had been established to look at this, one within 

Medicine and the other in Surgery, looking at elective and non-elective admissions and Mr Moloney would 

report back on this at a future meeting. 

Delayed Transfers of Care (DTOCs) had shown an increase in trend over the last few months. Mr Moloney 

informed the Board that a Cross Buffer Group had recently been established, chaired by the Chief 

Executive, which was attended by representatives from the Sector and the Community to discuss 

blockages to patient’s flow out of the hospital. The Trust was also working with its partners to ensure there 

was adequate capacity in the Community. 

Complaints continued to be high with 84 received for the month of May. This was a 22% increase on the 

previous month. The department was currently working through a backlog of out of date complaints and 

plans were being put in place for the transfer of complaint response formulation to the Divisions, with the 

complaints team concentrating on coordination and tracking. As previously raised by Mr Langley, he asked 

that a ‘snapshot’ be prepared on the ageing of the complaints, how many the Trust had and how long they 

were taking to respond to these, so the Board could have an idea of the speed these were being dealt with. 

Consideration would be given to whether it would be useful for the Board to look at the top 5/10 complaints 

to provide members with a feel for what was going on and if there was a common theme to the complaints 

received. It was agreed that the Quality & Safety Committee should look at this level of detail and a 

summary report be prepared for the Trust Board. 

In relation to referral to treatment (RTT), the Trust had not met the median waiting time target for those 

patients currently with an incomplete pathway during May and performance had deteriorated against the 

95% incomplete pathway waiting time standard. Actions were being taken by the Divisions to ensure 

patients were treated within the required timescale, but this had impacted on this particular performance 

target. More patients were treated within their 18 week RTT date than in the previous month, with an 

increase from 91.9% to 93%. The Trust had agreed with NHS London that it would clear the backlog of 

additional activity required, in order to achieve this target by September 2011. Recent analysis had shown 

that there had been a reduction of 20% in GP to Consultant referrals for the last six months (December 

2010 to May 2011) when compared to the same six month period in the previous year. The reduction was 

across a number of specialties, with Trauma and Orthopaedics, ENT and General Medicine seeing the 

highest reductions of over 25%. The Trust was currently working through the reasons for this and Mr 

Moloney informed the Board that certainly in April the Trust had seen the lowest level of referrals over the 

last 18 months. 


7 

The Trust continued to perform well with its Stroke Service, which was constantly improving and in Cancer 

performance had been sustained during April, May and June. The Trust’s mortality rate, although not yet 

rebased through Dr Foster, was demonstrating a much improved figure to last year. 

Mr Wood raised the issue of the staff appraisal rate at 78.60% and no narrative to explain why. The Board 

was informed that this was a rolling programme and the Divisions were provided with a lot of information on 

staff due to be appraised and could therefore plan accordingly. The Board was not happy with this 

performance and referred this to the Chief Executive to take up with the Divisional Directors, to establish 

that objectives had been agreed with all staff and for her to provide an update back to the Board. The 

Chief Executive confirmed that personal objectives had been agreed with all the Executive Directors. 

The Board asked the Chief Executive to review the report and provide assurance for the Trust Board that 

there were work programmes behind each one of the indicators and, where performance was below target, 

that this was being addressed. 

The Trust Board noted the content of the report and supported the actions to bring the performance back in 

line with trajectory/target. 

Action: Averil Dongworth 7.9.11 

2011/033 WORKFORCE KEY PERFORMANCE INDICATORS 

Mrs McAll presented the workforce key performance indicators for May including staff sickness absence, 

occupational health referrals, turnover hotspots and recruitment. Turnover of staff had reduced for the fifth 

month in succession, dropping by a further 0.11% in month to 10.99%, which was 1.1% below the average 

of other large acute Trusts. The staff sickness rate had risen to 4.82%, compared to 3.40% reported at the 

last Board meeting. Recruitment vacancies totalled 567 WTE, 453 of which related to non medical staff, 

with 500 posts going through the recruitment process at any one time. Each Division was supported by an 

HR Advisor and all reports were reviewed at performance meetings and actions recorded. This report was 

also presented to the Workforce Committee and it was noted that at the meeting earlier this week detailed 

feedback had been received from each Division. Mr Mahoney highlighted that it had been noted at the 

Workforce Committee meeting that there was still a discrepancy between the number of people in post and 

what was on the financial ledger and that there was some concern about how the financial figure was being 

interpreted by the Divisions in terms of recruitment. Mr Wragg explained the issues and the fact that the 

finance report was driven by the payroll data, whereas the workforce key performance indicator report was 

based on a ‘snapshot’ and it was difficult to reconcile the two. The Interim Chair proposed that this issue 

should be escalated to the Audit Committee for them to review in more detail. 

Mr Langley raised an issue relating to the staff survey actions and the fact that the themes identified, in 

particular staff retention and preventing harassment, bullying, abuse and discrimination, was not borne out 

by any statistics he had seen either at the Audit Committee, or in the case of staff retention, there did not 

appear to be an issue across the organisation. It was agreed that the Workforce Committee would look at 

this issue in relation to what the National staff survey said compared with the Trust’s own information, see if 

it was consistent and then take a view. The Board noted the vacancy ‘hotspots’ and that strategies were 

in place to overcome these, albeit some could be solved in the short term, but others were more long term 

issues. Mr Wood highlighted the relationship between the number of staff in post and the bank and agency 

spend and pointed out that he would not expect to see this level of agency spend continuing. Some of this 

related to overtime, but it was agreed that the Finance & Programme Management Committee would look 

at this and Mr Wragg, along with Mrs McAll, would prepare a trajectory to show how the agency spend was 

going to come down dramatically and when the Trust would start seeing this in terms of current spend. 


Action: David Wragg 8.9.11 

Ruth McAll 8.8.11 

Ruth McAll/David Wragg 26.7.11 


8 

2011/034 FINANCE REPORT – MONTH TWO (MAY) 2011/12 

Mr Wragg informed the Board that the YTD income and expenditure position at M2 was £12m deficit before 

£5.3m of impairments and reversals. The adverse variance to date against plan was £1.7m. He reported 

that the income position was over performing against target expected by the PCTs (M2 £1m and £1.9m 

YTD against the phased plan). The Trust was working closely with the PCTs on their QIPP plans, but there 

was a huge distance to go to reduce activity levels to what they expected. They were looking to get £1m 

out each month to deliver the QIPP. This gave rise to some degree of expenditure before looking at the 

value of the Cost Improvement Programme (CIP) element of £700/800k (£200k on PFI Soft FM contract yet 

to be finally agreed) and £600k overspend on maternity and obstetrics; running with a number of midwives 

not budgeted for (21 budgeted for, but had 35-40). Another element of over performance related to the 

movement of day cases into an outpatient environment, where the Trust was still performing the majority of 

these as day cases and charging accordingly. It was clear that evidence submitted by some other 

organisations indicated that they were carrying out this activity in outpatients, but if large volumes were 

transferred this could have a financial impact for the Trust. The biggest issues were in Endoscopy, Urology 

and Ophthalmology. It was agreed that the Finance & Programme Management Committee would look at 

this from a business perspective in terms of the flow and costs. The Board noted that one of the 

workstreams within the Project Management Office would be the QIPP workstream and Mr Moloney would 

prepare a report on progress so far and present to the Finance & Programme Management Committee. 

Once the Finance & Programme Management Committee had the opportunity to look at this, it would be 

brought back to the Board for further discussion, as it was crucial for the whole Board to agree the Trust’s 

strategy going forward. 

Overall CIP delivery in month fell short of plan by £0.6m and left the Trust with an unfavourable variance of 

£1m YTD. The major issue here was the failure to deliver the ward closures; two more wards were open 

than were planned. Major pressure being felt in the Medicine Division related to a significant issue on the 

length of stay programme. The overall exposure in the savings programme was assessed as £16.3m, 

comprising of £4.3m red risk rated schemes and the £12m adverse variance on the CIP performance so far 

to the planned £28.4m, and urgent steps were being considered to address this gap. Over the first two 

months of the financial year there had been an average increase in pay expenditure of £650k per month, 

which was due to the two wards still being open and not budgeted for, supervisory midwives and some 

other areas of CIP. 

There needed to be a major effort to get the clinically driven schemes associated with length of stay back 

on track and for risks to be managed around other major workstreams, e.g. outpatients and theatres. The 

Trust was looking at a negative control total of £40m, and the possibility of a further £10m on top of this. It 

was noted that as the Divisional Directors were not represented at the Trust Board meetings, the issue of 

the Board’s disappointment with the slippage on the CIP, in particular length of stay and ward closures, 

should be conveyed to them through the Chief Executive. The Board noted that the Director of Finance 

and the Director of Planning & Performance met with the Divisions every month at performance meetings 

and this message was conveyed to them very firmly. Due to the slippage in the programmes, these 

performance meetings were now being held on a two weekly basis until they were back on track. 

The Board was aware that KPMG was currently undertaking a Review on the CIP and other areas of the 

Trust in preparation for the Challenged Trust Board (CTB) report, and rather than wait for the outcome of 

this the Executive Team had agreed to go ahead with the establishment of a Project Management Office 

(PMO) led by the Director of Planning & Performance through his performance management regime. A 

resource had been engaged, which was endorsed by KPMG, to set this up and KPMG was absolutely 

confident that the PMO would get the CIPs back under control. Mr Wood felt that the Trust had to be 

pragmatic about what it could and could not deliver, so it was not in a position, as it had been in previous 

years, of not hitting targets set. He asked the Board to consider if there was anything that could be done 

with KPMG’s support, or the PMO, on a short term basis that would help re-energise the top 3, 4 or 5 

workstreams. The Board noted that the report to the CTB was due on the 13 July, but in the interim, prior 

to being advised if the CTB would provide the financial resource required for the PMO, the Trust should go 

ahead with its formal development, including Project Managers,, so it could be acted on immediately before 

the next Trust Board meeting, if the resource was forthcoming. The Board agreed to this approach. 


9 

Mr Wragg confirmed that there was no short term issue in relation to cash flow in terms of the agreed 

control total of £40m deficit, but the Department of Health and NHS London would not agree to any 

additional risk until they were certain the Trust could deliver on the CIP. Arrangements were in place with 

the PCTs for advancing cash against their contract. It was noted that activity figures were not included in 

the report; the Trust was reporting costs, but not outputs, and it was agreed that costs should be combined 

with activity. 

The Interim Chair had asked the Director of Performance & Planning to present a paper at the August Trust 

Board Seminar that provided the Board with a better understanding of the business of the Trust, linking 

income and expenditure to flow, so the Board was making a comparison between these two areas. 

Action: Neill Moloney 26.7.11 

Neill Moloney 3.8.11 

2011/035 MATTERS FOR NOTING: DECLARATION OF MEMBER’S INTERESTS FOR 2011/12 

The Trust Board noted the Declaration of Member’s Interests for 2011/12. 

2011/036 MATTERS FOR NOTING: EDUCATION AND LEARNING DIRECTORATE ANNUAL 

REPORT 2010/11 

The Trust Board noted the Education and Learning Directorate Annual Report 2010/11. The Interim Chair 

stated that a main objective of the Trust should be to become a ‘learning organisation’ and learn from areas 

like complaints or best practice and the Board agreed that this would be referred to the Chief Executive for 

her to prepare a report defining what a ‘learning organisation’ would look like, including input from the 

Education and Training departments on how they could introduce this into professional courses with the 

bespoke element that BHRUT wanted to achieve. Professor Warrens stated that this was a very good time 

to be doing this, as Universities were moving into a period where they were going to have to be more 

competitive. It was also a good time for the Trust to be squeezing more out of the money it was spending 

on education. 

2011/037 MATTERS FOR NOTING: MINUTES OF THE QUALITY & STRATEGY COMMITTEE 

MEETING HELD ON THE 12 APRIL 2011 

The Trust Board noted the minutes of the Quality & Strategy Committee meeting held on the 12 April 2011. 

2011/038 MATTERS FOR NOTING: MINUTES OF THE CHARITABLE FUNDS COMMITTEE 

MEETING HELD ON THE 19 APRIL 2011 

The Trust Board noted the minutes of the Charitable Funds Committee meeting held on the 19 April 2011. 

Now that the works had started on the Lavender Garden at Queen’s, focus would turn to the Rapid Arc 

project. 

2011/039 DRAFT AGENDA FOR SEPTEMBER 2011 TRUST BOARD MEETING AND ROLLING 

PROGRAMME FOR 2011 

The Board noted the draft agenda for the September 2011 Trust Board meeting and the rolling programme 

for 2011. 

2011/040 ANY OTHER BUSINESS 

No further business. 

Meeting closed at 3.30 p.m. 

The next meeting of the Barking, Havering and Redbridge University Hospitals NHS Trust Board will take 

place on Wednesday, 7 September 2011 at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s 

Hospital. 


EXECUTIVE SUMMARY 

TITLE: 

BOARD/GROUP/COMMITTEE: 

Quality and Patient Standards Performance 

Report – July 2011 

Trust Board 

1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE: 

The Quality and Patient Standards Performance Report 

provides an analysis of performance against trust-wide 

and national targets for the following domains: 

• Quality and Strategy 

• Operational Performance 

• Financial Performance 

• Human Resource Performance 

The following areas where performance is of concern for 

the month and/or for the year are discussed within the 

report: 

• MRSA 

• MRSA Screening 

• Venous Thromboembolism Risk Assessment 

• Single Sex Breeches 

• Emergency re-admissions

2. DECISION REQUIRED: CATEGORY: 

The Trust Board is asked to note the content of the report 

and support the actions to bring the performance back in 

line with trajectory/target. 

NATIONAL TARGET □ CNST 

□ CQC REGISTRATION □ HEALTH & SAFETY 

□ ASSURANCE FRAMEWORK 

CQUIN/TARGET FROM COMMISSIONERS 

□ CORPORATE OBJECTIVE …………………………….... 

□ OTHER …………………….. (please specify) 

AUTHOR: Steve Rubery, Head of Business Delivery 

PRESENTER: Neill Moloney, Director of Delivery 

DATE: July 21 st 2011 

3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST: 

Not applicable. 

4. DELIVERABLES 

The delivery of the Trust wide objectives. 

5. KEY PERFORMANCE INDICATORS 

Please see attached Trust Performance Dashboard. 

AGREED AT ______________________ MEETING 

OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 

REVIEW DATE (if applicable) ___________________________ 

2

Performance Report 

July 2011 

Performance Indicators - Exception Report 

1. Introduction 

This year’s national performance measures have not been separated out from the Trust’s local performance measures as in previous years. In 

2011/12 the dashboard displays four domains; Quality and Strategy, Operational Performance, Financial Performance and Workforce Performance. 

The performance of each of these domains contributes to the overall Trust RAG rating however when the Finance domain is rated ‘red’ the Trust’s 

rating will be ‘red’. 

This report provides the Board with an explanation for those performance measures which failed to meet the agreed target. Commentaries are 

provided by Senior Managers for those quality or operational indicators which did not meet either the Trust’s monthly or year to date (YTD) 

performance thresholds. There is no trust target for Serious Untoward Incidents therefore a performance statement will be included in this report each 

month in the quality and strategy section of the report. Finance and Human Resources performance are subject to separate reports to the Trust Board, 

since June 2011 where either the staff appraisal or basic life support training did not achieve the performance target a commentary has been included 

in the exception report. 

2. Performance Indicators 

This month the following Trust quality and strategy and operational performance measure were met; mortality, clostridium difficile. stroke, elective 

admissions on day of surgery, % daycase rate, DNA follow-ups, non-elective length of stay , cervical screening (lab results within two weeks), cancer 

targets, A&E 95% performance target at both sites and referral to treatment targets with the exception of the median for incomplete pathways 

3. Quality and Safety Performance Indicators 

For 2011/12 the focus is on those areas where performance measures, either monthly or YTD, have not been achieved. 

MRSA 

MEASURE 

YTD Performance – 3 cases 

Target – 2 cases 

MITIGATING ACTIONS 

The Trust remains over trajectory for the year, however we have had no cases of MRSA 

bacteraemia since early May. If there are no cases during August 2011, then the Trust will be back 

on trajectory. 

Page 1 of 11

MEASURE 

MRSA Screening – Elective and Emergency 

Elective YTD Performance – 71% 

Elective Target – 100% 

Emergency YTD Performance – 83% 

Emergency Target – 100% 

Venous Thromboembolism (VTE) Risk 

Assessment 

YTD Performance – 81.79% 

Target – 90% 


The Trust is well within target for Clostridium difficile, having had two cases in July and one case in 

a recently discharged patient. In order to assist in identifying problems earlier and preventing 

further cases the Infection Control service continues to review ward procedures in every patient 

who has a probable hospital acquired Clostridium difficile infection. Laboratory findings are 

presented to ward staff at the next handover and summarised for discussion at the infection control 

committee. 

The problem of incomplete compliance with MRSA screening has been highlighted to Divisional 

Leads. The service has identified some routes of admission into the Trust which may have been 

previously missed and have now started screening patients from these areas. 

The service is looking at changing the current audit methodology to capture greater numbers of 

patients and ensure the data is statistically significant. An automated process for capturing the 

information has been devised and it is anticipated that this will be in use from September 2011. 

This will then provide more robust data from which the service will be able to tackle the areas of the 

lowest conformance. 

The monthly target was exceeded this month with a score of 91.45% however recent poor monthly 

performance has resulted in a year to date (YTD) figure below the 85% target. The improvement 

during July 2011 has shown that the changes reported in last months Board Report have enhanced 

performance. Sustaining this level of monthly performance will ensure that the Service meets the 

YTD target. Regular ward visits by the Haematologists and Thromboprophylaxis teams continue. 

As stated in last month's update the Service continues to submit a central return based on audit 

data rather than census data until the next PAS upgrade, currently planed for December when 

additional functionality will allow a census based submission. 

Diagnostic Breaches 

YTD Performance – 134 

Target - 0 

There has been a significant reduction in the number of diagnostic breaches reported in July but 

with the performance target at zero further work needs to be undertaken. The increased emphasis 

from the Department of Health helps to focus the efforts of the teams and the Service is looking to 

bring the overall turnaround for all diagnostics below the national target. For July the Trust is 

showing a validated position of 8 breaches, compared to 34 in June. The breaches are broken 

down by diagnostic type as follows: 

Page 2 of 11

Single Sex Breaches 


Target – 0 

Serious Incidents 

MEASURE 

Elective and Non-elective Re-admissions

MEASURE 

Emergency YTD Performance – 12.86% 

Emergency Target – 9.24% 


The Readmissions Group has recognised the potential breadth of this project and has therefore 

been focusing on General Medicine as the largest volume specialty. To support this, the group has 

established a number of workstreams following an audit of medical readmissions within 14 days. 

The audit identified a number of health related groups (HRGs) with frequent readmissions. As 

expected these readmissions tended to be the patients with long term conditions. As existing 

pathways should be in place for many of these conditions it was decided to focus on 4 key 

conditions: 

• COPD 

• Falls 

• Dementia 

• Heart Failure 

Current pathways for these conditions are now being examined to understand if they are being 

followed, if they need updating and identify where the gaps in provision of services are. Initial 

analysis of COPD patient notes show that there is no documented evidence of referral to community 

services This will be followed, during September 2011 by a community event with relevant parties 

who impact on these pathways. 

Two further projects are being considered which include establishing ‘hot’ clinics for patients that 

require an urgent outpatient attendance that would prevent admission and also reviewing which 

patients can appropriately be managed in a planned elective pathway. 

Delayed Transfers of Care (DTOC) 


Target – 3.50% 

The month of July 2011 has seen an improvement in DTOCs to 4.15% from 5.55% in June with a 

year to date performance of 4.08%. 

The number of patients waiting for general rehabilitation and stroke rehabilitation beds (particularly 

those resident in Havering) has not improved. This has been bought to the attention of our 

Community partners and the stroke rehabilitation concern has been raised with NHS ONEL. 

Changes within Continuing Care teams in all areas of NHS ONEL have caused some delays with 

the ratification of decisions for continuing care. Again, this has been raised with NHS ONEL and at 

the cross- buffer meeting chaired by the Chief Executive. 

It is planned that the Discharge Team will transfer to the Medical Division from 1 August 2011. 

Page 4 of 11

MEASURE 

Number of Complaints and Complaints 

Responded to Within 30 days 

(Note: Complaints responded to are reported one month in 

arrears) 

Complaint Numbers 


Target – 150 

Complaint responses 

YTD Performance – 24% 


Patient Experience 

YTD Performance – Q1 -60% 

Q2 – 67% 

Q3 – 73% 

Q4 – 69% 

Target for all questions – 80% 


The Discharge Partnership Board meetings involving PCTs, Social Services and Community Health 

Services continue. Their most recent focus being: 

• Implementation of “Jonah” with the aim of seeing a reduction in Length of Stay (LOS) for 

patients with LOS over 20 days 

• Continuing care framework 

• Plans for the August bank holiday 

• Specialist rehabilitation 

The number of complaints received for the month of July 2011 was 93, a 9% increase on the 

previous month. Complaints are now being categorised according to the classifications in the 

complaints regulations 2009 and this has increased the number of complaints recorded. 

The response rate for June 2011 remains poor at 16% but this should improve as the new 

complaints process embeds. 

The roll out of complaints management to the Divisions has started. From 1 July 2011 the Medical 

Division and from 14 July 2011 the Women and Children Division accepted responsibility for the 

investigation and complaint formulation. It is expected that the roll out will continue with Surgery and 

Cancer, Diagnostics & Therapeutics Divisions assuming responsibility during August 2011. 

Once this new model is established it is anticipated that response rates will improve and the central 

complaint team will be able to concentrate on clearing the backlog of outstanding complaint 

investigations and responses. Once cleared the team should be in a position to undertake the 

analytical work required to provide robust evidence that this organisation is making changes to 

practices and processes as a result of the complaints received. 

A review has been undertaken of the responses to the patient experience real time survey which 

has been rolled out since January 2011 gradually across the Queens site. This as mentioned in 

previous reports has been slower than anticipated due to technical issues related to the 

reconfiguration of the hand held devices to accommodate the survey software. Data capture 

devices have been rolled out to 24 clinical areas to date and include hand held devices as well as 3 

kiosks. 

Page 5 of 11

MEASURE 


The review has shown that the uptake by patients has been poor, except in the Medical Division and 

therefore the monthly survey results may not be statistically valid. 

The action to improve uptake include revisiting and driving forward the process of roll out across 

both sites, engaging with staff and enable them to access the results in order to monitor the 

responses themselves. 

In addition this month the Director and Deputy Director of Nursing have reviewed the questions 

used for the Trust Board reporting and the overall questionnaire programme will be reviewed with 

the company to ensure user friendliness for patients and carers 

4. Operational Performance Indicators 

For 2011/12 the focus is on those areas where performance measures, either monthly or YTD, have not been achieved. 

MEASURE 

Outpatient First to Follow-up Ratio and DNA 

Rate 

FFU 

YTD Performance – 2.23 

Target –2.13 

DNA First 


Target – 9.70% 


There was deterioration in the first to follow-up ratio from 2.16 in June to 2.26 in July (YTD 

performance is 2.23). There was also a deterioration in the DNA rates for both first and follow-up 

appointments in July: new appointments rates increased from 9.46% in June to 9.92% in July and 

follow-ups from 9.64% to 10.00%. 

This is disappointing as several new schemes have been initiated during the quarter with the aim of 

improving both these performance areas. Late cancellation or establishment of clinics have a 

detrimental effect on the DNA rates. Investigations have shown that patients may be cancelled many 

times, receive multiple letters from the Trust and therefore may not attend the correct appointment. 

Where clinics are established late often the appointment letter does not reach the patient in time and 

the appointment is missed. A revised policy for the establishment and cancellation of clinics has 

been drafted and will be rolled out during August 2011 which should contribute to an improvement in 

the DNA rate. 

The Service is looking to re-establish the partial booking process by the end of September. Where a 

follow-up appointment is required in more than 8 weeks time the appointment will be ‘partially 

booked’ with the patient being placed on a follow-up appointment waiting list. The patient is 

contacted 6 to 8 weeks before the appointment date asking them to contact the Trust to make a 

Page 6 of 11

mutually convenient appointment. Those patients who do not respond will be referred back to their 

GP. It is expected that this will result in a reduction in DNAs. 

In order to improve the first to follow-up ratio performance the Service is looking into re-profiling many 

of the outpatient clinics to ensure that first to follow-up ratios are in line with best practice. 

Diagnostic Breaches 


Target - 0 

There has been a significant reduction in the number of diagnostic breaches reported in July but with 

the performance target at zero further work needs to be undertaken. The increased emphasis from 

the Department of Health helps to focus the efforts of the teams and the Service is looking to bring 

the overall turnaround for all diagnostics below the national target. For July the Trust is showing a 

validated position of 8 breaches, compared to 34 in June. The breaches are broken down by 

diagnostic type as follows: 

• MRI 5 

• Audiology 2 

• Gastroscopy 1 

The team is working particularly to reduce MRI breaches and create capacity to enable the 

department to respond to fluctuations in demand. It is anticipated that this change in process will be 

completed during August. 

Length of Stay 

Elective LOS 


Target – 3.6 

Elective LOS – excluding 0 days 



Non Elective LOS – excluding 0 days 



Non Elective Length of Stay (NEL LOS) continued to show an improved position reducing from 4.95 

days in June to 4.63 days in July. However, although the NEL LOS excluding 0 days performance 

this month reduced from 6.46 days in June to 6.29 days performance remains above the 2011/12 

target of 5.8 days. 

General Medicine has continued to show an improvement in NEL LOS with a further 0.87 days 

reduction in month. This has enabled Medicine to continue to reduce the number of medical patients 

in outlier wards and there has been an improved emergency access flow. However the length of stay 

reduction overall has been insufficient to enable us to close a ward at Queen’s during July. 

The Medical Directorate is currently working with the Surgery Directorate to review the ward closure 

programme on the KGH site, as this site routinely has higher bed availability. 

Work continues focusing on the usage of the Discharge Jonah tool for the identification of delays. 

This month has seen a reduction in the number of internal diagnostic delays however external 

Page 7 of 11

transfers, Social Services, Therapy reviews and nursing/residential home processes are still 

highlighted as issues. Supporting the highlighted delays the next phase of the Jonah programme 

improvements includes the provision of access to Discharge Jonah by Social Services and the 

creation of additional task lists e.g. endoscopy. In addition intensive support to support Discharge 

Jonah implementation will be provided to a new group of wards. 

The first four ambulatory care pathways will be introduced at the end of August 2011 to support 

admission avoidance and LOS reduction. They are: 

• Pneumothorax 

• Unilateral Pleural Effusion 

• Pneumonia 

• Low risk PE 

The 5 day a week consultant ward rounds project group is meeting with individual specialties to 

identify blockages to implementation. It is anticipated that an implementation plan will be available in 

September. 

Cervical Screening 

Results within two weeks 



% Women Seen by Midwife within 12 Weeks 

and 6 Days 

YTD Performance – 78% 


The turnaround performance target was not achieved in May 2011 due to a high number of bank 

holidays increasing laboratory turnaround time (though still within target). This low monthly figure 

(89%) has affected the year to date (YTD) performance with an YTD performance of 96%, despite 

good performance in June and July. In-laboratory turnaround time is the shortest ever and steps 

have been put by the Service to minimise the effects of future bank holidays in order to maintain 

them. It is expected that if PCT performance remains on target for the next three months the YTD 

figure will be back on target. 

The 12 week and 6 days percentage increased by 1% in July to 80.08%. The Service is currently 

working with the ONEL maternity commissioner to improve Trust performance. This is a new post 

which has been tasked with reviewing the antenatal pathway in the primary care setting, particularly 

the GPs role. Their initial task is to work with the Trust to agree a plan with the aim of improving the 

both the timeliness and the information contained in booking referrals. A risk assessment is 

undertaken at booking with the patient being referred onto the appropriate pathway. This is a 

continuous process and should the patient’s condition change then they will be referred onto a more 

appropriate pathway. The Service is currently reviewing its antenatal booking guidelines with the aim 

of booking referrals by ten rather than twelve weeks and six days national target. Successful 

implementation of these local guidelines should ensure that the national target of twelve weeks six 

days would be achieved. 

Page 8 of 11

Freedom of Information (FOI) – requests 

responded to within 20 working days 


Target -100% 

Although the number of FOI requests received in June 2011 has reduced to 28, the overall response 

rate has significantly reduced to 75.00%. 

This is as a result of a reduced performance for the Women and Children Division, and continued low 

performance within the Surgical and Corporate Divisions. It has been directly escalated to the 

relevant Divisional Directors/Managers and Executive Directors, to strengthen their internal FOI 

processes. To support this, the Departmental/Divisional PAs will now be included in the FOI reminder 

reports, to aid the conclusion of outstanding requests. 

The FOI process has also been updated to encourage Departments/Divisions to include additional 

information in their responses, where it will aid the applicant’s understanding and interpretation of the 

data provided. 

Accident and Emergency 

See table in mitigating actions column 

Against a target of 95% for Type 1 attendance the Trust achieved 98.54% at King George Hospital 

(KGH), and 95.1% at Queens Hospital (QH) for July 2011. This is the first time this has been 

achieved at both sites in 2011/12. This significant improvement in performance has been as a direct 

result of improving the ‘time to first assessment’ as described in last months Board Report. This new 

process is embedded between 9 a.m. and 5 p.m. during week days. The next action will be to 

increase the hours and extend it to weekends. Additionally action will be taken at KGH to ensure the 

processes to register and triage the patient is the same as that at Queens. This work will be 

completed by the end of August. 

Further work is required to improve the time to treatment performance. There is now a plan owned 

by the Emergency Department to deliver this. The plan involves a Rapid Assessment and Treatment 

(RAT) team who will move between three assessment areas within the Emergency Department. This 

will ensure the patient has been through the RAT process in the same area before being moved 

either to Majors or other appropriate location. At some point in the future this will include admittance 

straight to MAU. 

A pilot of a Night Flow Co-ordinator has significantly contributed to A&E’s improved performance and 

the post will become permanent. 

The performance against the new A&E quality indicators for the month of July 2011 is set out in the 

table below, last months performance is bracketed:- 

Page 9 of 11

Measure Target KGH QH 

Unplanned 

5% 6.6% (7.1%) 7.2% (6.1%) 

re-attendance – 

reattendances within 

7 days 

Left Department 

5% 2.9% (4.1%) 4.1% (5.2%) 

Without Being Seen 

Total Time in 

Department - 95th 

4hrs 4hrs (4hrs) 4hrs 

(6hrs 28 mins) 

Percentile 

Time to initial 

assessment - 95th 

15mins 2 mins (0mins) 19 mins (20 mins) 

Percentile 

Time to Treatment – 

Median 

60mins 

1 hr 10 mins 

(1hr16 mins) 

1hr 23 mins 

(1 hr 19 mins) 

The significant improvement in the 95% Type 1 access target links to the improvement this month in 

the national quality indicators above. These five measures are further subdivided into two categories 

with the Trust having met the requirement to achieve at least one measure in each category. KGH 

met three of the five standards and QH two of the five standards. The actions that have led to the 

improved Queens ‘front door’ performance detailed above will be implemented at KGH i.e. the 

recording of the RAT and triage processes. In addition, once additional consultants have been 

recruited, the RAT process at Queens will be extended to operate for a longer period. 

Ambulance handover times have improved at Queens in July to an average of 16.4 minutes (from 20 

minutes). KGH handover times remain static at circa 17 minutes and specific action is being taken to 

reduce this. 

There was one validated black breach at Queen’s in July which is a significant improvement from 

recent months. This is a direct result of the improved RAT system and patient flow. BHRUT was 

reported as having the least number of black breaches of all London acute trusts in July. The 

Ambulance Handover action plan has been submitted to and approved by the NWL Cluster and has 

been recommended by them as an example of best practice. 

Referral to Treatment 

RTT – incomplete median 

The Trust is achieving all RTT waiting time standards with exception of the median for incomplete 

pathways. Performance for this standard has slipped from 8.4 weeks to 9.4 weeks against a standard 

of 7.2 weeks. Discussions with commissioners carry on regarding the additional activity required to 

Page 10 of 11

YTD Performance – 9.4 weeks 

Target – 7.2 weeks 

ensure this median standard is met and that all specialties continue to meet the 90 and 95% admitted 

and non-admitted target. 

5. Human Resources Performance Indicators 

For 2011/12 commentaries will be provided where either the appraisal or basic life support training indicators fail to reach their monthly target. The 

Quality Care Commission (CQC) last year placed specific conditions on the Trust. These two HR indicators, as well as a number of others, were used 

by the CQC to monitor Trust performance. CQC conditions were lifted at the end of last financial year. 

MEASURE 

Appraisal Training 




The latest overall Trust appraisal rate is 72.09%. This month has seen improvements within 

individual divisions with CDT going from 72 - 74%, and Women & Children’s Division going up to 

68% from 64%. Surgery has remained consistent throughout the year with no major downturn. The 

Divisions with outstanding appraisal are being contacted through their HR advisor for plans to 

address the deficit. More staff have become eligible for appraisal this month which has accounted 

for some of the reduction in compliance. This time last year all doctors were accounted for but this 

year whilst they align to the doctor relicensing and revalidation cycle will appear in reporting as non 

compliant until the end of the year. Improving the rate remains high on the HR agenda and will be 

communicated out via the Link again during August. 

The August trial of new appraisal cards based upon the KSF core dimensions is still on track. 

1 Basic Life Support Training 



The latest resuscitation training compliance report, covering the period of 1st August 2010 - 31st 

July 2011 puts overall Trust compliance at 77.38%, a drop of 1.04% from the previous report. This 

time last year compliance for the same time period stood at 43%. There is a clear escalation 

process within the Service which alerts both individual staff members and line managers to book on 

to a training session. Awareness of the need to complete annual training is high with frequent 

communication to staff. Identification of non-compliant individuals continues and attendance 

compliance is being monitored at local and Divisional levels. 

A total of 827 Adult In-Hospital Life Support training places have been offered between January and 

July 2011, these places are in addition to the sessions offered within the Trust’s mandatory training 

and induction programmes. 

Page 11 of 11

Trust Performance Dashboard - July 2011 

QUALITY AND SAFETY 

Trust 

Cancer, Diagnostics and Therapeutics 

Medicine 

Surgical 

Womens and Children 

OPERATIONAL PERFORMANCE 



Medicine 

Surgical 


FINANCIAL PERFORMANCE 



Medicine 

Surgical 


WORKFORCE PERFORMANCE 



Medicine 

Surgical 

Womens and Children


Wgt No Indicator 

Quality and Safety 

Target 11- 

12 

Actual 

Mth 

Mnth 

Move 

YTD 

Status 

4 10 MRSA HAI 0 0 ► 3 

4 11 C Difficile HAI 81 2 ▼ 16 

4 12 MRSA Screening - Elective 100% 66.0% ▼ 71% 

4 13 MRSA Screening - Emergency 100% 83.0% ▲ 83% 

4 15 % Adult VTE Risk Assessed 90% 91.5% ▲ 81.97% 

4 95 No Diagnostic waits over 6 weeks 0 8 ▼ 134 

2 16 No of Same Sex Breaches 0 4 ▼ 99 

4 14 

Hospital Standardised Mortality 

Ratio Relative Risk (YTD)** 

100 89.9 

19 Mortality % (elective) n/a 0.17% ▲ 0.16% 

20 Mortality % (non -elective) n/a 3.65% ▼ 4.10% 

21 SUIs as % of incidents reported n/a 2.86% ▲ 2.36% 

22 Incident Rate per 100 admissions n/a 2.67% ▼ 5.44% 

4 23 

Emergency Readmissions


DoH Performance Framework To date 

Standards and Vital Signs 

User Experience (National Survey) 

Finance 

Registration 

Operational Performance 


Target 11- 

Mnth YTD 

Actual Mth 

12 

Move Status 

4 40 FFU Ratio 2.13 2.25 ▲ 2.23 

2 41 DNA First 9.70% 9.93% ▲ 10.03% 

2 42 DNA Follow-Up 10.30% 10.00% ▲ 9.93% 

4 43 LOS (Elective) 3.6 3.86 ▲ 3.75 

4 44 LOS (Non-Elective) 5.4 4.63 ▼ 4.94 

4 94 LOS (Elective- excluding 0 LOS) 4.0 4.34 ▲ 4.21 

4 96 

45 

LOS (Non- Elective-excluding 0 

LOS) 

Emerg Adm for Long Term 

Conditions 

5.8 6.29 ▼ 6.44 

46 No' of Low Value Procedures 

2 47 % Daycase rate - All 75% 87.1% ▲ 87.49% 

4 48 

% Women who have seen a 

midwife within 12 wks 

2 49 

Cervical Screening - Lab Results 

Within 2 Weeks* 

1 50 

Cervical Screening - Results 

Within 2 Weeks (GP to PCT)* 

51 

Number of FOI requests 

received 

1 52 

% FOI Requests responded to 

within 20 working days* 

90% 88.8% ▲ 78.0% 

98% 100.0% ► 100.0% 

98% 97.5% ▲ 96.2% 

318 33 ▲ 134 

100% 75.0% ▼ 83.8% 

4 60 62 Days - treated from referral 86% 95.1% ▲ 91.05% 

4 61 

2 Wk % seen all urgent refs & ref 

for breast 

4 62 

2 Wk GP RefTo 1st OP for susp 

cancer 

4 63 

2 Wk GP Ref To 1st OP for 

breast symptoms 

4 64 

31 Day 2nd Or Subs Treatment - 

Surgery 

4 65 

31 Day 2nd Or Subs Treatment - 

Drug 

93% 99.7% ▲ 100% 

93% 99.6% ▲ 100% 

93% 100.0% ► 100% 

94% 100.0% ► 100% 

98% 100.0% ► 100% 

4 66 31 Day DTT for all cancers 96% 100.0% ► 99.60% 

4 67 

62 Day RTT From Cancer 

Screening 

4 68 

62 Day RTT From Hosp 

Specialist 

4 69 

62 Days Urgent RTT of all 

cancers 

4 70 

31 Day Subs Treatment - 

Radiotherapy 

A&E 

KGH - Unplanned Re-attendance 

4 71 Rate - reattendances within 7 

days 

4 72 

4 73 

4 74 

KGH - Total Time in Department - 

95th Percentile (mins) 

KGH - Left Department Without 

Being Seen 

KGH -Time to initial assessment - 

95th Percentile (mins) 

90% 94.7% ▲ 91.23% 

85% 100.0% ▲ 92.31% 

85% 94.8% ▲ 90.92% 

94% 100.0% ► 100% 

5% 6.6% ▼ 6.90% 

240 239 ▼ 240 

5% 2.9% ▼ 3.90% 

15 2 ▲ 0 

4 75 

KGH -Time to Treatment - 

Median(mins) 

60 70 ▼ 74 

76 KGH - Ambulatory Care n/a 

77 KGH - Consultant Sign Off 

4 

4 

78 KGH - Service Experience 

QH - Unplanned Re-attendance 

Rate - reattendances within 7 

98 days 

QH -Total Time in Department - 

99 95th Percentile (mins) 

5% 7.2% ▲ 6.80% 

240 240 ▼ 417


DoH Performance Framework To date 


User Experience (National Survey) 

Finance 

Registration 

Operational Performance 


Target 11- 

Actual Mth 

12 

4 

QH - Left Department Without 

100 Being Seen 

4 

QH -Time to initial assessment - 

101 95th Percentile (mins) 

4 

QH -Time to Treatment - 

105 Median(mins) 

102 QH -Ambulatory Care n/a 

4 79 

103 QH -Consultant Sign Off 

104 QH -Service Experience 

Data quality indicators - % 

records invalid 

Mnth 

Move 

YTD 

Status 

5% 4.1% ▼ 5.40% 

15 19 ▼ 24 

60 83 ▲ 84 

5% 

Performance 

Under Review 

4 80 

Difference in number of A&E 

Attendances reported on A&E 90% -110% 0.0% ▼ 100.0% 

HES 

4 81 

Four-Hour Maximum Wait In A&E 

(types 1&2) 

95% 96.68% ▲ 92.08% 

4 91 


(types 1 - Queens) 

95% 95.10% ▲ 88.53% 

4 92 


(types 1 - KGH) 

95% 98.54% ▲ 95.94% 

4 82 RTT Admitted - 95th Percentile 23 20.9 ▼ 

4 83 

RTT Non-Admitted - 95th 

Percentile 

18.3 13.9 ▼ 

4 84 RTT Incomplete - 95th Percentile 28 23.7 ▼ 

85 

Number waiting on an incomplete 

RTT pathway 

tba 4374 ▼ 

2 86 RTT Admitted - Median 11.1 6.3 ▼ 

2 87 RTT Non-Admitted - Median 6.6 3.6 ▼ 

2 88 RTT Incomplete - Median 7.2 9.4 ▲ 

4 89 RTT admitted - 90% in 18 weeks 90% 0.9 ▲ 

4 90 

RTT non-admitted - 95% in 18 

weeks 

95% 1.0 ▼ 

Total Weighted Score 324 

Total Weight 

164 

Current performance Total 

1.98 

Performance Framework 2.57 

2.4 

2.1


DoH Performance Framework Quarter 4 


User Experience 

Finance 

Registration 


Financial Performance 

Target 11- 

12 

Actual 

Mth 

Mnth 

Move 

YTD 

Status 

4 B1 Initial Planning 3% -10.36% 

4 B2 YtoD - operating performance 3% -5.27% 

4 B3 YtoD - EBITDA 5% -1.91% 

4 B4 Forecast Op Performance 3% 10.08% 

4 B5 Forecast EBITDA 5% -0.02% 

4 B6 

Forecast change surplus/deficit 

outturn 

3% -0.10% 

4 B7 Underlying financial position % 0% -9.53% 

B8 EBITDA Margin % 5% -0.04% 

4 B9 BPPC Value% 95% 66.41% 

4 C1 BPPV Volume % 95% 42.49% 

4 C2 Current Ratio 100% 0.56 

4 C3 Debtor Days 30 19 

4 C4 Credit Days 30 61 

4 C5 Control Total 100% 127.01% 

4 C6 Performance against CIP 100% 55.92% 

4 C7 Income variance against plan 100% 102.63% 

Activity against Actual 

Performance 

4 E1 Outpatients - Activity 100.00% 97.5% ▼ 103.0% 

4 E2 Outpatients - Financial 100.00% 95.3% ▼ 101.0% 

4 E3 A&E - Activity 100.00% 119.3% ▲ 124.9% 

4 E4 A&E - Financial 100.00% 113.4% ▲ 116.9% 

4 E5 Day Cases - Activity 100.00% 123.8% ▲ 104.5% 

4 E6 Day Cases - Financial 100.00% 103.0% ▼ 135.4% 

4 E7 Inpatient - Elective Activity 100.00% 97.0% ▲ 91.5% 

4 E8 Inpatient - Elective Financial 100.00% 89.3% ▼ 89.8% 

4 E9 Inpatient - Non Elective Activity 100.00% 123.8% ▼ 121.8% 

4 F1 Inpatient - Non Elective Financial 100.00% 103.0% ▼ 114.4% 

Workforce Performance 


Target 11- Actual 

YTD 

Mnt Move 

12 Mth 

Status* 

2 A1 Staff Turnover 12% 10.00% ▲ 11.65% 

2 A2 Sickness Absence 3.60% 5.05% ▲ 4.30% 

4 A4 Appraisals (12 mth rolling) 100% 72.09% 

4 A5 

Basic Life Support Training (12 

mth rolling) 

*YTD status - annualised 

100% 77.38%


TITLE: 

Emergency Care Report on July 2011 performance 




PEQ……….…...……. 

□ STRATEGY……….….……. 

This Emergency Care report provides the following: 

• Update on performance against the Emergency 

Care standard 

• Informs the board of the current performance 

against the new emergency care standards 

• Provides an update on the work included in the 

Emergency Care Programme and actions taken 

within the last month to improve performance 

□ FINANCE ……..……… □ AUDIT ………….……..…. 

□ CLINICAL GOVERNANCE …………..………….....…… 

□ CHARITABLE FUNDS ………………………………...… 

TRUST BOARD 

□ REMUNERATION ………………………………….…... 

□ OTHER …………………………..……. (please specify) 


The Trust Board is asked to note the improved 

performance resulting from significant progress 

against the Emergency Care Programme. 

NATIONAL TARGET □ CNST 




Not applicable. 

□ CQUIN/TARGET FROM COMMISSIONERS 

CORPORATE OBJECTIVE …………………………….... 


AUTHOR: Neill Moloney, Director of Planning and 

Performance 

PRESENTER: Neill Moloney, Director of Planning and 

Performance 

DATE: 26 th August 2011 


Existing and new emergency care performance standards 



OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 

REVIEW DATE (if applicable) ___________________________

Barking and Havering University Hospitals 

NHS Trust 

Medical Division: 

Emergency Care Programme 

Trust Board Report 

on July 2011 Performance 

August 2011 

Emergency Care Trust Board Report August 2011 20110826 (2).Doc

1.0 Performance against First Attendance 

1.1 Performance in June 2011 

Against a target of 95% for Type 1 attendance (the target on which we are currently measured) 

the Trust achieved 98.54% at King George Hospital (KGH), and 95.1% at Queens Hospital (QH) 

for July 2011. This is the first time this has been achieved at both sites in a year, therefore not 

only demonstrates the effectiveness of implanting the initiatives, but also the tremendous effort 

made by the Emergency Care team . 

1.2 Activity impacting performance 

This significant improvement in performance has been as a direct result of reducing time to first 

assessment as described last month. This process is now embedded between the hours of 9 a.m. 

and 5 p.m. during week days. The next action will be to increase the hours and extend it into the 

weekend and plans are being developed to enable this to be implemented over the next 3 months 

In addition at the team will be delivering the same standard at KGH to ensure the accurate and 

timely registration and triage of the patient. This work will be completed by the end of August. 

The next step is to improve the time to treatment – target within 60 minutes. There is now a plan 

owned by the ED to deliver this which will involve a RATing team and a treatment team that will 

move between three assessment areas within the ED. This will ensure the patient is RATed 

(Rapidly assessed and treated) in the same area before being moved to Majors. 

Reduction in LoS 

There has been a reduction in the overall LoS for July in non elective from 4.95 to 4.63 days and 

a slight increase in elective LoS from 3.25 to 3.86 days. However once again a reduction in 

Medicine non elective LoS by 0.46 days (from 6.2 to 5.74 days has improved patient flow through 

the hospital.. This has enabled A&E to have the space to offload patients and enable the closure 

of Japonica ward at KGH. 

Night flow co-ordinator 

This was initially put in as a pilot and as it has significantly contributed to the improved 

performance in flow it will become a permanent role. The feedback from the reports is essential to 

the daily problem solving cycle of continued improvement. 

2.0 Performance against A&E Quality Indicators 

2.1 Performance in July 2011 

The performance against the new A&E quality indicators for the month of June *should this be 

June, July or August*2011 is set out in the table below:- 

This needs Teresa to validate 

Measure Target KGH QH 

Unplanned 

5% 6.6% (71%) 7.2% (6.1%) 

re-attendance – 

reattendances within 

7 days 

Left Department 

5% 2.9% (4.1%) 4/1% (5.2%) 

Without Being Seen 

Total Time in 

Department - 95th 

4hrs 4hrs (4hrs) 4hrs 

(6hrs 28 mins) 

Percentile 

Time to initial 15mins 2 mins (0 mins) 19 mins (20 mins) 


assessment - 95th 

Percentile 

Time to Treatment – 

Median 

60mins 

1 hr 10 mins 

(1hr16 mins) 

1hr 23 mins 

(1 hr 19 mins) 

Figures in brackets are June figures 

2.2 Delivering against the A&E Quality Indicators 

The significant improvement in the 95% Type 1 access target links to the improvement in the 

Quality Indicators. KGH is consistently green for 3 of the 5 standards and QH is now meeting 2 of 

the five standards as opposed to none previously. The actions that have improved Queens ‘front 

door’ performance will now be implemented at KGH in order to get the further gains on that site 

i.e. RATing recording and triage processes. In addition they will be rolled out at Queens for longer 

periods as previously discussed to improve further. 

The achievement against the improvement actions is monitored by a dashboard developed for the 

plan, with reports against progress from the SRO of each project, reviewed at the fortnightly 

Emergency Care Programme Board. Decisions made on next steps and/or remedial action where 

appropriate. 

The target for Quarter one for implementing these standards was to give assurance that we are 

recording and reporting data correctly. We have met this target. 

2.2 Ambulance Handover 

Ambulance handover times have improved at Queens in July to an average of 16.4 minutes. This 

is a significant improvement as previously it was consistently above 20 minutes. KGH handover 

times remain static at circa 17 minutes and specific action is being taken to reduce this which are 

to implement similar solutions as at Queens i.e. RATing and improved recording and triage 

process. 

There was 1 validated black breach at Queens in July which is a significant improvement from 

recent months when it has been 18 and above. This is a direct result of the improved RATing 

system and patient flow. BHRUT was reported as having the least number of black breaches out 

of all London acute Trusts for July, where the range was between 1 (BHRUT) and 57. 

Operationally the Trust continues to work with LAS to implement the changes agreed at the 

summit meeting on 11 th July 2011. These are all now captured in the Ambulance Handover action 

plan monitored at the Emergency Care Programme Board. This has been submitted to and 

approved by the NWL cluster who is leading on ambulance turnaround for London. It has been 

recommended by them to be used as best practice throughout London. 

3.0 Bed availability 

3.1 Discharge Jonah 

The re-launch of Discharge Jonah is now well under way as the process is becoming ‘business as 

usual’ on the wards identified in this first phase of implementation for intensive support. This will 

now roll out further with more focus at KGH as well as the remaining wards at Queens. This will 

improve the flow further and support making the improvements we have seen so far sustainable. 

3.2 Ambulatory Care 

The roll out of the Ambulatory care project is now underway and is being clinically led by Dr. Aklak 

Choudhury, supported by the BHRUT Project and Programme Management Office (PMO). 

Objectives: 

• To establish an ambulatory care service across both acute sites at BHRUT. 

• To understand and identify current ambulatory care pathways across all divisions and integrate them 

into the standardised model for ambulatory care (e.g. cellulitis. DVT) 

• To establish an ambulatory care service that works a 7 day week in day time hours across both sites 


• To develop ambulatory care pathways identified in the department of health top 50 ambulatory care 

pathways document 

• To develop a robust business case for a 30 pathway ambulatory care service 

Work completed to date includes: 

• Membership of Project team and clinical group defined 

• Ambulatory care pathway protocols developed and agreed clinically 

• LoS saving from ambulatory care analysis 

• First group of pathway protocols developed and agreed by clinicians 

• Development of further pathways underway 

• Website developed so that pathways will be published on the Intranet 

• Location established for ambulatory care unit 

• Dedicated Project Manager appointed 

Next steps 

The first group of pathways will be implemented in early August once they have been approved by the 

Evidence Based practice Committee. The second group will be rolled out by September. In the long term 

further pathways could be considered which may require additional resources and will need Community 

support. 

3.2 5 day a week ward rounds 

Dr. Deaner has now met with most medical teams to discuss their plans for taking this forward. 

There is a range of models proposed and there are some concerns that require working through. 

This programme is part of the Emergency Care Programme and now has a project manager who 

will support the actions going forward. The next steps will be to agree the most appropriate model 

for the teams, using lessons learned from other Trusts. 



TITLE: 

Maternity Update - July Monthly report 




The purpose of this briefing is to provide the Trust 

with an update on the monthly performance for 

maternity services and the progress against key 

performance indicators. 

The key areas to note are; 

• The performance for triage for July was 82%. 

This is an improvement of 19% since June. 

• The performance for the time to see an 

obstetrician in the obstetric assessment unit 

for July was 88%. This was a significant 

improvement from June’s performance which 

was 39%. 

• LSCS performance for the timeliness to 

perform emergency LSCS was 53%. The key 

reason identified related to the local guideline 

for the timing of grade 2 LSCS. 

• Activity levels within the unit were less 

variable during July and the implementation of 

the escalation policy was more robust. 

• Workforce – there was a small increase in the 

number of midwives recruited in the month of 

July with the remaining recruits clearly 

identified. 

• Other key areas highlighted in the report are 

governance, complaints, homebirths, 

supervision of midwives and training. 

Key issues identified relate to obstetric and 

anaesthetic workforce capacity. 

□ PEQ …23.8.11…………..….. □ 

STRATEGY……….….……. 

□ FINANCE ……..……… □ AUDIT ………….……..…. 



□ TRUST BOARD ……………………………….…………. 

□ REMUNERATION ………………………………….…... 



The Board are asked to note the content of the report. 

□ NATIONAL TARGET □ CNST 






AUTHOR/PRESENTER: Carol Drummond 

DATE: 24.8.11 


Continuing utilisation of bank and agency for midwifery to ensure appropriate staffing levels. 

4. DELIVERABLES


98% of women seen within 15 minutes of arrival within Triage 

98% of women seen within an hour of referral to an obstetrician within the obstetric assessment unit. 

All emergency LSCS performed within the graded time allocated. 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


2

Maternity Services Monthly Performance Report 

Trust Name 

Barking, Havering & Redbridge University 

Hospitals NHS Trust 

Reporting month July 2011 

Completed by 

Carol Drummond 

Divisional Director of Women & Children’s 

Services 

Reviewed by 

Deborah Wheeler 

Director of Nursing 

Neill Moloney 

Director of Planning & Performance 

Contact Details 

Barking, Havering & Redbridge University 

Hospitals NHS Trust 

1 st Floor Green Zone 

Maternity Services, Queens Hospital 

Rom Valley Way, Romford, RM7 0AG 

Tel: 01708 435 000 x 3894 

A monthly report will be provided to; monitor the progress made against the maternity 

services improvement plan, provide assurance that the safety and quality of maternity 

services are improving within BHRUT. It will summarise the themes and actions that have 

arisen from the weekly analysis of activity within the unit. 

