board of directors · 1 board of directors thursday 29 may 2014 . 9.15am – 11.50am . boardroom,...

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Board of Directors Thursday 29 May 2014 9.15am – 11.50am Boardroom, Level 4, Royal Berkshire Hospital We are here to provide a comprehensive service, based on clinical need, not an individual’s ability to pay. We aspire to the highest standards of excellence and professionalism and to put patients at the heart of everything we do. We are committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. We are accountable to the public, communities and patients that we serve.

Open Board Meeting – Part 1 Item Lead Time The meeting will commence with a patient story

Alistair Flowerdew

9.15 – 9.25

1. Apologies for Absence

Stephen Billingham -

2. Minutes: 30 April 2014 (Attached to approve)

Stephen Billingham 9.25 – 9.30

3. Matters Arising and Outstanding Actions Schedule (Attached to note)

Keith Eales 9.30 – 9.40

4. Declarations of Interest (Verbal to note)


Performance Reports

5. a) Chief Executive’s Report (Attached to note) b) Quality Performance Report (Attached to note) c) Care Group Performance (Attached to note) d) Finance Report (Attached to note)

Alistair Flowerdew/ Executive Team

9.40 – 10.40

Major Issues

6. A&E Update Report (Attached to note)

Sue Edees 10.40 – 10.55

7. CQC Intelligence Monitoring Assurance (Attached to note)

John Taylor 10.55 – 11.15

Agenda

2

Governance Items

8. Monitor Self-Certification (Attached to approve)

Craig Anderson/ Keith Eales

11.15 – 11.25

9. Standing Financial Instructions (Attached to approve)

Craig Anderson 11.25 – 11.35

10. Minutes of Meetings: (To note and agree recommendations) a) Board Strategy Group – 12 May 2014 b) Resources Committee – 12 May 2014 c) Audit & Risk Committee – 15 May 2014 d) Clinical Governance Committee – 22 May 2014

(Verbal to note)

Janet Rutherford Jane May Brian Hendon Janet Rutherford

11.35 – 11.50

Information Items

11. Board Work Plan (Attached to note)

Keith Eales -

12. Date of Next Meeting Monday 30 June 2014 (Verbal to note)


13. Exclusion of the Press and Public (Verbal to approve)


Closed Board Meeting - Part 2 The following section of the meeting will be closed to the press and public as the material to be discussed discloses exempt information as defined by the Freedom of Information Act.

Agenda Item 2

Minutes of the Board – 30 April 2014 1

Board Monday, 30 April 2014 9.15am – 1.00pm Boardroom, Royal Berkshire Hospital, Reading Members Present Mr. Stephen Billingham (Chairman and Non-Executive Director) Mr. Alistair Flowerdew (Acting Chief Executive) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance and Interim Deputy Chief Executive) Mr. John Barrett (Non-Executive Director) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mr. Peter Malone (Care Group Director, Planned Care) Ms. Jane May (Non-Executive Director) Dr. Brian Reid (Interim Medical Director) Mrs. Janet Rutherford (Non-Executive Director) In attendance Mr. Keith Eales (Director of Corporate Affairs & Secretary) Dr. Sue Edees (Care Group Director, Urgent Care) Mr. Paul Jones (Interim Director of Workforce & Organisational Development) Mr. Mark Robson (Director of Operations, Networked Care) (for minute 67/14) Mr. John Taylor (Interim Commercial Director) Mr. Jeremy Tozer (Interim Chief Operating Officer) Apologies Dr. Lindsey Barker (Care Group Director, Networked Care) There were two members of the press, four members of the public, three Governors, one member of staff and an observer from Deloitte present. The meeting commenced with a patient story from a mother who had attended Rushey ward. The experience had been calming, supportive and a significant improvement from giving birth two years previously. 62/14 Minutes: 31 March 2014

The minutes of the meeting held on 31 March 2014 were approved as a correct record and signed by the Chairman.

Minutes


Minutes of the Board – 30 April 2014 April 2014

63/14 Schedule of Matters Arising and Outstanding Decisions The Director of Corporate Affairs & Secretary submitted the schedule of matters arising

from the last meeting and outstanding issues from previous meetings. Progress against each decision was noted.

Minute 42/14: Quality Performance Report (Cancelled Appointments)

It was noted that a date had yet to be confirmed for the submission of a report to the Board. The Care Group Director, Planned Care would confirm the date.

Minute 43/14: Medical Records

The interim Medical Director advised that the report would be submitted to the May Board meeting.

Resolved: that

(a) the report be noted

(b) the Care Group Director, Planned Care confirm the date for the submission of the report to the Board on cancelled appointments

(c) the report in respect of medical Records be submitted to the May Board

meeting.

64/14 Declarations of Interests

There were no declarations of interest.

65/14 Chief Executive Report

The Acting Chief Executive submitted a report summarising key strategic and other issues since the March Board meeting. The Acting Chief Executive drew attention to the publication by Monitor of its three year strategy, the Care Quality Commission’s (CQC) national patient survey for 2013, the request from the Competition and Markets Authority for information on the impact of the proposed merger between Heatherwood & Wexham Park Hospitals NHS Foundation Trust and Frimley Park Hospital NHS Foundation Trust and the decision of the Berkshire West Clinical Commissioning Group federation to fund the extension of GP opening hours. The Director of Nursing advised that, in respect of the CQC survey, the Trust was at the average level of performance in respect of 73 questions, significantly better than average in nine and significantly worse than average in four. In response to a question, the Director of Nursing advised that there was one response which had been a surprise-that the Trust had performed significantly worse than average in respect of seeking the views of patients on the quality of care. A detailed analysis of the Trust position in the survey was being undertaken for the Board Patient Experience Group meeting in May.



Resolved: that the report be noted

66/14 Quality Performance Report The Director of Nursing submitted the quality performance report.

The Director of Nursing explained that the report provided a high level analysis with a focus on key performance issues. It was noted that shadow Care Group dashboards would be submitted to the Board in May. The Director of Nursing drew particular attention to areas of exception in respect of the Trust dashboard. These related to C. Difficile performance, serious incidents, admission to the ASU within four hours, the A&E four hour wait, complaints relating to attitude and behaviour and complaints responded to within 25 days. The Board noted the action being taken in respect of each. The Board noted the position of the Trust in respect of the national targets contained within the Monitor Risk Assessment Framework. The A&E and C Diff targets for the year had not been achieved. It was noted that validation of the 62 day cancer standard was continuing and could yet be achieved. The Care Group Director, Planned Care explained that the validation process was labour intensive and took time to complete. The Director of Nursing advised that there had been no cases of MRSA in the last year, and only one in the previous four years. The Director of Nursing advised that management of incidents remained challenging with a high backlog across the Trust. In addition, series incidents had exceeded the target with seven being recorded in March. Clarification was sought with regard the action being taken to reduce the number of incidents. The Director of Nursing advised that a target of a 50% reduction, by the end of April, had been set with, and achieved by, each of the Care Groups. The Board noted the position in respect of response times to complaints. It was noted that an action plan would be included as part of the Quality Account, to be considered by the Board in May. The Board noted that there had been a further never event in March, bringing the total to six. The Medical Director conformed that no patient harm had been caused in any of the cases. The Medical Director confirmed that a summary of each case and an action plan would be submitted to the Clinical Governance Committee. Resolved: that the report be noted

67/14 Care Group Performance Reports The Board received the monthly Care Group reports.

Urgent Care



The Care Group Director, Urgent Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. The Board noted that activity in the month was £2.5m below, and pay £1m above, forecast. The Care Group Director, Urgent Care advised that, in respect of pay costs, it had not been possible to reduce nursing expenditure as planned. This reflected patient acuity and, as a result, had presented challenges in reducing the level of 1:1 care. Clarification was sought on the reasons for income being below forecast. The Care Group Director, Urgent Care advised that this could reflect the impact of commissioner costs. Action was already being taken to review the skill mix in the light of the reduced income. It was noted that there was a £7m risk to the Trust budget from commissioners successfully implementing QIPPs.

Planned Care

The Care Group Director, Planned Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. Clarification was sought with regard to the financial benefit arising from the work of Newton Europe. The Care Group Director, Planned Care advised that more outpatient slots were now available as a result of the implementation of the Newton Europe recommendations.

Networked Care

The Director of Operations, Networked Care gave an overview of the Group dashboard, issues in respect of patient outcomes, experience, use of resources and key risks. The Care Group Director, Networked Care drew particular attention to issues in respect of microbiology accreditation, the proposed industrial action in Pathology, delayed transfers of care and activity at the Bracknell Clinic. Resolved: that (a) the report be noted

(b) a report be submitted to the May meeting of the Resources Committee setting

out the financial and operational impact of the Newton Europe work with the Trust

68/14 Finance Report

The Director of Finance submitted a report on the financial performance of the Trust for March 2014. The Director of finance advised that the Trust had reported a deficit of £0.02m in the month. This was £0.07m worse than forecast and £1m worse than budget. The year to date deficit was £6.79m. This compared with a forecast deficit of £3.5m. Once the Charity figures were included in the overall accounts, the deficit would be £6.12m. The Director of Finance advised that the key issues were in respect of income and control of pay. Whilst the corporate directorates and Networked Care had exceeded forecast



income, Urgent Care and Planned Care were behind forecast by £0.61m and £0.33m respectively. Pay was £0.13m worse than forecast principally due to nursing costs. The Director of Finance advised that the Continuity of Service Risk Rating (CoSRR) was 2, which was in line with the forecast. The Board noted that pay was better than forecast, at £21.27m due to delayed capital expenditure and a favourable movement in working capital. The Board expressed disappointment and concern at the year-end position of the Trust. Clarification was sought with regard to the possible impact of the year-end position on the early part of the 2014/15. The Director of Finance advised that the key areas for delivery of the budget were commissioner QIPPs, the Trust cost QIPPs, the growth in private patient income and control of headcount. Clarification was sought with regard to the level of uncoded episodes. The Director of Finance advised that the total for February amounted to £6,000. Clarification was sought with regard to the timing of the roll-out of service line reporting. The Director of Finance advised service line reporting was being used on a selective basis with specialties at present. Significantly greater use would be made of this by no later than June. Resolved: that (a) the report be noted

(b) the level of uncoded episodes be reported to the Resources Committee on a

monthly basis 69/14 A&E Update Report

The Care Group Director, Urgent Care submitted a report on action being taken to improve the performance of the Emergency Department in respect of achieving the A&E target and progress in respect of the Berkshire wide system recovery plan. The Care Group Director, Urgent Care advised that performance against the target in March had been 91.07%. This had contributed to a year-end position of 92.97%. Performance had improved since the middle of March, with the target being achieved in the first two weeks of April. This was against a backdrop of rising attendances and a significant number of patients in the Trust who were medically fit for discharge. The Care Group Director, Urgent Care explained that the factors underpinning the achievement in April were being assessed. However, the indications were that there had been a change in case mix, an increase in minors attendances and a reduction in bed occupancy in the Trust. It was noted that the trajectory submitted to Monitor and NHS England had been rejected. A revised trajectory had now been submitted. Resolved: that the report be noted



70/14 Berkshire West CCG Contract

The Director of Finance submitted a report setting out details of the 2014/15 contract with Berkshire West Clinical Commissioning Groups (CCG’s) and progress in respect of negotiations with other commissioners.

The Director of Finance gave an overview of contract income for the year. This included the

proposed contract with Berkshire West at a value of £203.63m. This was consistent with the Trust budget for 2014/15.

The Director of Finance explained that the key outstanding issue was in respect of first to

follow up appointments. It was anticipated that this matter would be resolved by the end of July through clinical discussions.

The Director of Finance gave an overview of risks and opportunities and other key issues. It

was noted that Berkshire West commissioners had agreed to cap marginal rate and readmission penalties at £3m, with £3m being reinvested in the Trust. The Committee commended the earlier agreement of the contract than in prior years and the successful re-investment of the £3m

The Committee noted that negotiations were nearing completion with Berkshire East

CCG’s. Discussions had not yet commenced with Oxfordshire CCG’s and specialist commissioners. The outcome of these negotiations would be submitted to the Committee for approval.

Resolved: that

(a) the contract arrangements with Berkshire West CCG’s for 2014/15 be recommended to the Board for approval

(b) progress with the contractual negotiations with other commissioners be

noted.

71/14 Nursing and Midwifery Staffing The Director of Nursing submitted a report providing an overview of the national

expectations of NHS providers and commissioners as set out by the National Quality Board and the Chief Nursing Officer of England.

The Director of Nursing explained that 10 key expectations had been set out in ‘How to

ensure the right people, with the right skill, are in the right place at the right time’. The Director of Nursing gave an overview of the position of the Trust in respect of each of the 10 expectations. The report also explained areas of future action to achieve and sustain compliance.

The Board noted that gaps in compliance would be addressed through the Trust’s recently

established Nursing Programme Board. Resolved: that the report be noted and the approach endorsed.



72/14 Emergency Preparedness Resilience and Response (EPRR) Assurance

The Acting Chief Executive submitted a report on the Statement of Compliance and improvement plan in respect of the EPRR standards. The Acting Chief Executive advised that providers of NHS funded care were required to work towards meeting the requirements of EPRR. The Trust had undertaken a self-assessment in October 2013 and an improvement plan had been prepared. All the actions set out in the plan had now been addressed. Resolved: that the Statement of Compliance be approved.

73/14 Nominations and Remunerations Committee Terms of Reference

The Director of Corporate Affairs & Secretary submitted a report setting out proposed changes to the terms of reference of the Nominations & Remuneration Committee. The Director of Corporate Affairs & Secretary explained that the proposed changes, which had been endorsed by the Committee, took account of the recommendations of an internal audit report. Resolved: that the revised terms of reference of the Nominations & Remuneration Committee be agreed.

74/14 Monitor Quarterly Return

The Director of Finance, Director of Corporate Affairs & Secretary and the interim Commercial Director submitted a report in respect of the quarter 4 return to Monitor.

The Finance Director explained that the Risk Assessment Framework required the

submission of a quarterly financial and governance combined return, comprising a number of declarations.

The Finance Director advised that the quarterly return required the Board to certify

confirmed or not confirmed in respect of three statements

• That the Board anticipated the Trust would continue to maintain a CoSRR of at least 3 over the next 12 months

• That the Board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds); and a commitment to comply with all known targets going forwards

• The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which have not already been reported

The Board was recommended to mark the statement in respect of the continuity of service

rating as “not confirmed”.



The Director of Finance explained that the plan submitted to Monitor showed the Trust

falling to a CoSRR of 1 at the end of June 2014 before returning to a 3 by December 2014 and a 4 by March 2016. Whilst action was being taken to improve the rating at the end of June 2014 to a 2, the statement should be marked as ‘not confirmed’.

The Board was recommended to mark the statement in respect of the compliance with

targets going forward as “confirmed”. It was noted that, on the basis of the information reported to the meting, there was now greater confidence in meeting the A&E target on a sustained basis.

With regard to exception reporting, the Board was recommended to mark this as

‘confirmed’ on the basis that there were no known issues requiring an exception report. Resolved: that

(a) the Acting Chief Executive and Director of Finance be authorised to sign the quarter 4 Monitor return

(b) the statement that the Board anticipated that the Trust would continue to

maintain a continuity of risk rating of at least 3 over the next 12 months be marked as ‘not confirmed’

(c) the statement that the Board was satisfied that plans in place are sufficient to

ensure: ongoing compliance with all existing targets (after the application of thresholds); and a commitment to comply with all known targets going forwards be marked as ‘confirmed’

(d) the statement that the Board confirms that there are no matters arising in the

quarter requiring an exception report to Monitor which have not already been reported be marked as ‘confirmed’

(e) the submission of the full return to Monitor be approved

75/14 Minutes of Meetings

The Board received the draft minutes of the following meetings Audit & Risk Committee 25 March 2014 Charity Committee 31 March 2014 Board Strategy Group 31 March and 16 April 2014 Resources Committee 16 April 2014 Quality Governance Group 22 April 2014 The Chairs drew attention to significant issues discussed and matters that had been agreed should be highlighted to the Board. The Board noted that it was proposed to hold a workshop in the integrated business plan after the May Board meeting. Resolved: that the minutes of the meetings be received and the recommendations therein endorsed.



76/14 Audit & Risk Committee Annual Report to the Board

The Board received the Audit & Risk Committee Annual Report. The Chairman of the Committee gave an overview of the report and explained that production of the document was considered to be good practice. It was suggested that the content of the document could be developed by providing further detail in respect of, for example, the number of high, medium and low risks in internal audit reports and key areas reviewed. The Chairman undertook to include this in future reports. Resolved: that the report be noted.

77/14 Board Work Plan The Board received the updated work plan for review.

Resolved: that the report be noted.

78/14 Date of Next Meeting

Resolved: that the next meeting of the Board be held at 9.30am on Thursday, 29 May 2014.

79/14 Exclusion the Press and Public Resolved: that the press and public be excluded from the remainder of the meeting

given the exempt nature of the business to be conducted, as defined by the Freedom of Information Act.

Chairman

Date 29 May 2014

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 3

May 2014 Board 1

Board Date Board Minute Subject Decision Owner Update November 2011 167/11 Real Estate Strategy

(RES) Final strategy to be submitted. Also January Board Minute 05/13.

Philip Holmes Real Estate Strategy will be completed in the month following the IBP’s approval

October 2013 157/13 Executive Report The interim Commercial Director review the structure and content of the Trust and Corporate Group dashboards to ensure the accuracy of the content and their consistency with the position reported in Care Group reports

John Taylor

Trust dashboard reviewed for accuracy and reported to Care Groups and Clinical Governance prior to finalising. Care Group template to be revised for July 2014.

November 2013 175/13 Executive Report The Chair of Audit & Risk Committee discuss with the Director of Finance a possible audit of activity to provide assurance that potential income was not being lost due to late reporting.

Craig Anderson

Proposal for mapping income processes under review by Informatics/ Finance Update to be provided at the May meeting of the Audit & Risk Committee (see 18/14). Proposal deferred as requiring discussion with new Director of IM&T.

November 2013 178/13 QGF/IBP timetables The Executive review the proposed timetable in respect of the QGF and IBP to bring forward completion dates for individual actions where possible

Alistair Flowerdew/ Caroline Ainslie

Quality Governance Framework will be submitted to the July Board.

January 2014 04/14 Executive Report The Care Group Director Planned Care arrange a post-Board briefing session with the clinical lead for Ophthalmology to discuss the performance of the service.

Peter Malone Scheduled to take place after the June Board meeting.

January 2014 10/14 Patient Engagement and Experience Strategy

A progress report on the implementation of the strategy be submitted to the July 2014 Board meeting.

Caroline Ainslie Scheduled for the June Board PEG meeting.

February 2014 18/14 Schedule of Matters Arising and Outstanding Decisions

The integrated business plan be submitted to the June Board meeting

John Taylor

IBP to be developed in tandem with Annual Plan process for June 2014

February 2014 21/14 Performance Report Ophthalmology be included in the areas covered by the target for reducing rescheduled appointments in 2014/15

Caroline Ainslie/ John Taylor

To be included in Quality Account (April 2014) and included in Board Quality Report (March 2014)


May 2014 Board 2

Good and poorly performing departments would be highlighted in the analysis of performance against waiting times.

Caroline Ainslie/ John Taylor

Scheduled for inclusion in April 2014 Quality Report

March 2014 39/14 (25/14) Matters Arising: Emergency Preparedness Resilience and Response Assurance

The Director of Finance advised that a summary of the costs of compliance would be submitted to the next meeting of the Board.

Craig Anderson Completed

March 2014 39/14 (35/14) Matters Arising: Budget Planning 2014/15

The Director of Finance advised that he would be discussing the rephasing of the Trust loans with the Foundation Trust Financing Facility within the next three months.

Craig Anderson Initial meeting held with FTFF. Proposal to develop options to be completed by September.

March 2014 46/14 Care Quality Commission (CQC) Intelligent Monitoring Report

The Executive give consideration to the opportunity for tracking, and giving advance warning of issues in respect of Trust performance against the indicators used by the CQC to produce the quarterly reports.

Alistair Flowerdew/ Caroline Ainslie

CQC Assurance Paper presented to May Board. Comprehensive assurance system will be in place by July to highlight risks of potential future IM risks and provides assurance that current IM risks are being effectively managed.

March 2014 74/14 Decontamination Business Case

An analysis be undertaken of the potential for the disposal of the remaining part of the Battle site Confirmation be provided that the contract placed no liabilities on the Trust in respect of staff at the end of the five year period

Philip Holmes Craig Anderson

Meeting arranged with SCAS and RBH estate agents to revisit options Awaiting final contract review.

March 2014 58/14 Monitor Operational Plan The Executive review as a priority the plans to achieve the 108 reduction in headcount

Alistair Flowerdew

Specific plans are not yet completed and verbal update to be given at Board.

April 2014 63/14 (42/14) Matters Arising: Quality Performance Report (Cancelled Appointments)

It was noted that a date had yet to be confirmed for the submission of a report to the Board. The Care Group Director, Planned Care would confirm the date.

Peter Malone Completed

April 2014 63/14 (43/14) Matters Arising: Medical Records

The report in respect of medical Records be submitted to the May Board meeting.

Brian Reid The Health Records Steering Group continues


May 2014 Board 3

to achieve improvements in the availability, quality and content of records through actions with ward admin staff, clinical staff and the medical records team. The success of actions taken following the audit in Nov 2013 will be monitored, re-audited and outcomes collated in a report for the Board and for the next Clinical Governance Committee (following discussion at the meeting of 22 May).

April 2014 67/14 Care Group Performance Reports

A report be submitted to the May meeting of the Resources Committee setting out the financial and operational impact of the Newton Europe work with the Trust

Craig Anderson Deferred to June Resources Committee

April 2014 68/14 Finance Report The level of uncoded episodes be reported to the Resources Committee on a monthly basis

Craig Anderson Actioned.

April 2014 80/14 Governor Attendance at Part 2 of the Board

A revised draft of the protocol be distributed to Board members for comment.

Keith Eales Completed

April 2014 82/14 Pre-Op and Ward Extra Ward Business Case

The Care Group Director, Planned Care investigate the issues raised at the meeting and provide an update to the Resources Committee on 12 May 2014

Peter Malone Completed.

April 2014 85/14 Incidents and Safeguarding Report

The trend in the number of serious incidents over the previous 18 months be submitted to the Clinical Governance Committee.

Caroline Ainslie Report to be submitted to the Clinical governance Committee in July 2014

April 2014 86/14 Draft Information Quality Strategy

The item be referred to the Resources Committee for consideration.

Tim Warren Completed.

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Royal Berkshire NHS Foundation Trust Agenda Item 5a

Board of Directors

Title: Chief Executive Report

Date: 29 May 2014

Lead: Alistair Flowerdew, Acting Chief Executive

Purpose: The purpose of this paper is to update the Board with a summary of key strategic and environment issues since the previous Board meeting: This includes items that may impact on policy changes, quality and financial risks in the health economy.

Key Points:

Key Items of note include:

• Report published by the Foundation Trust Network which highlights the costs incurred by hospitals to implement the recommendations of the Francis, Keogh and Berwick reviews to improve quality of care. The report emphasises that these costs have been incurred without additional funds for providers.

• The Kings Fund has published a report on the challenges faced by the NHS in meeting the increasing demand for health care with reducing funds. It uses the findings of a survey of six hospitals to explain how providers have coped and gives suggestions on how the productivity challenge can be met going into the future

• The proposed acquisition of Heatherwood and Wexham Park FT by Frimley Park Hospital NHS FT has been cleared by the Competition and Markets Authority and endorsed by Monitor.

Decision required:

The Board is asked to note the Chief Executive Report.

FOI Status:

This report will be made available on request.

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1 Cost pressures of implementing Francis and Keogh

1.1 The Foundation Trust Network (FTN) has published a document called “How much does high quality care cost?”. This is the report from a survey of NHS Foundation Trusts on the financial implications of implementing the recommendations of the Francis and Keogh reviews.

1.2 The report highlights the substantial financial investment required as a result of Francis and Keogh and identifies that all providers are facing significant costs in implementing the recommendations of the reviews.

1.3 The survey also indicates that:

• Providers are facing costs that are substantially higher than the funding provided through the additional uplift of 0.3%. For 2014/15 alone, acute providers are spending up to four times more than the funding provides.

• Acute providers are facing estimated costs of up to £1bn over, 2013/14-2015/16.

• Over 95% of the additional costs incurred relate to additional staff recruitment. One acute trust increased its full time nurses by 200 to increase staffing levels at night at a cost of £3.5m.

1.4 Responders to the survey also added that they are facing additional service development cost pressures as a result of: the roll out of seven day services; a move towards integration; redesign of A&E and other care pathways and a number of other initiatives. These are additional unfunded costs and the report suggests that unless commissioners fund these service improvements, providers will struggle to both redesign services to improve the quality of care and remain financially sustainable.

