Agenda Item: 5.1 REPORT TO THE TRUST BOARD 31 … TO THE TRUST BOARD 31 March 2016 ... A patient’s poor care following 2 ectopic pregnancies. ... there are action plans to deliver

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Agenda Item: 5.1

REPORT TO THE TRUST BOARD

31 March 2016

Title Integrated Performance Report

Lead Director

Paul Scott - Director of Finance & Performance Lisa Nobes –Director of Nursing & Quality Clare Edmondson –Director of HR Neill Moloney - Chief Operating Officer

Author(s)

Chief Information Officer – Mike Meers Acting Deputy Director of Nursing – Karen Kemp Simon Rudkins – Deputy Director of Finance Jennifer Canham – Deputy Director of Human Resources

Purpose To receive for information

Previously considered by Finance and Performance Committee

Executive Summary

Related Trust Objectives Sub-objectives

Consistently deliver great healthcare to every patient every day

Maintain our focus on safe care

Improve the effectiveness of our care

Ensure we always have caring staff for our patients

Improve the way our services are responsive to the needs of patients.

Ensure care is well-led by # team Ipswich

Improve the healthcare we provide to patients where and when you need it.

Improve our efficiency to ensure our patients receive better care

Ensure all our clinical staff undertake thoughtful practice

Develop our infrastructure to improve patient access to care and information

Flexible and responsive to future demands

Demonstrate leadership in addressing the needs of Suffolk

Understand future needs

Supporting our workforce to meet future demands

A hospital without walls

Risk and Assurance N/A

Related Board Assurance Framework Entries

Risk to financial sustainability of the Trust (935)

Financial Implications N/A

Legal Implications/Regulatory Requirements

None

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Action Required by the Trust Board The Trust Board is asked to receive for Information.

QUALITY

Harm free care

Falls

The total number of inpatient falls in February was 104 which equates to 6.1 falls per 1000

bed days. 47% of the total falls occurred between the hours of 2100 and 0700.

Of the 104 falls, 26 can be attributed to 11 patients who fell more than once. This represents

25% of the total.

There were no falls resulting in serious harm in February. There have been 12 patients YTD who have experienced a fractured neck of femur and 2 who experienced a serious head injury.

Grundisburgh have met their stretch target for 7 months running and demonstrates an upward trend. Brantham has only met their target twice YTD. Pressure ulcers

There were no avoidable pressure ulcers reported in February.

Woodbridge Ward have actively undertaken some intensive work with staff to improve the

documentation and use of the rounding tool following January’s RCA’s which has shown a

significant improvement in their documentation of care this month and is an example of

excellent learning and good practice.

There have been 4 incidents in last 4 months with inaccurate pressure ulcer risk

assessments which were completed initially on Brantham and not on transfer to ward areas.

There is a trend emerging from root cause analyses in the last 6 months that identify staff on

Brantham completing the risk assessment inaccurately. A plan to address this with

Brantham staff is being developed.

Infection Prevention and Control

C Difficile

There were 5 cases of C. Diff reported in February, one occurring on Somersham,

Debenham, Stradbroke and 2 cases on Washbrook. The ribotyping on the Washbrook cases

were different which demonstrates no transmission between patients.

Patient Experience

Complaints and PALS

42 complaints were raised in February, this compares with 48 in January, 37 in December,

45 in November and 54 in October.

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Of the 42 complaints, one was graded as high level. This case relates to a patient

exacerbating an ankle fracture having fallen in the toilet. 28 cases were graded as medium

level and 13 were graded as low.

Occasionally the Trust receives a complaint that covers a number of health care providers, in

which case a coordinated response is required. There were no ‘co-ordinated’ complaints

received in February.

Issues raised in February include:-

3 complaints relating to the standard of care provided on Sproughton ward.

Problems with cardiology referrals to Papworth hospital.

Failure to recognise a deteriorating patient on Haughley ward.

Delay in having a biopsy and diagnosis of cancer in an oral surgery patient.

Delay in a dermatology patient receiving treatment due to lost samples.

Poor communication and a delay in receiving a colorectal outpatient appointment.

Medication issues on Lavenham and Stowupland wards.

A patient’s poor care following 2 ectopic pregnancies.

2 complaints relating to poor obstetric care on Deben ward.

Overdue Complaints:

There were no overdue complaints in February.

Nine requests for an extension were made in February; five were Division 1 cases, three

were Division 2 cases and one was a Division 3 case. This compares with nine extension

requests being made in January, ten in December, five in November and eight in October.

Re-opened Complaints:

Three complaints were re-opened in February; this compares with 6 cases being re-opened

in January and four being re-opened in December. November and October also saw four

complaints being re-opened.

Of the three complaints that were re-opened, two relate to Division 2 and one relates to

Division 1. One Division 2 case was easily resolved by offering the patient a Trauma and

Orthopaedic clinic appointment, the other re-opened Division 2 complaint is currently being

re-investigated by the Rheumatology team. The Division 1 case relates to a stroke patient

and is currently being re-investigated within the Division.

24 Hour Courtesy Calls:

There were 3 failures to make the 24 hour courtesy calls in February; this is a higher level of

failure than recorded in previous months. One failure was in relation to a Renal Unit

complaint, one was in relation to a Trauma and Orthopaedic complaint and the other related

to an Estates and Facilities complaint.

Parliamentary and Health Service Ombudsman (PHSO):

One new case was referred to the PHSO in February; this complaint relates to a Division 2

Oral Surgery complaint.

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In February the Trust received the Ombudsman’s final report for a complaint regarding the

Emergency department. The complaint also refers to the patient’s GP and Mental Health

service provider. The final report indicates that the Ombudsman is upholding the complaint

and making recommendations including that each organisation involved should pay financial

recompense to the patient and her mother for the injustice they have suffered as a result of

the failings identified. The Trust has now written a letter of apology to the complainant and

paid recompense in line with the PHSO recommendations. The Trust must also provide the

complainant and the PHSO with a copy of the action plan in relation to this case by May

2016.

The number of Ipswich Hospital complaints that the Ombudsman upholds or partially

upholds is low when compared with the national average. To date, in 2015/16 25% of

complaints referred to the PHSO have been upheld or partially upheld, compared with the

national average of 45%.

There are currently seven Ipswich Hospital cases under investigation by the PHSO.

94% of the Division 2 courtesy calls were made in February, the one failure relates to a

Trauma and Orthopaedic case.

Patient Advice and Liaison Service:

PALS handled 210 contacts in February, following a higher than average number of contacts

being made in January (241). The usual range of contacts for PALS each month is between

180 and 220. Approximately 50% of the calls to PALS are graded as PALS 1 contacts as

they relate to straightforward matters such as signposting other service providers, lost

property, Access to Health Record requests, car park enquires and families trying to contact

inpatients.

Other matters, requiring some element of liaising or investigation, are graded as PALS 2.

Issues raised include:-

Cardiology patients being unable to contact the Cardiology department.

Urology patients chasing surgery or procedures dates.

Neurology patients chasing appointments

Colorectal patients chasing appointments and results.

Patients chasing Dermatology appointments.

Patients chasing Eye Clinic appointments

Patients chasing Trauma and Orthopaedic appointments.

Care and communication issues occurring on wards.

The PALS team handled 17 ward related concerns in February. This compares with 13 in

January, 20 in December and 24 in November. No particular ward stands out as having

more concerns raised through PALS but in general the matters raised by inpatients and their

families relate to discharge arrangements and families not knowing who to speak to on the

wards.

In each case where PALS have liaised with families and ward staff the issues raised have

been resolved without the need to raise a formal complaint.

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Family Carers of People with Dementia CQUIN

Dementia family carer CQUIN – to provide family carers of patients with dementia the

opportunity to provide feedback on support given to them by the hospital:

58 dementia carer packs were distributed – this was 100% of the carers identified who met

the CQUIN criteria.

10 follow up feedback calls were undertaken with all agreeing to take part. 90% felt confident

to leave their relative in our care; 100% felt supported some or all of the time. 90% reported

receiving a carers’ pack.

FINANCE

EXECUTIVE SUMMARY

Forecast outturn in 2015/16 of £22.1m

YTD at Month 11, Trust is £5.9m adrift of plan, deficit of £22.8m; actions in M12 will

adjust to FOT projection (including TPP)

Agreement with Lead Commissioner re 15/16 contract position – reduces financial

risk and improved cash flow in-year

Focus on Workforce initiatives to reduce Agency spend

Received loan to support working capital £18.5m deficit plan

FINANCIAL POSITION

The schedule of risks presented shows how the deficit of £22.8m at Month 11 (an adverse

variance to plan of £5.9m) reflects the increased risks facing the organisation against the

initial assessment at budget approval. The Risk & Opportunities schedule builds on the

Board-approved financial plan for 2015/16 of a deficit of £19.8m.

Community budgets are included within the Trust’s financial reporting; to date, there is

minimal variance to plan YTD and forecast, although a risk remains regarding continence

expenditure.

The table below presents a view by Division of both YTD at Month 11 and a run-rate

projection to year-end.

The primary reasons for the variance of £5.9m at Month 11 are:

M11 YTD FOT

Div 1 (2.1) (2.5) Adjusted M9 for Diag Imaging

Div 2 (1.5) (2.1)

Div 3 (1.1) (1.1) Adjusted M9 for Diag Imaging

Div 4 0.2 0.0

Reserves (1.3) 2.1 includes TPP adj M12

Variance (5.9) (3.6)

Plan (16.9) (18.5)

FOT (22.8) (22.1)

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Delayed Transfers of Care; these impact on the ability of the trust to discharge

patients into community care once the appropriate level of hospital-based care has

been concluded; this is a significant part of the Division 1 CIP plan

Higher than plan Non-elective activity; this impacts on capacity within the hospital

and also is a primary contributor to the level of agency staffing deployed within the

organisation

The Trust is undertaking a number of initiatives aimed at reducing the level of agency

expenditure across the organisation in line with the targets for agency reduction

issued centrally. Agency expenditure has reduced in recent months, and the Trust

achieved the 6% target in Month 11; Pay was higher than the previous month and is

anticipated to stabilise for the remainder of Quarter 4 and achieve the 6% target even

with increased activity.

The extrapolated run-rate from the M11 position to year end remains £26m, after release of

contingency and including estimate of financial pressures arising from additional activity over

the winter period. However, recognition of the investment in TPP during 2015/16 and

transfer of £0.75m from Capital to Revenue resource will result in the FOT £22.1m deficit

being achieved.

The table below shows a projected likely deficit of £22.1m (C).

Opportunities have been identified; there are action plans to deliver these:

Agency Expenditure: improvement has been delivered in Quarter 3 but the

sustainability of the significant reduction in Month 9 remains under scrutiny

Utilise an opportunity to move unused Capital Resource Limit non-recurrently in-year

to Revenue via receipt of income for the CRL unutilised (£0.75m has now been

agreed and reflected in M11 position)

Resolution of significant proportion of contractual challenges through the contract

agreement with lead commissioner for 2015/16 (achieved and reflected in YTD run-

rate)

Maximise CIP delivery (CIP is predicted to deliver target in-year and recurrent full-

year effect – financial impact already in YTD run-rate)

The Pathology Partnership is being treated as an investment, following receipt of a

revised business plan and agreement from the Partnership Board; this will not reduce

the cash flow requirement in-year but enables partner organisations to agree a

consistent accounting treatment (in Month 12, the Trust will reverse the revenue

provision apportioned in-year and transfer to the balance sheet).

The forecast, as shown in the Risk & Opportunities schedule, is to achieve a likely deficit of

£22.1m (C) in 2015/16 assuming delivery of the above mitigating actions.

The summary of the three scenarios as presented in the Risk & Opportunities schedule is as

follows:

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The Trust submitted an application for cash support to replace the interim working capital

facility in October; this was approved by the Department of Health in December and has now

been received by the Trust and has been used to repay the working capital facility; the sum

in both counts was £17.3m. The Trust has received a further £1.3m cash support in Month

11, reflecting the additional cash resource required against the £18.5m revised plan. There

is a set of criteria to which the Trust must adhere as part of the loan agreement conditions;

this is being reported to the executive via the Finance & Performance Committee.

NEXT STEPS

Monitoring of the performance of Divisions against Financial Recovery Plans agreed at the

Divisional Board-to-Board meetings continues, with Executive reviews with Divisions as

required where performance is more than £50k adrift from plans. At Month 11, Divisions are

delivering (individually and collectively) the revised projections within their Financial

Recovery Plans.

OPERATIONAL PERFORMANCE

Emergency Care

The Trust failed to achieve the 4 Hour wait target in February with 92.79%, year to date

performance fell just below 95% at 94.95% however the Trust remains the best performing

Trust year to date with the Midlands and East.

Activity continues to increase above 2014/15 levels 5.4 Year to Date. January and February

combined was 8.7% higher than 2014/15 (excluding the leap year additional day).

Cancer

The Trust achieved failed to achieve the 62 Day Upgrade target in February although

improved performance over January with 1 Trust breach and 1 shared breach in month. The

Summary Deficit £m

19.8

18.5

(22.1) (B)

(22.1) (C)

(26.2) (A)

Initial Plan

Best Case

Likely Case

Worst Case

Revised Plan

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Trust performance on the 62 2WW target maintained its improvement following its action

plan achieving the threshold for the sixth month in a row.

Diagnostics

The Trust achieved diagnostic threshold of less than 1% of patients waiting > 6 weeks in February 0.21% and is forecasting a year end position of 1.08% over the threshold if we had no more breaches and average activity. The Trust had 0 Non Obstretric Ultrasound breaches in month and has seen the waiting list in this area decrease from 1787 in April to 1112 in February.

Cancelled Operations for Non-Clinical Reasons.

The Trust continues to achieve the threshold for non-clinical cancellations of operations of below 1% with 0.52% of operations cancelled in February. Year to date the Trust is at 0.46% 212 compared to 277 in 2014/15.

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WORKFORCE PERFORMANCE

Staff in Post

Against a Trust establishment of 3756WTE, there were 3519WTEs in post at the end of February, compared with 3495WTE in January; an increase of 24WTE with 40.94 WTE new starters in February 2016.

The reduction in turnover from 9.3% in November continued to 8.2% in February, with a reduction to 5.4% in January for unplanned leavers. .

Recruitment

During February, there were 64.5 posts advertised, with 213 candidates invited for interview for 53 posts 31WTE were offered appointments.

Fortnightly Recruitment and Retention meetings continue with a project plan. All vacancies are assigned a case manager and a recruitment plan, which is reviewed and monitored regularly.

The Transformation Office continue to work with the Recruitment Office and the red to green recruitment tracker will go live in April.

The Trust continues to develop and implement recruitment strategies for hard to fill posts,

which are reported to Combined Board.