Page 1 of 11

Aim 

The purpose of this report is to summarise the progress made in the month of July against the 

maternity service improvement plan and the KPIs agreed with the commissioning team within ONEL. 

Introduction 

The senior members of the maternity service, along with the executive lead, meet with ONEL on a 

fortnightly basis to review weekly performance and agree actions to address any issues identified. The 

objectives that have been agreed and incorporated in the weekly reports and the monthly scorecard 

are; 

• Escalation policy is embedded and applied daily. 

• Effective utilisation of triage, with 98% of women being seen by the midwife within 15 minutes of 

arrival in triage. 

• All high risk women seen by an obstetrician within an hour of assessment. Once a woman is referred 

to the obstetric assessment unit (OAU), she is seen by a midwife on arrival and commenced on the 

appropriate pathway. The midwife then refers, where required, the woman to an obstetrician. The 

target is that 98% of women will be seen by an obstetrician within 1 hour of the referral 

• Effective treatment and management of risk: 

• No woman in established labour will remain on the antenatal ward. 

• Weekly analgesia audits to measure the percentage of women who receive their analgesia 

within the agreed target times. 

• Weekly activity figures looking at the % of elective and emergency caesarean sections. 

• Weekly breakdown of any Serious Incidents (SIs). 

Escalations 

Activity levels continue to be monitored on a daily basis for deliveries and postnatal discharges, to 

ensure the service can meet the demand safely. The implementation of the escalation policy has been 

more robust and ensured actions taken at the amber stage have prevented the unit having to enter a 

red status. 

An average optimum daily delivery rate has been established for both units and this is based on the 

average labouring time of a woman having her first baby being 12 hours and a woman who has had a 

baby previously being 4-6 hours. Elective caesarean sections are excluded in the labour ward capacity 

modelling as they do not occupy a labour bed. 

The status of the unit continues to be recorded on CMS and the 2 hourly bed texts now incorporate 

the same. 

Below is a summary, based on the actual activity on a daily basis, the unit exceeded the average daily 

delivery figure. There were no occasions where the status of the unit was declared as red and 

maternity services for the Trust interrupted. However there were 5 occasions, which corresponded 

with peaks in demand, where it was necessary to raise the unit status to amber. The table below 

illustrates the actions that were taken and the reasons why escalation was required. The graph 

demonstrates the daily activity levels for both sites. 

July 2011 Red days Amber Days Green Days Escalations 

0 5 26 5 

Page 2 of 11

Site Date Status 

Time 

From 

Time 

To 

Diverts 

in 

Place 

KGH 24/07/2011 Amber 3.00 6.50 No n/a 

QH 26/07/2011 Amber No n/a 

QH 27/07/2011 Amber No n/a 

KGH 28/07/2011 Amber 10.00 7.00 No n/a 

KGH 29/07/2011 Amber No n/a 

Diverts 

to Reason for Escalation Mitigation 

Reduction in availablity The co-ordinator for QH was 

of beds at the KGH site. informed that women calling 

KGH for advice would be 

redirected to Queens. Moved 

delivered women at KGH to a 

2 bedded bay and ensure that 

the paediatrician support was 

available in the morning to 

commence baby discharges as 

A reduction in available 

beds to accommodate 

labouring women who 

would be requiring the 

service 

A reduction in available 

beds to accommodate 

labouring women who 

would be requiring the 

service 

Lack of bed availability 

in the unit 

Lack of bed availability 

in the unit 

early as possible 

Paediatricians and midwives 

prioritised the women to be 

discharged to enable the 

postnatal ward to ensure bed 

capacity was available. No 

inductions were made during 

this period 





capacity was available. No 

inductions were made during 

this period 

In triage, women were advised 

to go to QH if required. 





capacity was available. 

In triage, women were advised 

to go to QH if required. 





capacity was available. 

Page 3 of 11

Daily Activity (excluding elective LSCS) 

Daily Deliveries from 28/03/2011 to Present (exc. Elective 

LSCS) 

40 

Number of Deliveries 

35 

30 

25 

20 

15 

Queens 

Hospital 

Queens 

Optimum 

King George 

Hospital 

Triage 

10 

5 

0 

28/03/11 

02/04/11 

07/04/11 

12/04/11 

17/04/11 

22/04/11 

27/04/11 

02/05/11 

07/05/11 

12/05/11 

17/05/11 

22/05/11 

27/05/11 

01/06/11 

06/06/11 

Days 

11/06/11 

16/06/11 

21/06/11 

26/06/11 

01/07/11 

06/07/11 

11/07/11 

16/07/11 

21/07/11 

26/07/11 

31/07/11 

The agreed standard is that 98% of women will be seen by a midwife within 15 minutes of arrival 

at triage. 

King George 

Optimum 

The overall average waiting time for the month of July has been 82% which is an improvement of 

19% on June 2011. The degree of fluctuation has lessened towards the end of the month, 

however it is recognised there are still issues to resolve to ensure that there is a more consistent 

level of achievement as well as improvement. 

There were no adverse clinical outcomes for women as a result of not being seen within 15 

minutes. The longest recorded wait was 48 minutes. 

The table below shows the achievement against the 98% standard on a daily basis for the month 

of July. 

Page 4 of 11

% of patients Seen within 15 minutes July 2011 

120 

% of Patients 

100 

80 

60 

40 

% of patients 

Seen within 

15 minutes 

20 

0 

01/07/11 

02/07/11 

03/07/11 

04/07/11 

05/07/11 

06/07/11 

07/07/11 

08/07/11 

09/07/11 

10/07/11 

11/07/11 

12/07/11 

13/07/11 

14/07/11 

15/07/11 

16/07/11 

17/07/11 

18/07/11 

19/07/11 

20/07/11 

21/07/11 

22/07/11 

23/07/11 

24/07/11 

25/07/11 

26/07/11 

27/07/11 

28/07/11 

29/07/11 

30/07/11 

31/07/11 

Date 

Issue identified 

Methods to capture data for time the 

women are seen are currently completed 

in paper format. All staff are encouraged 

to complete relevant documentation 

correctly. 

It is therefore difficult to capture the 95 th 

centile the longest time a woman has 

waited to be seen and the reasons for 

this due to staffing resource for data 

capture. 

Action to be taken 

To ensure that the paper based system is 

simplified to ensure complete records. End 

Aug 11. 

To explore the possibility of an IT solution for 

capturing the information and implement. End 

Sept 11 

To identify a member within the performance 

team and provide them with the paper based 

information to date to calculate and present the 

95 th centile. End Aug 11. 

Ability of current physical and staffing 

capacity to maintain 15 minute standard, 

when demand outweighs this capacity. 

New matron for labour ward has commenced 

and has an immediate objective to develop a 

contingency plan for dealing with peaks in 

demand. 

Activity data to be analysed since it has been 

recorded, by times of day over the 24 hour 

period for both telephone and clinical triage 

and the results used to inform the appropriate 

staffing rota going forward. 14 th Sept 11 

OAU Activity 

It has been agreed that 98% of women should be seen within 1 hour of arrival to the Obstetric 

Assessment Unit (OAU). The processes to accurately track activity and target have been 

embedded with the teams for the OAU during the daytime hours, but during the month of July 

Page 5 of 11

further work has been required for the out of hours assessment area, which has proved more 

challenging. 

The performance for June 2011 was very varied with an overall achievement of women being seen 

within 1 hour of referral at 39% - for July this has increased to an average of 88%. There were no 

adverse clinical outcomes for women as a result of waiting for longer than an hour. The longest 

wait to be seen by an obstetrician was 2 ½ hours. The main reason for delays, highlighted by the 

dips in performance on the graph below, was related to the out of hours obstetric capacity being 

able to respond to the demand, whilst prioritising the higher risk labouring women. A complete 

review of capacity incorporating workforce is being undertaken and will be presented to TEC in 

September with recommendations. 

No of Patients 

120 

100 

80 

60 

40 

20 

0 

% of patients requiring Obs input seen within 1 hr of Referral July 

2011 

01/07/11 

03/07/11 

05/07/11 

07/07/11 

09/07/11 

11/07/11 

13/07/11 

15/07/11 

17/07/11 

19/07/11 

Day 

21/07/11 

23/07/11 

25/07/11 

27/07/11 

29/07/11 

31/07/11 

% of patients 

requiring Obs 

input seen 

within 1 hr of 

referral 

Not all women who attend the OAU, will require referral to the obstetric team. Over 50% of women 

will be dealt with by the midwives in the unit and discharged home accordingly. 

Out of all the women seen in OAU during July, 92% were discharged home, with the remainder 

being admitted for either further antenatal care or labour care. 

Page 6 of 11

OAU Patient Destination Outcomes July 2011 

2% 6% Patient Outcome 

Home 

Patient Outcome 

Antenatal Ward 

Patient Outcome 

Labour Ward 

92% 


Methods to capture data for time the 

women are seen are currently completed 

in paper format. All staff are encouraged 

to complete relevant documentation 

correctly. 

It is therefore difficult to capture the 95 th 

centile the longest time a woman has 

waited to be seen and the reasons for 

this due to staffing resource for data 

capture. 


To ensure that the paper based system is 

simplified to ensure complete records. End 

Aug 11. 

To explore the possibility of an IT solution for 

capturing the information and implement. End 

Sept 11 

To identify a member within the performance 

team and provide them with the paper based 

information to date to calculate and present the 

95 th centile. End Aug 11. 

Recording waiting times in OAU 

overnight poor. 

Reinforce the data requirements with staff in 

the unit and ensure method is simplified, to 

support accurate recording. 

New matron for labour ward, tasked with 

reviewing and agreeing the staff 

Page 7 of 11

Effective treatment and management of risk 

Systems are in place to ensure women do not give birth outside of the labour ward environment. 

There were no inappropriate deliveries outside of the labour ward for the month of July. 

Analgesia audit. 

On a weekly basis, as part of visible leadership, an audit is undertaken to monitor the amount of 

time women are having to wait for their analgesia. The agreed standard is: 

• If a woman requests pethidine she should receive this within 15 minutes of the request. 

• If a woman request an epidural she should receive this within 30 minutes of request. 

During the month of July on average 88.75% of women received pethidine within 15 minutes of 

request, with the remainder receiving it within 30 minutes. 69% of women received their epidural 

within 30 minutes. Most of the delays were due to the fact that the anaesthetists were busy with 

another case in obstetric theatres. 

Caesarean Deliveries including elective activity 

Emergency Caesarean Sections 

When a decision is made to perform an emergency LSCS, the timing for this is dictated by the 

acuity of each case which is graded from 1-4. 

Grade 1 

Caesarean section is considered as urgent and has an immediate threat to the life of the woman 

and foetus. To be performed within 30 minutes. 

Grade 2 

Caesarean section is considered urgent with maternal or foetal compromise which is not 

immediately life threatening. To be performed within 30 minutes 

Grade 3 

Caesarean section is an emergency with no maternal or foetal compromise, but requires early 

delivery. To be performed within 75 minutes. 

Grade 4 

Caesarean section is classified as an elective caesarean at a time to suit the parents and the 

maternity teams. 

Queens Hospital 

Out of 125 Emergency LSCS which were performed at Queens Hospital, a total of 62 sets of notes 

were audited by the consultant body. It is recognised that this is only 50% 0f the total cases and 

due to the time constraints of reporting compounded by a retrospective method of audit, notes 

were not always available within the timeframe required. This matter has been rectified going 

forward to ensure that the audit is more robust. 

Grade 1 

Out of the 19 Grade 1 Emergency LSCS 84% met the target time of delivery within 30 minutes 

Grade 2 

Out of the 37 Grade 2 Emergency LSCS 24% met the target time of delivery within 30 minutes 

Grade 3 

Out of the 6 Grade 3 Emergency LSCS audited 50% met the target time of delivery within 75 

minutes. 

Page 8 of 11

King Georges Hospital 

There were 10 emergency LSCS at KGH, all of which were audited. 

Grade 1 

Out of the 2 Grade 1 Emergency LSCS 100% hit the target time of delivery within 30 minutes 

Grade 2 

Out of the 5 Grade 2 Emergency LSCS 100% hit the target time of delivery within 30 minutes 

Grade 3 

Out of the 3 Grade 3 Emergency LSCS audited 100% hit the target time of delivery within 75 

minutes. 

Top 3 reasons for delays 

1. Anaesthetist cover 

2. Theatre capacity 

3. Delayed consent (by mother) 


As this information was only tracked from 

13 th June 2011 it is difficult to make a 

comparison between June and July’s 

emergency LSCS rates. 

Auditing processes for Emergency LSCS 

were not fully developed so some notes 

were unable to be checked against the 

target times 

The Emergency LSCS time from decision 

to delivery for Grade 2 was not achieving 

target due to Grade 1’s taking priority. 

Delays due to lack of anaesthetic cover 

for Labour ward at Queens. 

Delays due to lack of theatre capacity. 

This has been formally raised as a 

concern by the LSA officer for London. 


As all information is now tracked on a weekly 

basis, this information collated for July 2011 

will be compared with August 2011 

Audit processes have now been fully 

developed and from 1 st August 2011 for the 

next monthly report, full details for all notes 

regarding Emergency LSCS will be audited and 

reported upon 

After discussions with the consultant body, 

reclassification of the Grade 2 was agreed with 

review of the NICE and RCOG guidelines. 

This has come into effect from 1 st August 2011 

so an improvement on the achievement of 

Grade 2 targets will become apparent. The 

new time is 60 minutes. 

Plan developed in partnership with anaesthetic 

department. 3 options developed and being 

presented to TEC on the 23.8.11 to agree way. 

There are clear resource implications with the 

preferred option. 

To develop a plan to move elective LSCS into 

main theatre. Plan to be developed by end of 

Sept 11. This will release obstetric theatre 

capacity to be utilised for emergency LSCS. 

Page 9 of 11

Balanced Scorecard. 

The balanced scorecard is attached for July. 

Attendance at meetings has improved overall. Terms of reference are being updated to reflect 

changes to roles and responsibilities, to ensure appropriateness of attendance. 

Work continues with the review and updating of guidelines. Recent external reviews into maternal 

deaths have also informed this process. It is expected that this work will be completed by the 

middle of September. 

There were 10 SUIs during July which is a significant increase. This included a maternal death, 

which will be investigated by an external team to ensure objectivity. A review of the Governance 

processes within maternity has been undertaken by the governance lead at NHSL and the 

recommendations will be taken forward. There is a clear plan in place to complete outstanding SUI 

reports and this is being led by the Associate Head of Midwifery for Governance and Quality. 

Complaints remain static. A review of complaints for April and May has been undertaken to identify 

themes and issues. The main area identified refers to attitude and communication. An external 

company has been engaged to support the department develop a bespoke programme to address 

this as well as leadership. The first stage is a scoping exercise within the unit, incorporating 

observation in the clinical areas and discussion with teams. 

Homebirths saw a slight increase for the month of July. A plan is in place and work has 

commenced on developing a homebirth team, with the expectation that this will be in place by the 

end of the year. 

The ability of the team to perform emergency caesarean sections within the graded time during 

July was on average 53%, when combining all the grades. The particular issue related to Grade 2 

LSCS. This has been discussed at the labour ward forum and in line with the RCOG and NICE 

guidance. The timescale for this has been changed to 75 minutes as opposed to 30 minutes. As 

highlighted above there are times when the anaesthetist is busy and this will delay the LSCS from 

starting. 

There continues to be a difficulty in recruiting Supervisors of Midwives to secure the 1 supervisor 

to 15 midwives ratio. Currently this stands at 1:24. The original intention was to achieve the ratio of 

1:15 by the beginning of October. Clearly this will not happen and the Contact Supervisor is 

arranging to meet with the Local Supervisory Authority Officer to agree on what further actions 

need to be taken. 

The mandatory training programme for maternity has been revised and the new format will 

commence on the 6 th September and will be multidisciplinary. 

Monthly workforce report 

The table below provides an update on the workforce for July. There remain 40 recruits in the 

recruitment process with start dates up to December. However the majority of these will be during 

October and November. 

There are currently adverts out for HDU clinical lead and Maternity Support workers. The decision 

is not to recruit to the Nurses vacancy until September to allow the current nurses to be orientated 

and settle in. Interviews have been held for the HDU band 7 post and an appointment has now 

been made. 

There have been 4 leavers this month 3 of which were Belgium midwives the reasons given for 

leaving following their exit interviews are: 

Page 10 of 11

• Further training 

• Training to be a sonographer 

• Acquired a midwifery job in Belgium 

The other midwife was from the teenage pregnancy department and she did not like doing the on 

calls 

Date 2011 May June July 

Midwives 

Nurses 

Funded 325.99 325.99 325.99 

In post 255.51 268.80 272.8 

Vacancy 70.48 57.19 53.19 

% 

vacancy 21.60% 17.50% 16.3% 

Leavers 0 4 

Funded 28.64 28.64 28.64 

In post 12.46 17.86 17.86 

Vacancy 16.18 10.78 10.78 

% 

vacancy 56.50% 37.6% 37.6% 

Leavers 2 

Nursery Nurses 

Maternity Support 

Workers 

Funded 13.41 13.41 13.41 

In post 12.61 12.61 11.61 

Vacancy 0.8 0.8 1.8 

% 

vacancy 5% 5% 13% 

Leavers 0 0 1 

Funded 80.95 80.95 80.95 

In post 75.03 72.13 73.1 

Vacancy 5.92 8.82 7.82 

% 

vacancy 7% 10% 9.60% 

Leavers 

Midwife to birth ratio- in post 1:38 1:35 1:35 

Exit interviews 0 3 4 

New starters 28 8 

Page 11 of 11

Barking, Havering and Redbridge University Hospitals NHS Trust 

MSLC Meeting MDT Attendance 

Maternity Risk management meeting MDT Attendance 

Serious Incident group - MDT Attendance 

Organisation 

Labour Ward Forum - MDT Attendance 

Number of guidelines over due for review 

Moderate Untoward Incidents 

SUIs 

Improved patient satisfaction 

Complaints 

On Target 

Target 

Of 

Concern 

Q4 10/11 Q1 11/12 Q2 11/12 

Q3 11/12 

Q4 11/12 

Action 

Required 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 

80% 

79.99% - 

50.01% 50% 60% Not held 50% Not held Not held 80% Not held 

79.99% 

80% 50.01% 50% 55.30% 20% 18% 18% 21% 80% 80% 

80% 

79.99% - 

50.01% 50% 55-66% 66% 81% 42% 66% 

80% 

79.99% - 

50.01% 50% 70% 70% 50% 50% 50% 80% 

5 10 41 41 41 41 41 28 23 

4 1 2 2 2 2 1 0 

0 1 2 4 1 2 +1 3 3 3 10 

NR NR NR 

6/mnth 17 + 3 pals 8+2 Pals 17 14 14 17 16 

Births Benchmarked to 9800 for 10/11 

817 818 - 899 900 813 762 821 777 830 840 843 

Activity 

Births in acute Queens LW setting target for Q3 11/12 

Births taking place at KGH 

Midwife led births - 

Homebirths 

No: of women booked - in total ( WXH) 

No: of women booked before 12 weeks and 6 days 

No: in utero transfers 

No: ex utero transfers 

% of normal births 

%instrumental vaginal births 

Total % C section (planned and unplanned) 

Emergecny LSC undertaken within graded time 

% of Spontaneous Vaginal delivery with episiotomy 

% of women who receive pharmocological pain releif within 30 minutes 

% Induction of labour 

% of women seen within 1 hour for a medical opinion in obstetric assessment 

unit. 

% of women seen within 15 minutes of arrival within triage 

Implementation of escalation process 

800 

667 623 684 647 695 664 676 

250 129 123 133 116 135 154 167 

TBC TBC TBC NR NR NR 

3% 2%- 2.9%

TITLE: 



Infection Prevention and Control annual report 

2010-2011 

Trust Board 7 September 2011 


This report covers the period 1 st April 2010 - 

March 31 st 2011. The IPCT had a significantly 

busier year with more requests for support, 

advice, and locally delivered training as well as 

requests for performance reports. With the 

more robust approach to root cause analysis of 

MRSA bacteraemias and Clostridium difficile 

deaths, and the ward based ward outbreak 

management training, there was significantly 

improved staff awareness and reporting of 

potential outbreaks of infection. 

The Trust achieved the annual Clostridium 

difficile improvement objectives. There were 111 

cases against a maximum target of 128. The 

Trust exceeded the annual target for MRSA 

bacteraemias which was 14 cases against a 

target of 11. Two patients had 5 bacteraemias 

reported between them, of which one was 

removed after appeal to the Department of 

Health. 

The continuing implementation of Saving Lives 

formed the basis of the infection control annual 

plan and half way through the year became the 

format for the Infection Control Committee 

agenda. Further work is required to achieve 

robust information to monitor delivery of the 

plan, but in conjunction with the visible 

leadership programme significant improvements 

have been made to clinical practice. The key 

risks during this period were exceeding the 

MRSA trajectory and multiresistant organism 

outbreaks in critical care units. 

MRSA screening for patients admitted as an 

emergency was implemented from December 

13 th 2010 which is provided through a laboratory 

based process, not point of care. 

Compliance with the High Impact Interventions 

(HII’s) has been a key topic on the infection 

control committee agenda to ensure there is a 

systematic approach across the Trust. Some 

HII’s are covered on the visible leadership 

programme carried out by senior nurses weekly. 

Data collection of other HII’s is being reviewed 

by divisions and IPCT. 

□ PEQ ……………..….. □ STRATEGY……….….……. 

□ FINANCE ……..……… □ AUDIT ………….……..…. 



□ TRUST BOARD ……………………………….…………. 

□ REMUNERATION ………………………………….…... 

x□ OTHER …Infection Prevention & Control Committee 

19.7.11 ………………………..……. (please specify)

There were 28 outbreaks of infection of 

diarrhoea and vomiting with Norovirus 

confirmed in 7 wards; total of 1092 bed days 

were lost. Previous year’s bed days lost during 

the same period were 1192. 9 wards were 

investigated for possible infection concerns, but 

not closed. In addition there were outbreaks of 

Multi Drug Resistant Acinetobacter (MDRAB) in 

ITU at KGH and multiresistant coliforms and 

MRSA in NICU at QH 

During the winter period there was a surge of 

patients with flu-like symptoms; of the 256 

admitted, 97 were positive to H1N1. 5 patients 

died during December 2010 and January 2011; 

two had influenza stated as the cause of death 

in part 1a of the death certificate, one had it 

stated in part 1b, and it was not a cause of 

death for the remaining two. All five patients 

had other underlying medical conditions. 

Training in infection prevention & control 

included passport study days, link nurse 

programme, general staff induction, and 

registered nurse and support workers induction. 

Audits undertaken include environmental, 

personal protective equipment audits and 

isolation audits 

Since August 2010, two additional antimicrobial 

pharmacists have joined the Trust to make an 

equivalent 2WTE. Significant improvements in 

antibiotic prescribing and management have 

been made with the pharmacists in post. 

They undertook a point prevalence study, 

antimicrobial stewardship, self-assessment of 

omitted and delayed doses of antimicrobials and 

an audit of gentamicin usage. The antibiotic 

policy was also reviewed and updated and a 

new Trust Antimicrobial Management Code will 

be launched on 1 st June 2011. 


Board members are asked to note the report, 

which will be published on the Trust’s website. 

A number of improvements have been made in 

practice during the year, which have formed the 

foundation for further work in 2011/12. 

x□ NATIONAL TARGET □ CNST 

x□ CQC REGISTRATION □ HEALTH & SAFETY 





AUTHOR: Sheila O’Mahony, Infection Control Matron 

PRESENTER: Deborah Wheeler, Director of 

Nursing/DIPC 

DATE: 25.8.11 

2



Achievement of national objectives for reduction in MRSA bacteraemia and C. difficle infections 

Achievement of CQUIN targets for reduction of catheter associated bacteraemia 


Targets as described above 

Number of bed days lost through ward closures for infection control reasons 

These are all reported in the Trust performance dashboard 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


Director of Infection Prevention and Control 

Annual Report 

April 2010 – March 2011 

Authors: 

Sheila O’Mahony 

Matron Infection Prevention & Control 

Dr Lindsey Bain 

Infection Control Doctor/Consultant Microbiologist

CONTENTS 

1.0 EXECUTIVE SUMMARY ………………………………………………………………………. 

2.0 BACKGROUND INFECTION PREVENTION AND CONTROL ARRANGEMENTS ….... 

2.1 Infection Prevention and Control Team structure…….………………………………. 

2.2 Budget allocation for infection prevention and control staffing ……………………… 

2.3 Infection Control Committee ……………………………………………………………. 

2.4 Infection Prevention and Control Annual Action Plan ……………………………… 

2.5 Reporting Line to the Trust Board 

2.6 Training/Education delivered by the Infection Prevention and Control Team …….. 

2.7 IPCT Training and Development ………………………………………………………. 

3.0 HEALTH CARE ASSOCIATED INFECTION RATES & OTHER IPC SURVEILLANCE 

3.1 Results of Mandatory HCAI Reporting ……………………....................................... 

3.1.1 MRSA Bacteraemia ……………………………………………………………. 

3.1.2 Clostridium difficile …………………………………………………………….. 

3.1.3 GRE Bacteraemia ………………………..……….......................................... 

3.1.4 Orthopaedic Surgical Site Infections …………………………………………. 

3.2 Trends in HCAI Statistics ……………………………………………………………….. 

3.2.1 Urinary associated bacteraemia ……………………………………………… 

6.3 Outbreaks, including Serious Untoward Incidents ………….. ………………………. 

6.3.1 Outbreaks of Norovirus (or presumed Norovirus) infection leading to 

closure of wards ………………………………………………………………… 

6.3.2 Multi-resistant Acinetobacter baumannii in Critical Care…………………… 

6.3.3 MRSA in Neonatal Units ………………………………………………………. 

6.3.4 Multi Drug Resistant Tuberculosis (MDRTB) ……………………………… 

7.0 HAND HYGIENE ………………………………………………………………………. 

8.0 DECONTAMINATION ………………………………………………………………… 

8.1 Arrangements …………………………………………………………………………….. 

8.1.1 Decontamination Committee Activities 

8.1.2 Review of the decontamination priorities for 2010/11………………. 

9.0 CLEANING SERVICES …………………………………………………………………. 

9.1 Management Arrangements Queen’s Hospital ………………………………………. 

9.1.1 Monitoring Arrangements ……………………………………… 

9.2 Management Arrangements KGH ……………………………………………… 

9.2.1 Monitoring Arrangements ………………………………………………… 

9.3 Patient Environment Action Team Audits (PEAT) Results 2010 …………. 

10.0 AUDITS …………………………………………………………………………… 

10.1 Extent of Audit Programme …………………………………………………….. 

Page 

2

10.2 Visible Leadership – improving the quality of nursing care using a 

continuous audit cycle …………………………………………………………… 

10.2.1 Process …………………………………………………………………… 

10.2.2 Results …………………………………………………………………… 

10.3 Audit Report from Antimicrobial Pharmacist ………………………………….. 

10.3.1 Antimicrobial audits completed ………………………………………… 

10.3.2 Key Actions Completed ………………………………………………… 

10.4 Antimicrobial Stewardship Self Assessment …………………………………. 

10.4.1 Training Conducted ……………………………………………………… 

10.4.2 Antimicrobial Guidelines and Policies 

10.4.3 Guidelines under Review ………………………………………………. 

10.4.4 Clostridium difficile Ward Round 

……………………………………………………… 

10.4.5 Action Plan for 2011/2012 …………………………………………….. 

11.0 CONCLUSIONS …………………………………………………………………. 

12.0 REFERENCES …………………………………………………………………… 

APPENDICES 

Appendix 1 

Infection Prevention & Control Team organisational chart 

……………………………………………………. 

Appendix 2 IPC Annual Trust Action Plan 2010-2011 

Appendix 3 IPC Annual Trust Action Plan 2011-2012 

3

1.0 Executive Summary 

This report covers the period 1 st April 2010 - March 31 st 2011. The IPCT had a significantly 

busier year with more requests for support, advice, locally delivered training as well as 

requests for performance reports. With the more robust approach to root cause analysis of 

MRSA bacteraemias and Clostridium difficile deaths and the ward based ward outbreak 

management training there was significantly improved staff awareness and reporting of 

potential outbreaks of infection. 

The Trust achieved the annual Clostridium difficile improvement objectives. There were 111 

cases against a target of 128. The Trust exceeded the annual target for MRSA bacteraemias 

which was 14 cases against a target of 11. Two patients had 5 bacteraemias reported 

between them, of which one was removed after appeal to the Department of Health. 

The continuing implementation of Saving Lives formed the basis of the infection control 

annual plan and half way through the year became the format for the Infection Control 

Committee agenda. Further work is required to achieve robust information to monitor against 

but in conjunction with the visible leadership programme significant improvements have been 

made to clinical practice. The key risks during this period were exceeding the MRSA 

trajectory and multiresistant organism outbreaks in critical care units. 

MRSA screening for patients admitted as an emergency was implemented from December 

13 th 2010 which is provided through a laboratory based process, not point of care. 

Compliance with the High Impact Interventions (HII’s) has been a key topic on the infection 

control committee agenda to ensure there is a systematic approach across the Trust. Some 

HII’s are covered on the visible leadership programme carried out by senior nurses weekly. 

Data collection of other HII’s is being reviewed by divisions and IPCT. 

There were 28 outbreaks of infection of diarrhoea and vomiting with Norovirus confirmed in 7 

wards; total of1092 bed days were lost. Previous year’s bed days lost during the same period 

were 1192. 9 wards were investigated for possible infection concerns, but not closed. In 

addition there were outbreaks of Multi Drug Resistant Acinetobacter (MDRAB) in ITU at KGH 

and multiresistant coliforms and MRSA in NICU at QH 

During the winter period there was a surge of patients with flu-like symptoms; of the 256 

admitted, 97 were positive to H1N1. 5 patients died during December 2010 and January 

2011; two had influenza stated as the cause of death in part 1a of the death certificate, one 

had it stated in part 1b, and it was not a cause of death for the remaining two. All five 

patients had other underlying medical conditions. 

Training in infection prevention & control included passport study days, link nurse 

programme, general staff induction, and registered nurse and support workers induction. 

Audits undertaken include environmental, personal protective equipment audits and isolation 

audits 

Since August 2010, two additional antimicrobial pharmacists have joined the Trust to make 

an equivalent 2WTE. Significant improvements in antibiotic prescribing and management 

have been made with the pharmacists in post. 

They undertook a point prevalence study, antimicrobial stewardship, self-assessment of 

omitted and delayed doses of antimicrobials and an audit of gentamicin usage. The antibiotic 

4

policy was also reviewed and updated and a new Trust Antimicrobial Management Code will 

be launched on 1 st June 2011. 

2.0 Background including infection Prevention & Control arrangements 

The work of the infection prevention & control department supports the Trust in minimising 

the risk of healthcare acquired infection to patients in accordance with and taking into 

account the duties of the Hygiene Code, NHS Litigation Authority (NHSLA) and the Care 

Quality Commission’s Core standards. The Trust complies with the requirements of 

Regulation 12 with regard to the code of practice for health and adult social care on the 

prevention of infection and related guidance. 

2.1 Infection Prevention & Control Team structure (IPCT) 

The Director of Infection Prevention & Control (DIPC) is the Director of Nursing, Deborah 

Wheeler. The DIPC is accountable to the Chief Executive and is responsible for the strategy, 

policy development and implementation and performance relating to all aspects of infection 

prevention and control. Appendix 1 shows the team structure 

The Infection Control Doctor (ICD) is Dr Lindsey Bain, who met with the IPCT fortnightly to 

review infection control issues and review any new guidance or policy changes. Dr Bain is 

allocated 4 professional activities (PAs) for infection control per week 

The infection prevention & control team operate during normal working hours, and consist of: 

1 wte band 8b Matron, 

2 wte band 7 senior infection prevention and control nurses (SIPCN’s) 

1 wte band 7 practice facilitator, 

2 wte band 6 infection prevention & control nurses (IPCN’s) 

1.67 wte band 4 administrative support. 

1 wte band 7 post had been vacant for a period of time and was difficult to recruit to, however 

it was filled in September 2010. The post holder commenced maternity leave in March 2011 

and is expected to return in March 2012 

1 wte vacant band 6 post was removed as an efficiency saving in April 2010. This and the 

band 7 maternity leave had an impact on workload and planning proactive work due to 

operational demands. 

2.2 Budget allocation for infection prevention and control staffing 

Staff Group 

Amount 

Nursing £ 308,966 

Administrative support £ 46,773 

Total £355,739 

The IPCT does not have a dedicated budget for consumables or other overheads required to 

deliver infection prevention and control training to staff. 

The Infection prevention and control service delivery is supported by many other staff and 

departments, but specifically by consultant microbiologists, antibiotic pharmacists, facilities 

dept, occupational health team and clinical matrons. The core infection prevention & control 

service is advisory and educational whilst maintaining programmes of audit, surveillance and 

management of outbreaks, both seasonal and unexpected. 

5

2.3 Infection Control Committee 

The Trust Infection Control Committee (ICC) met every 2 months and was chaired by the 

Director of Nursing in her role as DIPC. The membership and terms of reference were 

reviewed during the year, and senior representatives from each division are expected to 

attend or send a deputy. The format of the ICC changed half way through the year so the 

agenda could be reflect the infection control annual plan and therefore ensuring compliance 

with the Saving Lives High Impact Programme and compliance with the Health Act. All 

MRSA and Clostridium.difficile RCA’s are signed off by the DIPC and are presented as a 

summary action plan at each Infection Control Committee (ICC) 

Infection control policies were reviewed and updated as necessary. A root cause analysis 

policy was developed and implemented. The IPCT did training in wards that had 

bacteraemias using the National Patient Safety Agency (NPSA) tool. During the year more 

learning from RCA’s has occurred and there will be a further review of the policy and process 

in summer 2011 

2.4 Infection Prevention and Control (IPCT) Annual Action Plan 

The 2010-2011 annual plan focussed on achieving MRSA and Clostridium difficile targets, 

implementing the emergency MRSA screening, Saving Lives high impact interventions and 

compliance with the Health & Social Care Act and requirements of the Care Quality 

Commission. The year end updated plan is attached at Appendix 2 

The annual plan for 2011-2012 is attached at Appendix 3. Its implementation is monitored by 

the Infection Control Committee and reported to the Quality & Safety Committee, which is a 

committee of the Trust Board 

2.5 Training/Education delivered by the IPCT 

The IPCT maintained the monthly infection prevention & control passport study day for 9 

months of the year; 451 staff attended in this year. The infection prevention and control link 

nurses met quarterly and have an annual study day planned for late 2011. The latest link 

nurse programme included training to enable them to undertake the passport assessments in 

their own areas. 

The IPCT also contribute to the following training sessions: 

• General induction twice a month 

• RGN induction 2 weekly 

• Healthcare Assistant induction monthly 

• Junior doctor Induction twice a year 

• IV cannulation and venepuncture monthly 

• Trust mandatory training sessions weekly 

• Contracted services as required 

• Principles & Practices at London South Bank University twice a year totalling 30 hours 

of teaching 

• Ward based training as requested or deemed necessary, particularly after outbreaks 

of infection 

• Student nurse passport. For the year 2010-2011 this was only directed at 3 rd students 

but for year 2011-2012 it will include first and second year students. This will be 

monthly 

6

2.7 IPCT training and development 

The IPCT Matron attended the Trust Matrons’ development programme which ran for 12 

days over six months. Further development will be progressed through action learning sets 

facilitated by the Director of Education. The senior nurse for the IPCT attended the national 

Infection Prevention Society annual conference in September 2010 and presented a poster 

on intravenous cannula care bundles which BHR had introduced in the previous 2 years. The 

team’s practice facilitator is in her third year of a master’s degree. 

3.0 HCAI RATES AND OTHER IPC SURVEILLANCE 

3.1 Mandatory HCAI Reporting 

3.1.1 MRSA Bacteraemia 

Occurrences of MRSA bacteraemia are displayed in the graph below. 

For 2010/11 the target given to the Trust applied only to ‘hospital acquired’ cases (diagnosed 

more than 48 hours after admission). The target set was to reduce our rate to the median of 

all trusts’ rates the previous year. This was not more than 11 cases. We actually saw 15 

‘cases’, one of which was removed on appeal as one patient suffered ongoing infection 

despite all appropriate medical and surgical treatment. 

Although we did not achieve the target set, we did see a 25% reduction in cases compared 

with 2009/10. 

During 2010/11 the process of root cause analysis of each case was devolved to the 

divisions, who report outcomes and actions to the ICC. On review of the individual cases, 9 

were judged to have been potentially preventable: 3 post-operative infections, 3 venous 

catheter associated infections, 1 hospital acquired pneumonia, 1 infected pressure ulcer and 

1 contaminated blood culture. 

No. of new cases 

16 

14 

12 

10 

8 

6 

4 

2 

0 

MRSA Bacteraemias 2010/11 diagnosed >48 hours 

since admission 

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

Med 

Clin supp 

Cummulative total 

Surg 

W&C 

Target 

7

The graph below shows how BHRUT compares with other hospitals locally and nationally. 

For several years our improvement correlated with national figures, but has fallen off in the 

last 2 years. One obvious difference between BHRUT and other trusts is that we were late to 

implement screening of emergency admissions. Screening of emergency patients according 

to DoH guidance commenced in December 2010. This is monitored by monthly audit of 

wards. Compliance for February and March was 73% and 83% respectively. 

16.0 

14.0 

Trust-apportioned MRSA bacteraemia rate, with Trust-apportioned 

national & regional rate 


London 

rate per 10,000 bed days 

12.0 

10.0 

8.0 

6.0 

4.0 

England 

2.0 

0.0 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

Jan - Mar 

Apr - Jun 

Jul - Sep 

Oct - Dec 

2006 2007 2008 2009 2010 2011 2012 

Barking, Havering & Redbridge Hospitals NHS Trust 

3.1.2 Clostridium difficile 

Cases of this infection are shown in the graph below. The target applied only to those cases 

which occurred more than 48 hours after admission. 

As can be seen, BHRUT was within the target of 128, ending the year with 111 cases. 

However this was a disappointing result as we had 37% more cases than in 2009/10. The 

graph shows that there was a steady increase in cases from Spring onwards. Investigation 

of cases showed several small ward outbreaks, suggesting cross-infection was occurring. 

Enhanced cleaning introduced in August did not improve the situation. During the latter half 

of October, we introduced immediate individual patient review against a set of standards 

produced from our existing policy. This was undertaken within 24 hours of finding a case and 

the results fed back to ward staff and senior managers. It became apparent that there was 

failure in several areas, especially in immediate isolation of cases. Since this process was 

introduced, the number of cases has fallen back to previous rates and we will continue the 

immediate review process in 2011/12 

8

No. of new cases 

140 

120 

100 

80 

60 

40 

20 

0 

Clostridium difficile 2010/11 diagnosed >48 hours after 

admission 


Med 

Clin supp 

Cummulative total 

Surg 

W&C 

Target 

3.1.3 GRE Bacteraemia 

There were 6 cases this year, a considerable increase in cases compared with the previous 

two years. One patient had two episodes of infection, but otherwise there was no obvious 

connection between other cases. If this infection continues to rise in incidence, a systematic 

review will be undertaken. 

GRE Bacteraemia at BHRUH from October 2003 to March 


No. of cases 

8 

7 

6 

5 

4 

3 

2 

1 

0 

Oct-Dec 03 

Apr-Jun 04 

Oct-Dec 04 

Apr-Jun 05 

Oct-Dec 05 

Apr-Jun 06 

Oct-Dec 06 

Apr-Jun 07 

Oct-Dec 07 

Apr-Jun 08 

Oct-Dec 08 

Apr-Jun 09 

Oct-Dec 09 

Apr-Jun 10 

Oct-Dec 10 

KGH 

OCH/HWH/QH 

Total 

9

3.1.4 Orthopaedic Surgical Site Infections 

The surgical division are responsible for collection of the data and have been reporting the 

repair of neck of femur for the 3 periods tabled below which shows April 2010 – December 

2010. The data is uploaded to the Health Protection Agency web site by the Trauma Coordinator. 

There are still operational difficulties in collecting the information. 

Year 

and 

Period 

No. 

Operations 

Patient 

Questionnaire 

No. % 

given complete 

Surgical Site Infection 

Inpatient & Post discharge 

Readmission confirmed Patient reported All SSI* 

No. % No. % No. % No. % 

2010 Q2 

121 

0 0.0 

1 0.8 0 0.0 0 0.0 1 0.8 

2010 Q3 

127 

0 0.0 

1 0.8 0 0.0 0 0.0 1 0.8 

2010 Q4 

102 

0 0.0 

5 4.9 1 1.0 0 0.0 6 5.9 

*All SSI = Inpatient & readmission, post discharge confirmed and patient reported 

6.2 Trends in Health Care Associated Infection Statistics 

6.2.1 Urinary catheter associated bacteraemia 

As a result of audit in 2009/10, identifying this as an important cause of hospital acquired 

infection, the following initiatives were implemented 

• Introduction of standardised catheter packs 

• Ward based training for nursing staff to support packs 

• Guardian wards nominated for female catheter storage 

• Approval to appoint 2 continence nurse advisors 

• Catheterisation training for FY1 and FY2 junior doctors and part of direct observational 

practice (DOP) 

The two continence nurse advisors were not appointed as the trust failed to find suitable 

applicants. Urinary catheterisation has been added to the visible leadership audit 

programme 

During 2009/10 we managed to achieve a 20% reduction in cases, and set the same target 

for 2010/11. However we only managed to reduce cases by 10% as is shown in the graph 

below. 

10

60 

Urinary Catheter Associated bacteraemia 

April 2010 to March 2011 

50 

No. of cases 

40 

30 

20 

10 

0 


Med Clin Supp Surg 

W&C Target Cumm 

6.3 Outbreaks and incidents 

6.3.1 Outbreaks of Norovirus (or presumed Norovirus) infection leading to closure of 

wards 

Norovirus outbreaks occurred later in the year compared with previous years. The total 

number of wards affected was less than in 2009/10 which correlates with experience 

elsewhere in the region. 

12 

BHRUHT Wards closed due to outbreaks of diarrhoea 

including Norovirus November 2006 - March 2012 

10 

No. of wards closed 

8 

6 

4 

2 

0 

Nov-06 

Feb-07 

May-07 

Aug-07 

Nov-07 

Feb-08 

May-08 

Aug-08 

Nov-08 

Feb-09 

May-09 

Aug-09 

Nov-09 

Feb-10 

May-10 

Aug-10 

Nov-10 

Feb-11 

May-11 

Aug-11 

Nov-11 

Feb-12 

Wards closed due presumed Norovirus KGH 

Wards closed due presumed Norovirus Queen's 

11

Queen’s 

King George 

Wards closed: 

Wards closed: 

Medical wards x 8 Surgical wards x 8 Medical wards x 8 Surgical wards x 2 

Clinical Support Wards x 2 

Bed days lost*: 602 


Norovirus confirmed: 2/18 wards. Norovirus confirmed 2/10 wards 

Remainder: Cause unconfirmed but Remainder: Cause unconfirmed but 

compatible with Norovirus infection. compatible with Norovirus infection 

Wards investigated but not closed: Wards investigated but not closed: 

Medical wards x 5 Surgical wards x 1 Medical ward x 1 



Norovirus confirmed: 2/6 wards 

Norovirus confirmed: 0/3 Wards 

* Bed days lost = sum of empty beds on each day of ward closure. 

6.3.2 Multi-resistant Acinetobacter baumannii in Critical Care 

In September 2010 in KGH ITU a total of 8 patients were identified with Multi Drug Resistant 

Acinetobacter baumannii (MRDAB) whilst inpatients on ITU; 3 patients died and 5 patients 

were subsequently discharged home. Specimens were sent for typing and 3 out 6 had type 

OXA-23, suggestive of cross infection. This was reported as a serious incident. Outbreak 

meetings were held weekly until the unit was free from new cases for one month. 

6.3.3 MRSA in Neonatal Units 

Between February 2011 and April 2011 14 babies were colonised with MRSA or 

multiresistant coliforms in Queens Hospital NICU. No babies were infected. Outbreak 

meetings were held weekly and maximum infection control measures were implemented until 

no new cases were reported for 1 month. 

In both of the above outbreaks, similar issues regarding staffing levels and increased activity 

were noted as factors leading to reduced compliance with infection control practice. 

Both incidents were reported as serious incidents. 

6.3.4 Multi Drug Resistant Tuberculosis (MDRTB) 

In October 2010, a patient of no fixed abode with a substance dependency was admitted to 

Queens Hospital under the Public Health Act Section 2A for treatment of Multi Drug Resistant 

Tuberculosis. The admission required a negative pressure isolation room and, although this 

patient had previously been seen at KGH, this facility was not available there. 

The patient came directly to MAU at Queens Hospital, and was transferred to Ocean B ward 

for continuous negative pressure room isolation nursing until discharge in December 2010. 

The admission did raise operational issues about managing such patients in BHRUT. A 

multidisciplinary meeting is scheduled for June 2011 to discuss these issues and agree a 

protocol for admission and discharge for future MDRTB patients. 

7.0 HAND HYGIENE 

Hand hygiene continues to be a top priority in the Trust; training included hand hygiene 

awareness weeks which were held in May 2010 and in January 2011. This involved 

awareness stands in busy public parts of the hospital to encourage visitors, patients and staff 

12

passing to discuss and practice hand hygiene with the ultraviolet light box that highlights 

areas of the hands that are missed when using a training hand gel that glows under the light. 

Ecolab, who provide the Trust with the alcohol hand gel, installed holders at the end of the 

beds throughout the Trust. The product was also changed to a virucidal product at no extra 

cost. Hand hygiene compliance is monitored during visible leadership audits and following 

any outbreak of infection. The patient satisfaction survey tabled below highlights only a 

minor improvement in hand hygiene observed with nurses and a drop in compliance with 

doctors. 

No Question 2009 2010 Trend 

Q.26 Patient saw posters or leaflets asking patients or 

visitors to wash their hands or to use hand gels. 

90% 91% 

Q.34 Doctors always washed or cleaned their hands between 39% 36% 

touching patients. 

 

Q.39 Nurses always washed or cleaned their hands between 44% 45% 

touching patients. 

 

However, the visible leadership programme audit results demonstrate that nurses’ scores 

have improved slightly from 91.75 to 92.01% and the overall observed staff compliance 

score has moved from 82.65% to 88.52%. 

8.0 DECONTAMINATION 

. 

8.1 Arrangements 

The DIPC is the executive lead for decontamination. The Matron of IPCT investigates and 

escalates any operational issues. The Sterile Services Department (SSD) is fully accredited 

outsourced service and is overseen by a hard facilities contracts manager in BHRT, who 

manages any non compliances 

8.1.1 Decontamination Committee Activities 

The action plan, based on a Trust wide audit of decontamination services undertaken by an 

external independent decontamination consultant during 2009, has been progressed 

throughout the year at the Medical Devices & Decontamination group. A further review of 

decontamination services including SSD is planned for 2011-2012. 

8.1.2 Review of the Decontamination Priorities for 2010/11 

The priority for 2010/11 was to progress the decontamination audit report which is underway 

and continually reviewed at the medical devices and decontamination committee. 

9.0 CLEANING SERVICES 

9.1 Management Arrangements Queens Hospital 

• Queens hospital is a 939 bed PFI hospital. The hospital building is operated by a 

private sector partner (Catalyst Healthcare Management) who manage the Facilities 

Management Company, Sodexo. 

• Sodexo are responsible for providing the cleaning, 24hrs a day with work schedules 

for each ward/department. Queens is currently cleaned to National Standards of 

Cleanliness 2002 (NSC), however the NSC 2007 will be introduced gradually during 

the months of June and July. 

• A regular Operations Meeting is held monthly between the Trust, Sodexo and 

Catalyst; the format of these meetings is to discuss and resolve any operational issues 

13

during that period. Any issues that cannot be resolved at this meeting are escalated to 

the PFI Board meeting which again is held monthly, and the membership includes 

senior management from the Trust, Sodexo and Catalyst. 

• Catalyst issue a monthly report to the Trust to coincide with the PFI Board which 

incorporates the Key Performance Indicators, along with the cleaning scores achieved 

for the month. 

9.1.1 Monitoring Arrangements 

• Weekly walk around (environmental audit), which includes Soft and Hard Facilities 

Manager for the Trust, Sodexo Domestic Manager, Sodexo Estates Manager & 

representation from Catalyst 

• The format for the walk around is to visit a specific area, and monitor the whole 

environment 

• Matrons’ audit Includes Soft Facilities Manager for the Trust, Sodexo Manager and 

Trust Matrons, including the IPCT Matron . The format for the audit is to visit a specific 

area, with the relevant matron, and use the NSC audit tool (49 point audit tool) 

• Cleaning Audits: Sodexo Domestic Supervisors undertake audits using the NSC audit 

tool, inline with the frequencies for audit. 

9.2 Management arrangements KGH 

The Trust awarded a Total Facilities Contract to Sodexo in August 2009 for a period of 5 

years. There is a Contracts Manager to monitor the service provision. 

• Monthly TFM Operational meetings are held with Sodexo Management Team and 

the Trust TFM Management team whereby any operational issues are dealt with. . 

• The Domestic KPI report gives cleaning checklist scores for the month. 

• A TFM User Group meeting is also held monthly which comprises of Department 

Leads for Sodexo, the Trust Contracts Managers, Infection Control and a Matron/s 

to discuss the day to day issues on the wards and departments and any changes in 

procedures etc. 

• A quarterly review meeting is held between Senior Management of the Trust and 

Sodexo where issues have been escalated from the Operational meetings. 

9.2.1 Monitoring Arrangements 

• Domestic Service - Monitoring of the domestic service provision is carried out using 

the National Standards of Cleanliness 49 point audit tool. The contract requirement 

states that the cleaning of the hospital must be carried out to 2007 standards and 

frequencies. 

• Monthly combined audits are carried out with Deputy Director of Nursing, Infection 

Control and Soft Services Manager, 

• Matrons Audits are held bi-weekly with and Infection Control and Nursing audit biweekly. 

• The Soft Services Manager monitors Sodexo cleaning audits ward areas weekly. 

14

9.3 Patient Environment Actions Team Audits (PEAT) Results 2010 

PEAT audits are undertaken yearly, an internal inspection is planned for both sites in June 

The PEAT result for cleaning in 2010-2011 was good. 

Food Privacy & Dignity 

Environment Score 

Site Name 

Score 

King George Hospitals Good Excellent Good 

Queens Hospital Good Excellent Good 

10.0 AUDIT 

10.1 Audit Programme 

The IPCT undertake audits on an annual basis and as required due to an outbreak, incident 

or untoward event. 

The audits and results are as follows:- 

Audit 

No. of Wards/ 

departments audited 

Environment 

Isolation 

Personal Protective 

Equipment (PPE) 


50 wards/ 

departments 

43 wards/ 

departments 

59 wards/ 

departments 

Results 

% Range 

. 


No. of Wards/ 

departments 

audits 

2009-2010 

Results 

% Range 

2009-2010 

89-100 54 wards/ 70-100 

departments 

83-100 38 wards/ 73-100 

departments 

89-100 - - 

10.2 Visible leadership – improving the quality of nursing care using a continuous 

audit cycle. 

Last year’s annual report stated that the visible leadership programme was to be introduced 

across the Trust. It commenced in February 2010. 

• The intention behind visible leadership is for all the senior nursing team to spend the 

day on the wards every Monday. A rolling 13 week audit programme has now been 

consolidated for visible leadership, which include the following topics related 

specifically to Infection Prevention & Control. The IPCT join the senior team for these 

audits. 

• Observation of hand hygiene compliance is reviewed across all disciplines in every 

clinical setting 

• Intravenous Cannulae are audited by incidence of IV cannulae across the Trust and 

documentation of care 

• Urinary catheters are audited by incidence of patients with in dwelling catheters across 

the Trust including assessment of necessity for catheterisation 

15

Hand hygiene is audited every 6 weeks. These audits also enable BHRUT to report data, 

about catheters to the SHA monthly and track progress. The High Impact Actions for Nursing 

and Midwifery introduced in 2009 have been implemented, which include preventing infection 

to achieve a reduction in catheter acquired urinary tract infections. (CAUTI’s) 

10.2.1 Process 

On the timetabled days each clinical area is assessed by two staff members and the data 

collected and analysed on the day. A third of the patients in every relevant clinical area are 

audited. This enables immediate feedback to be given to the nurse in charge who creates an 

action plan which needs to be achieved before the audit is repeated. The matron has to 

confirm that the objectives and actions undertaken are SMART. The Divisional Nurse 

director is responsible for signing off the action plans once completed. 