1.5 The report recommends that more needs to be done by commissioners to ensure that the NHS Foundation Trusts and Trusts do not disproportionately bear the financial pressures imposed by the implementation of the recommendations of the Francis and Keogh reviews. The FTN recommends five changes:

• statutory bodies must fully consult providers to assess the financial and quality impact of every proposed national initiative for new service designs and innovation on providers before implementation;

• there should be a transparent and consultative process for determining service development uplifts each year;

• service development uplifts and payment systems must fully reflect the costs that providers face;

• there must be equal treatment for all providers, acute and non acute; and

• commissioners and providers need to work together to find local solutions to the funding challenges imposed by the Francis and Keogh reports and other local service development challenges that emerge.

1.6 These recommendations resonate with the Trust as it seeks to negotiate with local commissioners to ensure that we achieve appropriate levels of funding to continue to deliver high quality care without compromising our financial viability.

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2 The NHS productivity challenge

2.1 The King’s Fund has published a report “The NHS productivity challenge, experience from the frontline.” which traces the trend of NHS funding and the emerging challenges.

2.2 The NHS experienced the greatest growth in funding in its history between 1997/8 and 2008/9 with funding as a percentage of GDP increasing from 5.2% to 8.6% during this 12 year period. Funding has stagnated since 2009/10 and real terms growth is about 0.3%. Planning from 2015/16 onwards assumes a zero percent growth. NHS funding will fall back from 8% to about 6% of GDP. The anticipated creation of the Better Care Funds will also mean that an additional £2bn of NHS funds will also be transferred elsewhere.

2.3 Closing the funding gap: In the past NHS providers responded to funding shortages by restricting capacity such as allowing longer waiting lists and closing wards towards the end of the financial year. This is less tolerable in the current climate. The NHS needs to find innovative ways of stretching its limited funds. Nationally, the NHS has sought to reduce the initial £20b funding gap through:

• Traditional efficiency gains induced through the Payment by Result system which incentivises providers to cut costs. Acute trusts have faced a real cut in PbR prices of 6.3% between 2010/11 and 2014/15.

• Central initiatives: reducing management staff; reduced central budgets; staff pay restraints; and new ways of providing care such as shifting services out of hospitals.

• NHS QIPP savings (approximately 5% in 2011/12 and 2012/13).

2.4 Productivity ideas: suggestions on how NHS organisations can address the ongoing funding gap including a focus on:

• Infrastructure; estates, procurement and support services (back office).

• Workforce; reduced sickness and absence, flexible workforce and enhanced volume of work.

• Clinical practice; revised service models and their impact on efficiency and quality).

• Adoption of NICE recommendations and public health guidelines.

• Redesign of care pathways and integration of services.

2.5 However, the report highlights additional business drivers which should be explored such as:

• managerial practice and talent;

• quality of labour (workforce);

• use of Information technology;

• learning that is derived from continuous practice or best practice;

• service innovation and infrastructure and centralised or decentralised structures; and.

• competition forcing organisations to enhance productivity.

2.6 This report has significant implications for RBFT as we face many of the challenges highlighted above. The Trust welcomes the need for radical and innovative approaches to a sustainable and viable future.

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3 Fit for an ageing population

3.1 The Kings Fund has also published a report, “Fit for an ageing population” which describes the key elements of the care services for older people and how their improvement will lead to improvements in the overall quality of care and in the efficiency gains to the health economy.

3.2 It identifies key components of the services to older people which are interdependent and concludes that any deficit in any one of them affects the others. The key components of older people services include:

• Living well with complex co morbidities, dementia and frailty.

• Good acute hospital care when needed.

• Good discharge planning and post discharge support.

• High quality nursing or residential care for those who need it.

• Choice, control and support towards the end of life.

• Integration to provide person centred coordinated care.

3.3 The report asserts that transformation of older peoples care should shift towards coordinated person-centred care that is designed around the needs of the individual patients rather than diseases. Care should be focused on prevention and maintaining the independence of the patient. This will require integrated working between providers in primary and community services to achieve.

3.4 Referring to developments in healthcare, it highlights the growth in life expectancy; 48% of people died before the age of 65 when the NHS was first formed but this has reduced to 14%. The number of people aged 85 years and above has doubled over the past three decades. By 2030 one in five people in England will be over 65 years old and this cohort of people is the highest consumer of health and social care resources.

3.5 The report highlights key steps that could be adopted to improve the quality of care and integration of services for older people. The main steps are:

• define the care pathway from prevention of ill health to end of life;

• agree a shared overarching vision and some key standards between partners;

• involve older people and their carers in service redesigns from the outset;

• agree whole system outcome measures as well as outcome measures for the individual elements of the services; and

• implement best practice in all components of older people care.

3.6 We are a major partner, through our Networked Care Group, with other community based providers in delivering high quality integrated care for frail older people. The recommendations, examples and evidence of best practice in the documents are all relevant to our vision of enhancing the quality of the integrated services provided for frail older people.

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4 Care for the dying

4.1 The National Care of the Dying Audit for Hospitals, led by the Royal College of Physicians, has found significant variations in care across hospitals in England. A recently published report shows that major improvements are needed to ensure better care for dying people, and better support for their families, carers, friends and those important to them.

4.2 While previous audits had been based on the goals of care within the Liverpool Care Pathway for the Dying Patient (LCP), the new audit sampled the care of dying people in hospital, regardless of whether they were supported by the LCP or other care pathways or frameworks, and included more hospitals than the previous audits. Highlights include:

• Only 21% of sites had access to face-to-face palliative care services 7 days per week, despite a longstanding national recommendation that this be provided; most (73%) provided face-to-face services on weekdays only.

• Mandatory training in care of the dying was only required for doctors in 19% of trusts and for nurses in 28%, despite national recommendations that this be provided. 18% of trusts had not provided any training.

• 47% of trusts did not have a named board member with responsibility for care of the dying. In 42% of trusts care of the dying had not been discussed formally at trust board in the previous year and only 56% of trusts had conducted a formal audit of such care.

• Only 47% of trusts reported having a formal structured process in place to capture the views of bereaved relatives or friends prior to this audit.

5 Monitor: role of the medical director

5.1 Monitor and the NHS Trust Development Authority are exploring the development of a range of programmes to support medical directors as a means of promoting well led organisations delivering patient benefit. To this end, they have conducted a survey of medical directors (completed by 40%) to establish current support and requirements. Initial results have produced some interesting development opportunities:

• There is a need for a greater role clarity with more acknowledgement of the strategic as well as the operational aspects of the role;

• clearer training and career pathways supported by a means of identifying the medical directors of the future and making it a clearer career option that more people will consider;

• with a high proportion of medical directors new to the role, there is a need for more organisational and peer support, including mentoring and induction, particularly on corporate responsibilities, adopting a strategic outlook and growing personal resilience.

5.2 Effective medical directors are critical to securing sustainable improvements in the quality of patient care, a pressing concern now for trusts across the sector. Monitor and NHS TDA will continue to respond to these headline points as part of their growing development work programme.

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6 Merger update

6.1 The Competition and Markets Authority has given its clearance for the merger of Heatherwood and Wexham Park Hospital NHS Foundation Trust (HWFT) and Frimley Park Hospital NHS Foundation Trust (FPFT). Monitor has endorsed the clearance and has reiterated that the merger was the most viable way forward for HWFT and that further regulatory intervention would be not yield any benefits to the Trust or patients. Monitor indicated that it will now focus on the implementation of the merger to ensure that all associated risks are addressed and that the interest of the patient becomes the paramount concern.

6.2 The merger of HWFT and FPFT poses a challenge for RBFT in terms of competition for the Berkshire East health care market and a potential threat to the services that we provide in Bracknell Clinic. We will continue to work with HWFT to ensure our current partnership arrangements deliver the best care for patients.

7 Proposed development of private acute hospital at Maidenhead

7.1 Proprietors of a group of schools in Windsor and Maidenhead called Claires Court have published a public consultation document in respect of their planned development of three of their school sites which includes the build of an acute hospital to be called “Institute of Medicine and Surgery, Berkshire”. The proposed hospital is to be located in Maidenhead.

7.2 The consultation document indicated that the proposed hospital will provide both private and NHS services and would be built in partnership with Berkeley Homes. According to the notice of consultation, the hospital will be located on “a ten acre site and is planned to offer treatments for both private and NHS patients, providing acute and specialist services, undertaking complex medical procedures and treatments, and specialising in a range of complex medical areas such as cardiology, cardio-thoracic surgery, neuro-surgery, surgical oncology and complex orthopaedics”.

7.3 The publication also stated that “the new hospital will include intensive therapy and critical care units and provide specialist diagnostic imaging services, alongside offering the mainstream medical services currently available at existing private hospitals in the area. It will create around 400 direct new jobs covering a wide range of skills”.

7.4 The Trust will keep an eye on developments and consider potential impact posed by the proposal in its strategic planning process.

8 Meeting on future of healthcare in South Reading

8.1 A meeting was hosted by the MP of Reading West Mr Alok Sharma to discuss the future of healthcare in South Reading. The public were invited to discuss issues of concern with the key representatives of commissioners and providers. The attendees included senior executives from the Trust, Berkshire Healthcare NHS Foundation Trust, the chief officer of the Berkshire West federation of CCGs and representatives of the local authority and the Director of Public Health.

9 Posthumous honour for RBFT staff

9.1 Jimmy Cullen, a former employee of RBFT’s estates department who died last year has been honoured by Trust staff.

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9.2 Jimmy was a well known and much loved member of staff who was known for going above and beyond. He once stayed at work for three straight nights during the heavy snow of 2009 to ensure the A&E access road was clear and to keep a running supply of blankets and tea for stranded staff, outpatients and visitors.

9.3 A chair engraved with Jimmy’s name has been unveiled and located in the garden next to the acute medical unit.

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Royal Berkshire NHS Foundation Trust Agenda Item 5b

Board of Directors

Title: Quality Performance Report

Date: 29 May 2014

Lead: Caroline Ainslie, Director of Nursing

Purpose: The purpose of this paper is to provide the Clinical Governance Committee with an analysis of quality performance to the end of April 2014. The report covers performance against the Monitor Risk Assessment Framework, CQC as well as national and local key performance indicators.

Key Points: The Quality Performance Report is designed to provide high level analysis and identify and escalate key performance issues:

• Quality Report narrative: additional analysis and data of exception items requiring commentary. Includes performance issues.

• Quality Dashboard: highlighting quarterly, current month performance and forecast against the most significant indicators.

• Quality KPI Scorecard: additional metrics with granularity by theme, month and previous year’s outturn.

Appendices:

Items of note from this month’s report include:

• Infection Prevention and Control Annual Plan 2014/2015

• Dementia CQUIN/Dementia Carers Audit Report 2013/14

‘Red’ performance was recorded against 4 targets in the Trust dashboard in April:

• Serious Incidents reported.

• Cancer waiting time targets: 2 week wait suspected cancer, 2 week wait breast symptoms, 31 day drugs, 31 day surgery, 62 day from GP referral.

• Number of formal complaints received.

• Complaints relating to attitude & behaviour

Deteriorating performance was recorded against 3 targets and improved performance was recorded against 9 targets.

• Monitor: We are achieving the A&E target in April. However, given the challenges in this area we are closely monitoring performance. This and the potential failure of 62 day cancer target present the risk of failure to comply with the Risk Assessment Framework.

• CQC: CQC compliance has been included within the Quality Performance Report for the first time and a programme of assurance is being developed for the Board (and is outlined in a separate paper to the Board).

• Patient safety: Management of incidents remains challenging. Serious

2

Incidents have exceeded target, with 6 reported in April.

• Clinical effectiveness: Weekend HSMR 12 month rolling has reduced to 96.63 (March 13 to February 14) and the HSMR 12 month rolling all days of the week (March 13 to February 14) has reduced to 89.21. This figure will increase following rebasing and the final position for each indicator is likely to be 10 points higher but still within the expected range.

• Patient experience: Performance against the Net Promoter Score has improved to 79 which is better than target. The in house inpatient survey overall recommendation rate has reached its highest ever score at 99%. However, the number of formal complaints has risen in April and complaints related to behaviour and attitude is continues to rise.

• Staff: Appraisals and completion of mandatory and statutory training continue to increase slowly but remain below target. Sickness absence has reduced in April but is still higher than target.

.

Decision required:

The Board is asked to note the Quality Performance Report and the actions being taken.

FOI Status: This report will be made available on request.

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1 Introduction

1.1 The purpose of this report is to provide assurance to the Clinical Governance Committee and Board of Directors on compliance against the Monitor Risk Assessment Framework, national and local key performance indicators. It acknowledges significant and notable achievements, and highlights and discusses areas of concern or where performance has a less than favourable forecast.

2 Monitor compliance

2.1 The majority of targets continue to be met, but there risk of on-going compliance on key targets around A&E and Cancer.

2.2 A&E

2.3 Performance was 96.6% of patients treated in 4 hours in April 2014.

2.4 The Trust continues to keep Monitor informed of progress against the Berkshire West system recovery plan and ECIST recommendations are being implemented.

2.5 Cancer Waiting Times

2.6 Cancer access targets are currently showing as unachieved in April 2014 (this data is subject to ongoing validation).

• Two week wait (actual: 87.8% target 93%)

• Two week wait breast symptoms (actual: 87.3% target 93%)

• Cancer 31 day wait surgery (actual: 91.3% target 94%)

• Cancer 62 day from GP referral (actual: 79.8% target 85%)

2.7 Validation is ongoing and the final position is likely to improve. However it is highly unlikely that the two week wait or two week wait breast symptoms will be achieved this month. Achievement of the two week wait target for quarter 1 is unlikely. The main cause of two week wait breaches is due to the impact of the Easter Bank Holidays in month on available capacity in endoscopy, breast and dermatology. Additional consultant posts in endoscopy are out to advert.

Figure 1: 12 month trend waiting time to first appointment for suspected cancer

84%

86%

88%

90%

92%

94%

96%

Target = 93% Seen in 2 weeeks suspected cancer

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2.8 The 62 day target is also under threat this month. The major concern on the 62 day pathway remains CT where waits are over 2 weeks.

Figure 2: 12 month trend cancer waiting time 62 day from GP referral to diagnosis

3 Care Quality Commission Compliance

3.1 The CQC final report following its inspection of the Trust will be received during the week commencing 26 May 2014. The CQC will be holding a Quality Summit on 13th June to which it has invited key stakeholders such as Monitor, the CCG and Unitary Authorities. The Acting CEO will present the Trust’s response and a ‘rating’ will be agreed. Rating categories are outstanding, good, requires improvement or inadequate.

3.2 The next quarterly CQC Intelligent Monitoring report about the Trust will be published in early June 2014. The Trust will not be placed in a scored band as in previous reports, but will be placed in a ‘Trusts which have been previously inspected’ band. Risks will continue to be identified within the report. A paper (Appendix 2) has been prepared for the May Board setting out the processes in place to improve the Board assurance and early warning triggers associated with the CQC Intelligent Monitoring Report.

3.3 Within the March 2014 CQC Intelligent Monitoring Report, the Trust had four risks. The action relating to the risks is being monitored by the Quality Performance Committee – the latest position on the risks is outlined below:

3.4 Dr Foster: Hospital Standardised Mortality Ratio (weekend) – Elevated Risk.

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

Cancer diagnosis in 62 days of GP Referral Target = 85%

This indicator is not expected to be identified as a risk within the next CQC Intelligent Monitoring Report published in June 2014. The 12 months rolling HSMR (Dr Foster) from March 13 to Feb 14 was 98.82 on Saturdays and 93.06 on Sundays which is lower than expected (100 is the average value) when compared to other hospitals. Weekend HSMR 12 month rolling has reduced to 96.63 and the HSMR 12 month rolling all days of the week has reduced to 89.21. This figure will increase following rebasing and the final position for each indicator is likely to be 10 points higher but still within the expected range.

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Figure 3: HSMR weekends and all days of the week in 2013/14.

3.5 The Trust aims to reduce and sustain its weekend HMSR to the national benchmark of 100 or less by March 2015. We will build on improvements that the “Surviving Sepsis Campaign” has already achieved and in 2014/15 we aim that 90% of all patients admitted to the Emergency Department with a diagnosis of infection will receive antibiotics within one hour.

3.6 In addition to current work-streams in place for community acquired pneumonia, which is the main contributor to our raised weekend HSMR, a successful Quality Improvement project led by two junior doctors, with multi-disciplinary team input is in place on the Acute Stroke Unit to address aspiration pneumonia in stroke patients being internally fed. Rates have fallen from 60% to 0-5%. This work will be implemented to other wards for all patients fed with a naso-gastric tube, led by the Nutrition Team. In addition, this work is to be implemented in 9 other hospitals (4 in UK, 3 in USA and 1 in Netherlands; led by RBFT) through our membership of the international collaboration 'Global Comparators'.

3.7 The most recent Dr Foster performance data for pneumonia for the period March 13 – February 14 shows the relative risk for the Trust at 97.0 in February 14 which is within the expected range when compared to hospital trusts nationally.

Figure 4: Dr Foster HSMR performance data for pneumonia March 2013 to February 2014

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3.8 The Trust has been awarded £27,500 by Patient Safety Federation for work on sepsis involving international collaboration with the Global Comparators programme.

3.9 Never Events – Risk

3.10 The Trust is undertaking a trust-wide review in this area to focus on creating a learning culture, and culture change. This is being led by Planned Care supported by Dr Emma Vaux and the Quality Improvement team. There has been significant clinical engagement to drive this work forward, and actions being taken include:

. The Trust had five never events in 2013/14 (one has been downgraded) all of which have individual action plans to address the issues identified which are being monitored through the trust Clinical Outcomes & Effectiveness Committee, chaired by the Acting CEO. It is expected that Never Events will be identified as an elevated risk within the June 2014 Intelligent Monitoring Report.

• Development of a Theatre Patient Safety Strategy. • Launch of the Theatre Patient Safety Group in May 2014. • Human Factors Programme focusing on team working and technical and non

technical skills. • Bespoke clinical incident debriefing programme funded by the Making Every

Moment Count Programme. Piloting working with junior doctors around clinical incident reporting and patient safety.

• Surgical Sepsis Programme of work to be implemented with colorectal surgeons, in partnership with the Academic Health Science Network.

• Development of a bespoke Surgeon Leadership Programme in partnership with the Thames Valley Leadership Academy.

• Embedding WHO checklist team debrief using learning from Plymouth surgeons. • The Trust has been awarded £30,000 by Patient Safety Federation to support this.

3.11 Monitor Governance Risk Rating – Risk.

3.12

The Monitor Governance Risk rating since 7 March 2014 is green. This indicator is not expected to be identified as a risk within the next CQC Intelligent Monitoring Report published in June 2014

Composite risk rating of ESR items relating to staff turnover – Risk

3.13 In respect of Medical & Dental staff, turnover has reduced marginally from Q3 (9.60 %) to Q4 (9.17%). Discernible reductions in turnover have also been noticed for other occupational staff groups over the same period. However, turnover for Allied Health Professionals remains high and has increased from Q3 (18.28%) to Q4 (19.02%).

. Employee turnover continues to remain higher than desirable, meaning additional recruitment costs and a loss in continuity a care. For the period January – April 2014, the Trust has reduced turnover for other clinical staff with the exception of allied health professionals where there has been a small increase in turnover. The turnover for medical and dental staff has reduced from the previous quarter.

3.14 A Recruitment & Retention Strategy has been developed and is currently being consulted with clinical stakeholders, prior to approval at the June/July Board. In additional workforce reporting is being refined for 2014-15 to better inform management actions.

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4 Quality Report: Exceptions

4.1 Patient safety

4.2 Incidents.

4.3 There were no Never Events reported in April. The Trust reported 6 never events in the last year but we have now received confirmation from the area team that one of the reported events will be downgraded. The Quality Improvement Programme Director is working alongside the Theatre teams to a Theatre Safety Strategy, with key work focusing on surgeon leadership, behaviours and the surgical safety checklist.

In April there were 6 serious incidents reported on STEIS. Although 2 of these SI’s occurred on the same ward there is no obvious linkage to the events. An external review of Maternity services has been commissioned from the Royal College of Obstetricians and Gynaecologists and we are awaiting confirmation of the timing of this review.

4.4 The backlog of unapproved incidents on Datix has reduced to 325 incidents that have not been reviewed by the responsible manager or validated. The Care Groups delivered a 50% reduction at the end of April. The challenge is now to sustain this performance. The focus has now moved to corporate departments where there were a total of 151 unapproved incidents at the end of April.

Figure 5: Backlog of unapproved incidents

4.5 Infection Control:

0

100

200

300

400

500

600

Estates, Facilities and other

Urgent Care

Planned Care

Network Care

Unapproved incidents

The Department of Health has issued urgent guidance on actions needed to address the risk posed to trusts and other healthcare organisations by carbapenemase-producing enterobacteriaceae (CPE) and other carbapenem-resistant organisms. CPE represent one of the most serious emerging infectious disease threats that England currently faces, and the failure to control their spread now, while we still have the opportunity, could have substantial human health and financial consequences. Infections caused by these bacteria are extremely difficult to treat as they are resistant to carbapenems, which are considered ‘last resort’ antibiotics. Management of these infections is not only more difficult, affecting patient outcomes, but also significantly more costly for the healthcare system.

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4.6 The trust has implemented an immediate initial plan to identify high risk patients and screen them as per the guidance. Planning is in progress to address all aspects of this guidance.

4.7 Progress against the Clostridium Difficile target continues to improve with only 1 case reported in April.

Figure 6: Hospital acquired C Difficile 12 month trend

4.8 The Infection control annual plan was approved by the Infection Prevention Committee and is attached as Appendix 1 for information.

4.9 Maternity Care

4.10 1:1 care in labour also fell below target to 92% in April. Weekly monitoring is in place and will improve this position in May.

: the normal birth rate has reduced to 59% against a target of 63%. Less than 60% normal birth rate prompts a red flag. This has been impacted by the 50% closure of Rushey Unit. This indicator will be included in the KPI dashboard from next month.

4.11 The elective caesarean section rate continues to be higher than target (actual 15%, target 10%). An investigation is being undertaken which will report to the Quality Performance and Learning Committee in June 14.

4.12 Clinical effectiveness

4.13 Mortality Indicators:

4.14

See appendix 2 for details of a separate workstream designed to improve understanding and use of mortality data, which will provide enhanced assurance to the Board in July.

Stroke:

4.15 The CCG is assured that the Trust is performing well against the other stroke indicators, as evidenced through the Sentinel Stroke National Audit Programme (SSNAP) 2013.

The Trust has re-negotiated the removal of the locally set target to ensure that 90% of stroke patients are admitted to the Acute Stroke Unit within 4 hours with the CCG.

4.16 The CCG acknowledges that it is more important to focus on patient outcomes than the 4 hours target and in view of this has decided that they will continue to monitor the 4 hour to stroke unit target (allowing for clinical exceptions to be removed as agreed previously) but this will not be the focus for determining the quality of care being delivered to patients on the stroke pathway with the caveat that the Trust continues to perform well against the other stroke indicators.

0123456789

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Number of C Diff Infections 2014/15 Trust stretch target = 30

2014/15 Trust stretch target = 30 DH 2014/15 target = 40

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4.17 The CCGs still require the Trust to continue to improve performance against the 4 hour target for stroke patients ‘out of normal working hours’, in line with the Trusts work on improving 7 day working.

4.18 Patient experience

4.19 Performance against the Friends and Family Test (Inpatient Survey) has exceeded target for April (79 against target of 70). Overall response rates are 31.3% against a target of 30%. There are four wards across Urgent and Planned Care who are currently performing well below the threshold of 30%. Plans are in place to improve performance in May and an increase in performance is expected in June.

4.20 The in house inpatient survey overall recommendation rate has reached its highest ever score at 99%.

4.21 Complaints & PALS:

4.22 The Complaints department have initiated a survey to seek feedback from complainants about their levels of satisfaction with complaints handling. Results of this survey will be reported to the Patient Experience Committee.

The number of complaints has increased significantly in April 2014. Performance against responding to complaints in 25 days remains significantly short of target in Planned (44%) and Urgent Care Groups (40%). The average number of days taken to close a complaint was 35 in April.

4.23 Improving staff attitudes and communication

Figure 7: Complaints relating to behaviour and attitude 12 month trend

Complaints relating to behaviour and attitude have risen to 10 in April. 5 of these relate to medical staff.

02468

10121416

behaviour and attitude complaints

2014/15 target = 39

Linear (behaviour and attitude complaints)

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5 Workforce

5.1 Appraisals:

5.2

Appraisal rates, at 85%, are still short of the target of 95%. Whilst significant improvements have occurred across Care Groups and Corporate areas to make achievement of the target in those areas likely, Planned Care remains significantly below target at 76%.

Mandatory Training:

5.3

The snapshot position at the end April was 71.6% of staff had received Mandatory Training compared with the target of 85%. This is a 6% improvement on the previous month.