An HCA Open Day takes place each month to ensure a continual source of trained HCAs.

22 trainee HCAs commenced in February; 14 permanent and 8 flexible staffing

Retention

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Whilst there is a continuing focus on recruitment into the Trust, a programme has been

developed and is being implemented to gain a better understanding of why staff leave the

Trust and to mitigate the reasons.

National and regional data is being accessed to allow comparison of the Trust against other NHS employers. A staff workshop approach is being used to gain a more detailed immediate understanding of why staff remain with the Trust and what actions would support improved retention A Trust wide programme to exit data from those leaving is being developed and rolled out, enabling trends and hotspots to be identified. A revised exit interview process and paperwork has been launched across the Trust. Agency Workers

There are daily staffing reviews taking place to ensure that there are appropriate staffing levels across the hospital. A number of agencies provide workers to the hospital on a flexible arrangement via the framework agreements, when these are authorised by a member of the Trust Executive.

The daily staffing reviews and agency workstream programme continues. An internal audit on the agency utilisation and booking arrangements is scheduled to commence in March. Staff Volunteering Programme

In February 2016 there was a reduction in the usage of Staff Volunteers. Fewer day to day

usage of staff volunteers and a reduction in the number of multiple requests in one day ; this

has helped to increase the fill rate as shown below.

The number of staff volunteers in each team has remained static during February.

Number of requests vs fulfilled requests up to and including 28th February 2016.

Requests Fulfilled %

Bed making 33 13 39

Portering 12 11 92

Mealtime Support 92 34 37

Admin Support 6 6 100

Pharmacy Courier 0 0 0

Total 143 64 45%

Up to the 28th February 2016 these are the total number of hours spent volunteering in the

programme. These hours are based upon timesheets submitted by Staff Volunteers.

Bed Making 26

Mealtime 48

Portering 30.5

Admin 24

Pharmacy 10.5

Other 3

Total 142

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Sickness

Absence has decreased from 4.32% in January to 3.93% in February. There has been a decrease in the Community Long Term Absence from 5.64% in January to 3.09% in February. This has been the result of some long term absence cases returning to work.

Overall there has been a reduction of short term sickness cases across the Trust.

There is ongoing management of all cases including pro-active identification of those with >100 points, or where other trigger alerts have been identified and the continuation of monthly Stress Workshops.

HR Services are working with Occupational Health to support divisions in recognising ‘hot

spots’ to support appropriate management of all cases.

Induction Following a decline in local induction compliance in January at 83%, there has been an

improvement in compliance in February, which now stands at 96.1%, compared with the

target of 95%.

From 1 April 2016, the corporate induction programme will be changing and we will be facilitating two induction mornings per month (rather than just one). The revised programme will be far more interactive and will include greater focus on the culture of Ipswich Hospital, our values and other key information that may be useful to new Team Ipswich colleagues. There will be less focus on mandatory training although new staff will be required to complete their training requirements within 90 days of commencement. The new induction programme applies to all colleagues, including senior medical staff (consultants and SAS doctors).

Work is now underway to review and develop junior doctor induction.

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Mandatory Training

Mandatory Training compliance saw a minor reduction from to 88% in January to 87.7% in February against the target of 95%.

From 1 April 2016, the mandatory training programme will be changing. A mandatory training handbook with associated e-Assessment will be issued on an annual basis to all staff (including consultant and SAS grade doctors, volunteers and bank staff) and this will be valid from 1 April to 31 March of each year. The mandatory training handbook and e-Assessment should be completed by all staff between 1 April and 30 June of the year of issue. All staff will be required to read the handbook and complete the correct E-Assessment applicable to their role. Some subjects cannot be covered by the E-Assessment and necessitate a face to face course and therefore colleagues will be required to book and undertake these face to face mandatory courses, relevant to their role, as and when compliance expires. The handbooks are due to be delivered to departments from the 24th March onwards and a communication/information campaign is currently underway to advise staff of this change. Work will shortly be undertaken to update the divisional mandatory training compliance workbooks to be in line with the new mandatory training system.

Performance Development Review

Compliance has seen an increase in February to 85.1% against the Trust target of 85%.

The launch of the new appraisal documentation is underway and the new documentation will come into effect from 1 April 2016.

Training in the application of values based appraisal is being developed, with a pilot session to take place on 13th April 2016 – following this, regular training sessions for managers will occur, a train the trainer programme is also being looked into. Trust wide communications will shortly be taking place, along with guidance documentation for staff.

Job Planning As at 29 February 2016 20.6% job plans Trustwide had been signed and completed on the

e-job plan system with 83.%% engagement with e-job planning at different stages of

completion. Work progresses to agree the allocation of educational supervision time within

job plans. A meeting with LNC and Divisional representatives was held to agree the

allocation and the proposal is for agreement by the LNC on 4 April 2016. Following this, the

draft job plans will be submitted for approval.

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Summary Risks and OpportunitiesFor the Period Ended 29th February 2016

YTD FOT

Ref Risk/Opportunity Plan Risk

£3.5m

M11 YTD

Risk £m

FOT

Risk £m

SRO Likely

2015/16 Financial Plan (16.9) (19.8) (19.8)

RM1 FYE CIP is not fully delivered 0.0 0.0 0.0 COO 0.0

RM2 CYE CIP is not fully delivered (1.0) (1.1) (0.8) COO (0.8)

RM3 QIPP schemes reduce elective (0.2) 0.0 0.0 COO 0.0

RM4 Aggressive contract management (0.2) (6.0) (6.0) DoF (6.0)

RM5 NEL Activity is higher than planned (0.4) (2.0) (2.3) COO (2.3)

RM6 Division 2 continues to encounter problems with consistency and focus in clinical services. (0.4) (1.0) (0.6) HRD (0.6)

RM7 Historical culture of not delivering financial targets in clinical divisions (0.8) (1.3) (0.4) COO (0.4)

RM8 Developing new models of care and preparing to implement strategy require financial investment (0.3) 0.0 0.0 DoF 0.0

RM9 Non recurrent benefits in Divisional budgets 0.3 0.0 0.0 COO 0.0

RM10 Non recurrent income outside of contract 0.2 0.0 0.0 COO 0.0

RM11 CQUIN may not deliver as planned (0.4) 0.0 (0.2) COO (0.2)

RM12 Junior Doctor Cover Division (0.3) 0.0 (0.1) COO (0.1)

RM13 Repatriation of cardiac work (0.1) 0.0 0.0 COO 0.0

RM14 TPP (1.1) (2.0) (2.3) COO (2.3)

RM15 CQC (0.1) 0.0 0.0 COO 0.0

RM16 Winter Pressure impact; loss of elective, provision at higher cost 0.0 0.0 (1.0) COO (1.0)

RM17 Community JV contract 0.0 0.0 0.0 DoF 0.0

O1 Non-recurrent mitigations - contract agreement 1.3 5.3 5.1 DoF 5.1

Total Risks identified at budget setting (3.5) (8.1) (8.6) (8.6)

Contingency Released 3.5 2.2 2.2 2.2

Total Variance to Plan before opportunities - (5.9) (6.4) (6.4)

Total Financial Position - (22.8) (26.2) (26.2) (A)

O1 Non-recurrent mitigations 0.0 0.0 0.0 DoF 50% 0.0

O2 CYE CIP is fully delivered 0.0 0.0 0.8 COO 100% 0.8

O3 CYE CIP Over-delivery stretch 0.0 0.0 0.0 COO 0% 0.0

O4 TPP Technical 0.0 0.0 2.3 DoF 100% 2.3

O5 Agency Cap 0.0 0.0 0.3 COO 100% 0.3

O6 Lord Carter review - phasing into 2016/17 0.0 0.0 0.0 DoF 50% 0.0

O7 Winter planning to mitigate risk - in lead commissioner agreement 0.0 0.0 0.0 COO 100% 0.0

O8 Aggressive contract management 0.0 0.0 0.0 COO 100% 0.0

O9 Utilise Capital to revenue transfer 0.0 0.0 0.8 100% 0.8

Total Opportunities - - 4.2 4.2

Total Variance to Plan after opportunities (22.8) (22.1) (22.1)

(B) (C)

Trust Quality & Performance Report

March2016

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Contents

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Description Page

Quality 3

Finance 24

Operations 39

Workforce 51

Quality

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Highlights • There were no falls with serious harm or avoidable pressure ulcers reported

in February. • Harm-free care has reached the national target in February, reporting 95.8%

harm-free care and 97.76% new harm-free care. • The Trust recorded 5 cases of C Difficile in month which leaves current

performance at 28 cases year to date. However only 10 of these have been classed as trajectory as 17 cases were unavoidable and care delivered as policy.

• 0 cases of MRSA bacteraemia year to date. • Auditors have recorded compliance of 90.2% VTE assessment in February. • All Friends and family score results are benchmarking well against national

scores, except the emergency department’s recommender score which is below the national average. This is in the context of a much higher response rate in our emergency department than national average.

• Only two avoidable cardiac arrests were reported by the resuscitation team during February. The team completes a root cause analysis on each cardiac arrest call and decide if the cardiac arrest was avoidable.

Quality – Harm Free Care

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Highlights

• 95.8 % of patients on the day of study were harm-free from pressure ulcer, fall, VTE events and catheter associated urinary tract infections. This metric reports harm which has occurred at home, other provider or from Ipswich Hospital.

Assurance

• The rate of new harms (developed at IHT) for February was 2.24% making IHT specific harm free care 97.76%.

• The nursing audit plan for 2016/17 contains a planned audit for catheter associated urinary tract infections.

Quality – Infection Control

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Highlights • MRSA February

performance is 0 cases, the Trust has 0 cases year to date.

• The Trust recorded 5 cases of C Difficile in month taking it to 28 year to date. However only 10 of these have been classed as trajectory.

• 1 case of C Difficile was reported within the community hospitals in February- at Felixstowe.

Assurance

• All cases of C Difficile are reviewed as part of a root cause analysis process led by the infection prevention lead and signed off by the infection prevention lead at IESCCG.

• The Ipswich Hospital site infection control team maintain oversight of infection prevention and control at our three community hospitals.

Quality – Patient Falls at Ward level

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Highlights

• The Trust recorded 104 falls in Total at a ward level in February.

• 0 falls are reported as causing high harm.

• 25 falls were reported from our three community hospitals in January (reported a month in arrears). Bluebird lodge had 17 falls and Aldeburgh Community Hospital and Felixstowe Community hospital each reported 4 falls.

Assurance

• The falls per 1000 bed day rate fell slightly in month to 6.10 and was below that of the same period in 2014/15.

• Weekly auditing of falls assessment compliance continues and will be reported on the heatmap from April.

Quality – Pressure Ulcers

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Highlights

• The Trust had 0 avoidable grade 2,3 and 4 pressure ulcers recorded in February.

• The rate of avoidable pressure ulcers per 1000 bed days was 0

Assurance

• Each pressure ulcer- avoidable and unavoidable has an RCA approved by the tissue viability lead who also determines, following strict criteria, if the pressure ulcer was avoidable.

Quality – Patient Safety VTE

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Highlights • Auditors have recorded

compliance of 90.2% VTE assessment in February.

Assurance • Testing for the new VTE

assessment process on nervecentre commences in March with rollout planned for April.

• Nervecentre will ensure

clinicians receive an alert for VTE assessments not completed. Using this process, we anticipate recorded compliance will improve.

• Each incidence of VTE or pulmonary embolism developed in hospital is reviewed as part of a root cause analysis process.

Quality – Patient Safety SIRI

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Highlights

• The Trust recorded 4 SIRI in February and have had 50 year to date compared to 67 for the same period in 2014/15.

Assurance

• Weekly meetings of Divisional governance teams, complaints team, Director of Nursing, Director of Governance and Medical Director to review all incidents and ensure appropriate reporting of SIRIs.

• Detail of the reported SIRIs is contained within the serious incident report to confidential Board.

Quality – Patient Experience Inpatients

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Highlights

• Both the Inpatient FFT Score and response rates continue to track year to date above both the National and NHS England East average.

Assurance

• All negative scores which are associated with a comment are reviewed by the Divisional teams.

Quality – Patient Experience Outpatients

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Highlights

• The friends and family test score for outpatients was 95.4%. The decrease in score is often seen when response rates improve as a wider population of patients are surveyed.

Assurance

• National data is available for comparison of Outpatient FFT. The Trust is tracking above both the national and regional performance.

Quality – Patient Experience Emergency Care

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Highlights

• Friends and family test score in the Emergency Department improved to 75.8% of patients recommending ED in February 2016.

• Response rates have remained consistently high since October, tracking above benchmark data from NHS England.

Assurance

• The “recommender” score is consistently below the benchmark evidence from NHS England since October 2016. This correlates with much higher response rates at Ipswich Hospital as compared to the England benchmark and a decrease in recommender score is often seen with an improvement in response score.

Quality – Patient Experience Maternity

Highlights

• All areas of maternity provision continue to receive excellent scores with the friends and family test- above 95%. This is also in the context of high response scores.

Assurance

• The friends and family recommender score in all areas of maternity provision continues to score higher than the national average.

• No benchmark data is available on response rates.

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Quality – Maternity

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Mar Apr May June July August SeptemberOctober NovemberDecember January February Trend

Midwife to Mother Ratio 2015/16 1:30 1:30 1:31 1:31 1:31 1:30 1:30 1:31 1:30 1:30 1:30 1:30

Highlights

• The number of births and mothers delivered in February 2016 continues to be consistent with the numbers seen in February 2015.

Assurance

• The midwife to mother ratio continues to be 1:30, the national standard.

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Quality – Maternity

Highlights

• The caesarian section delivery rate has increased in February and increased in relation to performance last year

• 1:1 care in labour compliance has decreased throughout the year and is below performance last year.

Assurance

• These metrics will be focused on during the Division 3 accountability meeting and benchmark or national standards reported from next month if available to understand our target performance.

Quality – Heatmap Division One

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Highlights

• Division 1 has improved or maintained the CQC ratings across the majority of ward areas.

• Washbrook ward’s performance has deteriorated although this is largely due to infection prevention incidences- a norovirus outbreak and 2 C Difficile incidents. The ward was assessed as managing these incidents well by the infection prevention team.

Assurance

• Following Executive moderation of Sproughton’s performance, it was decreased into ‘inadequate’ in January and a quality improvement plan is being monitored through Quality recovery meetings with the Executive team.