10.2.2 Results 

These are presented on a dashboard which is sent fortnightly to ward teams, matrons and 

senior nursing team and is RAG rated. Areas score green with 100% compliance, amber if 

above 90%,red if 89% or below, and pink if below 50%. A sample of the results are below 

Improvement in urethral catheter 

Trend 

care June Sept Dec 

Trust Average 50.7% 58.69% 71.58% ↑ 

Improvement in Intravenous 

Trend 

cannula care Oct March May 

Trust Average 54.8 56.96 72.67 ↑ 

10.3 Audit Report from Antimicrobial Management 

Previously, the trust employed an antimicrobial pharmacist for three days each week 

(0.6wte). Since August 2010, two antimicrobial pharmacists have joined the trust to make an 

equivalent 2WTE. Since then, the following key areas of work have been developed by the 

antimicrobial pharmacists: 

10.3.1 Antimicrobial audits completed 

a) Point prevalence study 

A Trust wide largest point prevalence study was carried out in October 2010. This was a 

snapshot of antimicrobial use across the trust over a period of 3 days. 

Results 

• 649 patient charts assessed across 29 of the 43 wards across BHR hospitals. 

• Of the 649 patients seen, 224 patients were prescribed a total of 378 antimicrobials. 

• Documentation of allergy status was excellent (99.5%). 

• Documentation of nature of allergy was poor. 

• Documentation of indication was poor, 7% on drug chart and 60% in medical notes. 

• Documentation of duration/course length was also poor, 32% on the drug chart and 

14% in the medical notes. 

• Auto stop policy- 2 out of 378 antimicrobial prescription had antimicrobial sticker to 

alert doctor to review IV to oral and review duration of treatment. 

16

• Of the 52 restricted antibiotics prescribed, 66.1% included documentation in the 

medical notes or on drug chart indicating ‘Consultant microbiologist’s approval’. 

The Safe Medicines Practice Group, Infection Control Committee and the Drugs and 

Therapeutic Committee ratified the recommendations made based on the audit results. 

10.3.2 Key actions completed 

• The audit has been presented to the above groups, at the QH Grand round, KGH 

medical audit meeting and to all the pharmacists 

• A new Trust Antimicrobial Management Code will be launched on 1 st June 2011. The 

aim of this code is to promote the prudent use of antimicrobials by compliance with the 

key performance indicators. These indicators include documentation of indication, 

duration/review date/stop date on drug charts and medical notes; the code also aims 

to promote awareness of IV to oral switch. 

• There are now two designated drug administration sections for antimicrobials on the 

new drug chart. New drug chart to be implemented in May 2011. 

• Training sessions on antimicrobial stewardship have been initiated for pharmacists, 

medical students and prescribers 

• The referral system for inappropriate antimicrobial prescribing to antimicrobial 

pharmacist has been revised. 

b) Gentamicin 

An audit of 19 patients on gentamicin showed that none of the patients were given a 

gentamicin dose in accordance with the nomogram. Lower doses were given because of 

fear of toxicity and there were difficulties in interpreting the levels and using the nomogram 

as time dose given and time level taken not indicated. 

A new adult gentamicin dosing and monitoring guidelines will be implemented in April 

2011. This will be re-audited in July 2011 

c) Omitted and delayed doses of antimicrobials 

The Rapid Responses Report NPSA 2010 reducing harm from omitted and delayed 

medicines in hospitals stated that anti-invectives (antibacterial and anti-fungals) had the 

highest incidence reports including deaths of omitted and delayed doses. 

A point prevalence audit was carried out to determine the frequency and reasons for delayed 

and omitted antibacterial doses on omitted and delayed doses on antibacterials within the 

trust (including all routes of administrations). All wards (43) on both hospital sites were 

audited. All antibacterial prescriptions that required administration in the preceding 24 hours 

were included. Each care area (Medicine and Surgery) were audited separately. 

• 822 drug charts were assessed of which 353 patients were prescribed antibacterials 

(42.9%). 

• Of the patients prescribed, antibacterials 95 patients (26.9%) had omitted antibacterial 

dose(s) during the total course of their treatment and of these 50 patients (52.6%) had 

75 omitted doses within the preceding 24 hours 

• The audit highlighted that documentation of omitted doses of antibacterials was 

inadequate, 44% (33/75) of the doses omitted were not documented on the drug chart 

(i.e administration record box was left blank). Therefore it was not possible to 

determine the reasons for these omissions, particularly as there was was no 

information recorded on the drug chart or in patients’ notes and when nursing/medical 

staff were questioned they did not know. 

17

• Of the total amount of doses omitted in 24 hours: 

o 25.3 % (19/75) were due to unavailability of the administration route this 

included displacement of the cannula so IV doses of antibacterial could not be 

administered and NBM patients. 

o 14.6% (11/75) were due to refusal by the patient. 

Recommendations: 

• The audit results will be to presented to nursing directorate – senior nurses and all 

nurses 

• The importance of using the correct codes on the drug chart when a dose is not 

administered will be highlighted to nursing staff. Leaving administration sections of the 

drug chart blank is unacceptable. It is also important for nurses to document further 

explanation for omitted doses in the nursing notes 

10.4 Antimicrobial Stewardship Self Assessment 

Antimicrobial stewardship is included in the Health & Social Care Act 2008. Antimicrobial 

stewardship self-assessment tool is a strong recommendation by the DOH. The aim of the 

tool is to assess the Trust against evidenced based recommendations to ensure adequate 

antimicrobial stewardship and subsequently add to the Trust’s strategy for reducing HCAI’s. 

The antimicrobial stewardship self-assessment tool was completed by the antimicrobial 

pharmacists, consultant microbiologists, chief and deputy chief pharmacists. The responses 

were collated and the Trust’s scores from the toolkit were assessed. The following key 

recommendations were made: 

• A formal antimicrobial stewardship committee/group, which reports to the Drugs & 

Therapeutics Committee and informs the Trust’s Infection Control Committee, is 

required. 

• Clinical Governance- A written audit strategy and programme is required. 

• A written strategy for education and training is required. 

• Antimicrobial stewardship core training is required in addition to the induction 

programme and completion of an antimicrobial stewardship competency assessment 

by all prescribers. 

The results were presented to Drugs and Therapeutics Committee and ICC. The 

recommendations were ratified by both committees, and the Trust’s Chief Executive at the 

ICC meeting. 

10.4.1 Training conducted 

Antimicrobial stewardship training for new nurses as part of the Infection Control Passport - 

November 2010, February 2011 and March 2011. 

Antimicrobial teaching to medical students in October 2010, December 2010 and January 

2011. 

Antimicrobial stewardship training - ST1 & ST2 in February 2011. 

The point prevalence audit results were presented at the medical audit meeting at KGH in 

January 2011, Grand round (QH) in March 2011 and Pharmacists in February 2011 at KGH 

and QH. 

10.4.2 Antimicrobial guidelines and policies 

A new antimicrobial guideline development and implementation process is now in place. 

18

The following guidelines have been updated and approved by the Drugs and Therapeutic 

Committee: 

• Skin and Soft Tissue Infections 

• Gentamicin Guidelines 

• The Antimicrobial Management Code 

10.4.3 Guidelines under review 

• Gastro-Intestinal Infections 

• Lower Respiratory Tract Infections 

• Adult pocket Antimicrobial Guide 

• Urinary Tract Infections 

• Obstetrics and Gynaecology 

10.4.4 Clostridium difficile Ward Round 

The Antimicrobial Pharmacist conducted a pilot Clostridium difficile ward round with the 

Consultant Microbiologist for a period of two months. A formal independent review of 

Clostridium difficile patients by the antimicrobial pharmacist at Queen’s will be launched in 

May 2011. From June 2011, this will be launched at KGH. 

10.4.5 Action plan for 2011/2012 

• Launch Antimicrobial Management Code. 

• PPS Audit in July 2011 and repeated in October 2011. 

• Gentamicin Audit July 2011. 

• Set up formal Antimicrobial Stewardship Committee. 

• Write an antimicrobial audit strategy for Clinical Governance. 

• Prepare an Education and Training Strategy on antimicrobial stewardship. 

• Prepare an E-Learning module for FY1s on Antimicrobials. 

• Set up antimicrobial stewardship core training and competency assessment for all 

prescribers excluding consultations who will have their antimicrobial stewardship 

training as part of their mandatory yearly updates. 

• Set up a mandatory training for all nurses. 

• Continue Antimicrobial Stewardship training for Pharmacists. 

• Launch pocket size cards on antimicrobial for common infections. 

• Update and review antimicrobial guidelines. 

11.0 CONCLUSIONS 

It has been a challenging year for the Trust, who marginally missed out on achieving the 

MRSA target but did achieve the Clostridium difficile target. The visible leadership 

programme has been successful in engaging clinical staff and raising the expectations and 

standards in infection prevention and control practices. Overall it was a successful year. 

The priorities for 2011-2012 are to progress with the annual plan, ensuring a more robust 

process for root cause analysis training and wider implementation through out the Trust. 

12. 0 REFERENCES 

• Winning ways (DH 2003), 

• • Towards Cleaner Hospitals and lower rates of infection (DH 2004) 

• • A matron’s charter: an action plan for cleaner hospitals (DH 2004), 

• • Revised guidance on contracting for cleaning (DH 2004), 

• • Saving Lives: A delivery program to reduce healthcare associated infection (HCAI) 

including MRSA (DH 2005). 

• • Going further faster: implementing the Saving Lives delivery program (DH 2006) 

19

• • The Health Act 2006 Code of Practice for the Prevention and Control of Health Care 

Associated Infections (DH 2006) 

• • The national specifications for cleanliness in the NHS: a framework for setting and 

measuring performance outcomes. (NPSA 2007) 

• • Essential steps to safe clean care (DH 2007) 

• • Clean, safe care: reducing infections and saving lives (DH 2008) 

• • Board to ward how to embed a culture of HCAI prevention in acute trusts (DH 2008) 

• • Clostridium difficile infection: How to deal with the problem (HPA& DH 2009) 

20

APPENDIX 1 

Infection Prevention & Control Staff Chart 

Deborah Wheeler 

Director of Infection Prevention & Control 

& Director of Nursing 

Dr Lindsey Bain 

Infection Control Doctor 

Portia Omo-Bare 

Chief Pharmacist 

General Manager IC 

Sheila O’Mahony 

Matron, Infection Prevention & 

Control 

Lorraine Mulpeter 

Administrative Co-ordinator 

Sheree Black 

Administrative Co-ordinator 

Corinne Cameron-Watson 

Kate Martin 

Senior Infection Control Nurses 

Mercia Williams 

IC Practice Facilitator 

Tracey Morton 

Infection Control Nurse 

Lucy Ellis 

Infection Control Nurse 

Infection Prevention & Control Team May 2011 

21

Appendix 2 

Annual Trust Plan 2010-2011 to Prevent and Reduce Health Care Acquired Infections Updated March 


*Leads are responsible for action and supported by the infection prevention & control team as required 

Aim Actions Required Lead Review 

Date 

Progress/Comments 

22

Clinical Factors 

1.Investigation of MRSA 

Bacteraemia and C diff 

outbreaks 

To ensure that RCAs are 

undertaken for all MRSA 

Bacteraemia and c.diff. 

outbreaks, and that they follow a 

robust process and lessons are 

identified, shared and learned 

• Root Cause Analysis to be 

undertaken for all MRSA 

bacteraemia and C.diff outbreaks 

• Improvements identified from RCAs 

to be taken forward and monitored 

via action plans 

• RCA investigation tool to be 

reviewed and adapted to ensure it 

is robust and user friendly 

• Work with PCTs to develop a joint 

pathway for carrying out and 

learning lessons from pre-48 hours 

cases 

DIPC/IPCT/DND’s 

Complete 

Feb 2011 

• RCA summaries reported at 

executive team. PEQ ICC and 

Trust Board. Clinical risk 

committee 

• RCA tool adapted based on NPSA 

guidelines 

• Joint forums with both local PCTs 

set up to agree and implement 

streamlined processes for 

investigations Awaiting date 

• Hold RCA workshops to ensure all 

key staff are skilled in the process 

April 2011 

ongoing 

through 2011- 

2012 

Local ward training commenced 

December 2010 

Root Cause Analysis Policy (RCA) to be 

approved at November ICC 

Post 16/11/10 ICC amendments 

made and Chair’s approval given for 

policy to be uploaded onto intranet 

and policy implemented 

2. Hand Hygiene 

All staff working in clinical areas to 

meet a minimum of 95% 

compliance against standard 

• Deliver hand hygiene training for 

all staff on an annual basis 

• Carry out ongoing monthly audits 

to monitor compliance 

• Feedback and report on compliance 

DND’s/Matrons/Infec 

tion control team 

Complete 

Complete • Training sessions rolled out trustwide 

• Monthly audits undertaken by 

senior nursing team as part of 

Visible Leadership Initiative. 

23

y ward and speciality 

• Hold ward managers and 

consultants to account for non 

compliance 

• Continue promoting “Clean your 

hands” campaign for 2011 

• Results of audits shared at 

executive and local level, and 

reported to ICC 

• Developing reports for Trust 

Board, and local level showing 

corporate, divisional, ward 

performance as appropriate 

• Review poster placements and 

update where necessary 

Hand Hygiene Plan for 2011/12 to be 

approved at ICC May 31 st 2011 

3. Appropriate use of 

Personal Protective 

Equipment (PPE) 

4. Adherence to Saving Lives 

High Impact Interventions 

4.1 Central Venous Line 

Management HII1 

• Ensure all elements of PPE are 

available in clinical areas and use 

according to standard infection 

control policy guidance (SICP) 

• Audit to be undertaken as part of 

Annual Audit Plan 

Divisional Nurses 

DND’s for all 

Saving Lives 

items 

Complete 

All CV lines to be inserted and 

managed in accordance with Saving 

Lives Care Bundle Guidance 

• Carry out weekly audits to monitor 

compliance with all relevant Saving 

Lives Care Bundles 

• Feedback findings to ward teams 

ITU clinical lead 

Matrons, ward 

sisters 

January 2011 

Ongoing 

In 2011-2012 

plan 

• Weekly audits to be undertaken 

by critical care staff and results 

fed back to Infection Control 

Committee quarterly 

• Await updated CVC Policy 

4.2 Care of Intravenous 

Lines HII2 

24

All peripheral lines to be inserted 

and managed in accordance with 

Saving Lives Care Bundle Guidance 

• Hold ward managers and senior 

consultants to account for noncompliance 

• Performance management of 

persistently non-compliant staff 

• Ward level audits to be carried 

out as part of Visible Leadership 

Programme 

4.3 Prevention of Surgical Site 

Infections HII4 

All surgical sites to be cared for 

using aseptic technique in 

accordance with 


Trust to participate in the Health 

Protection Agency’s Surgical Site 

Infection Surveillance 

Scheme(SISS) 

• Agreed trust will report on 

orthopaedic repair of neck of femur 

Surgical DND 

ongoing in 

2011-2012 

plan 

• Recommend Orthopaedic division 

present paper re-compliance to 

Infection Control Committee 

• The Trauma Co-Ordinator is 

currently responsible for 

collecting SSIS data. A review of 

this system should be carried out 

before the next module 

commences 

Awaiting further review by Surgical 

Division 

4.4 Ventilation and 

Tracheostomies HII5 

All ventilated and tracheostomy 

patients to be managed in 

accordance with the Saving 


• ITU’s participate in the ICNARC 

surveillance scheme 

ITU Clinical 

Lead/Critical care 

Matrons 

ongoing in 


plan 

• To be discussed with IPCT rereporting 

mechanisms. Report 

awaited from Clinical Lead, ITU 

4.5 Urinary Catheter Care 

HII6 

25

All urinary catheters to be inserted 



• Implement urinary catheter care 

bundle HII6 

Continence Group 

Complete 

• Catheter policy to be 

approved at Nursing & 

Midwifery Board June 2011 

4.6 Clostridium difficile 


Antibiotics to be prescribed in 

accordance with national and 

local policies to minimise the 

use of broad spectrum 

microbials 

Prescribing practice to meet a 

minimum of 90% compliance with 

policy 

• Agree local policies for specific 

clinical areas, e.g. oncology 

• Provide ongoing training for junior 

Drs 

• Carry out ongoing 6 monthly audits 

to monitor compliance with Policy 

• Ward Pharmacists to check and 

challenge prescribing practice 

Consultant 

Microbiologist 

antibiotic lead/ 

Antibiotic pharmacist 

Complete and 

ongoing in 


plan 

Underway with antimicrobial 

pharmacists 

Prevent C. diff spread by adherence 

to care bundle guidance at all times 

5. Screening (Saving Lives – 

A strategy for NHS Trusts: a 

summary of best practice) 

Ensure 100% of elective patients to 

be screened for MRSA 

• Extend Trust Screening Protocol to 

include select elective patients 

• Ensure positive results are 

communicated and acted upon 

• To monitor screening rates with 

feedback to relevant areas 

Divisional manager 

for CSS 

Complete 

• All recurrent day attendees eg. 

Oncology/Haematology screened 

on first attendance and 3 

monthly thereafter. 

• Screening data held with IPCT. 

Implement emergency screening in 

priority phases 

• Business case in progress 

GM IPCT/Clinical 

26

directors 

Complete 

Implemented 13/12/2010 

6. Death associated with 

HCAIs • All patient deaths associated with 

HCAIs should be checked to ensure 

that the HCAI is accurately 

recorded as a cause of death or 

contributory factor 

• Sample of death certificates to be 

audited 

Medical Director 

Complete 

To be continued in 2011-2012 

7. Environmental issues 

Review all signage 

Floor signs 

Talking Kones 

Review of tools to support hand 

hygiene message and management of 

outbreaks of infections 

C. Cameron - 

Watson 

Complete 

1. All floor signs, Talking Kones and 

Banners have been checked by 

IPCT in preparation of the Winter 

season. 

External Banner 

Instillation of Sanipost hand 

Further implementation in 2011 

hygiene stations (both sites) 

Review of existing facilities 

Installation of additional alcohol 

dispensers at bed side 

Jan 2011 

C. Cameron – 

Watson 

March 2011 

Complete 

Review of in situ soap & alcohol 

dispensers 

Ecolab company 

27

Key: 

W 

G 

A 

R 

Not yet started 

Complete 

In progress, on track 

Overdue 

28

Draft Annual Trust Action Plan to Prevent and Reduce Health Care Acquired Infections 


Appendix 3 

*Leads are responsible for action and supported by the infection prevention & control team as required 

Aim Actions Required Lead Review 

Date 

Progress 

29

Clinical factors 

1. Reduction in number of MRSA 

Bacteraemias and staying within 

target of 8 bacteraemias 

• Agreed target of 8 bacteraemias 

for whole year 1.4.11 -31.3.12 

DIPC/IPCT/DND’s 

ICD 

31.3.12 

• Cases and RCA summaries 

reported at each committee 

meeting 

RCA investigation of each MRSA 

Bacteraemia 

• Monitor each bacteraemia 

undertake RCA and report to ICC 

• Improvements identified from 

RCAs to be taken forward and 

monitored via action plans 

DND to designate 

lead 

31.3.12 

3 cases so far since April 1 st 2011 

• RCA investigation tool and policy 

is to be updated and adapted to 

ensure it is robust and to be 

approved at ICC 

Lesley Marsh 


• All RCA’s to be signed off by 

DIPC added to RCA summary 

action plan and presented to ICC 

2. To monitor incidence of 

Meticillin Sensitive 

Staphylococcus Aureus 

Monitoring of compliance monthly 

and report to ICC 

ICD to send compliance scores to 

divisional directors 

• Monitor each infection and 

complete RCA report to ICC 

when signed off by DIPC 

Improvements identified from RCAs 

to be taken forward and monitored 

via action plans 

ICPT 

31.3.12 

***progress with results to be 

available at ICC 

IPCT/ Matrons 31.03.12 RCA’s being undertaken since April 

1 st 2011 

30

3. To monitor E. coli bacteraemias All E coli bacteraemias to be 

manually recorded then inputted on 

the Health Protection Agency MESS 

data base 

Infection control 

doctor 

IPCT 

31.3.12 Start reporting June 1 st 2011 

4. Hand Hygiene 

All staff working in clinical areas to 

meet a minimum of 90% compliance 

against standard 

• Deliver hand hygiene training for 

all staff on an annual basis as per 

separate hand hygiene training 

plan 

• Carry out ongoing monthly audits 

to monitor compliance 

• Feedback and report on 

compliance by ward and 

speciality 

DND’s/Matrons/Infec 

tion control team 

31.3.12 

. 

• Training sessions rolled out 

trust-wide 

• Monthly audits undertaken by 

senior nursing team as part of 

Visible Leadership Initiative. 

• Results of audits shared at 

executive and local level, and 

reported to ICC 

• performance as appropriate 

• Review poster placements and 

update where necessary 

Hand Hygiene Plan for 2011/12 to be 

approved at ICC 31/05/2011 

Complete 

5. Adherence to Saving Lives High 

Impact Interventions 

DND’s for all 

Saving Lives items 

5.1 Central Venous Line 


All CVC lines to be inserted and 

managed in accordance with Saving 


Report to ICC twice annually as per 

agreed timetable. 

• Carry out weekly audits to 

monitor compliance with all 

relevant Saving Lives Care 

Bundles 

• Feedback findings to ward teams 

ITU clinical lead 

Matrons, ward 

sisters 

31.03.12 • Weekly audits to be undertaken 

by critical care staff and results 

fed back to Infection Control 

Committee quarterly 

• Await updated CVC Policy ( 

5.2 Care of Intravenous Lines HII2 

All peripheral lines to be inserted and 

31

managed in accordance with 



agreed timetable to be agreed with 

DND’s as part of visible leadership 

• Ward level audits to be carried 

out as part of Visible Leadership 

Programme 

5.3 Prevention of Surgical Site 

Infections HII4 

All surgical sites to be cared for using 

aseptic technique in accordance with 


Trust to participate in the Health 

Protection Agency’s Surgical Site 

Infection Surveillance 

Scheme(SISS)currently reporting 

fractured neck of femurs 

• Ward managers and senior 

consultants to account for noncompliance 

• Performance management of 

persistently non-compliant staff 



Need more robust reporting with 

clinicians engagement 

• 

Surgical DND 

31.03.12 

• Recommend Orthopaedic 

division present paper recompliance 

to Infection Control 

Committee 

• The Trauma Co-Ordinator is 

currently responsible for 

collecting SSIS data. A review 

of this system should be carried 

out before the next module 

commences 

Awaiting further review by Surgical 

Division 

5.4 Ventilation and Tracheostomies 

HII5 

All ventilated and tracheostomy 

patients to be managed in 

accordance with the Saving Lives 

Care Bundle Guidance 



ITU Clinical 

Lead/Critical care 

Matrons 

31.03.12 

• To be discussed with IPCT rereporting 

mechanisms. Report 

awaited from Clinical Lead, ITU 

• ITU’s participate in the ICNARC 

surveillance scheme 

Complete 

As per CQUIN action plan 

32

5.5 Urinary Catheter Care HII6 

All urinary catheters to be inserted 





Continence Group 

o 

Continence Nurses not 

appointed (under review) 

Review method of promoting 

catheter care 

5.6 Clostridium difficile 


To meet annual target of 81 cases of 

C diff infections 

• Agreed target of 81 infections for 

whole year 1.4.11 -31.3.12 

• Monitor each infection, complete 

an exception report and 

undertake RCA if death occurred 

and is stated on part 1a of death 

certificate 

. and report to ICC 

• Improvements identified from 

RCAs to be taken forward and 

monitored via action plans 

DND’s ICD 

31/03/12 

• Prescribing training sessions 

introduced for ED, Surgery and 

FY1/2 Drs 

Antibiotics to be prescribed in 

accordance with national and local 

policies to minimise the use of broad 

spectrum microbials 

Prescribing practice to meet a 

minimum of 90% compliance with 

policy 

Prevent C. diff spread by adherence 

to care bundle guidance at all times 

• Agree local policies for specific 

clinical areas, 

• Provide ongoing training for 

junior Drs 

• Carry out ongoing 6 monthly 

audits to monitor compliance with 

Policy 

• Ward Pharmacists to check and 

challenge prescribing practice 

Consultant 

Microbiologist 

antibiotic lead/ 

Antibiotic pharmacist 

Complete and 

ongoing as 

per antibiotic 

plan 

6. Screening (Saving Lives – A 

strategy for NHS Trusts: a 

33

summary of best practice) 

Ensure all patients are screened for 

MRSA 

• Monitor Trust Screening Protocol 

to include all patients 

• Ensure positive results are 

communicated and acted upon 

• To monitor screening rates with 

feedback to relevant areas 

IPCT 

31-.03.12 

7. Death associated with HCAI’s 

• All patient deaths associated with 

HCAI’s should be checked to 

ensure that the HCAI is 

accurately recorded as a cause 

of death or contributory factor 


31.03.12 

8. Antibiotic action plan 2011-2012 

See separate plan 

Undertake review of junior doctors 

training for death certification 

Manisha Mdhani 

Dr Diane Oshiru 

31.03.12 

9. Environmental issues 

supporting hand hygiene and 

management of wards closed due 

to outbreaks of infection 

Review all signage 

Review ward posters rolling over 

from the clean your hands campaign 

or the 5 moments campaign 

Replace old posters 

IPCT 

31.03.12 

Floor signs 

Assess current state of floor signs 

and liaise with Sodexo to remove 

tatty stained signs 

Review possibility and costs of 

replacement of signs 

IPCT 

34

Talking Kones 

Establish which Kones are still 

functional 

IPCT 

External Banner 

Installation of Sanipost hand hygiene 

Stations (both sites) 

Check condition of external clean 

your hands banner 

Remove if tatty or soiled beyond 

reasonable repair 

Review costs of replacement if 

banner not suitable 

IPCT 

IPCT/Trust Contract 

Manager Soft FM 

Estates & Facilities 

Key: 

W 

G 

A 

R 

Updated May 2011 Sheila O’ Mahony Matron IPCT Lindsey Bain ICD Portia Omo- Bare General Manager 

Not yet started 

Complete 

In progress, on track 

Overdue 

35


TITLE: 

Quality and Safety Committee Escalation Report 




The minutes of the June Quality and Strategy Committee 

meeting can be found in the Information section. 

Item 44/2011 documents the agreement to change the name 

of the meeting to the Quality and Safety Committee. As part 

of the governance of the Committee it is required that timely 

escalation of items of interest to the Trust Board need to 

occur as soon as possible, therefore this and subsequent 

summaries will include the escalation of agreed items either 

for review or for information. 

During the Quality and Safety Committee meeting held on 

the 9 th August, 2011, it was agreed that the following items 

were to be escalated to the September Trust Board. 

□ TEC ……………..….. □ STRATEGY……….….…. 

□ FINANCE ……..……… □ AUDIT ………….……..…. 

x QUALITY & SAFETY …………..………….....………… 

□ WORKFORCE …………………………………………… 

□ CHARITABLE FUNDS ……………………………...… 

□ TRUST BOARD …………………………….…………. 

□ REMUNERATION ………………………………….…... 


Items for review on agenda: 

• Real Time Patient Survey (included in Performance 

Report) 

• Maternity Action Plan (included in Maternity 

Services Update) 

• Care Quality Commission Action Plan 

For information: 

Policy for Carers and Visitors (DCW) 

The policy for patient visiting aims to balance the 

therapeutic effect of patients spending time with 

relatives, carers and friends with the patient’s need for 

rest and the care for clinical staff to manage the ward 

and care safely and efficiently. 

For review of the policy please use the following link: 

http://aglovale/assets/pdfs/further_cats/policyvisiting.pdf 

Patient Experience Policy (DCW) 

The Strategy for delivering the patient experience 

elements of the Trust’s vision of being a healing, caring 

and serving organisation is structured around the 

individual patient experience headings defined by 

Southampton University Hospitals NHS Trust and was 

approved in November 2010. The Policy to outline 

how the Strategy will be delivered has been developed 

and includes the following areas of care: 

• Communication 

• Cleanliness and environment 

• Infection control 

• Essence of Care / Fundamental Care 

• Patient & Public Involvement & Feedback 

• Patient information 

• Spiritual care 

• Services for Families and Carers

• Bereavement Care 

• End of Life Care 

The Policy is currently being uploaded onto the Trust 

intranet for further information. 


As detailed in agenda items and for information. 


As relevant to each item 


As relevant to each item. 


As relevant to each item 

□ NATIONAL TARGET x RMST 

x CQC REGISTRATION □ HEALTH & SAFETY 



x CORPORATE OBJECTIVE 

…………………………….... 


AUTHOR/PRESENTER: Pam Strange/ Stephen 

Burgess 

DATE: 25 th August 2011. 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


2


TITLE: 

Finance Report – Month Four (July) 2011/12 



1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and 

DATE: 

• The YTD I&E position at M04 is £21.4m deficit before 

£5.3m impairments reversals and £16.1m after. 

Against plan to date the adverse variance is £4.5m. 

The Key variances to date being: 

• Income is £3.4m favourable net of (£1.2m) 

adverse variance in Divisional income. The 

Central Income variance is against the profiled 

part of the £361m Annual Plan. 

• Pay is (£4.2m) adverse. This is primarily across 

Medicine, W&Cs and Surgery. Temporary 

staffing spend is £3.7m in month, which 

represents a £0.3m increase on prior periods, 

mostly on Medical and Qualified Nursing. 

• Non Pay is (£1.8m) adverse. The main 

variances coming from: (£0.3m) on outsourcing; 

(£0.5m) from Bad Debt provisions; (£0.4m) on 

Med & Surg General equipment across all 

clinical divisions other than Medicine; (£0.2m) 

on Drugs from Oncology, Radiology and failed 

Medicine CIP; and (£0.1m) on Transport. 

• The I&E position for Month of July was £5.8m deficit, 

with a £2.1m adverse variance against budget. 

• CIP – £14.1m forecast shortfall in CIP against the 

£28m plan, of which 3.7m represents unidentified 

schemes. Within the £14.1m forecast shortfall there is 

potential mitigation of £4.9m from identified red rated 

schemes. 

• The FOT is a £56.7m deficit, excluding impairments, 

which represents a £15.7m shortfall against control 

total. Potential mitigation against this of £15.4m has 

been identified, with further details are set out in the 

report Section 5. 

□ S&SIB ………………□ EPB…...………….. 

□ FINANCE ……………□ AUDIT ….……..…. 

□ CLINICAL GOVERNANCE …………..…...... 

□ CHARITABLE FUNDS ………………………. 

TRUST BOARD ……………………………… 

□ REMUNERATION …………………………… 

□ OTHER ………………………(please specify) 

CATEGORY: 


□ STANDARDS FOR BETTER HEALTH 


□ TARGET FROM COMMISSIONERS 

CORPORATE OBJECTIVE To monitor the 

Trust’s progress in achieving its financial 

turnaround, achieving control targets and meeting 

its statutory financial duties going forward. 


AUTHOR/PRESENTER: 

Alan Davies, Deputy Director of Finance / David 

Wragg, Director of Finance 

DATE: 


Set out under key issues 

3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION: 

N/A 

4. DELIVERABLES: 

N/A 

5. EVIDENCE : 

N/A 

6. RECOMMENDATION/ACTION REQUIRED: 

AGREED AT ______________________ 

MEETING, OR 

REFERRED TO: ______________________ 

DATE: ____________________________ 

DATE: ____________________________ 

REVIEW DATE _________________________ 

(if applicable)

1. EXECUTIVE SUMMARY 

Monthly Net I&E Position 

2.0 

0.0 

-2.0 

A M J J A S O N D J F M 

£m 

-4.0 

-6.0 

-8.0 

-10.0 

Actual Budget Last Yr 

Trust Income and Expenditure 

In Month Year to date Annual Forecast 2010/11 

Actual Var Actual Var Budget Actual Var Actual 

(32,947) 379 Income inc. Divisional (132,656) 3,405 (395,567) (402,543) 6,976 (407,107) 

Expenditure 

24,058 (2,028) - Pay 95,689 (5,843) 269,537 284,478 (14,941) 281,042 

10,529 (502) - Non-pay 44,748 (2,133) 125,868 133,862 (7,994) 123,346 

1,641 (2,150) EBITDA 7,781 (4,571) (162) 15,797 (15,959) (2,719) 

ITDA 0.0 

1,177 (16) - Depreciation 4,650 18 14,176 13,991 185 13,120 

324 6 - Capital Dividends 1,295 23 3,955 3,877 78 3,368 

2,620 30 - Net Interest 7,687 (18) 22,997 23,029 (32) 20,337 

5,762 (2,130) Net position 21,413 (4,547) 40,966 56,694 (15,728) 34,106 

Impairments (5,318) (5,318) (5,318) (8,670) 

5,762 (2,130) Net position 16,096 (4,547) 35,648 51,376 (15,728) 25,436 

Memorandum Control Adj for 

(367) 

PCT QIPP 

(1,467) (4,400) (4,400) 

5,762 (2,496) Net position 16,096 (6,014) 31,248 51,376 (20,128) 

Divisional Performance 

In Month Year to date Annual Forecast 2010/11 

Actual Var Actual Var Budget Actual Var Actual 

(30,524) 686 Central Income (122,457) 4,331 (361,925) (371,577) 9,652 (372,099) 

Clinical Divisions: 

5,969 (671) - Medical 24,482 (1,689) 66,809 73,035 (6,226) 70,609 

8,211 (476) - Surgical 32,550 (1,577) 90,205 96,067 (5,862) 95,382 

4,476 (695) - Women & Children 17,269 (2,246) 44,498 50,283 (5,785) 46,300 

7,199 (222) - CDT 28,154 (547) 78,679 82,463 (3,784) 83,646 

6,304 (589) - Corporate 27,222 (1,721) 77,102 79,157 (2,055) 76,177 

32,158 (2,653) - Sub-total Divisions 129,677 (7,780) 357,293 381,005 (23,712) 372,114 

Mitigation 

32,158 (2,653) - Rev Sub-total Divisions 129,677 (7,780) 357,293 381,005 (23,712) 372,114 

6 (6) Finance adjmts 561 (468) (2,656) 58 (2,714) (2,019) 

(177) Reserves (654) 7,219 6,402 817 

1,170 (16) Depreciation 4,650 18 14,082 13,900 182 13,025 

2,944 36 Non-operating 8,982 5 26,951 26,905 46 23,085 

5,754 (2,130) Total 21,413 (4,547) 40,964 56,693 (15,729) 34,106 

Impairments (5,318) (5,318) (5,318) (8,670) 

5,754 (2,130) Net position 16,096 (4,547) 35,646 51,375 (15,729) 25,436 

Memorandum Control Adj for PCT 

(367) (1,467) 

QIPP 

(4,400) 

(4,400) 

5,754 (2,497) Net position 16,096 (6,014) 31,246 51,375

2. CLINICAL INCOME 

£M 

36.0 

34.0 

32.0 

30.0 

28.0 

26.0 

24.0 

22.0 

20.0 

Income by POD 

CLINICAL INCOME ACTUALS 

A M J J A S O N D J F M 

Actual Budget Last Yr 

In Month Year to date Forecast 

Actual Var Actual Var Actual Var 

(1,580) 119 AandE (6,218) 470 (18,655) 1,409 

(2,052) 33 Critical Care (8,560) 614 (24,679) 842 

(4,351) (165) DC & EL (17,185) (651) (50,903) (1,929) 

(11,279) 795 NEL (44,757) 3,499 (140,857) 10,349 

(867) 101 XBD (3,415) 396 (10,742) 1,250 

(1,306) 3 Direct Access (5,158) 10 (15,279) 31 

(2,606) (112) OP First Attendances (10,294) (444) (30,492) (1,315) 

(2,999) 69 OP Follow Ups (11,847) 272 (35,091) 807 

(439) 26 OP Procedures (1,735) 104 (5,139) 308 

(3,304) (66) Other (13,379) (100) (39,925) (2,180) 

(30,784) 803 Total (122,548) 4,171 (371,763) 9,571 

Divisional Performance 

In Month Year to date Forecast 

Actual Var Actual Var Actual Var 

(3,015) 67 CDT (11,973) 234 (35,904) 770 

(9,114) 463 Medical (35,892) 1,843 (110,818) (82) 

(12,015) 312 Surgical (47,927) 1,716 (143,818) (1,948) 

(6,579) 337 Women & Children (26,323) 1,692 (79,964) 4,665 

(30,723) 1,179 - Sub-total (122,114) 5,486 (370,504) 3,405 

(61) (377) Corporate (434) (1,318) (1,258) (3,934) 

0 841 PCT QIPP 0 3,366 0 10,100 

(30,784) 803 Net position (122,548) 4,171 (371,763) 9,571 

Key points: 

• There was a further over-performance of £0.8m in month, 

increasing the year to date over-performance to £4.2m. The 

forecast outturn over-performance is £9.6m, against the annual 

contract Plan of £361m. Month 4 actuals are based on an 

extrapolation of the Month 3 actual billed data 

• The majority of the over-performance to date continues to be 

generated by Non Elective activity, with over-performance of 

£0.8m in month, £3.5m year to date and a forecast outturn of 

£10.3m. 

• It should be noted that Non Elective income lost, due to activity 

breaching the threshold above which the 30% marginal tariff is 

charged, is £2.4m year to date with a forecast of £7.6m for the full 

year. 

• Day Case and Elective income continues to run behind plan, 

£651k year to date (3.6%). 

• Outpatient income overall is marginally behind contract, with first 

attendances reducing and follow up activity increasing, which 

worsens the follow up ratios significantly. 

• A&E activity is over-performing by £0.5 (8.2%) year to date, 

primarily since transfer of activity to the Queens UCC had yet to 

be effected at M4 (implemented in August). 

• The year to date and forecast outturn position is net of £0.7m and 

£3.6m provisions respectively, in relation to anticipated PCT 

challenges or recording issues, for; radiotherapy non-elective 

threshold, ITU & obstetrics non-elective. 

• The Divisional performance analysis table is compared with the 

original Trust plan (£371m), which is the basis on which the 

Divisional expenditure budgets have been set and is in line with 

capacity plans. The £10.1m QIPP/PCT demand management is 

shown on a separate line. 

• All Divisions show over-performance to date, although the 

forecast assumes a tailing off of the Surgical Division overperformance, 

where a prudent assumption has been made that 

increased income target for ISTC activity later in the year will not 

be met. 

• The shortfall in Corporate is primarily represented by the £4m 

Marketing target (£1.3m year to date) 

• The forecast outturn over-performance has reduced by £0.8m, 

primarily due to inclusion of £1.6m agreed PCT QIPP schemes 

(see section 5. for detail), of which £1.0m was incorporated in to 

last month’s forecast (i.e. (£0.6m adverse in month movement 

from QIPP)

3. PAY EXPENDITURE 

£M 

Monthly Pay Expenditure 

25.0 

24.0 

23.0 

22.0 

21.0 

20.0 


Actual Budget Prior Yr Actual 

Expenditure By Pay Group 

In Month (£'000) 

Year to date (£'000) 

Actual Var Actual Var 

7,176 (507) Medical 28,756 (1,823) 

7,896 (522) Nursing - Qualified 31,470 (1,528) 

1,750 (274) Nursing - Unqualified 6,773 (771) 

3,435 (79) ST&T 13,718 (152) 

3,110 (50) Management & Admibn 12,224 22 

691 23 Ancillary 2,748 109 

24,058 (1,409) Total 95,689 (4,143) 

Key points: 

• Total temporary staff spend is £3.7m in month and £13.8m YTD. The 

general trend is an increase in Permanent spend with little 

movement in temporary spend overall. 

• Medical staffing agency spend and additional session spend has 

now increased within Medicine. 

• Nursing – Temporary staff in Divisions with the exception of W&C 

is decreasing as substantive posts are filled. 

• Scientific & Therapeutic temporary spend would have been down 

in month had it not been for £98k of Radiology Bank retro 

bookings. 

• W&C have a YTD spend on temporary staff of £2.6m against total 

pay budget of £13.9m (18.7%) 

• Medicine have a YTD spend on temporary staff of £4.8m against 

total pay budget of £22.2m (22%) 

• Surgery have a YTD spend on temporary staff of £3.9m against 

total pay budget of £25m (15.6%) 

Pay Expenditure by Division 




5,676 (322) Medical 22,948 (788) 

6,538 (375) Surgical 26,239 (1,286) 

3,968 (492) Women & Children 15,542 (1,615) 

5,413 (161) CDT 21,388 (263) 

21,594 (1,351) - Sub-total 86,116 (3,952) 

2,464 (58) Corporate 9,573 (191) 

24,058 (1,409) Net position 95,689 (4,143)

PAY EXPENDITURE (Contd.) 

30.0 

Split of pay permanent / temporary (Run Rate 10/11 11/12) 

25.0 

20.0 

£M 

15.0 

10.0 

5.0 

0.0 

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

Permanent Bank Agency 

25.0 

20.0 

15.0 

10.0 

5.0 

0.0 

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

Permanent 2010/11 Bank 2010/11 Agency 2010/11 

Permanent 2011/12 Bank 2011/12 Agency 2011/12

4. NON-PAY EXPENDITURE 

£M 

12.0 

11.0 

10.0 

9.0 

8.0 

Non-pay expenditure 



Key points: 

• Drugs – YTD mostly Oncology and then Medicine CIP, 

Radiology, Rheumatology and Ophthalmology. 

• Clinical Supplies – Gynaecology £(66)k, Midwifery £(55)k 

Womens & Childrens Mgt £(76)k failed consumables CIP 

programme, Theatres £(83)k 

• General Supplies & Services is predominantly due to (£96k) on 

Womens & Childrens from recruitment fees and Patient 

Transport and (£48k). 

• Other is largely made up of £(483)k on Bad Debt Provisions, 

£(269)k Outsourcing and external Tests, (£100k) Compromise 

agreement, £(338)k on PFI which will mostly be rectified after 

the Deed of Variation is signed, and £(89k) on External Agency 

in Corporate. 

• The fall in overall non-pay expenditure in the month is primarily 

due to a re-classification of PFI operating expenditure to PFI 

interest (retrospective to Month one 

Expenditure By Non Pay Category 




2,537 18 Drugs 9,982 (180) 

2,685 (98) Clinical supplies & services 10,393 (160) 

1,554 (23) General supplies & services 6,290 (185) 

1,376 68 Premises & fixed plant 5,788 (20) 

2,386 (442) Other 12,304 (1,286) 

PFI 

10,538 (477) Total 44,757 (1,831) 

Non Pay Expenditure By Division 




792 44 Medical 3,563 (158) 

2,026 (24) Surgical 7,879 22 

755 (166) Women & Children 2,708 (413) 

2,304 (56) CDT 9,095 (329) 

5,876 (201) - Sub-total 23,244 (878) 

4,542 (176) Corporate 20,711 (574) 

110 (90) Central Income & Finance Adj 792 (370) 

10,529 (468) Net position 44,748 (1,822)

5. CIP and Key Work stream Summary 

£m 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0.0 

Apr 

May 

Jun 

Jul 

Aug 

CIP Workstream Summary 

Budget 

Sep 

Oct 

Nov 

Actual/Forecast 

Dec 

Jan 

Feb 

Mar 

Key Points: 

• In month delivery grew by £0.24m to £1.0m, 

although still an adverse variance to budget of 

£0.9m 

• June forecast identified £0.9m, actual delivery 

marginally better than forecast. 

• Total full year forecast increased by £2.4m to 

£18.7m includes further mitigating actions to reduce 

readmissions (£2.0m reduced ‘penalty’ currently red 

risk rated) and £0.4m net additional new actions. 

• Overall value of green rated schemes increased by 

£2.2m to £10.0m, reflecting higher certainty over the 

delivery of a number of schemes. 

• Further stretch activities continue to be evaluated, 

Workstream Summary 

(all figures in £'000) 

Annual Statement In Month Statement Ytd Statement 

Data 

Key Worsktream 

11-12 Green Amber Red 11-12 11-12 In Mth In Mth In Mth Ytd Sum of Ytd 

Targets 

F-cast Variance Target Delivery Variance Target Ytd Variance 

Reducing LOS and ward closure programme 5,455 2,072 389 858 3,319 (2,136) 591 200 (391) 1,858 700 (1,157) 

Outpatient Operations 948 475 314 105 895 (53) 79 28 (51) 316 113 (203) 

ISTC bid and Theatres productivity 1,357 - 500 - 500 (857) 113 - (113) 452 - (452) 

Collaborative Working & Outsourcing 1,411 136 275 - 411 (1,000) 34 29 (6) 137 114 (23) 

Control of premium rate staff expenditure 3,096 319 587 1,006 1,912 (1,184) 299 49 (250) 510 61 (449) 

Key Staff recruitment 486 254 150 - 404 (81) 40 8 (31) 167 83 (84) 

Managerial tier reduction and other staffing reductions 2,460 1,169 251 220 1,641 (820) 160 101 (59) 486 379 (107) 

Service Line Reporting and Service Reviews 500 - - - - (500) - - - - - - 

Local CIP 8,756 5,607 1,634 387 7,628 (1,128) 367 553 186 1,679 1,824 146 

Unidentified 3,757 - - - - (3,757) 241 - (241) 340 - (340) 

Readmissions - - 2,000 2,000 2,000 - - - - 

Grand Total 28,226 10,034 4,099 4,577 18,710 (9,517) 1,924 968 (956) 5,945 3,276 (2,669)

Divisional Summary By Workstream 

(all figures in £'000) 

Annual Statement 

In Month Statement 

Ytd Statement 

Division 

Key Worsktream 

11-12 Green Amber Red 11-12 11-12 In Mth In Mth In Mth Ytd Sum of Ytd 

Targets 

F-cast Variance Target Delivery Variance Target Ytd Variance 

Medicine & Emergency Care Reducing LOS and ward closure programme 3,970 1,660 389 858 2,907 (1,063) 456 179 (277) 1,453 613 (840) 

Outpatient Operations 158 - - 105 105 (53) 13 - (13) 53 - (53) 

Control of premium rate staff expenditure 1,200 - 270 680 950 (250) 233 - (233) 333 - (333) 

Managerial tier reduction and other staffing r 456 276 81 - 358 (99) 66 49 (17) 159 111 (48) 

Local CIP 866 133 152 339 625 (242) 92 34 (58) 275 155 (120) 

Unidentified 2,610 - (2,610) 240 - (240) 317 - (317) 

Readmissions - - 2,000 2,000 2,000 - - - - 

Medicine & Emergency Care Total 9,261 2,070 892 3,982 6,944 (2,317) 1,100 262 (838) 2,590 879 (1,711) 

Surgical Reducing LOS and ward closure programme 1,485 412 - - 412 (1,073) 135 21 (114) 405 88 (317) 

Outpatient Operations 450 450 - - 450 - 38 - (38) 150 - (150) 

ISTC bid and Theatres productivity 1,357 - 500 - 500 (857) 113 - (113) 452 - (452) 

Control of premium rate staff expenditure 763 - 167 - 167 (596) - - - - - - 

Managerial tier reduction and other staffing r 525 144 - - 144 (381) - - - - - - 

Service Line Reporting and Service Reviews 500 - - - - (500) - - - - - - 

Local CIP 3,823 3,403 100 - 3,504 (319) 323 310 (13) 1,241 1,101 (140) 

Unidentified 265 - - - - (265) - - - - - - 

Surgical Total 9,167 4,409 767 - 5,176 (3,991) 608 331 (277) 2,248 1,189 (1,060) 

Women & Children Managerial tier reduction and other staffing r 614 483 - - 483 (131) 51 35 (16) 205 180 (24) 

Local CIP 759 159 234 - 393 (366) 51 38 (13) 141 53 (88) 

Unidentified 334 - - - - (334) 7 - (7) 28 - (28) 

Women & Children Total 1,707 642 234 - 876 (832) 109 73 (36) 373 233 (139) 

Cancer, Diagnostics & Therapeutic Outpatient Operations 340 25 314 - 339 (1) 28 28 (0) 113 113 (0) 

Collaborative Working & Outsourcing 1,411 136 275 - 411 (1,000) 34 29 (6) 137 114 (23) 

Control of premium rate staff expenditure 1,133 319 150 326 795 (338) 66 49 (17) 177 61 (116) 

Key Staff recruitment 486 254 150 - 404 (81) 40 8 (31) 167 83 (84) 

Managerial tier reduction and other staffing r 865 266 170 220 657 (209) 43 17 (26) 123 88 (35) 

Local CIP 1,877 807 948 48 1,803 (74) 71 116 46 160 152 (9) 

Unidentified 548 - (548) (5) - 5 (5) - 5 

Cancer, Diagnostics & Therapeutic Total 6,659 1,808 2,007 594 4,409 (2,250) 277 247 (29) 872 611 (261) 

Corporate Managerial tier reduction and other staffing r - - - - - - - - - - - - 

Local CIP 1,431 1,104 200 - 1,304 (127) (170) 54 224 (139) 364 502 

Corporate Total 1,431 1,104 200 - 1,304 (127) (170) 54 224 (139) 364 502 

Grand Total 28,226 10,034 4,099 4,577 18,710 (9,517) 1,924 968 (956) 5,945 3,276 (2,669)

ONEL QIPP 

• ONEL provided the Trust with its latest QIPP projection on 4 th August. 

• The Trust has reviewed the detail behind the schemes and have identified a £1.6m net income reduction from the total £7.3m identified by the PCT’s. 

• Much of the activity reductions identified relate to activity the Trust would carry out at a marginal tariff. 

• There is a reasonable expectation that marginal rate activity is performed at marginal costs, and therefore the required expenditure reduction is also £1.6m. 

PMO Code Description PCT Plan at 4/8/11 Associated BHRUT 

Income Share 

Associated BHRUT 

Cost Reduction 

PD001a PCDF - Adult - 0 0 

PD001b PCDF - Paediatric - 0 0 

PD001c Delayed Transfers of Care - changes to emergency care 

- 0 0 

pathways 

New Commissioning for outcomes 2,294 688 (688) 

PD013a Outpatient Shifts 540 540 (540) 

PD011a Decommission @ 100% BHRT 1,304 0 0 

PD016 NELTC 1,260 0 0 

PD017 NELTC (Re procurement) - 0 0 

BD002 Long Term Conditions - Community Services 600 180 (180) 

BD003 Haemoglobinopathy service - 0 0 

HV004 Chronic Obstructive Pulmonary Disease 125 38 (38) 

HV006 Stroke Care - 0 0 

PD003 Urgent Care Centre % - 0 0 

PD006 Single Point of Access - 0 0 

PD010 Ambulatory Care BHRT & WX - 0 0 

PD012 Procedures of Limited Clinical Effectiveness (PoLCE) 756 0 0 

RE001a Cardiovascular disease project (Implement Gold 

80 80 (40) 

Standard Framework and One Stop Shop) 

RE002 Children's community nursing - asthma and diabetes - 

48 14 (14) 

BHRT 

RE003 Decommission Anti-coagulation - BHRT - 0 0 

RE005 LTC patient centered case management - BHRT 60 18 (18) 

RE009 Acute visiting service within community (Roving GP) 240 72 (72) 

7,307 1,630 (1,590)

Mitigating Actions Not Yet Included in Trust Forecast 

The I&E forecast set out above does not include the following mitigating actions, which have yet to be confirmed: 

Scheme Division £'000 £'000 

Red Rated Scheme Included in CIP Forecast 

Further Length of Stay Stretch - Cornflower B Medicine 858 

Outpatient Operations Medicine 105 

Emergency Care - Agency Premium Reduction Medicine 680 

AHP Premium rate Staff Costs CDT 326 

Staff Structure CDT 220 

Local CIP's Medicine 339 

Local CIP's CDT 48 

Readmissions Medicine 2,000 

Stretch Targets Identified in 4th August SHA update not in divisional forecast 

Premium rate Staff Reductions (Agency to Perm) Surgery 275 

W&C 201 

CDT 648 

Theatres Stretch Surgery 361 

Outpatients Stretch Trustwide 414 

Further Ward Closures Surgery 400 

Local CIP Opportunities Surgery 796 

Local CIP Opportunities W&C 305 

4,577 

3,400 

Marginal Costs Associated with QIPP Plans Trustwide 1,570 

Marketing Initiatives Trustwide 2,000 

ISTC - Successful Tender Award 1,400 

Balance Sheet Review Opportunities previously included in forecast 2,000 

CQUINS - Achieve 75% target (budget assumes 50%) 550 

Total 15,497 

Maximium Additional Potential 

Readmissions 1,000 

CQUINS - Achieve 100% 550 

Total 1,550

6. Divisional Summaries 

Cancer, Diagnostic & Therapeutics 

CDT Net Expenditure Position 

9.0 

8.0 

7.0 

6.0 

5.0 

4.0 



Performance by I&E Category 

In Month Year to date 


(517) (6) Income (2,330) 46 

5,413 (161) Pay expenditure 21,388 (263) 

2,304 (56) Non-pay expenditure 9,095 (329) 

Unallocated CIP 

7,199 (222) Net position 28,154 (547) 

Performance By Specialty 



75 (38) Clinical Services Mgt 311 (39) 

213 12 Healthcare Records 873 28 

352 (3) Medical Secretaries 1,375 21 

1,511 49 Oncology 5,775 20 

328 (4) Outpatients 1,300 (4) 

1,738 39 Pathology 7,318 (164) 

598 (7) Pharmacy 2,331 20 

1,641 (265) Radiology 5,901 (411) 

742 (7) Therapies 2,969 (19) 

7,199 (222) Net position 28,154 (547)

CDT Key Variance Narrative. 

• Income 

o 

• Staffing 

o 

o 

o 

o 

• Non-Pay 

o 

o 

o 

Income £(6)k (A). Adverse variance in month being IFR/ICDF income growth £60k being partially mitigated by under-performance of 

in HCA drug income £(50)k and Pharmacy Commercial Operations £(15)k. 