Sickness absence:

6 Data Quality

The absence rate has reduced in April to 2.9%.

6.1 As part of the Quality Accounts external audit opinion, the following have been subject to data testing during March/April 2014:

• Cancer 62 day; GP referral

• C.Difficile.

6.2 The auditors did not identify any issues that impact on their ability to issue a limited assurance opinion in respect of this indicator.

6.3 The auditors also conducted data testing on reporting of cancelled operations and a number of issues with this data were identified:

• Testing of the cancelled operations indicator has given them concerns in respect of the completeness of information held on cancelled operations for 'not clinical' reasons as records provided by the Information could not be reconciled to the data held on the BlueSpier theatre system.

• Their testing also highlighted instances where the reported data could not be verified to supporting information on the Trust’s BlueSpier theatre system and/or the EPR system.

• They have identified an inconsistent approach taken by the different departments and specialties across the Trust for reporting purposes i.e. there were inconsistencies with the source of this data: EPR, the BlueSpier theatre system or locally held records.

6.4 The Executive will be formulating a detailed action plan to reconcile the two systems and provide assurance that the cancelled operations data is accurate. This will be in place by end of June 2014.

7 Contact

Contact: Caroline Ainslie, Nursing Director

John Taylor, Acting Commercial Director

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Quality Performance Report: Appendix 1 Infection Prevention and Control Annual Plan 2014/2015

The table below identifies the high level actions that are to be addressed and monitored through the delivery of the infection prevention and control annual plan for 2014/15. The objectives of this action plan follow the Code of Practice on the Prevention and Control of Infections and Related Guidance. It is proposed that achievement against this plan will be reported monthly to the infection control committee and relevant objectives monthly to the board.

Strategic Principle Objective Measures

1.

Provide the best patient experience

Develop an understanding of the surgical site infection rates for breast surgery planned orthopaedics and c section

Develop strategy, implement actions and monitor trends to better understand how we can improve care for patients. Audits will be reported to the ICC and where appropriate the board

2

Deliver the best health outcome

Achieve CCG target of no more than 1 case of hospital acquired MRSA Bacteraemia

Achieve CCG target of less than 40 reportable, avoidable trust acquired cases of Clostridium Difficile

Achieve robust antimicrobial stewardship whilst managing the septic patients in a timely manner

Reduce the number of patients with catheter related urinary tract infections

Cases of Clostridium Difficile are reported monthly to the board

RCA of every reportable case of Clostridium Difficile is undertaken and discussed with the CCG

Re invigorate hand hygiene with a focus on the 5 moments of hand hygiene. Hand hygiene scores reported monthly to the care group boards and Quality Performance Committee, with exceptions reported to Board.

Audits of: - clinical indication and 3 day review on the antibiotic drug chart; accuracy of sepsis identification and management including microbiological sampling to be to be fed back to the care group boards.

Develop a multi-professional group to develop strategy, implement actions and monitor trends to better understand how we can improve care for patients needing or with urinary catheters and to reduce the incidence of avoidable catheter-related urinary tract infections whilst in hospital.

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Strategic Principle Objective Measures

3

Provide the best value healthcare

Exposure of patients to cross contamination of infectious diseases are identified and contained rapidly and patients receive appropriate treatment

Infectious diseases are robustly tracked and 2 or more cases linked on any ward are investigated by the IPC team

Minimise the risk of staff cross contamination by having robust arrangements in place for reviewing the immunisation status of health care workers and providing vaccinations in line with Department of Health guidance and monitoring the uptake of vaccination. Uptake of vaccination

4

Develop to be the best place to work, train and learn

Achieve mandatory training requirements

Quarterly reports on IPC mandatory training uptake are disseminated to the relevant staff groups and reviewed by the ICC and where relevant to the board

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Quality Performance Report: Appendix 2 Dementia CQUIN/Dementia Carers Audit Report Indicator 3.1 FAIR assessment Find, Assess, Investigate and Refer. Undertake case finding for at least 90 per cent of patients aged 75 and over admitted as an emergency for >72 hours and where patients are identified as potentially having dementia ensuring that at least 90 per cent are appropriately referred on to specialist services.

FAIR assessment

80

85

90

95

100

105

April

MayJu

ne July

AugSep

tOct Nov

DecJa

n Feb

March

Month

Perc

enta

ge FindAssessRefer

Indicator 3.2 Clinical Lead Ensure there is sufficient leadership of dementia within providers and appropriate training of staff. Dr Hannah Johnson has been clinical lead for dementia since January 2013. She is assisted in this task by the Dementia steering group and the older person’s mental health liaison team. Karen Rudman is the Practice educator who leads for dementia training. Training Completed Dementia Champions There have been champions recruited from all wards as well as departments such as radiology, endoscopy and therapists. Numbers at the initial 24 Registered Nurses 7 Health Care Assistants 3 Occupational Therapists 3 Radiographers 14 Student Nurses

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There has been an introductory all day session (20th Nov 2013) and bimonthly sessions running to the proposed teaching schedule E-learning 6 have completed the e-learning in the last quarter Induction Training 81 in the last quarter have had training in dementia awareness as part of the induction to the Trust. SIM training Each ward is sending two members of staff at a time to SIM training where a scenario involving a patient with dementia is played out. If their ward does not have this as their specific scenario they are present to watch another team run through this. In the last quarter 17 nursing staff and 12 HCA had been through this training. Ward Based Training given to individual wards by the older peoples mental health

Behavioural and Psychology Symptoms in Dementia - Redlands ward (11th Nov 2013) Dementia and challenging behaviours – Kennet ward (24th Sep 2013)

Doctors

Grand round for senior doctors has had a session on capacity and consent involving patients with dementia (30th May 2013) Delirium and dementia specific training sessions have been held in foundation teaching (20th Feb 2014) and core medical training (29th Oct 2013 + 31st Jan 2014).

Therapists Training given by the older person’s mental health liaison team to the occupational therapy department

Dementia and observation skills (5th Nov 2013) Carers of people with dementia (29th Jan 2014) Dementia – what is it? (6th Mar 2014)

Training given by the older person’s mental health liaison team to the physiotherapy department

Dementia, delirium, depression and the OPMHLT (2nd Apr 2014)

Indicator 3.3 Monthly Audit of Carers Providers must demonstrate that they have undertaken a monthly audit of carers of people with dementia to test whether they feel supported.

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Currently we are asking the occupational therapists to give out questionnaires.

Month Total Quality of dementia care 1 Dissatisfied – 4 Satisfied Involvement in care Leaving Hospital

1 2 3 4

Always Sometimes No Don't know Yes No Don’t know N/A

May 2 2 1 1 1 1

June 7 1 2 4 4 2 1 6 1

July 10 2 2 6 5 3 2 8 1 1

Aug 8 2 6 5 2 1 8

Sept 6 3 3 3 2 1 5 1

Oct 5 1 1 3 2 1 2 4 1

Nov 4 1 3 3 1 2 2

Dec 10 1 4 5 5 4 1 8 2

Jan 12 1 1 4 6 4 4 3 1 9 2 1

Feb 12 2 10 5 6 1 10 2

Mar 9 3 6 4 3 6 1 2

Feedback May We should have been present when patient was assessed - only the OT was

involved, who was excellent June I don’t know what questions to ask so worry I won't have asked relevant ones.

Focus on physical needs, delay in diagnosis resulted in deterioration of dementia, Drs and nurses need to communicate with carers & family members and listen to them about patients needs.

July Was unaware a dementia specific regime should have been in place Thanks to the OT for supporting us through various difficulties and setting up

help in our home Aug My grandmother has been admitted several times this year, and as the next of

kin for my grandmother who has severe dementia and aphasia I am yet to be contacted by a Dr to discuss the case. I rely solely on Drs and nurses for information and my grandmother has had 6 failed discharges, so clear communication is very important.

We were treated very well and cannot think of any improvement More than satisfied, it has been a fantastic support for my husband and me.

Sept Medication was changed without being told. Oct Very difficult to get any information about patient's condition, treatment,

prognosis. It appeared that the patient wasn't getting the care and treatment hoped. Hospital ward staff have lost shoes, trousers, bra and top.

Nov On arrival at night I had to push to stay with mum who was very distressed and confused. There was no concern about the medical side of things but not accommodating for the person with dementia. I was eventually allowed to stay and this relaxed my mother.

Dec I cannot thank the staff enough for their care and kindness, how can we repay you all.

With limited number of staff on ward it was impossible to provide specialist care.

Jan A doctor was available at visiting times to talk about updates

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I'm not getting any info on her future. She has been in a care home for 6 months, could she return? Prognosis please?

Nurses were fantastic as were all ward staff. OT was very helpful but there was zero information given from the Dr's as to her ongoing medical conditions.

I wasn’t told he was moved to another ward. It is difficult to judge on dementia care as I wasn’t there all the time and my father’s memory does not allow him to recall events.

Wrong ward and untrained for mental health staff. This ward was not suitable for someone with dementia trying to recover from an operation for a subdural haemotoma. My husband was constantly being told to go back to bed when he wandered around. Although staff were concerned about him most of the nurses and assistants had no idea how to handle dementia patient. This led to my husband becoming more agitated and the staff had to eventually call security who were confrontational and escalated the situation.

Feb We worked so visited after 5pm so could only speak with nurses. They did as much as they could with mum. Her memory Is poor and she forgets

a question and what Dr's are saying. I am concerned re communication with hearing aids. No facility for changing

batteries and patients are left for days without hearing aids working making them cut off from the world.

This is the first time we have been offered support. March Things are always good Outcomes

1. We are looking at the way we are giving out the questionnaires. It is difficult to stand over people to watch them fill out a form and don’t want to seem like the carers are being badgered. Having comments made on the questionnaire is much more informative. Possibilities are getting a volunteer to help with the feedback as more independent also the older persons mental health liaison team whilst they are speaking with families.

2. The comments from the questionnaires have been raised in the dementia steering group.

3. Many comments relate to communication. Plans on the elderly care wards to make it more visible who is looking after the patient. Wards have leaflets on how to contact consultants. With the enhanced recovery pathway it is hoped there will be more clarity on the pathway of care.

4. New equipment is being purchased through the dementia friendly wards project to help with patients who are distressed whilst in hospital.

5. There are guidelines about allowing carers to stay with their relative and also what they are entitled to. This information needs to be fed to staff. A screensaver documenting this is ready to go live.

6. There are facilities to change hearing aid batteries and also all wards were given personal listening devices to help those whose hearing aids are temporarily out of action.

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Trust Quality Dashboard

18

Trust KPI Scorecard

Meeting the C.Diff objective 3 5 9 5 1 4 4 1 3 1 2 1 40 40

Harm Free Care - All Harms (PST) 90.9% 93.2% 94.6% 95.0% 92.1% 94.0% 93.6% 91.2% 91.5% 93.3% 94.5% 93.78% 95% 93.1%

Harm Free Care - New Harms (PST) 96.9% 96.4% 97.6% 98.1% 96.1% 97.8% 98.0% 96.7% 97.2% 97.3% 97.6% 98.27% 97.2%

Pressure Ulcers New (PST) 0.94% 0.81% 1.06% 0.31% 0.63% 0.65% 0.49% 0.79% 0.15% 0.29% 0.78% 0.17% 0.64%

Pressure Ulcer Incidence per 1,000 bed days 1.48 1.26 0.95 1.22 0.70 0.89 1.28 1.63 0.95 0.76 1.21 0.38 0.95

Grade 3 or 4 avoidable pressure ulcers (SI)

3 3 4 1 1 2 2 1 0 0 2 0 20

New catheters with a UTI (PST) 0.78% 1.30% 0.91% 0.16% 1.42% 0.81% 0.65% 1.10% 1.38% 1.47% 0.47% 0.52% 0.95%

Patient Falls per 1,000 bed days 4.7 5.1 5.1 5.4 4.3 3.9 4.6 4.4 4.7 4.4 4.1 3.6 <5 4.4

Patient falls resulting in Harm (SI) 2 0 0 2 1 2 0 0 3 2 3 2

Rate of Reportable Patient Safety Incidents/100 admissions

5.7 4.02 7.0 N/A

Unapproved Incidents no data no data no data no data no data 557 446 336 313 504 558 325 N/A

All serious incidents (SI) 8 7 7 3 6 11 2 4 6 10 7 6 75

Medication Errors 277 299 72 76 108 111 832

Number of patient safety incidents reported

5070 315 8798 5070

HSMR 12 months rolling weekdays 101.29 101.88 101.52 99.59 99.51 98.29 94.57 92.89 89.23 87.15 June July 100 N/A

HSMR 12 months rolling weekend 118.97 117.19 117.88 116.16 114.49 112.61 113.06 111.77 105.08 96.63 June July 100

HSMR 12 months rolling all days 105.5 105.49 105.37 103.55 102.89 101.61 99.02 97.47 93.01 89.21 June July 100

HSMR weekdays 85.24 104.58 93.80 77.01 97.80 89.03 64.56 78.28 73.77 83.52 June July 100

HSMR weekend 97.71 92.29 114.04 106.82 111.12 97.53 106.48 92.70 57.91 64.80 June July 100

HSMR all days 88.97 100.06 98.55 83.80 100.88 91.07 75.74 82.36 70.34 78.50 June July 100

Out-turn 2013/14Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13Patient Safety Indicator May-13 Jun-13 Jan-14 Feb-14 Apr-14 Target

2014/15Mar-14

19

Cancer 2 week wait: cancer suspected 94.2% 94.8% 94.2% 94.4% 93.2% 94.8% 94.3% 95.0% 91.2% 94.6% 93.2% 87.8% 93% 93.6%

Cancer 2 week wait: breast patients 93.0% 94.7% 94.2% 94.4% 94.4% 96.5% 94.4% 93.2% 95.1% 94.9% 89.4% 87.3% 93% 93.9%

Cancer 31 day wait: to first treatment 96.6% 97.4% 99.0% 98.3% 99.0% 99.5% 98.5% 99.3% 97.1% 97.0% 96.9% 96.3% 96% 98.1%

Cancer 31 day wait: drug treatments 98.3% 100.0% 100% 98.4% 100% 96.4% 96.9% 100.0% 96.3% 94.1% 96.0% 100% 98% 99.5%

Cancer 31 day wait: surgery 100.0% 100.0% 94.4% 100% 94.4% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 91.3% 94% 96.6%

Cancer 31 day wait: radiotherapy 98.9% 97.1% 98.0% 97.6% 100.0% 96.6% 100% 98.9% 91.2% 97.6% 97.8% 99.1% 94% 97.6%

Cancer 62 day wait: GP Referral 85.6% 83.1% 91.0% 85.2% 90.8% 81.0% 86.0% 90.2% 87.3% 75.9% 82.8% 79.8% 85% 86.2%

Cancer 62 day wait: screening referral 93.8% 94.4% 95.2% 100% 88.9% 91.9% 85.0% 100.0% 88.2% 81.3% 90.0% 90.0% 90% 91.7%

62 day consultant upgrade: all cancers 100.0% 100.0% 100.0% N/A 100.0% 80.0% 100.0% 66.7% 100.0% N/A 100.0% 33.3% - 90.0%

Pts spend 90% time on an acute stroke unit

90.0% 94.0% 92.0% 90.0% 91.0% 91.4% 91.0% 96.3% 93.3% 86.0% 91.4% 92.50% 90.9%

Admission to Acute Stroke Unit within 4 hours

64.0% 75.0% 76.0% 61.0% 65.0% 75.4% 65.5% 69.2% 72.7% 62.8% 72.7% 62.5% 68.5%

Stroke patients scanned within 24 hours 97.0% 92.0% 96.0% 94.0% 96.0% 93.0% 90.0% 94.0% 98.0% 98.0% 93.0% 98.10% 94.7%

Discharged to their normal place of residence

92.0% 89.0% 89.0% 86.0% 100.0% 98.0% 92.0% 86.0% 94.0% 94.0% Data 90.0% 92.5%

Average Length of Stay (days) 14 15 22 19 14 13 21 19 15 15 19 20 16

Women giving birth have 1:1 delivery of care

100% 100% 99% 99% 100% 98% 98% 99% 100% 99% 99% 92% 99%

Emergency re-admissions within 30 days 7.9% 7.7% 7.2% 7.3% 7.2% 7.1% 6.7% 7.5% 6.8% 7.1% 6.3% 6.8% 7.3%

Elective re-admissions within 30 days 7.3% 6.7% 4.7% 4.6% 3.8% 4.5% 4.4% 5.7% 3.5% 4.6% 4.1% 4.5% 4.3%

Patients in ED/CDU with a diagnosis of sepsis receive antibiotics in one hour

no data no data 93% 53% 58% 90% 75% 71% 42% 100% 100% 75% N/A

Nutrition risk assessment in 24 hours 80% 85% 81% 77% 80% 82% 83% 80% 79% 76% 77% 81% 80%

Nutrition risk assessment in 48 hours 91% 93% 93% 93% 92% 92% 94% 93% 91% 89% 91% 93% 92%

Fractured Neck of Femur: Surgery in 36 hours

76.7% 80.0% 51.3% 77.4% 63.1% 70.5% 81.0% 68.0% 83.7% 84.8% 77.5% 74.0% 74.7%

VTE Risk Assessment 96.7% 95.8% 96.2% 95.3% 95.0% 95.5% 95.8% 95.3% 95.2% 95.1% 96.1% 96.4% 95.6%

Adult IP who receive appropriate VTE prophylaxis

91.2% 96.4% 93.4% 91.4% 89.6% 85.4% 94.7% 94.9% 85.5% 95.2% 89.2% 91.2% 91.65%

Unplanned returns to theatre within 48 hours

0.11% 0.12% 0.00% 0.00% 0.12% 0.12% 0.26% 0.00% 0.00% 0.00% 0.00% 0.30% 0.0%

Out-turn 2013/14

Target 2014/15Clinical Effectiveness Indicator May-13 Apr-14Nov-13 Dec-13 Jan-14 Feb-14 Mar-14Jun-13 Jul-13 Aug-13 Sep-13 Oct-13

20

Trust Patient Survey - overall rating 95% 96% 97% 96% 96% 98% 97% 96% 97% 96% 96% 99% 97% 96%

Inpatient survey question: “Involved as much as desired in decisions about care

86 87 90 87 87 83 82 78 84 84 80 86 86 85

Inpatient survey question: “Informed about medication side effects”

91 89 90 81 87 79 64 83 86 82 85 85 85 86

FFT Response Inpatients 16.3% 41.0% 32.3% 29.3% 32.7% 33.4% 27.7% 27.0% 38.2% 36.3% 30.6% 31.3% 27.66% 29.51%

FFT Response A&E 1.6% 15.3% 8.9% 13.0% 15.0% 9.9% 32.6% 24.1% 22.7% 27.5% 25.55% 19.1% 27.66% 15.82%

FFT Net Promoter Score A&E 58 51 55 48 54 56 46 52 57 59 56 63 70 53

FFT Response Maternity 7.28% 9.65% 13.61% 16.65% 13.39% 11.54% 18.5% 27.66% 12.05%

FFT Net Promoter Score Maternity 71 74 70 70

Single sex accommodation - breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints about behaviour and attitude 3 6 10 7 3 8 5 15 8 2 8 10 70

Number of Complaints 33 33 32 31 31 36 34 36 36 26 29 44 3000 2982

Average response time data data data data data data data data data data data 35 25 days

Diagnostics in 6 weeks % 98.8% 99.2% 94.2% 99.9% 100% 100% 100% 96.7% 75.6% 68.9% 71.1% 70.1% 96.9%

A&E: 4hr Limit (type 1 &2) 97.2% 97.1% 94.8% 97.3% 92.6% 93.8% 92.6% 90.2% 89.4% 88.7% 91.1% 96.1% 95% 92.10%

Seen within 4 hours - RBH site Type 1 only

96.9% 96.8% 94.3% 97.4% 92.1% 92.1% 92.5% 88.6% 88.4% 87.3% 90.6% 95.6% 95% 92.12%

Outpatient cancellation rate 27.2% 28.1% 28.8% 29.9% 28.5% 28.3% 26.8% 29.8% 27.9% 27.9% 29.3% 28.5% 28.4%

Appointments cancelled by hospital and rescheduled (4 Surgical specialities)

10.8% 7.7% 9.8% 10.5% 8.6% 7.6% 8.7% 10.1% 8.7% 7.2% 10.1% 8.8% 9.27%

Jan-14 Feb-14 Mar-14Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13Patient Experience Indicator May-13 Jun-13 Apr-14 Target 2014/15

Out-turn 2013/14

21

Appraisal rate 84% 80% 79% 80% 78% 81% 84% 85% 87% 85.00% 95% 87.0%

Completed Mandatory Training data data data data data data data data 61% 65% 69% 71.60% N/A

Sickness/absence 3.1% 2.9% 2.9% 2.7% 2.7% 3.0% 3.1% 2.9% 3.1% 3.2% 3.2% 2.9% 2.8% 3.1%

Vacancy rate 4.4% 3.9% 4.2% 3.4% 2.5% 2.6% 2.6% 2.4% 1.9% 1.4% 1.6% 8.1% 5% 3.0%

Agency spend % of total staff cost 6.9% 5.9% 5.4% 5.8% 5.0% 4.1% 4.5% 4.7% 6.6% 4.4% 5.5% 6.4% 5.3% 5.1%

Workforce turnover 1.1% 1.1% 1.1% 0.8% 1.8% 0.9% 0.9% 1.1% 0.9% 0.8% 1.3% 1.1% 13.4%

Delayed transfers of care 5.5% 5.2% 5.2% 3.6% 4.2% 4.1% 4.7% 4.1% 5.3% 4.4% 3.6% 3.29% 4.5%

Operations cancelled by the hospital on the day of surgery for non-clinical reasons

0.42% 0.83% 0.39% 0.43% 0.50% 0.32% 0.45% 1.29% 0.42% 0.76% 0.49% data 0.55%

Cancelled operations re-scheduled in 28 days

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 15.0% 0.0% 0.0% 5.8% data 4.78%

Theatre Utilisation 85.3% 87.2% 88.3% 84.8% 91.0% 91.0% 93.0% 84.0% 89.0% 85.0% 86.0% 87.0% 87.5%

Average elective length of stay 2.8 2.9 2.5 2.7 2.8 2.4 2.4 2.7 2.8 2.7 2.5 2.9 2.7

Average non-elective length of stay 4.66 5.27 4.7 4.6 4.6 4.8 4.3 4.4 4.7 5.3 4.7 4.6 4.7

Clinical Coding Completeness 95.1% 81.1% 99.0% 98.5% 93.5% 90.6% 97.3% 83.3% 89.7% 88.8% 80.0% 66.3% 97.2%

NHS number coding (IP) 99.2% 99.2% 99.4% 99.1% 99.3% 99.0% 99.4% 98.9% 99.1% 99.2% 99.3% 99.1% 99.4%

% Appointments cancelled by RBFT 15.3% 15.5% 16.1% 17.2% 15.4% 15.2% 14.4% 16.5% 15.8% 15.4% 16.8% 16.2% 15.8%

% Appointments cancelled by patient 12.1% 12.5% 12.4% 12.3% 12.9% 12.8% 12.1% 13.0% 11.8% 12.1% 12.1% 12.2% 12.3%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14Staff and Efficiency Indicator May-13 Jun-13 Jul-13 Aug-13 Sep-13 Apr-14 Out-turn 2013/14

Target 2014/15

Presentation title here

Agenda Item 5c

Care Group Performance

May 2014

1


Contents Page Lead

1. Networked Care Group Report 3 Lindsey Barker

2. Urgent Care Group Report 8 Sue Edees

3. Planned Care Group Report 12 Peter Malone

2


1. Networked Care Group Dashboard

Patient Experience

Clinical Outcomes

Finance

Patient Surveys (NPS) *

Access & Activity ***

Pay against…

Non Pay against…

Income against…

73 ((£0.08)m)

£0.20m

Falls / 1000 bed days

Dr Foster mortality alerts

SI

Cdiff

Pressure ulcers / 1000 bed days

>70

>85%

£0.00m

£0.00m

£0.00m

2014/15 YTD Av pcm

14/15 Feb

2014/15 Target pcm

100%

2014/15 Feb

(£0.08m)

£0.20m

14/15 YTD

100%

<5.0

<2

0

<1

<1.5

0.1

1

0.1

April saw an increase in serious incidents reported, RCAs are being completed (4 vs average of 1.5 pcm). Finance figures include QIPP targets (6.95%). The Care Group is challenging each service to achieve the required efficiency savings and has put in financial controls to ensure expenditure is focused on patient care. Particular improvement in the control of agency spend and 100% coding of episodes.