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

3 2 3 3 2 4 4 4 4 4

3 4 4 4 5 4 5 5 4 4

3 3 4 4 4 4 4 4 4 5

3 3 3 4 4 4 4 3 4 4

3 3 4 4 4 4 5 4 4 5

3 2 3 3 4 4 3 4 3 4

3 3 3 3 5 3 4 4 3 4

4 3 4 4 4 4 4 3 4 5

3 3 4 4 4 4 5 4 4 5

3 3 4 4 4 4 3 4 3 4

2 2 3 3 3 3 3 4 4 3

2 2 3 3 4 4 3 4 3 4

Percentage

Fail Score

Quality

Score

0 - <5% 5

5 - <15% 4

15 - <30% 3

30 - <50% 2

50%+ 1

Inadequate

Inadequate

Woodbridge Ward 2

CQC Rating

Outstanding

Good

Requires Improvement

Shotley Ward (Stroke Unit) 4

Sproughton Ward 3

Washbrook Ward 2

Haughley Ward 3

Kesgrave Ward 3

Kirton Ward 3

Claydon Ward 4

Debenham Ward 4

Grundisburgh Ward 3

Ward HeatMap Dashboard for :

Medicine and TherapiesWard Name Apr

Brantham Ward 2

Capel Ward 4

Quality – Heatmap Division One

17

Domain ID Indicator Weight Target BRAN CAP CLA DEB GRUN HAUG KES KIR SHOT SPRO WASH WOOD

C01 % Recommending - inpatients 2 90.0% 84.9% 97.5% 95.7% 95.5% 92.0% 92.3% 95.6% 100.0% 100.0% 100.0% 97.5% 98.0%

C08 Mixed Sex Accommodation Breaches 4 0 0 0 0 0 0 0 0 0 0 0 0 0

W01 Respect - A cheerful, friendly welcome 1 95.0% 100.0% 101.0% 100.0% 100.0% 100.0% 100.0% 103.0% 100.0% 100.0% 100.0% 100.0% N/R

W02 Kindness - Kind people who care about you: 1 95.0% 100.0% 101.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% N/R

W03 Listen and Involve – Full involvement in your care: 1 80.0% 100.0% 103.2% 107.1% 100.0% 100.0% 100.0% 118.2% 300.0% 100.0% 100.0% 100.0% N/R

W04 Listen and involve- Family carer involvement: 1 70.0% 100.0% 100.0% 100.0% 105.3% 100.0% 100.0% 103.1% 100.0% 100.0% 100.0% 100.0% N/R

W05 Professional - Reassurance and safety: 1 80.0% 106.5% 116.7% 133.3% 100.0% 100.0% 100.0% 136.4% 140.0% 100.0% 100.0% 120.0% N/R

W06 Efficient – An organised and efficient service 1 50.0% 106.4% 101.5% 106.7% 106.3% 100.0% 100.0% 123.5% 105.6% 100.0% 118.2% 117.2% N/R

W07 Response rate - inpatients 2 30.0% 56.3% 44.5% 33.3% 31.4% 46.3% 44.8% 36.0% 39.0% 66.7% 35.4% 39.2% 51.0%

W14 Extremely Unlikely Response 1 0 0 0 0 0 0 0 1 0 0 0 0 0

W35 Ward Staff Turnover 1 0.0% 8.6% 3.0% -3.1% -2.5% 0.0% 0.0% 0.0% 8.8% -2.6% 3.0% 5.0%

W36 Monthly Ward actual staffing versus planned (Reported One Month

in Arrears)

1 90.0% 97.9% 96.2% 93.0% 93.6% 93.9% 93.5% N/S 93.6% 94.2% 92.3% 95.2% 96.6%

S01 Cleaning audit score 1 95.0% 98.0% 100.0% 97.9% 100.0% 100.0% 100.0% 100.0% 95.8% 91.7% 97.9% 93.9% 100.0%

S03 Clinical equipment cleaning 1 95.0% 100.0% 100.0% 100.0% 97.3% 100.0% 94.6% 100.0% 97.1% 100.0% 100.0% 97.3% 100.0%

S04 Hand Hygiene compliance 1 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 100.0% 100.0%

S05 MRSA Bacteraemia: Hospital 2 0 0 0 0 0 0 0 0 0 0 0 0 0

S06 MSSA Bacteraemia: Hospital 2 0 0 0 0 0 0 0 0 0 0 0 0 0

S07 MRSA decolonisation 1 95.0% 100.0% N/R 100.0% 100.0% 88.9% N/R 73.3% N/R N/R N/R N/R N/R

S08 C.Diff Infection: Hospital 2 0 0 0 0 0 0 0 0 0 0 0 2 0

S09 Never Events 5 0 0 0 0 0 0 0 0 0 0 0 0 0

S10 Patient falls (total) at Ward level (variable targets) 2 Var 10 7 2 5 3 6 9 1 6 10 6 10

S11 Patient falls (high harm or death) 2 0 0 0 0 0 0 0 0 0 0 0 0 0

S12 Avoidable Pressure Ulcers - grade 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0



S16 SIRIs 3 0 0 0 0 0 0 0 0 0 0 0 1 0

S17 Safety Thermometer 2 95.0% 95.2% 92.6% 100.0% 100.0% 100.0% 96.3% 96.6% 96.4% 100.0% 89.3% 92.9% 78.6%

S18 High Harm Medication Errors 5 0 0 0 0 0 0 0 0 0 0 0 0 0

S20 Number of Avoidable Cardiac Arrests 2 0 0 0 0 1 0 0 0 0 0 0 0 0

S23 MEWS documentation and escalation audit 1 90.0% N/R 100.0% N/R 25.0% N/R 100.0% 100.0% 100.0% N/R 100.0% 100.0% N/R

S25 Nutrition assessment 1 95.0% 86.7% 92.6% 95.7% 95.8% 100.0% 92.6% 96.4% 89.3% 100.0% 96.4% 78.6% 96.4%

S26 Nutrition re-assessment in 7 days 1 60.0% 100.0% 100.0% 104.5% 95.8% 96.3% 96.3% 96.4% 100.0% 100.0% 100.0% 100.0% 100.0%

S27 High risk patients (MUST score>2) referred to dietician 1 80.0% 100.0% 100.0% 91.3% 91.7% 100.0% 88.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

S30 VTE completed Risk assessment 2 98.0% 86.3% N/S 91.2% 92.3% 95.3% 92.3% 89.6% 98.7% 87.8% 93.9% 94.2% 98.6%

S31 VTE Prophylaxis compliance 2 95.0% 100.0% N/S 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Total Maximum Weighted Score 62 62 62 62 62 62 62 62 62 62 62 62

Total Failed Indicators Score 7 9 2 7 3 4 7 1 3 7 13 4

Monthly Failed Percentage Performance 11.3% 14.5% 3.2% 11.3% 4.8% 6.5% 11.3% 1.6% 4.8% 11.3% 21.0% 6.5%

Ward Score 4 4 5 4 5 4 4 5 5 4 3 4

Ward HeatMap for February: Medicine and Therapies

Caring

Well-Led

Safe

Scores

Quality – Heatmap Division Two

18

Highlights

• CCU and Stradbroke performance has improved from January.

• Lavenham’s performance has dropped from last month and Needham has been rated 3 for 2 consecutive months.

Assurance

• Common themes of poor performance against expected targets will be discussed at the monthly accountability meeting.


4 4 3 4 4 4 4 4 3 4

4 2 3 3 5 4 3 4 4 3

4 4 4 4 4 4 3 4 4 4

3 3 3 3 3 4 4 4 3 3

2 3 4 3 3 5 4 4 4 4

3 3 4 4 4 4 3 4 4 4

3 3 3 4 3 4 4 4 3 4

Percentage

Fail Score

Quality

Score

0 - <5% 5

5 - <15% 4

15 - <30% 3

30 - <50% 2

50%+ 1

Good


Inadequate

Inadequate

Stowupland Ward 3

Stradbroke Ward 3

CQC Rating

Outstanding

Martlesham Ward 4

Needham Ward 3

Saxmundham Ward 3


Surgery

Ward Name Apr

Critical Care Unit 3

Lavenham Ward 3

Quality – Heatmap Division Two

19

Domain ID Indicator Weight Target CCU LAV MART NEED SAX STO STRA

C01 % Recommending - inpatients 2 90.0% 100.0% 95.2% 100.0% 97.6% 92.9% 100.0% 93.3%

C08 Mixed Sex Accommodation Breaches 4 0 0 0 0 0 0 0 0

W01 Respect - A cheerful, friendly welcome 1 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

W02 Kindness - Kind people who care about you: 1 95.0% 100.0% 100.0% 101.8% 100.0% 100.0% 100.0% 100.0%

W03 Listen and Involve – Full involvement in your care: 1 80.0% 100.0% 130.0% 102.0% 100.0% 100.0% 100.0% 100.0%

W04 Listen and involve- Family carer involvement: 1 70.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

W05 Professional - Reassurance and safety: 1 80.0% 100.0% 110.0% 118.5% 100.0% 100.0% 109.4% 150.0%

W06 Efficient – An organised and efficient service 1 50.0% 100.0% 137.5% 108.9% 133.3% 116.7% 105.2% 133.3%

W07 Response rate - inpatients 2 30.0% 80.0% 88.1% 26.8% 22.2% 51.9% 41.5% 44.8%

W14 Extremely Unlikely Response 1 0 0 0 0 0 0 0 0

W35 Ward Staff Turnover 1 4.7% -5.8% 0.0% 3.1% -2.4% 0.0% -6.3%


in Arrears)

1 90.0% 92.2% 93.1% 95.9% 97.6% 97.3% 93.6% 93.4%

S01 Cleaning audit score 1 95.0% 95.3% 95.9% 98.0% 95.9% 100.0% 93.8% 97.9%

S03 Clinical equipment cleaning 1 95.0% 100.0% 100.0% 100.0% 92.1% 100.0% 100.0% 97.2%

S04 Hand Hygiene compliance 1 100.0% 100.0% 100.0% 100.0% 90.0% 100.0% 100.0% 100.0%

S05 MRSA Bacteraemia: Hospital 2 0 0 0 0 0 0 0 0

S06 MSSA Bacteraemia: Hospital 2 0 0 0 0 0 0 0 0

S07 MRSA decolonisation 1 95.0% N/R 87.5% N/R 100.0% 53.3% N/R 100.0%

S08 C.Diff Infection: Hospital 2 0 0 0 0 0 0 0 1

S09 Never Events 5 0 0 0 0 0 0 0 0

S10 Patient falls (total) at Ward level (variable targets) 2 Var 0 12 1 2 10 1 2

S11 Patient falls (high harm or death) 2 0 0 0 0 0 0 0 0

S12 Avoidable Pressure Ulcers - grade 2 2 0 0 0 0 0 0 0 0



S16 SIRIs 3 0 0 1 0 0 0 0 0

S17 Safety Thermometer 2 95.0% 87.5% 89.7% 100.0% 95.7% 92.0% 95.5% 100.0%

S18 High Harm Medication Errors 5 0 0 0 0 0 0 0 0

S20 Number of Avoidable Cardiac Arrests 2 0 N/A 0 0 1 0 0 0

S23 MEWS documentation and escalation audit 1 90.0% N/A 100.0% N/R 100.0% 100.0% N/R N/R

S25 Nutrition assessment 1 95.0% 100.0% 84.6% 100.0% 68.0% 100.0% 100.0% 100.0%

S26 Nutrition re-assessment in 7 days 1 60.0% 100.0% 100.0% 100.0% 54.2% 100.0% 100.0% 100.0%

S27 High risk patients (MUST score>2) referred to dietician 1 80.0% 100.0% 100.0% 100.0% 84.0% 77.3% 100.0% 100.0%

S30 VTE completed Risk assessment 2 98.0% 88.9% 81.1% 93.4% 87.9% 94.4% 86.6% 90.1%

S31 VTE Prophylaxis compliance 2 95.0% 100.0% 90.9% 100.0% 100.0% 100.0% 93.5% 100.0%

Total Maximum Weighted Score 59 62 62 62 62 62 62

Total Failed Indicators Score 4 13 4 10 8 5 4

Monthly Failed Percentage Performance 6.8% 21.0% 6.5% 16.1% 12.9% 8.1% 6.5%

Ward Score 4 3 4 3 4 4 4

Ward HeatMap for February: Surgery

Caring

Well-Led

Safe

Scores

Quality – Heatmap Division Three

20

Highlights

• Deben’s performance has picked up again in February

• Somersham has seen a sustained improvement for the last 3 months

Assurance

• Further midwifery and child specific metrics need to be developed to ensure the metrics accurately report a good service.


4 2 4 5 4 3 5 4 4 4

3 3 4 4 4 4 5 4 4 4

2 3 4 4 4 4 4 4 3 4

4 3 3 5 5 4 5 5 5 5

3 3 3 4 4 4 4 3 4 4

2 3 3 3 4 3 3 4 4 4

3 3 3 3 3 4 5 5 4 5

Percentage

Fail Score

Quality

Score

0 - <5% 5

5 - <15% 4

15 - <30% 3

30 - <50% 2

50%+ 1

Good


Inadequate

Inadequate

Somersham Ward 3

Stour Gynae Centre 3

CQC Rating

Outstanding

Deben Ward 3

Framlingham Wards 2

Orwell Ward 3


Women, Children and Cancer

Ward Name Apr

Bergholt Ward 3

Brook Ward 3


21

Domain ID Indicator Weight Target BERG BROO DEBE FRAM ORWE SC SOME

C01 % Recommending - inpatients 2 90.0% 98.6% N/A N/A N/A N/A 98.0% 92.0%

C05 % Recommending - birth 1 90.0% 100.0% 100.0% N/S

C06 % Recommending - post natal ward 1 90.0% 100.0% N/A 91.2%

C08 Mixed Sex Accommodation Breaches 4 0 N/A 0 0 N/A 0 0 0

W01 Respect - A cheerful, friendly welcome 1 95.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W02 Kindness - Kind people who care about you: 1 95.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W03 Listen and Involve – Full involvement in your care: 1 80.0% N/A N/A N/A N/A N/A 101.5% 116.7%

W04 Listen and involve- Family carer involvement: 1 70.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W05 Professional - Reassurance and safety: 1 80.0% N/A N/A N/A N/A N/A 128.6% N/R

W06 Efficient – An organised and efficient service 1 50.0% N/A N/A N/A N/A N/A 102.2% N/R

W07 Response rate - inpatients 2 30.0% 25.8% N/A N/A N/A N/A 33.8% 27.5%


W35 Ward Staff Turnover 1 0.0% 0.0% 3.5% -1.7% -2.6% 2.8% -5.3%


in Arrears)

1 90.0% 94.5% 94.4% 98.5% 95.2% 99.6% 92.8% 98.0%






S07 MRSA decolonisation 1 95.0% N/R N/R N/R 100.0% N/R N/R N/R


S09 Never Events 5 0 0 0 0 0 0 0 0

S10 Patient falls (total) at Ward level (variable targets) 2 Var N/A 0 0 N/A 0 0 1

S11 Patient falls (high harm or death) 2 0 N/A 0 0 N/A 0 0 0




S16 SIRIs 3 0 0 0 0 0 0 0 0

S17 Safety Thermometer 2 95.0% N/A 100.0% 100.0% N/A 100.0% 100.0% 100.0%


S20 Number of Avoidable Cardiac Arrests 2 0 0 0 0 0 0 0 0

S23 MEWS documentation and escalation audit 1 90.0% N/S N/S N/S N/A N/S N/R 100.0%

S25 Nutrition assessment 1 95.0% N/A N/A N/A N/A N/A 100.0% 87.0%

S26 Nutrition re-assessment in 7 days 1 60.0% N/A N/A N/A N/A N/A 100.0% 91.3%

S27 High risk patients (MUST score>2) referred to dietician 1 80.0% N/A N/A N/A N/A N/A 100.0% 91.3%

S30 VTE completed Risk assessment 2 98.0% N/A 87.3% 92.3% N/A 96.3% N/R 88.7%

S31 VTE Prophylaxis compliance 2 95.0% N/A 100.0% N/R N/A 100.0% N/R 100.0%




Ward Score 4 4 4 5 4 5 4

Ward HeatMap for February: Women, Children and Cancer

Caring

Well-Led

Safe

Scores


22

Highlights

Assurance

• Further midwifery and child specific metrics need to be developed to ensure the metrics accurately report a good service.