Year to date £46k (F) being ICDF/IFR growth £249k mitigated by under performance in HCA £(169)k and Pharmacy commercial 

operations £(47)k. 

Medical staff £(101)k (A) being Radiologists retrospective bookings £(90)k 

Year to date over spend £(106)k (A) being Radiologists as above. 

Nursing staff £ (10)k (A). In month overspend being unallocated CIP target for outpatient productivity which is largely covered by 

non-recurrent Management & Clerical vacancies. 

Year to date over spend being £(62)k being reflection of CIP target. 

Scientific Therapeutic and Technical staff £(56)k (A) In-month adverse movement being delivery of high cost Radiology Polyclinic 

support and Radiographer CIP slippage £(33)k Pathology agency premium £(28)k and Therapy agency premium £(12)k. 

Year to date £(177)k (A) being Radiographer Polyclinic and CIP slippage £(91)k, Pathology £(34)k, Therapy £(34)k mitigated by 

vacancies in Pharmacy £33k 

Management and Admin £6k (F). In month favourable position reflects vacancies in Outpatient to support productivity improvement 

£14k. 

Year to date under spend £80k being Medical Secretariat £26k, Outpatients £51k and Healthcare Records £31k non-recurrently 

supporting CIP targets. 

Drugs £ (4) k (A). In month over spend in cancer prescribing £20k and coding issues relating to Radiology mitigated by retrospective 

VAT uplift of £51k. 

Year to date £ (111) k (A) being cancer prescribing £(72)k. 

Clinical Supplies & Services £(11)k (F) Overspend in Coiling and related high cost consumables £(97)k mitigated by under spend 

in MRSA consumables £41k and retrospective VAT reclaim £34k. 

Year to date £(34)k (A) relates to high consumable usage in Nuclear Medicine. 

Other Non-Pay £(58)k (A). Radiology Commercial section partnership £(22)k, Pathology Sent Away £(15)k and CIP slippage on 

procurement program £(28)k. 

Year to date £(169)k is Radiology Commercial section £(74)k, Pathology Sent Away Services £(58)k and profusion scan out sourcing 

£(10)k.

Medicine & Emergency 

Medical Division Net Expenditure 

8.0 

7.0 

£M 

6.0 

5.0 

4.0 






(499) (67) Income (2,028) (134) 

5,676 (322) Pay expenditure 22,948 (788) 

792 44 Non-pay expenditure 3,563 (158) 

(325) Unallocated CIP (610) 

5,969 (671) Net position 24,482 (1,689) 

Performance by Specialty 

In Mo nth Year to date 


1,568 95 A+E & Acute Assessment 6,412 215 

235 (5) Bed & Site Management 949 (32) 

5 55 1 Cardio log y 2,1 45 68 

216 (6 6) Care of the Elderly 772 (216) 

(1) (467) Emergency Management (1) (624) 

566 21 Endoscopy 2,452 (84) 

2,253 (163) General Medicine 9,311 (586) 

191 (7 9) Medical Management 919 (355) 

21 (3 6) Renal 38 (100) 

365 27 Respiratory 1,484 25 

5,969 (671) Net position 24,482 (1,689)

Medicine & Emergency Key Variance Narrative. 

• Income 

o 

• Staffing 

o 

Income £(67)k (A). CIP slippage on KGH Renal Dialysis accommodation £(21)k whilst contractual agreement with BLT negotiated 

(likely, benefit of this scheme will transfer to Estates), provision made for QH Renal Contract dispute £(20)k and downturn in Junior 

Doctor Deanery income £(20)k. 

Year to date is £(134)k (A). KGH Renal Dialysis £(83)k contractual delay and QH Renal provision £(20)k. 

Medical staff £(265)k (A). In month deficit due to CIP slippage on A&E Medical Staff recruitment £(211)k and Outpatient productivity 

£(13)k being further compounded by temporary staff bookings in respect of Vacancies, high sick leave, additional ward cover and 

Endoscopy out of hour sessions £(35)k. 

Year to date £(510)k (A). CIP slippage £(400)k and £(110)k Temporary Staff premiums 

o 

Nursing Staff £(42)k (A). In-month adverse movement through Ward closure CIP slippage (x2) £(178)k and additional sessions 

covering Endoscopy capacity limitation £(19)k being partially resourced Divisional Vacancies and temporary staff reductions £159k. 

Year to date £(311)k (A). Due to Ward CIP slippage of £(488)k, Endoscopy sessions £(70)k against Vacancies £247k 

o 

Admin & Clerical £(28)k (A). In month deficit reflects non-recurrent adjustment transferring year to date opportunity arising from 

delayed recruitment to CIP. 

Year to date £10k (F). Clerical Support Vacancies. 

• Non-Pay 

o Drugs £33k (F). In month benefit relates to retrospective VAT financing £26k, downturn in Gastro / Respiratory prescribing £30k 

against CIP Ward closure / drug management CIP slippage £(23)k. 

Year to date variance is £(57)k (A). CIP slippage totalling £(45)k. 

• Cost Improvement Programme 

o 

Unallocated Gap £(325)k (A). Current month deficit reflects Estate Ward closure drift £(90)k and Divisional gap £(240)k. 

Year to date £(610)k (A). Reflects Estate Ward Closure £(297)k and Divisional Gap £(317)k

Women & Children’s 

Women & Children Net Expenditure 

6.0 

5.0 

£M 

4.0 

3.0 

2.0 






(247) (14) Income (980) (166) 

3,968 (492) Pay expenditure 15,542 (1,615) 

755 (166) Non-pay expenditure 2,708 (413) 


4,476 (695) Net position 17,269 (2,246) 




697 (64) Gynaecology 2,753 (246) 

2,014 (377) Midwifery 7,589 (1,033) 

325 (20) NICU / SCBU 1,298 (86) 

862 (148) Paediatrics 3,501 (702) 

545 (45) Sexual Health 2,021 (35) 

32 (42) W&C Management 107 (144) 

4,476 (695) Net position 17,269 (2,246)

Womens & Childrens Key Variance Narrative. 

• Income – Under-achieved by (£14k) for the month of July, (£166k) Year to Date. 

o 

There are a number of small adverse variances in month but the key issues are from previously externally funded posts (£14k) and 

Junior Doctors shortfall (£9k). Plans should be drawn up to disinvest from these previously funded areas and the necessary 

adjustments to budgets made. 

• Pay – Over-spent by (£492k) for the month of July, (£1.6M) Year to Date. 

o 

o 

Medical staff over-spent by (£98k). The majority of this over-spend is in Paediatrics which is (£78k) in month. This is due to the 

premium cost of vacancies backfilled with Agency at Middle Grade level in excess of the vacancies that are currently available. 

Gynaecology over-spent is (£15k) in the month due an over establishment in Junior Grades as well as Agency Juniors still being 

used. 

Year to date deficit is (£407k), Paediatrics (£315k) & Gynaecology (£98k). 

The Nursing & Midwifery over-spent by (£366k). The majority of this over-spend sits with Midwifery (£313k) as Temporary staff 

spend drives this position as the department attempts to achieve the 1:29 ratio without the permanent staff. This level of spend is 

anticipated to continue until September when recruitment is likely to be up to establishment. However the required level of budget 

still needs to be agreed in order to have the correct budgeted ratio. Paediatrics is over-spent by (£38k) due to temporary staff 

expenditure due to the type of Activity and the Bed base being used above the budgeted level. 

Year to date deficit is (£1.1M). Midwifery (£821k), Paediatrics (£206k) and NICU is (£56k). 

• Non Pay – Over-spent by (£166k) for the month of July, (£413k) Year to Date. # 

o Clinical Supplies & Appliances is over-spent by (£83k). In month this is due to capital equipment purchases which did not have 

Capital Planning Group sign off and were ordered locally by Gynaecology (£33k). (£19k) is due to unfound Divisional Cost 

Improvement Programme which is aligned to the Consumables work stream. 

Year to date deficit is (£199K). Failed Cost Improvements (£76k) & Medical & Surgical Equipment in Midwifery (£53k) & Gynaecology 

(£66k). 

o General Supplies and Services is over-spent by (£44k). Recruitment of overseas midwives in Midwifery cost (£23k) and more costs 

associated with this recruitment are expected in future periods. (£23k) in Midwifery is for Red books which is offset by income above. 

Year to date deficit is (£101k) of which (£96k) relates to Midwifery. 

o 

Other Non pay is over-spent by (£18k). This is mainly due to External consultancy fees charges which are not funded. 

Year to date deficit is (£89k), of which (£66k) relates to Paediatrics. 

• Cost Improvement Programme – under-achieved by (£23k) for the month of July, (£52k) Year to Date. 

o This represents the balance of the Cost Improvement Programme gap detailed below that currently does not have a plan.

Surgical 

£M 

Surgical Division Net Expenditure 

8.5 

8.0 

7.5 

7.0 

6.5 






(352) (83) Income (1,567) (174) 

6,538 (375) Pay expenditure 26,239 (1,286) 

2,026 (24) Non-pay expenditure 7,879 22 

6 Unallocated CIP (139) 

8,211 (476) Net position 32,550 (1,577) 




39 2 Admissions 148 13 

947 11 Anaesthetics 3,842 (203) 

659 (22) Critical Care 2,691 (4) 

138 6 Day Surgery 543 30 

56 4 Dermatology 258 (17) 

301 20 Ear, Nose & Throat 1,178 97 

905 (42) General Surgery 3,579 (145) 

50 10 MaxFax 209 27 

347 (6) Neurology 1,384 (38) 

1,092 (114) Neurosciences 4,133 (257) 

303 21 Ophthalmology 1,339 (85) 

38 Orthodontics 142 9 

760 9 Orthopaedics 3,104 (42) 

25 (3) Pain Management 99 (13) 

561 (56) Rheumatology 2,143 (62) 

145 (223) Surgical Management 563 (640) 

1,472 (89) Theatres 5,738 (254) 

373 (4) Urology 1,455 8 

8,211 (476) Net position 32,550 (1,577)

Surgery Key Variance Narrative. 

• Income – Under-achieved by (£83k) for the month of July, (£174k) Year to Date. 

o 

o 

The CFS under achieved income (£51k) drives this position in the month. Junior Doctor’s Income has under-achieved by (£28k). 

Of the YTD (£174k) under-achievement (£141k) year to date can be attributed to the CFS Income line. The unit closed at the end of 

the reported month. 

• Pay – Over-spent by (£375k) for the month of July, (£1,2m) Year to Date. 

o 

Medical staff over-spent by (£186k). Half of this was due to failed Cost Improvement Programme (£124k) relating to Theatre 

Productivity, Outpatient Activity & PCT demand management failure. The specialties with the largest over-spends were 

Neurosciences/Stroke (£50k) which was related to Junior grade agency costs & Anaesthetics (£25k) due to agency premiums spent on 

Middle Grades. 

o 

o 

o 

The year to date Medical Staffing is (£819k) over-spend which relates to CIP slippage (£487k), Neurosciences (£160k), General Surgery 

(£114k) and Anaesthetics (£122k). 

Qualified Nursing Staff over-spent by (£175k). Failed Cost Improvement Programme of (£198k) for the schemes relating to 

Theatres efficiency and Surgical Ward closures that haven’t come to fruition drive this position. It is however offset by under-spends 

in all of the specialties with the exception of Critical Care (£30k). 

Nursing and Midwifery Qualified year to date over-spend is (£458k) of which (£643k) is missed CIP plan although all Specialities 

under-spend with the exception of Critical Care, Ophthalmology, Theatres and Urology. 

• Non Pay – over-spent by (£24k) for the month of July, under-spent £22k Year to Date. 

o 

Non Pay over-spends by (£24k) this is attributed to Clinical Supplies & Appliances in Theatres who were (£43k) over-spent in the 

month. 

o 

Year to date Non Pay under-spends by £22k with small under-spends offsetting Drugs which is currently over-spent by (£19k). 

• Local Cost Improvement Programme – Over achieved by £10k for the month of July, (£139k) Year to Date. 

o The local 3% Cost Improvement Programme over achieved in the month due to a realignment of Anaesthetics savings however this will 

not continue month on month without significant contributions from other specialties. A summary of the full Cost Improvement 

Programme can be seen below.

Corporate 

£M 

8.0 

7.0 

6.0 

5.0 

4.0 

Corporate Directorates Net Expenditure 



Performance by Directorate 


320 (92) Chief Executive 889 (133) 

781 2 Director of Finance 3,502 (369) 

329 (102) Director of Human Resources 1,086 (267) 

128 3 Director of Nursing 479 37 

152 (5) Dir. of Performance & Planning 592 102 

78 (184) Education (28) (397) 

2,962 (231) Head of Estates 14,093 (457) 

1,012 2 Medical Director 4,081 59 

37 (38) R&D 197 (207) 

504 57 Strategy & Planning 2,332 (88) 




(638) (286) Income (2,964) (750) 

2,399 7 Pay expenditure 9,475 159 

4,542 (176) Non-pay expenditure 20,711 (574) 


6,304 (589) Net position 27,222 (1,721) 

6,304 (589) Net position 27,222 (1,721) 

Corporate Key Variance Narrative. 

• Head of Estates £(231)k in M04 / £(457)k YTD. 

• Education £(184)k in M04 / £(397)k YTD. Although some recovery expected this is mostly due to reductions in various deanery funding 

streams. 

• Director of HR £(102)k in M04 / £(267)k YTD. Largely from CIP slippage and Income recovery in Occupational Health and some over 

establishment issues within HR. 

• Trust Board £(92)k M04 / £(133)k YTD mostly from Corporate External Agency and dual CEO costs. 

• R&D £(38)k in M04 / £(207)k YTD largely as a result of CLRN funding reductions. Planning is underway to recover the full position through 

other funding streams by Year End. 

• Director of Finance £34k Fav M04 / £(133)k Adv YTD - £(100)k YTD Compromise agreement in Turnaround. 

• Strategy & Planning £57k Fav in M04 / £(88)k Adv YTD. The YTD position mostly on various items on Computer Maintenance including an 

additional PACS charge.

7. OVERALL DIVISIONAL PERFORMANCE 

The following table brings together the Divisional proportion of the central (PCT) income over or under performance, alongside the net 

expenditure position for each Division, to give an overall financial performance picture for each Division. Income performance has been 

adjusted to allow for notional direct marginal costs of 50%, with a further 10% for Clinical Support Services. It should be noted this does 

not represent a ‘true SLR’ position for each Division, as not all income will be directed aligned with expenditure, but nevertheless 

provides a high level view of the performance of each Division. 

(£'000 favourable/(adverse) variance 

Note 

Medical 

Division 

Surgical 

Division 

Womens' & 

Children 

Division 

CDT 

Division 

Total 

A 

Central Income Over / (Under) Perf. Against 

Plan 1 1,843 1,716 1,692 234 5,486 

B 

Adjustment to income performance for 

marginal rate 2 -922 -858 -846 432 -2,192 

C=A+B Net income performance 922 858 846 666 3,291 

D 

Net Expenditure (Over) / Under Spends 

£'000 3 -1,689 -1,577 -2,246 -547 -6,056 

E=C+D Net income and expenditure performance -768 -719 -1,400 119 -2,768 

Memo: CIP underperformance -1,711 -1,060 -139 -261 -3,171 

Notes: 

(1) The Divisional position represents performance against plan, excluding £10.1m (£2.5m YTD) of PCT 

QIPP/demand management plans, which is the basis on which Divisional budgets have been set, and is therefore the 

appropriate comparator for overall performance purposes 

(2) Only 50% of the income over/under performance is attibuted to Clinical Divisions (as an approximation of the 

marginal cost impact), with 10% attributed to CDT for the impact on clinical support services 

(3) Divisional over/underspending, including local Divisional income

8. BALANCE SHEET 

Current Prior Last 

(£m) period period Yr End 

Jul-11 Jun-11 Mar-11 

Non-current assets 397.5 397.7 388.9 

Current assets 

Inventories 6.7 6.8 7.0 

Trade and other receivables 39.0 37.6 29.7 

Cash and cash equivalents 1.4 6.8 2.8 

47.1 51.2 39.5 

Current liabilities 

Trade and other payables -78.3 -76.1 -48.2 

Borrowings -5.7 -5.6 -5.3 

Provisions -2.1 -2.1 -1.8 

Net current assets/(liabilities) -39.0 -32.6 -15.8 

Non-current liabilities: 

Borrowings -258.0 -259.3 -260.2 

Trade and other payables -4.9 -4.9 -4.9 

Provisions -4.6 -4.4 -5.0 

Total assets employed 91.0 96.5 103.0 

Financed by taxpayers' equity: 

Public dividend capital 307.3 307.3 307.2 

Retained earnings -232.5 -227.0 -216.3 

Revaluation reserve 15.4 15.4 11.3 

Donated asset reserve 0.8 0.8 0.8 

Total taxpayers' equity 91.0 96.5 103.0 

Key points: 

• Overall balance sheet position shows reduction of 

£5.5m in total assets compared with M3, due to in 

month I&E deficit, which was largely met by reduction 

in cash balances (cash down £5.4m in month) 

Current Prior Last 

KPIs period period Yr End 

Jun-11 Jun-11 Mar-11 

Average Debtors days 20 26 21 

Debtors >90 days £'000 1,216 -161 592 

Debtors >180 days £'000 681 665 1,536 

Debtors >365 days £'000 2,240 2,460 2,599 

>365 days provided £'000 1,719 1,652 

Average creditor days 61 53 58 

Current ratio 0.56 0.63 0.71 

Better payment practice code performance: 

- Non-NHS - Volume paid on time 2,394 3,465 2773 

- Volume % paid on time 47.54% 46.01% 27.96% 

- Value paid on time £19,965k £6,763k £5,150K 

- Value % paid on time 83.18% 53.10% 35.85% 

- NHS - Volume paid on time 11 122 316 

- Volume % paid on time 40.74% 53.28% 34.39% 

- Value paid on time £543k £519k £1,630k 

- Value % paid on time 27.40% 28.36% 30.52%

9. CAPITAL AND CASHFLOW 

Summary Cashflow - Year to date £000's 

Operating Deficit -7,517 

Interest Paid -9,824 

PDC Dividend Paid 0 

Interest received 264 

Impairments -4,744 

Net I&E deficit (cash impact) -21,821 

Depreciation and Amortisation 4,620 

Movements in working balances: 

Decrease in Inventories 243 

Increase in Trade and Other Receivables -8,258 

Increase in Trade and Other Payables 29,109 

Decrease in Provisions -170 

- sub-total 3,723 

Capital expenditure -2,914 

Revenue Rental Income 404 

Net cashflow before financing 1,213 

Capital Element of Finance Leases and PFI -2,692 

Loans repaid 0 

Public Dividend Capital Received 0 

Net Increase/(Decrease) in Cash and Cash Eq -1,479 

Opening cash balance 2,830 

Closing cash balance 1,351 

Capital Expenditure (£'000) Allocation YTD expenditure % of alloc spent 

Medical Equipment 780 344 44% 

IT 2,195 900 41% 

Estates 3,271 1,314 40% 

Capital TVEs 218 0 0% 

Revenue to Capital 150 45 30% 

Unclassified 

Sub-total 6,614 2,602 39% 

KGH Polyclinic 900 0 0% 

Unallocated 

Total programme 7,514 2,602 35% 

MES Refresh 5,500 933 17% 

Major schemes: 

Maternity 2,000 0 0% 

A&E 3,000 0 0% 

Cardiac Lab 3,000 0 0% 

CT Scanners 2,000 0 0% 

PAS Procurement 2,900 0 0% 

SAN Virtualisation (Server 1,000 0 0% 

Procurement automation 1,100 0 0% 

28,014 3,535 13% 

Cashflow - Key points: 

• The main point to note is an increase in YTD I&E 

cash deficit to £21.8m. 

• Trade and other payables has also increased YTD, 

primarily represented by SLA payments in advance 

received from Havering, Barking and Dagenham 

and Redbridge PCTs totalling £24m 

Capital - Key points: 

• Year to Date Capital expenditure is £3.5m with £0.9m of this part of the 

Managed Equipment Refreshes. 

• The Trust’s Capital Planning Group (CPG) has agreed a Capital 

Programme of £13.9m, plus an additional £15.0m externally funded 

schemes which will require PDC support. 

• The majority of the £5.5m allocation for MES Refreshes will be spent in 

October 2011. 

.

10. Financial Risk Rating 

The weighted financial risk score for July was 1.33, very similar to the June score of 1.35. 

Financial indicators for acute & ambulance trusts : BHRUT JULY 2011 

SCORING 

Criteria 

Initial Planning 

Metric 

Planned Outturn as a proportion of 

Turnover 

Formula for organisations with a 

planned operating breakeven or surplus 

SHA expected operating surplus or 

breakeven - 

planned operating surplus or breakeven 

Planned Income 


planned operating deficit 

x 100 x 100 

Planned operating deficit 

Planned Income 

Weight (%) 

5 5 

Measure 

-10.4% 

3 2 1 

Any operating deficit less than 2% of income OR 

Planned operating breakeven or surplus that is 

an operating surplus/breakeven that is at variance 

either equal to or at variance to SHA expectations 

to SHA expectations by more than 3% of planned 

by no more than 3% of income. 

income. 

Operating deficit more than or equal to 2% of 

planned income 

BHRUT Raw 

Score JUL 11 

BHRUT 

Weighted 

Score JUL 11 

1 0.05 

Year to Date 

YTD Operating Performance 

Formula for organisations with a YTD 

actual operating breakeven or surplus 

YTD planned operating breakeven/ 

surplus/deficit - YTD actual operating 

breakeven or surplus 

Forecast Income 

Formula for organisations with a YTD 

actual operating deficit 

x 100 YTD operating deficit 

x 100 


25 

20 

-5.3% 

YTD operating breakeven or surplus that is either Any operating deficit less than 2% of income OR 

equal to or at variance to plan by no more than 3% an operating surplus/breakeven that is at variance 

of forecast income. 

to plan by more than 3% of forecast income. 


forecast income 

1 

0.20 

YTD EBITDA 

YTD EBITDA 

Actual YTD Income 

x 100 

5 

-1.9% 

Year to date EBITDA equal to or greater than 5% 

of actual year to date income 

Year to date EBITDA equal to or greater than 1% Year to date EBITDA less than 1% of actual year 

but less than 5% of year to date income to date income. 

1 

0.05 

Forecast Outturn 

Forecast 

Forecast Operating Performance 

EBITDA 


forecast operating breakeven or 

surplus 

Planned operating breakeven/ 

surplus/deficit - Forecast operating 

breakeven or surplus 


x100 

Forecast EBITDA 


Formula to be used for organisations 

with a forecast operating deficit 

Forecast operating deficit 


x100 

40 

20 

x 100 5 

-10.1% 

0.0% 

Forecast operating breakeven or surplus that is 

either equal to or at variance to plan by no more 

than 3% of forecast income. 

Forecast EBITDA equal to or greater than 5% of 

forecast income. 

Any operating deficit less than 2% of income OR 

an operating surplus/breakeven that is at variance 

to plan by more than 3% of income. 

Forecast EBITDA equal to or greater than 1% but 

less than 5% of forecast income. 


income 

Forecast EBITDA less than 1% of forecast income. 

1 

1 

0.20 

0.05 

Rate of 

Change in 

Forecast 

Surplus or 

Deficit. 

(Current period forecast surplus/deficit) - (Prior period forecast surplus/deficit) 


x 100 15 

-0.1% 

Still forecasting an operating surplus with a 

movement equal to or less than 3% of forecast 

income 

Forecasting an operating deficit with a movement 

Forecasting an operating deficit with a movement 

less than 2% of forecast income OR an operating 

of greater than 2% of forecast income. 

surplus movement more than 3% of income. 

2 

0.30 

Underlying Financial 

Position 

Finance Processes & Balance Sheet 

Efficiency 

Underlying 

Position % 

EBITDA Margin 

(%) 

Better 

Payment 

Practice 

Code Value 

% 

Better 

Payment 

Practice 

Code 

Volume % 

Current 

Ratio 

Debtor Days 

Creditor 

Days 

Underlying Breakeven/Surplus/Deficit 

Underlying Income 

Underlying EBITDA 

Underlying Income 

Value of ALL Bills paid within target 

Value of ALL Bills paid within the year 

Volume of ALL Bills paid within target 

Volume of ALL Bills paid within the year 

Current Assets 

Current Liabilities 

Debtors as at current period 


*Operating Position = Retained Surplus/Breakeven/deficit less impairments 

x 100 

10 

x 100 5 

x 100 

20 

5 Underlying breakeven or Surplus 

2.5 

x 100 2.5 

5 

x365 5 

-9.4% 

-0.8% 

66% 

42% 

0.56 

Creditors as at current period 

x365 

Total Expenditure 5 

61 

19 

Underlying EBITDA equal to or greater than 5% of 

underlying income 

95% or more of the value of NHS and Non NHS 

bills are paid within 30days 

95% or more of the volume of NHS and Non NHS 

bills are paid within 30days 

Current Ratio is equal to or greater than 1. 

Debtor days less than or equal to 30 days 

Creditor days less than or equal to 30 

An underlying deficit that is less than 2% of 

underlying income. 

Underlying EBITDA equal to or greater than 5% 

but less than 1% of underlying income 

Less than 95% but more than or equal to 60% of 

the value of NHS and Non NHS bills are paid 

within 30days 

Less than 95% but more than or equal to 60% of 

the volume of NHS and Non NHS bills are paid 

within 30days 

Current ratio is anything less than 1 and greater 

than or equal to 0.5 

Debtor days greater than 30 and less than or equal 

to 60 days 

Creditor days greater than 30 and less than or 

equal to 60 days 

An underlying deficit that is greater than 2% of 

underlying income 

Underlying EBITDA less than 1% of underlying 

income 

Less than 60% of the value of NHS and Non NHS 

bills are paid within 30 days 

Less than 60% of the volume of NHS and Non 

NHS bills are paid within 30 days 

A current ratio of less than 0.5 

Debtor days greater than 60 

Creditor days greater than 60 

100 100 18 1.33 

1 

1 

2 

1 

2 

3 

1 

0.05 

0.05 

0.05 

0.025 

0.10 

0.15 

0.05

Summary Report for Trust Board on the Workforce Committee held on 8 August 2011 

Items for escalation: None. 

Workforce KPIs: 

Each of the Divisions went through their KPI’s. 

The incorporation of employee relations cases in the KPIs was welcomed as this will 

contribute to improving the management of these. 

Ruth McAll confirmed she is in the process of finalising arrangements for mediation/early 

issues resolution training for managers; this is one of the initiatives to address and reduce 

the large number of formal employee relations cases in the Trust. 

A review of cases in relation to costs and resource is also being undertaken to inform a 

discussion about how best in the short and medium term to reduce the backlog of cases. 

This will be taken to the next Workforce Committee. 

It was reported that an engagement strategy was underway at the Trust and would include 

initiatives such as open staff meetings ‘big conversation’, refreshing of Team Brief and the 

use of short, real time staff surveys. 

Linda Baker confirmed the establishment control project is underway in partnership with 

Finance. 

John Fletcher expressed concern at staff working excessive hours in relation to fitness to 

work and quality of care. It was agreed this would be looked into. 

Recruitment Hotspots and use of agencies verbal update: 

A review of the way we gather information on reasons for leaving and use exit interviews 

would be undertaken to inform a focus on retention as well as recruitment. HR in conjunction 

with the Divisions were validating recruitment hot spots and plans over the coming year in 

order to ensure the temporary staff usage was reduced and corresponding overspends in 

agency and bank staff decreased 

Well Being presentation 

Steve Reipond attended from Occupational Health and provided an update on a number of 

initiatives including the rebranding of his department to the Occupational Health and 

Wellbeing Service, Wellbeing days, audit of implementation of NICE guidance for staff and 

wellbeing, stress audit and creation of wellbeing champions. 

It was suggested a staff well being slot should be incorporate into induction which will be 

looked into. 

The next meeting of the Workforce Committee is on the 12 September 2011. 

Interim Chairman: Mr Edwin Doyle 

Chief Executive: Mrs Averil Dongworth


TITLE: 

Workforce Key Performance Indicators 


TEC & Trust Board 

1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and DATE: 

• The overall number of FTE's in post across the 

Trust increased by 8.13 FTE's on the June 

position and has increased by 210.04 FTE's 

√ TEC – August 2011 □ EPB ………..……. 

across the 12 month period. 

• The number of starters has fallen for the 5th □ FINANCE …………… □ AUDIT ………..…. 

month in succession, there were 40.73 FTE 

starters in July compared to 46.59 FTE's in June 

however, viewing the current medical and nonmedical 

recruitment in process demonstrates 

that higher numbers are expected from 

September onwards. The number of FTE 

leavers has increased from 35.25 FTE's in June 

to 44.96 FTE's in July, Divisions have been 

tasked to actively promote Exit interviews so that 

'reasons for leaving' can be truly understood. 

• Starters & leavers data analysis over the same 

period differs from the staff in post growth for 

the same 3 reasons as in previous reports. 

1. If new starters commence employment or leave 

after the payroll cut off date (midmonth) they will not 

□ CLINICAL GOVERNANCE …………..…...…… 

□ CHARITABLE FUNDS ………………………...… 

√ TRUST BOARD September 2011 

□ REMUNERATION ………………………….…... 

□ OTHER ………………………. (please specify) 

CATEGORY: 

be entered or removed onto/off ESR until month end 

– therefore they will not appear on the staff in post □ NATIONAL TARGET □ CNST 

report generated from ESR until the following month. 

2. Staff who increase or decrease their hours will 

affect the reported FTE’s in post but not the starters 

and leavers 

3. Timliness of managers completing and submitting 

the appropriate forms to HR - for entering onto ESR. 

• For the month July the Trust continued to carry a 

number of vacancies at 575.80 FTE's or 10.03% 

vacancy gap. Vacancies are now calculated 

using monthly information provided by finance on 

Budgeted FTE's, Contracted staff in post and the 

variance between the 2 which equals the 

□ STANDARDS FOR BETTER HEALTH 

□ HEALTH & SAFETY 


□ TARGET FROM COMMISSIONERS 

□ CORPORATE OBJECTIVE ………………….. 

vacancy gap, this is then compared to live …………………………………………………….. 

recruitment activity to provide the number of 

vacancies outstanding. Contracted staff in post 

equals the number of physical people therefore 


is a true reflection of the vacancy gaps across 

the Trust. This method of reporting has been AUTHOR/PRESENTER: 

agreed with Finance. The current vacancy gap 

Author – Linda Baker – Head of workforce 

and temporary staff is discussed in more detail in 

Planning 

a separate report. 

• Trust annualised turnover has risen this month 

11.65% from 11.02%, but is still 0.35% below the 

average of other large acute Trusts. 

Presenter – Ruth MCall – Director of Workforce 

DATE: 

1

• Following the peak during the winter months 

from January to April the sickness absence rate 

reduced back by 1..86% from 5.26% to 3.40% 

before peaking again at 4,82% in May. and then 

again at 5.05% in July .BHRUT's benchmarked 

position shows us as currently sitting 1.45% 

above the Trust target of 3.6% and 0.85% above 

the 4.20% average of all other large acute 

Trusts. 

• Trust-wide there was a total of 125 sickness 

absence cases processed & handled by the 

occupational Health department in July 2011 

Management referral & Management referral 

review at 38% and 42% respectively, 

demonstrate the highest levels of OH activity 

relating to the Trust. As expected as one of the 

largest staff groups within the Trust A&C at 33% 

has the highest number of referrals to the OH 

department, closely followed by Registered 

Nursing & midwifery and HCA's & support 

workers at 21% respectively. 

• A separate non- medical staff ER casework 

report is embedded within the main report 

• Highlights of the Divisonal Workforce KPI 

Scorecards are contained within the main Trust 

scorecard 


None 

3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION: 

N/A 

4. DELIVERABLES: 

Continuous measurement and monitoring of workforce performance against NHS and local agreed targets 

5. EVIDENCE : 

ESR data 

IView Data 

NHSIE data 

6. RECOMMENDATION/ACTION REQUIRED: 

No action for information only 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 

REVIEW DATE ___________________________ 

(if applicable) 

2

TRUST - WORKFORCE KEY PERFORMANCE INDICATORS - JULY 2011 

Indicator Target 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 YTD 

Staff In Post 4998.01 5013.64 5015.97 5041.69 5055.96 5048.64 5067.50 5075.97 5121.85 5157.15 5192.63 5215.55 5223.68 210.04 

Starters *¹ 36.09 53.00 61.74 50.77 54.37 25.36 61.09 38.17 87.27 71.44 55.83 46.59 40.73 646.36 

Leavers *¹ 24.78 65.31 46.36 37.91 32.76 32.50 36.28 27.96 50.95 37.23 32.60 35.25 44.96 480.07 

Turnover (Annualised) 

*¹ 

Vacancies (FTE's) 

Contracted FTE's via 

Finance ledger 

Trust Sickness Absence 

% for month 

12.0% 11.3 11.5 11.8 12.0% 10.9% 11.3% 11.2% 11.1% 11.1% 11.1% 11.0% 11.0% 11.65% 

645.10 637.22 619.19 575.80 

3.6% 4.45 4.07 3.73 4.06 4.41 4.83 5.26 4.51 3.78 3.40 4.82 3.63 5.05 

Trust Sickness Absence 

Rolling 12 Month Period 

3.6% 4.45 4.26 4.08 4.08 4.14 4.26 4.40 4.42 4.34 4.25 4.30 4.25 4.30 

Trust Estimated Cost of 

Sickness Absence 

(Month) *² 

£439,139 £506,637 £442,607 £516,051 £542,212 £599,608 £656,574 £534,500 £523,387 £414,606 £672,178 £482,909 £668,946 £6,560,215 

Appraisals 90.0% 44.3% 54.8% 60.0% 72.7% 85.3% 94.7% 93.1% 87.95% 83.11% 83.06% 78.60% 72.40% 72.09% 

Resus 90.0% 53.6% 73.5% 93.3% 93.1% 89.72% 87.60% 85.52% 80.26% 78.42% 77.38% 

Paybill Budget £22,178,669 £22,275,433 £22,332,464 £22,079,274 £22,318,004 £22,078,804 £21,864,418 £22,163,900 £21,604,748 £22,977,669 £22,735,275 £22,223,328 £22,030,665 £266,683,982 

Paybill £22,977,291 £23,849,384 £23,624,550 £23,960,015 £23,441,035 £23,418,239 £23,464,872 £23,262,763 £22,585,510 £23,625,127 £23,999,750 £24,005,808 £24,058,435 £283,295,488 

Bank/Agency Spend £2,875,803 £4,130,296 £4,048,638 £3,948,964 £3,452,504 £3,370,796 £3,224,520 £3,375,070 £2,662,629 £3,360,963 £3,437,137 £3,361,872 £3,662,378 £42,035,767 

% Paybill Budget spent 

on bank & Agency staff 

12.97% 18.54% 18.13% 17.89% 15.47% 15.27% 14.75% 15.23% 12.32% 14.63% 15.12% 15.13% 16.62% 15.76% 

Overtime Spend (£) £129,554 £207,553 £175,450 £179,732 £192,744 £171,410 £100,662 £137,196 £104,214 £114,580 £131,254 £93,063 £104,179 £1,712,037 

IHB FTE Bookings 632.81 654.68 678.60 669.04 610.13 591.49 634.39 608.99 709.58 628.10 663.81 637.33 677.85 7763.99 

IHB FTE Booked as a % 

of Substantive SIP 

12.66% 13.06% 13.53% 13.27% 12.07% 11.72% 12.52% 12.00% 13.85% 12.18% 12.78% 12.22% 12.98% 12.68% 

*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotation 

*² Estimated cost of sickness absence is calculated by ESR and from August 2010 includes on-costs, i.e. Employers Pension and NI costs 

1

Staff in Post 

Turnover 

FTE 

5500.00 

5300.00 

5100.00 

4900.00 

4700.00 

4500.00 

Percentage 

12.5 

12.0 

11.5 

11.0 

10.5 

10.0 

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 

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 

Month 

Month 

Staff in Post 

Actual Turnover 

Target Turnover 

FTE 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Starters & Leavers in Month 

Starters 

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 

Month 

Leavers 

Starters & leavers data analysis over the same period differs from the staff in post 

growth for the same 3 reasons as in previous reports. 

1. If new starters commence employment or leave after the payroll cut off date 

(midmonth) they will not be entered or removed onto/off ESR until month end – therefore 

they will not appear on the staff in post report generated from ESR until the following 

month. 

2. Staff who increase or decrease their hours will affect the reported FTE’s in post but 

not the starters and leavers 

3.Timliness of managers completing and submitting the appropriate forms to HR - for 

entering onto ESR. 

Staff in Post ( SIP ) 

The overall number of FTE's in post across the Trust increased by 8.13 FTE's on the June position and has 

increased by 210.04 FTE's across the 12 month period. Registered Midwives have increased by 13.51 FTE's 

this month and 54.49 FTE''s over the 12 month period. There have been several recruitment, over-recruitment 

and retention strategies in Registered Nurse and Midwifery areas 

Starters & leavers 

The number of starters has fallen for the 5th month in succession, there were 40.73 FTE starters in July 

compared to 46.59 FTE's in June however, viewing the current medical and non- medical recruitment in 

process demonstrates that higher numbers are expected in September. The number of FTE leavers has 

increased from 35.25 FTE's in June to 44.96 FTE's in July, Divisions have been tasked to actively promote Exit 

interviews so that 'reasons for leaving' can be truly understood. 

Vacancies 

For the month June the Trust continues to carry a significant number of vacancies at 619.19 FTE's or 10.6% 

vacancy gap. Vacancies are now calculated using monthly information provided by finance on Budgeted FTE's, 

Contracted staff in post and the variance between the 2 which equals the vacancy gap, this is then compared to 

live recruitment activity to provide the number of vacancies outstanding. Contracted staff in post equals the 

number of physical people therefore is a true reflection of the vacancy gaps across the Trust. This method of 

reporting has been agreed with Finance. The current vacancy gap and temporary staff is discussed in more 

detail in a separate report. 

Turnover 

Trust annualised turnover has risen this month 11.65% from 11.02%, but is still 0.35% below the average of 

other large acute Trusts. 

Trust Overall Scorecard - July 2011 - Workforce Information Department

SICKNESS ABSENCE 

Real-Time Sickness Absence 

Sickness Absence - Real-time Data v Rerun 3 months later 

Percentage 

7.00 

6.50 

6.00 

5.50 

5.00 

4.50 

4.00 

3.50 

3.00 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Apr-11 

Month 

BHRUT Target Other Large Acute 

May-11 

Jun-11 

Jul-11 

Percentage 

6.00 

5.00 

4.00 

3.00 

2.00 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Month/Year 

Real-time Re-run 3 months + 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Apr-11 

Sickness absence 

Following the peak during the winter months from January to April the sickness absence rate reduced back by 1..86% from 5.26% to 3.40% before peaking again at 4,82% in May. and then again at 

5.05% in July .BHRUT's benchmarked position shows us as currently sitting 1.45% above the Trust target of 3.6% and 0.85% above the 4.20% average of all other large acute Trusts. 

In line with national , regional and local requirements to improve workforce productivity and efficiency we have reviewed and revised our sickness absence target to 3.60% and as discussed in previous 

workforce dashboards and focus reports the workforce information team now re-run sickness absence reports 3 months retrospectively in order to ensure that all absence data has been entered onto ESR 

and our view of actual sickness rates is a true picture which also brings us in line with the IView methodology for the data warehouse.. 

Undertaking this exercise previously has demonstrated a difference of between -1 & -2% in our reported sickness absence rates, which has been shown to be accurate and consistent. 

The sickness absence reports continues to be re-run with a 3 month lag in addition to the 'real time reports' in order to ensure data quality & consistency is being maintained. The graph above shows that 

the reported 'real time' sickness absence rates for April 11 was 3.40%..Having re-run the report 3 months later the reported rate for the same month as 3.79% - a gap of 0.39% 


Occupational Health Activity relating to Sickness Absence 

All of the referrals to OH are related to sickness absence. These are either current absence or ongoing issues with either long term or frequent short term sickness absence 

Trust-wide there was a total of 125 sickness absence cases processed & handled by the occupational Health department in July 2011 

Management referral & Management referral review at 38% and 42% respectively, demonstrate the highest levels of OH activity relating to the Trust. As expected as one of the largest staff groups within 

the Trust A&C at 33% has the highest number of referrals to the OH department, closely followed by Registered Nursing & midwifery and HCA's & support workers at 21% respectively. 

These high levels of related OH activity - especially management referrals correlate with the high sickness absence rates at cost centre level within the Divisions - suggesting that management are using 

the appropriate resources to manage sickness absence. 

It has been the policy of the occupational health and wellbeing department to, where possible, decrease the amount of reviews that are carried out, unless clinically necessary. This has been strongly 

promoted over the past 12 months, with even more emphasis in the past 6 months, with clinical staff being instructed to answer all questions asked (in a management referral), employing a bullet point 

style of answer where possible. This is an attempt to give specific answers to specific questions and cut down on the ‘management issues’ that are increasingly forming a large part of the referral cause 

and reason. 

Divisonal Workforce Referrals to Occupational Health - July 2011 v Divisonal 

Rolling 12 month sickness absence rates 

Cross Referencing Divisional workforce referrals to OH against 

Divisional Sickness absence rates (rolling 12 months) 

Number of Referrals 

50 

45 

40 

35 

30 

25 

20 

15 

10 

5 

6.00% 

5.00% 

4.00% 

3.00% 

2.00% 

1.00% 

Sickness absence rate 

Number of 

rerrals to OH 

rolling 12 

month 

sickness 

absence rate 

The graph to the left demonstrates the latest divisional rolling 12 month 

sickness absence rates versus then umber of referrals to occupational 

health. Data shows that whilst CDT is demonstrating the second highest 

rolling 12 month sickness absence rate in the Trust at 4.8% they also 

demonstrate high levels of Divisionally related OH activity - 47 in month. 

In the main these are management referral reviews.(45%) which 

correlate with the high sickness absence rates across the Division 

suggesting that management are using the appropriate resources to 

formally manage sickness absence. 

In comparison W&C Division continue to have the highest 12 month 

sickness absence rate at 5.01% and have increased their number of OH 

referrals this month to 24- suggesting they are trying to improve the 

management of staff sickness absence 

0 

CDT Corporate Emergency Medical Surgical W&C 

Division 

0.00% 


Non -Medical Staff Employee 

Relations Cases 

Number 

active in 

Month Target 

Number 

more than 

3 months 

old 

Number more 

than 12 

months old 

New cases 

in month 

Capability No UHR 

4 Of 1 1 

Capability UHR 10 Which 6 

1 

Grievance 8 6 1 

5 

Non- Medical Staff ER Casework report 

Yet to be 

agreed 

Employee 

Relations.doc 

Disciplinary 24 12 2 

5 

Bullying & Harassment 

3 2 1 

Employee Tribunals 4 1 

2 

Medical Staff Employee Relations 

Cases 

Capability No UHR 

Capability UHR 

Grievance 

Disciplinary 

Bullying & Harassment 

Employee Tribunals 

Number 

active in 

Month 

Number 

more than 

3 months 

old 

Target 

Of 

3 Which 2 

Yet to be 

8 agreed 

7 

6 

Number more 

than 12 

months 

New cases 

in month 

Medical ER Case work - 

An up to date report on medical ER casework will be presented by the Medical Director, however, the number of ER cases being managed Trust-wide for the senior medical workforce, are concluding and 

a reduction of cases is expected from August 2011. Four cases are now closed, only one was subject to a conduct hearing, one progressing with a GMC assessment and two resulted in informal action. 

Outstanding cases are due to be progressed to hearings scheduled for 2nd and 9th August 2011. It is disappointing that we have very little being reported in sickness absence management this quarter, as 

the trust reliance on temporary spend is growing, vacancies are still the most reported causal. Further analysis is being undertaken to understand how to support the positive management of absence with 

the Medical HR and Medical Management team. 

Trust-wide responses to ET1 forms continue to be undertaken by Medical Personnel with input from the responding managers, resulting in mitigating most claims to ‘case management discussions’ rather 

than ‘hearings’. This is the second quarter to report that there has not been any spend in legal advice to date in managing this reported ER activity. 

We had expected to see a continuous rise in casework as new frameworks such as job planning and ER become embedded into the organisations culture on approach to revalidation. Only one job 

planning mediation has been progressed. It is now expected that this number will increase after the peer review activity in early July 2011. 

There have been a total of 21 GMC queries into the Medical Directors office over the last quarter these queries are now centrally linked to the ER activity data, which allows the trust to respond within 

timeframes and enables us to provide any supporting investigations whenever a fitness to practice is initiated. 

The strong and successful culture of supportive and pastoral care continues to be delivered through the Post Graduate Medical Education Centre to training junior doctors and junior Trust grade doctors, 

with an average of six trainees per month being supported through this process. 


Legal Costs Related to Medical & Non- Medical ER / ET 

Cases - In month 

Beechcroft ( Trust Solicitors) Risk Matrix 

Period 1/06/11 to30/06/11 

Division Costs to date Estimated costs 

£1,696 £6,300 plus £35,00 

CDT 

£7,183 £13,950 plus 

Medical £23,146 £54,345 

Surgical £42,588 £52,900 

W&C £2,458 £4,500 

TOTAL 

£77,071.00 £131,995 plus 

Risk 

High 

Medium 

Medium 

Medium 

Medium 

High 

Medium 

Low 

Financial Risk 

Expected total 

outlay on case 

over £50000 

Expected total 


between £20000 

and £50000 


under £20000 

Reputational Risk 

Test Case or case likely to 

generate significant Press 

interest 

Case that might generate 

some 

Press interest 

Routine case of no particular 

significance 

Case Prospects 

Likelihood of winning the 

case less than 40% 

Likelihood of winning the case 

between 40% and 60% 

Likelihood of winning the case 

more than 60% 


DIVISIONAL HIGHLIGHT REPORTS 

EMERGENCY DIVISION 

Indicator 

Staff In Post 

Turnover (Annualised) *¹ 

Vacancies Contracted FTE's 

via Finance ledger 

Target Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 YTD 

267.14 269.27 278.07 278.71 278.71 289.00 288.55 293.55 318.95 319.65 321.20 321.10 53.96 

12.0% 19.1% 19.6% 18.7% 18.6% 19.3% 19.8% 19.7% 17.8% 16.1% 15.1% 14.4% 15.4% 

53.29 45.20 41.55 42.67 

Divisional Sickness Absence 

For Month 

3.6% 1.70% 3.34% 3.12% 4.02% 4.47% 6.24% 4.03% 2.02% 1.87% 2.53% 3.35% 4.93% 



Appraisals Compliance 

Resus Compliance 

3.6% 2.52% 2.72% 3.16% 3.16% 3.38% 3.78% 3.82% 3.62% 3.44% 3.36% 3.34% 

90.0% 35.2% 41.42% 73.00% 83.04% 91.23% 90.95% 91.21% 87.87% 89.21% 88.16% 81.89% 78.68% 

90.0% 61.57% 78.97% 92.58% 89.96% 87.50% 88.48% 82.33% 85.93% 88.85% 89.96% 

Pay bill Budget 

£1,430,127 £1,310,942 £1,299,199 £1,299,199 £1,299,199 

£1,293,576 £1,293,576 £1,293,755 £1,795,469 £1,724,769 £1,622,745 £1,299,274 £16,961,830 

Pay bill 

Bank/Agency Spend 

% Pay bill Budget spent on 

bank & Agency staff 

Overtime Spend (£) 

IHB FTE Bookings 

£1,870,016 £820,910 £1,814,615 £1,746,625 

£1,711,880 

£1,790,580 £1,823,491 £1,723,480 £1,773,178 £1,694,756 £1,664,617 £1,672,958 £20,107,106 

£806,180 £759,943 £730,881 £640,059 £613,529 £666,928 £696,766 £582,879 £572,041 £510,876 £478,901 £512,332 £7,571,315 

43.11% 57.97% 56.26% 49.27% 47.22% 51.56% 53.86% 45.05% 31.86% 29.62% 29.51% 39.43% 44.64% 

£2,911 £3,629 £2,480 £4,338 £3,267 £3,363 £4,146 £5,560 £4,764 £3,710 £3,074 £3,601 £44,843 

97.95 99.78 94.78 89.15 90.20 92.16 83.37 86.94 79.16 69.00 63.34 67.20 1013.03 


The overall number of FTE's in post across the Division decreased by 0.10 FTE's on the June position but has increased by 53.96 FTE's across the 12 month period. Primarily these increases have 

been in the Registered Nursing & Midwifery staff group which has remained static in month at 190.21 FTE's but has increased by 38.04 FTE''s since January following the formulation of the 

recruitment, over-recruitment and retention strategy at bands 5 & 6 . Conversely the medical staff group has decreased in month by 1.00 FTE and the medical workforce has only grown by 2.00 

FTE's over the 12 month period, despite similar initiatives. 


TURNOVER HOTSPOTS 

Combined QH & 

SIP Aug 2010 

SIP Jul 2011 

Average 

Leavers 

Turnover 

Band 5 Band 6 Band 7 Band 8a Overall 

57 41 22 7 127 

84 49 25 7 165 

71 45 24 7 146 

19 4 1 1 25 

26.95% 8.89% 4.26% 14.29% 17.12% 

Details of Actions to address turnover hotspots 

A&E detailed turnover and leavers update for monitoring purposes - The effects of the registered nurse band 5 overseas recruitment & over-recruitment strategy is demonstrated above - where at 

QH A&E band 5 registered nursing turnover has fallen from 50% to 29.79% since March. KGH A&E band 5 registered nursing turnover has also fallen from 44.4% to 21.28% over the same period. This 

means the combined rate has fallen from 47.9% to 26.95% - almost a 50% reduction in turnover at this level. Clearly when measuring the annualised turnover rates all leavers in the 12 month period are 

utilised in the calculation - therefore the period before the recruitment strategy was formulated when the leaver rate was high is impacting upon the reported rate here. The division must ensure that the 

staff recruited in this initiative are retained and delivery of their retention strategy is paramount in ensuring that turnover rates continue to fall. As anticipated within the strategy this is beginning to impact 

upon temporary staff spend in this area - already discussed in this scorecard. 

The band 6 situation has remained static with no recruitment or leaver activity over the past 4 months - however further work needs to be done by the departments to develop a strategy to recruit to the 

outstanding vacancies at this level. 

FTE's 

175.00 

150.00 

125.00 

100.00 

75.00 

50.00 

25.00 

0.00 

Combined A&E Qualified Nursing - Staff in Post V IHB Booking V 

Annualised Turnover 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Month 

Apr-11 

May-11 

Jun-11 

Jul-11 

Aug-11 

Sep-11 

Oct-11 

N&M Qual (IHB) N&M Qual (SIP) N&M Qual (Turnover) 

35.00% 

30.00% 

25.00% 

20.00% 

15.00% 

10.00% 

5.00% 

0.00% 

Turnover % 

Effects of the A&E over-recruitment strategy - Staff in post V Turnover V 

IHB Bookings - trends analysis 

The graph to the left demonstrates the effects of the Combined A&E 

departments strategy to recruit to the existing Registered nursing vacancies - 

especially band 5 , and over-recruit in order to stabilise the departments. and 

reduce reliance on temporary staff 

The graph clearly identifies the points at which these new recruits came into post 

and the steady growth in numbers since, whilst, as predicted turnover has fallen 

by 42% over the 6 month period and IHB bookings have fallen by 64% to date. 

Staff in post numbers have been mapped through to the end October by looking 

at current recruitment in process and predicting turnover rates in order to allow 

realistic adjustment of the staff in post numbers going forward. Projected 

numbers and turnover rates are indicated by dotted lines. 

There is a separate IHB report which has predicted further temporary staff 

reductions based upon current recruitment activity. 


VACANCY HOTSPOTS 

QH A&E Medical Staff with 10.00 FTE vacancies 

QH A&E Nursing with 6.45 FTE vacancies at Registered nursing level - in the main at band 6 

KGH A&E Medical staff with 14.44 FTE Vacancies 

KGH A&E Nursing with 14.03 FTE Vacancies at registered nursing level - in the main at bands 5 & 6 

EDMU with 4.53 FTE vacancies 

NON-MEDICAL RECRUITMENT ACTIVITY 

Table 1 

Division 

Emergency Care 

(A&E) 

TOTAL 

Staff Groups 

Nursing/Midwifery 

HCA 

A&C inc Managers & senior managers 

AHP/STT 

Vacancies - Contracted 

Via the Ledger) 

17.54 

8.71 

0.44 over 

0.02 

25.83 

WTE in 

recruitment 

process 

Variance - remaining 

vacancies 

15.22 (2.32) 

0.00 (8.71) 

0.00 0.44 over 

0.00 (0.02) 

15.22 (10.61) 

RED = Over funded establishment ( ) = vacancies 

Table 2 

Projected Start Dates of Non Medical Recruitment in process ( Excluding vacancies out to advert ,including - post 

Emergency Division - Non Medical 

staff 

N&MW 

HCA's & support workers 

A&C inc managers & senior managers 

1st - 15th 

August 

WTE 

16th -31st 

August 

WTE 

1st -15th 

Sept WTE 

16th-30th 

Sept WTE 

1st -15th 

October 

WTE 

16th-31st 

October 

WTE Total 

6.00 3.63 2.59 1.00 2.00 0.00 15.22 

0.00 0.00 0.00 0.00 0.00 0.00 0.00 

0.00 0.00 0.00 0.00 0.00 0.00 0.00 

AHP/STT 

0.00 0.60 0.00 0.00 0.00 0.00 0.00 


Non Medical Recruitment in process 

According to the financial Ledger the Emergency division as a whole is carrying 42.67 Contracted FTE vacancies as at July 2011, of which 25.83 FTE's relate to non- medical vacancies and 17.54 of 

these relate to registered nursing . This situation wasn't anticipated in light of the strategy to over-recruit to their existing A&E nursing vacancies however, there are currently a further 15.22 FTE's in the 

recruitment process- leaving a further 2.32 vacancies at this level. Should all the non-medical candidates currently in the recruitment process ( post interview and offer but not in post) actually start in 

post, at the highest level the division will have 10.61 vacancies outstanding - Table 1 . The situation does not show the staggered effect of staff coming into post over time - Table 2 and take into account 

Divisonal annualised turnover of 15.4% equalling an average of 3.65 FTE leavers per month. 