4.9

Complaints – 25 day response <85%

<5.0

<2

Yr End Forecast

(PCM) Yr End

Forecast

People

Sickness rate

Appraisal rate

Vacancies

95%

5.0%

2.8%

90.7%

2.8%

5.7% 5.7% 5.0%

Mandatory Training 85%

3

<70

<1

2014/15 Target pcm

73

4.9

1 <1.5

4 4

(£0.30)m (£0.30)m

90.7% 95.0%

2.8% 2.8%

74.1% 74.1% 85.0%


4 4

Networked Care Group Summary Best patient outcomes:

• Pain management waiting times improved across the service

• Care crew fully recruited to undertake group activities and one: one care.

• Palliative care have secured funding to provide settling in support for End of Life patients which will be incorporated into the care crew.

Best patient experience:

• “Dementia Friendly” wards media launch with good TV / press coverage

• Bracknell Urgent Care Centre opened on time, with corresponding referrals to radiology and fracture clinic (new activity)

• Trustwide falls workshop run by the Care Group – back drop of falling incidence

• Study into delirium commence on Emmer Green Ward, with OPMHT

• Complaints & SIs rose in April, trends and RCAs to be conducted

• Patient Leadership course underway to ensure patient involvement is integral to trust strategy and performance

Best place to work, train & learn

• Appraisal completion remains over 90%

• Continuous improvements being recorded in mandatory training completion rates

• Sickness absence remains on target

Best Value

• Achieved a surplus of £914k for April

• £175K on income / cost saving in April vs £412K pro rata of £4.95M (6.95%) savings plan

• £70K underspend on nursing budgets, (agency £31K under budget limit)

• Aseptics provision £10K savings April, on target for £50K savings per month (in house provision)

• Uncoded episodes “cleared” for February and March 2014

Key risks

• Bracknell Soft FM contract to end September 2014 – replacement / extension required

• Short fall in QIPP projects to achieve 6.95% savings target

4


5 5

Spoke Hospitals – Bracknell

5

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CT US Xray

Choose and Book referrals continue to climb. Radiology increases with Urgent Care Centre Opening. Lost some clinics due to Easter

Bracknell Radiology Activity


Networked Care Group – 14/15 QUIPP Summary M01

6

•Opportunities identified so far equate to £3.5M

•Risk adjusted total is low due to evidence of documentation at time of database freeze.

•Subsequent PIDs have been submitted

•Additional projects will be required to achieve 6.95% savings

•Each week the NCG Board is receiving 2 specialty plans to review options to make efficiency savings.

•QIA / PIDs are being written in line with Board decisions

•The risk adjusted figure is forecast to rise next month

Month 1 figures are not yet closed (only forecast)

Cost Income Total

In Year opportunities identified to date

£2.2m £1.3m £3.5M

No of schemes 38 31

Target £4.95M

Risk adjusted total £1.4M

(Figures as at 02.05.14)


Delayed Transfers of Care

7

Target < 20 patients Target < 20 patients for < 5 days)

0 5

10 15 20 25 30 35 40 45 50

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Patie

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Use of Discharge Lounge by ward


2. Urgent Care Group Dashboard 8

Patient Experience Finance

2014/15 Target pcm

2014/15 YTD Av pcm 2014/15 Apr Yr End Forecast

2014/15 Target 2014/15 YTD 2014/15 Apr Yr End Forecast

Patient Surveys 70 77 77 70 Pay against budget £0 £(0.06)m £(0.06)m

Complaints - 25 day response 85% 40% 40% 85% Non Pay against Budget £0 £0.02m £0.02m

Access & Activity Income against budget £0 £0.15m £0.15m

Clinical Outcomes People

Falls Prevalence <5 4 4 <5 Appraisal Rate 95% 86.30% 86.30% 95%

Pressure Ulcers 1.6 1.3 1.3 1.6 Sickness rate 2.80% 3.% 3% 2.80%

Cdiff <1 0 0 <1 Vacancies 5% 3.90% 3.90% 5%

SI 2 2 2 2 MAST

85% 71.1% 71.1% 85%

Dr Foster Mortality Alerts No new alerts


9

Urgent Care Group Summary

9

Best patient outcomes: Performance is amber the month; A&E target was achieved with 95.70% in the calendar month of April. Paediatrics achieved 100% for cancer target in month however Respiratory had 2 breaches due to diagnostic/admin waits. The radiology recovery plan is on trajectory for CT and Ultrasound there has been slippage in MRI due to unavoidable delays in the commissioning of the new 3T scanner. The Radiology Services manager is providing a detailed update to the commissioners to be submitted with the DMO1 return. Stroke achieved their diagnostic waits in month an improvement on March. Birth numbers increased in month as forecast. Best patient experience: Our response to complaints within 25 days remains below our target. Plans are in place to improve response times across the care group. Complaints remain lower across the care group compared to last year, with no complaints in the Acute Medical Unit a great achievement by the team. Best place to work, train &learn: A new ‘Star of the Month’ commenced in paediatrics to recognise staff giving exceptional performance. Work to improve sickness rates in Maternity are showing a forth month of improvement reporting 4.5% Staff appraisals across the care group continue to receive high priority. MAST continues to validated each month to ensure accurate reporting. Best value The care group finished the month ahead of budget at £2.12m contribution. Income is ahead of budget by £0.15m primarily in the emergency directorate . The care group costs are overspent by £40k in month. This includes QIPP savings allocated in 1/12ths across the year. Initiatives led by the Director of Nursing are in place to reduce agency spend across nursing budgets. Workshops continue to close the QIPP gap, plans for the total £4.8 million should be completed by month end (May) The ability to report GP direct access for radiology is now possible and accurate. This shows that since September 2013 there has been an average increase of over 1100 attendances per month Key Risks Recovery plan agreed with commissioners for diagnostic imaging waiting times, ensuring we receive full payment is critical and there is a continued increased demand in radiology outstripping capacity Unknown income position and reliability of data Estate issues in Maternity Ventilation/ air cooling in ICU CCG achieving QIPPS putting NEL income at risk Planned closure of Redlands 22 beds to accommodate development of theatres Continued closure of 2 birthing rooms on Rushey Midwifery led unit Delivery of cost QIPPs


A&E Quality Indicators 10

A&E Performance (Calendar Month of April)

April – 84.07% compliance to <15min handover 2272 handovers – 3*> 60mins 30-60mins - 20

0

20

40

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170

190

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ED Attendances & Breaches April 2014

Attends Average Breaches Admits

Patient Experience Target Apr-14 Seen within 4 hours - RBH site Type 1&2 only 95% 95.70% Unplanned Reattendance rate <5% 0.8% Median wait arrival to treatment < 60mins 48 mins Total time spent in A&E (95th Percentile) < 4 hours 235 Left department without being seen <5% 1.9%

Time to initial assessment Median wait to assessment over 15 min for ambulance cases <15 mins

19


11

QIPP Delivery

11

Plan (monthly) Actual

Nursing & Midwifery related QUIPPs £k £k

Service review 38 8

Skill mix/12 hr shifts/agency/1:1's 38 47

Maternity Sickness 21 10

Bed base 21 0

Sub total Nursing QUIPPs 117 65

Drs related QUIPPs 53 38

Admin related QUIPPs 21 9

Radiology PACs 25 34

Ingenica Project 13 6

Further savings Cardiology Pacemakers / ICD's 8 3

Radiology Transflux 4 0

Carry forwards 12 12

Sub total 136 102

Total Pay + Non Pay QUIPPs 241 168

Income QUIPPs 83 26

Total 324 194

Urgent Care Group 2014/15 QUIPPs (current plans)


3. Planned Care Group Dashboard

12

Patient Experience Finance

2014/15 Target pcm

2014/15 YTD Av pcm

2014/ 15 April

Yr End Forecast

2014/15 Target YTD

April

Yr End Forecast

Patient Surveys >70 80.4 84 >70 Pay against budget N/A 0.1m 0.1m

N/A

Complaints - 25 day response

>85% 44% 44% 85% Non Pay against Budget

N/A

(0.1m) (0.1m)

N/A

Access & Activity Income against budget

N/A

(0.46m) (0.46m)

N/A

Clinical Outcomes People

Falls prevalence per 1000 <5.0 2.2 2.2 2.2 Appraisal Rate 95% 83% 83% 95%

Pressure Ulcers per 1000 0.53 1.1 1.1 0.53 Sickness rate 2.8% 2.4% 2.4% 2.8%

Cdiff per case 0.5 0 0 0 Vacancies 5% 12.3% 12.3% 5%

SI 0 0 0 0 MAST

85% 69.1% 69.1% 85%

Dr Foster Mortality Alerts

0 0.13 0 0

There were no serious incidents this month however there was a spike in RAMI and SHMI with a corresponding value of 1.6 on the CHKS outcome. Further investigations are to take place to look at the reasons.


Care Group Exceptions

13

13

Access targets Cancer The validations are still to be completed. The 2ww target is unlikely to be achieved for the month. Capacity in endoscopy has been identified as a risk area and additional consultant posts are out to advert. Breast and Dermatology are also likely to fail this target. The 62 day target is also under threat this month. The major concern on the 62 day pathway remains CT where waits are at over 2 weeks. The team continues to work hard to achieve compliance. Business cases are being developed to improve robustness of performance. 18 weeks The 18 week data is not validated. Intelligence within the care group shows all targets with the exception of admitted in Ophthalmology will be achieved. Ophthalmology continues to operate the backlog reduction action plan for cataracts. The trajectory shows completion at the end of June. People The appraisal rate has improved slightly to 83% from 82.7% the previous month. This rate remains below the Trust target however and continues to be a priority area for the management team. Mandatory Training has increased slightly to 69.1% from 67.1% with further increases expected. Attendance has also seen improvement at 2.4% the previous month was 3.0%, this rate should continue to decrease through this financial year. Agency Spend has gone up this month, back to previous levels of 5.5%. Outcomes There is a slight change in the overall care group mortality. Both RAMI and SHMI graphs show this. Further detailed review to identify where the increases have happened show increases in BCC and general surgery, although these are not significant and within the normal variation seen.


Care Group Summary 14

Patient Experience The number of complaints received has increased in April for the second month in a row to 24. The main themes are communication and treatment by doctors followed by administration issues. The PALS continue to be centred around the administration and access to appointments. The number of complaints responded to in 25 days has improved (44%). There were no serious incidents recorded. There were no reportable cases of C Diff. 86% of outpatients are seen within 6 weeks. The net promoter score for April is 84 with a rolling average of 72. Finance The Care Group income was £11.37m for April. Overall income was £0.46m adverse to budget. CCG income was £640k adverse, partially compensated by drugs income, £240k favourable. Total costs were on budget. Key risk is income - we need to improve theatre utilisation at the spokes and ensure more effective backfilling of lists when they go down last minute. The budget incorrectly contains theatre and gastro business case income which should be phased from M7 and M4 respectively. Impact £0.5m. In addition the gastro non-elective income budget is incorrect due to changes in the PoD rota. Year-on-year (April 2013 v April 2014) like for like the Care Group’s surplus is up £160k. Key issues are: -CCG underlying activity was £640k adverse to budget. The specialties significantly down are Gastroenterology, which is £341k under budget and Orthopaedics £471k (see above). Overall, non pay spend is £100k adverse, no major issues as driven by oncology drugs costs which are recovered through income. Pay is £100k favourable. Activity Activity issues are gastro non-elective and orthopaedics due to business case income for the new theatres being included.


15

Cancer Targets 15

Target

Feb -14 Mar-14 Q4 Year

13/14 Apr-14

Final Final Final Final

Two Week Wait 93% 93.1% 93.2% 93.0% 93.6% 85.7%

2 week wait breast symptom

93% 94.9% 89.7% 93.3% 94.0% 78.3%

31 day 1st treated

96% 97.0% 96.2% 97.1% 98.2% 96.4%

31 day Chemo. 98% 98.3% 100% 99.5% 99.5% 100%

31 day Surgery 94% 94.1% 95.2% 95.5% 96.6% 88.2%

31 day Radiotherapy

94% 97.6% 98.9% 96.2% 97.8% 98.0%

Other 94% 100% 100% 100% 100% 100%

62 day (2ww) 85% 75.9% 87.4% 85.1% 86.7% 77.2%

62 day screening 90% 81.3% 100% 88.4% 92.2% 90.0%

62 day upgrade Not pub

100% 100% 100% 90.6% 50.0%

Performance Validations have not been completed, however the 14 day target will not achieved. The areas that have shown increased demand with associated capacity issues are breast, gastroenterology and dermatology. 62 day performance also remains a concern and we’re reliant on very fast treatment once diagnosed and staged Actions: Abdominal Surgery -Locum Gastroenterologist has been appointed for 1 additional all day 2ww clinic per week (14 patients) -Additional clinics agreed by the Consultant gastroenterologists. -Interviews for substantive posts Gastroenterology are end of May.

-Additional breast clinics are being provided at RBH and Spire -Business case for another onco-plastic breast surgeon being developed

-Additional hysteroscopy kit has been prioritised as very urgent for Planned Care -Gynaecology are working to develop a one stop PMB / OP hysteroscopy clinic. -Business case for an extra colposcopy list has been approved by PCG baord (flexible consultant, nurse and admin)

Lung - Local provision of EBUS has been delayed due to lack of pathology support. -Provision of PET scans at other providers is being investigated as there are delays of 3-4 weeks at our current provider (Oxford). Guidelines state patients should be scanned in 5 days, reported in 2. A 2nd PET scanner is now due in September.

Radiology - Meetings with WLO twice weekly have commenced, to prioritise patients on the cancer pathway. -Extra lists being run at Dunedin

Finance (£000’s) 13/14 Budget 13/14 Actual Variance

Pay -365 -350 15

Non-Pay -45 -28 17

MDT income 216 216 0

PP income - 15 15

Total -194 -147 47


Planned Care Group – 14/15 QIPP Summary M01 16

0.0 500.0

1,000.0 1,500.0 2,000.0 2,500.0 3,000.0 3,500.0 4,000.0 4,500.0 5,000.0

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£000

's

FY13/14

Cumulative phasing of Cost QIPP Delivery v Cost Target FY14/15

Cumulative FYE savings achieved to date

Actuals

Cost Income

Risk adjusted value £1.429m £2.450m

In Year £3.450m £5.565m

No of schemes 38 41

Month 1 figures are not yet closed (only forecast) • Please note that not all schemes have figures against them (Cost projects currently have the potential to achieve £4.738m). • Large project workstreams are being set up; project teams are being initiated; PIDs are being developed; and financials and phasing are being calculated.

Version 1 – May 2014 1

Royal Berkshire NHS Foundation Trust Agenda item 5d

Board of Directors

Title: April 2014 – Financial Performance

Date: 29 May 2014

Lead: Craig Anderson, Director of Finance

Purpose: To provide the Board with a summary setting out the highlights of the Trust’s financial performance

Key Points: • £2.08m deficit in the month/ YTD, which is £0.02 better than budget.

• The key issues remain delivery of income and control of pay.

• Income, at £27.84m, was £0.03m worse than budget, with Planned Care Group behind by £0.46m, partially offset by better than budgeted income in Networked Care Group, Urgent Care Group, and Corporate

• Pay costs in line with budget, but not sustainable as the current run rate would result in full year pay £5m more than budget.

• Non pay was £0.08m better than budget, with all areas favourable with the exception of Drugs, Other Establishment Expenses and Miscellaneous services.

• COSRR 2

• Cash at £17.32m is behind the Budgeted £18.00m, but we expect to recover the gap in June.

Decision required:

To NOTE the report

FOI Status This report will be made available on request

1

Board of Directors

Title: Director of Finance Report

Date: 29 May 2014

Lead: Craig Anderson

Purpose: To update the Trust Executive and Board on the financial results of the Trust for April 2014

Decision Required:

To NOTE the contents of this report

Agenda Item 5d

2

Executive Summary Financial Targets The financial aim for 2014/15 is to maintain an FRR of 3 through:

- Delivering a £1.0m deficit; Driving Planned Care recapture of market share and growth of private patients; Delivering cost QIPPs of £18.5m; Maintaining cash above £8m; Managing capital spend

Area of Review

Key Highlights Month Rating

COSRR COSRR of two with a £1.040m gap to three. Driven by EBITDA and cash.

EBITDA EBITDA : £(0.13m, (0.46)% in M01, £0.02m ahead Budget. Activity / Income : Income behind budget £0.03m driven by primary care trust income £0.46m lower than budget. Pay Costs : £17.30m, £0.02m favourable to forecast in month, driven nursing,Pharmacists and Ancillary & Maintenance. Drugs : Income better than forecast (up £0.36m). Cost higher than budget (£(0.18)m) Non Pay : £0.25m better than budget driven by all lines with the exception of Other Establishment Expenses QIPPs : Full year cost QIPPs in budget of £18.5m. Achieved M01 circa £0.79m

Liquidity / Cash

Cash of £17.32m below budget £18.00m

Capital YTD expenditure of £0.19m with a further £2.71m committed, totalling £2.9m.

Key finance issues

CASH

INCOME Issues •On plan, despite activity from theatres business case being phased across the full year rather than just in the second half. Actions being taken •Drive timely go live of new theatres in Planned Care •Drive activity and hence income through Planned Care. •Review Network Care for income opportunities. •Track activity for evidence of delivery of CCG QIPPs

PAY Issues •£17.30m in month, so on budget but not sustainable. At that run rate pay would be £5m over budget Actions being taken •All recruitment requires confirmation that within budget and all substantive roles are signed off by the Exec. •Manage Urgent Care pay, particularly nursing pay •Drive delivery of QIPPs

KEY ISSUES

Financial Highlights

£mPrior year 40.31Current year to date 17.32Full year Budget 17.05

Cash£m

Prior year (6.79)Current year to date (2.08)Full year Budget (0.99)

Surplus

4

1. Financial Position

Overall Financial Performance - on budget, but we need to make large savings if we are to stay there.

A detailed statement of comprehensive Income is attached at Appendix (Vii)

Key messages:

• Overall income on budget, as better than budget Drugs Income offset Income from Activities £0.5m worse than budget

• Pay on budget, but if we continue to run at £17.3m/mth then full year will be £5m worse than budget

• Drugs cost high, but offset by better than budget Drugs Income

• Non Pay excl Drugs less than budget, but only because of £0.88m of central budget adjustments (eg contingency). Directorates worse than budget were NCG £0.26m, IT (£0.1m) and Corporate Affairs (£0.07m).

• COSRR 2 • Cash just below budget but will recover in June

Care Group/Corporate Results vs Budget in month • UCG ahead of Budget with income £0.15m, pay £(0.06)m

and non-pay £0.02m • PCG worse of budget due to income £(0.46)m, pay £0.10m

and non-pay £(0.10)m, driven by phasing of activity on theatres business case

• NCG behind Budget with income £0.20n, pay £(0.08)m and non-pay £(0.31)m

• Corporate Services less than Budget

Results for Month 1£m

Actual Vs Budget Actual Vs BudgetIncome 27.84 (0.03) 27.84 (0.03)

Pay (17.30) (0.02) (17.30) (0.02)

Drugs (3.00) (0.18) (3.00) (0.18)

Non Pay ex Drugs (9.10) 0.25 (9.10) 0.25

Other (0.52) (0.01) (0.52) (0.01)

Exceptional Items (0.00) (0.00) (0.00) (0.00)

Surplus/(Deficit) (2.08) 0.02 (2.08) 0.02

COSRR 2.0

Actual Budget Actual Budget

Cashflow from Operations (3.95) 0.42

Cash 17.32 18.00 17.32 18.00

EBITDA (0.13) (0.14) (0.13) (0.14)

EBDITDA margin -0.5% -0.5% -0.5% -0.5%

Net Surplus/(Deficit)

Actual £mVs Budget

£m Actual £mVs Budget

£mUrgent Care 2.12 0.11 2.12 0.11

Planned Care 1.69 (0.46) 1.69 (0.46)

Networked Care 0.91 (0.18) 0.91 (0.18)

E&F (1.78) 0.13 (1.78) 0.13

Corporate Services (5.02) 0.42 (5.02) 0.42

Total Trust (2.08) 0.02 (2.1) 0.02

MONTH YTD

MONTH YTD

MONTH YTD

5

Income on budget overall, although income from activities £0.5m behind.

Key Messages • Income from activities £(0.45)m below budget, all within

PCG and a result of activity for the Theatres business case being phased across the year rather than from mid year – so this will reverse in Q3 and Q4

• CQUINs included at 90% • Provisions made for risk on diagnostic imaging and first

to follow ups to bring them in line with plan. • Provision made for risk on NEL marginal rate for

providers other than BWCCG’s • Risk that income for Physician of the Day (“POD”) is not

being split correctly between NCG and UCG. • Risk that won’t be able to recover all income accrued

because of the limited time and resource to address informatics issues on activity data.

Actions • Understand and correct the informatics algorithm that

allocates POD income HA • Ensure informatics resource is adequately targeted to

ensure that issues that will affect contract invoices are addressed before flex and freeze dates. HA

• Drive delivery of theatres and of planned care income growth PM

• Drive income from activities SE/LB • Track activity for evidence of delivery of CCG Qipps

PM/SE/LB

Income

Actual £mVs Budget


£mIncome from Activities 23.37 (0.46) 23.37 (0.46)

Drug Income 2.41 0.36 2.41 0.36

Other Patient Care Income 0.34 (0.06) 0.34 (0.06)

Other Operating Income 1.72 0.13 1.72 0.13

Total Income 27.84 (0.03) 27.84 (0.03)

MONTH YTD

23.00

25.00

27.00

29.00

31.00

33.00

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Monthly Income £m

2013/14 Actual

2014/15 Actual

2014/15 Budget

2014/15 Q1F

0.95

1.00

1.05

1.10

1.15

1.20

1.25

1.30


Average Daily income £m

2013/14 Actual

2014/15 Actual

6

Pay costs on budget, but not sustainable at the current run rate

Key Messages • If Pay remains at the current level for the rest of

the year, we will be £5m over budget (see red circle on chart below)

• All new requests for recruitment being validated by Finance that they are within cost centre budget.

Pay costs £(0.27)m up vs prior month • Last month included £0.2m release of holiday pay

accrual • From April the cost of IT contractors now included

in pay (was in non pay before)

Pay Costs £(0.02)m worse vs Budget • All pay categories showing better than budget

other than Other Pay, which is where QIPP targets are held. This gives risk that active cost centres could recruit up to budget and drive overall Trust pay over budget.

Actions • All pay QIPPs to be driven down to active cost

centres • All vacancies that pre date Finance check on

budget to be cancelled and re-requested, so that we can be sure that recruitment will not drive cost centres over budget.

Pay Costs £m

Group Description M11 2014 M12 2014 M01 2015 MoM var Month vs Budget

YTD vs Budget Month YTD

Medical Staff (4.82) (4.58) (4.85) (0.26) 0.25 0.25 105 105

Nursing (7.02) (6.98) (6.77) 0.21 0.54 0.54 97 97

PAMs (0.97) (0.92) (0.95) (0.03) 0.02 0.02 108 108

Scientist and PTBs (1.17) (1.05) (1.08) (0.03) 0.05 0.05 101 101

Pharmacists (0.19) (0.19) (0.19) 0.00 0.01 0.01 97 97

Admin & Management (2.37) (2.50) (2.54) (0.04) 0.05 0.05 115 115

Ancil lary & Maintenance (0.80) (0.78) (0.76) 0.02 0.05 0.05 96 96

Other Pay (0.01) (0.03) (0.18) (0.14) (0.99) (0.99) 391 391Pay (17.34) (17.03) (17.30) (0.27) (0.02) (0.02) 103 103

Of Which: Agency (0.78) (1.00) (1.02)

Agency as a % of Total Pay 0.0% 5.8% 5.9%

Pay Costs £m

By Care Group M11 2014 M12 2014 M01 2015 MoM var Month vs Budget

YTD vs Budget Month YTD

UCG (5.64) (5.67) (5.42) 0.25 (0.06) (0.06) 97 97

PCG (5.61) (5.53) (5.62) (0.09) 0.10 0.10 103 103

NCG (3.67) (3.67) (3.63) 0.03 (0.08) (0.08) 105 105

Total Care Group (14.92) (14.87) (14.68) 0.19 (0.03) (0.03) 101 101

Estates & Facil ities (0.85) (0.82) (0.82) (0.00) 0.05 0.05 95 95

Chief Nursing Officer (0.25) (0.29) (0.25) 0.04 0.02 0.02 92 92

Chief Medical Officer (0.26) (0.22) (0.26) (0.03) (0.02) (0.02) 90 90

Corporate Affairs (0.06) (0.07) (0.06) 0.01 0.01 0.01 88 88

Commercial Directorate (0.07) (0.13) (0.18) (0.04) (0.10) (0.10) 322 322

Finance (0.33) (0.14) (0.34) (0.20) 0.01 0.01 98 98

Chief Exec & Non-Execs (0.02) (0.02) (0.02) 0.00 0.00 0.00 48 48

Human Resources (0.19) (0.19) (0.18) 0.01 (0.02) (0.02) 108 108

Corporate - Other (0.27) (0.04) (0.28) (0.24) 0.10 0.10 272 272

Capital Charges & PDC Divide 0.00 0.00 0.00 0.00 0.00 0.00 0 0

IT (0.13) (0.23) (0.23) 0.00 (0.04) (0.04) 567 567

TOTAL Other (2.42) (2.16) (2.62) (0.46) 0.01 0.01 114 114Pay (17.34) (17.03) (17.30) (0.27) (0.02) (0.02) 104 104

VS BUDGET INDEX VS PY

VS BUDGET INDEX VS PY

15.00

15.50

16.00

16.50

17.00

17.50

18.00


Monthly Total Pay £m

2013/14 Actual

2014/15 Actual

2014/15 Budget

2014/15 Q1F

7

Non Pay Costs – Drugs – Over budget but offset by Drugs Income

Key Messages • £0.18m over budget, but more than offset by

Drugs Income, £0.36m better than budget

Drugs £(0.18)m adverse to Budget • YTD Drugs income as a percentage of cost at

73.4% is better than budget, 70.5%

Drugs £(0.18)m higher vs Budget • PCG £(0.17)m adverse including Cancer drugs

non recoverable / CDF £(0.06)m and Lloyds March pharmacy invoice £(0.04)m higher than accrual

• NCG £(0.05)m adverse.