• Orwell performance will be reviewed at Division 3 accountability meeting.


4 2 4 5 4 3 5 4 4 4

3 3 4 4 4 4 5 4 4 4

2 3 4 4 4 4 4 4 3 4

4 3 3 5 5 4 5 5 5 5

3 3 3 4 4 4 4 3 4 4

2 3 3 3 4 3 3 4 4 4

3 3 3 3 3 4 5 5 4 5

Percentage

Fail Score

Quality

Score

0 - <5% 5

5 - <15% 4

15 - <30% 3

30 - <50% 2

50%+ 1

Good


Inadequate

Inadequate

Somersham Ward 3

Stour Gynae Centre 3

CQC Rating

Outstanding

Deben Ward 3

Framlingham Wards 2

Orwell Ward 3


Women, Children and Cancer

Ward Name Apr

Bergholt Ward 3

Brook Ward 3


23

Domain ID Indicator Weight Target BERG BROO DEBE FRAM ORWE SC SOME

C01 % Recommending - inpatients 2 90.0% 98.6% N/A N/A N/A N/A 98.0% 92.0%

C05 % Recommending - birth 1 90.0% 100.0% 100.0% N/S

C06 % Recommending - post natal ward 1 90.0% 100.0% N/A 91.2%

C08 Mixed Sex Accommodation Breaches 4 0 N/A 0 0 N/A 0 0 0

W01 Respect - A cheerful, friendly welcome 1 95.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W02 Kindness - Kind people who care about you: 1 95.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W03 Listen and Involve – Full involvement in your care: 1 80.0% N/A N/A N/A N/A N/A 101.5% 116.7%

W04 Listen and involve- Family carer involvement: 1 70.0% N/A N/A N/A N/A N/A 100.0% 100.0%

W05 Professional - Reassurance and safety: 1 80.0% N/A N/A N/A N/A N/A 128.6% N/R

W06 Efficient – An organised and efficient service 1 50.0% N/A N/A N/A N/A N/A 102.2% N/R

W07 Response rate - inpatients 2 30.0% 25.8% N/A N/A N/A N/A 33.8% 27.5%


W35 Ward Staff Turnover 1 0.0% 0.0% 3.5% -1.7% -2.6% 2.8% -5.3%


in Arrears)

1 90.0% 94.5% 94.4% 98.5% 95.2% 99.6% 92.8% 98.0%






S07 MRSA decolonisation 1 95.0% N/R N/R N/R 100.0% N/R N/R N/R


S09 Never Events 5 0 0 0 0 0 0 0 0

S10 Patient falls (total) at Ward level (variable targets) 2 Var N/A 0 0 N/A 0 0 1

S11 Patient falls (high harm or death) 2 0 N/A 0 0 N/A 0 0 0




S16 SIRIs 3 0 0 0 0 0 0 0 0

S17 Safety Thermometer 2 95.0% N/A 100.0% 100.0% N/A 100.0% 100.0% 100.0%


S20 Number of Avoidable Cardiac Arrests 2 0 0 0 0 0 0 0 0

S23 MEWS documentation and escalation audit 1 90.0% N/S N/S N/S N/A N/S N/R 100.0%

S25 Nutrition assessment 1 95.0% N/A N/A N/A N/A N/A 100.0% 87.0%

S26 Nutrition re-assessment in 7 days 1 60.0% N/A N/A N/A N/A N/A 100.0% 91.3%

S27 High risk patients (MUST score>2) referred to dietician 1 80.0% N/A N/A N/A N/A N/A 100.0% 91.3%

S30 VTE completed Risk assessment 2 98.0% N/A 87.3% 92.3% N/A 96.3% N/R 88.7%

S31 VTE Prophylaxis compliance 2 95.0% N/A 100.0% N/R N/A 100.0% N/R 100.0%




Ward Score 4 4 4 5 4 5 4

Ward HeatMap for February: Women, Children and Cancer

Caring

Well-Led

Safe

Scores

Finance

24

Subject

Purpose

Responsible

Executive

Author of

attached report 2015/16 initial plan is a deficit of £19.8m, revised plan submitted of £18.5m deficit

Financial Risk rating is 1

Month 11 YTD I&E position is a favourable variance of £1.2m to plan, £22.8m YTD deficit

Clinical Income of £214.2m is £1.3m above plan

YTD Operating expenditure of £250.1m is £8.1m in excess of plan

YTD EBITDA adjusted is (£9.4m), which is £5.5m behind 15/16 plan

Risk Evaluation The Trust Cash balance is £0.6m at the end of Month 11

PMO Review of Risk Profile & CIP delivery with Trust Executive

Project Manager to develop Carter principles action in place

Monitoring of FRP by Executive with formal reviews with Divisions if >£50k variance

Agreement on 15/16 contract reached with CCG, removes contracual risk and improves cash

position

Paper Seen By

Report to the Finance & Performance Committee for the Period Ended 29 February 2016

Management

Actions

Finance Report

Report on key financial indicators for the Month of February 2016

Director of Finance and Performance

Simon Rudkins, Deputy Director of Finance

25

Summary Statement of Comprehensive IncomeFor the Period Ended 29th February 2016

Figures £000's

Actual

£000

Plan

£000

Variance

£000

Actual

£000

Plan

£000

Variance

£000

Plan

£000

NHS Clinical income 20,161 19,020 1,141 214,244 212,898 1,346 232,985

Non-NHS Clinical Income 220 134 86 2,001 1,494 507 1,623

Research & Training 831 826 6 8,903 8,842 61 9,609

Other Operating Income 2,122 1,499 623 18,451 14,744 3,708 16,007

Total income 23,333 21,478 1,855 243,600 237,978 5,622 260,224

Pay (13,588) (13,936) 348 (149,142) (148,170) (972) (162,386)

Non-pay (9,491) (8,522) (969) (100,937) (93,745) (7,192) (102,157)

Total expenses (23,079) (22,458) (621) (250,078) (241,915) (8,164) (264,544)

EBITDA 254 (980) 1,234 (6,479) (3,937) (2,542) (4,319)

EBITDA % 1.1% -4.6% -2.7% -1.7%

Loss on Disposal - - - 1 - 1 -

Depreciation (806) (784) (22) (8,688) (8,622) (66) (9,406)

PDC Dividend (195) (263) 68 (2,702) (2,896) 195 (3,160)

Interest receivable 2 2 (0) 23 24 (1) 27

Interest payable (210) (157) (53) (2,180) (1,782) (397) (1,944)

Retained surplus/(deficit) (955) (2,182) 1,227 (20,023) (17,213) (2,810) (18,802)

Recharges (Internal) - - - - - - -

Donated Asset income (13) - (13) (2,968) - (2,968) - Donated Asset Depreciation 18 24 (6) 196 265 (70) 289 Impairments - 1 (1) 12 8 3 9

Normalised surplus/(deficit) (950) (2,157) 1,207 (22,784) (16,939) (5,845) (18,504)

In Month Year to Date Full Year

26

Financial Plan 2015/16 profile

The original split between Income, Pay and Non-pay is shown above; as CIPs are delivered (CIP target initially sits within non-pay), this alters the live budget split

ie - if an income-related CIP scheme is delivered, an income budget is created and a corresponding reduction in the CIP target within non-pay is made

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 TOTAL

Income 20,445 20,512 19,768 21,295 19,648 20,386 21,292 20,614 20,371 20,564 19,228 20,237 244,360

Pay (12,953) (12,800) (12,801) (12,819) (12,852) (12,873) (12,898) (12,912) (12,922) (12,936) (12,946) (13,149) (154,861)

Non-Pay (9,835) (9,404) (9,222) (9,444) (9,048) (9,072) (8,777) (8,606) (8,894) (8,600) (8,428) (8,676) (108,002)

Total (2,343) (1,692) (2,255) (968) (2,251) (1,558) (383) (904) (1,445) (972) (2,147) (1,587) (18,504)

(3,500)

(3,000)

(2,500)

(2,000)

(1,500)

(1,000)

(500)

0

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

2015/16 Financial Plan Profile

Plan Actual

27

Summary Risks and OpportunitiesFor the Period Ended 29th February 2016

YTD FOT

Ref Risk/Opportunity Plan Risk

£3.5m

M11 YTD

Risk £m

FOT

Risk £m

SRO Likely

2015/16 Financial Plan (16.9) (19.8) (19.8)

RM1 FYE CIP is not fully delivered 0.0 0.0 0.0 COO 0.0

RM2 CYE CIP is not fully delivered (1.0) (1.1) (0.8) COO (0.8)

RM3 QIPP schemes reduce elective (0.2) 0.0 0.0 COO 0.0

RM4 Aggressive contract management (0.2) (6.0) (6.0) DoF (6.0)

RM5 NEL Activity is higher than planned (0.4) (2.0) (2.3) COO (2.3)

RM6 Division 2 continues to encounter problems with consistency and focus in clinical services. (0.4) (1.0) (0.6) HRD (0.6)

RM7 Historical culture of not delivering financial targets in clinical divisions (0.8) (1.3) (0.4) COO (0.4)

RM8 Developing new models of care and preparing to implement strategy require financial investment (0.3) 0.0 0.0 DoF 0.0

RM9 Non recurrent benefits in Divisional budgets 0.3 0.0 0.0 COO 0.0

RM10 Non recurrent income outside of contract 0.2 0.0 0.0 COO 0.0

RM11 CQUIN may not deliver as planned (0.4) 0.0 (0.2) COO (0.2)

RM12 Junior Doctor Cover Division (0.3) 0.0 (0.1) COO (0.1)

RM13 Repatriation of cardiac work (0.1) 0.0 0.0 COO 0.0

RM14 TPP (1.1) (2.0) (2.3) COO (2.3)

RM15 CQC (0.1) 0.0 0.0 COO 0.0

RM16 Winter Pressure impact; loss of elective, provision at higher cost 0.0 0.0 (1.0) COO (1.0)

RM17 Community JV contract 0.0 0.0 0.0 DoF 0.0

O1 Non-recurrent mitigations - contract agreement 1.3 5.3 5.1 DoF 5.1

Total Risks identified at budget setting (3.5) (8.1) (8.6) (8.6)

Contingency Released 3.5 2.2 2.2 2.2

Total Variance to Plan before opportunities - (5.9) (6.4) (6.4)

Total Financial Position - (22.8) (26.2) (26.2) (A)

O1 Non-recurrent mitigations 0.0 0.0 0.0 DoF 50% 0.0

O2 CYE CIP is fully delivered 0.0 0.0 0.8 COO 100% 0.8

O3 CYE CIP Over-delivery stretch 0.0 0.0 0.0 COO 0% 0.0

O4 TPP Technical 0.0 0.0 2.3 DoF 100% 2.3

O5 Agency Cap 0.0 0.0 0.3 COO 100% 0.3

O6 Lord Carter review - phasing into 2016/17 0.0 0.0 0.0 DoF 50% 0.0

O7 Winter planning to mitigate risk - in lead commissioner agreement 0.0 0.0 0.0 COO 100% 0.0

O8 Aggressive contract management 0.0 0.0 0.0 COO 100% 0.0

O9 Utilise Capital to revenue transfer 0.0 0.0 0.8 100% 0.8

Total Opportunities - - 4.2 4.2

Total Variance to Plan after opportunities (22.8) (22.1) (22.1)

(B) (C)

28

Divisional PerformanceIHT DIV Month 11 YTD

Actual Plan Variance Actual Plan Variance M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Div1 436 167 268 4,995 7,307 (2,312) (69) (498) (341) (142) (272) (113) (596) (438) (424) (406) 268 (2,312)

Div2 1,231 1,083 148 13,259 14,800 (1,542) (69) (260) 98 13 (331) (73) (440) (301) 89 (417) 148 (1,542)

Div3 450 387 63 5,385 6,531 (1,146) (158) (224) 49 393 (325) (120) (106) (109) 49 62 63 (1,146)

Div4 (3,061) (3,787) 726 (46,553) (45,586) (967) 304 977 201 (750) 338 (114) (445) (196) (1,406) (602) 726 (967)

Community (6) (8) 3 130 8 122 - - - - - - (10) (23) 36 117 3 122

(950) (2,157) 1,207 (22,784) (16,939) (5,845) 8 (5) 7 (486) (589) (421) (1,599) (1,067) (1,656) (1,246) 1,207 0 (5,845)

IHT TOTAL Month 11 YTDActual Plan Variance Actual Plan Variance M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Income 23,320 21,478 1,842 240,632 237,978 2,654 373 (149) 886 502 56 355 (468) 248 (431) (561) 1,842 2,654

Pay (13,588) (13,936) 348 (149,142) (148,170) (972) (234) (4) (607) (486) (133) (99) (96) (14) 343 12 348 (972)

Non-Pay (9,491) (8,520) (970) (100,937) (94,746) (6,191) 66 257 (208) (363) (194) (652) (788) (987) (1,367) (984) (970) (6,191)

CIP 0 (1) 1 0 1,001 (1,001) (173) (84) (37) (131) (261) 11 (204) (325) (144) 347 1 (1,001)

Financing (1,191) (1,177) (14) (13,337) (13,002) (334) (23) (24) (26) (7) (57) (36) (43) 13 (57) (60) (14) (334)

(950) (2,157) 1,207 (22,784) (16,939) (5,845) 8 (5) 7 (486) (589) (421) (1,599) (1,067) (1,656) (1,246) 1,207 0 (5,845)