MEDICAL RECRUITMENT ACTIVITY 

Table 3 

Emergency Medicine 

Post 

No of FTE vacant 

posts 

FTE being recruited to 


vacancies 

Action to address variance 

Consultant in 


Middle Grade Trust 

Doctor 

Basic Grade Trust 

Doctor 

DIVISIONAL 

24.44 

8.00 

12.00 

15.00 

35.00 

10.56 

2 x offers made (1xIHB, 1 x Latitudes) 

3 x Offers made via Open Day (2 x started Aug, 1 x awaiting Tier 2), 1 x offered via Agency 

(awaiting Tier 2) 1 x offered PT via Dept. Overseas recruitment campaign in progress 

Australia and Ireland, two agencies out to advert. A&E Overseas recruitment career 

11 offers made on Doctors Open Day held on 27 June 2011 (3 x awaiting Tier 2), 2 offers 

made following interviews by department 

Active over recruitment - struggling to retain due to large vacancies 

Table 4 

Projected Start Dates of Recruitment in process ( post interview and acceptance of conditional 

offer but not yet in post) By FTE's & staff group 

Emergency 

Division - Medical 

staff 

M&D Consultant 

M&D Middle Grades 

M&D Basic Grades 

Total 

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 

0.00 0.00 0.00 0.00 0.00 2.00 0.00 

0.00 0.00 0.00 0.00 6.00 4.00 4.00 

0.00 10.00 2.00 2.00 0.00 0.00 0.00 

0.00 10.00 2.00 2.00 6.00 6.00 4.00 



Medical Recruitment in process 

As at July 2011 the financial ledger showed there were 24.44 Contracted FTE medical staffing vacancies within the Emergency Division. Should all the medical staffing vacancies currently in process 

be recruited to, at the highest level there would be no vacancies and in fact the situation would be 10.56 FTE's over-establishment- feedback from the Associate Director medical staffing identifies this 

is a deliberate strategy due to difficulties in retaining staff. However, the situation also does not show the staggered effect of staff coming into post over time.. There are focused campaigns underway 

to attempt to bridge the vacancy gap - as described above and on previous page however, progress is slow. 


SURGICAL DIVISION 

Indicator 

Staff In Post 





For Month 







1248.46 1261.71 1276.70 1279.18 1284.62 1288.17 1293.02 1293.42 1305.73 1317.25 1317.26 1318.57 70.11 

12.0% 11.1% 11.9% 11.9% 10.4% 10.9% 10.6% 10.5% 10.2% 9.8% 9.2% 9.2% 9.3% 

206.77 187.77 196.41 198.39 

3.6% 3.12% 3.40% 2.87% 3.31% 3.65% 4.33% 3.57% 3.34% 2.75% 4.57% 3.41% 4.58% 

3.6% 3.36% 3.37% 3.25% 3.26% 3.26% 3.33% 3.47% 3.48% 3.47% 3.39% 3.50% 3.48% 

90.0% 53.8% 59.58% 72.79% 88.35% 95.10% 94.78% 88.58% 82.27% 85.05% 83.46% 81.02% 79.02% 

90.0% 50.08% 69.56% 91.84% 93.13% 89.84% 89.14% 87.97% 83.61% 82.01% 79.21% 

£6,194,709 £6,035,536 £6,084,270 £6,117,176 £6,003,323 £6,006,785 £6,068,837 £6,069,700 £6,315,688 £6,181,766 £6,159,190 £6,173,456 £73,410,436 

Pay bill 

£6,604,995 £6,669,671 £6,614,210 £6,540,467 £6,582,818 £6,330,528 £6,379,308 £6,522,453 £6,469,615 £6,634,686 £6,596,278 £6,537,943 £78,482,972 


£1,214,079 £1,317,763 £1,211,271 £1,042,833 £1,062,618 £791,010 £925,402 £913,975 £960,176 £1,017,999 £917,045 £1,002,132 £12,376,303 





19.60% 21.83% 19.91% 17.05% 17.70% 13.18% 15.41% 15.06% 15.82% 16.12% 14.83% 16.27% 16.86% 

£81,533 £62,729 £68,392 £78,802 £67,531 £13,440 £16,167 £13,652 £20,635 £19,440 £16,440 £15,723 £474,484 

97.95 99.78 94.78 89.15 90.20 92.16 83.37 86.94 79.16 69.00 63.34 67.20 1013.03 


The overall number of FTE's in post across the Division increased by 1.29 FTE's on the June position and 70.11 FTE's across the 12 month period. Primarily these increases have been in the N&MW 

registered staff group which has increased by 2.72 FTE's in month and 34.21 FTE's since January. 

VACANCY HOTSPOTS - BY SPECIALITY 


Anaesthetic Medical staff with 15.07 FTE vacancies 

Neurosciences with 39.41 FTE vacancies at Medical staff , HCA & Registered nurse levels 

Theatres with 25.99 FTE vacancies at HCA, Registered Nurse and PTB level 

Urology with 8.17 FTE vacancies at Medical staff and registered nurse level. 

Orthopaedics with 33.40 FTE vacancies at Medical staff , HCA & Registered nurse levels 

ENT with 12.64 FTE vacancies at Medical staff , HCA & Registered nurse levels 

Critical care with 29.70 FTE vacancies at Registered Nurse and HCA level 

General Surgery - 17.56 Vacancies at Medical staffing, Registered nurse & HCA level 

Table 1 

Division 

Surgery 

TOTAL 

Staff Groups 


HCA 

A&C inc Managers & senior 

managers 

AHP/STT 

Vacancies - 

Contracted FTE's - 


99.97 

39.08 

3.61 

12.41 

155.07 

WTE in recruitment 

process 

59.9 

11.81 

0.5 

0.43 

72.64 


vacancies 

(40.07) 

(27.27) 

(3.11) 

(11.98) 

(82.43) 


table 2 


interview and acceptance of conditional offer but not yet in post) By FTE's & staff group 

Surgical Division - Non Medical staff 

N&MW 



AHP/STT 

1st - 15th 

August 

WTE 

16th -31st 

August 

WTE 

1st -15th 

Sept WTE 

16th-30th 

Sept WTE 

1st -15th 

October 

WTE 

16th-31st 

October 

WTE Total 

14.92 9.00 3.00 6.00 19.24 7.74 59.90 

2.00 1.00 1.00 0.00 2.81 5.00 11.81 

0.00 0.00 0.00 0.50 0.00 0.00 0.50 

0.43 0.60 0.00 0.00 0.00 0.00 0.43 


Non Medical 

According to the financial Ledger the Surgical division as a whole is carrying a number of vacancies 198.39 Contracted FTE's as at July 2011 , of which 155.07 FTE vacancies relate to non-medical 

staff. Should all the non-medical candidates currently in the recruitment process actually start in post, at the highest level there would be 82.43 vacancies remaining - table 1 . The situation does not 

show the staggered effect of staff coming into post over time - Table 2 and take into account the Divisonal annualised turnover of 9.3% equalling an average of 7.63 FTE leavers per month. 


Surgical Division 

Anaesthetics - Post 

Consultant Intensivist 

Specialty Doctor Anaesthetics 

Specialty Doctor Critical Care 

LAT ST3+ 

Middle Grade Anaesthetics 

Middle Grade Trust Doctors 

Urology - Posts 

Consultant Lower GI 

Speciality Doctor Urology 

Middle Grade Urology 

Basic grade Urology 

Musculoskeletal Posts 

No of FTE vacant posts FTE being recruited to 

1.00 

3.00 

5.00 

1.00 

5.00 

2.00 

2.00 

1.00 

1.00 

1.00 

Consultant in Rheumatology 

1.00 

Consultant T&O 

1.00 

Speciality Doctor T&O 

1.00 

Specialty Doctor Rheumatology 

1.00 

Basic Grade T&O 

4.00 

Research Fellow T&O 

1.00 

Surgical Specialties -Posts 

Consultant Orthodontist 

1.00 

Speciality Doctor Ophthalmology 

1.00 

Specialty Doctor Neurosurgery 

1.00 

Speciality Doctor ENT 

1.00 

Specialty Doctor Stroke 

2.00 

SpR LAT Neurosurgery 

1.00 

Specialty Doctor Dermatology 

1.00 

Basic Grade Neurosurgery 

2.00 

Basic Grade ENT 

2.00 

DIVISIONAL TOTAL 43.32 

43.00 

Variance - 

remaining 

vacancies 

(0.32) 


AAC arranged for 31.08.11 

3 posts recruited to starting 1 x Oct, 2 x Nov 

5 posts recruited to started June 

Failed to recruit, to re-advertise 

Advert closing 08.08.11 

2 posts offered started in June 2011 (Overseas Lithuanian 

2 x Offers made 1 x starting 19.09.11, 1 x starting 03.10.11 

Post recruited to starting Nov 2011 

Post recruited starting Aug 2011 

Post advertised 06.07.11, short listing stage 

Post recruited to (Start date in Sep 2011) 

Awaiting JD Approval 


Dept advised to put on hold 

4 posts recruited to (1 withdrawn) 

Post recruited to 


Post on hold, Dept to convert to Consultant post 

Post recruited to started 01.08.11 


Post recruited to 1 x starting Sep 2011, 1 x offer sent 

Post recruited to starting Oct 2011 

Post recruited to start in Sep 2011 

Interviews arranged for 09.08.11 

2 x offers made, to start in Sep 2011 

Table 4 

Projected Start Dates of Medical Staff Recruitment in process ( post interview and acceptance of conditional offer but not yet in 

Surgical Division - Medical staff 




1.00 0.00 0.00 0.00 0.00 0.00 0.00 

M&D Middle Grades 1.00 0.00 1.00 1.00 1.00 1.00 1.00 


1.00 0.00 1.00 1.00 1.00 1.00 1.00 

Medical 

As at July 2011 there were 43.32 contracted FTE medical staffing vacancies within the Surgical Division. Should all the medical staff currently in the recruitment process be recruited to, at the 

highest level there would be 0.32 FTE vacancies remaining (table 3) . However, the situation also does not show the staggered effect of staff coming into post over time (Table 4) - hence the 

need for monthly monitoring of vacancies versus staff in post. There are focussed campaigns underway to recruit to these posts as identified on previous page. 

WOMENS & CHILDREN'S DIVISION 

Indicator 

Staff In Post 


722.86 721.72 734.77 754.67 758.55 758.43 761.20 774.55 785.92 796.96 811.26 814.67 91.81 



12.0% 11.7% 13.0% 13.1% 10.6% 11.6% 12.0% 11.5% 11.0% 10.5% 10.7% 11.0% 13.4% 




For Month 






Pay bill 






106.06 87.44 86.56 79.82 

3.6% 5.70% 5.46% 5.47% 5.60% 7.06% 6.50% 4.82% 4.68% 4.39% 4.85% 2.38% 5.56% 

3.6% 4.65% 4.92% 5.06% 5.17% 5.48% 5.63% 5.53% 5.43% 5.33% 5.28% 5.04% 5.21% 

90.0% 53.2% 54.98% 61.17% 77.35% 90.55% 88.92% 83.75% 77.33% 75.30% 70.24% 64.19% 68.57% 

90.0% 57.42% 72.97% 91.44% 89.70% 85.03% 80.03% 75.83% 66.49% 61.76% 66.06% 

£3,387,223 £3,349,561 £3,342,544 £3,342,544 £3,339,493 £3,343,998 £3,343,998 £3,336,212 £3,473,768 £3,473,768 £3,473,768 £3,452,899 £40,659,776 

£3,615,345 £3,580,056 £3,514,660 £3,442,433 £3,436,428 £3,554,285 £3,550,330 £3,748,296 £3,764,460 £3,880,509 £3,928,131 £3,968,435 £43,983,368 

£627,856 £695,206 £579,180 £421,360 £397,302 £425,219 £508,255 £600,449 £594,352 £642,717 £667,286 £717,006 £6,876,188 

18.54% 20.76% 17.33% 12.61% 11.90% 12.73% 15.20% 17.96% 17.82% 18.50% 19.21% 20.64% 199.14% 

£18,331 £13,664 £14,285 £15,408 £17,809 £20,145 £16,258 £13,267 £12,936 £15,898 £9,120 £9,399 £176,520 

112.16 113.17 105.68 88.49 91.55 96.68 96.48 128.90 115.17 121.87 125.98 139.73 1335.86 


The overall number of FTE's in post across the Division increased by 3.41 FTE's on the June position and has increased by 91.81 FTE's across the 12 month period. Primarily these increases have 

been in the Midwifery staff group which has increased by a further 13.51 FTE's in month and a 33.41 FTE increase since January. This is expected in light of the focused recruitment campaign and 

strategy to over-recruit in recent months - although there still remains a c13.1% (42.91 FTE) vacancy gap. There are a further 1.8 FTE over-seas midwives expected to start in August, then a further 

22 FTE in September and October giving a total of 45.8 midwives expected to start in the next 3 months. Assuming there are no leavers in the interim this will bring the total of midwives in post to 

328.97 FTE's - 2.89 FTE's over-establishment 


Gynaecology with 9.04 FTE vacancies at Medical staffing, Registered nurse & HCA level. 

Midwifery with 36.02 FTE vacancies at Midwives, Registered nurse, and HCA level 


Paediatrics with 16.40 FTE vacancies at Medical staffing, Registered nurse & HCA level. 

NICU/SCBU with 15.13 FTE vacancies at Registered nurse level 

Table 1 

Divisions 

W&C 

Staff Groups 


HCA 

Vacancies - 



69.85 

3.21 


process 

86.80 

3.42 


vacancies 

16.95 

0.21 

TOTAL 


AHP/STT 

0.21 over 

0.49 

73.34 

3.80 

0.00 

94.02 

4.01 

(0.49) 

20.68 


Table 2 



W&C Division - Non Medical staff 

N&MW 



AHP/STT 

1st - 15th 

August 

WTE 

16th -31st 

August 

WTE 

1st -15th 

Sept WTE 

16th- 

30th 

Sept 

WTE 

1st -15th 

October WTE 

16th-31st 

October 

WTE Total 

4.00 7.80 9.00 32.00 29.00 5.00 86.80 

0.00 0.00 0.00 1.00 0.00 2.42 3.42 

1.80 0.00 0.00 1.00 0.00 1.00 3.80 

0.00 0.00 0.00 0.00 0.00 0.00 0.00 

Non Medical 

According to the financial Ledger the w&c Division as a whole is carrying 79.82 Contracted FTE vacancies as at July 2011, of which 73.34 FTE's relate to non- medical vacancies. With the yields from the 

current midwifery over-recruitment and paediatric recruitment initiatives, current recruitment in process will leave this staff group over-establishment by 16.95 FTE's, should all the successful candidates 

come into post - table 1. However, The situation does not show the staggered effect of staff coming into post over time - table 2 and take into account Divisonal annualised turnover of 13.4% equalling 

an average of 6.4 FTE leavers per month- which will negate the over-establishment effect in part. Therefore monthly monitoring of vacancies versus SIP is essential. 


Table 3 

Women's & Children's Division 

Women's Posts 

Consultant in O&G 

1 x ST1/2 LAS (GPVTS Gaps) Paeds 

Trust Overall Scorecard - July 2011 - Workforce Information Department 

No of FTE vacant posts FTE being recruited to 

2.00 

1.00 

Variance - 

remaining 

vacancies 


2 posts offered 1 starting Aug 2011, 1 starting Nov 2011 

1 post recruited to starting August 2011

Children's Posts 

Consultant in Paediatrics (named Dr for 

safe guarding) 

Consultant with Acute Paeds, HDU and 

A&E interest 

Specialty Doctor Paeds 

2 x ST4 LAT 

Middle Grade Trust Doctor 

Basic Grade Paeds/A&E 

Basic Grade Trust Doctor 

DIVISIONAL TOTAL 

No of FTE vacant posts 

6.48 

FTE being recruited 

to 

1.00 

Variance - 

remaining 

vacancies 

1.00 

2.00 

2.00 

3.00 

4.00 

3.00 

19.00 12.52 


Awaiting VCP approval (introduction of consultant hybrid model to reduce reliance on 

Middle Grade Doctors) 

Post out to Ad, AAC 16.09.11 

Failed to recruit x1, post on hold 

Advert out, closed 03.08.11 interviews tba 

2 x Posts recruited to starting August 2011, 1 x re-advertised 

4 x Posts recruited to starting August 2011 

3 x Posts recruited to 1 x starting Aug 2011, 1 x Sep 2011, 1 x Oct 2011 


Table 4 

Projected Start Dates of Recruitment in process ( post interview and acceptance of conditional offer but not 

yet in post) By FTE's & staff group 

W&C Division - Medical Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 


2.00 0.00 0.00 1.00 0.00 0.00 2.00 


2.00 3.00 0.00 0.00 0.00 0.00 0.00 


5.00 1.00 1.00 0.00 0.00 0.00 0.00 

Total 

9.00 4.00 1.00 1.00 0.00 0.00 2.00 

Medical 

As at July 2011 the financial ledger showed there were 6.48 Contracted FTE medical staffing vacancies within the Women's & Children's Division, with the current recruitment initiatives should all 

candidates come into post there will be zero vacancies and the Division will be 12.52 FTE's over-establishment - Table 3,. However, The situation does not show the staggered effect of staff coming into 

post over time - table 4 and take account of the turnover within the staff group. 

MEDICAL DIVISION 

Indicator 

Staff In Post 





897.59 893.64 892.16 890.50 881.28 888.34 891.23 904.06 910.51 926.82 924.12 927.06 29.47 

12.0% 9.6% 10.5% 11.0% 9.7% 10.6% 10.2% 10.8% 11.7% 11.6% 11.0% 11.2% 11.6% 

118.14 126.15 109.40 77.53 



For Month 






Pay bill 


3.6% 5.12% 3.09% 4.40% 4.39% 3.99% 5.45% 5.13% 4.26% 3.56% 5.53% 5.04% 5.54% 

3.6% 4.36% 3.94% 4.05% 4.12% 4.10% 4.29% 4.40% 4.38% 4.30% 4.41% 4.46% 4.63% 

90.0% 57.0% 64.93% 75.74% 86.77% 95.17% 93.83% 90.67% 83.38% 84.66% 76.65% 66.15% 63.41% 

90.0% 46.83% 94.08% 93.31% 94.08% 92.66% 90.20% 88.80% 83.14% 83.09% 80.39% 

£3,665,337 £3,576,468 £3,477,366 £3,673,866 £3,663,405 £3,772,944 £3,687,776 £3,521,774 £3,820,904 £3,922,348 £3,843,100 £3,818,783 £44,444,071 

£3,173,847 £3,883,878 £3,924,632 £3,190,987 £3,867,620 £3,973,826 £3,781,731 £3,794,175 £3,907,166 £4,161,068 £4,071,506 £402,549 £42,132,985 

£731,937 £682,579 £710,721 £666,477 £623,475 £676,795 £580,607 £537,133 £674,382 £757,221 £671,173 £645,896 £7,958,396 





23.06% 19.07% 20.44% 18.14% 17.02% 17.94% 15.74% 15.25% 17.65% 19.31% 17.46% 16.91% 17.91% 

£4,624 £3,871 £4,180 £4,176 £7,309 -£192 £3,509 £4,140 £1,670 £7,994 £2,046 £3,979 £47,306 

135.69 152.66 170.96 173.12 150.17 179.94 158.26 184.43 170.07 175.68 155.73 148.14 1954.85 


The overall number of FTE's in post across the Division increased by 2.94 FTE's on the June position and increased by 29.47 FTE's across the 12 month period. Primarily these increases have 

been in the Nursing & Midwifery staff group which has increased by 35.92 FTE's in the last 12 months. This increase is due to several focused recruitment campaigns in recent months. 


Cardiology with 20.55 FTE vacancies at Registered nurse, PTB and HCA levels 

General Medicine with 23.38 FTE vacancies at Medical staff, Registered Nurse & HCA 

levels 

Endoscopy with 12.61 FTE vacancies at Medical staffing and HCA level. 

Respiratory with 13.38 FTE vacancies at registered nurse and HCA levels. 



Table 1 

Division 

TOTAL 

Medicine 

Staff Groups 


HCA 

A&C inc Managers & senior 

managers 

AHP/STT 

Vacancies - 



27.02 

29.11 

4.92 

5.65 

66.7 


process 

18.00 

15.60 

4.28 

1.00 

38.88 


vacancies 

(9.02) 

(13.51) 

(0.64) 

(4.65) 

27.82 


Table 2 



Medical Division - Non Medical staff 

N&MW 



AHP/STT 

Non Medical 

1st - 15th 

August 

WTE 

16th -31st 

August 

WTE 

1st -15th 

Sept WTE 

16th- 

30th 

Sept 

WTE 

1st -15th 

October WTE 

16th-31st 

October 

WTE Total 

1.00 0.00 0.00 15.00 0.00 2.00 18.00 

6.00 6.00 1.00 1.00 1.60 0.00 15.60 

2.28 0.00 0.00 2.00 0.00 0.00 4.28 

0.00 0.00 0.00 0.00 0.00 1.00 1.00 

According to the financial Ledger the Medical division as a whole is carrying 77.53 Contracted FTE vacancies as at July 2011, of which 66.70 FTE's relate to non- medical staffing vacancies Should all 

the non-medical candidates currently in the recruitment process ( post interview and offer but not in post) actually start in post, at the highest level there would be 27.82 vacancies remaining - table 1 . The 

situation does not show the staggered effect of staff coming into post over time - Table 2 and take into account the Divisonal annualised turnover of 11.6% equalling an average of 6.92 FTE leavers per 

month. Therefore monthly monitoring of vacancies versus SIP is essential Targeted campaigns are continuing 


Table 3 

Medicine 

Post 

Consultant in Acute Medicine 

Consultant in Gastro 


posts 

FTE being recruited 

to 

4.00 

1.00 

Consultant Physician and 

Endocrinologist 

1.00 

SpR LAS in Renal 1.00 

Trust Overall Scorecard - July 2011 - Workforce Information Department 


vacancies 


2 posts recruited to (1 x starting Sep 1x starting Nov), awaiting new advert 



Post recruited to start date 15 Aug 2011

SpR LAS in Acute Medicine 1.00 

SpR LAS in Endocrine 

2.00 

SpR LAS in Cardiology 

1.00 

SpR LAS Acute Elderly Meds 

2.00 

training gaps 

12.00 

DIVISIONAL TOTAL 

10.83 

25.00 

14.17 

Post advertised, short listing stage, interviews tba 

1 x start in Aug 2011 (recruited to) and 1 x start in Sept 2011 to re- 

Failed to recruit - Re-advertised closing 19.08.11 

Successful candidate withdrew, p yadvert closed, interviews tba g 

awaiting CRB 

Projected Start Dates of Recruitment in process ( post interview and acceptance of conditional offer but not yet in post) 

By FTE's & staff group 

Medical Division - Medical staff 




Total 


0.00 1.00 0.00 1.00 1.00 1.00 1.00 

2.00 4.00 1.00 0.00 0.00 0.00 0.00 

11.00 1.00 0.00 0.00 0.00 0.00 0.00 

13.00 6.00 1.00 1.00 1.00 1.00 1.00 

Medical staff - recruitment in process 

As at July 2011 the financial ledger showed there were 10.83 Contracted FTE medical staffing vacancies within the Medical Division. Should all the medical staff currently in the 

recruitment process be recruited , at the highest level there would be zero vacancies and in fact the division would be 14.17 FTE's over their funded establishment - table 3. However, 

the situation also does not show the staggered effect of staff coming into post over time - table 4 versus staff leaving hence the need for monthly monitoring of vacancies versus staff in 

post. 

CDT DIVISION 

Indicator 

Staff In Post 



1366.81 1362.26 1356.45 1351.06 1342.40 1347.53 1352.78 1362.65 1354.59 1358.85 1371.33 1373.96 

7.15 

12.0% 9.0% 9.3% 9.2% 9.0% 9.1% 8.6% 8.4% 8.4% 8.7% 9.2% 9.0% 9.5% 



151.53 160.95 149.52 143.03 


For Month 

3.6% 3.79% 4.07% 4.56% 5.2% 5.97% 5.89% 5.33% 3.80% 3.33% 5.64% 4.05% 5.94% 







Pay bill 




3.6% 3.70% 3.82% 4.01% 4.3% 4.54% 4.73% 4.81% 4.69% 4.56% 4.66% 4.61% 4.80% 

90.0% 53.1% 58.36% 72.46% 83.4% 95.45% 93.15% 86.07% 83.60% 82.16% 78.24% 72.19% 74.71% 

90.0% 63.67% 84.3% 98.78% 96.75% 91.71% 89.72% 88.98% 83.94% 80.66% 77.57% 

£5,180,713 £5,157,589 £5,064,327 £5,062,314 £5,033,069 £4,833,826 £4,974,336 £4,975,408 £5,311,902 £5,275,674 £5,286,287 £5,251,513 £61,406,958 

£5,560,224 £5,316,507 £5,433,920 £5,384,119 £5,332,277 £5,385,535 £5,368,272 £5,202,347 £5,320,068 £5,313,838 £5,341,787 £5,412,515 £64,371,409 

£714,691 £539,329 £615,821 £559,878 £571,153 £604,485 £596,609 £457,331 £486,388 £445,366 £458,474 £589,898 £6,639,423 

13.80% 10.46% 12.16% 11.1% 11.35% 12.51% 11.99% 9.19% 9.16% 8.44% 8.67% 11.23% 10.81% 



£91,975 £83,704 £79,822 £81,811 £68,599 £58,173 £90,328 £62,561 £66,710 £77,646 £56,049 £68,125 £885,503 

72.53 74.30 72.04 

62.06 

56.61 66.83 72.32 77.88 75.38 93.32 99.16 104.88 927.31 


The overall number of FTE's in post across the Division increased by 2.63 FTE's on the June position and has increased by 7.15 FTE's across the 12 month period. As 

expected as one of the largest staff groups within the Division primarily these increases have been in the A&C staff group which has increased by 8.14 FTE's since April 

following a recruitment freeze in late 2010 

VACANCY HOTSPOTS 

Pharmacy with 9.23 FTE Vacancies at Pharmacist and PTB level 

Healthcare Records with 30.09 FTE vacancies at A&C level. 

Pathology - with 15.12 FTE vacancies at PTB level 

Radiology with 29.07 FTE vacancies at Radiologist and PAMS levels 

Therapies with 26.31 FTE vacancies at PAMS level 

Outpatients with 16.54 FTE vacancies at A&C, Registered Nurse and HCA levels 

Oncology with 9.98 FTE vacancies at Medical, A&C and STT staff levels 



Table 1 

Divisions 

TOTAL 

CDT 

Staff Groups 


HCA 


AHP/STT 

Vacancies - Contracted 

FTE's - Via the Ledger) 

4.84 

3.12 

50.76 

72.01 

130.73 


process 

3.8 

2.96 

11.17 

58.71 

76.64 


vacancies 

(1.04) 

(0.16) 

(39.59) 

(13.30) 

(54.09) 


Table 2 



CDT Division - Non Medical staff 

N&MW 



AHP/STT 

1st - 15th 

August 

WTE 

16th -31st 

August 

WTE 

1st -15th 

Sept WTE 

16th- 

30th 

Sept 

WTE 

1st -15th 

October WTE 

16th-31st 

October 

WTE Total 

1.80 0.00 0.00 1.00 1.00 0.00 3.80 

1.00 0.00 0.00 1.96 0.00 0.00 2.96 

3.50 0.67 3.00 4.00 0.00 0.00 11.17 

16.08 11.61 9.69 16.00 0.73 4.60 58.71 

Non Medical 

According to the financial Ledger the CDT division as a whole is continuing to carry a significant number of vacancies at 143.03 Contracted FTE's as at July 2011, of which 130.73 vacancies 

relate to non-medical staff Should all the non-medical candidates currently in the recruitment process ( post interview and offer but not in post) actually start in post, at the highest level there 

would be 54.09 Contracted FTE non- medical vacancies remaining - Table 1 The situation also does not show the staggered effect of staff coming into post over time - Table 2 and take into 

account Divisonal annualised turnover of 9..5% equalling an average of 9.55 FTE leavers per month. Therefore monthly monitoring of vacancies versus SIP is essential if gaps are to be 

bridged. 


Table 3 

Cancer, Diagnostic and Therapeutics 



Posts 

posts 

Consultant Cross Sectional General Breast 

Consultant General interventional 

Consultant in Cellular Pathology 

Specialty Doctors 

SpR LAT Oncology 

Basic Grade Haem & Onc 

DIVISIONAL TOTAL 12.30 

Table 4 

FTE being recruited to 

1.00 

1.00 

1.00 

3.00 

1.00 

2.00 

9.00 

Variance - 

remaining 

vacancies 

(3.30) 


Three AAC panels held failed to recruit, division reviewing workforce plan to issue instruction 

Failed to recruit x1, post to be re-advertised. Awaiting instruction from Dept 

1 x post offered, awaiting start date 

Post closed, short listing stage 

Post on hold 

2 x Posts recruited to at Open Day held on 27.06.11, 1 x started 03.08.11, 1 x start Sep 2011 

Projected Start Dates of Recruitment in process ( post interview and acceptance of conditional offer but not 

yet in post) By FTE's & staff group 

CDT Division - Medical staff 




Total 

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 

0.00 0.00 0.00 0.00 2.00 1.00 

0.00 1.00 0.00 3.00 0.00 0.00 

1.00 1.00 0.00 0.00 0.00 0.00 

1.00 2.00 0.00 3.00 2.00 1.00 

Medical staff - recruitment in process 

As at July 2011 the financial ledger showed there were 12.30 Contracted FTE medical staffing vacancies within the CDT Division. Should all the medical staffing vacancies be recruited to, at the 

highest level there would be 3.30 Contracted FTE vacancies remaining - Table 3. However, the situation also does not show the staggered effect of staff coming into post over time - Table 4 - hence 

the need for monthly monitoring of vacancies versus staff in post. There are focused campaigns underway to recruit to these posts as identified above 


TITLE: 

Activity Report August 2011 





For the period April – July 2011 performance against plan 

for the Payment by Results (PbR) Points of Delivery 

(PODs) is summarised in the table below: 

POD 

Planned 

Activity 

(Apr-Jul) 

Actual 

Activity 

(Apr-Jul) 

% 

Variance 

YTD 

A&E 50773 61214 20.54 

Daycase 13105 13447 2.61 

Elective 2793 2565 (8.18) 

Non Elective 22308 26659 19.51 

OPFA 55952 54705 (2.23) 

OPFUP 119770 128441 7.24 

OPPROC 8474 10649 25.66 

As can be seen, there is significant overperformance in the 

A&E, Non-Elective, Outpatient Follow-up and Outpatient 

Procedure PODs, Daycase and Outpatient First 

Attendances are broadly on plan and there is significant 

underperformance in the Elective POD. 

When compared to the same period in 2010/11, activity in 

the ‘emergency care’ PODs (A&E, non-elective) is at a 

similar or higher level, however activity in the ‘planned 

care’ PODs (elective, daycase, outpatient first attendance, 

outpatient follow-up attendance) is at a significantly lower 

level. 

□ PEQ ……….….……..…. □ STRATEGY……….….……. 

□ FINANCE ……..……… □ AUDIT ………….……..…. 



TRUST BOARD 7 th September 2011 

□ REMUNERATION ………………………………….…... 

□ OTHER ……………………..……. (please specify) 


The Trust Board is asked to: 

o 

o 

Note and discuss the current activity levels; 

Discuss and agree any actions to be taken to 

mitigate the financial risks related to current levels 

of performance. 




CQUIN/TARGET FROM COMMISSIONERS 



AUTHOR: Steve Rubery, Head of Business Delivery 

PRESENTER: Neill Moloney, Director of Planning and 

Performance 

DATE: 25 th August 2011


Potential overperformance of £10M based on current levels of activity. 


N/A. 


N/A. 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


2

Activity Report August 2011 

Introduction 

For the period April – July 2011 performance against plan for the Payment by Results (PbR) 

Points of Delivery (PODs) is summarised in the table below: 

POD Plan Actual Variance Variance 

% 

A&E 50773 61214 10431 20.54 

Daycase 13105 13447 342 2.61 

Elective 2793 2565 (228) (8.18) 

Non Elective 22308 26659 4351 19.51 

OP First Attendance 55952 54705 (1247) (2.23) 

OP Follow-up 119770 128441 8671 7.24 

OP Procedure 8474 10649 2175 25.66 

As can be seen, there is significant overperformance in the A&E, Non-Elective, Outpatient 

Follow-up and Outpatient Procedure PODs, Daycase and Outpatient First Attendances are 

broadly on plan and there is significant underperformance in the Elective POD. 

Each individual POD is discussed in more detail below. 

A&E 

Performance against plan is showing a month on month overperformance with a year to date 

variance of 20.54%: 

The 2011/12 activity plan was set in line with the Commissioner’s expectations that a transfer of 

activity from A&E to Urgent Care would occur. Overperformance in months 1-4 is reflective of 

the delayed transfer of the management responsibility for the Urgent Care Centre at Queen’s 

Hospital to the Trust, which finally happened on 1 st August 2011.

As can be seen from the graph below, the overall A&E activity undertaken by the Trust is almost 

identical to that undertaken during the same period in 2010/11: 

Non-Elective 

Non-Elective activity is overperforming against plan at a similar rate to A&E, however the year 

on year position shows that the Trust is undertaking approximately 5% more non-elective activity 

than in the same period in 2010/11.

The Trust has, with agreement from Commissioners, implemented Ambulatory Care during the 

latter part of 2010/11. This service enables patients who would previously have been admitted 

non-electively to be managed in the community without the need for an admission. If the activity 

that is now managed as Ambulatory Care is included with the non-elective numbers to give a 

like for like comparison (as these patients would previously have been managed by a nonelective 

admission), then the total quantum of non-elective activity is up 10% when compared to 

the same period in 2010/11:

Outpatients 

Outpatient first attendances are performing broadly in line with plan and outpatient follow-ups 

are significantly over plan: 

The activity plan for outpatients was set significantly lower than 2010/11 out-turn due to PCT 

QIPP initiatives and activity for both first attendances and follow-up attendances is lower than 

the same period for 2010/11:

Referrals to the Trust have been falling significantly since April 2010, with the month on month 

referrals down 15% when compared to the same period in 2010/11, so it would be anticipated 

that outpatient first attendances will continue at a lower level than in 2010/11:

Outpatient procedures are overperforming against plan and activity is broadly in line with the 

same period in 2010/11. 

Daycase/Elective 

Daycase activity is broadly in line with plan, however elective activity is performing significantly 

below plan:

Due to PCT QIPP and Procedures of Limited Clinical Effectiveness (PoLCE) schemes, the plan 

for daycases and electives was set lower than the 2010/11 out-turn, so current activity levels are 

7% and 15% below the same period for 2011/12:

Conclusion 

Activity levels are either overperforming or are broadly in line with plan for all PODs with the 

exception of elective, which is significantly underperforming. When compared to the same 

period in 2010/11, activity in the ‘emergency care’ PODs (A&E, non-elective) is at a similar or 

higher level, however activity in the ‘planned care’ PODs (elective, daycase, outpatient first 

attendance, outpatient follow-up attendance) is at a significantly lower level.


TITLE: 

Care Quality Commission 




A&E and Staffing Action Plan 

An action plan to address the range of concerns raised by 

the CQC, including the Warning Notices for A&E and 

Staffing, that were detailed in the previous Trust Board 

Report has been developed and is attached. 

The robust and agreed format previously used for the 

maternity issues was used as the basis for responding to 

the concerns, and to supplement the information provided 

the Trust’s latest Emergency Access Action Plan and 

Pneumonia action plan were embedded. 

The action plan was submitted to the CQC by the deadline 

of the 22 nd August, with copies sent to the Trust’s 

Compliance Inspectors. 

Trustwide Visit 

Inspectors spent the week of the 25 th July on Queen’s site 

followed by a week commencing the 15 th August at King 

George and Queen’s Hospitals. The CQC on-site visit was 

completed on Tuesday the 23 rd August. 

□ TEC 23.8.11…..….. □ STRATEGY……….….……. 

□ FINANCE ……..……… □ AUDIT …………………… 

□ QUALITY & SAFETY …Draft 9.8.11..………….....…… 


□ TRUST BOARD ……………………………….…………. 

□ REMUNERATION ………………………………….…... 



Trust Board is asked to note the action plan and to ensure 

implementation is appropriately monitored. 

□ NATIONAL TARGET 

X CQC REGISTRATION 

□ CNST 

□ HEALTH & SAFETY 






AUTHOR/PRESENTER: Mr Stephen Burgess, Medial 

Director 

DATE: 23 August 2011 

Failure to comply with the CQC Registration process has the potential to jeopardise the Trust’s services, finances and 

reputation. 


Compliance with the concerns and Warning Notices for A&E and Staffing as raised by the CQC in their compliance 

reports received on 20.6.2011 



OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


QUEEN’S HOSPITAL 

ACTION PLAN – CQC REVIEW OF COMPLIANCE JUNE 2011 

CQC Related 

Outcome 

Aim Objective Action Measureable 

Outcome 

(Evidence of 

success) 

deadline SRO Milestone 

(Progress Check 

Point – Date and 

Measurement) 

Progress 

Update 

Evidence 

1. respecting and involving people 

who use services 

To improve 

staff training 

to enable 

patients to 

feel 

involved 


confident in 

their care in 

A&E 

QH: Staff in A&E 

give clear 

explanations to 

patients about why 

they are here and 

what is being done 

Review content of the following 

staff training to ensure clarity 

around trust expectation to 

involve patients: 

Education 

- Induction 

- Education programme 

for junior doctors 

- Mandatory training 

- Nursing education 

programme 

Improvement in 

patient survey 

for A&E 

Reduction in 

complaints with 

this element by 

25% 

31.12.11 

and 3- 

monthly 

review 

Magda Smith, 

Divisional Director for Medicine & 

A&E 

Implementation 

of survey 

Monitoring of 

complaints 

from August 


Not started 

Started 

Key QH: Queen’s Hospital KGH: King George Hospital 1



CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

1. respecting and involving people who use services 

To roll out 

hourly 

rounding 

across the 

Trust on 

both sites to 

ensure we 

are 

consistently 

meeting 

patients’ 

fundamental 

needs. 

QH: Hourly rounds 

are performed 

consistently and 

patients’ basic needs 

are met 

• Review current practice 

against new information 

circulated at London 

Quality matters meeting. 

• Review pilot areas in 

August 2011 and audit 

practice. 

• Review pilot and agree way 

forward with Trusts 

documentation group. 

• Implement hourly rounding 

within all adult areas across 

the Trust by December 


• Audit practice as part of 

visible leadership quarterly 

as from January 2012 and 

review action needed. 

Quarterly 

review on 

visible 

leadership in 

2012 will 

demonstrate 

that all adult 

areas within the 

trust are 

undertaking 

hourly rounding 

in accordance 

with Trust 

policy and 

patients’ basic 

needs are met. 

31.7.11 

31.8.11 

31.8.11 

31.12.11 

31.4.12 

Lesley Marsh 

Assistant director of nursing 

NMB in 

September will 

have audit 

results 

presented 

implementation 

plan signed off 

by NMB in 

September 


all areas not 

already 

undertaking 

hourly rounding 

programme will 

commence 

implementation 

in November 

Current 

practice 

reviewed and 

meets the 

information 

circulated by 

NHS London. 

Audit of 

practice in 

pilot areas 

ends 25 th 

August. 

Written tool 

Hourly 

rounding in 

place in A&E 

at QH & KGH 

also: 

Queens: 

Sunrise A&B, 

Sky 

Harvest A, 

Bluebell B, 

Clementine 

A&B, Amber 

A&B 

KGH: 

Fern, 

Foxglove, Elm 

and Erica 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

4: care and welfare of people who use services 

To reduce 

the number 

of hospital 

acquired 

pressure 

ulcers at 

category 

3+4. 

QH & KGH: Ensure 

accurate and 

comprehensive 

documentation of 

care of people with 

pressure ulcers 

• Revise SKIN bundle 

against RCA findings and 

implement updated version 

– sent to printers in July – 

aim for implementation as 

from Sept 2011. 

• Train staff how to complete 

skin bundle via Mandatory 

training and on link worker 

programme. 

• Audit practice quarterly as 

part of visible leadership 

and review actions needed. 

Quarterly audit 

will 

demonstrate 

accurate and 

comprehensive 

documentation 

of people with 

pressure 

ulcers. 

1.9.11 

Ongoing 

Quarterly 

audit 

Lesley Marsh 

Assistant Director of Nursing 

Sign off Skin 

bundle at NMB 

in June 2011 

Full ward roll 

out September 


Training 

programme 

written by 


Included in 

mandatory 

training from 


Link worker 

training 

scheduled for 

August 2011. 

Approved by 

NMB June 


Scheduled 

for roll out on 

return from 

printers 

Training 

programme 

written 

MT training 

commenced 


Link worker 

programme 

scheduled for 

30.8.11 to 

include skin 

bundle 

SKIN bundle 

and minutes 

Programme 

MT training 

pack 

Agenda 

Practice audit 

in July and 

October 2011 

Quarterly 

audit in July - 


average 

result is 

87.53% 

Audit tool 

results 

dashboard 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

Improve 

patient flow 

through 

A&E. 

Reduce 

waits, and 

ambulance 

trolley waits 

Ensure the full and 

timely 

implementation of 

the Trust’s 

Emergency Access 

Action Plan and 

monitor compliance 

See Emergency Access Action 

Plan 

Emergency Care Plan 

20010623.10.xls 

Progress 

against A&E 

action plan 

monitored at 

Emergency 

Care 

Programme 

Board. 

Ongoing 

Magda Smith, 

Divisional Director 

Improved 

performance 

against 95% 

access target 

and A&E 

Quality 

Indicators 

Improved 

performance 

against 

indicators 

over the past 

6 weeks 

4: care and welfare of people who use 

services 

To reduce 

the number 

of poor 

patient 

discharge 

experiences 

Improve discharge 

arrangements. 

Patients discharged 

at appropriate times 

with necessary 

equipment and 

medication 

Implement discharge checklist. 

Operational Policy for hospital 

discharge: 

- education programme for 

staff 

- Operational policy for 

ambulance transport 

Visible 

leadership 

audit process. 

All patients fully 

compliant with 

discharge 

checklist. 

TTAs 

prescribed 24 

hrs in advance 

in 80% inpatient 

discharges 

(excluding 

acute 

assessment 

areas) 

Ongoing 

Caroline Moore 

Divisional Nurse Director 

Decrease in 

delays to 

medically fit for 

discharge 

Reductions in 

DTOCs. 

Reduction in 

LoS 

Discharge 

planning tool 

implemented. 

Weekly 

audits on 

ward through 

Visible 

Leadership 

Electronic 

Discharge 

Summary 

implemented 

to support 

80% of TTAs 

prescribed 

24-hr prior to 

discharge 

DTOCs 3.5% 

LoS reduced 

by 0.67 for NEL 

patients in 

June 2011 

TTA logs kept 

in Pharmacy 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

Improve the 

care of 

patients 

with 

pneumonia 

To ensure the full 

and timely 

implementation of 

the Pneumonia 

action plan and 

monitor compliance. 

See Pneumonia Action Plan. 

PWC Pneumonia 

Action Plan (final) (2). 

Individual as 

listed in 

Pneumonia 

Action Plan 

As 

detailed 

in Action 

Plan 

Magda Smith. 

Divisional Director 

Individual as 

listed in 

Pneumonia 

Action Plan 

Current audit 

in place, 

expected 

completion 2- 

weeks 

Latest data 

available on 

Dr Foster. 

Dr Foster Data 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

5: meeting nutritional needs 

To improve 

the 

nutritional 

standard of 

care across 

the Trust so 

that patients 

do not 

experience 

significant 

unplanned 

(more than 

5%) weight 

loss. 

Patients will have 

timely assessment of 

nutritional needs and 

intake. 

Patients mealtimes 

will not be disturbed 

• Implement the 

amalgamation of visible 

leadership and productive 

ward as from July 2011 with 

a thematic approach. 

• Implement “food for 

thought” month for July. 

• Audit using VL at end of 

July across the Trust - this 

will consider assessment 

and action taken following 

initial review. 

• Observe a mealtime using 

nutritional audit tool at end 

of July on every ward. 

• Monitor compliance with 

“food for thought” at review 

meeting in August 

• Review the following during 

August – protected 

mealtimes, food delivery 

and services, standard 

service level agreements, 

protected mealtimes and 

nutrition related policies. 

• Hold a RCA day in August 

to discuss findings and 

agree way forward. 

• Write action plan from the 

RCA review and continue 

quarterly audit. 

Quarterly audit 

will 

demonstrate 

timely 

assessment of 

nutritional 

needs and 

intake and 

action taken. 

This will include 

mealtimes not 

being disturbed 

unless clinically 

necessary. 

1.7.11 

1.7.11 

25.7.11 

25.7.11 

10.8.11 

31.8.11 

31.8.11 

30.9.11 

Lesley Marsh 

Assistant Director of Nursing 

NMB to ratify 

plan in June 


Communication 

plan for food for 

thought month 


Practice audit 

in July 2011 

Results from 

mealtime 

observations to 

go to review 

meeting in 


Protected 

mealtime 

standard 

reviewed 

Food delivery 

and services 

process 

reviewed 

NMB ratified 

plan June 


Achieved 

Achieved - 

trust wide 

average is 

84.05% 

Achieved 

Achieved 

In progress 

NMB minutes 

Copies of all 

ward reports. 

Dashboard with 

results and 

audit tool. 

Copies of all 

ward reports. 

Meeting notes. 

Protected 

mealtimes draft 

agreed, NG 

competencies 

in draft format. 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

5: meeting nutritional needs (contd.) 

Standard 

service level 

agreements 

reviewed and 

approved by 

NMB Sept 11 

Nutrition 

policies 

reviewed 

RCA day in 

August 

arranged 

Action plan 

written and 

ratified by 

In progress 

In Progress 

RCA day 

deferred – 

new date yet 

to be agreed 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

9: management of medicines 

Ensure all 

patients 

leave 

hospital with 

their 

medicines 

by ensuring 

all 

prescriptions 

are written 

up in 

advance as 

per trust 

policy 

Ensure 

there are 

processes 

for learning 

from 

medicine 

related IR1 

incidents 

across the 

whole trust 

QH: There is safe 

administration of 

medicines on all 

wards 

Review trust policy for ensuring 

all prescriptions are written 24 

hours in advance. 

Communicate to all clinical 

leads and consultants to ensure 

they and their juniors are fully 

aware. Communicate to all 

pharmacists to ensure they are 

fully aware and identify patients 

in advance. 

Review TTA transcribing and 

independent prescribing 

policies and process to enable 

pharmacists to transcribe or 

prescribe to speed the process. 

IR1 group will send monthly 

report to all wards and 

divisions. IR1s and action 

taken will be published in a new 

monthly prescribing newsletter. 

TTAs are 

written in 

advance. 

Reduction in 

complaints 

from patients. 

Policy written 

and approved 

by Drug & 

Therapeutics 

Committee and 

Nursing & 

Midwifery 

Board 

IR1 reports 

sent to wards 

and divisions. 

Monthly 

newsletter 

published. 

Sept 


Ongoing 

Nov 2011 

Sept 




Monthly 

monitoring and 

reporting of 

TTAs reported 

to divisions. 

Numbers of 

prescriptions 

written or 

transcribed by 

pharmacists 

recorded 

monthly. 

Reports sent to 

wards and 

divisions. 

First monthly 

newsletter 

published by 

31.8.11 

80% of TTAs 

are written in 

advance. 

This 

information is 

not yet 

available. 

Report 

circulation 

immediate. 

Draft 

newsletter 

ready for next 

Drugs & 

Therapeutic 

Committee 

approval prior 

to release. 

TTA logs kept 

in pharmacy 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

9: management of medicines 

Ensure all 

patients 

leave the 

hospital with 

the correct 

medicine 

Ensure 

there are 

processes 

for learning 

from 

medicine 

related IR1 

incidents 

across the 

whole trust. 

KGH: there are clear 

processes for 

learning from 

medicines incidents 

Undertake a training 

programme with nurses on all 

wards on giving medicines to 

patients. 

IR1 group will send monthly 

report to all wards and 

divisions. IR1s and actions 

taken will be published in a new 

monthly prescribing newsletter. 

Training 

programme has 

been 

developed and 

given to all 

nursing staff on 

all wards. 

Record of 

training kept by 

ward. 

Reports sent to 


divisions. 

Monthly 

newsletter 

published. 

Oct 2011 

Sept. 




Programme 

written by 

30.10.11 

Report sent to 


divisions. 

Monthly 

Newsletter 

published by 

31.8.11. 

Scoping 

meeting held. 

Draft 

newsletter 

ready for next 

Drugs & 

Therapeutic 

Committee 

approval prior 

to release 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

13: Staffing 

To deliver 

patient care 

All wards will be 

staffed to their 

agreed shift numbers 

Re-launch of the Trust staffing 

Matrix as per Bed Management 

Policy. 

Daily Action log for duty 

matrons to record staffing 

issues and actions taken. 

Re-launched agreed funded 

staffing levels for each ward. 

Use of the 

escalation 

policy to 

manage the 

risk 

completed 

John Fletcher/ Caroline Moore/ Judith 

Douglas/Sue Lovell 

Divisional Nurses 

All in place and 

to be 

monitored. 

Staffing levels 

are monitored 

through the bed 

meetings. 

Maternity and 

NICU are 

monitored on a 

daily basis by 

the Pathways 

Facilitator and 

the NICU 

matron 

In place 




CQC Related 

Outcome 


Outcome 

(Evidence of 

success) 




Measurement) 

Progress 

Update 

Evidence 

21: records 

To improve 

compliance 

with the 

Trust’s 

health 

record 

policies 

Patient personal 

records are all held 

securely. 

Information can be 

located in them 

when required 

Ensure all notes are stored in 

appropriate locations and not 

left in un-secure areas. 

Additional locking cabinets 

ordered for areas where access 

to the notes is needed out-ofhours. 

Review of clinical information to 

be undertaken. Trust lead 

appointed to establish working 

party to address this. 

No notes left 

unsecured at 

any time 

Notes contain 

all relevant 

information for 

timely and 

appropriate 

decision 

making. 

Completed 

TBC 

Mr Stephen Burgess 


Monitoring of 

notes stored in 

areas outside 

of secure 

medical 

records 

libraries. End 

Aug.2011 

Review of 

output from 

newly 

established 

working party. 

End Sept.2011 

Patient 

personal 

records are 

all held 

securely 

Information 

can be 

located in 

notes when 

required. 


PNEUMONIA MORTALITY REVIEW ACTION PLAN FINAL 

Pneumonia guidelines 

RECOMMENDATION 

1. The Trust should update the existing 

antibiotic policy to reflect revised 

recommendations for empirical 

antibiotic regimens and the need to 

diagnose and initiate treatment in the 

initial assessment area. Clarity should 

also be provided on duration of therapy 

and when to switch from IV to oral 

therapy. (Page 20) 

2. The Trust should develop local 

guidelines for all aspects of pneumonia 

management, including oxygen 

monitoring and therapy, not just 

antibiotic prescribing. (Page 20) 

PRIORITY & 

SRO 

1 month 

DIPC & Clinical 

Leads in 

Microbiology 

Director of 

Clinical 

Governance 

2-3 months 

Divisional 

Director of 

Medicine & 

Director of 

AGREED ACTION OUTCOME RAG 

RATING 

A consensus view needs to be 

reached involving the Chest 

physicians and the Microbiologists 

because there is divergence 

between the new BTS advice, 

current policies and Microbiology 

Society guidance previously 

published. This requires a meeting 

of both groups. 

• To review antibiotic policy and 

bring in line with BTS Guidance 

published in October 2009. 

• Provide clear therapeutic 

pathways (for transcription into 

pocket reference cards – see 

18). 

• Automatic stop policy needs to 

be re-launched with all staff. 

• MAB 

• Nursing & Midwifery Board 

• To Chief Pharmacist for 

distribution amongst pharmacy 

staff 

• Article in the Link 

Guidelines on pneumonia 

management to include 

• Blood gas policy 

• Oxygen monitoring and therapy 

• Antibiotic therapy 

December meeting (Lead 

Microbiologist on leave) 

Current Antibiotic policy in place to 

be updated 

This action plan point discussed at 

MAB in 11/09. 

Discussed at Nursing and Midwifery 

Board 11/09. Chief Pharmacist 

aware of work. 

Agreement reached in meeting on 

22/12/09. Implementation plan in 

hand. 

Antibiotic policy agreed 22/12/09 

Simple blood gas policy updated and 

circulated. 