Actions • QIPP projects on Waste management , aseptic

unit.LB

Non Pay - Drugs

Actual £mVs Budget


£mUrgent Care (0.25) (0.00) (0.25) (0.00)

Planned Care (1.48) (0.17) (1.48) (0.17)

Networked Care (1.27) (0.05) (1.27) (0.05)

Other (0.00) 0.04 (0.00) 0.04

Total Drugs (3.00) (0.18) (3.00) (0.18)

MONTH YTD

1.80

2.00

2.20

2.40

2.60

2.80

3.00

3.20


Monthly Drugs spend £m

2013/14

2014/15 Actual

2014/15 Budget

2014/15 Q1F

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%


Monthly Drugs Income %

2013/14

2014/15 Actual

2014/15 Budget

2014/15 Q1F

8

Non Pay Costs – Excluding Drugs better than budget at Trust level, but £0.5m worse than budget in care groups

Key messages

• Better than budget and we haven’t used the budgeted contingency

• Most Non Pay QIPPs still held within Miscellaneous Services, hence that line showing worse than budget

• £0.26m worse than budget in NCG, driven by high costs for pathology reagents (£0.04m) and hearing aids (£0.05m) and Miscellaneous Services (£0.2m)

• New leases have been budgeted, but are yet to commence at M01 £0.07m

Actions

• Drive delivery of cost QIPPs All exec directors

Non Pay ex Drugs

Actual £mVs Budget


£mClinical Service & Supplies (3.35) 0.16 (3.35) 0.16

General Supplies & Services (0.49) 0.15 (0.49) 0.15

Establishment Expenses (0.29) 0.04 (0.29) 0.04

Other Establishment Expenses (0.82) (0.01) (0.82) (0.01)

Prem, Trans & Fixed Plant (1.48) 0.04 (1.48) 0.04

Depreciation (1.43) 0.01 (1.43) 0.01

Leases (0.10) 0.09 (0.10) 0.09

Miscellaneous Services (1.13) (0.22) (1.13) (0.22)

Total Non Pay ex Drugs (9.10) 0.25 (9.10) 0.25

MONTH YTD

Non Pay ex Drugs

Actual £mVs Budget


£mUrgent Care (0.82) 0.02 (0.82) 0.02

Planned Care (2.11) 0.07 (2.11) 0.07

Networked Care (1.36) (0.26) (1.36) (0.26)

Estates & Facilities (1.15) 0.06 (1.15) 0.06

HFMS 0.08 0.03 0.08 0.03

Other Corporate (3.73) 0.34 (3.73) 0.34

Total Non Pay ex Drugs (9.10) 0.25 (9.10) 0.25

MONTH YTD

7.00

7.50

8.00

8.50

9.00

9.50


2013/14

2014/15 Reported

2014/15 Budget

2014/15 Q2F

9

FY Cost QIPPs budgeted at £18.5m for FY 14-15

Please see detailed slide on QIPPs in Executive Report

10

Appendices

The following reports are included as Appendices: Appendix (i) Statement of Comprehensive Income Appendix (ii) Statement of Comprehensive Income (SOCI): Month vs Budget – By Area Appendix (iii) Care Group Financials Appendix (iv) Income by Point of Delivery Appendix (v) Statement of Financial Position (SOFP) Appendix (vi) Cash Flow Statement Appendix (vii) Downside Cash Position Appendix (viii) Capital Expenditure Summary Appendix (ix) Financial Risk Rating Appendix (x) Service Line Reporting - Update

DOF Report Craig Anderson

11

Appendix (i) Statement of Comprehensive Income for Month 01

£'m Act Budget PY vs Budget vs PY Act Budget PY vs Budget vs PYIncome from Activities 25.78 25.88 24.67 (0.10) 1.12 25.78 25.88 24.67 (0.10) 1.12 Primary Care Trusts Income 23.37 23.83 22.71 (0.46) 0.66 23.37 23.83 22.71 (0.46) 0.66 Specific Drug Funding 2.41 2.05 1.95 0.36 0.46 2.41 2.05 1.95 0.36 0.46 Drugs Income 2.23 1.87 1.81 0.36 0.42 2.23 1.87 1.81 0.36 0.42 Drugs Income - Infliximab 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Drugs Income - Herceptin 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Devices Income 0.18 0.18 0.14 (0.00) 0.03 0.18 0.18 0.14 (0.00) 0.03 Department Of Health Income 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Other Patient Care Income 0.34 0.40 0.38 (0.06) (0.04) 0.34 0.40 0.38 (0.06) (0.04)Other Operating Income 1.72 1.58 1.52 0.13 0.20 1.72 1.58 1.52 0.13 0.20

Total Income 27.84 27.87 26.56 (0.03) 1.28 27.84 27.87 26.56 (0.03) 1.28 Medical Staff (4.85) (5.09) (4.60) 0.25 (0.25) (4.85) (5.09) (4.60) 0.25 (0.25)Nursing (6.77) (7.31) (6.96) 0.54 0.19 (6.77) (7.31) (6.96) 0.54 0.19 PAMs (0.95) (0.97) (0.88) 0.02 (0.07) (0.95) (0.97) (0.88) 0.02 (0.07)Scientist and PTBs (1.08) (1.13) (1.07) 0.05 (0.01) (1.08) (1.13) (1.07) 0.05 (0.01)Pharmacists (0.19) (0.20) (0.19) 0.01 0.01 (0.19) (0.20) (0.19) 0.01 0.01 Admin & Management (2.54) (2.59) (2.21) 0.05 (0.33) (2.54) (2.59) (2.21) 0.05 (0.33)Ancillary & Maintenance (0.76) (0.80) (0.78) 0.05 0.03 (0.76) (0.80) (0.78) 0.05 0.03 Other Pay (0.18) 0.81 (0.04) (0.99) (0.13) (0.18) 0.81 (0.04) (0.99) (0.13)

Total Pay (17.30) (17.28) (16.73) (0.02) (0.57) (17.30) (17.28) (16.73) (0.02) (0.57)Drugs (3.00) (2.82) (2.44) (0.18) (0.56) (3.00) (2.82) (2.44) (0.18) (0.56)Clinical Service & Supplies (3.35) (3.50) (3.45) 0.16 0.11 (3.35) (3.50) (3.45) 0.16 0.11 General Supplies & Services (0.49) (0.64) (0.66) 0.15 0.16 (0.49) (0.64) (0.66) 0.15 0.16 Establishment Expenses (0.29) (0.34) (0.27) 0.04 (0.02) (0.29) (0.34) (0.27) 0.04 (0.02)Other Establishment Expenses (0.82) (0.81) (0.70) (0.01) (0.12) (0.82) (0.81) (0.70) (0.01) (0.12)Prem, Trans & Fixed Plant (1.48) (1.52) (1.77) 0.04 0.29 (1.48) (1.52) (1.77) 0.04 0.29 Depreciation (1.43) (1.44) (1.33) 0.01 (0.10) (1.43) (1.44) (1.33) 0.01 (0.10)Leases (0.10) (0.19) (0.08) 0.09 (0.02) (0.10) (0.19) (0.08) 0.09 (0.02)Miscellaneous Services (1.13) (0.91) (0.85) (0.22) (0.28) (1.13) (0.91) (0.85) (0.22) (0.28)

Total Non Pay (12.10) (12.17) (11.55) 0.08 (0.54) (12.10) (12.17) (11.55) 0.08 (0.54)PDC Dividend (0.42) (0.42) (0.42) 0.00 (0.00) (0.42) (0.42) (0.42) 0.00 (0.00)Interest Receiveable (0.10) (0.09) (0.10) (0.01) 0.00 (0.10) (0.09) (0.10) (0.01) 0.00

Total Other (0.52) (0.51) (0.52) (0.01) (0.00) (0.52) (0.51) (0.52) (0.01) (0.00)Exceptional (0.00) (0.00) (0.01) (0.00) 0.00 (0.00) (0.00) (0.01) (0.00) 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Net Surplus/(Deficit) (2.08) (2.10) (2.25) 0.02 0.17 (2.08) (2.10) (2.25) 0.02 0.17

Month YTD

Appendix (ii): Statement of Comprehensive Income - By Area

12

M01

Month £m Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs BudIncome 8.61 0.15 10.90 (0.46) 7.18 0.20 26.70 (0.11) 0.23 0.02 0.90 0.05 0.01 0.01 27.84 (0.03)Pay (5.42) (0.06) (5.62) 0.10 (3.63) (0.08) (14.68) (0.03) (0.82) 0.05 (1.80) (0.04) 0.00 0.00 (17.30) (0.02)Non-Pay (1.07) 0.02 (3.59) (0.10) (2.63) (0.31) (7.29) (0.39) (1.15) 0.07 (3.73) 0.37 0.08 0.03 (12.10) 0.08 Other 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.40) 0.04 (0.12) (0.05) (0.52) (0.01)Exceptional 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) 0.00 0.00 (0.00) (0.00)

Net Surplus/(Deficit) 2.12 0.11 1.69 (0.46) 0.91 (0.18) 4.73 (0.53) (1.74) 0.14 (5.02) 0.42 (0.04) (0.01) (2.08) 0.02

M01

YTD £m Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs Bud Act Vs BudIncome 8.61 0.15 10.90 (0.46) 7.18 0.20 26.70 (0.11) 0.23 0.02 0.90 0.05 0.01 0.01 27.84 (0.03)Pay (5.42) (0.06) (5.62) 0.10 (3.63) (0.08) (14.68) (0.03) (0.82) 0.05 (1.80) (0.04) 0.00 0.00 (17.30) (0.02)Non-Pay (1.07) 0.02 (3.59) (0.10) (2.63) (0.31) (7.29) (0.39) (1.15) 0.07 (3.73) 0.37 0.08 0.03 (12.10) 0.08Other 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.40) 0.04 (0.12) (0.05) (0.52) (0.01)Exceptional 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) 0.00 0.00 (0.00) (0.00)

Net Surplus/(Deficit) 2.12 0.11 1.69 (0.46) 0.91 (0.18) 4.73 (0.53) (1.74) 0.14 (5.02) 0.42 (0.04) (0.01) (2.08) 0.02

Total Care Groups

Corporate Services HFMS RBFT

Urgent Care Planned Care NetworkCare Estates & Facilities Corporate Services HFMS RBFT

Urgent Care Planned Care NetworkCare Estates & FacilitiesTotal Care Groups

Appendix (iii) : Care Group Financials - NCG


13

FINANCIAL YEAR 2013/14 - COMPARISON OF NETWORKED CARE ACTUAL RESULTS TO BUDGET

Values in m's (£)

Actual BudgetVariance to

Budget Actual BudgetVariance to

Budget

Income from activities (excl drugs) 5.88 5.88 0.00 5.88 5.88 0.00

Drugs Income 1.01 0.87 0.14 1.01 0.87 0.14

Other Patient Care Income 0.07 0.07 0.00 0.07 0.07 0.00

Other Operating Income 0.23 0.15 0.07 0.23 0.15 0.07

Total Income 7.18 6.98 0.20 7.18 6.98 0.20

Medical Staff -1.00 -1.00 0.00 -1.00 -1.00 0.00

Nursing -1.15 -1.23 0.07 -1.15 -1.23 0.07

PAMs -0.32 -0.34 0.02 -0.32 -0.34 0.02

Scientist and PTBs -0.72 -0.69 -0.02 -0.72 -0.69 -0.02

Pharmacists -0.17 -0.19 0.02 -0.17 -0.19 0.02

Admin & Management -0.27 -0.29 0.02 -0.27 -0.29 0.02

Ancillary & Maintenance -0.02 -0.01 0.00 -0.02 -0.01 0.00

Other Pay 0.01 0.20 -0.18 0.01 0.20 -0.18

Total Pay -3.63 -3.56 -0.08 -3.63 -3.56 -0.08Pay as % of income 0.51 0.51 0.51 0.51

Drugs -1.27 -1.22 -0.05 -1.27 -1.22 -0.05

Clinical Services and Supplies -1.12 -1.01 -0.11 -1.12 -1.01 -0.11

General Services and Supplies -0.02 -0.04 0.01 -0.02 -0.04 0.01

Establishment Expenses -0.04 -0.04 0.00 -0.04 -0.04 0.00

Other Establishment Expenses -0.01 0.00 -0.01 -0.01 0.00 -0.01

Prem, Trans & Fixed Plant -0.04 -0.07 0.03 -0.04 -0.07 0.03

Leases 0.00 0.00 0.00 0.00 0.00 0.00

Miscellaneous Services (Excl Internal Recharges) -0.13 0.06 -0.18 -0.13 0.06 -0.18

Internal Recharges 0.00 -0.01 0.00 0.00 -0.01 0.00

Total Non Pay (excl depn) -2.63 -2.33 -0.31 -2.63 -2.33 -0.31

Operating Surplus (Loss) 0.91 1.10 -0.18 0.91 1.10 -0.18

Margin (Surplus/ Loss as a % income) 13% 16% 13% 16%

MONTH 01 MONTH 01 YTD

Appendix (iii) : Care Group Financials - NCG


14

Financial position Commentary:

In April , Networked Care achieved a surplus of £915k.

Income:

Overall as a Care Group, CCG activity income was in l ine with budget. However, there are two areas of concern

- Elderly Care (£358k Adverse) - NEL activity is 30% below budget. The budget includes growth of 4.5%, but reported activity is 27% below the 2013-14 monthly average.

- Renal (£61k Adverse) - Renal PD activity (£30k Adv) and transplant (£15k Adv). Both Rheumatology and General Medicine outperformed the budget by £132k and £141k respectively. The General Medicine NEL activity is 168% higher than March, and investigation is required to understand whether this is driven by budget or reporting changes. The Rheumatology budget has been set at a lower level than the average monthly activity level last year.

Pay: Medics: As a Care Group, Medics pay has come in on budget this month. Elderly care medics costs have come in £14k above budget - £8k of this relates to costs for the acute physician in Urgent Care - these costs will move across to UCG in M02. There are £26k agency costs in month, which are being discussed with the Clinical Director.

Dermatology medic costs will increase in 14/15 due to stopping a subcontract giving an overall cost reduction of circa £50k.

Nursing: Nursing pay is £71k favourable against budget this month, with a £43k reduction on last month.

Elderly Care are costs are operating below budget in month, the new nursing skil l mix is fully reflected in the budget.

Bank/ Agency costs are £36k down on last month, and represent a 40% reduction on the 13-14 Qtr 4 average.

Scientists: Audiology Scientists pay spend is £23k above budget in month, and £29k above the month 12 pay spend level. The department is currently using agency to backfil l 3 x band 7 posts which were vacant in 13-14 and are therefore outside of the budget base. Work is underway to define and agree upon the skil lmix for this area. Pathologists pay is down on the qtr 4 average (2.5%), however, these costs are expected to increase over the next few months as posts are fi l led from the 24 hour working patterns.

Non Pay: Pathology Consumables spend continues to remain high, particularly in Biochemistry and Microbiology. Finance, PMO and Pathology continue to work together on this issue. The stock ordering, receipting and holding processes will be reviewed for these departments and an action plan proposed. Audiology - Digital Hearing aid spend through GN Resound Ltd was £66k in month, which was 128% higher than the expected April spend level of £29k (per Audiology). Work is in progress to establish whether prior period invoices have been paid in month. Work will also be done with audiology to determine and review their stock ordering and holding process.

HIV drugs costs were above the expected level in April , driven by March Lloyds costs coming in circa 100% higher than the 13-14 average.

Key risks to financial performance

By the end of April , the accounts showed savings of £175k against budget plan of £412k •The Care Group Board is discussing, approving and supporting the directorates as they draft their options to save 4% of pay. QIA and PIDs are being written with the PMO where required. The early implementation of these projects is critical to Networked Care achieving savings of £4.95m during 14/15. •There are as yet the PIDs are being produced to reduce non-pay. Concentration is required on controlling the clinical supplies costs in microbiology, biochemistry, renal and audiology, to keep them within their budget. • Ensuring the recording of all activity remains as high priority for the Care Group - we continue to focus on the audiology pathway and general uncoded activity , patients 'not checked out' on EPR and the recording of the 14/15 service developments.

Key Opportunities/Actions

• Rationalise, organise and monetise the home delivery of medicines to patients • Re-presentation of the service developments not agreed by the CCG for future funding e.g. surgical liaison officer • Review of the productivity and the skill mix of the Audiology team and establishment of new and expanding services in Bracknell • Partnership agreement with Surrey Pathology to provide consolidated gynae cytology services. • Implementation of the agreed pay reduction options. • Review the stock control systems in microbiology, biochemistry and audiology • Integrated procurement with the Trusts hoping to create Berkshire Surrey pathology partnership, focussing on Biochemistry. • 15% challenge to the directorates to reduce their drug expenditure.

Appendix (iii) : Care Group Financials - PCG


15

FINANCIAL YEAR 2014/15 - COMPARISON OF PLANNED CARE ACTUAL RESULTS TO BUDGET

6 6 6 YTD_M06 YTD_M06 YTD_M06

2014 2014 2014 2014 2014 2014

Actual Budget Variance Actual Budget Variance

Income from activities (excl drugs) 9.39 10.03 (0.64) 9.39 10.03 (0.64)

Drugs Income 1.26 1.03 0.24 1.26 1.03 0.24

Other Patient Care Income 0.15 0.22 (0.07) 0.15 0.22 (0.07)


Total Income 10.90 11.37 (0.46) 10.90 11.37 (0.46)

Medical Staff (2.28) (2.39) 0.11 (2.28) (2.39) 0.11

Nursing (2.14) (2.38) 0.24 (2.14) (2.38) 0.24

PAMs (0.27) (0.28) 0.00 (0.27) (0.28) 0.00

Scientist and PTBs (0.22) (0.25) 0.03 (0.22) (0.25) 0.03

Admin & Management (0.72) (0.72) (0.00) (0.72) (0.72) (0.00)

Ancillary & Maintenance (0.01) (0.01) 0.00 (0.01) (0.01) 0.00

Other Pay 0.02 0.30 (0.28) 0.02 0.30 (0.28)

Total Pay (5.62) (5.73) 0.10 (5.62) (5.73) 0.10Pay as % of income 52% 50% 1% 52% 50% 1%

Contracted wte -1463.21 -1643.56 180

Drugs (1.48) (1.31) (0.17) (1.48) (1.31) (0.17)

Clinical Services and Supplies (1.51) (1.64) 0.13 (1.51) (1.64) 0.13

General Services and Supplies (0.20) (0.23) 0.03 (0.20) (0.23) 0.03

Establishment Expenses (0.06) (0.06) 0.01 (0.06) (0.06) 0.01

Other Establishment Expenses (0.00) (0.00) 0.00 (0.00) (0.00) 0.00

Prem, Trans & Fixed Plant (0.07) (0.05) (0.03) (0.07) (0.05) (0.03)

Leases (0.03) (0.03) 0.00 (0.03) (0.03) 0.00

Miscellaneous Services (Excl Internal Recharges) (0.24) (0.16) (0.07) (0.24) (0.16) (0.07)

Total Non Pay (excl depn) (3.59) (3.49) (0.10) (3.59) (3.49) (0.10)

Operating Surplus (Loss) 1.69 2.16 (0.46) 1.69 2.16 (0.46)

Contribution % 15.5% 19.0% 15.5% 19.0%

MONTH 1 MONTH 1 YTD

Appendix (iii) : Care Group Financials - PCG


16

Financial positionCommentary

Income:

The Care Group income was £11.37m for March. Overall income was £0.46m adverse to budget. CCG Income was £640k adverse, partially compensated by drugs income, £240k favourable.

Key issues are:- CCG underlying activity was £640k favourable to budget. The specialties signif icantly down are Gastroenterology, which is £341k under budget and Orthopaedics £471k.

- Gastro is primarily caused by changes in the POD rota, which are not budgeted. The Gatro consultants have reduced their POD rote f rom doing 5 out of 17 to 2 out of 14. This has impacted monthly non-elective activity which is down on budget by £366k. In addition, we are awaiting the arrival of two additonal consultants which will improve elective activity and the income for these consultants is incorrectly budgeted.

- Orthopaedic activity has increased but is showing as down on budget due to income f rom the new theatre business case being incorrectly included in month 1 (the theatres will not be on stream until at least October and this income needs to be rephased to ref lect).- Drugs income - higher than budget mainly due to oncology drugs increasing.

The pay position of PCG is £100k lower than budget this month

Nursing continues to be extremely well controlled and is £240k favourable to budget this month, although agency costs are too high in Hunter / Lister and Hopkins - recruiting to vacancies will resolve this but it will take time.

Admin and management has reduced this month and is on budget as a result. The holding of two Planned Care Board vacancies and elmination of all interim costs in the Care Group has facilitated this

The adverse variance on Other pay is the gap between the agreed budget control total and Planned Care staf f ing costs budgeted to include vacancies, QIPPS, pay uplif t and increments.

Non-pay:

Overall, non pay spend is £100k adverse, no major issues as driven by oncology drugs costs which are recovered through income.

Key Risks to Financial performance

Key risk is income - we need to improve theatre utilisation at the spokes and ensure more ef fective backf illing of lists.

The estate is always a concern as the Care Group consistly loses theatres due to breakdowns or water ingress. There is no contingency in the plan to cover such eventualties

Cancellations on the day of surgery, although reduced f rom the position a year ago, are still too high and there is a project plan to process to reduce.

Ophthalmology - cost risk through outsourcing, income risk through loss of market share as 18 week backlog still exists

Key Opportunities

Improved coding / f ibroscan / private patients / reduced outsourcing / improved theatre utilisation esp at spokes / Bracknell growth especially through MSK and Urgent Care Centre/ contined growth of private patients / cash up clinics / check green forms / increased outpatient activity through Newtons initiatives / reduce theatre cancellations on the day

BUPA private patient income is expected to improve as a result of Bracknell being approved and the range of work RBH is approved for being expanded.