Div1 Month 11 YTDActual Plan Variance Actual Plan Variance M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Income 5,962 5,471 491 66,057 64,346 1,710 363 (12) 283 (185) 63 254 (78) 182 (37) 7 491 1,710

Pay (3,983) (4,075) 91 (45,251) (44,080) (1,171) (171) (149) (309) (209) (54) (103) (148) (98) 160 (205) 91 (1,171)

Non-Pay (1,543) (1,237) (307) (15,811) (13,667) (2,143) 4 (132) (205) 38 (123) (225) (265) (384) (500) (218) (307) (2,143)

CIP 0 8 (8) 0 709 (709) (267) (205) (112) 213 (159) (40) (106) (139) (47) 10 (8) (709)

Financing 0 0 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0

436 167 268 4,995 7,307 (2,312) (69) (498) (341) (142) (272) (113) (596) (438) (424) (406) 268 0 (2,312)


Income 7,971 7,461 510 87,232 85,242 1,990 143 (102) 514 288 (20) 81 154 260 327 (165) 510 1,990

Pay (4,564) (4,566) 1 (50,542) (49,510) (1,031) (113) 106 (203) (269) (99) (125) (138) (128) (23) (40) 1 (1,031)

Non-Pay (2,175) (1,801) (375) (23,431) (20,926) (2,505) 2 (167) (125) (294) (175) (8) (499) (437) (224) (206) (375) (2,505)

CIP 0 (12) 12 0 (5) 5 (101) (97) (88) 287 (36) (22) 43 4 9 (6) 12 5

Financing 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1,231 1,083 148 13,259 14,800 (1,542) (69) (260) 98 13 (331) (73) (440) (301) 89 (417) 148 0 (1,542)


Income 5,593 5,656 (63) 63,376 64,474 (1,097) (268) (133) 191 131 (248) 181 (244) (108) 58 (215) (63) (1,097)

Pay (3,040) (3,150) 110 (33,485) (34,266) 781 101 13 (25) 83 39 (6) 106 130 153 104 110 781

Non-Pay (2,090) (2,196) 106 (24,358) (23,863) (495) 133 13 8 (109) (46) (218) 77 (30) (178) (79) 106 (495)

CIP 0 92 (92) 0 347 (347) (122) (118) (124) 288 (71) (77) (45) (101) 16 251 (92) (347)

Financing (13) (15) 1 (148) (161) 13 (1) 0 0 0 0 0 0 0 1 1 1 13

450 387 63 5,385 6,531 (1,146) (158) (224) 49 393 (325) (120) (106) (109) 49 62 63 0 (1,146)

Div4 & Reserves Month 11 YTDActual Plan Variance Actual Plan Variance M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Income 2,824 1,944 880 19,169 19,136 33 135 98 (102) 268 261 (160) (342) 71 (874) (201) 880 33

Pay (1,358) (1,505) 147 (16,849) (17,112) 263 (51) 26 (69) (91) (19) 135 1 105 50 28 147 263

Non-Pay (3,349) (2,973) (376) (35,684) (34,719) (965) (73) 542 114 1 149 (202) 35 (293) (402) (461) (376) (965)

CIP 0 (90) 90 0 (50) 50 317 336 285 (919) 6 150 (96) (90) (121) 93 90 50

Financing (1,178) (1,162) (15) (13,189) (12,841) (348) (23) (26) (27) (9) (59) (37) (44) 11 (58) (61) (15) (348)

(3,061) (3,787) 726 (46,553) (45,586) (967) 304 977 201 (750) 338 (114) (445) (196) (1,406) (602) 726 0 (967)

Community Month 11 YTDActual Plan Variance Actual Plan Variance M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Income 970 946 24 4,799 4,781 18 - - - - - - 42 (157) 96 13 24 18

Pay (643) (640) (2) (3,016) (3,202) 186 - - - - - - 83 (23) 3 125 (2) 186

Non-Pay (333) (314) (19) (1,653) (1,570) (82) - - - - - - (135) 156 (63) (21) (19) (82)

CIP 0 0 0 0 0 0 - - - - - - 0 0 0 0 0 0

Financing 0 0 0 0 0 0 - - - - - - 0 0 0 0 0 0

(6) (8) 3 130 8 122 - - - - - - (10) (23) 36 117 3 0 122

29

Summary Statement of Financial PositionFor the Period Ended 29th February 2016

Figures £000's

Opening

Actual

£000

Plan

£000Var

Actual

£000

Plan

£000

Variance

£000

Revised

Fixed assets 134,320 135,024 135,074 (50) 137,666 137,566 100

Stock 4,153 4,134 3,749 385 4,151 3,751 400

Debtors 13,417 19,122 12,464 6,658 12,856 12,856 -

Cash 8,539 114 1,385 (1,271) 1,000 1,300 (300)

Current l iabilities (24,581) (33,686) (21,462) (12,224) (31,388) (23,921) (7,467)

Net Current Assets 1,528 (10,316) (3,864) (6,452) (13,381) (6,014) (7,367)

Creditors > 1 yr (25,762) (42,667) (23,863) (18,804) (41,923) (23,799) (18,124)

Provisions (1,125) (1,180) (1,455) 275 (1,197) (1,470) 273

Net Assets 108,961 80,861 105,892 (25,031) 81,165 106,283 (25,118)

Public Dividend Capital 86,030 92,719 110,420 (17,701) 92,719 111,973 (19,254)

Revaluation Reserve 33,735 27,702 28,924 (1,222) 27,923 28,924 (1,001)

I&E reserve (10,804) (39,560) (33,452) (6,108) (39,477) (34,614) (4,863)

Taxpayers Equity 108,961 80,861 105,892 (25,031) 81,165 106,283 (25,118)

Year to Date Forecast

The Trust is funding its deficit through loan finance (within creditors > 1 year). The plan anticipated the issue of PDC for thispurpose.

30

Summary Cash Flow StatementFOR THE 11 MONTH PERIOD ENDED 29 FEBRUARY 2016

Forecast

Actual

£000

Plan

£000

Variance

£000

Actual

£000

Plan

£000

Variance

£000

March

£000

Income

SLA Contract NHS Income 21,142 17,530 3,612 209,863 194,193 15,670 18,333

TDA Income - - - - - -

Clinical NHS Income 1,968 926 1,042 17,199 10,888 6,311 1,780

Clinical Non-NHS Income (Paying Patients, Overseas Visitors) 49 62 (13) 730 679 51 63

Research & Training Income 2,570 846 1,724 8,096 9,573 (1,477) 866

Other Operating Income 1,059 1,050 9 15,734 16,652 (918) 1,632

PDC Capital & Loans 426 - 426 35,074 13,300 21,774 1,300

Operating Income 27,214 20,414 6,800 286,696 245,286 41,411 23,974

Expenditure

Employee Benefits (inc Agency) (13,713) (12,748) (965) (143,324) (140,105) (3,219) (13,658)

Other non pay - (exc Agency) (11,724) (9,614) (2,110) (112,338) (97,278) (15,060) (7,023)

Loans & Leases (65) (61) (4) (18,678) (671) (18,007) (142)

Interest & Dividends (139) (170) 31 (2,946) (3,444) 498 (1,721)

Capital expenditure (1,195) (1,722) 527 (9,014) (12,073) 3,059 (1,000)

Operating Expenses (26,836) (24,315) (2,521) (286,300) (253,571) (32,729) (23,544)

Net Operating inflow/(outflow) 378 (3,901) 4,279 396 (8,285) 8,682 430

Opening months's cash balance 192 192 - 174 174 - 570

Closing month's cash balance 570 (3,709) 4,279 570 (8,111) 8,682 1,000

Cash in Transit/Petty Cash (456) n/a n/a (456) n/a n/a

Cash held on Ledger 114 (3,709) 3,823 114 (8,111) 8,226

Month - February 2016 YTD

0

5

10

15

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

£m's

Cash at Bank - Ledger Balance

Cash at Bank 2015/16 Cash at Bank 2014/15

Commentary

Plan figures are as per submitted to TDA on 22nd April 2015

Forecast figures are the revised forecast figures as at 29th February 2016

MonthThe cash position is favourable to plan for February by £4.3m, mainly due to the following:

- Increase in SLA Contract income due to increase in tariffs for 15/16 & receipt of Overperformance income for 14/15 & up to Month 10 15/16- Increase in Clinical Income due to receipt of funding for Suffolk Community Healthcare of £0.8m - Receipt of Health Education England income of £2.6m in month for payment of M9-11 due to dispute on

contract figures- Lower than expected Capital Expenditure during the month of £0.5m

YTDThe cash position YTD to February 2016 is favourable by £8.7m. The increase in income for SLA contracts (incl Community), Overperformance and the Loan drawdown has been offset by an increase in Pay & Non Pay costs and the repayment of the £17.3m Loan in January.

Cash in Transit/Petty Cash- £4k Petty Cash- £460k Outstanding cheques/Cash in Transit/Unallocated payments

We have increased our Loan Facil iity from £13.3m to £17.3m in 2015/16 and all of this has been util ised now. In January, the Working Capital Facility was replaced with a Loan and this is reflected in the Loan Income and Loan

repayment l ines above, the impact in January being zero.

31

Summary Capital ExpenditureFor the Period Ended 29th February 2016

Figures £000's Actual

£000

Plan

£000

Variance

£000

Actual

£000

Plan

£000

Variance

£000

Strategic schemes 631 534 97 4,383 4,778 (395)

Other schemes 617 606 11 4,834 7,501 (2,667)

Total Capital Programme (exc donated assets) 1,248 1,140 108 9,217 12,279 (3,062) Donated Assets (13) (285) 272 (2,968) (3,753) 785

Total Capital Programme (Inc donated assets) 1,235 855 380 6,249 8,526 (2,277)

Asset disposals - - - - - -

Net capital expenditure 1,235 855 380 6,249 8,526 (2,277)

Month YTD

WMC costs continue to progress. Macmillan contributions to WMC have been bil led regularly to Month 11 and the Trust has invoiced £1.915m to date. Medical Equipment expenditure at Month 11 is almost complete for the year. Expenditure for the Estates programme is sti l l

behind plan but is due to spike in Month 12 as several projects near completion. Overall IT expenditure is due to meet expectedoutturn figures.£2,250k of committed expenditure relating to the 15/16 plan is not included in the Actuals above, which should be realised asActual spend / receipts in Month 12.

Revisions to the 15/16 Capital Programme has allowed the Trust to accommodate the Bridge School planned purchase & the financial lease of Switchgear in relation to Bio Fuels.

32

Cost ImprovementFor the Period Ended 29th February 2016

33

NHS Clinical Income - Contract PerformanceFor the Period Ended 29th February 2016

Activity

Actual

no.

Plan

no.

Var

no.

Actual

no.

Plan

no.

Var

no.%

Elective Day Cases 3,630 3,077 553 39,385 35,835 3,550 9.9%

Elective Inpatients 614 605 9 6,604 6,739 (135) -2.0%

Outpatients 30,340 27,705 2,635 339,912 323,672 16,240 5.0%

Non Elective 2,965 2,524 441 31,188 29,093 2,095 7.2%

Maternity Episodes 372 301 71 3,810 3,573 237 6.6%

Accident & Emergency 6,763 5,734 1,029 77,455 75,729 1,726 2.3%

Total 44,684 39,946 4,738 498,354 474,641 23,713 5.0%

Income

Actual

£000

Plan

£000

Var

£000

Actual

£000

Plan

£000

Var

£000%

CCG 15,324 14,493 831 171,790 169,631 2,159 1.3%

NHSE 2,950 2,832 117 35,232 33,282 1,950 5.9%

Other 1,887 1,694 193 7,223 9,985 (2,762) -27.7%

Total 20,161 19,020 1,141 214,244 212,898 1,346 0.6%

Price variance 451 476 (1,115) 430 1,346

Volume variance 2,256 -

Total variance 1,141 1,346

Month YTD

34

NHS Clinical Income - Contract PerformanceFor the Period Ended 29th February 2016

Finance

Figures £000's

Actual Budget Var Actual Budget Var %

Elective Day Cases DC 2,365 2,173 192 25,646 24,873 773 3.1%

Elective Inpatients EL 1,747 1,833 (87) 19,129 20,125 (996) -5.0%

Outpatients OP 3,299 3,117 182 36,361 35,861 499 1.4%

Non Elective NEL 4,798 4,455 343 53,193 52,129 1,064 2.0%

Maternity MAT 610 569 41 6,998 6,727 272 4.0%

OP Diagnostic Imaging OPUI 407 369 37 4,311 4,476 (165) -3.7%

OP Care Package OPCP 750 681 70 8,334 7,968 366 4.6%

Accident & Emergency A&E 790 652 138 9,075 8,669 406 4.7%

Renal Renal 323 231 91 3,261 3,107 154 4.9%

Direct Access DA 237 217 20 2,636 2,751 (115) -4.2%

Critical Care CC 645 566 79 6,199 6,600 (401) -6.1%

Excluded Drugs & Devices EXDD 2,033 1,947 85 23,226 22,222 1,004 4.5%

Other C&V C&V 499 475 24 5,476 5,379 97 1.8%

Block BL 1,667 1,391 276 9,582 10,026 (444) -4.4%

Penalties Fine (37) (28) (9) (412) (405) (7) 1.8%

Provisions PROV (95) (112) 17 (1,430) (1,265) (165) 13.1%

CQUIN CQ 304 476 (173) 3,360 3,678 (318) -8.7%

Other Other (181) 7 (187) (701) (24) (676) 2807.6%

Total exc High Cost Drugs 18,128 17,073 1,056 191,018 190,676 342 0.2%

Total High Cost Drugs 2,033 1,947 85 23,226 22,222 1,004 4.5%

Total Income 20,161 19,020 1,141 214,244 212,898 1,346 0.6%

Month YTD

35

Detailed Capital ExpenditureFor the Period Ended 29th February 2016

Figures £000's

Actual

£000

Plan

£000

Variance

£000%

Actual

£000

Plan

£000

Variance

£000%

Strategic schemes:

APU (Compliant Aseptic Unit) 3 - 3 0.0 % 1,445 1,467 (22) (1.7)%

Woolverstone Macmillan Centre 302 504 (202) (50.0)% 2,144 2,686 (542) (15.6)%

Replace Linear Accelerator Works - - - 0.0 % 24 25 (1) (4.0)%

Replace MRI Building Works 326 30 296 176.7 % 770 600 170 (22.1)%

New MRI Scanners (Finance Lease) - - - 0.0 % - - - 0.0 %

New Gamma Camera (Finance Lease) - - - 0.0 % - - - 0.0 %

Renal Dialysis Contract Provision - - - (100.0)% - 622 (622) (100.0)%

Sub Total Strategic Schemes 631 534 97 18.2 % 4,383 5,400 (1,017) (18.8)%

Other schemes:

Site Developments 138 70 68 (30.0)% 756 1,240 (484) (47.2)%

Backlog Maintenance 82 175 (93) (94.8)% 627 1,741 (1,114) (65.3)%

Medical Equipment 106 300 (194) 35.4 % 1,809 2,240 (431) (12.2)%

IT Schemes 266 38 228 137.2 % 1,116 1,273 (157) (27.8)%

Prior Year Carry-Overs 12 - 12 0.0 % 154 - 154 0.0 %

Garret Anderson Asset replacement - 23 (23) 1287.0 % 319 257 62 4.9 %

Tender Bids - - - 0.0 % - 75 (75) (100.0)%

Donated Assets 13 - 13 0.0 % 53 53 - 0.0 %

Reserve - - - 0.0 % - - - 0.0 %

Sub total other schemes 617 606 11 1.8 % 4,834 6,879 (2,045) (29.7)%

Total Capital Programme 1,248 1,140 108 9.5 % 9,217 12,279 (3,062) (24.9)%

Funded by donation (13) (285) 272 (43.5)% (2,968) (3,753) 785 (14.8)%

Charge against capital resource 1,235 855 380 44.4 % 6,249 8,526 (2,277) (26.7)%

Month YTD

WMC costs continue to progress. Macmillan contributions to WMC have been billed regularly to Month 11 and the Trust has inv oiced £1.915m to date. Medical Equipment expenditure at Month 11 is almost complete for the year. Expenditure for the Estates programme is stil l behind plan but is due to spike in Month 12 as several projects near completion. Overall IT expenditure is due to meet expected outturn figures.