Guidance summary to all consultants 

in line with BTS Pneumonia 

Guideline. 

1


PRIORITY & 

SRO 

Medical 

Education 


RATING 

To be used to inform the education Policy for Prescription and 

of all consultants and junior doctors Administration of Oxygen in Adults 

across the Trust 

reviewed by the Evidence Based 

Practice Committee. 

2


PRIORITY & 

SRO 


RATING 

Training for all physicians to be 

completed. QH 26/10/09 

KGH 23/11/09 

Blood gas interpretation prompts 

appropriate action in 100% of 

patients 

3. The Trust should review its current 

plans for service re-design to ensure 

that the new recommendations are 

reflected in the changes which are 

currently being implemented. (Page 20) 

Documentation and quality of notes 

4. The findings above, and the results of 

the Trust’s own audit of clinical 

documentation, should be used to 

develop comprehensive guidelines for 

maintaining clinical notes and 

associated documentation standards. 

This should include: 

• the importance of clear, legible 

note taking and appropriate signoff 

• expected set of notes, charts and 

forms 

• expected medical history and 

clerking documentation 

• results of investigations 

Pro-forma for documentation of patient 

Audit compliance – audit tool to be 

developed from KPI’s in policy 

3-6 months All significant changes in service 

need to have risk assessments 

completed as part of 

implementation. When replicating 

services, all learning from original 

service needs to be included in the 

set up and development of the 

service. Consideration of staff 

rotation to support implementation. 

1 month 

Clinical 

Governance 

Manager 

Divisional 

Director of 

Medicine 

Implementation of medical records 

action plan to include development 

of standards. 

New clerking pro forma in use in 

AAU includes CURB 65, 

thromboprophylaxis guidelines and 

results for investigations, to be 

rolled out across the Trust 

Audit of A & E clerking 

documentation will be carried out 

w/k commencing 23/11/09. 

Snapshot audit completed 29.10.09 

by Divisional Director of Medicine 

and Clinical Governance Director. 

Audit findings to be reported to 

Clinical Governance meetings, 

(Compliance KPI in MAU audit tool). 

Replication of KPIs for audit and 

review for appropriateness following 

implementation and ongoing 

reporting to the Clinical Governance 

meetings. MAU to be started at 

KGH 1st December. 

Findings to be shared with MAU 

team meeting, Divisional meetings 

and MAB and Nursing & Midwifery 

Committee. 

Completed and circulated /8/12/09. 

Completed. 

3


journey through hospital (Page 27) 

PRIORITY & 

SRO 


RATING 

5. All medical, nursing and other clinical 

staff should receive additional training 

on these guidelines and senior nurses 

and clinicians should take responsibility 

for ensuring appropriate standards are 

maintained across clinical teams. 

(Page 27) 

6. The Trust should implement a regular 

programme of spot-check audits to 

monitor whether standards are 

improving. The results of these audits 

should be monitored and appropriate 

clinicians held accountable if practice 

continues to outside of the Trust’s 

2-3 Months 

Divisional 

Directors and 

Director of 

Nursing 

2-3 months 

Clinical 

Governance 

Manager to coordinate 

Training of good quality note 

keeping and records form part of 

the Junior Doctor Induction process 

and are specifically tested for in the 

mini-pat work based assessment 

that all trainees carry out sever 

times each year. 

Nursing documentation under 

review and fast track assessment 

documentation established and in 

use on the acute assessment 

wards. Training for the use of an 

Early Warning Tool (MEWS) in 

progress across both sites. 

Updated MEWS documentation 

NICE compliant and in process of 

being printed 

Matrons audit ‘Chart Checking’ 

monthly and reporting to Matrons’ 

Forum the results 

Senior Sisters undertaking 

competency checking of Staff 

Nurses according to the Vital Sign 

Guidelines and competency check 

list 

Rolling programme of 

unannounced simple audits of 

notes. 

Programme agreed. 

A&E record audit completed and 

report circulated. 

Additional session on record keeping 

added to induction programme. 

Improved compliance of relevant 

documentation according to NMC 

guidelines 

Improved early detection of 

deteriorating patients and averting 

‘Failure to Rescue’ cases 

DD for Medicine and CGD 

commenced audits 10/11/09. 

Audit tool on intranet (CRABEL 

Score) 

4

policy. (Page 27) 


Management of pneumonia 

7. It is essential that clerking takes full 

account of the patient history, including 

GP referrals and past medical history 

(as reported by the patient and from 

reviewing previous admissions). 

Where necessary, a member of the 

clinical team should contact the GP 

surgery and/or nursing home to obtain 

relevant clinical information, including 

details of any packages of care that 

may be in place. (Page 30) 

8. It is essential that all CXRs are 

reviewed and the results documented 

in the notes, at clerking, to facilitate 

prompt diagnosis and treatment within 

four hours of admission. Formal 

reporting should be documented 

routinely. (Page 34 Paragraphs 95-96) 

9. The Trust should offer the CRP test 

routinely to all patients admitted with 

suspected pneumonia and the results 

transcribed into the notes at clerking. 

This recommendation will facilitate 

prompt diagnosis and ensure that there 

is a baseline against which to monitor 

an individual’s patient’s progress. 

PRIORITY & 

SRO 

1 month 

Divisional 

Director of 

Medicine 

Clinical 

Governance 

Manager 

Immediate 

Divisional 

Director of 

Medicine & 

Clinical 

Governance 

Manager 

Immediate 

Divisional 

Director of 

Medicine 

General 

Manager for 

Pathology 


RATING 

Divisional Director of Medicine to 

work with Clinical Governance 

Manager to devise a template for 

audit of clerking. 

Initial audit of A & E clerking 

records to be carried out w/k 

commencing 23/11/09. 

Consultant responsible for the 

patient will review the CXR and 

document findings into the patient 

record. There is a portion of the 

post take form for this. Comment 

on the CXR by more junior staff 

should also be entered into the 

notes when they see the films. 

Divisional Director of Medicine to 

work with Clinical Governance 

Manager to devise a template for 

audit of clerking in MAU. 

Level D evidence – CRP to be 

measured within 24 hours of 

admission (ideally on first blood 

test). To be repeated before 

discharge to ensure it is falling. 

Review of Biochemistry protocols 

on tests from A&E. 

KPI for audit. 

Audit completed and findings 

circulated. 

Divisional Director for Clinical 

Support has written to all consultants 

making them aware of this 

requirement 

KPI for audit completed. 

Part of education and training and 

ongoing audit. Offered to all 

pneumonia patients in the A&E 

Department. 

5


(Page 34 

Paragraphs 97-101) 

10. FBC, Us and Es, LFTs and oxygen 

assessment should be undertaken 

routinely at admission and the results 

transcribed onto the clerking proforma. 

(Page 34, Paragraphs 102-105) 

PRIORITY & 

SRO 

Immediate 

Divisional 

Director of 

Medicine 


RATING 

This forms part of the triage and 

clerking process (clerking pro forma 

as detailed in 4.) 

To include as part of the KPI for 

audit of MAU. 

Record audit as evidence of 

compliance. 

11. When recording oxygen saturation 

results or ABGs, it should be clearly 

stated if the measurements were made 

on oxygen or air. (Page 34 Paragraphs 

106-111) 

Immediate 

Divisional 

Director of 

Medicine 

This forms part of the triage and 

clerking process (clerking pro forma 

as detailed in 4.) 

To include as part of the KPI for 

audit of MAU. 

A&E Nursing staff reminded of the 

need to document saturation results 

and whether taken on oxygen or in 

air. Maintenance audits in place re 

documentation. 

12. The Trust should provide junior clinical 

staff with training on the interpretation 

of ABGs and ensure that clear 

arrangements are in place for 

escalation for Senior and/or Specialist 

Assessment. 

(Page 34 Paragraphs 106-111) 

13. Following diagnosis, the severity of 

pneumonia should be assessed for all 

patients using the CURB-65 scoring 

system and clinical judgement. It is 

recommended that a section be added 

to the clerking pro forma to ensure that 

this is not overlooked. 


CURB score. Not recorded in any case 

14. The CURB-65 score should inform the 

initial management plan for the patient 

with respect to microbiological 

investigations, antibiotic therapy and 

Immediate 

Director of 

Education 

Immediate 

Divisional 

Director of 

Medicine 

Immediate 

Divisional 

Director of 

Medicine 

Sessions to be held at QH and 

KGH. 

Training for all grades of junior staff 

on a rolling programme. 

CURB score 65 only valid for 

patients with community acquitted 

pneumonia and is included in the 

clerking pro forma. 

CURB score included in medical 

assessment pro forma. 

Snapshot audits to be completed 

through a rolling programme 

Session completed at Queens on 

02.11.09. KGH date on 23/11/09 

All patients with chest infections 

have a CURB score on admission 

and prompted to repeat daily. KPI 

for MAU audit tool. 

Snapshot audit completed in 

November 09. Monthly snapshot 

audit programme agreed. Full audit 

of mortality in progress August 2011. 

6


location of treatment (including 

discharge back to the community, 

where the score demonstrates that the 

patient has a low severity pneumonia). 


15. The Trust should communicate the 

importance of microbiological 

investigations to all clinical staff, setting 

out the circumstances when these 

investigations are indicated and 

reinforcing the need to carry these out 

prior to starting antibiotic treatment 

wherever possible. (Page 38 


16. The Trust should ensure that the 

results of all microbiological tests are 

recorded in the notes and that 

appropriate action is taken in response 

to the results e.g. changing antibiotic 

regimens where the results 

demonstrate resistance to empirical 

treatment. (Page 38 Paragraphs 119- 

128) 

17. The Trust should ensure that findings 

and trends arising from the 

bacteraemia surveillance are reported 

regularly to clinicians and Trust 

management, together with 

recommendations for changing clinical 

practice, where data demonstrates that 

this is required. As a minimum, this 

should be reported to the relevant 

Divisional Governance Committees 

and, where adverse trends are 

PRIORITY & 

SRO 

1 month 

DIPC & Clinical 

Leads in 

Microbiology 

Immediate 

Divisional 

Director of 

Medicine 

1 month 

Acting Head 

Infection 

Control Nurse 


RATING 

To include in antibiotic policy – see 

section 1. 

Antibiotic policy process agreed. 

To be rolled out in accordance with 

plan. 

Infection Control policy approved 

July 2011. 

Ensure appropriate recording of 

microbiology tests in relation to 

antibiotic regimes at every 

intervention. 

To be agreed by Infection Control Completed 

All positive blood cultures are 

reviewed by a Consultant 

Microbiologist within 48 hours. KPI 

for record audit. 

7


identified, this should be reported to the 

Clinical Governance Committee. (Page 

38 Paragraphs 119-128) 

PRIORITY & 

SRO 


RATING 

8


18. The Trust should adopt the new BTS 

recommendations (2009 guidelines) for 

microbiological testing in order to 

increase the speed and accuracy of 

diagnosis and effectiveness of 

treatment: 

• Blood cultures and 

pneumococcal urine PCW antigen are 

now recommended for all patients with 

moderate severity CAP as well high 

severity CAP. 

• A rapid testing and reporting 

service for pneumococcal urine antigen 

should be available to all hospitals 

admitting patients with CAP. 

• Legionella urine antigen tests 

should be performed for all patients 

with high severity CAP. Again, a rapid 

testing and reporting service for 

Legionella urine antigen should be 

available to all hospitals admitting 

patients with CAP. 

• For all patients who are 

Legionella urine antigen positive, 

clinicians should send respiratory 

specimens such as sputum and 

request Legionella culture. 

Page 38 Paragraphs 119-128 

19. After the antibiotics policy has been 

updated, the Trust should reintroduce 

the pocket sized printed copy of the 

Antibiotics Policy and ensure that all 

Prescribers have access to a copy. 

(Page 49) 

PRIORITY & 

SRO 

1 month 

Divisional 

Director & 

Divisional 

Manager for 

Clinical Support 

2-3 months 

Divisional 

Nurses for 

Medicine & 

Surgery 


RATING 

All testing in place and included in 

the policy and covered in teaching 

sessions for junior doctors. 

A consensus view needs to be 

reached involving the Chest 

physicians and the Microbiologists 

because there is divergence 

between the new BTS advice, 

current policies and Microbiology 

Society guidance previously 

published. This requires a meeting 

of both groups. 

• Urine antigen available in hours. 

Consideration for point of care 

test available in ITU, HDU, MAU 

and A&E. 

• Microbiology Consultants 

disagree as test does not alter 

therapy or provide information 

on organisms susceptibility. 

Identify reasons for delay and 

process implement escalation 

process – see Section 1. 

• Develop flash card 

Business case developed for 

additional testing long term. 

Antibiotics administered at the time 

of prescription. (KPI for MAU/SAU 

tool). 

The antibiotic policy up-dated Jan 

2009. 

9


PRIORITY & 

SRO 


RATING 

Amendments uploaded on to the 

intranet Antibiotic policy. 

Awareness raised through the 

intranet and teaching sessions. 

Pharmacy will be producing 1000 

antibiotic policy booklets and the 

most up-to date version will always 

be on the intranet. The booklet will 

be re-produced every 5 years. 

Junior doctors carrying laminated 

sheets which are also adhered to the 

drug trolley. 

10


20. The Trust should communicate the 

principles behind antibiotic prescribing 

for pneumonia to all junior A & E and 

Medical clinicians ensuring that this 

covers severity, choice, length of 

treatment and the importance of 

starting treatment within four hours of 

admission. (Page 49) 

21. The Trust should display a copy of the 

antibiotic policy for LRTIs in all relevant 

clinical areas including A & E, AAU, 

ITU, HDU and the respiratory wards. 

(Page 49) 

22. The Trust should involve Ward 

Pharmacists / Clinical Pharmacists in 

antibiotic prescribing decisions e.g. 

through their attendance at the post 

take and consultant ward rounds. 

(Page 49) 

23. The Trust should ensure that a clear 

indication (reason for prescribing) is 

documented in the clinical notes, at the 

time that antibiotics are prescribed. 

(Page 49) 

PRIORITY & 

SRO 

2-3 months 

Divisional 

Director of 

Medicine & 

Clinical Leads 

for Microbiology 

Immediate 

Divisional 

Manager 

Clinical Support 

2-3 months 

Deputy Chief 

Pharmacist 

Immediate 

Divisional 

Director of 

Medicine 


RATING 

Include in induction. 

Agreement reached on antibiotic 

prescribing and shared with medical 

staff. This is also part of audit KPI. 

All patients to be given antibiotics 

within 4 hours of arrival. First dose 

of antibiotic to be given in A&E. 

Full access in A&E. Laminate key 

sections of the antibiotic policy and 

display in relevant areas.e.g. 

respiratory medical wards 

Interviews for 1 fulltime antibiotic 

pharmacist prescriber planned for 

4/12/09. This will support post-take 

rounds on QH site. Additional 

resources required if both sites to 

be covered. This post will attend a 

Cons Microbiologist ward round. A 

business case will be developed for 

additional resource to cover KGH 

site. It is not possible without 

additional resources to attend all 

consultant ward rounds but ward 

pharmacists review all prescription 

charts for appropriateness. 

To write letter to all consultants to 

ensure reason for prescribing 

antibiotics is documented in notes 

Immediate access to all antibiotics in 

policy for A&E (KPI for MAU audit 

tool). 

Completed 

Pharmacist appointed to role but will 

require to give notice. 

Business plan 2010-2011 includes 

request for additional post at KGH. 

Ward pharmacists review all 

prescriptions and query any 

inappropriate antibiotic prescribing. 

0.4 wte antibiotic pharmacist 

appointed to previous outstanding 

vacancy– awaiting recruitment 

process. Antibiotic pharmacist in 

place. 

Letter of instruction issued by 

Divisional Director on 17/11/09 to 

consultants to remind teams to a) 

document diagnosis and b) 

document antibiotics in line with 

11


24. The Trust should review how 

communication between prescribers 

and nursing staff can be improved to 

ensure that delays do not occur 

between an antibiotics being prescribed 

and administration. This could be by 

way of a communications board or 

book on the ward and/or through 

nursing staff attending ward rounds. 

(Page 49) 

25. The Trust should review stock lists for 

the A & E Department, AAU, ITU, HDU 

and the Respiratory Wards to ensure 

that the first choice and alternative 

choice antibiotics, used in the 

management of pneumonia, are 

available in all of these locations. 

(Page 49) 

PRIORITY & 

SRO 

2-3 months 

Divisional 

Nurses 

Immediate 

Clinical Leads 

for Microbiology 

and Deputy 

Chief 

Pharmacist 


RATING 

BHRUHT policy 

To be agreed through discussion at 

Nursing & Midwifery Board 

To be communicated via the MDT 

meeting and Jonah. 

Within hours prompt response from 

pharmacy for non stock antibiotics. 

Out of hours, prompt response from 

site management. 

To be agreed. Discuss feasibility of 

1) Implementing escalation 

procedure for sick patients to 

ensure timely access to restricted 

antibiotics in Emergency Drug 

Cupboard or 2) Keeping restricted 

antibiotics in locked cupboard in 

critical ward areas (ITU / HDU / A/E 

/ AAU etc). To be treated as 

Controlled Drugs - as Dr Melzer’s 

suggestion 

No decision has been made yet 

around feasibility of keeping 

restricted antibiotics on respiratory 

wards 

Discussed at Nursing and Midwifery 

Board -actioned through Matrons 

and Senior Sisters meetings. 

KPI for audit. 

1. ITU / HDU; All first choice and 

alternative choice antibiotics are now 

stocked in these areas. 

2. A/E: All first choice and alternative 

choice antibiotics added to stock list. 

At Queens, these are now 

present in A/E and administration is 

being recorded in a Controlled 

Register. At KGH, we are awaiting 

Works Dept who have been asked to 

put a lock on the designated 

cupboard 

3. Admission Units: All first choice 

and alternative choice antibiotics are 

now stocked in these areas. 

Administration is being recorded in a 

Controlled Register 

26. The Trust should review and simplify 1 month Establish a locked draw/cupboard Completed 

12


the current arrangements for accessing 

restricted antibiotics out of hours. 

Consider introducing controls at ward 

level e.g. treating restricted antibiotics 

as ‘controlled drugs’ rather than holding 

a central stock in an emergency drug 

cupboard with access via the On-site 

co-ordinator. (Page 49) 

PRIORITY & 

SRO 

Divisional 

Nurse for 

Medicine & 

Emergency 

Care 


RATING 

in the ITU/HDU and A&E on both 

sites that will be solely for the 

storage of the above medicines. 

Medicines added to the stock list 

for these areas in a designated 

section on the stock list. 

Top-up system agreed that when 

these medicines are 

ordered/supplied they are replaced 

by the top-up tech, not just sent to 

the ward. 

Nurses who hold the keys to these 

cabinets know that they can only 

release drugs on the approval of a 

named Consultant Microbiologist. 

Each specialty to maintain a 

register (kept in the same 

cupboard) detailing: 

Date, Time, patient name/hospital 

no., diagnosis, drug(s) issued and 

quantity, approved by (name of 

Cons Microbiologist). 

Periodic audit by pharmacists going 

to these areas of the registers to 

ensure: 

-that supplies are appropriate (i.e. 

indications known, micro approval, 

date/time – was when pharmacy 

was closed) 

- no lending to other areas (who 

should access via EDR) 

- that these antibiotics are 

reviewed. 

13


PRIORITY & 

SRO 


RATING 

14


27. The Trust should ensure that antibiotic 

regimens are changed where blood 

and sputum cultures demonstrate 

resistance to empirical treatment. 

(Page 49) 

28. The Trust should consider introducing a 

formal mandatory training session for 

all prescribers on the principles of 

antibiotic prescribing (this should cover 

general principles as well as specific 

principles on the more serious 

infections such as pneumonia and 

septicaemia). (Page 49) 

29. Oxygen should be prescribed on the 

Inpatient Prescription and 

Administration Record and the clinician 

should ensure that the method of 

administration, flow rate and target 

oxygen saturation are recorded. 

Nursing staff should sign for the 

administration of oxygen on every drug 

round. 

Page 51 (Paragraphs 170-174) 

PRIORITY & 

SRO 

Immediate 

Divisional 

Director of 

Medicine & 

Divisional 

Leads for 

Microbiology 

2-3 months 

Director of 

Education 

Immediate 

Divisional 

Directors 


RATING 

Include in antibiotic policy – see Microbiologist check every positive 

section 1. 

culture and review the patient 

accordingly. 

Education Board to agree a way 

forward. 

Oxygen should be prescribed 

according to Trust guidelines, 

method of administration and target 

saturation should be recorded. 

Nursing staff should sign for the 

administration of oxygen at each 

drug round 

There is new NICE guidance. 

Education Board Agenda item 

November 

Topics for discussion at Matrons and 

Sisters meetings in November. Audit 

tool developed to monitor 

implementation. 

A new protocol in line with NICE 

guidance, which has been reviewed 

and accepted by the Evidence- 

Based Practice Group 

This was included in the doctors 

training sessions for blood gas 

training. 

Included in documentation audit. 

30. The Trust should audit clinical practice 

against recommendations set out in the 

BTS guidelines for Emergency Oxygen 

1 month 

Divisional 

Director of 

Baseline audit completed. Audit 

tools developed 

Three month rolling audit to be 

Rolling audit in place 

15


use in Adult Patients to identify and 

address where care currently falls 

outside of best practice. (Page 51 


PRIORITY & 

SRO 

Medicine (for 

delegation) 


RATING 

implemented linked to nursing 

observation charts (dependent on 

new nursing documentation). 

New nursing documentation in 

place. 

Education process in place 

16


31. All acutely ill patients, including those 

with pneumonia should have a plan for 

physiological monitoring, documented 

in the notes, at clerking. This plan 

should be reassessed frequently and 

also when care is escalated. (Page 52 


PRIORITY & 

SRO 

1 month 

Divisional 

Director of 

Medicine 


RATING 

Pneumonia pathway 

Checklist written and circulated for 

All patients to have physiological comment and implementation. Will 

monitoring with the use of one of be laminated and retained in A&E 

the PAR/MEWS/SECS scoring and MAU. 

systems. This will lead to escalation 

of both the clinical teams /on call 

AND an outreach service from Pathways completed and circulated. 

HDU/ITU. This is work in progress 

32. The Trust should undertake a review in 

order to understand and address the 

reasons behind the deficiencies we 

identified in monitoring and recording of 

observations. (Page 52 Paragraphs 

175-181) 

1 month 

Director of 

Nursing 

Implementation of medical records 

action plan. 

Discussion at Nursing & Midwifery 


Topic for Matrons and Sisters 

meeting 

Established Observations Steering 

Group including engagement with 

senior sisters re staff 

competencies. Engage with LSBU 

re student nurse competencies and 

enhance Mandatory Training to 

include observations of vital signs 

and escalation of the acutely ill 

patient including training for Health 

Care Assistants and Registered 

Nurses 

Review of nursing documentation 

completed. 

Improve audit of observation charts 

undertaken monthly by matrons on 

wards 

Reduce incidences of ‘Failure to 

rescue’ 

Trained and untrained staff 

competencies improved and updated 

supported by research evidence and 

documented guidelines 


recommendations in the NICE clinical 

guideline “Acutely Ill patients in 

hospital” have been implemented, 

2-3 months 

Clinical 

Governance 

Manager 

To review implementation of NICE 

guidance to identify weaknesses in 

process 

The following evidence has been 

provided to support the Partial 

Compliance statement: 

17


particularly with respect to staff training 

and assessment of competencies in the 

monitoring, measurement, 

interpretation and prompt response to 

the acutely ill patient. (Page 52 


PRIORITY & 

SRO 


RATING 

• Draft Core Standard on Airway 

• Copy of the Daily Patient Progress 

Further review of compliance 

Record (Nursing Doc) 

underway 

• Failure to Rescue Proposal (dated 

Jan 2008) 

• HCA Training Proposal Skills 

Update Night Staff (dated May 

2007. L. Malyon) 

• Observational Chart (Nursing doc) 

• SECS 48 System for evaluating 

Critically Sick document 

• EWS Presentation 

• Core Standard 2 – Breathing 

• Early Warning Systems Audit 

Presentation 

• HCA Skills Attendance sheet – 

May/June 2007 

• Patient Observation Chart 2a 

(Nursing doc) 

• ICNARC Report 2008 

18


34. The Trust should ensure that all 

patients have a thrombosis risk 

assessment on admission and that 

prophylactic Clexane® is prescribed for 

those patients who are identified as 

being at risk on the basis of this 

assessment and for those who are not 

fully mobile, unless there is a 

contraindication to treatment. (Page 54 

Paragraphs 189) 

35. The Trust should ensure that patients 

with prolonged illness are assessed for, 

and provided with, an appropriate level 

of nutritional support. (Page 56 


PRIORITY & 

SRO 

Immediate 

Divisional 

Director of 

Medicine 

Director of 

Clinical 

Governance 

1 month 

Divisional 

Nurses & 

Matrons 


RATING 

New clerking pro forma in use in Findings to be shared with MAU 

AAU includes CURB 65, 

team meeting, Divisional meetings 

thromboprophylaxis guidelines and and MAB and Nursing & Midwifery 

results for investigations, to be Committee 

rolled out across the Trust 

Audit of A & E clerking 

documentation will be carried out 

w/k commencing 23/11/09. 

Spot audits to be carried out. 

Audit of MUST tool 

Nutrition Team to audit MUST tool. 

Appointment of Assistant Director 

of Nursing to lead on 

documentation audit. 

Report to NM Board with Action Plan 

Included in Visible Leadership 

programme. 

Hospital pathway for acute patients 


necessary support is provided to 

embed the new AAU processes at 

Queen’s Hospital and to ensure the 

prompt implementation of a similar 

system at King Georges’ Hospital. 

(Page 62 Paragraph 212) 

Immediate 

Divisional 

Director of 

Medicine 

Replication of MAAU at Queens to 

be implemented at KGH as from 

01.12.09 

The MAAU is set up and functioning 

well at Queen’s. Replication of the 

consultant model process is in place 

at KGH and there is assurance that 

no patient with pneumonia bypasses 

the MAU. KPI’s for monitoring have 

been agreed by the Clinical 

Governance Committee. 

Audit of service to be started mid 

February, reviewing January patient 

admissions. 

19


37. The Trust should conduct analysis of 

data on the admission and care of 

acutely ill patients to inform the system 

review described above. This should 

include the place and time of admission 

and the distribution across the Trust 

following admission. (Page 62 

Paragraph 221) 

38. The Trust should conduct a full review 

of the pathway for acutely ill patients, 

incorporating, but not limited to the 

areas described above. This should 

result in a prioritised implementation 

plan designed to deliver improved 

acute care. (Page 62 Paragraph 216- 

222) 

39. Clinicians should implement robust 

governance processes that incorporate 

the prompt use of clinical outcome 

information arising from audit data. 

Where possible, this data should be 

captured as part of routine care. (Page 

62 Paragraph 216-222) 

40. The Trust should ensure that BIPAP 

can be provided routinely when 

required on HDU. (Page 62 

Paragraph 208) 

Inappropriate admissions and primary care pathway 

41. The Trust should agree with local PCTs 

to conduct a joint prospective audit on 

a sample of elderly frail admissions to 

assess how well prevention of 

admission measures are being 

PRIORITY & 

SRO 

1 month 

Divisional 

Nurses and IT 

2-3 months 

Divisional 

Director of 

Medicine & 

A&E Clinical 

Leads 

1 month 

Clinical 

Governance 

Manager 

1 month 

Divisional 

Director of 

Surgery 

2-3 months 

Clinical 

Governance 

Manager for 

BHRT & 


RATING 

Action to be agreed 

Documentation review completed 

with new documentation introduced 

to MAAU; replicated at KGH. 

Preliminary discussions with 

Anaesthetics 

Guidance on the mortality and 

morbidity data agreed at Clinical 

Audit Committee in September 

2009. 

Review requirement for BIPAP 

equipment for HDU 

Action to be agreed. 

Darzi Fellow to assist with 

development of pneumonia 

pathway. 

Preparation work completed. John 

Coakley leading on interventions 

between A&E and Critical Care. 

Further progress delayed due to loss 

of clinical leadership. To be reviewed 

urgently. 

Guidance rolled out across the Trust. 

Clinical Governance Analyst 

identifies early indication of 

increased episodes of poor 

outcomes. 

BIPAP equipment identified for use 

when necessary - Completed. 

Funding to be approved by 

Chairman’s action. Procurement to 

action. Procured and in place. 

Terms of Reference and audit tools 

agreed on 29 January 2010. Audit to 

commence mid February. Auditor 

identified within the Darzi Fellowship 

junior doctor management trainee. 

20


implemented. This audit would help all 

organisations in the local health 

economy identify areas where joint 

work, including social services, can 

make improvements to the pathway for 

acutely ill and vulnerable patients. 


Nursing observations 

42. The Trust should seek assurance that 

registered nurses understand their role 

and have the competence to discharge 

it. This should be assessed through the 

performance management and 

appraisal system and additional training 

provided where appropriate. (Page 67 


PRIORITY & 

SRO 

Clinical Audit 

Managers for 

PCTs 

1 month 

Divisional 

Nurses & 

Matrons 


RATING 

External clinician to quality check 

18/12/09 Discussion held at the Co- and develop report. Audit to 

Commissioning Team and 

continue on a quarterly basis 

agreement reached to identify lead. throughout the year. 

Lead personnel from the Trust and 

Outer North East London (ONEL) 

organisations to carry this work 

forward. 

Action through appraisal systems 

Agreed action plan on education in 

relation to observations. 

100% of all nurses must be 

appraised 

Ongoing compliance monitoring. 

All processes in place and being 

monitored for compliance. 

43. Nurses should improve the taking and 

recording of observations, hydration 

care and fluid chart management. This 

should be monitored by senior nurses 

daily and regular audits introduced 

similar to that of the NPSA Check Your 

Charts week audit and the Getting the 

Basics Right Observation Campaign. 


1 month 

Divisional 

Nurses & 

Matrons 

Medical record action plan 

Monitoring of medical records 

action plan updated by item 

(Attachment 1) 

Nursing documentation under 

revision. 

‘Check Your Charts’ introduced. 

Discussed and implementation 

programme approved at Matrons 

meeting. 

21


44. Quality of nursing care should be 

measured on how dignified and 

compassionate care is using: 

• Essence of Care; Benchmarks 

for the care environment: DH 

2003; and 

• Age Concern On Our Terms 

Dignity; 

• The Challenges of Measuring 

dignity: The Picker Institute 

2008; and 

• Caring in Confidence 

Framework: DH 2007. 


PRIORITY & 

SRO 

2-3 months 

Director of 

Nursing 


RATING 

• Establish actions against 

issues and survey and audit patient 

focused benchmarks in real time on 

regular basis 

Appointment of Patient Experience 

Assistant Director 

Establish Patient Experience 

Improvement Board and sub 

groups to address specific issues 

related to BHRUT 

Report to IPEG , SSIB and The 


Establish visible clinical leadership 

days of the senior nursing team to 

support clinical staff, educate and 

direct 

Develop senior clinical staff with a 

leadership programme – bid 

submitted to NHS London 

Appointed – to commence in post 

30.11.09 

Established Oct 09, with 

multidisciplinary membership, 

patients and outside partners. 

Establish Action plan and 

engagement with clinicians to actio 

Enable staff through education, 

direct guidance and supervision and 

role model leadership from the 

senior nursing team 

King’s Fund development 

programme for Clinical Directors 

completed 

Significant failings in patient care 

45. The Trust should investigate each of 

the clinical incidents identified in the 

Executive Summary in accordance with 

the Incidents and SUI reporting policy. 

Action plans should be developed to 

address issues at a system and 

individual level and implemented 

immediately. Page 23) 

Clinical Governance 

2-3 months 

Director of 

Clinical 

Governance 

Case review of identified patients 

undertaken by independent 

consultant and senior nurse. 

Additional recommendations to be 

implemented. 

22


46. The Trust should undertake a 

comprehensive review of clinical 

governance processes now that they 

have been operating a year. The scope 

of this review should include: 

• Use of good meeting 

disciplines such as agendas, 

pre-prepared papers, 

documented actions and follow 

up; 

• Attendance and active 

participation from clinical staff; 

• Communication of issues and 

priorities to and from the 

Board; 

• Embedded use of tools such as 

the risk register; and 

• Ownership and accountability 

for actions. 


47. As part of its plans to update the 

performance dashboard, the Trust 

should: 

• Update the thresholds used to 

assign red, amber and green 

ratings. This processes should 

be informed by external 

benchmarking information as 

much as possible; 

• Report information at an 

additional level of granularity, 

for example by division; and 

• Further develop the reporting 

of clinical quality indicators, 

PRIORITY & 

SRO 

2-3 months 

Director of 

Clinical 

Governance 

Immediate 

Director of 

Planning & 

Delivery & 

Director of 

Clinical 

Governance 


RATING 

To be reviewed – actions to be Review completed. Amendments to 

agreed 

agendas including clear expectations 

of exception reports and clarity 

around what is for information, what 

is for decision and what is for 

discussion. Draft agendas prepared 

early to ensure sufficient time for 

preparation. 

Actions to be agreed – Consult Non 

Executive and Executive Directors 

Trust Board discussion 11/09. 

Review of Red Bell and Dr Foster 

KPIs to be included in the Clinical 

Governance KPIs which have been 

approved along with the process for 

review, at December Clinical 


23


including patient safety, patient 

experience and effectiveness. 

Executive and non-executive directors 

should be consulted as part of this 

development process. 


48. The Trust should update the Board 

Performance Dashboard to include 

HSMR at Trust and divisional level 

(where possible). (Page 71 


49. The Trust should ensure that the other 

mortality indicators above are 

monitored regularly. This could be in a 

quarterly mortality report rather than in 

the monthly performance matrix. (Page 


50. The Trust should identify resource to 

take responsibility for analysing 

mortality information using Dr Foster. It 

should also invest in additional training 

for key staff. This training should 

include increasing management’s 

awareness of the strategic functionality 

of the Dr Foster system and detailed 

training for relevant staff on the day to 

day reporting tools. (Page 71 


51. The information team should run a 

report of red bell alerts monthly. The 

Board should consider including this 

PRIORITY & 

SRO 

2-3 months 

Director of 

Planning & 

Delivery & 

Director of 

Clinical 

Governance 

1 month 

Director of 

Planning & 

Delivery & 

Director of 

Clinical 

Governance 

1 month 

Director of 

Planning & 

Delivery 

1 month 

Director of 

Planning & 


RATING 

Actions to be agreed – consultant 

Non Executive and Executive 

Directors 

Actions to be agreed – consultant 

Non Executive and Executive 

Directors 

Member of clinical governance staff 

identified to lead on mortality 

review with specialties. 

Dr Foster training (Train the 

Trainers) set for 08/12/09. Training 

programme for Consultants and 

other interested staff under 

development, 

Regular report produced 

Completed and presented to 

November Trust Board 

Paper to Trust Board 11/09 

Senior Leaders event 17/11/09, 

group work to identify outliers, action 

for ongoing monitoring, decisions on 

training. 

Training programme in place. 

Red bell reports running from 

November 09. To be reviewed by 

CG Analyst and fed back to 

24


information in the performance 

dashboard, with exception reports from 

the Medical Director on the action 

taken to investigate mortality outliers. 


52. The Quorum for the Clinical 

Governance Committee should be 

reviewed to ensure that there is always 

NED representation and that staff of 

appropriate seniority are in attendance. 


PRIORITY & 

SRO 

Delivery & 

Director of 

Clinical 

Governance 

2-3 months 

Director of 

Clinical 

Governance & 

Chair of CG 


RATING 

specialties via clinical governance 

arrangements. 


describing new function of Clinical 


New process agreed at Clinical 

Governance Committee 11/09 

Quality Committee replaced Clinical 

Governance Committee. Chaired by 

Trust Chairman 

53. Attendance at the Clinical Governance 

Committee should be by appropriately 

senior staff, with fully briefed deputies 

where attendance is not possible. 

Page 71 Paragraphs 245-248) 

54. As part of the clinical governance 

review recommended above, the Trust 

should consider the terms of reference 

for all committees and whether there is 

appropriate time allocated to consider 

all areas of responsibility effectively. 

Where necessary, Committee roles and 

responsibilities should be adjusted. The 

Clinical Governance Committee should 

consider more frequent meetings or 

cyclical reporting to ensure that there is 

time for sufficient challenge and 

debate. (Page 71 Paragraphs 245- 

248) 

2-3 months 

Director of 

Clinical 

Governance & 

Chair of CG 

2-3 months 

Director of 

Clinical 

Governance & 

Chairs of 

Committees 

Chairman of CG Committee and 

CG Director to review all committee 

structures inline with new ToR. 

Included in Terms of Reference. 

Terms of Reference for Clinical 

Governance Committee approved at 

11/09 meeting. [Cross reference to 

Section 46]. 

Revised 2011. 

25


55. Where discussions result in action, 

there should be clear agreement on the 

required action, owner, timescale and 

expected outcome so that there is clear 

accountability and progress can be 

monitored. 


56. The Trust should implement the 

proposed changes to clinical 

governance in the medical division and 

introduce a programme of checks and 

audits to ensure that the changes are 

implemented as planned and delivering 

the expected benefits. (Page 75 


PRIORITY & 

SRO 

1 month 

Director of 

Clinical 

Governance 

2-3 months 

Clinical 

Governance 

Manager & 

Divisional 

Director of 

Medicine 


RATING 

Develop a cohesive action planning Action planning process included in 

process that has clear KPIs for Trust Board paper for approval 

monitoring progress 

11/09. 

Arrangements under review 

DD for Medicine to review with leads 

for clinical governance and audit. 

Engagement with mortality review 

process discussed and clinician 

engagement obtained. To be rolled 

out as part of the Clinical 

Governance programme. [Cross 

reference to section 63]. 

57. The clinical governance review 

recommended above should consider 

divisional and specialty governance 

arrangements. It is often at this level 

where there is increased variation in 

the way that meetings are conducted. 


58. Actions arising in governance meetings 

should be clearly agreed and 

documented. Processes should also be 

agreed regarding how the committee 

will satisfy itself that actions have been 

appropriately implemented and/or 

whether any follow up audits are 

required to assess the impact. (Page 


59. The clinical governance lead for cancer 

services and clinical governance 

2-3 months 

Clinical 

Governance 

Manager 

1 month 

Clinical 

Governance 

Manager 

1 month 

Clinical 

Monitor variations in governance 

arrangements and make 

recommendations for synergy 

across the Trust 

Process to be agreed with clinical 

governance facilitators and clinical 

governance leads. 

New Division support for clinical 

governance Aug 2011 

Meeting arranged to address 

Review of Consultant Attendance at 

Clinical Governance meetings from 

Jan to Oct 09 completed. 

Clinical Governance facilitators are 

the monitors of all governance 

meetings. 

Process revalidated and agreed. 

Agreed CG data set emailed to 

26


manager should meet to consider 

clinical governance data in advance of 

the monthly meetings to help prioritise 

the agenda and hold individuals to 

account. This includes the planned 

changes to incident monitoring and 

reporting. (Page 76 Paragraphs 261- 

264) 

60. The milestones in the work stream 

monitoring tool used by the S&SIB 

should be refined to include 

measurable KPIs and targets that can 

be used to evaluate the impact of 

planned changes. (Page 77 


61. The KPIs and thresholds used to 

assign a red, amber or green rating 

should be agreed when the work 

stream is approved so that the 

progress updates by the Senior 

Responsible Officer are less 

judgemental. These thresholds should 

be updated regularly as the work 

streams develop and evolve. (Page 77 


62. When action plans are agreed by the 

Board, or any of the clinical governance 

sub-committees, they should be 

prioritised and a process agreed to 

monitor and measure implementation 

progress. The review of clinical 

governance arrangements 

recommended above should consider 

whether one of the existing committees 

PRIORITY & 

SRO 

Governance 

Facilitator & 

Clinical 

Governance 

Lead for 

Cancer 


RATING 

process needed 

Cancer CG Lead monthly. 

1 month The development of the ‘red bell’ 

report and the additional data 

developed for the Trust Board will 

be monitored through SSIB. 

1 month 

Director of 

Clinical 

Governance 

1 month 

Director of 

Clinical 

Governance 

Use of risk matrix. Management of 

risk register. Escalation of 

uncontrolled risks. 

Develop a cohesive action planning 

process that has clear KPIs for 

monitoring progress. 

Included in Terms of Reference for 

Clinical Governance Committee. 

KPIs form part of the quality 

dashboard discussed at SSIB. 

The new Board Assurance 

framework process has been agreed 

at SSIB and the Audit Committee 

05/11/09 


27


should lead on the monitoring of clinical 

quality action plans or whether a new 

group should be created with 

responsibility for managing the 

operational implementation of these 

plans. (Page 78 Paragraphs 268-270) 

63. The Trust should ensure that 

appropriate time for clinical audit and 

other essential clinical governance 

processes is included in consultant job 

plans and objectives for relevant 

clinical staff. (Page 80 Paragraphs 

274-281) 

64. As part of the scoping process for each 

clinical audit, key milestone should be 

agreed. These should be recorded in 

the clinical audit database and used by 

the clinical governance managers and 

divisional governance leads to hold 

relevant clinicians to account. The 

Clinical Audit Committee should 

receive an update report regularly of 

ongoing audits as well as those that 

have been completed. This analysis 

should include exception reporting 

when key milestones have not been 

achieved. (Page 80 Paragraphs 274- 

281) 

65. The criteria for mortality reviews for 

A&E and Critical Care patients should 

be finalised and implemented promptly. 


PRIORITY & 

SRO 

2-3 months 

Medical 

Director & 

Divisional 

Directors 

Immediate 

Clinical 

Governance 

Manager 

1 month 

Divisional 

Directors of 

Medicine & 

Surgery 


RATING 

The job planning process is 

currently under review and it has 

been agreed that dedicated 

sessions are required. This still 

needs to be formulated. This is in 

compliance to Revalidation 

obligations. 

It has been agreed in Medicine that 

2.5 SPAs will be included in the job 

plan and this will be monitored for 

activity compliance of which clinical 

governance is a key component. 

Development of escalation plan Completed and in place 

Format to be agreed 

Format agreed at Senior Leaders 

event and Clinical Governance 

Committee December 09. Full 

process in place between 

Performance and Clinical 

Governance. Reports to be received 

28


66. The areas of focus should be informed 

by other indicators of patient safety 

such as Dr Foster red bell alerts, 

unusual deaths (identified by Dr 

Foster), complaints and incidents. 

(Page 81 


PRIORITY & 

SRO 

1 month 

Divisional 

Directors of 

Medicine & 

Surgery and 

Clinical 

Governance 

Leads 


RATING 

by Clinical Governance Committee. 

Triangulation of data 

Clinical Governance Analyst using 

range of indicators to try and collate 

data. 

67. The format of the mortality reviews 

should be consistent with best practice 

such as the global trigger tool 

recommended by the NHS Institute. 


1 month 

Clinical 

Governance 

Manager 

To circulate global trigger tool 

Circulated to Clinical Audit 

Committee for Review. 

Review date January 2010. Also for 

consideration at Clinical Governance 

Committee January 2010. 

68. The mortality review database should 

be developed so that it can assist the 

Clinical Audit Committee to monitor (as 

a minimum): 

• Trend in number and 

percentage of unexpected 

deaths by directorate 

• Number of incomplete reviews 

and length of time they have 

been outstanding 

• Detailed action plans including 

owner, timescale, 

measurement of impact 

• Trust or division-wide trends 

from findings 


1 month 

Senior 

Accreditation 

Clinical 

Governance 

Manager 

To be formulated 

Use of global trigger tool to be 

included in the Incident Policy 

Review at CAC 16/11/09 

Mortality review spreadsheet 

designed to report on review activity 

for divisions. 

29


69. Mortality reviews should be carried out 

by someone independent of the 

clinician responsible for the patient at 

the time of death. (Page 81 


PRIORITY & 

SRO 

1 month 

Clinical 

Governance 

Manager 


RATING 

To oversee and audit independent Included in mortality review process 

process 

guidance. 

70. In addition to addressing the target of 

reducing the number of complainants, 

the Trust should also focus on the 

themes arising from complaints relating 

to clinical and nursing issues, which 

have a very significant impact on 

patient care. Root cause analysis 

should be performed on the themes 

identified, in order to enable the Trust 

to identify required changes where 

appropriate. (Page 84 Paragraphs 

287-295) 

71. Action plans should be developed in 

response to root cause analysis, which 

will enable the Trust to implement 

appropriate changes to clinical practice. 

Such action plans should be reviewed 

and approved by the Clinical 

Governance Committee. (Page 84 


72. The Trust should implement the Patient 

Experience Tracker promptly. The 

questions asked should link to the 

Improving Patient Experience Strategy 

and local priority areas including dignity 

of the patient experience. Wards 

should be held accountable for 

ensuring that patient feedback is 

2-3 months 

Senior 

Accreditation 

Manager 

1 month 

Senior 

Accreditation 

Manager 

2-3 months 

Director of 

Nursing 

To develop RCA on selected 

themes 

Complaints process now 

responsibility of Director of Nursing. 

Complaint process transferred to 

Divisional responsibilities 

To develop action plans on RCA 

findings 

Action to be agreed 

Business Plan accepted and 

submitted to the Capital Planning 

Group 13 th Jan 10 

Review of a number of different 

suppliers, submit with waiver tender 

late Jan 10 

Circulating all complaints to senior 

staff. RCA to be themed and 

presented to the Clinical Governance 

Committee (Patient Safety) 

bimonthly starting December 2009. 

RCA review underway. Specific 

areas highlighted for attention. 

Action plans to be agreed at Clinical 

Governance Committee (Patient 

Safety). 

Data to be used to triangulate 

evidence for KPIs. 

Improve information/engagement 

and feedback from patients to enable 

greater focus on priorities to improve 

the patient experience 

Hand held real time survey in place – 

30


received regularly and acted upon. 

(Page 85 Paragraph 298) 

PRIORITY & 

SRO 


RATING 

Enable patient and staff focus Jan 11. 

groups 

Benchmark through LIPEC Group 

at NHS London 

Feedback from Improving Patient 

Experience Group. 

73. The Trust should implement processes 

to monitor performance against clinical 

governance objectives during the year 

and summarise performance in the 

Clinical Governance Annual Report 

within three months of the year end. 


74. Information monitored by the Clinical 

Governance Committee should include 

increased use of data intelligence on 

relative performance against previous 

periods, other parts of the hospital and 

other NHS organisations. Information 

on different clinical governance areas 

should be triangulated to identify 

potential trends. Information that should 

be compared in this way includes 

complaints, SUIs, incidents, 

unexpected deaths and staffing levels. 

(Page 86 


75. The Trust should register key staff on 

the LIPS programme. At a minimum 

this would usually include an interested 

and committed consultant to do 

2-3 months 

Director of 

Clinical 

Governance 

2-3 months 

Director of 

Clinical 

Governance 

2-3 months 

Divisional 

Directors & 

Divisional 

Clinical Governance objectives 

completed in line with Trust Board 

objectives and monitored through 

the Annual Report. 

Monthly Clinical Governance 

meetings to be set up. 

Develop draft terms of Reference to 

include rigorous review of mortality, 

morbidity, SUIs, monitoring of 

action plans (high level) and 

triangulated data. 

Senior consultant dedicated time to 

review complaints and incidents 

and manage process will be 

nominated LIPS programme 

Report to Board 11/09 

Draft Terms of Reference to go to 

Board 11/09 with supporting PWC 

report and action plan 

LIPS course not attended but range 

of patient safety initiatives in place. 

PEQ Board agreed to defer 

attendance on LIPS programme due 

31


monthly case note reviews, a senior 

consultant and nurse who have the 

ability to lead and influence the safety 

improvement agenda and a patient 

safety manager who will facilitate day 

to day improvement work. 


76. The patient safety strategy should 

include be updated to include 

consideration of all NPSA and NHSI 

initiatives and participation where 

appropriate. The Clinical Governance 

Committee should approve the decision 

about which initiatives the Trust will 

participate in and receive reports on the 

outcomes. 


77. The Trust should introduce monitoring 

of the KPIs in the ward performance 

dashboard across the Trust as well as 

on investment wards and the control 

population. As noted in the nursing 

section above, this should include 

complete observations and care plans. 


PRIORITY & 

SRO 

Nurses 

1-2 months 

Director of 

Clinical 

Governance 

2-3 months 

Director of 

Nursing 

May 09 

Sept 09 

March 2010 

Nov 2010 

Nov 09 

Oct 09 


RATING 

attenders. 

to high numbers of senior staff 

needing to attend and time 

Course to be booked. 

constraints. 

Strategy to be updated 

• Establish ‘Nurse Pathfinder 

Project’ 

• Project commenced Sept 

09 for 6 months against 

KPIs, including Productive 

Wards and Control wards – 

monitor monthly 

• Roll out Productive Ward 

Programme over 24 

months, 6-8 wards on a 2 

monthly roll out programme 

led by The Practice 

Development Team 

• Roll out KPIs to other 

generic wards in the trust 

and monitor against project 

and productive wards – 

Approved at January Clinical 

Governance Committee 

Analyse enhanced levels of nurses, 

lean working and control wards 

against KPIs over period of project 

Implement actions from sub groups 

to improve compliance with 

undertaking observations and 

32


78. The Trust should develop an action 

plan for the implementation of e- 

rostering for nursing staff. Management 

information from the system should be 

used to inform ward, directorate and 

divisional reporting. (Page 89 


PRIORITY & 

SRO 

Oct 09 and 

ongoing 

3 months 

Director of 

Human 

Resources 

March 2010 


RATING 

June 10, if project effective accuracy 

• Mid project report 

submitted to SSIB 13 th Jan Reduce ‘Failure to Rescue’ cases 

10 

and mortality rates 

• Establish Observations 

Steering Group and sub 

groups 

• Audit observations 1 week 

a month on every ward 

• Review of the manual 

rosters 

• Business case for MAPS 

electronic rostering 

• Review system in operation 

in another trust 

Enablement of uniform rostering with 

auditable working hours. 

Business case presented to Finance 

Committee and supported. 

33


TITLE: 

Board Assurance Framework – Quarter 1 (April-June) 

2011/12 




The Board Assurance Framework (BAF) containing the 

high / extreme risks for Quarter 1 is attached for Trust 

Board consideration. The overview chart provides an ‘at a 

glance’ position statement of changes that have occurred 

in relation to Quarter 4, 2010-11. 

The BAF has been considered by the Trust Executive 

Committee (TEC) and it has been agreed that the attached 

risks are required to be highlighted to the Trust Board. 

The BAF includes a progress against action column which 

provides information on the current situation. 

Each extreme risk identified has an action plan as 

described on the framework. 

□ TEC ……23.8.11..….. □ STRATEGY……….….…… 

□ FINANCE ……..……… □ AUDIT ………….…………. 

□ QUALITY & SAFETY …………..………….....……….… 

□ WORKFORCE ………………………………………….… 


□ TRUST BOARD ……………………………….……….…. 

□ REMUNERATION ………………………………….…..... 



The Trust Board is asked to review the BAF and note the 

controls in place to mitigate the extreme risks to the Trust 

meeting its objectives. 

□ NATIONAL TARGET □ RMS 




As described in the action plans. 


As described in the action plans 


As described in the action plans. 




AUTHOR/PRESENTER: Mr Stephen Burgess, Medical 

Director 

DATE: 25.08.11 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


Board Assurance Framework 2011/2012 

Including Extreme Risks from the Trust Risk Register 

Quarter April to June 2011 

• The Board Assurance Framework identifies all the Trust’s principal objectives within its five ambitions:- Patient Safety, Finance, Workforce, 

Partnership Working, and Foundation Trust status. 

• It also describes the risks which present a major threat to achievement of any of the objectives and are not well controlled. 

• Those risks are identified initially through review of the objectives themselves. Alternatively they may initially be identified by Divisions as operational 

risks. 

• All significant risks whether to the objectives or otherwise are also described on the Trust Risk Register. 

• The Framework and the Risk Register will provide confirmation that there are action plans to put in place controls for the risks they contain and that 

there is assurance that plans and controls are robust. 

• Those risks which present a major threat to any of the objectives and are not well controlled are defined and graded as Extreme (red). By definition 

all the Trust’s Extreme risks appear on the Framework. Each has an action plan attached. 

• Significant risks which require high level attention but do not present a major threat to any of the objectives are defined and graded as High (orange) 

and are described on the Risk Register but not on the Framework. Oversight of their control and assurance is allocated to the responsible Division. 

• Extreme risks that threaten any of the objectives but which then become better controlled will be downgraded to High and will be relegated from the 

Framework to the Risk Register alone and oversight of their control will be allocated to the responsible Division. 

• The Framework will be reviewed by the Audit Committee at each meeting and by the Board 6 monthly. 