Headcount reductions

Agency reduction esp Hunter / Lister and Hopkins wards

Job plan changes - elimination of 18 SPAs targetted - value £220k of cost / >£2m of income

ActionsDriving the activity in 14/15 more ef fectively and approval and delivery on key projects:Newton outpatientsImproved codingDecontaminationBracknell MSK Tier 2Pre-OpGeneral Surgery & Private WardLaminar f low theatres & Orthopaedic centre

Appendix (iii) : Care Group Financials - UCG


17

£m

Actual BudgetVariance to

Budget Actual BudgetVariance to

Budget

Income from activities (excl drugs) 8.23 8.18 0.05 8.23 8.18 0.05

Drugs Income 0.14 0.15 -0.01 0.14 0.15 -0.01

Other Patient Care Income 0.09 0.04 0.05 0.09 0.04 0.05


Total Income 8.61 8.46 0.15 8.61 8.46 0.15

Medical Staff -1.47 -1.58 0.10 -1.47 -1.58 0.10

Nursing -3.21 -3.44 0.23 -3.21 -3.44 0.23

PAMs -0.34 -0.35 0.01 -0.34 -0.35 0.01

Scientist and PTBs -0.07 -0.07 0.01 -0.07 -0.07 0.01

Pharmacists 0.00 0.00 0.00 0.00 0.00 0.00

Admin & Management -0.36 -0.37 0.01 -0.36 -0.37 0.01

Ancillary & Maintenance 0.00 0.00 0.00 0.00 0.00 0.00

Other Pay 0.02 0.44 -0.42 0.02 0.44 -0.42

Total Pay -5.42 -5.36 -0.06 -5.42 -5.36 -0.06Pay as % of income 0.63 0.63 0.63 0.63

Contracted wte 0.00 0.00 0.00 0.00 0.00 0.00

Drugs -0.25 -0.24 0.00 -0.25 -0.24 0.00

Clinical Services and Supplies -0.63 -0.83 0.20 -0.63 -0.83 0.20

General Services and Supplies -0.05 -0.08 0.03 -0.05 -0.08 0.03

Establishment Expenses -0.03 -0.05 0.03 -0.03 -0.05 0.03

Other Establishment Expenses -0.01 0.00 0.00 -0.01 0.00 0.00

Prem, Trans & Fixed Plant -0.04 -0.03 -0.01 -0.04 -0.03 -0.01

Leases 0.00 0.00 0.00 0.00 0.00 0.00

Miscellaneous Services (Excl Internal Recharges) -0.05 0.16 -0.21 -0.05 0.16 -0.21

Internal Recharges -0.01 -0.01 0.00 -0.01 -0.01 0.00

Total Non Pay (excl depn) -1.07 -1.09 0.02 -1.07 -1.09 0.02

Operating Surplus (Loss) 2.12 2.00 0.11 2.12 2.01 0.11

Margin (Surplus/ Loss as a % income) 25% 24% 25% 24%

Month 1 Month 1 YTD

FINANCIAL YEAR 2014/15 - COMPARISON OF URGENT CARE ACTUAL RESULTS TO BUDGET

Appendix (iii) : Care Group Financials - UCG


18

Financial Position Commentary on the Urgent Care Group Month 1 Financial position

Care Group Pay costs are £0.25m lower than the previous month and £(0.06)m higher than budget

Care Group contribution at £2.12m is £0.11m ahead of budget Medical staffing costs decreased by £0.09m in Month 1 and were £0.10m below budget:

Income is £0.15m better than budget

A&E/AMU combined income is £0.20m higher than budget, although £(0.04)m down on March

CDU Drs costs decreased by £0.07m in Month, this related to an decrease of £0.06m in the accrual for SPR agency staff when compared with Month 12. In month agency usage in line with budgeted headcount

ICU income is £(0.05)m lower than budget with decreased activity in the first half of the month

Obstetrics 4 SPR in post without budget £(0.01)m. CMO cover provided with backfill costs in UCG.

Radiology Income is £(0.02)m off budget. Although activity is ahead of budget there is a provision against the income reducing DI income to contract level.

Paediatric 1 new consultant in post and increased payments to specialist registrars driving a £(0.03)m movement month on month, however this is broadly in line with budget.

Cardiology income from activities is £(0.01)m behind budget due to reduced NELST delivery. Overall income for the specialty is ahead of budget with increased private patient income £0.05mRespiratory Income is £(0.01)m behind budget. Reduced excess bed days the principal cause

Nursing/Midwifery costs decreased by £0.12m in Month 1 (month on month) and are £0.23m favourable to budget:

Maternity income is £0.06m ahead of budget. Risk share has been accrued in line with budget.Paediatrics income £(0.04)m behind budget. NEL Paeds and NICU activity both lower than budget.

Maternity and Children’s £0.08m lower than budget and £0.01 down month on month driven by maternity vacancies.

Risks and Opportunities to budget:Acute Med Nursing costs were £0.04m lower than budget and £0.02m lower than March driven by vacancies on the stroke unit.

Income risk remains in Cardiology and Respiratory as the level of income seen in M1 remains in line with the reduced run rate evidenced in Q4 13/14. Paediatric income has declined against budgeted run rate. Key risk Recovery plan agreed with commissioners for diagnostic imaging waiting list. Ensuring full payment is critical

Emergency Nursing costs were £(0.04)m higher than budget, although £0.07m lower than prior month. This variance to budget was driven by A&E/AMU which together are £(0.02)m higher than budget and ICU £(0.02)m which contains 11 WTE transferred from PCG (budget has not been transferred)

Pay Increased headcount as a result of transfers. Budget to be confirmed

Care Group Non Pay costs decreased by £0.49m in Month 1 and are £0.02m lower than budget.

Non pay M1 contains one time benefit of £0.08m Radiology has a one time benefit due to over accrual of the new PACS contract £0.08m and recurrent saving of £0.04m due to the renegotiated price. Maternity and children’s has reduced £0.11m month on month

Management action is identifying and implementing full programme of QIPP in line with budgeted £4.8m target

Appendix (iv) : Point of Delivery - Month


19

March 2014

All CCGs (including NCAs)

POD Group POD Detail

Annual Budget

(Activity)

Annual Budget (£'000)

Mth 12 Only Budget

(Activity)

Mth 12 Only Budget (£'000)

Mth 12 Only Actual

(Activity)

Mth 12 Only Actual (£'000)

Mth 12 Only Var (Activity)

Mth 12 Only Var (£'000)

A&E Accident & Emergency 101,671 11,786 9,090 1,054 9,739 1,167 649 113A&E Total 11,786 1,054 1,167 113

Outpatient Outpatient FA Multi Prof Cons Led 4,347 777 367 66 317 57 (50) (9)Outpatient FA Single Prof Cons Led 153,533 23,232 12,864 1,967 12,338 2,033 (526) 66Outpatient FA Single Prof Non-Cons Led 10,003 1,159 842 98 945 109 103 11Outpatient FUP Multi Prof Cons Led 7,094 877 599 74 668 105 69 31Outpatient FUP Single Prof Cons Led 236,437 23,740 19,500 2,010 19,764 1,940 264 (70)Outpatient FUP Single Prof Non-Cons Led 64,128 3,529 5,380 299 4,857 269 (523) (30)Non Face to Face 1,798 46 150 4 175 5 25 1Outpatient Procedures 28,718 7,367 2,517 624 4,043 897 1,526 273

Outpatient Total 60,729 5,142 5,414 271

Inpatient Elective Inpatients 8,580 26,109 712 2,211 708 2,448 (4) 237Elective Excess Bed Days 2,735 708 220 60 213 56 (7) (4)Day Cases 33,904 30,119 2,826 2,550 3,061 2,735 235 185Regular Day Admission 2,217 686 189 58 217 81 28 23Emergency Inpatients (Excluding Maternity) 30,552 67,269 2,698 6,014 2,345 5,211 (353) (804)Maternity Inpatients 12,589 16,486 1,126 1,474 958 1,279 (168) (195)Emergency Same Day 1,134 977 101 87 203 175 102 88Emergency Short Stay 3,001 2,195 268 196 258 182 (10) (15)Emergency Excess Bed Days 19,195 4,860 1,696 435 2,324 589 628 154Maternity Excess Bed Days 2,273 541 203 48 133 32 (70) (16)

Inpatient Total 149,951 13,134 12,787 (347)

Critical Care Adult Critical Care 3,729 5,027 334 449 374 491 40 42Neonatal Critical Care 5,756 3,832 515 343 279 174 (236) (168)Surgical HDU 1,543 856 222 122 0 0 (222) (122)

Critical Care Total 11,028 9,715 1,071 914 653 666 (418) (249)

Renal Renal 76,470 11,003 6,525 932 6,273 897 (252) (34)Renal EPO Drugs 457 39 40 1

Renal Total 11,460 970 937 (33)

Drugs PbR Excluded Drugs 24,061 2,021 2,539 518PbR Excluded Devices 1,830 154 180 26

Drugs Total 25,891 2,175 2,719 544

Other Orthotics Direct Access 3,588 872 303 74 317 79 14 5Pathology Direct Access 3,015 6,946 250,659 588 257,184 584 6,525 (4)Radiology Direct Access 34,515 1,355 3,068 115 4,836 174 1,768 60Anti Coagulant Reviews 99,559 796 8,431 67 8,483 67 52 0Diagnostic Imaging 64,046 7,143 5,428 605 5,347 541 (81) (64)Maternity Ultrasound 11,762 906 996 77 1,096 84 100 8Post Discharge Rehab 323 194 27 16 15 9 (12) (8)Pre-op Assessments 19,868 817 1,687 69 1,389 57 (298) (12)Rehab Bed Days 5,307 1,661 475 149 388 121 (87) (27)Unbundled Activity 1,908 325 162 28 229 42 67 15Non PbR Block Items 15,055 1,255 1,253 (2)Other 36,624 427 2,267 36 2,813 44 546 8

Other Total 36,498 3,078 3,055 (23)

Adjustments ESD Discount (150) (13) (90) (78)Audiology Hearing Aid Assessment Discount (re Pathway Tariff) (230) (19) (16) 3SCAS Delays Penalties (300) (25) (19) 6CQUINs 6,257 544 871 327Best Practice Top Ups 2,500 219 141 (78)Non Elective Threshold 0 0 0 0Non Elective Readmissions 0 0 0 0NEL Threshold & 30-day Readmits net of re-investment 0 0 (83) (83)Outpatient-DI Contract Penalty 0 0 (99) (99)Diagnostic Imaging risk-share 0 0 (12) (12)Contract Data Challenges (750) (65) (59) 6Contract Income Provision 0 0 (845) (845)Contract Income Provision Release re 2012/13 & 2013/14 0 0 1,603 1,603Est of addnl income between WD3 and WD7 Activity Extracts 0 0 0 0Est of addnl income re missing items 0 0 0 0Est of reduction in NEL activity Corporate, Cardiology and Respiratory 0 0 0 0Phasing Adjustment 0 (515) 0 515Adjust Budget to Top-Down Total (1,648) (137) 0 137

Adjustments Total 5,680 (11) 1,393 1,404

Other Income from Activites TVIC Dermatology 1,996 166 166 (0)Bowel Screening 640 53 48 (5)Oxford Morbid Obesity Service 317 26 0 (26)Change re Spells in Progress (vs M12 12-13) 0 0 199 199Others 331 35 57 22

Other Income from Activities Total 3,285 281 470 189

TOTAL (= 'Income from Activities') 314,993 26,738 28,608 1,870

20

Appendix (v): Statement of Financial Position

Analysis : • Cash at £17.32m – behind Budgeted

position of £18.01m. • Accrued income high because of

delay in agreeing final invoicing value for 13/14 with BWCCGs. Fully billed in May. Cash due in June.

February 2014 March 2014 April 2014Annual PlanApril 2014

Assets £m £m £m £mAssets, Non-CurrentIntangible Assets, Net 9.42 9.30 9.15 9.10Property, Plant and Equipment, Net 188.23 188.18 187.24 187.81Other Investments, at Cost 3.91 4.36 4.28 3.70Deferred Tax Assets 0.00 0.00 0.00 0.00Other Receivables, Non-Current 0.90 0.89 0.88 0.75Assets, Non-Current, Total 202.46 202.73 201.55 201.36

Assets, CurrentInventories 4.83 5.21 5.09 4.70NHS Trade Receivables, Current 2.28 3.34 2.49 2.50Non-NHS Trade Receivables, Current 1.44 1.58 1.55 1.20Other Receivables, Current 1.51 0.90 1.35 1.80Accrued Income 11.27 8.67 9.41 5.00Prepayments, Current, non-PFI related 2.56 1.35 1.38 2.16Cash and Cash Equivalents, Total 18.58 21.27 17.32 18.01 Assets held for sale 2.25 2.25 2.25 2.25Assets, Current, Total 44.72 44.57 40.84 37.62

ASSETS, TOTAL 247.18 247.30 242.39 238.98

LiabilitiesLoans, non-commercial, Current (DH, FTFF, NLF, etc) (3.67) (3.67) (3.67) (3.67)Deferred Income, Current (2.17) (2.14) (2.08) (0.50)Provisions, Current (4.26) (3.31) (3.56) (5.50)Current Tax Payables (4.00) (3.95) (3.94) (4.00)Trade Creditors, Current (6.78) (9.09) (5.48) (5.00)Other Creditors, Current (2.73) (2.75) (2.73) (2.75)Capital Creditors, Current (2.71) (2.54) (2.25) (1.00)Accruals, Current (16.57) (17.05) (17.44) (16.00)Payments on Account (0.40) (1.87) (1.57) (2.00)PDC dividend creditor, Current (2.08) 0.00 (0.42) (0.42)Interest payable on non-commercial interest bearing borrowings, current (0.26) (0.36) (0.47) (0.47)Other Liabilities, Current (1.60) 0.00 (0.40) (0.05)Liabilities Current, Total (47.23) (46.74) (44.01) (41.36)

NET CURRENT ASSETS (LIABILITIES) (2.51) (2.17) (3.17) (3.74)

Loans, Non-Current non-commercial (DH, FTFF, NLF, etc) (30.57) (30.57) (30.57) (30.58)Provisions, Non-Current (0.31) (0.30) (0.30) (0.30)Deferred Tax liability (0.10) (0.10) (0.10) (0.10)Trade and Other Payables, Non-Current (0.50) (0.50) (0.47) (0.46)Liabilities Non-Current, Total (31.48) (31.47) (31.44) (31.44)

TOTAL ASSETS EMPLOYED 168.47 169.09 166.94 166.18

21

Appendix (vi): Cash Flow Statement

April14 YTD April 14 YTD April 14Actual Actual Projection

£000 £000 £000

Opening cash Balance 21.27 21.27 21.50

Income 27.84 27.84 27.80Expenditure (excluding depreciation) (27.97) (27.97) (27.95)

Cash generated (0.13) (0.13) (0.15)

Working Capital(Increase)/decrease in inventories 0.12 0.12 0.00(Increase)/decrease in receivables (0.33) (0.33) 0.14(Increase)/decrease in asssets held for s 0.00 0.00 0.00Increase/(decrease) in payables (2.89) (2.89) (2.35)

(3.10) (3.10) (2.21)

Capex (Capital expenditure) (0.63) (0.63) (1.03)PDC paid 0.00 0.00 0.00

Financial ActivityInterest income/ (Expense) (0.09) (0.09) (0.09)Other 0.00 0.00 (0.02)

(0.09) (0.09) (0.11)

Loan Drawdown 0.00 0.00 0.00Loan (Repayment) 0.00 0.00 0.00

Net increase/(decrease) in cash (3.95) (3.95) (3.50)

Closing Cash Balance 17.32 17.32 18.00

Appendix (vii): Downside Cash Position

Assumptions • No trust QIPPs included.

QIPPs will be recognised when delivered

• Tariff Deflator 1.2% • Pay 1% • General inflation 2.5% • Drug cost/income 4% • CCG Qipps £9m

Key Messages • Without delivery of Trust cost QIPPs

cash runs out in Q1 2015/16 if CCGs deliver their QIPPs.

• Where CCGs do not deliver their QIPP cash runs out in Q1 2015/16

Actions • Delivery of QIPPs • Delivery of new Theatres • Drive PCG growth

2014/15 (£m) Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15Flat Act 17.32 14.73 17.26 17.58 12.88 6.90 9.73 10.25 6.83 8.22 4.74 6.21CCG QIPPS 17.32 14.54 16.87 17.00 12.08 5.90 8.54 8.87 5.25 6.46 2.77 4.08CCG Act Growth 17.32 14.83 17.46 17.86 13.33 7.43 10.34 10.96 7.63 9.12 5.67 7.32

Lowest balance in quarter 14.54 5.90 5.25 2.77

2015/16 (£m) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16Flat Act 5.25 3.30 (0.47) (1.45) (6.27) (11.62) (9.37) (10.01) (16.20) (15.22) (17.82) (15.96)CCG QIPPS 2.91 0.60 (3.57) (4.92) (10.19) (15.96) (14.08) (15.09) (21.67) (21.03) (24.05) (22.51)CCG Act Growth 6.36 4.60 1.02 0.23 (4.48) (9.68) (7.24) (7.71) (13.74) (12.60) (15.09) (13.04)

Lowest balance in quarter (3.57) (15.96) (21.67) (24.05)

2016/17 (£m) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17Flat Act (17.96) (20.00) (23.79) (24.80) (29.64) (35.02) (32.79) (33.46) (39.67) (38.71) (43.33) (41.49)CCG QIPPS (24.71) (27.12) (31.31) (32.68) (37.97) (43.77) (41.91) (42.95) (49.55) (48.93) (53.97) (52.45)CCG Act Growth (14.97) (16.82) (20.43) (21.24) (25.97) (31.20) (28.78) (29.27) (35.33) (34.21) (38.72) (36.69)

Lowest balance in quarter (31.31) (43.77) (49.55) (53.97)

23

Appendix (viii): Capital Expenditure Summary

2014/15 Original

Plan

2014/15 Revised Forecast

Spend to Date

Commit-ments

Orders to be raised

Sub Total

Intended to be

leased

£m £m £m £m £m

Medical Equipment 2.00 2.00 (0.06) (0.20) (1.74) (2.00) 0.00IT Infrastructure 3.00 3.00 (0.08) (1.78) (1.14) (3.00) 0.00Statutory Compliance 2.50 2.50 (0.03) (0.41) (2.06) (2.50) 0.00Backlog Maintenance 2.00 2.00 (0.02) (0.24) (1.74) (2.00) 0.00

Major Works - A&E 0.70 0.70 (0.00) (0.03) (0.67) (0.70) 0.00 - Pre Op / New Ward 1.00 1.00 (0.00) (0.03) (0.97) (1.00) 0.00 - Maternity Ventilation 0.40 0.40 (0.00) (0.00) (0.40) (0.40) 0.00 - Decontamination 0.55 0.55 (0.00) (0.02) (0.53) (0.55) 0.00 - WBCH Single Sex Accom 0.12 0.12 (0.00) (0.00) (0.12) (0.12) 0.00 - Other 0.25 0.25 (0.00) (0.00) (0.25) (0.25) 0.00

Total 12.52 12.52 (0.19) (2.71) (9.62) (12.52) 0.00

Q1 Q2 Q3 Q4 Total

£m £m £m £m £m

Medical Equipment (0.00) (0.00) (0.00) (0.00) (0.00)IT Infrastructure (0.00) (0.00) (0.00) (0.00) (0.00)Statutory Compliance (0.00) (0.00) (0.00) (0.00) (0.00)Backlog Maintenance (0.00) (0.00) (0.00) (0.00) (0.00)

(0.00) (0.00) (0.00) (0.00) (0.00)Major Works (0.00) (0.00) (0.00) (0.00) (0.00) - A&E (0.00) (0.00) (0.00) (0.00) (0.00) - Pre Op / New Ward (0.00) (0.00) (0.00) (0.00) (0.00) - Maternity Ventilation (0.00) (0.00) (0.00) (0.00) (0.00) - Decontamination (0.00) (0.00) (0.00) (0.00) (0.00) - WBCH Single Sex Accom (0.00) (0.00) (0.00) (0.00) (0.00) - Other (0.00) (0.00) (0.00) (0.00) (0.00)

Total (0.00) (0.00) (0.00) (0.00) (0.00)

Budget 0.00

( Under ) / Over Budget 0.00 0.00 0.00 0.00 0.00

April 14 Performance against capital budgets is shown

24

Appendix (ix): Continuity of Service Risk Rating

Risk Ratings April 2014Required for a

rating of 3£m

Revenue available for Debt Service £m (0.12) 1.04

Debt Service £m (0.53)

Debt Service Cover metric (0.23)

Debt Service Cover rating 1

Cash for CoS liquidity purposes £m (10.49) 6.53

Operating Expenses within EBITDA £m (27.97)

Liquidity Metric (11.25)

Liquidity rating 2

Continuity of Service Risk Rating 2

25

Appendix (x): Service Line Reporting Key Messages • This is produced on a quarterly

basis, so figures shown are the same as last month for YTD Q3

• Figures carry a significant health warning given the on-going validation work

• Key changes from Q2 – On-going validation work – Better allocation of income – Orthotics and GUM now

showing as separate specialties

– Improved allocation of CNST cost

• Progress on validation work improving:

– Paediatrics and Rheumatology signed off as materially correct

– Orthopaedics and Renal now started

– Still no engagement from Ophthalmology

– Now scheduling in Geriatric and Cardiology

– Being driven by interim who is here until 30 June

• Deep dive work – In progress with examples

raised in all care groups. – PWC working on Obstetrics

and Respiratory

£'000

Specialty Group

Direct and Indirect

Income [ A ]

Direct and Indirect

Costs [ B ]

Contribution to

Overheads [ A - B ]

Contribution % to Trust Overheads

Overhead Costs [ C ]

Net Surplus/ Deficit

Total 255,972 191,886 64,086 25% 61,484 (3,076)Networked Total 65,755 49,811 15,944 24% 14,206 1,549Networked Audiological Medicine 5,791 2,612 3,179 55% 656 2,521Networked Clinical Haematology 6,338 5,564 774 12% 1,244 (481)Networked Dermatology 4,648 1,841 2,807 60% 425 2,372Networked Endocrinology 1,842 1,540 302 16% 452 (159)Networked General Medicine 453 232 221 49% 78 142Networked Geriatric Medicine 12,043 10,221 1,822 15% 3,544 (1,727)Networked GUM 4,263 2,071 2,192 51% 528 1,664Networked Neurology 2,179 2,203 (24) -1% 575 (652)Networked Orthotics 646 461 185 29% 114 71Networked Pain Management 631 425 206 33% 167 38Networked Palliative Care 304 25 279 92% 4 275Networked Pathology 5,642 5,076 566 10% 1,440 (929)Networked Rehabilitation 2,267 2,001 266 12% 573 (312)Networked Renal 12,604 9,732 2,872 23% 2,920 (67)Networked Rheumatology 5,848 5,566 282 5% 1,403 (1,134)Networked Therapies 256 241 14 6% 81 (73)Others Total 3,933 1,150 2,782 71% 279 2,501Others Other Services 3,285 603 2,683 82% 141 2,542Others Psycology 1 0 1 86% 0 (2)Others Wheelchair Service 646 547 99 15% 138 (39)Planned Total 111,516 85,427 26,089 23% 27,021 (2,886)Planned Anaesthetics 409 163 246 60% 72 61Planned Cancer 190 614 (424) -223% 128 (552)Planned Clinical Oncology 13,158 10,682 2,477 19% 2,553 (152)Planned ENT 5,612 3,711 1,901 34% 1,470 374Planned Gastroenterology 11,318 8,283 3,035 27% 3,019 (52)Planned General Surgery 15,548 13,104 2,444 16% 4,597 (2,545)Planned Gynaecology 6,061 4,512 1,549 26% 1,438 (66)Planned Ophthalmology 18,621 12,694 5,927 32% 3,612 2,123Planned Oral Surgery 2,087 1,518 569 27% 450 110Planned Plastic Surgery 742 556 185 25% 142 43Planned Trauma & Orthopaedics 30,239 23,603 6,637 22% 7,506 (1,668)Planned Urology 7,531 5,988 1,543 20% 2,035 (562)Urgent Total 74,768 55,498 19,271 26% 19,977 (4,240)Urgent Accident & Emergency 11,464 9,619 1,844 16% 2,838 (1,420)Urgent Cardiology 12,644 8,326 4,318 34% 2,781 1,469Urgent Critical Care Medicine 7,439 4,381 3,059 41% 1,794 1,264Urgent Obstetrics 15,295 13,119 2,175 14% 4,602 (5,174)Urgent Paediatric Medicine 13,274 9,940 3,334 25% 3,585 (447)Urgent Radiology 5,997 3,954 2,043 34% 2,301 (337)Urgent Thoracic Medicine 8,656 6,158 2,498 29% 2,077 404


2014 / 15 QIPP Programme – Progress Report

The final target for cost savings for the 2014/15 Programme has been set at £19.7m, which includes £1.2m contingency.

The Trust has identified £15.5m of ideas / plans to date. The latest PMO risk assessment of this is £7.1m which reflects the fact that many of the opportunities are still at an early stage and are being developed into robust plans to give assurance of delivery. In addition to this, teams have identified c£10m of income opportunities this year – some of which is within budget. This is currently being validated.

Bi weekly performance meetings are now underway with each Care Group to meet with the Interim COO, Head of PMO and Deputy Finance Director to review projects line by line to provide additional support and challenge – this has resulted in a £2m increase in the risk rating over the last 2 weeks and a challenge has been set to improve the rating by 100% by the end of June.

PwC have now been commissioned to support Care Groups and Corporates in developing existing plans and additional opportunities to close the gap – they will begin their work week commencing 27th May 2014.

Work is underway on all 9 of the trust wide / transformational projects. Some have progressed quicker than others – although each Programme now has dedicated project management support, further support will be provided by PwC who will review opportunities to bring the work forward and / or identify further efficiencies within each Programme.

The governance structure for QIPP has been reviewed and changed to ensure sufficient time is allocated each month for the Executive to review progress and agree additional strategic actions that need to be taken to drive forward the Programme.

The current PMO risk rating of the QIPP Programme is £7.1m against a cost target of £19.7m. Additional performance meetings are in place and additional support from PwC will commence from 27th May

ED Update April 2014 1

Royal Berkshire NHS Foundation Trust Agenda item 6

Board of Directors

Title: Accident and Emergency Recovery Plan

Date: May 2014

Lead: Sue Edees Care Group Director Urgent Care

Purpose:

The purpose of this paper is to inform the Board of the A&E performance and progress against the Berkshire West system wide recovery plan

Key Points: The Trust has been successful in achieving the 4 hour trolley wait target for April 2014 achieving 95.7% The improved performance in April has continued, with many of the planned initiatives now delivering and supporting the achievement of the target A revised trajectory has been submitted to NHS England and Monitor showing achievement of quarter one following agreement at the Urgent Care Programme Board on the 24th

April.