£2,250k of committed expenditure relating to the 15/16 plan is not included in the Actuals above, which should be realised as Actual spend / receipts in Month 12.Revisions to the 15/16 Capital Programme has allowed the Trust to accommodate the Bridge School planned purchase & the financ ial lease of Switchgear in relation to Bio Fuels.

36

Cashflow Forecast13 Week Forecast 2015/16 & 2016/17

49 50 51 52 53 1 2 3 4 5 6 7 8

29-Feb 07-Mar 14-Mar 21-Mar 28-Mar 04-Apr 11-Apr 18-Apr 25-Apr 02-May 09-May 16-May 23-May

£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Income

Clinical income 14,608 332 4,503 25 14,483 125 4,503 125 125 14,583 4,503 125 125

Non-clinical income 356 341 525 625 25 125 525 725 125 125 525 725 125

Financial support - IRWC - - 1,300 - - - 1,500 - - - 1,500 - -

Financial support - Loan - - - - - - - - - - - - -

Operating Income 14,965 674 6,328 650 14,508 250 6,528 850 250 14,708 6,528 850 250

Expenditure

Employee Benefits - payroll (23) (12) - (13,140) - - - (5,442) (7,800) - - (5,442) (7,800)

Agency - - - - - - - - - - - - -

Non-pay costs (1,956) (3,335) (1,298) (500) (1,244) (1,000) (4,053) (241) (1,850) (1,000) (4,053) (1,000) (3,141)

Capital expenditure - (250) - - - - - - (1,500) - - - -

Loans and leases - - - - - - - - - - - - -

Interest and dividend - - (1,448) - - - - - - - - - -

Financial Support Repayment - - - - - - - - - - - - -

Operating Expenses (1,978) (3,597) (2,746) (13,640) (1,244) (1,000) (4,053) (5,683) (11,150) (1,000) (4,053) (6,442) (10,941)

Net Operating inflow/(outflow) 12,986 (2,923) 3,581 (12,990) 13,264 (750) 2,475 (4,833) (10,900) 13,708 2,475 (5,592) (10,691)

Previous week's cash balance 1,090 14,076 11,153 14,734 1,744 15,008 14,258 16,733 11,900 1,000 14,708 17,183 11,590

Closing week's cash balance 14,076 11,153 14,734 1,744 15,008 14,258 16,733 11,900 1,000 14,708 17,183 11,590 900

Notes:

1. This forecast is based on the position at 9 March and uses actual data to date.

2. Payment dates are known for Tax, NI, Pension and Salary Payments (19th, 22nd and 28th of each month - or the previous working day)

3. Payment to NHSLA for Hospital Negligence Insurance paid by Direct Debit on 15th of each month (runs for 10 months from April to January, but last two payments are spread equally over December-March)

4. Dividend settlements are made around the 15th of September and 15th of March

5. Monthly funding is received on the 15th of each month

6. Remaining cashflow monthly figures have been evenly apportioned over the month

7. This is using the updated base line 2015/16 Cashflow Forecast and is adjusted to reflect the Serco addressable spend over the year which is payable as follows:

- £1.85m to be invoiced on WD1 and paid by WD10

- £1.85m to be invoiced on WD10 and paid by WD15

37

Working Capital - Debtors29th February 2016

Figures £000's

Trade Debtors by Age

Aged Analysis of Trade DebtorsFigures £000's <30 days 31-60 days 61-90 days >90 days Total

Current Month 1,212 1,046 920 2,491 5,668

Previous month 3,244 1,286 2,753 1,378 8,660

Movement in Month (2,032) (240) (1,833) 1,113 (2,992)

NHS £000s <30 days 31-60 days 61-90 days >90 days Total January Movement Movement %

NHS Commissioning Board 197 68 - 24 289 275 14 4.8%

NHS Suffolk/Ipswich & East 234 97 277 514 1,122 987 135 12.0%

NHS Norfolk & Suffolk FT 101 - 115 82 298 486 (188) -63.1%

Health Education England 3 - - - 3 1,933 (1,930) -64333.3%

Colchester Hospital 7 1 224 3 235 233 2 0.9%

Other NHS 279 244 139 638 1,300 2,462 (1,162) -89.4%

Total NHS 821 410 755 1,261 3,247 6,376 (3,129) -49.1%

Non NHS £000s

<30 days 31-60 days 61-90 days >90 days Total January Movement Movement %

Pharmacy - - - - - 1 (1) #DIV/0!

Miscellaneous 307 600 154 996 2,057 1,976 81 3.9%

Payroll 4 1 8 112 125 124 1 0.8%

Occupational health - - - - - - - #DIV/0!

Private patients 56 33 2 23 114 82 32 28.1%

Overseas patients 24 2 1 99 125 101 24 19.2%

Total Non NHS 391 636 165 1,230 2,421 2,284 137 6.0%

Total Debtors 1,212 1,046 920 2,491 5,668 8,660 (2,992) -34.5%

< 30 days 31-60 days 61-90 days > 90 days

NHS trade debtors 25% 13% 23% 39%

Non-NHS trade debtors 16% 26% 7% 51%

Total Trade Debtors 2014-15 v 2015-16

0

0.5

1

1.5

2

2.5

3

<30 days 31-60 days 61-90 days >90 days

Total NHS Total Non NHS

0

5

10

15

20

25

30


£m

2015-16 2014-15

0

0.5

1

1.5

2

2.5

3

3.5

4



0

5

10

15

20

25

30


£m

2015-16 2014-15

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5



0

5

10

15

20

25

30


£m

2015-16 2014-15

0

0.5

1

1.5

2

2.5

3

3.5



0

5

10

15

20

25

30


£m

2015-16 2014-15

Key Notes:

NHS

Overall NHS debtors have decresed by £3.1m from last month, mainly due to settlement of overdue invoices by Health Education England. The debtors processing and chasing is undertaken by Serco and the Trust will l iaise with them to ensure every effort is stil l being made to chase and recover debts in a more timely fashion.

Other non-NHS

Non NHS debtors have increased in the month by £137k. Finance and Payroll are l iaising to review the processes around Payrol l overpayments and to ensure the policy and processes are updated regarding this to ensure any overpayments are recovered in a more timely manner.

Total Debtors

The overall debtors decreased by 34.5% due to the above factors.

There has been an increased effort in chasing debt and this is to be backed up by the issue of a new Credit Control procedure which is now in place, to ensure that the appropriate steps are taken to improve the cash position of the Trust, in close liaison with Serco

0

0.5

1

1.5

2

2.5

3



Notes

31-60 days

Other NHS contains invoices amounting to £143k for Mid Essex CCG, £32k for Public Health England & £17k for Cambridge & Peterborough CCG

Non NHS Misc includes invoices for The Pathology Partnership (£287k) , MacMillan Cancer Research (£161k) & Suffolk Social Services (£46k)

61-90 days

Other NHS includes outstanding invoices amounting to £32k for

Great Ormond Street Hospital, & £21k for Sunderland CCG.Non NHS Misc includes invoices for Abbotts Diabetes Care (£136k)

>90 days

Other NHS contains invoices amounting to £344k for North East Essex CCG, £111k for Papworth Hospital, £106k for Public Health England & £32k for GOSH, together with a Credit Balance for NHS

W London (£36k).Non NHS Misc includes outstanding invoices for The Pathology Partnership (£824k), Suffolk Social Services (£77k) & HM Coroners

Office (£39k)Payroll debts account for £112k, an increase of £23k from last monthOverseas patients account for £99k with one patient owing £46K,

which is being repaid.

0

5

10

15

20

25

30


£m

2015-16 2014-15

38

Working Capital - Creditors29th February 2016

Trade Creditors by Age

<30 days

£000

31-60 days

£000

61-90 days

£000

>90 days

£000

Total

£000

Current Month

Year to date Non NHS Creditors 4,615 424 433 437 5,909

Year to date NHS Creditors 26 (0) (1) 1 26

Total Creditors 4,641 424 432 439 5,936

Previous Month

Year to date Non NHS Creditors 3,799 2,760 352 482 7,393

Year to date NHS Creditors 181 360 257 152 950

Total Creditors 3,979 3,120 609 634 8,343

Movement 662 (2,696) (177) (195) (2,407)

< 30 days 31-60 days 61-90 days > 90 days Total

Non-NHS trade creditors 78% 7% 7% 7% 100%

NHS trade creditors 99% 0% -3% 4% 100%

Analysis of Trade Creditor Aged Balance

Better Payments Practice Code - Year to Date Volume

within 30

days

Volume %

within

target

Value %

within

target

Total

NHS and Non-NHS creditors (Received Date basis) 52,809 71.4% 75.3% 73,984

NHS only trade creditors (Received Date basis) 841 50.3% 44.8% 1,672

Target 95.0%

10 day local and small suppliers payment

Volume

within 10

days

Volume %

within

target

Value %

within

target

Total

Year to date

Target 95.0%

Total Trade Creditors 2014-15 v 2015-16

Unavailable

0

2

4

6

8

10

12


£m

2015-16 2014-15

0

1

2

3

4

5


YTD Non NHS Creditors YTD NHS Creditors

0

2

4

6

8

10

12


£m

2015-16 2014-15

-1

0

1

2

3

4

5



0

2

4

6

8

10

12


£m

2015-16 2014-15

0

1

2

3

4

5



0

2

4

6

8

10

12


£m

2015-16 2014-15

0

1

2

3

4

5



0

2

4

6

8

10

12


£m

2015-16 2014-15

Key Notes:

Since 1st April 2014, Serco have taken on the Accounts Payable function on behalf of the Trust. Two

payment runs are performed each week.

> 90 days Non-NHSWe are holding a balance of £437k. Invoices total £508k, which includes invoices for TPP (£324k), Astraia

(£65k) & CSC Computing (£47k) . These are offset by credit notes totall ing £71k, which include the following: Medical 24 (£14k) & Medco (£18k). We will work with Serco to ensure these credits are checked and offset against future invoices or the money recovered if the supplier is no longer used.

> 90 days NHSWe are holding a balance of £1k, which represents 3 outstanding invoices.

-1

0

1

2

3

4

5



Operations

39

Highlights • The Trust Cancelled operations for non-clinical reasons was 0.52% in

February 2016 .

• The Trust achieved the 6 week diagnostic wait performance in February at 0.21%.

• The Trust achieved the 18 Week Incomplete Pathway performance with 95.9% and saw a reduction in the number of patients waiting on an incomplete 18 week pathway to 707.

• Year to date the Trust emergency care activity is 5.4% higher than 2014/15 or 3954 more attendances. With ambulance conveyances up 1730 or 7.84%.

Operations – 18 Weeks

Highlights

• The Trust achieved the non admitted and incomplete 18 Week access targets at a trust level.

• The Trust saw a reduction in the number of patients waiting >18 weeks on the incomplete pathway from 711 to 707.

Assurance

• RAP in place to improve incomplete performance

• All areas working to reduce the number of over 18 week patients in both admitted and non admitted and have ben set targets to achieve this

40

Code Treatment function% seen @

18wks Total <18 No. 18+

100 General Surgery 82.7% 237 196 41

101 Urology 71.1% 128 91 37

110 Trauma & Orthopaedics 91.2% 376 343 33

120 Ear, Nose & Throat (ENT) 97.2% 108 105 3

130 Ophthalmology 89.5% 238 213 25

140 Oral Surgery 82.1% 112 92 20

150 Neurosurgery ~ 0 0 0

160 Plastic Surgery 51.6% 128 66 62

170 Cardiothoracic Surgery ~ 0 0 0

300 General Medicine 100.0% 1 1 0

301 Gastroenterology 100.0% 63 63 0

320 Cardiology 100.0% 13 13 0

330 Dermatology ~ 0 0 0

340 Thoracic Medicine 100.0% 13 13 0

400 Neurology 100.0% 1 1 0

410 Rheumatology 100.0% 2 2 0

430 Geriatric Medicine 100.0% 57 57 0

502 Gynaecology 97.0% 168 163 5

X01 Other 85.4% 103 88 15

999 Total 86.2% 1748 1507 241

Feb 2016 Admitted pathways

Adjusted

Code Treatment function% seen @

18wks Total <18 No. 18+

100 General Surgery 97.4% 737 718 19

101 Urology 96.8% 404 391 13



130 Ophthalmology 99.3% 574 570 4

140 Oral Surgery 90.7% 290 263 27


160 Plastic Surgery 88.6% 35 31 4




320 Cardiology 98.8% 410 405 5

330 Dermatology 68.9% 729 502 227


400 Neurology 97.8% 226 221 5

410 Rheumatology 100.0% 176 176 0


502 Gynaecology 99.6% 239 238 1

X01 Other 98.5% 1164 1146 18

999 Total 94.6% 6493 6142 351

Feb 2016 Non-admitted

pathways

Operations – 18 Weeks

41

Based on 'On' a pathway only

Code Treatment function% waiting

@ 18wks Total <18 No. 18+

100 General Surgery 93.9% 1966 1846 120

101 Urology 91.2% 1300 1186 114



130 Ophthalmology 95.7% 1444 1382 62

140 Oral Surgery 96.0% 1178 1131 47


160 Plastic Surgery 85.3% 265 226 39




320 Cardiology 99.2% 829 822 7

330 Dermatology 89.2% 1672 1491 181


400 Neurology 99.5% 792 788 4

410 Rheumatology 100.0% 364 364 0


502 Gynaecology 99.0% 958 948 10

X01 Other 99.3% 1809 1796 13

999 Total 95.9% 17260 16553 707

Feb 2016 Incompletes

Operations – Emergency Care

Highlights

• The Trust failed to achieve the 4 hour wait target in Feb at 92.79%.