• For all objectives which are threatened by risks that are High (orange) but not Extreme (red), for ease of reference those High risks are noted on the 

Framework but not fully described 

BAF 1 ST Quarter 2011-12 (Trust Board – Sept 2011) 

1

Objective 1 Q4 Q1 Objective 2 Q4 Q1 Objective 3 Q4 Q1 Objective 4 Q4 Q1 Objective 5 Q4 Q1 

Patient Safety Finance Workforce Partnership 

Working 

Foundation Trust 

Status 

Diagnostic Service Financial Governance Workforce Planning Partnership working Foundation Trust 

status 

CQC Registration Cost Control 

Improvement 

Patient Safety Income Maximisation 

Health & Safety 

Resuscitation 

Maternity Services 

Information Choose & 

Book 


Length of Stay 

Infection Control 

Information 

Governance 

Cancer Waits 

18 Week Targets 


2

Principal Risk 

Residual 

Risk, 

following 

controls in 

place 

Key Controls 

In place 

Assurances 

on Controls 

Actions/Update 

Progress against 

action 

Lead 

Principal Objective 1.2 CQC Registration 

Extreme Red Risk: 263 & 299 

Unannounced visits from CQC resulted in 

warning notices being issued to Queen's 

Maternity and A&E Services causing high 

levels of media attention resulting in: 

• Loss of confidence by patients and 

stake holders in ability to deliver safe 

maternity services 

• Extreme Damage to reputation 

• Demoralisation of staff 

• Potential reflection in recruitment and 

retention 

Full and timed action 

plan in place covering 

all elements of CQC 

recommendations 

Action plan 

implementation to be 

monitored via TEC, to 

the Audit Committee 

and Trust Board. 

Maternity service 

weekly dashboard in 

place 

A & E action plan 

monitored by the 

Emergency Task Force. 

August TEC to agree 

and review progress 

against the plan 

As described in plan 

Mr Stephen 

Burgess, 

Medical 

Director 

Principal Objective 1.6 Maternity Services 

Extreme Red Risk: 163 

High level of activity increases the risk of 

harm to women in labour when 1:1 care in 

labour cannot be achieved in 90% of 

cases. 

Line bookings for 

agency midwives in 

place. 

Further recruitment of 

Midwives from Italy and 

Ireland. 

Utilisation of internal 

bank to cover gaps. 

Implementation of 

Maternity Escalation 

Policy when sudden 

staffing issues occur. 

RNs and Nursery 

Nurses appointed to 

reduce workload of 

Midwives. 

Audit 1:1 care of labour 

monthly 

Review incidents 

related to staffing via 

weekly and monthly risk 

meetings. 

Report updates to Trust 

Quality & Safety 

meeting. 

Strategy presented and 

monitored by Trust 


Review funded ratio of 

midwives against 10/11 

deliveries/activity levels 

Recruitment strategy 

agreed to improve fill 

rates and retention for 

midwifery. 

Increase recruitment in 

Europe. 

Complete HDU RN 

recruitment. 

Reorganise service 

configuration and 

systems to improve 

efficiencies and 

utilisation of staffing. 

As described in plan. 

Carol 

Drummond, 

Divisional 

Director W&C 

Exec: Deborah 

Wheeler, 

Director of 

Nursing 

Report and investigate 

suspension of services 

Plan to open co-located 

MLU at Queen’s. 


3


Residual 

Risk, 

following 

controls in 

place 

Key Controls 

In place 

Assurances 

on Controls 



action 

Lead 

High Orange Risk: 168 

Management of Patient Records: 

Maternity records not on tracker system. 

Risk – delays in retrieving notes to answer 

complaints, review incidents and legal 

claims. Clinical audits delayed. 

Risk of inadequate consultation and 

discussion at appointments and meetings. 

NEEDS TO 

BE RED 

Manual Tracker system 

in place. 

One central filing 

system at KGH 

Designated obstetric 

coders 

A new system is being 

looked at, also looking 

at the possibility of 

tracking obstetric notes 

in PAS by identifying 

them with a letter 

against the district 

number. 

Carol 

Drummond, 

Divisional 

Director W&C 

Principal Objective 1.8 Emergency Medicine 


A&E service improvement. 

Non delivery of 4 hour target to achieve 

98% of patients seen and treated in 4 

hours. 

Poor rating for the annual health check 

Poor patient experience 

Established Emergency 

Care Programme 

Board (ECPB) monitors 

all actions for 

improvement. 


programme benefits. 

Reported to ECPB 

ECPB reports to TEC 

and Trust Board 

Paper presented to 

Trust Board March 

2011 by Director of 

Performance and 

Planning on Emergency 

Care and trajectory for 

NHS London plus 

Emergency Care 

Taskforce demonstrates 

progress to achieve 

98% of patients seen 

and treated in 4 hours 

Increase bed availability 

to reduce patients 

staying within the A&E 

department more than 4 

hours 

Establish ECPB 

Project on Ambulatory 

Care, Readmissions 

and Jonah making 

progress, plus additional 

bed capacity created. 

Patient flow significantly 

improved and resulting 

impact on performance 

against 4 hour standard. 

Dr Magda 

Smith, 

Divisional 

Director 

Medicine 

Maintain improved 

resilience within the 

A&E systems and 

throughput to the MAAU 


Lack of space for unloading causes delay 

in handing patients over to A&E, delays to 

treatment and inability of nurses to care 

appropriately for A&E patients. 

Improvement in patient 

flow. 

Discharge planning 

improvements. 

Implementation of 

Jonah. 

Report to ECPB, TEC 

and Trust Board 

Rapid assessment led 

by Consultant 

New rapid assessment 

and treatment (RAT) 

process introduced in 

A&E 

RAT process 

introduced at Queen’s 

and being rolled out 

at KGH. 

Dr Magda 

Smith, 

Divisional 

Director 

Medicine 


4


Residual 

Risk, 

following 

controls in 

place 

Key Controls 

In place 

Assurances 

on Controls 



action 

Lead 

Principal Objective - 2.2 – Cost Control/Improvement 


Achieve financial target - Failure in 

financial management and budgetary 

control including expenditure restrictions, 

leading to supply chain disruptions 

Budget statements, 

Finance reports. 

Vacancy Panel, 

Procurement Control, 

Oracle. 

Revised financial 

reporting & 

management 

framework established 

Reviewed by EC, 

Finance Committee and 

Trust Board. 

David Wragg, 

Director of 

Finance 

Finance Committee & 

Programme 

Management Board. 

Planned outturn for 

2011/12 agreed with 

SHA with SHA 

£40.9m deficit before 

impairment. 

Under constant 

reviewed by CIP/QIPP 

Programme Board, 

TEC, Finance 

Committee and Board 


5


Residual 

Risk, 

following 

controls in 

place 

Key Controls 

In place 

Assurances 

on Controls 



action 

Lead 

Principal Objective - 2.3 – Income Maximisation 


Achieve Financial Target: CIP and cost 

improvement - Failure to deliver turnaround 

efficiency programme leaving Trust 

Vulnerable to reputational damage 

Programme 

management controls 

Programme 

Management office 

CIP built into budgets 

at 28 gross. 

David Wragg, 

Director of 

Finance 

Currently risk assessed 

position stands at £9m 

shortfall, with extra 

pressures of £4m 

Under constant review 

by PEQ 

Principal Objective – 3 Workforce Planning 


Surge capacity Sky A and ability to deliver 

service required due to workforce issues 

both medical and nursing 

Lead Matron & Lead 

Consultant 

engagement with inhouse 

bank. 

Executive decision to 

employ substantively 

Dr Magda 

Smith, 

Divisional 

Director 

Medicine 


6

1 

REPORT TO: 

REPORT FROM: 


Chief Executive 

DATE: 19 August 2011 

SUBJECT: 

FOR: 

INTERIM CHAIR & CHIEF EXECUTIVE’S REPORT 

Information 

______________________________________________________________ 

1. INTRODUCTION 

This report contains a summary of: 

• Actions taken under emergency powers 

• Executive decisions 

• National Issues/News 

• Local Issues/News 

2. RECOMMENDATION 

The Board is asked to note this report. 

3. ACTIONS TAKEN UNDER EMERGENCY POWERS 

No actions have been taken by the Interim Chairman or Chief Executive 

acting under emergency powers. 

4. EXECUTIVE DECISIONS 

The Trust Executive have been meeting on a weekly basis and have 

reviewed and inputted into several reports prior to their submission to the 

Trust Board, such as the Maternity Services Update, Emergency Care 

Update, Care Quality Commission Action Plan Update and the Board 

Assurance Framework. 

Interim Chair & Chief Executive’s Report – August 2011

2 

5. NATIONAL ISSUES/NEWS 

The Quarter: Quarter 4, 2010/11 

Strong performance in the final quarter of 2010/11 has put the NHS on 

track to face the challenges of the transitional year ahead, according to 

the latest edition of The Quarter, published recently. David Flory’s report 

provides a summary of the NHS financial position and performance 

against the national priorities set out in the Revision to the Operating 

Framework for the NHS in England 2010/11. Nationally the Performance 

Framework results have improved, although a number of Trusts continue 

to perform poorly. PCTs and SHAs have reported a surplus of £1375m, 

with a surplus of £121m reported in Trusts. 

For further information go to: 

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStati 

stics/DH_ 087335. 

NHS Chief Executive’s Innovation Review: 

Sir Ian Carruthers, on behalf of the NHS Chief Executive, has issued a call 

for evidence on how the adoption and diffusion of innovations can be 

accelerated across the NHS. This is part of a wider engagement process 

that will report in November 2011. Sir Ian is keen to hear your views, and 

has also written to industry, other government departments, the academic, 

scientific and voluntary sectors and social care to seek their input. The 

review closed on the 31 August 2011. 

For further information go to: www.dh.gov.uk/innovationreview 

Health Profiles released for your local area: 

People in England are living longer and fewer people are dying 

prematurely from heart disease and stroke. The 2011 Local health 

profiles, published by The Public Health Observatories, in partnership with 

the Department of Health, provide statistics for each local area and 

indicate how any area is performing against the national average. 

Launched on the first day of the Local Government Association (LGA) 

annual conference, the Health Profiles give up to date information on key 

health issues such as childhood obesity, skin cancer (malignant 

melanoma), deaths from smoking, hospital stays due to alcohol misuse 

and early deaths from cancer and heart disease, information which is 

essential for planning local services for communities. 


www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_127915 

National liaison and diversion development network: 

The establishment of this network of local services for adults and young 

people in criminal justice settings, will help those with health problems into 

appropriate treatment. The network will support work to make services 

nationally available by 2014. 


www.dh.gov.uk/en/Healthcare/Offenderhealth/DH_127793 


3 

Organising for quality and value – delivering improvement 

programme: 

In July’s Expert on Call, Alice O’Neill and Jenny Bramhall, Associates at 

the NHS Institute, talked about the Organising for Quality and Value: 

Delivering Improvement Programme. The programme supports NHS 

organisations to develop the service improvement skills of their clinical 

and operational staff, providing them with a solid foundation in quality and 

service improvement methods. 

Link: https://nhs.webex.com/nhs/onstage/g.phpt=a&d=847146652 

SHA Clustering Arrangements: 

David Nicholson has written to all SHA Chief Executives setting out the 

arrangements agreed recently at the NHS Management Board for 

clustering SHAs. It includes detail on geographical areas, structures and 

operating model, governance, quality and safety, HR processes, national 

arrangements and development. 

For more information go to: 

www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolle 

agueletters/DH_128351 

Healthy Lives, Healthy People: Update and way forward: 

The Government has published a response to the public health white 

paper consultation and NHS Listening Exercise. It reaffirms the 

Government’s determination to create a more effective public health 

system and sets out progress to date. 

For more information go to: 

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic 

yAndGuidance/DH_128120 

Secretary of State announces fifth cohort of pathfinders: 

The Secretary of State announced the latest cohort of pathfinder 

commissioning groups at the Annual NHS Confederation Conference in 

July. In total 257 groups, covering around 97% of the population (around 

50m people), have come forward so they can directly commission services 

focused on delivering best results for their patients. 

Link: http://healthandcare.dh.gov.uk/fifth-cohort-of-pathfinders 

Council for Healthcare Regulatory Excellence (CHRE) to develop 

national standards for senior NHS leaders: 

The Department of Health has commissioned the CHRE to develop 

national standards of probity, behaviour and competence for senior NHS 

leaders to provide a clearer understanding of what is expected of them. 

Link: www.chre.org.uk/media/18/408 

NHS Continuing Healthcare National Framework: 

The letter from Gill Ayling, Deputy Director – Older People and Dementia, 

highlights the opportunities that local Quality, Innovation, Productivity and 

Prevention (QIPP) workstreams working on the commissioning of NHS 

continuing healthcare may offer. It reminds colleagues of the importance 

of adhering to the NHS Continuing Healthcare National Framework 


4 

processes for determining eligibility for NHS Continuing Healthcare. 

Link: 


agueletters/DH_128293 

Munro review of child protection – Government response: 

The Department of Education published the Government response to 

Eileen Munro’s review of child protection in July 2011. Government will 

take forward further detailed work with key partners. This will include 

building on the Department of Health’s work to date on the practical 

implications of NHS reform for safeguarding children. 

Link: www.education.gov.uk/munroreview 

Energise for Excellence: 

Launched at the NHS Confederation conference recently, the document 

outlines how NHS organisations can make significant quality 

improvements and cost reductions, through active NHS board support of 

Energise for Excellence. 

Link: www.institute.nhs.uk/e4eseniorleadersC2A 

Safe and secure handling of medicines: 

To support patient safety, all hospitals should ensure they have in place a 

robust policy, signed off by the Trust Board, for the safe and secure 

handling of medicines and that managers and all staff who prescribe, 

dispense or administer medicines, are familiar with the policy. 

Link: www.rpharms.com/support-pdfs/safsechandmeds.pdf 

Extending Choice of Any Qualified Provider: 

The Government has committed to extending patients’ choice of Any 

Qualified Provider with phased implementation from April 2012. Guidance 

is now available for commissioners, as well as current and prospective 

providers of NHS funded services. It sets out how patients’ choice of 

provider will be extended during the transition until April 2013. 

Link: 

www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_125442 

NHS (Charges to Overseas Visitors) regulations 2011 and guidance: 

New regulations and guidance on charging overseas visitors for NHS 

hospital treatment came into force on 1 August 2011. These include 

some new exemption from charge categories, an extended disregarded 

absence period for UK residents, and revised guidance on when to 

provide treatment to those not entitled to it free. 

Link: 


yAndGuidance/DH_127393. 


5 

NHS Premises Assurance Model: 

The universal NHS premises assurance model has been released to 

support the NHS in enhancing the quality and safety of NHS premises, 

while also increasing efficiency and effectiveness. 

Link: 


yAndGuidance/DH_128702. 

Accelerating the release of public land for development: 

The Government has announced plans to build 100,000 new homes on 

public sector land. As one of the largest owners of public sector land, the 

NHS is expected to contribute to the delivery of these homes. There is a 

data collection exercise to support this initiative. 

Link: 


agueletters/DH_128624. 

Equality Delivery System (EDS): 

The EDS is now available for use by NHS organisations. It has been 

designed to help all NHS organisations understand how equality can drive 

improvements and strengthen the accountability of services to staff, 

patients and the public. 

Link: www.eastmidlands.nhs.uk/eds 

Future ownership and management of PCT – owned estate: 

Further to the announcement on 6 January 2011 on the proposed 

transfers of PCT – owned estate to aspiring community Foundation Trusts, 

guidance has now been published which extends the policy to include 

transfers of property to Foundation Trusts and NHS Trusts. This 

guidance supercedes the FAQs published on 16 February 2011. 

Link: 


yAndGyuidance/DH_129008 

Board Development – addressing health inequalities/patient 

experience: 

This nine month NHS board development programme from the National 

Leadership Council uses expert knowledge to aid thinking about how an 

organisation responds to diverse population needs, makes the connection 

between diversity, inclusion and core business and leverages diversity for 

innovation and improvement. 

Link: www.nhsleadership.org.uk/workstreams-inclusionboarddevelopment.asp 

Diagnostic tool for emerging clinical commissioning groups: 

A new developmental, self-assessment tool to enable emerging clinical 

commissioning groups (CCGs) to understand and reflect upon their 

values, culture, behaviours and wider organisational health is now 

available. Emerging CCGs are encouraged to use the tool early on in 


6 

their journey to support their organisational development over the next 12- 

18 months. 

Link: http://healthandcare.dh.gov.uk/diagnostic-tool-for-emerging-clinicalcommissioning-groups/ 

Approving PFI schemes and Deeds of Safeguard: 

This note explains the Department’s policy on approving proposed Private 

Finance Initiative (PFI) schemes and their management during the 

transition period of the Government’s NHS reforms. It also explains the 

new policy with regard to Deeds of Safeguard, through which the 

Secretary of State for Health stands behind the long term obligations of 

Foundation Trusts to their PFI schemes. 

Link: www.dh.gov.uk/health/2011/08/pfi-approvals/ 

NHS Future Forum to carry out new work on key health issues: 

The Government has asked the NHS Future Forum, a group of health 

experts, to carry out a new phase of conversations with patients, service 

users and professionals, following the recent listening exercise on 

proposals to modernise the NHS. The Forum will provide independent 

advice on the following four themes: information, education and training, 

integrated care and the public’s health. 

For further information: www.dh.gov.uk/health/2011/08/future-forum/ 

NHS Staff Survey: 

The NHS Staff Survey Coordination Centre published the detail of the 

2011 national staff survey last week. Trusts now need to prepare for the 

launch of the survey in late September. The Coordination Centre will 

make the necessary documents available, as well as detailed guidance 

notes. The annual survey is an important way of ensuring the views of 

NHS staff inform local improvements. It also enables the Department of 

Health to assess the effectiveness of national NHS staff strategies and 

policies, such as training and flexible working. 

For more information read Sir David Nicholson’s letter to NHS Leadership 

Teams: www.dh.gov.uk/health/2011/08/nhs-staff-survey/ and go to: 

www.nhsstaffsurveys.com 

NHS transfer to social care – 2011/112 returns: 

The Department made available £648m in 2011/12 for transfer to local 

authorities for social care activities that also benefit health. This letter 

from David Flory, Deputy NHS Chief Executive and David Behan, Director 

General Social Care, asks PCT Finance Directors for information to 

establish how the social care funding is being used. 

Link: www.dh.gov.uk/health/2011/08/social-care-allocation/ 

Patient Reported Outcome Measures (PROMs) latest data release: 

The Health and Social Care Information Centre published the latest 

release of PROMs data on 17 August. This twelfth monthly release 

comprises both post-operative health outcomes and pre-operative data 

broken down by provider, and contains finalised data for April 2009 – 

March 2010 and provisional data for period April 2010 – March 2011. 

Link: www.ic.nhs.uk/statistics-and-data-collections/hospital-care/patientreported-outcome-measures-proms 


7 

Transfers of PCT- owned estate: 

Further to the publication on 4 August 2011 of guidance relating to 

transfers of PCT owned estate to aspiring community Foundation Trusts, 

Foundation Trusts and NHS Trusts, the Department has received and 

responded to a number of questions. A supplementary ‘Frequently Asked 

Questions’ document has therefore been added. 

Link: www.dh.gov.uk/health/2011/08/pct-estate-future-ownership-andmanagement-of-estate-in-the-ownership-of-primary-care-trusts-in-england/ 

6. LOCAL ISSUES/NEWS 

New Non-Executive Director: 

Professor Anthony Warrens has been appointed as the new University 

Non-Executive Director for a period of four years, with effect from 30 June 


Care Quality Commission Update: 

The CQC has now finished their on-site inspections, having looked at the 

Emergency Department and the care pathway through to the wards, 

Maternity Services at King George and Queen's and Vascular Surgery at 

Queen's. Staff worked very hard during the inspection, either in providing 

evidence, or attending interviews, and the Trust acknowledges everyone’s 

contribution. 

We are unclear yet as to the timing of the report, but believe it should be 

no later than mid October. 

Notification of Inspection of Safeguarding and looked after 

Children’s Services in Havering commencing Monday, 12 September 

for two weeks: 

The Local Council/Director of Children’s Services will be the main point of 

contact for the inspection, liaising directly with the Ofsted Lead Inspector. 

The Trust, as health partners, will coordinate its joint involvement with the 

Council’s Team and nominate a lead health contact to represent the 

various health interests to the Council and to CQC for communications 

and administrative arrangements. The findings from the review will 

contribute to Ofsted’s overall assessment and report on Council services, 

but in addition, information about each healthcare organisation will be 

used to contribute to CQC’s other systems of assessment, including 

assessment of compliance with the Essential Standards of Quality and 

Safety. If, in the course of an inspection, any serious concerns are 

identified then these would be referred to others in the CQC for 

consideration. 

Rewarding Excellence in Healthcare IT: 

Congratulations to Dr Aklak Choudhury, Respiratory Consultant and 

Associate Divisional Director for Medicine, for being shortlisted as a finalist 

in the “Best Use of IT to promote patient safety” category at the EHI 

Awards 2011 in association with BT. The reward recognizes an individual 

who has made an outstanding contribution to their organisation, or the 

sector in the past year. The awards ceremony is on Wednesday, 6 


8 

October and the Chief Executive, Medical Director and Director of Medical 

Education, along with other senior colleagues, will be attending, in order to 

support Dr Choudhury. 



TITLE: 

Cancer Services Management Board Annual 

Report 




□ PEQ ……………..….. □ STRATEGY……….….……. 

□ FINANCE ……..……… □ AUDIT ………….……..…. 



X TRUST BOARD ……………………………….…………. 

□ REMUNERATION ………………………………….…... 








X OTHER For Information (please specify) 

AUTHOR/PRESENTER: Dr Ian Grant 

DATE: 13 th September 2010 



20010/11 has been an another extremely busy year for the Cancer Management Board, with a host of new 

initiatives and directives to implement, including the Model of Care for London. The Trust also went through 

the second round of annual peer review, which involves the MDT’s self assessing themselves and the 

Cancer Management Team internally validating their self assessment. To achieve this the following has 

been achieved: 

• Development of Pre Chemotherapy Nurse Led Review Clinic; 

• Hosting National Study Day – ‘Setting up an Oral Chemotherapy Clinic’; 

• Reduction in Door to Needle Time for Neutropenic Sepsis; 

• Implementation of 24 hour Triage for 24/7 Advice on Chemotherapy Complications; 

• Treated first prostate patient with IMRT (Intensity Modulated Radiotherapy); 

• Radiotherapy successfully completed first peer review self-assessment and external visit; 

• Breast centralised to KGH; 

• Completed annual Peer Review process; 

• Responded to the London Case for Change and Model of Care documents; 

• Began talks with other partners to implement recommendations within the Model of Care document; 

• Improved recruitment into clinical trials; 

• Fully recruited to the cancer clinical trials department; 

• Implemented the Somerset Cancer Register; 

• Improved capture of our subsequent treatment; 

Investigated and audited all “red bells” on Dr Foster.


Cancer Waiting Times THRESHOLD & TARGET YTD 

14 Day 

BOS 14 Day 

31 Day (to 1st Tx) 

62 Day 

31 Day (Subsequent Tx's) 

31 Day Drug Sub Tx 

31 Day Surgery Sub Tx 

31 Day Radiotherapy Sub Tx 

62 Day Screening 

62 Day Consultant Upgrade 

88 - 93% 99.66% 

93% 99.60% 

91 - 96% 99.14% 

80 - 85% 83.69% 

93 () - 98% 98.21% 

93 - 98% 99.09% 

89 - 94% 99.39% 

89 () - 94% 97.10% 

85 - 90% 93.26% 

80 - 85% 86.53% 


OR 

REFERRED TO: __________________________ 

DATE: ____________________________ 

DATE: ____________________________ 


2

ANNUAL REPORT FOR 

THE CANCER SERVICES 

MANAGEMENT BOARD 

This Annual Report was agreed by Dr Ian Grant, Chair, Cancer Services 

Management Board on 25.8.11. 

- 1 -

Section Category Page 

1 Introduction 3 

2 Key Achievements 3 

3 Key Challenges 4 

4 Attendance – CSM Board 4 

5 Workload 6 

6 Research and Clinical Trials 11 

7 Patient Feedback 12 

8 Data Collection 12 

9 Audit 12 

10 Advanced Communications Skills 12 

Course 

11 Cancer Waiting Times Performance 13 

12 Peer Review 14 

Appendices Appendix 1 – BHRUT Patient Survey 

Appendix 2 – Patient Survey Action 

Plan 

Appendix 3 – Peer Review Action Plan 

- 2 -

1. Introduction 

The Cancer Services Management Board (CSMB) is the strategic and decision 

making forum for the Trust’s Cancer Services. There is representation from the 

Clinical Leads for each MDT, Cancer Services Management and the North East 

London Cancer Network (NELCN). 

The Trust catchment population is 750,000 based on Havering, Barking and 

Dagenham, Brentwood and Redbridge PCTs and Cancer Service is provided at two 

hospitals; Queen’s Hospital, Romford and King George Hospital, Ilford. 

The Trust provides treatment for the following tumour sites: 

Breast Lung Colorectal 

Upper GI Urology Haematology 

Gynaecology H&N (inc Thyroid) Skin 

Brain and CNS 

Paediatrics (Level 1 POSCU) 

Palliative Care 

Chemotherapy services are provide in dedicated day units at both Queen’s Hospital 

and King George Hospital, whilst Radiotherapy services are provided from 3 Linacs 

based at Queen’s Hospital. 

2. Key Achievements 

Cancer services have developed significantly in the past year including: 

• Development of Pre Chemotherapy Nurse Led Review Clinic; 

• Hosting National Study Day – ‘Setting up an Oral Chemotherapy Clinic’; 

• Reduction in Door to Needle Time for Neutropenic Sepsis; 

• Implementation of 24 hour Triage for 24/7 Advice on Chemotherapy 

Complications; 

• Treated first prostate patient with IMRT (Intensity Modulated Radiotherapy); 

• Radiotherapy successfully completed first peer review self-assessment and 

external visit; 

• Breast centralised to KGH; 

• Completed annual Peer Review process; 

• Responded to the London Case for Change and Model of Care documents; 

• Began talks with other partners to implement recommendations within the 

Model of Care document; 

• Improved recruitment into clinical trials; 

• Fully recruited to the cancer clinical trials department; 

• Implemented the Somerset Cancer Register; 

• Improved capture of our subsequent treatment; 

• Investigated and audited all “red bells” on Dr Foster. 

- 3 -

3. Key Challenges 

The main challenges for cancer services and the CSMB this year include: 

• Financial constraints; 

• Achieving the 62-day CWT targets; 

• Improving attendance at the CSMB; 

• Improving outcomes following the National Cancer Patients Survey; 

• Increase in activity across all tumour sites. 

4. CSMB Attendance 

Please see below for the CSMB attendance for 2010/11 

- 4 -

Attendees 27/05/10 19/07/10 24/09/10 10/12/10 04/02/11 % 

Dr. Ian Grant √ √ √ √ √ 100% 

Lucy Gladman √ √ √ √ √ 100% 

Judith Douglas √ AP 20% 

Liz Lyon √ AP √ √ 60% 

Bob Park AP √ √ 40% 

Paul Trevatt √ 20% 

Alexandra Lawrence √ 20% 

Elizabeth Hadley √ 20% 

Claire Bates AP √ √ √ 60% 

Michael Apps AP 0% 

Mrinal Saharay AP AP AP 0% 

Hesham Kaddour √ AP AP AP 20% 

David Khoo √ AP AP 20% 

Seeni Naidu √ √ AP 40% 

Mohsin Patel 0% 

Nana Ababio √ √ 40% 

Emma Staples 0% 

Seb Bavetta 0% 

Mark Wilkinson √ AP √ √ 60% 

Caroline Moren √ AP √ AP √ 60% 

Martin Wade 0% 

Shannon Katiyo √ AP √ √ 60% 

Andrew Gage √ √ 40% 

Anand Kelkar √ √ 40% 

Cheriya Abdulla √ √ 40% 

Tan Vandal √ √ 40% 

Sandy Gujral √ AP √ AP 40% 

Chandra Mohan AP AP 0% 

Sherif Raouf √ 20% 

Jackie Hartigan √ √ √ 60% 

Geraldine Soosay √ √ 40% 

- 5 -

5. Workload 

During 2010/11 Cancer Services dealt with the following workload: 

Numbers of 1 st 

treated 

Numbers of Subsequent 

Treatments 

Tumour Site 62-day 31-day Drug Surgery Radiotherapy 

Brain/CNS 4 83 6 16 16 

Breast 377 409 183 94 263 

Gynaecology 69 117 21 4 40 

Haematology 113 323 55 0 44 

Head and 

Neck 29 49 0 10 11 

Lower GI 152 313 95 55 19 

Lung 131 297 24 0 42 

Other 4 7 2 0 2 

Sarcoma 2 2 0 0 0 

Skin 190 218 1 35 6 

Upper GI 98 150 14 25 13 

Urology 399 623 64 107 146 

TOTAL 1568 2591 465 330 602 

These data exclude screening patients 

Total 2WW 

Target 

referrals 

GP/GDP 

Referrals 

1st seen in 

period 

Total 

Breast 

Symptom 

referrals 

1st seen 

in period 

Tumour 

Group 

Brain/CNS 71 

Breast 2614 2258 

Gynaecology 1186 

Haematology 178 

Head and 

Neck 1019 

Lower GI 1691 

Lung 387 

Paediatrics 124 

Sarcoma 54 

Skin 1820 

Upper GI 1039 

Urology 1640 

TOTAL 11823 2258 

Year on year comparison is shown below: 

- 6 -

62-Day Treatments 

1800 

1600 

1400 

1200 

1000 

800 

62-day 2009/10 

62-day 2010/11 

600 

400 

200 

0 

Brain/C 

NS 

Breast 

Gynaec 

ology 

Haemat 

ology 

Head 


Neck 

Lower 

GI 

62-day 2009/10 4 375 54 81 44 158 129 7 0 139 78 345 1414 

62-day 2010/11 4 377 69 113 29 152 131 4 2 190 98 399 1568 

Lung 

Other 

Sarcom 

a 

Skin 

Upper 

GI 

Urology 

TOTAL 

31-Day Treatments 

3000 

2500 

2000 

1500 

31-day 2009/10 

31-day 2010/11 

1000 

500 

0 

Brain/C 

NS 

Breast 

Gynaec 

ology 

Haemat 

ology 

Head 


Neck 

Lower 

GI 

31-day 2009/10 82 403 94 274 67 289 285 10 0 165 121 549 2339 

31-day 2010/11 83 409 117 323 49 313 297 7 2 218 150 623 2591 

Lung 

Other 

Sarcom 

a 

Skin 

Upper 

GI 

Urology TOTAL 

- 7 -

Subsequent Treatments - Drug 

500 

450 

400 

350 

300 

250 

Drug 2009/10 

Drug 2010/11 

200 

150 

100 

50 

0 

Brain/C 

NS 

Breast 

Gynaeco 

logy 

Haemat 

ology 

Head 


Neck 

Lower 

GI 

Drug 2009/10 8 43 22 44 0 70 42 1 0 0 13 15 258 

Drug 2010/11 6 183 21 55 0 95 24 2 0 1 14 64 465 

Lung 

Other 

Sarcom 

a 

Skin 

Upper 

GI 

Urology 

TOTAL 

Subsequent Treatment - Surgery 

350 

300 

250 

200 

150 

Surgery 2009/10 

Surgery 2010/11 

100 

50 

0 

Brain/C 

NS 

Breast 

Gynaec 

ology 

Haemat 

ology 

Head 


Neck 

Lower 

GI 

Surgery 2009/10 20 79 4 1 3 62 5 0 0 13 20 110 317 

Surgery 2010/11 16 94 4 0 10 55 0 0 0 35 25 107 330 

Lung 

Other 

Sarcom 

a 

Skin 

Upper 

GI 

Urology TOTAL 

- 8 -

Subsequent Treatment - Radiotherapy 

700 

600 

500 

400 

300 

Radiotherapy 2009/10 

Radiotherapy 2010/11 

200 

100 

0 

Brain/C 

NS 

Breast 

Gynae Haema 

cology tology 

Head 


Neck 

Radiotherapy 2009/10 18 22 21 13 0 11 22 0 0 0 3 7 117 

Radiotherapy 2010/11 16 263 40 44 11 19 42 2 0 6 13 146 602 

Lower 

GI 

Lung 

Other 

Sarco 

ma 

Skin 

Upper 

GI 

Urolog 

y 

TOTAL 

2WW Referrals 

14000 

12000 

10000 

8000 

6000 

Series1 

Series2 

4000 

2000 

0 

Brain/CN 

S 

Breast 

Gynaecol 

ogy 

Haematol Head and 

Lower GI 

ogy Neck 

Series1 79 2654 1167 159 1008 1706 438 122 48 1638 1018 1508 11545 

Series2 71 2614 1186 178 1019 1691 387 124 54 1820 1039 1640 11823 

Lung 

Paediatri 

cs 

Sarcoma Skin Upper GI Urology TOTAL 

- 9 -

Breast Other Symptoms 

2500 

2450 

2400 

2350 

Breast 

2300 

2250 

2200 

2150 

Total Breast Symptom referrals 2009/10 Total Breast Symptom referrals 2010/11 

Breast 2468 2258 

This demonstrates that there has been a general increase in the overall numbers of 

patients we are treating at BHRUT. 

One key achievement is the improved capture of our subsequent treatments. 

- 10 -

6. Research and Clinical Trials 

The table below shows the trials that the Trust has participated in and recruited to: 

Randomised 

Portfolio Entered 

ALSTMPCA NCRN 2 CLOSED 

AML 16 NCRN 5 

AML 17 NCRN 3 

AvAglio 9 

BOSS NCRN 10 

CHHiP NCRN 4 

FOXTROT NCRN 3 

FRAGMATIC NCRN 2 

LaMB 1 

Myeloma XI 8 

PET Trial in Hodgkins 

dis NCRN 1 

IMPORT LOW NCRN 0 

OE05 NCRN 6 

Pacifico NCRN 2 

Persephone NCRN 15 

RADICALS NCRN 6 

RATHL NCRN 11 

Rchop 14 v 21 NCRN 6 

SCOT NCRN 25 

SOFEA 1 

SPIRIT 2 NCRN 3 

STAMPEDE NCRN 11 

Supremo NCRN 6 

TOTAL 140 

Registered 

BBC Study NCRN 22 

FAST Sub-study 4 

GLACIER 4 

MDS BIO STUDY NCRN 33 

NSCCG NCRN 43 

NSHLG NCRN 63 

O HERA B020652 5 CLOSED 

PPAR; Peroxisome 

Prolif 7 

Transdermal Estradiol 

(T) 4 

UKGPCS (Marsden 

Gene) 15 

TOTAL 200 

- 11 -

7. Patient Feedback 

During 2010/11, the Trust participated in the National Cancer Patients Survey, the 

results of which can be found in appendix 1 and the associated action plan in 

appendix 2. 

8. Data Collection 

Cancer Services continued to achieve the monthly and quarterly CWT data upload 

deadlines throughout 2010/11. 

9. Audit 

Cancer Services participated in the following National Audits during 2010/11: 

• LUCADA (Lung) 

• DAHNO (Head and Neck) 

• NBOCAP (Lower GI) 

10. Advanced Communications Skills Training 

The following clinicians have undertaken the ACST: 

Dr Biju Krishnan 

Mr Anthony Pittathankal 

Dr Ian Grant 

Mr Akin Ojo 

Dr Alison Brownell Mr Steven Snooks 

Dr Claire Hemmaway Dr Eliot Sims 

Dr Jane Stevens 

Dr Rajech Banka 

Dr Emma Staples Dr Andrew Gage 

Dr Elizabeth Hadley Mr Shiv Banot 

Dr Anthony Gershuny Miss Alexandra Lawrence 

Dr R Subramaniam Mr Joe Huang 

Dr Sherif Raouf 

Mr Aman Bhargava 

Dr Claire Bates 

Dr Martin Wade 

Dr Robert Chew 

Dr Simon Davison 

Mr Sandy Gujral 

Dr Danielle Piras 

Mr Tan Vandal 

Dr F Carabott 

Mr Mrinal Saharay Miss Sabrina Shah-Desai 

- 12 -

11. Cancer Waiting Times 

Waiting Times 

THRESHOLD 

& TARGET 

Quarter 

One 

Quarter 

Two 

Quarter 

Three 

Quarter 

Four 

YTD 

14 Day 

BOS 14 Day 

31 Day (to 1st Tx) 

88 - 93% 99.90% 99.81% 99.61% 99.32% 99.66% 

93% 99.65% 99.21% 100% 99.62% 99.60% 

91 - 96% 98.62% 98.94% 99.69% 99.29% 99.14% 

62 Day 

80 - 85% 82.38% 82.78% 87.04% 82.30% 83.69% 

31 Day 

(Subsequent Tx's) 94% 94.50% 99.03% 99.09% 99.06% 98.21% 

31 Day Drug Sub 

Tx 93 - 98% 98.55% 98.84% 100.00% 98.89% 99.09% 

31 Day Surgery 

Sub Tx 89 - 94% 100% 100% 98.81% 98.70% 99.39% 

31 Day 

Radiotherapy Sub 

Tx 89 () - 94% 85% 98.44% 98.71% 99.28% 97.10% 

62 Day Screening 

85 - 90% 96.15% 92.08% 93.33% 90.16% 93.26% 

62 Day Consultant 

Upgrade 80 - 85% 90.12% 86.57% 85.56% 73.08% 86.53% 

- 13 -

12. Peer Review 

BHRUT cancer services will once again be peer reviewed this year; 

Desk Top 

Review - MDT 

Members DO 

NOT need to 

attend 

Internal Validation 

Date and Time - MDT 

members DO need to 

attend 

External 

Peer 

Review 

All Meeting Rooms 

at QH 

AOS 

1st September 

10am-11am 


11am-12pm 

N/A 

Seminar 6 

Education Centre 

Brain/ CNS 

29th November 

2pm -3pm 

29th November 

3pm -4pm 

N/A 

Radiology Meeting 

Room 

Breast KGH 

6th September 

9am-10am 


10am-11am 

N/A 


Room 

Chemotherapy 


2.30pm - 3.30pm 


3.30pm - 4.30pm 

N/A 

Seminar 6 


Colorectal 

H&N 

Lung KGH 

27th September 

11am-12pm 


1pm-2pm 


4pm-5pm 


12pm-1pm 


2pm-3pm 

22nd September 

11am-12pm 

24th 

November 


30th 

November 

Meeting Room, 


2011 - BLT Cancer Day 2 

Desk Top Review - 

Cancer Day 2, 

Internal Validation 

N/A 

Room TBA 

Lung QH 


11am-12pm 


12pm-1pm 

N/A 

Seminar 2 


Gynae 

Paediatrics 


12pm-1pm 


3pm-4pm 


9am-10am 


1pm-2pm 


4pm-5pm 


10am-11am 

Radiotherapy 

N/A 

Sarcoma N/A 


Skin 

11am-12pm 

TYAC TBA TBA N/A 

Upper GI 

Urology 


9am-10am 


1pm-2pm 

Seminar Room 6, 

N/A Education Centre 

24th 

November 

2011 Cancer Day 2 


3pm-4pm N/A Cancer Day 2 


10am-11am N/A Cancer Day 2 


2pm-3pm 

N/A 


Room 

- 14 -

Following the peer review visit last November 2010, work has been undertaken to 

address the Immediate Risks, Serious Concerns and Concerns that were raised for 

the Skin, Upper GI and Urology MDTs. The updated action plan can be found at 

appendix 3. 

The deadline for submission for this years peer review documentation is the 30 th 

September 2010. 

- 15 -

National Cancer Patient Experience Survey 2010 


Introduction 

The Cancer Reform Strategy (CRS) published in 2007 set out a commitment to establish a 

new NHS Cancer Patient Experience Survey programme. The 2010 National Cancer Patient 

Experience Survey was designed to monitor national progress on cancer care; and to 

provide information that could be used to drive local quality improvements; and to help 

gather vital information on the Transforming Inpatient Care Programme, the National Cancer 

Survivorship Initiative and the National Cancer Equality Initiatives. 

Participating Trusts 

158 acute hospital NHS Trusts providing cancer services took part in the survey. Primary 

Care Trusts, some of whom provide cancer services, were excluded from the survey, as 

were some specialist hospital Trusts because of very low patient numbers. 

Patients selected to take part 

The survey included all adult patients (aged 16 and over) with a primary diagnosis of cancer 

who had been admitted to an NHS hospital as an inpatient or as a day case patient, and had 

been discharged between 1st January 2010 and 31st March 2010. 

Patients eligible for the survey were taken from Trust patient administration systems; the 

inclusion criteria were that the patient had an International Classification of Disease (ICD10) 

code of C00-99 (excluding C44) or D05. The types of cancer patients included in the 2010 

survey included, for the first time, significant numbers with rarer cancers as well as patients 

in the “Big 4” cancer groups – i.e. breast, prostate, lung, and colorectal/Lower GI. 

Trust samples were checked rigorously for duplicates and patient lists were also deduplicated 

nationally to ensure that patients did not receive multiple copies of the 

questionnaire. 

Survey method 

Postal surveys were sent to patients’ home addresses following their discharge. Up to two 

reminders were sent to non-responders. A freepost envelope was included for their replies. 

Patients could call a free telephone line to ask questions, complete the questionnaire 

verbally, or to access an interpreting service. 

Response rate 

A total of 109,477 patients who had received treatment for cancer during January to March 

2010 were included in the national sample for the Cancer Patient Experience Survey. These 

patients fell into 13 different cancer groups. 

1007 eligible patients from this Trust were sent a survey, and 581 questionnaires were 

returned completed. This represents a response rate of 63% once deceased patients and 

questionnaires returned undelivered had been accounted for. The national response rate 

was 67% (67,713 respondents). 

2



Percentage scores 

The questions in the cancer survey have been summarised as the percentage of patients 

who reported a positive experience. For example, “Percentage of patients who were given a 

complete explanation of their diagnostic tests” and “Percentage of patients who said that 

nurses did NOT talk in front of them as if they were not there”. Neutral responses, such as 

“Don’t know” and “I did not need an explanation” are not included in the denominator when 

computing the score. 

The higher the score, the better the Trust’s performance. 

Trusts with small numbers of respondents or small numbers in 

particular tumour groups 

Some Trusts have relatively small numbers of cancer patients, so the total number of 

respondents to the survey may be low despite the high response rate. Reports for these 

Trusts have been completed in the normal way, but the results for these Trusts need to be 

treated with caution. It is important to recognise however, that the low numbers of 

respondents in these Trusts is simply the result of low numbers of cancer patients being 

treated. 

In almost all Trusts, there were tumour groups where the number of respondents was less 

than 20; this is particularly true of tumour groups representing rarer cancers. Where 

numbers of respondents in a particular tumour group is less than 20, we have used the 

convention of leaving the relevant cell blank. This is further explained in the introduction to 

the tumour group tables in this report. 

Benchmark charts 

Percentage scores are displayed on benchmark bar charts in the following section. Each bar 

represents the range of results across all Trusts that took part in the survey for one question. 

The bar is divided into: 

• a red section: scores for the lowest-scoring 20% of Trusts 

• a green section: scores for the highest-scoring 20% of Trusts 

• an amber section: scores for the remaining 60% of Trusts. 

The black circle represents the score for this Trust. For example, if the circle is in the green 

section of the bar, it means that the Trust is among the top 20% of Trusts in England for that 

question. The line on either side of the circle shows the 95% confidence interval (the amount 

of uncertainty surrounding the Trust’s score). 

3



The table below each benchmarking chart represents the Trust score for each question in 

the first column (represented by the black circle on the benchmarking chart). The confidence 

intervals in columns two and three are shown on the chart as the black line running through 

the Trust score. The fourth and fifth columns represent the upper threshold for the lowest 

scoring 20% and the lower threshold for the highest scoring 20% (i.e. the end of the red 

section and the beginning of the green section on the chart). The sixth column displays the 

highest Trust’s score for this question and the seventh column displays the number of 

respondents who gave this answer for this question. The eighth column displays a '+' 

alongside any question where the Trust's score falls within the lowest 20% of Trust 

scores for that question. 

Further information 

Full details of the survey method are in the National Report of the Cancer Patient Experience 

Survey 2010, which is available at www.quality-health.co.uk; and further details of survey 

development, nationally agreed methodology, and cognitive testing are also available at 

www.quality-health.co.uk. 

4



Who responded to the survey at this Trust 

581 patients responded to the survey from the Trust. The tables below show the numbers of 

patients from each tumour group and the age and sex distribution of these patients. 

Respondents by tumour group 

Tumour Group 

Number of 

respondents* 

Breast 150 

Colorectal / Lower Gastrointestinal 107 

Lung 47 

Prostate 27 

Brain/Central Nervous System 8 

Gynaecological 45 

Haematological 85 

Head and Neck 9 

Sarcoma 3 

Skin 4 

Upper Gastrointestinal 46 

Urological 48 

Other 2 

* These figures will not match the numerator for all questions in the ‘comparisons by tumour 

group’ section of this report because not all questions were answered by all responders. 

Age and sex 

The survey asked respondents to give their year of birth. This information has been 

amalgamated into 6 age bands. 20 people did not provide their gender or age. Of the 561 

who did, the age and gender distribution for the Trust was as follows: 

16-25 26-35 36-50 51-65 66-75 75+ Missing Total 

Men 1 0 15 75 88 51 11 241 

Women 1 6 46 106 82 69 10 320 

Total 2 6 61 181 170 120 21 561 

5



Trust results 

Seeing your GP 

Saw GP once/twice before being told had to 

go to hospital 

First appointment no more than 4 weeks 

after referral 

Patient thought they were seen as soon as 

necessary 

Patient's health got better or remained about 

the same while waiting 

Question 

Q1 Saw GP once/twice before being told 

had to go to hospital 

Q2 

Q3 

Q5 

First appointment no more than 4 weeks 


Patient thought they were seen as soon 

as necessary 

Patient's health got better or remained 

about the same while waiting 

Percentage for 

this Trust 

Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 

lowest scoring 

20% of all Trusts 

Threshold for 

highest scoring 


Highest Trust's 

percentage 

score 

Number of 

responders for 


75% 71% 79% 72% 79% 90% 435 

90% 87% 93% 88% 93% 99% 398 

79% 76% 83% 78% 85% 94% 432 

Scored % in 

lowest 20% of 

Trusts 

73% 69% 77% 74% 82% 92% 441 + 

6



Diagnostic tests 

Staff gave complete explanation of purpose 

of test(s) 

Staff explained completely what would be 

done during test 

Given easy to understand written information 

about test 

Given complete explanation of test results in 

understandable way 

Question 

Q7 Staff gave complete explanation of 

purpose of test(s) 

Q8 

Q9 

Q10 

Staff explained completely what would 

be done during test 

Given easy to understand written 

information about test 

Given complete explanation of test 

results in understandable way 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


75% 72% 79% 78% 84% 93% 472 + 

78% 74% 82% 81% 87% 95% 495 + 

80% 76% 84% 81% 88% 94% 379 + 

70% 66% 74% 73% 80% 91% 502 + 

7



Finding out what was wrong with you 

Patient told they could bring a friend when 

first told they had cancer 

Patient felt they were told sensitively that 

they had cancer 

Patient completely understood the 

explanation of what was wrong 

Patient given written information about the 

type of cancer they had 

Question 

Q12 Patient told they could bring a friend 

when first told they had cancer 

Q13 

Q14 

Q15 

Patient felt they were told sensitively 

that they had cancer 

Patient completely understood the 

explanation of what was wrong 

Patient given written information about 

the type of cancer they had 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



68% 64% 72% 65% 76% 86% 476 

Scored % in 

lowest 20% of 


80% 77% 83% 81% 86% 96% 567 + 

75% 71% 78% 71% 77% 93% 569 

60% 56% 65% 62% 70% 82% 466 + 

8



Deciding the best treatment for you 

Patient given a choice of different types of 

treatment 

Possible side effects explained in an 


Patient given written information about side 

effects 

Patient definitely involved in decisions about 

which treatment 

Question 

Q16 Patient given a choice of different types 

of treatment 

Q17 

Q18 

Q19 

Possible side effects explained in an 



side effects 

Patient definitely involved in decisions 

about which treatment 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


78% 72% 84% 79% 86% 96% 165 + 

72% 68% 76% 68% 75% 85% 535 

80% 76% 83% 74% 83% 90% 527 

66% 62% 71% 67% 75% 83% 394 + 

9



Clinical Nurse Specialist 

Patient given the name of the CNS in charge 

of their care 

Patient finds it easy to contact their CNS 

CNS definitely listened carefully the last time 

spoken to 

Get understandable answers to important 

questions all/most of the time 

Last time seen, time spent with CNS about 

right 

Question 

Q20 

Q21 

Q22 

Q23 

Q24 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Patient given the name of the CNS in 

charge of their care 87% 84% 90% 81% 88% 97% 546 

Patient finds it easy to contact their CNS 

74% 70% 78% 70% 80% 92% 447 

CNS definitely listened carefully the last 

time spoken to 90% 88% 93% 90% 94% 100% 466 

Get understandable answers to 

important questions all/most of the time 90% 87% 93% 89% 93% 97% 422 

Last time seen, time spent with CNS 

about right 94% 91% 96% 93% 97% 100% 459 

Scored % in 

lowest 20% of 


10



Support for people with cancer 

Hospital staff gave information about support 

groups 

Hospital staff gave information on getting 

financial help 

Hospital staff told patient they could get free 

prescriptions 

Question 

Q25 

Q26 

Q27 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


Hospital staff gave information about 

support groups 67% 63% 72% 74% 83% 94% 412 + 

Hospital staff gave information on 

getting financial help 46% 41% 51% 42% 58% 74% 333 

Hospital staff told patient they could get 

free prescriptions 63% 58% 69% 63% 74% 85% 273 

11



Operations 

Admission date not changed by hospital 

Staff gave complete explanation of what 

would be done 

Patient given written information about the 

operation 

Staff explained how operation had gone in 


Question 

Q29 Admission date not changed by hospital 

Q30 

Q31 

Q32 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



89% 85% 92% 87% 92% 99% 308 

Staff gave complete explanation of what 

would be done 82% 77% 86% 81% 87% 93% 295 

Scored % in 

lowest 20% of 



the operation 59% 54% 65% 62% 73% 91% 283 + 

Staff explained how operation had gone 

in understandable way 67% 62% 73% 69% 77% 89% 304 + 

12



Hospital doctors 

Got understandable answers to important 


Patient had confidence and trust in all 

doctors treating them 

Patient thought doctors knew enough about 

how to treat their cancer 

Doctors did not talk in front of patient as if 

they were not there 

Patient's family definitely had opportunity to 

talk to doctor 

Question 

Q34 

Q35 

Q36 

Q37 

Q38 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Got understandable answers to 

important questions all/most of the time 80% 76% 84% 77% 85% 95% 345 


doctors treating them 81% 77% 85% 80% 88% 100% 378 

Patient thought doctors knew enough 

about how to treat their cancer 90% 87% 93% 87% 92% 100% 370 

Doctors did not talk in front of patient as 

if they were not there 80% 76% 84% 79% 86% 100% 374 

Patient's family definitely had 

opportunity to talk to doctor 62% 56% 67% 61% 70% 79% 338 

Scored % in 

lowest 20% of 


13



Ward nurses 

Got understandable answers to important 


Patient had confidence and trust in all ward 

nurses 

Nurses did not talk in front of patient as if 

they were not there 

Always / nearly always enough nurses on 

duty 

Question 

Q39 

Q40 

Q41 

Q42 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


Got understandable answers to 

important questions all/most of the time 61% 56% 66% 67% 78% 95% 323 + 


ward nurses 58% 53% 63% 61% 72% 90% 377 + 

Nurses did not talk in front of patient as 

if they were not there 75% 71% 79% 79% 87% 100% 373 + 

Always / nearly always enough nurses 

on duty 50% 45% 55% 57% 68% 89% 372 + 

14



Hospital care and treatment 

Patient did not think hospital staff 

deliberately misinformed them 

Patient never thought they were given 

conflicting information 

Always given enough privacy when discussing 

condition or treatment 

Always given enough privacy when being 

examined or treated 

Hospital staff did everything to help control 

pain all of the time 

Always treated with respect and dignity by 

staff 

Question 

Q43 

Q44 

Q45 

Q46 

Q47 

Q48 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Patient did not think hospital staff 

deliberately misinformed them 87% 83% 90% 84% 89% 100% 372 

Patient never thought they were given 

conflicting information 76% 72% 81% 76% 82% 92% 374 

Scored % in 

lowest 20% of 


Always given enough privacy when 

discussing condition or treatment 79% 75% 83% 80% 86% 95% 375 + 

Always given enough privacy when 

being examined or treated 92% 89% 94% 91% 95% 100% 370 

Hospital staff did everything to help 

control pain all of the time 82% 78% 86% 82% 87% 95% 308 

Always treated with respect and dignity 

by staff 72% 67% 76% 78% 86% 96% 370 + 

15



Information given to you before leaving hospital and home support 

Given clear written information about what 

should / should not do post discharge 

Staff told patient who to contact if worried 

post discharge 

Family definitely given all information needed 

to help care at home 

Patient definitely given enough care from 

health or social services 

Question 

Q49 Given clear written information about 

what should / should not do post 

discharge 

Q50 

Q51 

Q52 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


75% 70% 79% 78% 85% 95% 338 + 

Staff told patient who to contact if 

worried post discharge 87% 84% 91% 89% 94% 100% 360 + 

Family definitely given all information 

needed to help care at home 55% 49% 60% 53% 62% 77% 324 

Patient definitely given enough care 

from health or social services 62% 57% 68% 52% 66% 80% 271 

16



Hospital care as a day patient / outpatient 

Staff definitely did everything to control side 

effects of radiotherapy 

Staff definitely did everything to control side 

effects of chemotherapy 

Staff definitely did everything they could to 

help control pain 

Hospital staff definitely gave patient enough 

emotional support 

Waited no longer than 30 minutes for OPD 

appointment to start 

Patient thought doctor spent about the right 

amount of time with them 

Doctor had the right notes and other 

documentation with them 

Question 

Q54 

Q56 

Q57 

Q58 

Q60 

Q61 

Q62 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Staff definitely did everything to control 

side effects of radiotherapy 85% 80% 91% 78% 86% 100% 157 

Scored % in 

lowest 20% of 


Staff definitely did everything to control 

side effects of chemotherapy 79% 75% 83% 82% 89% 95% 340 + 

Staff definitely did everything they could 

to help control pain 75% 70% 79% 79% 86% 92% 334 + 

Hospital staff definitely gave patient 

enough emotional support 65% 60% 69% 66% 76% 84% 404 + 

Waited no longer than 30 minutes for 

OPD appointment to start 69% 65% 73% 61% 77% 88% 520 

Patient thought doctor spent about the 

right amount of time with them 94% 92% 96% 92% 95% 98% 528 

Doctor had the right notes and other 

documentation with them 94% 92% 96% 93% 97% 100% 513 

17



Care from your general practice 

GP given enough information about patient's 

condition and treatment 

Practice staff definitely did everything they 

could to support patient 

Question 

Q63 

Q64 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Scored % in 

lowest 20% of 


GP given enough information about 

patient's condition and treatment 89% 87% 92% 91% 96% 99% 419 + 

Practice staff definitely did everything 

they could to support patient 64% 59% 69% 64% 74% 86% 346 + 

18



Your overall NHS care 

Hospital and community staff always worked 

well together 

Given the right amount of information about 

condition and treatment 

Patient did not feel that they were treated as 

'a set of cancer symptoms' 

Question 

Q65 

Q66 

Q67 



Lower 95% 

confidence 

interval 

Upper 95% 

confidence 

interval 

Threshold for 



Threshold for 




percentage 

score 

Number of 



Hospital and community staff always 

worked well together 57% 53% 62% 57% 67% 74% 520 

Scored % in 

lowest 20% of 


Given the right amount of information 

about condition and treatment 86% 83% 89% 86% 90% 96% 561 + 

Patient did not feel that they were 

treated as 'a set of cancer symptoms' 77% 74% 81% 77% 84% 92% 555 + 

19



Comparisons by tumour group for this Trust 

The following tables show the Trust and the national percentage scores for each question broken down by 

tumour group. Where a cell in the table is blank this indicates that the number of patients in that group was 

below 20 and too small to display. 