Decision required:

Support the work being undertaken

FOI Status This report will be made available on request.


1 Background

1.1 The revised trajectory submitted in February to NHS England and Monitor was not accepted due to the continued improved performance of the Trust since the beginning of March 2014

1.2 A further revision was agreed with achievement of the 4 hour target in quarter one. The revised trajectory does recognise dips in performance that are predictable during bank holiday.

Revised Trajectory

Week Ending

6 Apr 13 Apr 20 Apr 27Apr 4May 11May 18May 25May 1 Jun 8 Jun 15 Jun 22 Jun 29Jun Quarter A&E

Cumulative Year To Date

95.38%

95.79%

96.30%

95.61%

93.04%

A&E Weekly Actual

Performance 95.38

% 96.24

% 97.35

% 93.54

% 96.87

%

A&E Weekly Performance

Trajectory 95.38

% 96.24

% 97.35

% 93.23

% 94.77

% 93.60% 94.94

% 96.03

% 94.68

% 96.17

% 95.56

% 94.82

% 96.03

% A&E Monthly Performance

Trajectory

95.54%

95.00

%

95.65%

95.37%

A&E Average daily

attendance 264 267 276 284 255 265 272 270 275 270 270 270 265

Medically fit

actual 47 54 40 38 45 52

Medically Fit for discharge

trajectory 30 30 30 30 25 25 25 25 20 20 20 20 20

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

0

10

20

30

40

50

60

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

6th Apr 20th Apr 4th May 18thMay 1st Jun 15th Jun 29th Jun

A&E Performance and Trajectory 2013-2014 (Type 1and2 ) A&E Cumulative Year To Date A&E Weekly Actual Performance A&E Weekly Performance Trajectory Medically Fit for discharge trajectory Medically fit actual


2 Current Position 2.1 Attendances were not as high in April compared to March with an average each day of 275

and admission average of 81.

2.2 There was a dip in performance following the Easter weekend; work is underway with the

CCG to ensure community cover is in place for Whitsun half term.

2.3 The Emergency Care Unit (ECU) has not been escalated and enabled the triage of patients

suitable for same day discharge to be seen and discharged, by both the Emergency Department Consultants and the Advanced Nurse Practitioners.

2.4 This has been complimented by the Acute Physicians and Interface Geriatrician working 5

days a week in support of the Physician of the day who is now on duty until 10pm; increasing same day discharges from the Acute Medical Unit, and allowing for triage of GP calls where admission can be avoided.

2.5 Bed occupancy has been below 90% for the month, attributed to the effective practices of

discharge on the same day and the work of the length of stay project group.

2.6 Work to enhance this further is underway to compliment the emergency department

extension being undertaken this year.

0

5

10

15

20

25

30

35

40

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

13th

14th

15th

16th

17th

18th

19th

20th

21st

22nd

23rd

24th

25th

26th

27th

28th

29th

30th

T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W

Same-day Discharges Comparison

Total AMU & ECU 2014 CDU April 2013

April 2013 sameday discharges = 257 April 2014 sameday discharges = 566 = 120% increase, releasing 20 beds


3 Trust Actions

3.1 Work is being undertaken to discharge patients in a more timely manner with Care Group Directors of Nursing leading a daily review of all discharges taking place after 11 am each day and a Trust wide action plan led by both the Chief Operating Officer and the Director of Nursing.

3.2 The number of patients on the medically fit list continues to run above trajectory, with issues being addressed via the twice weekly conference call. The overall length of stay of patients on the medically fit list has reduced thanks to the effectiveness of the Navigation team.

4 Recommendations

4.1 The Trust Board is asked to note the continued developments and actions across the Urgent Care pathway of care and support the work being undertaken within the Trust towards achieving the 4 hour A&E target.

5 Contact Contact: Sue Edees Clinical Director Urgent Care Phone: 0118 322 6772

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Regional A&E Weekly A&E Performance Ryl Berkshire Frimley Buckinghamshire

Heatherwood Oxford Univ 95% Target

Version 3 – May 20 2014 1


Board of Directors

Title: Board assurance on the CQC Intelligent Monitoring Report

Date: 27 May 2014

Lead: John Taylor, Acting Commercial Director

Purpose: This paper outlines the approach to be taken that will deliver assurance to the Board of Trust’s performance in relation to the indicators that feature within the CQC’s Intelligent Monitoring Report.

Key Points: • The Board requires assurance that governance processes within the Trust encompass all the indicators that feature in the CQC Intelligent Monitoring (IM) report.

• The Board needs to be advised prospectively of potential risks relating to the RBFT that may feature in the CQC’s quarterly Intelligent Monitoring (IM) Report.

• The Board needs ongoing assurance as to the mitigating actions relating to risks that have featured in previous IM reports about the Trust.

• By the July 2014 Trust Board, the Trust will have an assurance system in place which enables the Board to be advised of potential future IM risks and gives assurance that current IM risks are being effectively managed.

• Trusts that have recently been inspected will not be banded but placed in a separate band ‘recently inspected’.

Decision required:

The Board is asked to approve the approach outlined in this paper.

FOI Status This report will be made available on request.


1 Background

1.1 The CQC is revising its approach to regulating NHS acute Trusts, which includes revisions to its inspection methodology, ratings approach and how it monitors the performance of Trusts in-between inspections. The principal tool for the latter is the Intelligent Monitoring (IM) Report.

1.2 The Trust has been informed that it will be given actual ratings following its March 2014 inspection rather than shadow ratings. This means that the Trust will receive a Trust-wide rating, rating for each Trust location and domain and a rating for each of the core services inspected. Rating categories are outstanding, good, requires improvement or inadequate. Ratings will be based primarily on the results of the most recent inspection together with intelligence that the CQC has about the Trust from its stakeholders and intelligent monitoring reports. Ratings can be changed based on subsequent inspection findings.

1.3 The Intelligent Monitoring report is published quarterly by the CQC and contains a set of indicators for each Trust that review a range of information including patient experience, staff experience and performance, addressing the key questions the CQC asks of services: are they safe, effective, caring, responsive and well-led?

1.4 The CQC uses indicators to raise questions about the quality of care but it does not use them on their own to make final judgements. These judgements are based on a combination of inspection results, intelligent monitoring analysis and local information from the Trust and other organisations, such as Monitor and the Clinical Commissioning Groups.

1.5 The Trust has received two IM Reports to-date, in October 2013 and March 2014. The October report contained 9 higher than expected risks (4 elevated risks and 5 risks) and the March report contained 4 higher than expected risks (1 elevated risk and 3 risks).

1.6 The next quarterly CQC Intelligent Monitoring report about the Trust will be published in early June 2014. Following an inspection, Trusts are exempt from the 1-6 banding system assigned to each Trust following the publication of each Intelligent Monitoring Report. Trusts that have undergone inspection will be placed in a 'previously inspected band'. The approach to scoring indicators within the Intelligent Monitoring Report remains unchanged for Trusts that have been inspected in that risks and elevated risks will continue to be identified.

1.7 Following the publication of the October 2013 and March 2014 reports, the Board has asked for assurance that the indicators contained within the IM report are monitored internally and where performance is exceptional, that these risks be reported to the Trust Board in advance of the publication of each IM report.

1.8 The Board needs ongoing assurance as to the mitigating actions relating to risks that have appeared in previous IM Reports.

1.9 The Board has asked John Taylor, Acting Commercial Director to recommend how the Board can be given these assurances.


2 The Intelligent Monitoring report

2.1 There are currently 93 indicators within the Intelligent Monitoring Report, which the CQC uses to address the safety, effectiveness, responsive, caring and well-led key lines of enquiry that it has developed.

2.2 The CQC uses the most up-to-date datasets that it can access and the time period varies depending on the dataset. For most indicators, other than those published annually such as national surveys, the performance data is refreshed every quarter.

2.3 To understand how the Trust currently monitors the indicators within the IM report, it is possible to categorise the indicators into four groups;

(a) Quality measures for which there is currently a monthly direct reporting process to the Trust Board:

(i) Never events

(ii) Avoidable infections

(iii) Patient safety incidents

(iv) Proportion of patients risk assessed for venous thromboembolism

(v) Access measures

(vi) Monitor governance risk rating

(vii) Response rate to NHS England Friends and Family Test

(viii) Reporting to the National Reporting and Learning System (NRLS)

(b) Clinical performance indicators for which there is currently an effective reporting and monitoring process to the Trust Board:

(i) Hospital standardised mortality ratios (HSMR) calculated by Dr Foster Intelligence.

(ii) Performance in national audits

(c) The results of annual surveys, the results from which are reported annually to the Trust Board;

(i) Inpatient survey

(ii) CQC Maternity survey

(iii) Staff survey

(d) Indicators which are not comprehensively currently monitored either within the Trust or are not reported or there is a lack of clarity over robustness of reporting to the Trust Board for which the current governance mechanism needs to be reviewed and appropriate systems introduced where required;

(i) Dr Foster outlier alerts (these are reviewed at the Data Outliers Group and in the future will be reported by exception to the Quality Performance Committee and Board).


(ii) Emergency readmission rates following elective and emergency admission. Emergency readmission rates are currently reported to the Board, this work-stream needs to clarify whether the figure reflects both emergency readmissions following an elective and emergency admission, which are the indicators within the IM report.

(iii) Data quality of data returns to HSCIC. This indicator is not currently reported internally. The work-stream needs to understand from the CQC the composition of the indicator within the IM Report and reflect internal reporting processes accordingly.

(iv) Secondary uses services (SUS) data accuracy. This data is collated but not reported internally.

(v) Specific staffing indicators - The Interim Human Resources Director is reviewing these indicators in conjunction with a review of the Workforce Report for the Board in Quarter 1 2014/15.

(vi) GMC National Training Survey – Trainee’s overall satisfaction. The results currently are presented to the Trust Workforce and Education Board and not to the Trust Board.

(vii) PROMs

(e) Experience information which is collated by the CQC which is not possible for the Trust to influence or report to the Board prospectively:

(i) Patient experience information reported on NHS Choices, Patient Opinion and to the CQC.

(ii) Staff concerns reported to the CQC (whistle-blowing alerts).

2.4 In order to enable the Board to be informed in advance of any risks that may appear in subsequent reports, to assure the Board that past risks are being effectively managed and to implement governance and reporting systems for indicators which are not currently reported on either at all and/or to the Board by exception, the Acting Commercial Director will lead a work-stream with the following deliverables:

(a) By 27 May 2014 Trust Board:

(i) Give Board assurance relating to the mitigating actions for the risks that featured within the March 2014 IM Report. These are reported on within the Quality Performance Report to the Board.

(ii) Identify potential risks that may feature within the June 2014 Intelligent Monitoring Report. In identifying an indicator as a ‘risk’ or ‘elevated risk’, the CQC incorporates an element of comparative performance with other Trusts, so where an indicator has been identified by the Trust as ‘risk against target’, it may not be identified by the CQC as a risk within the Intelligent Monitoring Report. However, for the purposes of Board assurance, the list below represents indicators that have been awarded an amber or red risk within the March 2014 Quality Performance Report Dashboard and/or where it is known that the Trust performance does not meet the ‘expected’ level identified by the CQC within the IM Report and therefore may be identified as a ‘risk’ or


‘elevated risk’ within the June 2014 Intelligent Monitoring Report. These risks are retrospective in nature. There are some indicators that feature within the IM Report that are not currently monitored within the Trust, these may appear as a risk within the IM Report but are not included in the list below. Performance on these is planned to be reportable by the September 2014 IM Report – this analysis will be prospective in nature:

(a) Never Event Incidence

(b) Incidence of Clostridium difficile

(c) Proportion of reported patient safety incidents that are harmful

(d) A&E waiting times more than 4 hours

(e) Cancer 62 day wait for first treatment from urgent GP referral

(f) Patients waiting over 6 weeks for a diagnostic test

(g) The proportion of patients whose operation was cancelled

(h) Turnover rate for medical and dental staff and other clinical staff

(iii) Outline the plan and timetable which will enable the Board to receive assurance of the prospective risks that may feature in the September 2014 IM Report and the governance process within the Trust that tracks and monitors past risks.

(b) By June 2014 Trust Board;

(i) Map the current internal reporting process for all IM indicators including Director ownership and Committee responsible for monitoring performance.

(ii) Identify IM indicators for which performance is not currently reported on or monitored within the Trust.

(iii) For IM indicators that are currently not reported or monitored, recommend the implementation of a governance and reporting system that delivers Board assurance.

(iv) For each IM indicator, identify a Lead-Director who is responsible for its performance and associated reporting.

(c) For the July 2014 Trust Board, based upon the implementation of the system above, deliver assurance to the Trust Board on potential risks that may feature within the September 2014 IM Report and continue to report on mitigating actions relating to past risks.

3 Legal / Financial /Risk Management Implications

3.1 There are no legal or financial implications to this report.

3.2 It is imperative that the relevant Director, who is the owner of the risk (s) within the IM report, reflects the risks on his/her organisational Risk Management Register.


4 Conclusion and Next Steps

4.1 To-date the Board has not been informed in advance about potential risks that may feature within the Trust’s Intelligent Monitoring Report.

4.2 The Acting Commercial Director will lead a work-stream, which will deliver assurance to the Board that the indicators within the IM report are effectively monitored within the Trust and that potential future risks are reported by exception to the Trust Board by the end of July 2014.

5 Recommendations

5.1 The Trust Board is asked to: (i) Note the approach and timetable outlined within this report.

6 Attachments

6.1 The following are attached to this report:

(a) Appendix 1 – RBFT Intelligent Monitoring Report 13 March 2014

7 Contact Contact: John Taylor, Acting Commercial Director Alex Baker, Healthcare Standards Manager Phone: 0118 322 7445

Royal Berkshire NHS Foundation Trust

Intelligent Monitoring Report

13 March 2014

Report on

What does this report contain?

Further details of the analysis applied are explained in the accompanying guidance document.

What guidance is available?

We have published a document setting out the definition and full methodology for each indicator. If you have any queries or need more information, please email [email protected] or use the contact details at www.cqc.org.uk/contact-us

Royal Berkshire NHS Foundation Trust RHW

NHS Trusts that have had an inspection at the time of producing this update of Intelligent Monitoring have not been assigned a banding; all other indicator analysis results are shown in their report. “Recently inspected” is stated for these trusts. This is to reflect the fact that CQC’s new comprehensive

inspections will provide its definitive judgements for each organisation.

We have used a number of statistical tests to determine where the thresholds of "risk" and "elevated risk" sit for each indicator, based on our judgement of which statistical tests are most appropriate. These tests include CUSUM and z-scoring techniques. Where an indicator has 'no evidence of risk' this refers to where our statistical analysis has not deemed there to be a “risk” or “elevated risk”. For some data sources these thresholds are determined by a rules-

based approach - for example concerns raised by staff to CQC (and validated by CQC) are always flagged in the model.

Intelligent Monitoring: Report on 13 March 2014

CQC has developed a new model for monitoring a range of key indicators about NHS acute and specialist hospitals. These indicators relate to the five key questions we will ask of all services – are they safe, effective, caring, responsive and well-led? The indicators will be used to raise questions about the

quality of care. They will not be used on their own to make judgements. Our judgements will always be based on the result of an inspection, which will take into account our Intelligent Monitoring analysis alongside local information from the public, the trust and other organisations.

This report presents CQC’s analysis of the key indicators (which we call ‘tier one indicators’) for Royal Berkshire NHS Foundation Trust. We have analysed

each indicator to identify two possible levels of risk.

Intelligent Monitoring Report 13 March 2014 Page 2 of 10

mailto:[email protected]

http://www.cqc.org.uk/contact-us

RHW 93 Royal Berkshire NHS Foundation Trust

Risks Elevated risks 5Overall 3 1 3

15

932.69%

186

Elevated riskRiskRiskRisk

Royal Berkshire NHS Foundation TrustTrust Summary

Priority banding for inspectionNumber of 'Risks'

Dr Foster Intelligence: Composite of Hospital Standardised Mortality Ratio indicatorsNever Event incidenceMonitor - Governance risk ratingComposite risk rating of ESR items relating to staff turnover

Number of 'Elevated risks'Overall Risk ScoreNumber of Applicable IndicatorsProportional ScoreMaximum Possible Risk Score0 1 2 3 4 5

Overall

Count of 'Risks' and 'Elevated risks'

Risks

Elevated risks

Intelligent Monitoring Report 13 March 2014 Page 3 of 10

Section ID Indicators Observed Expected Risk?

Never Events STEISNE Never Event incidence 3 - Risk

CDIFF Incidence of Clostridium difficile (C.difficile) 45 35.47 No evidence of riskMRSA Incidence of Meticillin-resistant Staphylococcus aureus (MRSA) 0 1.77 No evidence of risk

Deaths in low risk

diagnosis groupsMORTLOWR

Dr Foster Intelligence: Mortality rates for conditions normally associated with a very low rate of

mortality.16 - No evidence of risk

NRLSL03 Proportion of reported patient safety incidents that are harmful 0.32 0.29 No evidence of risk

NRLSL04 Potential under-reporting of patient safety incidents resulting in death or severe harm 14 46.76 No evidence of risk

NRLSL05 Potential under-reporting of patient safety incidents 5209 7769.6 No evidence of risk

Venous Thromboembolism VTERA03 Proportion of patients risk assessed for Venous Thromboembolism (VTE) 0.96 0.95 No evidence of risk

SHMI01 Summary Hospital-level Mortality IndicatorTrust's mortality rate

is 'As Expected' - No evidence of risk

COM_HSMR Dr Foster Intelligence: Composite of Hospital Standardised Mortality Ratio indicators - - Elevated risk

HSMR Dr Foster Intelligence: Hospital Standardised Mortality Ratio 1369 1298.15 No evidence of risk

HSMRWKDAY Dr Foster Intelligence: Hospital Standardised Mortality Ratio (Weekday) 966 934.24 No evidence of risk

HSMRWKEND Dr Foster Intelligence: Hospital Standardised Mortality Ratio (Weekend) 369 308.86 Elevated risk

COM_CARDI Composite indicator: In-hospital mortality - Cardiological conditions and procedures - - No evidence of riskHESMORT24CU In-hospital mortality: Cardiological conditions - - No evidence of risk

MORTAMI Mortality outlier alert: Acute myocardial infarction - - No evidence of risk

MORTARRES Mortality outlier alert: Cardiac arrest and ventricular fibrillation - - No evidence of risk

MORTCABGI Mortality outlier alert: CABG (isolated first time) Not included Not included Not included

MORTCABGO Mortality outlier alert: CABG (other) Not included Not included Not included

MORTCASUR Mortality outlier alert: Adult cardiac surgery Not included Not included Not included

MORTCATH Mortality outlier alert: Coronary atherosclerosis and other heart disease - - No evidence of risk

MORTCHF Mortality outlier alert: Congestive heart failure; nonhypertensive - - No evidence of risk

MORTDYSRH Mortality outlier alert: Cardiac dysrhythmias - - No evidence of risk

MORTHVD Mortality outlier alert: Heart valve disorders - - No evidence of risk

MORTPHD Mortality outlier alert: Pulmonary heart disease - - No evidence of risk

COM_CEREB Composite indicator: In-hospital mortality - Cerebrovascular conditions - - No evidence of riskHESMORT21CU In-hospital mortality: Cerebrovascular conditions - - No evidence of risk

MORTACD Mortality outlier alert: Acute cerebrovascular disease - - No evidence of risk

Mortality: Trust Level

Mortality

Royal Berkshire NHS Foundation TrustTier One Indicators

Avoidable infections

Patient safety incidents

Intelligent Monitoring Report 13 March 2014 Page 4 of 10 Indicators displaying * represent a suppressed value between 1 and 5

Section ID Indicators Observed Expected Risk?COM_DERMA Composite indicator: In-hospital mortality - Dermatological conditions - - No evidence of risk

HESMORT35CU In-hospital mortality: Dermatological conditions - - No evidence of risk

MORTSKINF Mortality outlier alert: Skin and subcutaneous tissue infections - - No evidence of risk

MORTSKULC Mortality outlier alert: Chronic ulcer of skin - - No evidence of risk

COM_ENDOC Composite indicator: In-hospital mortality - Endocrinological conditions - - No evidence of riskHESMORT29CU In-hospital mortality: Endocrinological conditions - - No evidence of risk

MORTDIABWC Mortality outlier alert: Diabetes mellitus with complications - - No evidence of risk

MORTDIABWOC Mortality outlier alert: Diabetes mellitus without complications - - No evidence of risk

MORTFLUID Mortality outlier alert: Fluid and electrolyte disorders - - No evidence of risk

COM_GASTRComposite indicator: In-hospital mortality - Gastroenterological and hepatological conditions

and procedures- - No evidence of risk

HESMORT27CU In-hospital mortality: Gastroenterological and hepatological conditions - - No evidence of risk

MORTALCLIV Mortality outlier alert: Liver disease, alcohol-related - - No evidence of risk

MORTBILIA Mortality outlier alert: Biliary tract disease - - No evidence of risk

MORTGASHAE Mortality outlier alert: Gastrointestinal haemorrhage - - No evidence of risk

MORTGASN Mortality outlier alert: Noninfectious gastroenteritis - - No evidence of risk

MORTINTOBS Mortality outlier alert: Intestinal obstruction without hernia - - No evidence of risk

MORTOGAS Mortality outlier alert: Other gastrointestinal disorders - - No evidence of risk

MORTOLIV Mortality outlier alert: Other liver diseases - - No evidence of risk

MORTOPJEJ Mortality outlier alert: Operations on jejunum - - No evidence of risk

MORTPERI Mortality outlier alert: Peritonitis and intestinal abscess - - No evidence of risk

MORTTEPBI Mortality outlier alert: Therapeutic endoscopic procedures on biliary tract - - No evidence of risk

MORTTEPLGI Mortality outlier alert: Therapeutic endoscopic procedures on lower GI tract - - No evidence of risk

MORTTEPUGI Mortality outlier alert: Therapeutic endoscopic procedures on upper GI tract - - No evidence of risk

MORTTOJI Mortality outlier alert: Therapeutic operations on jejunum and ileum - - No evidence of risk

COM_GENIT Composite indicator: In-hospital mortality - Genito-urinary conditions - - No evidence of riskHESMORT31CU In-hospital mortality: Genito-urinary conditions - - No evidence of risk

MORTUTI Mortality outlier alert: Urinary tract infections - - No evidence of risk

COM_HAEMA Composite indicator: In-hospital mortality - Haematological conditions - - No evidence of riskHESMORT28CU In-hospital mortality: Haematological conditions - - No evidence of risk

MORTDEFI Mortality outlier alert: Deficiency and other anaemia - - No evidence of risk

COM_INFEC Composite indicator: In-hospital mortality - Infectious diseases - - No evidence of riskHESMORT26CU In-hospital mortality: Infectious diseases - - No evidence of risk

MORTSEPT Mortality outlier alert: Septicaemia (except in labour) - - No evidence of risk

COM_MENTA Composite indicator: In-hospital mortality - Conditions associated with Mental health - - No evidence of riskHESMORT33CU In-hospital mortality: Conditions associated with Mental health - - No evidence of risk

MORTSENI Mortality outlier alert: Senility and organic mental disorders - - No evidence of risk

COM_MUSCU Composite indicator: In-hospital mortality - Musculoskeletal conditions - - No evidence of riskHESMORT36CU In-hospital mortality: Musculoskeletal conditions - - No evidence of risk

MORTPATH Mortality outlier alert: Pathological fracture - - No evidence of risk

COM_NEPHR Composite indicator: In-hospital mortality - Nephrological conditions - - No evidence of riskHESMORT30CU In-hospital mortality: Nephrological conditions - - No evidence of risk

MORTRENA Mortality outlier alert: Acute and unspecified renal failure - - No evidence of risk

MORTRENC Mortality outlier alert: Chronic renal failure - - No evidence of risk

Mortality


Section ID Indicators Observed Expected Risk?COM_NEURO Composite indicator: In-hospital mortality - Neurological conditions - - No evidence of risk

HESMORT34CU In-hospital mortality: Neurological conditions - - No evidence of risk

MORTEPIL Mortality outlier alert: Epilepsy, convulsions - - No evidence of risk

COM_PAEDIComposite indicator: In-hospital mortality - Paediatric and congenital disorders and perinatal

mortality- - No evidence of risk

HESMORT32CU In-hospital mortality: Paediatric and congenital disorders - - No evidence of risk

MATPERIMOR Maternity outlier alert: Perinatal mortality - - No evidence of risk

COM_RESPI Composite indicator: In-hospital mortality - Respiratory conditions and procedures - - No evidence of risk