• Year to date performance fell below the 95% threshold at 94.95% above the national average of 90%.

• Activity continues to increase above 2014/15 levels 5.4 Year to Date. January and February combined was 8.7% higher than 2014/15 (excluding the leap year additional day).

Assurance

• A detailed emergency Care action plan is in place and being monitored by the Trust Executive and Combined Board.

42

Emergency Care – Ambulance Delays

43

Operations – Cancer

Highlights

• The Trust achieved all Cancer Targets in February currently apart for the 62 Day Upgrade target. With 2 breaches out of 9 patients and 31 Day Subsequent Surgery with 3 patients breaching out of 35.

• Final validated performance will be available in March performance report.

• The trust continues to undertake breach analysis of all patients failing the cancer targets.

44

Operations – Cancer

45

Avg total

patients per

month (based

on 2013/14)

Max breaches

per month to

maintain

standard Breach ratio April May June Q1 2015/16 July August September Q2 2015/16 October November December Q3 2015/16 January February

Aggregate - 2WW (93%) 96.3% 96.7% 96.3% 96.5% 97.7% 98.1% 96.0% 97.3% 96.0% 95.8% 96.4% 96.1% 97.2% 96.8%

Aggregate - 62 Day (86%) 83.9% 80.8% 85.0% 83.4% 85.9% 85.6% 90.8% 87.5% 88.5% 93.0% 90.9% 90.7% 91.3% 87.5%

Total Patients Seen 714 775 918 2407 930 797 855 2584 874 882 917 2673 736 845

Confirmed breaches 21 24 27 72 20 13 36 69 37 33 32 102 21 22

Performance (min 93%) 97.1% 96.9% 97.1% 97.0% 97.8% 98.4% 95.8% 97.3% 95.8% 96.3% 96.5% 96.2% 97.1% 97.4%

Risk 97.1% 96.9% 97.1% 97.0% 97.8% 98.4% 95.8% 97.3% 95.8% 96.3% 96.5% 96.2% 97.1% 97.4%

Min patients required to meet target 300 343 386 1029 286 186 514 986 529 471 457 1457 300 314

Target passed, breach appointment 0 0 0

Patients with target in month 0 0 0

Total Patients with appointments 101 85 113 299 113 96 93 302 92 120 89 301 90 130


Performance (min 93%) 91.1% 95.3% 90.3% 92.0% 96.5% 95.8% 97.8% 96.7% 97.8% 92.5% 95.5% 95.0% 97.8% 93.1%


Target passed, no attendance

Target in month

Total treatments 169 152 175 496 195 165 167 535 178 151 181 510 159 152


Performance (min 96%) 97.0% 97.4% 98.3% 97.6% 97.9% 95.2% 98.2% 97.2% 96.1% 98.0% 98.9% 97.6% 98.7% 96.1%


Target passed, no TCI

Patients with target in month

Total treatments 96 79 91.5 266.5 95 90.5 98.5 285 88.5 77 93.5 259 74 73

Confirmed breaches 18 15.5 15.5 49 15 13.5 9.5 38 11 6.5 9 26.5 5 10

Performance (min 85%) 81.3% 80.4% 83.1% 81.6% 84.2% 85.1% 90.4% 86.7% 87.6% 91.6% 90.4% 89.8% 93.2% 86.3%




Total treatments 11.5 7 12.5 31 15 10.5 12 37.5 10.5 10 15.5 36 14 10

Confirmed breaches 0 0 0.5 0.5 0 1 0 1 0 0 1 1 1 0

Performance (min 90%) 100.0% 100.0% 96.0% 98.4% 100.0% 90.5% 100.0% 97.3% 100.0% 100.0% 93.5% 97.2% 92.9% 100.0%




Total treatments 4 5 9 18 14 7 8.5 29.5 5 6 12 23 3.5 9

Confirmed breaches 0 2 1 3 2.5 1 1.5 5 1 0 1 2 2 1.5

Performance (>93.6%) 100.0% 60.0% 88.9% 83.3% 82.1% 85.7% 82.4% 83.1% 80.0% 100.0% 91.7% 91.3% 42.9% 83.3%





Performance (min 94%) 96.7% 100.0% 96.3% 97.7% 100.0% 96.2% 100.0% 99.1% 100.0% 100.0% 100.0% 100.0% 95.5% 91.4%






Performance (min 98%) 100.0% 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100% 98.6% 99.5% 100.0% 98.3%






Performance (min 94%) 97.9% 97.5% 97.1% 97.5% 98.0% 97.5% 94.8% 96.7% 96.4% 95.6% 94.4% 95.5% 98.9% 99.1%




2WW - Suspected Cancer 675 47 1 in 15

31 Day - First Treatments 157 6 1 in 25

62 Day - Upgrades 11

SLA requires

>= national

performance

(2012/13 =

93.2%)

n/a

1 in 156912WW - Symptomatic

Breast

62 Day - 2WW 84 12 3 in 20

62 Day - Screening 14 1 1 in 10

31 Day - Subsequent

Radiotherapy82 4 1 in 17

31 Day - Subsequent

Surgery24 1 1 in 17

31 Day - Subsequent Drug

Therapy56 1 1 in 50

Operations – Stroke

46

Ipswich Hospital

Stroke MetricsV-08/05/15 V 09/06/15 V 07/07/15 v 07/07/15V 04/08/15 V 03/09/15 V 06/10/15 V 06/10/15V 10/11/15 V 08/12/15 V 12/01/16 V 12/01/16V 09/02/16 UV 11/03/16

Description of Metric Source of Metric Apr-15 May-15 Jun-15 Qtr 1 Jul-15 Aug-15 Sep-15 Qtr 2 Oct-15 Nov-15 Dec-15 Qtr 3 Jan-16 Feb-16

% 85% 88% 95% 89% 88% 90% 92% 90% 85% 88% 92% 89% 92% 78%

Threshold 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 89% 96% 100% 100%

Threshold 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

% 95% 92% 97% 95% 97% 100% 97% 98% 96% 93% 98% 95% 94% 90%

Threshold 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% 100% 96% 100% 99% 98% 100% 100% 99% 93% 100% 94% 96% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% 100% 93% 95% 96% 100% 96% 100% 99% 100% 95% 100% 98% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% 80% 90% 100% 91% 78% 75% 56% 70% 100% 88% 92% 92% 100% 75%

Threshold 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

Penalty Risk Clause GC9 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

% 86% 100% 86% 93% 78% 100% 90% 86% 88% 100% 100% 94% 80% 86%

Threshold 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65%

=>Trajectory

<Trajectory

65% of patients with low risk

TIA have access to MRI,

Carotid Scan or Doppler

within 7 days (seen,

2015_2016 CCG

Contract

SHA Metric: Proportion of

patients, eligible for

thrombolysis, receiving it

within 4.5 hours.*note 5

Anglia Stroke and

Heart Network * see

note 1 below

Vital Sign: >60% people who

have a TIA and are high risk

(ABCD 2 score 4 or more) are

scanned and treated within 24

hours of contact but not

admitted

2015_2016 CCG

Contract

Network metric: Proportion of

Stroke patients with access to

a brain scan within 24 hours

Anglia Stroke and

Heart Network

Patients with suspected stroke

to have access to an urgent

brain scan in the next slot

within usual working hours or

less than 60 minutes out of

hours as defined from time to

time by the Anglia Stroke &

Heart Network

Anglia Stroke and

Heart Network *see

note 4 below

Network metric; Proportion of

stroke patients admitted to a

stroke unit within 4 hours

Anglia Stroke and

Heart Network

Network metric: Proportion of

Stroke patients and carers

with a joint health and social

care plan on discharge

Anglia Stroke and

Heart Network

Key - V = Validated by IHT and UV = Unvalidated

Vital Signs: - Proportion of

patients spending 90% of their

stay on a stroke unit

Anglia Stroke and

Heart Network *see

note 6 below

Proportion of patients in Atrial

Fibrillation, presenting with

stroke, receiving anti-co-

agulation.

Anglia Stroke and

Heart Network

Operations – Diagnostics

Highlights • The Trust achieved the

diagnostic threshold with 0.21% of patients waiting > 6 weeks in February and is now forecasting a year end position of over the 1% threshold.

Assurance • Increased hours of part time

sonographer – increase of 4 sessions per week

• Additional activity being sourced from sonographers/consultants

• Exploring direct access activity being undertaken by GP Federation as required.

• Sourcing locum radiologists/sonographers to undertake specialist work.

• Exploring incentivising sonographers to undertake backlog clearance

47

Weeks >

Wait >

00 <01 01 <02 02 <03 03 <04 04 <05 05 <06 06 <07 07 <08 08 <09 09 <10 10 <11 11 <12 12 <13 13 + Total

Waiting list

size

compared

with the

previous

month

Total

breaches

% of

breachesActivity

Activity

levels

compared

with the

previous

month

YTD

Apr-15 1493 1197 992 494 623 514 46 21 2 5382 Increase 69 1.28% 8204 Decrease 1.28%

May-15 1146 1547 1043 769 643 416 25 17 9 4 1 2 1 5623 Increase 59 1.05% 8667 Increase 1.16%

Jun-15 1393 1184 896 747 459 292 13 10 7 4 1 1 5007 Decrease 36 0.72% 9546 Increase 1.02%

Jul-15 962 997 870 604 449 276 22 8 1 1 1 2 1 4194 Decrease 36 0.86% 10142 Increase 0.99%

Aug-15 855 967 803 574 515 270 68 36 19 8 1 1 1 4118 Decrease 134 3.25% 8395 Decrease 1.37%

Sep-15 1154 1007 812 486 294 181 13 8 5 7 3967 Decrease 33 0.83% 9246 Increase 1.30%

Oct-15 1281 1205 1035 633 353 221 22 10 5 4 1 4770 Increase 42 0.88% 9351 Increase 1.24%

Nov-15 1260 1075 938 677 366 217 16 10 6 1 4566 Decrease 33 0.72% 9436 Increase 1.17%

Dec-15 567 970 1042 810 585 278 42 38 30 8 5 4375 Decrease 123 2.81% 8721 Decrease 1.35%

Jan-16 1212 1122 876 594 229 172 7 8 4 3 1 4228 Decrease 23 0.54% 9662 Increase 1.27%

Feb-16 1071 990 958 702 400 138 4 4 1 4268 Increase 9 0.21% 8178 Decrease 1.18%

1.08%Actual Year End

Highlights

• The Trust continues to achieve the threshold for non clinical cancellations of operations of below 1% with 0.52% of operations cancelled in February for non clinical reasons.

• Year to date the Trust is at 0.46% 212 compared to 277 in 2014/15.

48

Operations – Theatres

Monthly FFCE's for all elective patients April 2015 - March 2016

(Refreshed Monthly)

2015/16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total

Elective 490 545 582 584 517 545 576 522 497 484 527 5869

DayCase 3603 3358 3585 3776 3445 3797 3743 3787 3530 3726 3737 40087

Total Elective FFCEs 4093 3903 4167 4360 3962 4342 4319 4309 4027 4210 4264 0 45956

No of on the day Cancellations by the

hospital for a non clinical reason24 5 29 18 13 23 30 20 16 12 22 212

% Cancellations of Total Elective FFCEs 0.59% 0.13% 0.70% 0.41% 0.33% 0.53% 0.69% 0.46% 0.40% 0.29% 0.52% 0.46%

1% Standard for Cancellatons to FFCEs 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%Daycase as a percentage of total

electives88.03% 86.04% 86.03% 86.61% 86.95% 87.45% 86.66% 87.89% 87.66% 88.50% 87.64% 87.23%

Inpatients as a percentage of total

electives11.97% 13.96% 13.97% 13.39% 13.05% 12.55% 13.34% 12.11% 12.34% 11.50% 12.36% 12.77%

Ratio of IP : DC 0.14 0.16 0.16 0.15 0.15 0.14 0.15 0.14 0.14 0.13 0.14 0.15

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

0

5

10

15

20

25

30

35

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% C

an

ce

lla

tio

ns o

f T

ota

l E

lecti

ve

FFC

Es

Nu

mb

er

of

Ca

nce

lla

tio

ns

No of on the day Cancellations by the hospital for a non clinical reason % Cancellations of Total Elective FFCEs 1% Standard for Cancellatons to FFCEs

Theatre Utilisation

Highlight Reports

• Theatre Utilisation rose to 82.2% in January 2016.

49

Operations Discharge Summary Compliance

Highlights

• The Trust continues to exceed the contractual requirement for discharge correspondence to be sent within 24 hours within the Inpatient environment.

• Compliance within the Emergency department fell to 87.70%.

• Outpatient performance fell below the contractual requirement at 93.43% in February 2016.

Assurance

• Weekly performance monitoring is underway to ensure continued improvements in ED and sustained delivery within outpatients.

50

Workforce

51

Highlights • Absence has decreased from 4.32% in January to 3.93% in February. There has been a

decrease in the Community Long Term Absence from 5.64% in January to 3.09% in February. This has been the result of some long term absence cases returning to work. Overall there has been a reduction of short term sickness cases across the Trust.

• Following a decline in local induction compliance in January at 83%, there has been an improvement in compliance in February, which now stands at 96.1%, compared with the target of 95%.

• From 1 April 2016, the corporate induction programme will be changing and we will be facilitating two induction mornings per month (rather than just one). The revised programme will be far more interactive and will include greater focus on the culture of Ipswich Hospital, our values and other key information that may be useful to new Team Ipswich colleagues. There will be less focus on mandatory training although new staff will be required to complete their training requirements within 90 days of commencement. The new induction programme applies to all colleagues, including senior medical staff (consultants and SAS doctors).

Workforce Dashboard

Indicator Trust Target Trust (Previous Month)

Trust Current Month

Month on Month Trend

Rating

WTE in post 3756* 3495 3519

Turnover % 10% 8.6% 8.2%

Sickness % (Month) 3.5% 4.32% 3.93%

Mandatory Training 95% 86% 88.7%

PDR 85% 82% 85.1%

Induction 95% 91% 96.1%

24/03/2016 Trust Workforce Data Report 52

* - Trust Establishment

Staff In Post in February

Key Messages:

Against a Trust establishment of 3756WTE, there were 3519WTEs in post at the end of February, compared with 3495WTE in January; an increase of 24WTE with 40.94 WTE new starters in February 2016.

