Public Board of Directors papers 27-10-22

EXECUTIVE SUMMARY

Introduction

The Integrated Performance, Quality & Finance report presents a summary dashboard that provides an overview of performance.

Safe • No serious incidents were reported in September. There were 7 incidents reported in month with the classification of moderate, details of which can be found on slide 8. All the incidents are still progressing through to full root cause analysis. No never events were reported in month. • There are 5 Trust level risks scored at 15+. Details of these can be found on slide 12.(shows 1 incident with a score of 20) • The sepsis threshold was not met in month, all have been reviewed, delay due gaps in PGD trained staff on duty. Improvement plan in place. • Safer staffing numbers have met the required acuity levels to ensure appropriate levels of safety and care for our patients. Indicative staffing, in line with nursing establishments, is set to maintain a 1:6 nurse to patient ratio. On occasion this has been extended to 1:8 which is in line with recommended national staffing ratios. However, at these times there have been no reported patient safety incidents. Responsive • Performance against the 62 day standard has shown a small improvement from August. The 62 day standard has not been met with a performance of 71.5%, subject to validation. The 62 day unvalidated upgrade performance is much closer to the standard with a performance of 83.7%. The internal 24 day target has improved and is at 82.0%. All 62 and 24 day breaches are reviewed to ensure any delays are understood and plans can be implemented to mitigate any future delays. All 31 day targets and 18 week RTT standards have been achieved in September subject to validation. Performance against the CWT thresholds is constantly monitored. • Referrals in September reduced slightly from August but remain high. The overall trend continues to be significantly higher than the 21/22 average. • Activity levels are now monitored against agreed 22/23 plan. As at month 6 Chemotherapy deliveries and radiotherapy fractions along with non elective spells continue to be above plan whilst all other points of delivery are either on plan or tracking slightly below plan. Effective • There were 6 cases of C-Difficile, 5 cases of E-Coli, 2 cases of Klebsiella, 3 cases of Pseudomonas & 3 cases of MSSA in September that were deemed attributable to the Trust. No lapses in care have been identified. • There were 5 cases of hospital acquired nosocomial Covid-19 infections in September. • Staff absence levels reduced significantly in September but remain over the target of 3.4%. • There continues to be improvement against the essential training threshold, however PDR performance has reduced from August and is now under the target of 84%. Well – Led • The trust is reporting a month 6 position of £58k surplus compared to a breakeven plan within the latest plan submission of an annual break even control total. • The month 6 I&E deficit is £8,912k, prior to adjusting for donated depreciation, charitably funded capital donations, donated grant income, donated consumables, transfers by absorption and impairments. • The cash balance is £160,008k. • Performance to month 6 is £4,639k below the proposed plan submitted to NHSE&I. The Paterson scheme is behind plan but still anticipated to meet plan by year end and conclude then. IFRS 16 leases which were anticipated to be contractually entered into by this point are yet to be committed. 35