Seeing your GP 

Q1. Saw GP once/twice 

before being told had 

to go to hospital 

Q2. First appointment 

no more than 4 weeks 


Q3. Patient thought 

they were seen as soon 

as necessary 

Q5. Patient's health got 

better or remained 

about the same while 

waiting 

Cancer type This Trust National This Trust National This Trust National This Trust National 

Breast 88% 92% 94% 96% 82% 83% 90% 91% 

Colorectal / Lower Gastro 69% 70% 87% 88% 80% 78% 72% 74% 

Lung 65% 66% 88% 95% 74% 84% 75% 71% 

Prostate 77% 77% 86% 84% 65% 88% 

Brain / CNS 

Gynaecological 70% 71% 93% 90% 80% 77% 69% 72% 

Haematological 61% 62% 84% 90% 71% 81% 59% 66% 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 68% 67% 97% 91% 83% 79% 42% 62% 

Urological 90% 81% 92% 88% 85% 83% 93% 87% 

Other Cancers 

All cancers 75% 75% 90% 90% 79% 81% 73% 78% 

20



Diagnostic tests 

Q7. Staff gave 

complete explanation 

of purpose of test(s) 

Q8. Staff explained 

completely what 

would be done during 

test 

Q9. Given easy to 

understand written 

information about test 

Q10. Given complete 

explanation of test 

results in an 



Breast 75% 83% 80% 85% 89% 85% 77% 79% 


Lung 75% 80% 86% 86% 72% 85% 67% 76% 

Prostate 80% 83% 70% 86% 52% 77% 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 72% 78% 80% 83% 80% 84% 67% 74% 

Urological 72% 80% 75% 84% 79% 86% 71% 76% 

Other Cancers 

All cancers 75% 81% 78% 84% 80% 85% 70% 76% 

21



Finding out what was wrong with you 

Q12. Patient told they 

could bring a friend 

when first told they 

had cancer 

Q13. Patient felt they 

were told sensitively 

that they had cancer 

Q14. Patient 

completely understood 

the explanation of 

what was wrong 

Q15. Patient given 

written information 

about the type of 

cancer they had 


Breast 79% 78% 84% 87% 81% 79% 71% 71% 


Lung 70% 73% 78% 81% 80% 75% 75% 61% 

Prostate 65% 69% 81% 83% 70% 78% 50% 75% 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 55% 69% 80% 78% 72% 73% 47% 59% 

Urological 54% 65% 66% 81% 79% 77% 49% 63% 

Other Cancers 

All cancers 68% 71% 80% 83% 75% 74% 60% 66% 

22



Deciding the best treatment for you 

Q16. Patient given a 

choice of different 

types of treatment 

Q17. Possible side 

effects explained in an 




about side effects 

Q19. Patient definitely 

involved in decisions 

about which treatment 


Breast 86% 87% 80% 75% 86% 88% 73% 72% 


Lung 83% 75% 87% 83% 58% 72% 

Prostate 62% 71% 72% 77% 48% 74% 

Brain / CNS 

Gynaecological 71% 75% 80% 83% 63% 73% 


Head & Neck 

Sarcoma 

Skin 

Upper Gastro 71% 73% 86% 80% 74% 71% 

Urological 59% 67% 61% 68% 53% 70% 

Other Cancers 

All cancers 78% 83% 72% 72% 80% 79% 66% 71% 

23



Clinical Nurse Specialist 

Cancer type 


the name of the 

CNS in charge of 

their care 

This 


National 

Q21. Patient finds 

it easy to contact 

their CNS 

This 


National 

Q22. CNS definitely 

listened carefully 

the last time 

spoken to 

This 


National 

Q23. Get 

understandable 

answers to 

important 

questions all/most 

of the time 

This 

National 


Q24. Last time 

seen, time spent 

with CNS about 

right 

This 


National 

Breast 94% 93% 75% 72% 88% 91% 90% 91% 92% 94% 

Colorectal / Lower 

Gastro 94% 87% 83% 78% 94% 93% 94% 92% 98% 96% 

Lung 98% 91% 76% 75% 91% 91% 90% 89% 93% 93% 

Prostate 74% 81% 85% 91% 

Brain / CNS 

Gynaecological 74% 88% 68% 72% 93% 91% 81% 90% 93% 95% 

Haematological 93% 81% 81% 77% 92% 92% 95% 91% 91% 95% 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 82% 90% 65% 75% 89% 92% 86% 90% 92% 95% 

Urological 63% 69% 44% 75% 88% 92% 78% 90% 96% 96% 

Other Cancers 

All cancers 87% 84% 74% 75% 90% 91% 90% 91% 94% 95% 

24



Support for people with cancer 

Q25. Hospital staff 

gave information 

about support groups 


gave information on 

getting financial help 

Q27. Hospital staff told 

patient they could get 

free prescriptions 

Cancer type This Trust National This Trust National This Trust National 

Breast 81% 86% 56% 53% 58% 61% 

Colorectal / Lower Gastro 61% 78% 36% 46% 71% 74% 

Lung 74% 84% 81% 71% 86% 80% 

Prostate 65% 78% 

Brain / CNS 

Gynaecological 62% 79% 42% 52% 

Haematological 64% 77% 41% 52% 69% 74% 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 60% 79% 39% 55% 62% 75% 

Urological 50% 60% 4% 26% 

Other Cancers 

All cancers 67% 79% 46% 50% 63% 68% 

25



Operations 

Q29. Admission date 

not changed by 

hospital 

Q30. Staff gave 

complete explanation 

of what would be done 



about the operation 

Q32. Staff explained 

how operation had 

gone in 



Breast 94% 94% 83% 86% 69% 77% 68% 72% 


Lung 

Prostate 

Brain / CNS 


Haematological 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 80% 86% 

Urological 80% 85% 81% 84% 55% 65% 72% 72% 

Other Cancers 

All cancers 89% 89% 82% 85% 59% 68% 67% 73% 

26



Hospital Doctors 

Cancer type 

Q34. Got 


answers to 

important 

questions all/most 

of the time 

This 

National 


Q35. Patient had 

confidence and 

trust in all doctors 

treating them 

This 


National 

Q36. Patient 

thought doctors 

knew enough 

about how to treat 

their cancer 

This 


National 

Q37. Doctors did 

not talk in front of 

patient as if they 

were not there 

This 


National 

Q38. Patient's 

family definitely 

had opportunity to 

talk to doctor 

This 


National 

Breast 84% 83% 87% 84% 95% 91% 80% 88% 69% 68% 

Colorectal / Lower 

Gastro 82% 83% 81% 85% 91% 90% 87% 80% 60% 65% 

Lung 67% 77% 70% 81% 86% 86% 91% 81% 61% 65% 

Prostate 

Brain / CNS 

Gynaecological 75% 82% 72% 83% 77% 89% 71% 86% 60% 66% 

Haematological 81% 81% 84% 80% 95% 85% 76% 82% 66% 68% 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 85% 79% 73% 82% 80% 87% 84% 78% 52% 66% 

Urological 81% 79% 83% 85% 90% 91% 73% 80% 42% 59% 

Other Cancers 

All cancers 80% 81% 81% 84% 90% 89% 80% 83% 62% 66% 

27



Ward Nurses 

Q39. Got 


answers to important 

questions all/most of 

the time 

Q40. Patient had 

confidence and trust in 

all ward nurses 

Q41. Nurses did not 

talk in front of patient 

as if they were not 

there 

Q42. Always / nearly 

always enough nurses 

on duty 


Breast 65% 74% 57% 66% 72% 86% 51% 62% 


Lung 48% 69% 83% 83% 43% 68% 

Prostate 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 50% 71% 46% 64% 62% 80% 29% 60% 

Urological 68% 73% 71% 70% 73% 83% 60% 65% 

Other Cancers 

All cancers 61% 73% 58% 66% 75% 83% 50% 62% 

28



Hospital care and treatment 

Q43. Patient did not 

think hospital staff 

deliberately 

misinformed them 

Q44. Patient never 

thought they were 

given conflicting 

information 

Q45. Always given 

enough privacy when 

discussing condition or 

treatment 


Breast 88% 90% 78% 80% 79% 84% 


Lung 87% 84% 87% 77% 83% 82% 

Prostate 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 75% 84% 72% 75% 72% 81% 

Urological 88% 87% 88% 82% 80% 82% 

Other Cancers 

All cancers 87% 87% 76% 79% 79% 82% 

Q46. Always given 

enough privacy when 

being examined or 

treated 

Q47. Hospital staff did 

everything to help 

control pain all of the 

time 

Q48. Always treated 

with respect and 

dignity by staff 


Breast 94% 93% 86% 88% 71% 83% 


Lung 83% 93% 86% 82% 

Prostate 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 92% 92% 71% 83% 56% 80% 

Urological 83% 92% 70% 82% 75% 82% 

Other Cancers 

All cancers 92% 93% 82% 85% 72% 82% 

29



Information given to you before you left hospital and home support 

Q49. Given clear 


about what should / 

should not do post 

discharge 

Q50. Staff told patient 

who to contact if 

worried post discharge 

Q51. Family definitely 

given all information 

needed to help care at 

home 

Q52. Patient definitely 

given enough care 

from health or social 

services 


Breast 90% 88% 94% 95% 52% 57% 66% 59% 


Lung 90% 91% 48% 60% 

Prostate 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 76% 78% 81% 91% 58% 60% 64% 64% 

Urological 70% 79% 71% 86% 47% 55% 54% 50% 

Other Cancers 

All cancers 75% 82% 87% 92% 55% 58% 62% 60% 

30



Hospital care as a day patient / outpatient 

Q54. Staff definitely 

did everything to 

control side effects of 

radiotherapy 


did everything to 

control side effects of 

chemotherapy 


did everything they 

could to help control 

pain 


definitely gave patient 

enough emotional 

support 


Breast 90% 85% 81% 85% 80% 85% 73% 69% 


Lung 71% 86% 73% 84% 55% 74% 

Prostate 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 64% 82% 75% 82% 66% 71% 

Urological 48% 77% 48% 71% 

Other Cancers 

All cancers 85% 82% 79% 85% 75% 83% 65% 71% 

Q60. Waited no longer 

than 30 minutes for 

OPD appointment to 

start 

Q61. Patient thought 

doctor spent about the 

right amount of time 

with them 

Q62. Doctor had the 

right notes and other 

documentation with 

them 


Breast 80% 63% 97% 92% 96% 94% 


Lung 52% 71% 91% 94% 91% 95% 

Prostate 59% 74% 100% 93% 92% 94% 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 64% 70% 91% 94% 90% 94% 

Urological 61% 76% 86% 95% 88% 95% 

Other Cancers 

All cancers 69% 68% 94% 94% 94% 95% 

31



Care from your general practice 

Q63. GP given enough 

information about 

patient's condition and 

treatment 

Q64. Practice staff 

definitely did 

everything they could 

to support patient 

Cancer type This Trust National This Trust National 

Breast 92% 95% 61% 68% 

Colorectal / Lower Gastro 90% 93% 56% 70% 

Lung 89% 93% 59% 71% 

Prostate 76% 93% 70% 73% 

Brain / CNS 

Gynaecological 85% 93% 36% 66% 

Haematological 89% 94% 73% 66% 

Head & Neck 

Sarcoma 

Skin 

Upper Gastro 89% 91% 82% 71% 

Urological 92% 93% 74% 71% 

Other Cancers 

All cancers 89% 93% 64% 69% 

32



Your overall NHS care 

Q65. Hospital and 

community staff 

always worked well 

together 

Q66. Given the right 

amount of information 

about condition and 

treatment 

Q67. Patient did not 

feel that they were 

treated as 'a set of 

cancer symptoms' 


Breast 58% 61% 86% 89% 77% 78% 


Lung 54% 65% 89% 88% 74% 79% 

Prostate 48% 63% 81% 87% 81% 81% 

Brain / CNS 



Head & Neck 

Sarcoma 

Skin 

Upper Gastro 48% 61% 80% 87% 77% 78% 

Urological 56% 64% 87% 87% 69% 84% 

Other Cancers 

All cancers 57% 61% 86% 88% 77% 80% 

33



The National Cancer Patient Experience Survey was undertaken by Quality Health, which specialises 

in measuring patients’ experiences of hospital, primary care and mental health services, using this 

information to improve the quality of health care and the responsiveness of health services to patients 

and service users’ needs. 

Quality Health works with all acute hospitals in England, all independent providers of hospital care, 

and all Health Boards in Scotland using rigorous survey methods to evaluate the quality of services to 

patients, the outcomes of operative procedures and health gain, and establish the views of NHS staff. 

Quality Health also works for healthcare system providers in the Middle East and in Wales and 

Northern Ireland. 

Quality Health is an approved contractor for the Care Quality Commission survey programmes of 

patients and staff in the NHS and also undertakes data collection and survey systems for the National 

Patient Reported Outcomes programme on behalf of the Department of Health. Quality Health has 

headquarters in North Derbyshire. 

Further information on the National Cancer Patient Experience Survey programme and the 2010 

survey can be obtained at www.quality-health.co.uk 

© Crown Copyright 

Produced by the Department of Health 

The text of this document may be reproduced without 

formal permission or charge for personal or in-house use. 

Pre Publication December 2010 

www.quality-health.co.uk 

E-mail info@quality-health.co.uk 

34

Action Plan for: Cancer………… 

Created by ……… Nichole McIntosh and Judith Douglas ….……… 

On the …… 11 May 2011 …….. 

Presented to the Patient Experience Committee on the 23 June 2011 

Objective 

1 All clinical areas will 

have access to high 

quality standardised 

care regarding their 

journey which will 

include information on 

what is to be expected 

before, during and 

following an episode of 

care 

2 All clinical areas 

especially OPD will 

have signposting and 

posters displaying the 

cancer support groups, 

welfare advice, cancer 

information and CNS 

contact details. 

3. All clinical areas will 

have access to high 

quality patient 

information re 

diagnostic procedures 

Cancer Action Plan - April 2011 

Actions 

Review all the information that is 

provided to patients to ensure that. 

1. the standards as outlined by the 

patient information group are 

being adhered to. 

2. an indication is given regarding 

how long patients should allow 

for an appointment. 

3. information on discharge to 

ensure that patients receive the 

right amount of information at the 

right time 

The information being provided is 

consistent with the information 

being provided by our community 

partners 

Arranged walk around the OPD and 

main foyers of both hospitals, with 

the Matron OPD matron for 

oncology and the Macmillan service 

manager 

Radiology to update leaflets 

currently in use. 

Radiology to present these to the 

group for agreement. 

Leaflets to be distributed to all 

Lead 

Officer 

Each CNS to 

review 

information 

gaps. 

Work with 

ward 

staff/day unit 

to agree 

information 

pre 

admission 


discharge. 

Judith 

Douglas 

Alita 

Deterville 

Judith 

Douglas 

Target Date 

for 

Completion 

of Action 

October 2011 



Expected 

Outcome 

Standardised high 

quality patient 

information is 

available in clinical 

areas 

Standardised 

posters and 

information to 

enable patients to 

be signposted to 

relevant services 

and support 

Standardised and 

accessible leaflets 

are available for 

patients re their 

diagnostic 

procedure prior to 

Current 

Position 

Information is available 

and not shared across 

the patient pathway. 

Gaps emerge at 

preadmission and 

discharge 

Information available but 

has not been widely 

distributed 

Radiology currently 

updating the patient 

information leaflets in use 

Senior Responsible Officer: Deborah Wheeler, Director of Nursing Judith Douglas, Divisional Nurse Director, Clinical Support Services 

RAG 

Rating 

RED 

RED 

RED

clinical areas and all patients to be 

able to access the leaflets prior to 

the planned procedure 

attending for that 

procedure. 

4. 

. 

Staff in clinical areas will 

have access to 

appropriate training to 

ensure that they are 

equipped with the 

knowledge and skills to 

provide safe, effective 

care to patients with 

varying levels of need. 

5. Raise awareness and 

understanding of the 

importance of adequate 

documentation of a 

cancer diagnosis in the 

medical records 

6. To ensure that patients 

have a quick and 

efficient pathway from 

arrival in the day unit to 

completion of treatment. 

7. Clinicians to undertake 

advanced 

communication skills 

training 

1. review of current education and 

training currently provided within 

the Trust, LSBU and the hospice. 

2. following the review agree further 

commissioned courses. 

3. Agree informal training that the 

CNS’s could jointly provide to 

other non specialist clinical staff. 

To ensure all patients with a cancer 

diagnosis are clearly documented in 

the notes, to ensure accurate 

coding. 

To discuss at the medical records 

committee re use of HRG codes by 

clinicians 

To discuss with the clinicians re the 

use of codes. 

To ensure that patients have an 

acceptable patient experience with 

treatment 

To ensure all patients diagnosed 

with cancer are informed in 

accordance with the Breaking 

Significant News policy 

CNS’s 

(group 

members) 

Divisional 

Nurse 

Director – 

Clinical 

support 

Services, 

Judith 

Douglas 

Portia Ome- 

Bare 

Liz Bradley 

Judith 

Douglas 

Ongoing. 

Review to take 

place 

September 


development 

of programme 

December 


December 



December 


Review of 

commissioned 

courses. 

Agreement of 

programme for 

CNS’s to deliver 

Staff have the 

required 

knowledge, skills 

and confidence to 

provide safe, 

effective care to 

patients. 

Accurate codes are 

used to document 

the care provided. 

Treatment 

delivered in a 

timely manner 

To look at provision 

and uptake of 

courses. 

Alison Wade CNS has 

been looking to develop 

an internal oncology 

course. 

Some Trust wide 

discussion has taken 

place. 

Need to review progress 

from previous patient 

feedback. 

RED 

RED 

RED 

Cancer Action Plan - April 2011 

Senior Responsible Officer: Deborah Wheeler, Director of Nursing Judith Douglas, Divisional Nurse Director, Clinical Support Services

Barking Havering and Redbridge NHS Trust and Localities Peer Review Remedial Action Plans 

Senior Responsible Officer: Dr Ian Grant 

Managerial Lead: Lucy Gladman 

CANCER SERVICES PEER REVIEW ACTION PLAN 

March 2011 

Measure No. 

Skin 

Immediate Risks 

08-6A-101j/ 

102j/ 08-2J- 

117/ 118 

Concerns and comments 

raised by Peer Review 

PCT non-compliant 

community skin cancer 

services – GPs excising 

over 10 skin cancers per 

year 

No agreed clinical 

governance arrangements 

for community 

practitioners 

Actions and Progress Timescale Responsible 

Lead 

Skin - NHS 

Redbridge.doc 

Sept 2010 – GPs are still excising skin cancers, but 

the IOG is currently being reviewed for the PCTs and 

awaiting new measures. Until then, the MDT 

continues to feedback to GPs when patients need to 

be referred to the MDT and to PCTs on those GPs 

undertaking excisions 

Ongoing 

Redbridge PCT 

B&D PCT 

Havering PCT 

RAG 

Serious Concerns 

- Unable to video conference 

with the SSMDT 

BLT are switching to BT N3 which should allow all 

Trust’s to connect – may be a cost pressure to each 

Trust if our N£ is not compatible with BT 

30 th April 2011 Lead Clinician 

for Cancer, 

NELCN Network 

Director 

Interim Chair: Mr Edwin Doyle 

Chief Executive: Averil Dongworth

Measure No. Concerns and comments 


08-2J-102/ Lack of oncology 

103 

consultant at the MDT 

- CNS not present at all 

clinics appointments when 

patients are given a 

diagnosis of cancer 

08-2J-111 Communicating a patients 

diagnosis within 24 hours 


Lead 

Consultant identified – job plan needs urgent review 30 th April 2011 GM – Oncology, 

CD - Oncology 

Clinics are being reviewed and to try and book 30 th June 2011 Clinical Lead - 

patients to QH for their results so that the CNS is 

MDT 

present 

If the patient is seen at KGH then the diagnosis form 

is faxed to the CNS or MDT Coordinator for the CNS 

to fax to the GP 

Completed 

Clinical Lead for 

Skin/ CNS 

RAG 

Concerns 

08-2J-104 

08-2J-122 

08-2J-117 

08-2J-114 

Engagement by the MDT 

with the NSSG 

Patients not routinely 

offered a permanent record 

of consultation 

Advanced communication 

skills course still 

outstanding 

CNS completed specialist 

study 

Lead Clinician needs to attend Skin TAB Ongoing Clinical Lead – 

MDT 

All patients now offered copy of the letter Completed Clinical Lead – 

MDT 

Last core member booked onto course 

CNS has applied for radiotherapy course and agreed 

that H&N credits will count as appropriate 

30 th September 


CNS identified 

course 

Clinical Lead - 

MDT 

Lead Nurse for 

Cancer 

Upper GI 


08-2F-206 Incomplete staffing for a 

specialist MDT. Requires: 

Interventional radiologist 

Sub-specialised pathology, 

imaging and dietitian 

- Inefficient way of running 

MDTs – job plans of the 

gastroenterologists need to 

be altered to allow them to 

attend the Thursday MDT 

Concerns 

- Improve use of the urgent 

referral system by GPs 

Havering PCT have agreed to fund Dietitian posts; 

awaiting start date, sub-specialisation in pathology 

started and more interventional radiologists being 

trained and employed. 

Too complex to rearrange the job plans of so many 

clinical staff 

Open evening held, have identified slots on GP 

education sessions 



DM & DD - 

Surgery 

Ongoing GM - Medicine 

Ongoing 


UGI/ GM - 

Oncology



- Review access to EUS 

delays staging 

- Frequency with which 

elective surgery is 

postponed due to lack of 

ITU beds 

- Inadequate post discharge 

care from dietitian and 

community nurses 

- Inadequate support for 

data collection 

- Review workload 

information of the MDT, 

and include surgical 

procedures and numbers of 

patients having nonsurgical 

treatments 

08-2F-221 Members need to attend 

national advanced 


08-2F-237 

training programme 

Need letter regarding MDT 

remedial action to improve 

recruitment results to 

clinical trials 

Urology 


- Staffing of the team does 

not reflect that expected of 

a specialist team serving a 

population of 700,000 

- Lack of designated uroradiologist; 

imaging not 

reviewed prior to MDT 

meetings and lack of 

sufficient cover 


Lead 

Only one member of consultant staff can undertake 

GM - Medicine 

EUS 

Has improved with additional beds Completed DM & DD - 

Surgery 

Havering PCT have now agreed to fund dietitian 

posts; awaiting start date 

GM – 

Therapies/ 

PCTs 

Completed GM – Oncology 

Somerset database now implemented which should 

aid data collection 

Data from audits being reviewed Ongoing Clinical Lead for 

UGI 

Identify funding and course availability; consider 

running trust specific training 

March 2012 

Lead Clinician/ 


Cancer/ General 

Manager 

Lead Clinician to write for this year’s self assessment September 2011 Clinical Lead for 

UGI 

Have appointed 3 new consultants Completed DM & DD – 

Surgery 

Now have a two designated uro-radiologist who 

provide cross cover 

Completed GM – Radiology 

RAG



- CNSs could not identify 

themselves to bladder 

cancer patients as early in 

their pathway as they 

would wish and could not 

be at oncology clinics 

- The clinics in which 

patients were given their 

diagnosis were overbooked 

and restricted the time 

needed to discuss 

treatment plans 

- Slow turnaround times in 

histopathology 

- Limited theatre time 

resulted in delays in 

patients having surgery so 

targets are being breached 

Concerns 

- The MDT had not entered 

data to the BAUS national 

clinical database which is a 

requirement from April 

2010 

08-2G-221 Members need to attend 

national advanced 


training programme 


Lead 

Improvements have been made and some clinics Ongoing 


now have a CNS in attendance 

Cancer 

Sub-specialisation has been introduced and 

improved access 

Sub-specialisation has been introduced and 

turnaround times are reducing 

The department has sub specialised and are 

compliant with minimal operative requirements and 

improved access 

Will be able to start collecting with the introduction of 

Somerset; departmental training to be undertaken. 

Completed GM - Surgery 

Ongoing GM - Pathology 

Completed GM - Surgery 

30 th April 2012 Clinical Lead for 

Urology/ GM – 

Oncology 

All members have attended ACST Completed Lead Clinician/ 


Cancer/ GM – 

Oncology 

RAG 

Breast (Queen’s) 


- HER2 status not always 

available at time of 

treatment planning 


Meeting with pathologists taken place and Clinical 

Director for pathology will ensure that the department 

request HER2 testing on all ER and PR positive 

patients. Will also become part of the MDS prior to 

the report being issued 

Completed 

Clinical Director 

- Pathology



- Lack of detailed workplan 

to support the 

centralisation of the breast 

services onto one site. 

08-2B-103 

Lack of core MDT 

attendance at NSSG 

- Radiology reports not 

available in time which 

delays the patient pathway 

- Need digital mammography 

for screening 

Lung (KGH) 


08-2C-106 No cover for the core 

oncologist at the MDT 

08-2C-102 

08-2C-102 

Concerns 

08-2C-106 

Oncologist over committed 

to fulfil lead role for clinical 

trials 

Not Palliative Care cover at 

the MDT 

Attendance of the Thoracic 

surgeon at the MDT – no 

named cover 


Lead 

Gantt chart has been developed – regular minuted Completed DD – surgery 

meetings also review the progress. 

and CSS 

Breast Vascular 

Project Gantt Chart V 

This will reduce the number of sites from 3 to 2; 

centralisation of outpatients will take place by 2012 

The current clinical lead has attend ever TAB since 

taking over as lead for the Breast MDT and the team 

has agreed to attend as many of the TAB as possible 

from now on. 

Radiology has managed to recruit to most of its 

Radiologist vacancies and the remaining vacancies 

have applicants to be shortlisted for forthcoming 

interviews. Unable to appoint but two locums due to 

start to support this area. A business case is being 

prepared for a third post, 

Tariff agreed so digital mammography will be 

introduced with the expansion of the screening 

service 

Provision will be made for the SpR to cover for the 

consultant oncologist, via video link from QH; 

delayed as the current SpR rota is one member of 

staff down. 

Clinical trials to be discussed for more patients at the 

Lung MDT and quarterly performance reports to be 

circulated. 

The Palliative Care named nurse has recently 

returned from extended leave and will be in 

attendance at the MDT from 2011 onwards. 

The Zonal Team were satisfied that the back-up 

arrangements in place were sufficent 

Completed Clinical Lead – 

MDT 

Completed GM – Radiology 

30 th June 2011 GM – 

Radiology, DD – 

CSS 



GM – Oncology 

January 2011 Clinical Lead – 

MDT 

Completed 


Cancer 

Completed Clinical Lead - 

MDT 

08-2C-112 Core histopathologist does Histopathologist has applied Completed Clinical Director 

RAG




Lead 

not currently participate in 

– Pathology 

EQA 

08-2C-117 No bereavement service The bereavement service is a PCT/commissioning 30 th June 2011 Lead Nurse for 

issue and we will develop links with external 

Cancer 

bereavement services. The lead nurse for cancer 

has been in discussion with the Trust chaplains 

regarding the provision of drop in sessions and offer 

relatives charitable services such as CRUSE 

08-2C-132 Current portfolio of trials Clinical trials to be discussed for more patients at the Ongoing Clinical Lead – 

and recruit to trials is poor Lung MDT and quarterly performance reports to be 

MDT 

circulated. 

08-2C-124/ NSSG referral guidelines Have recently completed 2 Network audits Competed Clinical Lead – 

129 

08-2C-118 

08-2C-128 

and Network audit 

Patients not routinely 

offered a permanent record 

of consultation 

Improve input and review 

of LUCADA data 

- Is team collecting and 

reporting the full dataset for 

Clinical Lines of Enquiry 

This information is contained within the patient 

information leaflet given to patients in clinic. To be 

discussed at the AGM on 18 th January 2011as to the 

best way to ensure that it is documented in the 

patient’s notes. It will be added to the 2010-2011 

operational policy. 

The 2010-2011 annual report for KGH will contain a 

local breakdown of figures. An action plan from the 

2009 LUCADA data will be discussed at the AGM on 

the 18 th January 2011, and written into the 2010- 

2011 work-plan. 

Somerset cancer registry has just been implemented 

in the Trust which will make the collection of the 

LUCADA data more robust. The MDT is also part of 

the ILCOP and will have more data in 2011 Annual 

Report 

MDT 

April 2011 Clinical Lead - 

MDT 

April 2011 Clinical Lead - 

MDT 

September 2011 Clinical Lead - 

MDT 

RAG 

Radiotherapy 


10-3T-116 Senior SpR deemed 

competent to prescribe, 

localise and approve 

radical plans. 


Training and competencies for SpRs have now been 

introduced. 

Completed 

GM – Oncology, 

Head of 

Radiotherapy 

and Medical 

Physics



- No procedure in place to 

identify areas within 

radiotherapy physics that a 

MPE is authorised to act 

Concerns 

10-3T-113 

Radiographer 1, who 

switches on the machine, 

has not actively ID the 

patient; no documented 

patient ID process for pretreatment 

- Increase resources for 

clinical oncologists and 

physics QA for 

implementing IMRT service 

development has not been 

identified in job plans 

- Low number of treatment 

and time lapse between 

cervix intra-cavitary 

insertions. This needs to 

be addressed through a 

Network review of 

Brachytherapy services as 

measured against the RCR 

Brachytherapy 

recommendations 

10-3T-128 

10-3T-129 

Staffing levels for 

Therapeutic Radiographers 

and Related Professions 

Staffing levels for Medical 

Physics 


Lead 

A policy has now been produced and approved Completed GM – Oncology, 

by Stephen Duck who was present at the 

Head of 

original peer review visit 

Radiotherapy 


Physics 

Document is currently being reviewed 30 th April 2011 Head of 

Radiotherapy 


Physics 

Job planning currently being undertaken for 

consultant oncologists 

To be discussed at the NELCN Radiotherapy Group 

Currently recruiting to vacant posts; due to Trust 

financial will never comply with measure 

Due to Trust financial will never comply with 

measure 

31 st August 2011 Clinical Lead for 

RT 



Ongoing 

Ongoing 


RT 

Head of 

Radiotherapy 


Physics/ GM - 

Oncology 

Head of 

Radiotherapy 


Physics/ GM - 

Oncology 

RAG

Measure No. 

10-3T-130 

10-3T-309 

10-3T-310 

10-3T-401 

10-3T-402 

10-3T-403 

Concerns and comments 


Fulfilling the Training and 

Education Strategy 

IMRT – Individual patientspecific 

quality assurance/ 

quality control 

IMRT – External quality 

control audit for ongoing 

IMRT 

Brachytherapy – interim 

phase implementation 

programme 

Brachytherapy – final 

outcome phase workload 

Brachytherapy – treatment 

protocols and standard 

operating procedures 

Breast (KGH) 


- HER2 status not always 

available at time of 

treatment planning 

- Recent changes in the 

working practice of the 

radiology department 

have stopped the 

department providing 

injections locally which 

means that patient’s 

requiring sentinel node 

biopsies need to travel 

between three sites, 


Lead 

Strategy in place but will take 3 years to implement Ongoing Head of 

Radiotherapy 


Physics 

First patient treated Complete Head of 

Radiotherapy 


Physics 

Inter-departmental audit is being worked up 30 th June 2011 Head of 

Radiotherapy 


Physics 

To be discussed at the NELCN Radiotherapy Group 30 th September Clinical Lead for 


RT 



Meeting with pathologists taken place and Clinical 

Director for pathology will ensure that the department 

request HER2 testing on all ER and PR positive 

patients. Will also become part of the MDS prior to 

the report being issued 

From the 21 st March 2011 all SLNB injections will be 

undertaken at King George Hospital 

Guide wires still being inserted at Victoria Hospital 

but plan is to move to KGH 





Completed 

Completed 


RT 


RT 

Clinical Director 

- Pathology 

GM – Oncology/ 

GM - Radiology 

RAG



King Georges, Queens 

and Victoria Hospital, in 

order to complete the 

procedure, this often 

involves travelling 

between sites with wires 

inserted 

- Whilst progress is being 

made to move to a joint 

MDT the MDT need to 

ensure that current plans 

are progressed in a 

timely way 

- There is a concern that 

following plans to merge 

the breast services of 

BHRT there will be an 

inequity of service to 

patients across the three 

sites, for example in the 

provision of digital 

mammography. Further 

work is required to fully 

understand the impact of 

moving to a single team 

and any differences in 

service that this may 

create 


Lead 

Now hold joint MDT Completed Lead Clinician - 

Breast 

Screening QA action plan nearly completed Ongoing Lead Clinician - 

Breast 

RAG

Approved at Quality & Safety 

Committee meeting on 9 th 


QUALITY & SAFETY COMMITTEE 

Part I 

Minutes of the meeting held on Tuesday 14 th June 2011 at 14.00 hrs in Board Rooms 1&2, 

Trust Headquarters, Queen’s Hospital, Romford. 

Present: 

Apologies: 

Not present: 

Edwin Doyle, Chairman (Chair) (ED) 

Averil Dongworth, Chief Executive (AD) 

Magda Smith, Divisional Director – Medicine (MS) 

Tan Vandal, Acting Divisional Director – Surgery (TV) 

Ian Grant, Divisional Director - Clinical Support (IG) 

Pam Strange, Clinical Governance Director (PS) 

Deborah Wheeler, Director of Nursing (DCW) 

Arshiya Khan, Divisional Manager – Women & Children (AK) 

Portia Omo-Bare, Chief Pharmacist (POB 

Imogen Shillito, Director of Communications (IS) 

John Alcolado, Director of Medical Education (JA) 

John Fletcher, Divisional Nurse Director, Surgery (JF) 

Lyn Wilson, Quality Systems Manager (LW) (Minutes) 

Elaine Clark, Patient Representative / Chair of IPEG (EC) 

Stephen Burgess, Acting Medial Director (SB) 

Carol Drummond, Divisional Director – Women & Children (CD) 

Alison Crombie, Education Director (AC) 

Cris Robinson, Clinical Governance Accreditation Manager (CR) 

Jane Moore, NE London Sector Director of Public Health (JM) 

Michael White, Non Executive Director (MW) 

41/2011 Apologies 

The above apologies were noted. 

42/2011 Minutes of the Meeting held on 12 th April 2011 (Part I) 

The minutes were agreed as a true record. 

43/2011 Matters Arising 

The members were pleased to note the draft August agenda. 

No comments had been received on the proposed work Programme for the 

Committee. Members were asked by ED to ensure it was kept up to date. 

Action Log 

It was noted that IS was still working to develop clear guidance for Divisions 

on risks to reputation. 

Checks were also going to be made by MS that details of the Commissioners 

who worked on the dementia care pathway had been sent to Jane Moore. 

Action 

All 

IS 

MS 

Quality & Safety Committee / Pt.I Minutes - June 2011 (approved 9.8.11) / CR 1

DCW reported that an End of Life Care Board has been established that 

includes palliative care issues (Liverpool Care Pathway). Members heard that 

the Dept. of Health patient survey performance scores can be adjusted if the 

survey is replicated. Furthermore the Trust has commissioned a real-time 

survey which is currently underway. It was pointed out that patients should 

be notified of the NHS Choices website as an alternative feedback 

mechanism. Patients are also given ‘leaving hospital’ leaflet and it was 

considered important that this included feedback mechanisms they could use. 

All other matters were either completed or covered by the agenda. 

44/2011 Revised Terms of Reference 

All the changes to the terms of reference of the Committee including the 

change of title were approved. 

AD then proposed that all the QSC feeder committees and groups review 

their own terms of reference referring any exceptions through to the QSC via 

the relevant Division. POB was concerned that the Drugs & Therapeutic 

Committee and Evidence Based Practice Committee required more tangible 

reporting lines that can be evidenced 

A general discussion then ensued about the current committee structures and 

what mechanisms could be employed to reduce the numbers of large reports 

being provided for meetings and tighten reporting arrangements and the 

identification of risks. It was agreed that a meeting should be convened with 

suggestions on a way forward brought to the next meeting. 

45/2011 Divisional Quality Dashboard 

PS explained to the members the changes to the Dashboard from the 

previous iteration. There was a consensus that the information provided was 

generally more useful. Individual members were asked to review what they 

were providing for inclusion in the dashboard, making sure it was accurate 

and up-to-date. 

Members were asked to review whether the important key performance 

indicators were included in the dashboard and to notify SB if this was not the 

case. Further discussion ensued around the inclusion of staffing information, 

visible leadership results, and a better description of risks with more explicit 

information. 

AD pointed out that the dashboard was different from the Trust’s Risk 

Register and Board Assurance Framework which includes the high level risks; 

exception reports only should be included on the QSC dashboard. 

It was also pointed out that the Trust’s governance framework should be more 

accurately mapped out and SB was asked to provide an update on this to the 

next meeting. 

The Chairman requested that SRO’s are clearly identified, by name and title 

against key items in future to improve accountability and provide an audit trail; 

this was supported by the Chief Executive. 

It was noted that the Cancer, Diagnostics & Therapeutics Division were 

evolving a new divisional dashboard that would help populate the QSC 

dashboard in future. 

It was felt important that CQUINS and Commissioner KPIs should be included 

in the dashboard in future and this should be taken up with Steve Rubery. 

It was agreed that AK would review the W&C dashboard to ensure 

consistency with their KPIs and Assurance Framework. 

Members were reminded that the Divisions were responsible for developing 

robust action plans and that their implementation should be reported to the 

Action 

AD, 

DCW, 

PS, SB 

All 

SB 

CR 

SB 

AK 

Div. Dirs. 


Divisional Boards with exceptions reported to the QSC via the dashboard. 

During the discussions about the dashboard concerns were raised about the 

low attendance at maternity risk MDT meetings and AK was asked to 

escalate this issue and report to the next meeting of the QSC on what action 

had been taken. ED stressed the importance of keeping attendance registers 

and following up on non-attenders. 

In relation to the Trust’s overview section, the addition of a narrative would 

greatly help provide assurance to the Trust Board as the figures in 

themselves do not provide that. Specifically, in relation to the risks to 

reputation, IS suggested we undertake a hand held patient survey with clear 

questions to determine the level of women’s confidence in using our maternity 

services; this would help also with the number of Freedom of Information 

requests being received. DCW to consider this suggestion. 

46/2011 Mortality Report 

PATIENT SAFETY 

PS explained that the Trust was currently showing at 107% following a further 

rebasing of Dr Foster data and that although still an outlier, this was an 

improvement on the Trust’s previous position. AD questioned whether it 

would be possible for the Trust to improve to less than 100% this year and it 

was agreed it was potentially possible. 

The report showed that Red Bells have all been checked, a process that 

continues monthly. No issues of concern are identified in the current report 

that includes data up to the end of March 2011. 

A review is underway between the data held by the Trust and that held by Dr 

Foster to understanding a discrepancy in perinatal deaths. There has been 1 

Red Bell in June relating to two deaths after live births. The notes of these 

cases are being reviewed. 

PS reported that the Health Records and Coding Group meet next week and, 

in addition, Dr Brownell is looking to make improvements in the quality of 

notes and coding. 

A pilot is being established to consider the impact the new Medical Examiner 

roles will have; from next year medical examinations will take place in the 

community. 

Following the introduction of Quality Care 24/7 the number of weekend 

deaths was reducing. AD suggested this needed further investigation as it 

was not clear at the present time what was making the difference. 

IG felt that audits should be carried out on all Red Bell cases, particularly 

querying leukaemia red bells and the number of patients that are dying in 

hospital rather than in community palliative care situations. 

PS explained the process for monitoring mortality and following up on red 

bells but AD considered that the report needed further clarification. A 

spreadsheet showing red bells by Division and describing the actions being 

taken and where action was not possible/or improved was suggested by ED 

and it was proposed that this should include narrative. PS was asked to take 

this suggestion forward. 

All members were pleased to see the improvement in the Trust’s mortality 

status. 

Action 

AK 

DCW 

PS 


47/2011 Workforce Review 

MS reported that Consultant recruitment in medicine and emergency services 

is progressing although there are still vacancies for junior doctors. 

Suggestions were put forward about alternative methods of attracting staff 

and MS explained that overseas recruitment, Deaneries and agencies were 

already being used. Band 5 nurses are fully recruited to and in post, although 

Band 6 still have some vacancies. A plan is in place to mitigate the risks 

associated with senior nurses being released to attend a training programme. 

A&E continues to be a high risk for medical staffing. The Trust has 8 

Consultant vacancies out of 18. Consultant hours have been increased in 

response to fill for known vacancies. There is 1 agency locum employed at 

the time to complete the rota. Middle grade recruitment has been very poor 

despite a variety of interventions (as agreed in the ED recruitment plan). The 

5 SHO vacancies should be filled by August. 

There are daily risk mitigation meetings with Consultants helping wherever 

possible. 

The group discussed the national recruitment shortages and it was noted that 

the Trust was using every avenue open to them to interest staff in joining the 

Trust. 

48/2011 Radiology Access Times 

IG advised the KPI for 24 hr turnaround inpatients came into force from the 1 st 

April. It was noted that we have 150 CT patients and 75 MRI patients a day, 

which is an increase of between 10-15% on last year’s figures. The report 

highlighted that turnaround times are currently poor but an action plan is 

currently in place to review the processes. 

Members were told of the steps being taken to make improvements 

highlighting that the Trust was current best in London for trauma CT 

turnaround times. 

It was noted that the radiology scanners were in planned use for 12 hrs a day 

/ 7 days a week which is high for this type of equipment; although they are 

available 24/7. The potential for 24 hr planned usage was raised by the ED 

and IG agreed to update the report after considering this issue. JA queries 

whether there were inbuilt delays for urgent requests as this had been 

highlighted to him by trainees. This issue would also be considered with a 

further report on this topic to the next QSC meeting. 

49/2011 Care Quality Commission Update 

ED thanked members for the efforts made that have resulted in the lifting of 

the appraisal and resuscitation condition, however noting that appraisal rates 

were again dropping. 

IS pointed out that the CQC decisions around their dignity and nutrition review 

carried out at KGH in March 2011 were still to be received. 

AD recommended that the action plan to address the CQC’s concerns with 

the Trust’s maternity services should become a standing item on the agenda 

and the current version of the action plan should be distributed to members 

for review. Any issues identified by members should be referred to Carol 

Drummond or Deborah Wheeler. AK was asked to take this recommendation 

back for appropriate action. 

Action 

IG 

AK / CD 


50/2011 Enhanced Recovery Programme 

CLINICAL EFFECTIVENESS 

TV advised that the enhanced recovery programme has been put into 4 areas 

– rectal surgery, hips, bladder and prostate cancer and hysterectomy. 

Performance in prostate/bladders is very good. The length of stay (LoS) 

situation with hips is currently 5 days with 4 days as the target. 

Colonectomies currently LoS is 10 days with 3-4 days the national average; 

this is potentially because we have a smaller amount of cases to deal with. 

We only have 2 of the 6 surgeons able to perform this surgery with interviews 

next month for more appropriately qualified surgeons. 

If the Trust is able to achieve the year end CQUIN target of 20% for 

laparoscopic resections there is an additional £600k available and TV was 

confident that this could be achieved. 

A discussion followed about patient choice of open or keyhole surgery and the 

potential for retraining surgeons to use the new technologies. Where 

retraining was not being taken up, ED felt that the Chief Executive should 

consider the wider implications to the Trust. 

51/2011 Vascular Centralisation Report 

It was confirmed by TV that the vascular centralisation had been completed 

from the 21 st March and so far was going well. The vascular MDT is held at 

Queens with treatment decisions being made collectively although attendance 

issues remain an issue which is being addressed. 

The members discussed the potential risk of vascular patients attending KGH 

and requiring treatment. MS advised that the transfer processes were in 

place but the group felt that any delays should be monitored by the 

committee. TV advised there had been no incidents to date. MS and ED 

requested more formal monitoring of the care pathway. AD suggested the 

same level of monitoring should be available for the breast centralisation. TV 

and MS were asked to lead on both these monitoring requests. 

The peer review has been cancelled. 

52/2011 Research & Development 

The members noted that there were governance issues in R&D and it was 

agreed that the report would need to be expanded in future to cover more 

governance issues. JA pointed out that we should have Bart’s oversight, but 

as this is not yet established there is a risk. The group also felt that the 

financial aspects should be referred back for further expansion. 

PATIENT EXPERIENCE 

53/2011 Paediatrics – Introduction of 24-Hr Short Stay Assessment 

DCW explained that there were financial implications with the introduction of 

the 24-hr short stay. AK explained the unit was being introduced to reduce 

pressure in paediatric A&E and following introduction at KGH there have been 

no issues. The introduction at Queen’s is yet to begin. 

It was noted that the introduction of the short stay unit was intended to reduce 

length of stays and the members agreed to support the model proposed 

although ED suggested the financial implications be referred to the Finance 

Committee not the QSC. 

Action 

AD 

TV / MS 

SB 


54/2011 Patient Experience – Real Time Monitoring 

The members noted the report which generated considerable discussion. 

They noted there had been IT configuration problems and our IT/Elephant are 

working on these technical issues although this is taking longer than 

anticipated. Once resolved the information should provide good comparative 

data. 

IG pointed out that in the report Clementine B was put in the wrong Division, 

he also felt we were very poor at recording ethnic origin. It was also noted 

that each Division was responsible for cascading the report to their doctors 

and nurses. 

The use of this data was queried by IS, but DCW replied that until the data 

was available it was unclear of its value and it would probably be 6 months 

before the data became more meaningful to the organisation, but it was 

important to ensure we are asking the right questions. 

55/2011 Improving Patient Experience feedback 

The minutes of the last IPEG meeting were noted. 

The discussion reverted to the issue of being able to demonstrate that 

committees are taking appropriate actions and that work is not being 

duplicated or missed. It was noted that workstreams had not been included in 

the IPEG minutes. 

It was agreed that the committee workload should be streamlined to ensure 

that everything relating to patient experience is fed into IPEG. This 

suggestion was agreed by EC. 

56/2011 Care & Compassion Ombudsman Report, February 2011 

It was confirmed by DCW that the video from the Despatches, Channel 4 

programme is being used in our mandatory training programmes and the 

Care and Compassion report was used as the focus of the Trust’s internal 

Nurses’ Day event. The Trust has introduced Nursing & Midwifery Awards for 

ward improvements identified by the Visible Leadership Audits. This has had 

a good effect because staff feel their work is being recognised. 

EC reported that the IPEG Committee were impressed with the maternity 

audit. 

57/2011 LINks ‘Enter & View’ Visits 

ED requested that in future the reports from Enter & View visits should be 

circulated on line with only summaries brought to the QSC. DCW explained 

the reports covered 4 enter & view visits. The first 2 were supposed to be trial 

runs but these were subsequently included in their reports. Havering LINk are 

requesting an August visit to Maternity. 

DCW will be asking the LINks to combine their visits instead of individual 

visits as this would make life easier for staff. AD questioned how the findings 

from these reports would be followed up. 

Action 

58/2011 Any Other Business 

There was no other business. 

59/2011 Dates of Future Meetings 

Meetings have been arranged at 14.00 hrs in Board Rooms 1&2 on the 

following dates: 9 th August / 11 th October / 6 th December 


ACTION LOG 

43/2011 MATTERS ARISING 

Work Programme information to be kept updated. 

Progress with developing Divisional guidance on risks to reputation 

Commissioner information completed 

44/2011 TERMS OF REFERENCE 

Committee structures and reporting review to be undertaken – meeting to be 

arranged. 

45/2011 DIVISIONAL DASHBOARD 

Information to be submitted to be reviewed by Division to ensure it is 

comprehensive and accurate. 

Agenda to identify SROs by name and title in future 

Trust governance framework to be reviewed and reported on to August meeting. 

CQUINs and KPIs to be included in dashboard following discussion with Steve 

Rubery. 

W&C dashboard to be reviewed to ensure consistency with their KPIs and 

Assurance Framework 

Exceptions against Divisional action plans to be reported via dashboard. 

Low attendance at maternity risk MDT meetings to be escalated for appropriate 

action with update to August meeting. 

Consideration to be given to carrying out a patient survey maternity services to 

determine women’s confidence levels. 

46/2011 MORTALITY REPORT 

Spreadsheet required for future meetings showing red bells by Division and 

describing actions taken and/or where actions are not possible. 

48/2011 RADIOLOGY ACCESS TIMES 

Further briefing report required on this topic for the August meeting. 

49/2011 CARE QUALITY COMMISSION 

CQC Maternity action plan to be standing agenda item at all meetings. 

50/2011 ENHANCED RECOVERY PROGRAMME 

Consideration to be given to the Trust wide management of surgeon retraining in 

the use of new technologies 

51/2011 VASCULAR CENTRALISATION 

Formal care pathway monitoring KPIS to be developed and reported for Vascular 

and Breast centralisation. 

52/2011 RESEARCH & DEVELOPMENT 

Report to Committee to be expanded in future to include governance issues. 

Financial elements should be further expanded upon in future reports. 

Responsibility 

Div. Dirs. 

IS 

MS 

AD, DCW, PS, 

SB 

Div. Dirs 

CR 

SB 

SB 

CD 

Div.Dirs 

CD 

DCW / CD 

PS 

IG 

CD / PS 

AD 

TV / MS 

SB 


TRUST BOARD MEETING 

Wednesday, 2 November 2011 at 1.00 pm 

Board Room, Trust Headquarters 

Queen’s Hospital 

A G E N D A 

1. Apologies for Absence 

2. Minutes of the meeting held on 7 September 2011 (Attachment A) 

3. Matters Arising and Actions 

4. QUALITY AND PATIENT STANDARDS 

4.1 Quality & Patient Standards Performance Report – (Attachment ) 

September 2011 (AD/DCW/RMcA) 

4.2 Emergency Care Update (MS) (Attachment ) 

4.3 Maternity Services Update (CD) (Attachment ) 

4.4 Quality & Safety Committee Escalation Report (SB) (Attachment ) 

5. FINANCE, WORKFORCE AND ACTIVITY 

5.1 Finance Report – Month 6 (September) 2011/12 (DIW) (Attachment ) 

5.2 Workforce Key Performance Indicators (RMcA) (Attachment ) 

5.3 Activity Report – September 2011 (NM) (Attachment ) 

5.4 Workforce Committee Escalation Report (RMcA) (Attachment ) 

6. GOVERNANCE: 

6.1 Care Quality Commission Report (SB) (Attachment ) 

7. INFORMATION 

Matters for Noting: 

7.1 Interim Chair and Chief Executive’s Report (Attachment ) 

7.2 Research & Development Annual Report 2011 (Attachment ) 

7.3 Minutes of the Quality & Safety Committee meeting held on (Attachment ) 

the 2011 

7.4 Minutes of the Strategic Partnership Board meeting (Attachment ) 

7.5 Minutes of the Charitable Funds Committee meeting held on (Attachment ) 

the 2011 

7.6 Draft Agenda for January 2012 Trust Board Meeting and Rolling (Attachment ) 

Programme for 2012 

8. Any Other Business 

Date of Next Meeting: The next public meeting will be held on Wednesday, 

4 January 2012 at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s Hospital 

9. Questions from the Public 

10. Exclusion of the Public and Press In accordance with the Public Bodies Admission to Meetings 

Act), to resolve to exclude members of the public and press from the remainder of the meeting. 

Trust Board Agenda – 2 November 2011 1

Trust Board papers 7th September 2011 - Barking Havering and ...

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