Actions:

Continued focus on recruitment and retention (see following pages)


Turnover & Leavers

Key Messages:

The reduction in turnover continued at 8.2% in February, with a reduction to 5.4% for unplanned leavers.

Actions:

Continued focus on retention, using exit interviews and on-line surveys to inform staff retention plans.

Planned Leavers – can be planned for such as Retirees, End of Fixed Term Contract Unplanned Leavers – unexpected leavers such as voluntary resignation.


Starters, Leavers & Planned Nursing Recruitment

Key Messages: Recruitment continues to be challenging with a vacancy factor of 6%. Due to changes with the NMC registration process introduced in January, European recruitment of RNs has significantly diminished and there are some hard to recruit to posts which are taking longer to fill.

Actions: All vacancies have a case manager and a recruitment plan and these are reviewed and monitored.

Planned Leavers – can be planned for such as Retirees, End of Fixed Term Contract Unplanned Leavers – unexpected leavers such as voluntary resignation.


New Starters in February


Sickness Absence for February

Key Messages: Absence % has decreased from 4.32% in January to 3.93% in February. There has been a significant decrease in the Long Term Absence in the community locations from 5.64% in January to 3.09% in February.

Actions: The Community locations have benefitted from the result of several long term cases returning to work and HR Services established that the recording of the sickness information in the community locations was being undertaken with some inaccuracies, which has now been rectified

HR Services are working with Occupational Health to support divisions in recognising ‘hot spots’ to support appropriate management of all cases.


Sickness Reasons in February

Key Messages: February continues the trend of psychological issues causing the highest number of days absence, and there has been a slight increase in February. 25% of long term absence was as a result of psychological issues. 27% of short tem absence cases are due to colds and coughs.

Actions: • The Health and Wellbeing Group,

chaired by the Occupational Health Consultant is currently reviewing the reasons across the hospital to identify if there are additional areas of specific advice and guidance may assist to improve areas.

• The Health and Wellbeing group are liaising with external bodies to develop management training and support for managing staff who are absence due to Anxiety/Stress/Depression.

• There continue to be some data quality issues being addressed, where on some occasions the reason for the absence has been omitted from the data entry, and therefore, further work is continuing to ensure that all absence is recorded correctly and accurately


Employee Relations Cases in February


Key Messages: During February there were 33 formal live cases and of these 16 were disciplinary, 5 capability, 3 grievances, and 4 redeployments

Actions: • All cases are managed in

accordance with the relevant Trust policy and procedure.

• Throughout these processes all staff are supported utilising a range of support mechanisms including Occupational Health, Care – confidential support service for all Trust staff and Chaplaincy

Local Induction Compliance & Corporate Induction Satisfaction

Key Messages:

Following a decline in local induction compliance in January at 83%, there has been an improvement in compliance in February, which now stands at 96.1%, compared with the target of 95%.

Key messages and actions – corporate induction:

- Day 1 saw an increase in satisfaction scores (great) in February 2016.

- Launch of new Induction programme to take place in April 2016. In response to feedback, the new sessions will be more interactive, fast paced and include important information for new starters.


Staff Friends & Family Test (Staff FFT)

Key Messages:

• The Staff Friends & Family Test is currently being undertaken in Divisions 3 and 4 with a closing date of 31 March 2016. The results will be made available during April 2016. A national comparison of our results compared to other NHS organisations should be available from late May/beginning of June 2016.


Recruitment Planner for February


Staff Group Recruitment Plan 2015 - 16 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

Actual/Anticipated starters 2 1 3 0 1 1 1 1

Response to adverts 2 1 3 0 1 1 1 1

Actual/Anticipated starters 12 18 21 27 14 14 14 14 14 14 14 14

Bank HCA Trainee nurses, UCS - Headcount not WTE 0 8 10 5 12

HCA Training Programme 12 10 9 22 12 12 12 12 12 12 12 12 12

Response to experienced HCA adverts 0 0 2 0 2 2 2 2 2 2 2 2 2

Actual/Anticipated starters 4.73 4.49 3.80 6.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

Response to adverts 4.73 4.49 3.80 6.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

Ward Clerk apprentices 0 0 0 0

Actual/Anticipated starters 1 2 1 1 4

Pharmacy students 0 0 0 0 4

Physiotherapist Student appointments 0 0 0 0

Response to adverts 1 2 1 1

Actual/Anticipated starters 4 0 0 0 1 1

Response to adverts 4 0 0 0 1 1

Actual/Anticipated starters 0 0 0 1

Response to adverts 0 0 0 1

Actual/Anticipated starters : Consultants 0 1 1.5 2 2 2 2 5

Excluding rotational posts 0 0 0 0 1

Royal College Conferences Dates TBD 0 0 0 0

Response to adverts 0 1 1.5 2 2 2 5

Actual/Anticipated starters 3.4 7.9 13.0 23.0 13.9 8.9 28.9 28.9 28.9 3.9 23.9 23.9 23.9

Response to adverts 3.37 2.9 3.8 4 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9

International Recruitment: Visit (TBD) 0 4 4 0 8 20 20 20 20 20 20

International Recruitment: Skype 0 1 5 1 2 5 5 5 5

Return to Practice 0 0 0 3

Newly Qualified 0 0 0 15 21

Nursing Times Conference 0 0 0 0

Medical and Dental

Nursing and Midwifery

Registered

Add Prof Scientific and

Technic

Additional Clinical Services

Administrative and Clerical

Allied Health Professionals

Estates and Ancillary

Healthcare Scientists

Staff vacancy data (wards & theatres)


Comments

Bed N

umbe

rs

Curre

nt Fu

nded

Estab

lishm

ent

(inclu

des H

ouse

keep

ing)

Total

Fund

ed RN

Estab

lishe

ment

Total

Fund

ed H

CA Es

tablis

heme

nt

Total

RN Va

canc

ies

total

RN re

cruit

ed (n

ot st

arted

)

Total

HCA

Vaca

ncies

Total

HCA

recr

uited

(not

star

ted)

Total

Mate

rnity

leav

e hou

rs (w

te)

Mate

rnity

leav

e hou

rs re

cruit

ed in

to (w

te)

Total

long

term

sick

Vaca

ncy r

ate m

inus v

acan

cies r

ecru

ited t

o RN

Vaca

ncy r

ate m

inus v

acan

cies r

ecru

ited t

o HCA

Vaca

ncy r

ate a

gains

t fun

ded e

stabli

shm

ent (

%)

Notes* Monthly recruitment to

vacancies reported, and numbers of

staff leaving and forward plans for

recruitment

Division One

Emergency Medicine

ED - 87.67 68.19 18.95 4.78 2.70 0.15 0.00 4.77 0.00 0.00 2.08 0.15 2.23 2.5%

Brantham 38 57.68 42.54 15.14 2.25 1.77 1.57 1.00 0.92 0.00 0.00 0.48 0.57 1.05 1.8%

Capel 27 34.20 23.41 10.79 4.54 4.00 1.00 1.00 1.00 1.00 0.00 0.54 0.00 0.54 1.6%

Medicine One

Kirton ARCU 28 38.67 26.52 12.15 2.97 2.00 1.39 1.00 2.00 0.00 1.00 0.97 0.39 1.36 3.5%

Shotley 25 33.60 21.38 12.22 2.13 1.00 0.00 0.00 0.00 0.00 0.00 1.13 0.00 1.13 3.4%

Claydon 24 34.96 26.55 8.41 5.00 2.61 0.00 0.00 1.00 0.00 0.80 2.39 0.00 2.39 6.8%

Sproughton 28 37.05 20.80 16.25 1.83 1.00 3.20 1.61 2.00 0.00 1.00 0.83 1.59 2.42 6.5%

Medicine Two

Debenham 24 27.67 17.49 10.18 2.45 1.00 0.53 0.00 0.00 0.00 0.00 1.45 0.53 1.98 7.2%

Woodbridge 28 30.60 14.07 16.53 3.54 1.00 0.89 0.23 1.00 0.00 0.00 2.54 0.66 3.20 10.5%

Washbrook 28 33.06 19.42 13.61 3.85 2.00 1.57 0.00 0.00 0.00 0.60 1.85 1.57 3.42 10.3%

Haughley 27 32.91 19.45 13.46 1.70 1.00 0.00 0.00 2.00 0.00 1.00 0.70 0.00 0.70 2.1%

Grundisburgh 27 33.15 19.48 13.67 3.20 1.00 0.00 0.00 0.00 0.00 0.00 2.20 0.00 2.20 6.6%

Kesgrave 28 0.00 0.00 0.00 0.0% ESCALATION

Division Two

Surgery

Stowupland 25 29.74 17.74 12.00 3.13 0.00 1.00 0.00 1.56 0.00 0.00 3.13 1.00 4.13 13.9%

Stradbroke 27 33.04 18.18 14.86 3.80 1.00 1.39 0.00 0.00 0.00 1.00 2.80 1.39 4.19 12.7%

Lavenham 40 59.13 37.36 21.77 6.84 2.61 0.80 0.80 2.92 0.00 1.33 4.23 0.00 4.23 7.2%

T & 0

Martlesham 28 25.50 17.58 7.92 0.00 0.00 0.29 0.00 0.00 0.00 1.46 0.00 0.29 0.29 1.1%

Needham 28 29.80 19.18 10.62 1.86 1.00 0.80 0.00 0.00 0.00 0.80 0.00 0.80 0.00 0.0%

Saxmundham 27 36.35 19.18 17.17 4.60 1.00 0.00 0.00 2.60 0.80 0.00 3.60 0.00 3.60 9.9%

East Theatres 32.78 26.93 5.85 0.00 0.00 0.00 0.00 1.00 0.00 1.75 0.00 0.00 0.00 0.0%

Theatres

South Theatres 44.21 22.26 15.68 4.00 1.00 0.80 0.80 0.00 0.00 0.00 3.00 0.00 3.00 6.8%

Raedwald 46.11 32.41 13.70 0.00 0.00 0.00 0.00 3.80 0.00 1.00 0.00 0.00 0.00 0.0%

Blyth Theatres 31.46 18.22 13.24 1.00 0.00 0.00 0.00 1.80 0.00 0.00 1.00 0.00 1.00 3.2%

Cri tica l Care Unit 12 61.32 49.87 10.45 5.80 3.00 0.90 0.00 3.00 0.00 0.00 2.80 0.90 3.70 6.0%Division Three

Oncology

Somersham 25 28.86 19.91 9.15 1.40 0.00 0.00 0.00 1.00 0.46 0.00 1.40 0.00 1.40 4.9%WomensStour + Gipping +

EGAU 18 18.64 11.50 7.14 4.86 0.00 0.00 0.00 1.61 0.61 0.00 4.86 0.00 4.86 26.1% new establ ishmnet agreed for 6 beds

Maternity - Al l 147.16 116.53 33.63 5.78 0.00 4.00 0.00 5.21 4.00 2.00 5.78 4.00 9.78 6.6%

Childrens

Bergholt 21 30.80 23.57 7.23 2.71 0.00 0.51 0.00 1.22 0.00 0.00 2.71 0.51 3.22 10.5%

PAU/PIU 6 11.09 7.23 3.86 0.14 0.00 0.53 0.00 1.64 0.00 0.00 0.14 0.53 0.67 6.0%

NNU 20 46.76 40.55 6.21 0.92 0.00 1.45 0.00 3.18 1.12 0.61 0.92 1.45 2.37 5.1% Decembers figures

1160.9 817.5 371.8 85.08 30.69 22.77 6.44 45.23 6.87 14.35 53.5 16.3 69.1 5.9%

Vacancy Rate

Mandatory Training and Appraisal Compliance

Key messages and actions (Mandatory Training): - Face to face subject dates are now available for staff to book onto.

- The mandatory training Intranet site is continually being improved and updated and includes information on the new process

- The new handbook is currently in print and will be distributed in late March 2016.

- Staff will be expected to complete the handbook and relevant e-Assessment between April – June 2016 - this will ensure compliance in 7 out of the 10 core mandatory subjects (other subjects covered in face to face sessions)

- Work to update the mandatory training divisional workbooks to reflect the new system will be undertaken in April.

- Communications with key stakeholders have been in place for sometime, Trust wide communications with all staff will be taking place in March.

Actions (Appraisals):

- The final touches are being made to the new appraisal documentation which will come into effect from 1 April 2016. A communications plan and training programme is in the process of being worked up .


Job Planning – in February

Key Messages:

As at 29 Jan 2016 20.6% job plans Trust wide had been signed and completed on the e-job plan system. 83.%% engagement with e-job planning at different stages of completion.

Actions:

A proposal on Educational Supervision programme activity allocation within job plans will be taken to the next LNC in April 2016


SARD – Strengthened Appraisal Revalidation Database

Agency Activity

Key Messages:

There are daily staffing reviews taking place to ensure that there are appropriate staffing levels across the hospital. A number of agencies provide workers to the hospital on a flexible arrangement via the framework agreements, when these are authorised by a member of the Trust Executive.

Actions:

Continue with the daily staffing reviews and agency workstream programme.

An internal audit on the agency utilisation is scheduled to commence in March.


WK1

WK2

WK3

WK4

Abovecap

68 77 62 87

Withincap

57 57 54 66

020406080

100120140160180

RN

WK1

WK2

WK3

WK4

Abovecap

4 14 13 18

Withincap

44 56 37 45

01020304050607080

HCA

WK1

WK2

WK3

WK4

Abovecap

10 5 5 5

Withincap

15 15 18 20

0

5

10

15

20

25

30

Other Clinical

February

WK1

WK2

WK3

WK4

Abovecap

71 63 67 69

Withincap

16 11 9 13

0102030405060708090

100

Medical

WK1

WK2

WK3

WK4

Abovecap

17 22 18 24

Withincap

0 0 0 0

0

5

10

15

20

25

30

Non Clinical

42%

18%

7%

26%

7%

Total Shifts Booked 1st - 28th February 2016

RN

HCA

OtherClinical

Medical

NonClinical

February

Appendix 1. Recruitment Consultant Vacancies - February


Appendix 2. Recruitment Non Consultant Grade Vacancies - February


Appendix 3a. Recruitment Hard to Recruit to Posts 1 - February


Red – No appointment made Amber –Appointment made start date to be determined Green – Appointment made

Appendix 3b. Recruitment Hard to Recruit to Posts 2 - February


Red – No appointment made Amber –Appointment made start date to be determined Green – Appointment made

Documents

Agenda Item: 5.1 REPORT TO THE TRUST BOARD 31 … TO THE TRUST BOARD 31 March 2016 ... A patient’s poor care following 2 ectopic pregnancies. ... there are action plans to deliver