HESMORT25CU In-hospital mortality: Respiratory conditions - - No evidence of risk

MORTASTHM Mortality outlier alert: Asthma - - No evidence of risk

MORTBRONC Mortality outlier alert: Acute bronchitis - - No evidence of risk

MORTCOPD Mortality outlier alert: Chronic obstructive pulmonary disease and bronchiectasis - - No evidence of risk

MORTPLEU Mortality outlier alert: Pleurisy, pneumothorax, pulmonary collapse - - No evidence of risk

MORTPNEU Mortality outlier alert: Pneumonia - - No evidence of risk

COM_TRAUMComposite indicator: In-hospital mortality - Trauma and orthopaedic conditions and

procedures- - No evidence of risk

HESMORT37CU In-hospital mortality: Trauma and orthopaedic conditions - - No evidence of risk

MORTCRAN Mortality outlier alert: Craniotomy for trauma - - No evidence of risk

MORTFNOF Mortality outlier alert: Fracture of neck of femur (hip) - - No evidence of risk

MORTHFREP Mortality outlier alert: Head of femur replacement - - No evidence of risk

MORTHIPREP Mortality outlier alert: Hip replacement - - No evidence of risk

MORTINTINJ Mortality outlier alert: Intracranial injury - - No evidence of risk

MORTOFRA Mortality outlier alert: Other fractures - - No evidence of risk

MORTREDFB Mortality outlier alert: Reduction of fracture of bone - - No evidence of risk

MORTREDFBL Mortality outlier alert: Reduction of fracture of bone (upper/lower limb) - - No evidence of risk

MORTREDFNOF Mortality outlier alert: Reduction of fracture of neck of femur - - No evidence of risk

MORTSHUN Mortality outlier alert: Shunting for hydrocephalus - - No evidence of risk

COM_VASCU Composite indicator: In-hospital mortality - Vascular conditions and procedures - - No evidence of riskHESMORT23CU In-hospital mortality: Vascular conditions - - No evidence of risk

MORTAMPUT Mortality outlier alert: Amputation of leg - - No evidence of risk

MORTANEUR Mortality outlier alert: Aortic, peripheral, and visceral artery aneurysms - - No evidence of risk

MORTCLIP Mortality outlier alert: Clip and coil aneurysms - - No evidence of risk

MORTOFB Mortality outlier alert: Other femoral bypass - - No evidence of risk

MORTPVA Mortality outlier alert: Peripheral and visceral atherosclerosis - - No evidence of risk

MORTREPAAA Mortality outlier alert: Repair of abdominal aortic aneurysm (AAA) - - No evidence of risk

MORTTOFA Mortality outlier alert: Transluminal operations on the femoral artery - - No evidence of risk

MATELECCS Maternity outlier alert: Elective Caesarean section - - No evidence of riskMATEMERCS Maternity outlier alert: Emergency Caesarean section - - No evidence of riskMATSEPSIS Maternity outlier alert: Puerperal sepsis and other puerperal infections - - No evidence of risk

Maternity and women's

health

Mortality



MATMATRE Maternity outlier alert: Maternal readmissions - - No evidence of riskMATNEORE Maternity outlier alert: Neonatal readmissions - - No evidence of riskCOM_HESELRE Composite indicator: Emergency readmissions following an elective admission - - No evidence of risk

HESELRE Emergency readmissions following an elective admission (Cross sectional) 613 647.72 No evidence of risk

HESELRECU Emergency readmissions following an elective admission (CUSUM) - - No evidence of risk

COM_HESEMRE Composite indicator: Emergency readmissions following an emergency admission - - No evidence of riskHESEMRE Emergency readmissions following an emergency admission (Cross sectional) 2947 3296.82 No evidence of risk

HESEMRECU Emergency readmissions following an emergency admission (CUSUM) - - No evidence of risk

PROMS41 PROMs EQ-5D score: Groin Hernia Surgery No risk identified - No evidence of risk

PROMS42 PROMs EQ-5D score: Hip Replacement (PRIMARY) No risk identified - No evidence of risk

PROMS44 PROMs EQ-5D score: Knee Replacement (PRIMARY) No risk identified - No evidence of risk

MINAP22Proportion of patients who received all the secondary prevention medications for which they

were eligible1.00 0.90 No evidence of risk

NHFD01The proportion of cases assessed as achieving compliance with all nine standards of care

measured within the National Hip Fracture Database.0.76 0.6 No evidence of risk

SSNAP14 Proportion of patients scanned within 1 hour of clock start (SSNAP Pilot Report 2 - trust level) 0.59 0.5 No evidence of risk

IPSurTalkWorInpatient Survey 2012 Q34 "Did you find someone on the hospital staff to talk to about your

worries and fears?" (Score out of 10)6.23 - No evidence of risk

IPSurSupEmotInpatient Survey 2012 Q35 "Do you feel you got enough emotional support from hospital staff

during your stay?" (Score out of 10)7.3 - No evidence of risk

IPSurHelpEatInpatient Survey 2012 Q23 "Did you get enough help from staff to eat your meals?" (Score out

of 10)7.18 - No evidence of risk

IPSurInvDeciInpatient Survey 2012 Q32 "Were you involved as much as you wanted to be in decisions about

your care and treatment?" (Score out of 10)7.35 - No evidence of risk

IPSurCntPainInpatient Survey 2012 Q39 "Do you think the hospital staff did everything they could to help

control your pain?" (Score out of 10)8.07 - No evidence of risk

IPSurOverall Inpatient Survey 2012 Q68 "Overall..." (I had a very poor/good experience) (Score out of 10) 7.83 - No evidence of riskFFTNHSEscore NHS England inpatients score from Friends and Family Test (Score out of 100) 61.87 - No evidence of risk

Treatment with dignity

and respectIPSurRspDign

Inpatient Survey 2012 Q67 "Overall, did you feel you were treated with respect and dignity

while you were in the hospital?" (Score out of 10)8.92 - No evidence of risk

Meeting physical needs

Overall experience

Compassionate care

PROMs

Audit

Re-admissions



IPSurConfDocInpatient Survey 2012 Q25 "Did you have confidence and trust in the doctors treating you?"

(Score out of 10)8.83 - No evidence of risk

IPSurConfNurInpatient Survey 2012 Q28 "Did you have confidence and trust in the nurses treating you?"


MatSvBirAdv

Maternity Survey 2013 C1 "At the very start of your labour, did you feel that you were given

appropriate advice and support when you contacted a midwife or the hospital?" (Score out of

10)

8.49 - No evidence of risk

MatSvBirComMaternity Survey 2013 C2 "During your labour, were you able to move around and choose the

position that made you most comfortable?" (Score out of 10)8.66 - No evidence of risk

MatSvCarBatMaternity Survey 2013 D6 "Thinking about your stay in hospital, how clean were the toilets and

bathrooms you used?" (Score out of 10)7.84 - No evidence of risk

MatSvCarInfMaternity Survey 2013 D3 "Thinking about the care you received in hospital after the birth of

your baby, were you given the information or explanations you needed?" (Score out of 10)7.46 - No evidence of risk

MatSvSfIntMaternity Survey 2013 C12 "Did the staff treating and examining you introduce themselves?"


MatSvStafConMaternity Survey 2013 C14 "If you raised a concern during labour and birth, did you feel that it

was taken seriously?" (Score out of 10)8.12 - No evidence of risk

MatSvStfDigMaternity Survey 2013 C18 "Thinking about your care during labour and birth, were you

treated with respect and dignity?" (Score out of 10)9.02 - No evidence of risk

MatSvStfWorMaternity Survey 2013 C13 "Were you and/or your partner or a companion left alone by

midwives or doctors at a time when it worried you?" (Score out of 10)7.54 - No evidence of risk

COM_AD_A&E Composite indicator: A&E waiting times more than 4 hours - - No evidence of risk

AD_A&E13Proportion of patients spending more than 4 hours in Type 1 only A&E departments from

arrival to discharge, transfer or admission0.08 0.05 No evidence of risk


arrival to discharge, transfer or admission0 0.05 No evidence of risk


arrival to discharge, transfer or admissionNot included Not included Not included

COM_RTT Composite indicator: Referral to treatment - - No evidence of risk

RTT_01Monthly Referral to Treatment (RTT) waiting times for completed admitted pathways (on an

adjusted basis): percentage within 18 weeks95.05% 90.00% No evidence of risk

RTT_02Monthly Referral to Treatment (RTT) waiting times for completed non-admitted pathways:

percentage within 18 weeks99.99% 95.00% No evidence of risk

RTT_03Monthly Referral to Treatment (RTT) waiting times for incomplete pathways: percentage within

18 weeks94.17% 92.00% No evidence of risk

DIAG6WK01 Diagnostics waiting times: patients waiting over 6 weeks for a diagnostic test 0 0.0076 No evidence of riskWT_CAN26 All cancers: 62 day wait for first treatment from urgent GP referral 0.89 0.85 No evidence of riskWT_CAN27 All cancers: 62 day wait for first treatment from NHS cancer screening referral 0.95 0.9 No evidence of riskWT_CAN22 All cancers: 31 day wait from diagnosis 0.99 0.96 No evidence of riskCND_OPS02 The proportion of patients whose operation was cancelled 0.0045 0.0081 No evidence of risk

Trusting relationships

Access measures

Maternity Survey



CND_OPS01The number of patients not treated within 28 days of last minute cancellation due to non-

clinical reason0.0213 0.0391 No evidence of risk

AMBTURN06Proportion of ambulance journeys where the ambulance vehicle remained at hospital for more

than 60 minutes0.0026 0.0224 No evidence of risk

Discharge and Integration DTC40Ratio of the total number of days delay in transfer from hospital to the total number of

occupied beds0.0227 0.022 No evidence of risk

NRLS14 Consistency of reporting to the National Reporting and Learning System (NRLS) 5 months of reporting - No evidence of risk

COM_SUSDQ Data quality of trust returns to the HSCIC - - No evidence of risk

SUSA&E02Percentage of Secondary Uses Service (SUS) records for Accident and Emergency care with valid

entries in mandatory fields.99.35% 97.50% No evidence of risk

SUSAPC02Percentage of Secondary Uses Service (SUS) records for inpatient care with correct entries in

mandatory fields.95.61% 98.80% No evidence of risk

SUSOP02Percentage of Secondary Uses Service (SUS) records for outpatient care with valid entries in

mandatory fields.98.64% 98.33% No evidence of risk

FFTRESP02 Inpatients response percentage rate from NHS England Friends and Family Test 27.38% 27.66% No evidence of risk

MONITOR01 Monitor - Governance risk ratingMonitor risk rating:

Currently under investigation

- Risk

TDA01 TDA - Escalation score Not included Not included Not included

NTS12 GMC National Training Survey – trainee's overall satisfaction Within Q2/IQR - No evidence of risk

STASURBG01NHS Staff Survey - The proportion of staff who would recommend the trust as a place to work

or receive treatment71.66% 65.19% No evidence of risk

NHSSTAFF04 NHS Staff Survey - KF7. The proportion of staff who were appraised in last 12 months 87.44% 83.13% No evidence of risk

NHSSTAFF06NHS Staff Survey - KF9. The proportion of staff reported receiving support from immediate

managers0.68 0.65 No evidence of risk

NHSSTAFF07NHS Staff Survey - KF10. The proportion of staff receiving health and safety training in last 12

months70.95% 75.37% No evidence of risk

NHSSTAFF11NHS Staff Survey - KF15. The proportion of staff who stated that the incident reporting

procedure was fair and effective0.64 0.62 No evidence of risk

NHSSTAFF16NHS Staff Survey - KF21. The proportion of staff reporting good communication between senior

management and staff32.89% 28.67% No evidence of risk

ESRSIC Composite risk rating of ESR items relating to staff sickness rates - - No evidence of riskESRSIC01 Proportion of days sick due to back problems in the last 12 months 0.0019 0.0025 No evidence of risk

ESRSIC02 Proportion of days sick due to stress in the last 12 months 0.0043 0.0064 No evidence of risk

ESRSIC03 Proportion of days sick in the last 12 months for Medical and Dental staff 0.0067 0.035 No evidence of risk

ESRSIC04 Proportion of days sick in the last 12 months for Nursing and Midwifery staff 0.0331 0.0431 No evidence of risk

ESRSIC05 Proportion of days sick in the last 12 months for other clinical staff 0.0372 0.0451 No evidence of risk

ESRSIC06 Proportion of days sick in the last 12 months for non-clinical staff 0.0378 0.0393 No evidence of risk

Staffing

Partners

Reporting culture

Staff survey

Access measures


Section ID Indicators Observed Expected Risk?ESRReg Composite risk rating of ESR items relating to staff registration - - No evidence of risk

ESRREG01 Proportion of Medical and Dental staff that hold an active professional registration 0.99 0.99 No evidence of risk

ESRREG02 Proportion of Nursing and Midwifery staff that hold an active professional registration 1 0.98 No evidence of risk

ESRTO Composite risk rating of ESR items relating to staff turnover - - RiskESRTUR01 Turnover rate (leavers) for Medical and Dental staff 0.19 0.1 Risk

ESRTUR02 Turnover rate (leavers) for Nursing and Midwifery staff 0.14 0.11 No evidence of risk

ESRTUR03 Turnover rate (leavers) for other clinical staff 0.17 0.12 Risk

ESRTUR04 Turnover rate (leavers) for all other staff 0.11 0.12 No evidence of risk

ESRSTAB Composite risk rating of ESR items relating to staff stability - - No evidence of riskESRSTA01 Stability Index for Medical and Dental staff 0.82 0.94 No evidence of risk

ESRSTA02 Stability Index for Nursing and Midwifery staff 0.88 0.91 No evidence of risk

ESRSTA03 Stability Index for other clinical staff 0.84 0.9 No evidence of risk

ESRSTA04 Stability Index for non clinical staff 0.89 0.9 No evidence of risk

ESRSUP Composite risk rating of ESR items relating to staff support/ supervision - - No evidence of riskESRSUP01 Ratio of Band 6 Nurses to Band 5 Nurses 0.38 0.42 No evidence of risk

ESRSUP02 Ratio of Charge Nurse/ Ward Sister (Band 7) to Band 5/6 Nurses 0.18 0.19 No evidence of risk

ESRSUP03 Proportion of all ward staff who are registered nurses 0.75 0.72 No evidence of risk

ESRSUP04 Ratio of consultant doctors to non-consultant doctors 0.66 0.63 No evidence of risk

ESRSUP05 Ratio of band 7 Midwives to band 5/6 Midwives 0.44 0.25 No evidence of risk

ESRSTAFF Composite risk rating of ESR items relating to ratio: Staff vs bed occupancy - - No evidence of riskESRRAT01 Ratio of all medical and dental staff to occupied beds 4.41 4.3 No evidence of risk

ESRRAT02 Ratio of all nursing staff to occupied beds 1.76 1.82 No evidence of risk

ESRRAT03 Ratio of all other clinical staff to occupied beds 2.31 2.01 No evidence of risk

ESRRAT04 Ratio of all midwifery staff to births 31.03 28.4 No evidence of risk

FLUVAC01 Healthcare Worker Flu vaccination uptake 0.5 0.58 No evidence of risk

WHISTLEBLOW Whistleblowing alerts - - No evidence of riskGMC GMC - Enhanced monitoring - - No evidence of riskSafeguarding Safeguarding concerns - - No evidence of risk

SYECQC Share Your Experience - the number of negative comments is high relative to positive

comments7 4.6 No evidence of risk

NHSchoices NHS Choices - the number of negative comments is high relative to positive comments 19 21.66 No evidence of riskP_OPINION Patient Opinion - the number of negative comments is high relative to positive comments 2 1.43 No evidence of riskCQC_COM CQC complaints 31 24.8 No evidence of riskPROV_COM Provider complaints 459 741.55 No evidence of risk

Qualitative intelligence

Staffing


1


Board of Directors

Title: Annual Plan Board Statements 2014/15

Date: 29 May 2014

Lead: Keith Eales Craig Anderson

Purpose: To approve self-certification statement as part of the Monitor Annual Plan submission for 2014/15.

Key Points: • The Board is required to consider a number of board statements as part of the Annual Plan process and to self certify that each statement is ‘confirmed’ or ‘not confirmed’.

• The Trust is required to make the following declarations to Monitor in accordance with the relevant sections of the NHS provider licence.

- Systems for compliance with licence conditions - Availability of resources and accompanying statement

• On the basis of the supporting analysis provided in respect of the statements it is recommended that the Board should self certify that each statement is ‘confirmed’.

• Responses to further statements will be submitted to the Board in June ahead of submission to Monitor by 30 June 2014.

Decision required:

The Board is recommended to self certify that each of the Monitor Annual Plan statements for 2013/14 is ‘confirmed’.

FOI Status This report will be made available on request

1 Background

1.1 The Compliance Framework published by Monitor requires foundation trusts to submit an Annual Plan each year. The Plan is used by Monitor primarily to assess the risk that a foundation trust may breach its Licence in relation to finance and governance. Monitor will also assess the quality of the underlying planning processes. The Board approved Part I of the plan in March. Part 2 will be submitted in June.

1.2 As part of the submission the Board is required to self certify against a number of prescribed statements as either ‘confirmed’ or ‘not confirmed’.

1.3 The position in respect of three statements must be submitted by 30 May. Further statements must be submitted by 30 June.

2

1.4 If the Board feels it is unable to fully certify a particular statement, the guidance states that the Board

‘….should make an alternative declaration by amending the self certification as necessary and including an y significant prospective risks and concerns the FT has in respect of delivering quality services and effective quality governance and

…must provide a commentary explaining the reasons for the absence of a full self certification and the actions it proposes to take to address it.’

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the Trust.’

2 Comment

2.1 The Board statements are listed in the appendix to this report, together with a commentary supporting a ‘confirmed’ declaration.

2.2 The Board is invited to consider whether it is able to certify each statement or whether further evidence is required. Should the Board be unable to fully certify then amendments to the appropriate statement and supporting commentary should be considered.

3 Recommendation

3.1 The Board is recommended to self certify that the three board statements for 2014/15 can be confirmed.

4 Attachments

4.1 The following is attached to this report:

(a) Self-Certification Statement for May

5 Contact Contact: Keith Eales Phone: 0118 322 8439

3

Appendix 1

Annual Plan Board Statements 2013/14 Statement Lead Commentary

1. Following a review for the purpose of

paragraph 2(b) of licence condition G6, the Directors of the Licensee are satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution

Keith Eales The Trust has a management and reporting structure in respect of compliance with the Licence. Overall compliance is monitored by the Audit and Risk Committee. A six monthly assessment of Trust compliance with the Licence is undertaken by the Committee. The last assessment was in March 2014. This indicated compliance with the Licence and evidence of processes in place to ensure continuing compliance. The reporting systems through to the Board provide information in respect of performance against targets, financial performance and remedial action being taken where necessary to ensure continuing compliance with regulatory requirements. During the course of 2013/14 the Trust has been the subject of an investigation by Monitor for potential breach of licence conditions. This reflected concerns in respect of the breach of the A&E target, a failure to address issues highlighted in the APR Stage 2 review in 2012/13, Board governance concerns and a drop in the COSRR to 2. Whilst this suggested a parallel breach of licence conditions, the investigation was concluded on the basis that the Trust was taking the necessary action to address the areas of concern. The Trust was awarded a green Governance Risk Rating at the conclusion of the investigation. On this basis, the Board is recommended to mark the statement as ‘confirmed’.

2. The board declares that the Licensee continues to meet the criteria for holding a licence.

Keith Eales The Board is recommended to mark the statement as confirm on the basis of the comments above.

4

Statement Lead Commentary

3. Either: a) After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the Required Resources available to it after taking account distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate. Or: b) After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services Or: c) In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to it for the period of 12 months referred to in this certificate.

Craig Anderson After making enquires the Directors make declaration (b). Whilst the Directors feel that they will have the Required Resources available for the 12 months referred to in this declaration our plans reflect a continued under delivery of QIPPs by our commissioners. If the commissioner delivery of QIPPs improves then it will expose the Trust to significant unfunded costs. Sources of Board Assurance:

• 2013/14 Accounts confirmed as being prepared on a going concern basis following external audit.

• Monitor Annual Plan for 2014/15 through 2015/16 and Trust

Budget for 2014/15.

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Version 1.0 – May 2014 1


Trust Board

Title: Standing Financial Instructions

Date: 29 May 2014

Lead: Craig Anderson

Purpose: To update the Board on the outcome of the annual review of the Trust Standing Financial Instructions (SFI’s) and to seek approval for the amendments to the document

Key Points: Significant changes have been made to the presentation of the main body of the SFI’s, but there has been little change to the underlying content. The updated presentation makes it easier to find relevant content.

All iproc authorisers and cost centre managers will be required to certify that they have read, understood and will comply with the SFI’s

Changes to delegated authorities (Table 1 – marked with track changes on the attached copy)

a) Item1.7: changes to formalise process on disposal of assets

b) Items 2.3 to 2.5: consolidated onto one row

c) Item 2.9: signing of contracts previously only with CEO, now CEO or DOF

d) Items 3.1 to 3.3: approval of income contracts previously only with CEO, now CEO or DOF

e) Items 4.1 and 4.2: consolidated onto one row

f) Item 4.1: to correct the wording from “Board Executive Directors” to “Executive Directors” regarding the maximum delegated authority limit that can may be varied downwards by the CEO or DOF

g) Item 4.1: new requirement for Care Group DOF or Deputy DOF to certify that purchase requisitions over £5,000 are within budget

h) Item 4.6: authorisation of non ward and non clinic based agency now requires authorisation by 2 of 7 of the Exec.

i) Items 5.1 and 5.2: authorisation to recruit now requires authorisation by 2 of 7 of the Exec

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Version 1.0 – May 2014 2

j) Item 6.5: authorise the Financial Controller and Deputy Director of Finance to write off debt of up to £5,000.

k) Item 7.1: to authorise the Head of Legal Services to authorise payments up to £10,000 for payments resulting from legal claims.

Decision required:

The Board is asked to APPROVE the updated SFI’s as tabled

Contact: Phone:

Craig Anderson, Director of Finance 0118 322 8833

Attachment Standing Financial Instructions

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Standing Financial Instructions – updated May 2014Version Feb 14 revision 4.0 Page 1 of 38 1

Trust Standing Financial Instructions

Standing Financial Instructions of the


As Revised in February May 2014

For review by the Audit and Risk Committee 25 March 201419 May 2014


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Table of Contents

Table of Contents 2

Introduction including definitions 3

Powers of Authority and Delegation 5

Corporate Responsibilities of all Trust employees and staff 7

Responsibilities of the Chief Executive 10

Responsibilities of the Director of Finance 15

APPENDIX A - RESERVATION OF POWERS TO THE BOARD OF DIRECTORS

AND DELEGATION OF POWERS 27

Certification 37

Formatted: Normal, Indent: Left: 0.95 cm

Formatted: Font: Not Bold

Formatted: Font: 11 pt, Bold

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Introduction Purpose These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of the Foundation Trust (including its subsidiary and charity), its Directors, staff, officers and agents in relation to all financial matters. They explain the financial responsibilities, policies, processes and procedures adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law, Government policy and best practice in order to achieve probity, accuracy, economy, efficiency and effectiveness in the way in which the Trust manages its finances. They identify the financial responsibilities which apply to everyone working for or on behalf of the Trust. They do not provide all the detailed procedural advice. These statements must therefore be read in conjunction with the detailed financial procedure notes and other policies referred to within this document. All Trust policies are available on the Trust internal website or from the finance function. All financial responsibilities, policies, processes and procedures relating to the Trust and subsidiaries must be approved by the Director of Finance. Authority and Compliance These SFIs have been compiled under the authority of the Board of Directors of the Foundation Trust. They have been reviewed by the Trust Audit and Risk Committee and by the full Board of Directors and have their full approval. All staff employed by the Trust will comply with these instructions at all times. Failure to comply will result in disciplinary action up to and including dismissal. These SFIs supersede all previous editions. All breaches of these regulations, including evidence of fraud or irregularity will be investigated in accordance with the Trust’s Human Resources and Local Counter Fraud Policy (CG155). Any significant breaches of Financial Regulations will be referred to the Director of Finance and the Audit Committee. The Director of Finance will consider the necessary course of action, which may in certain circumstances include taking disciplinary action. In the event that a staff or Board member becomes aware of an irregularity or breach of any of the SFIs, or systematic breach or abuse of the levels of delegated authority, and is concerned about the reporting or notification of such actions through the normal management channels, the Trust has a clear ‘Raising Concerns at Work (Whistleblowing) Policy (CG055)’ on the intranet which should be followed in such circumstances. All such matters will be reported to Audit Committee by the Director of Finance.

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Certification All Officers with iproc authority and all Officers who are cost centre managers will be required to certify that they have read, understood and will comply with these SFI’s. Terminology Definitions CEO Chief Executive Officer

DOF Director of Finance HMRC Her Majesty’s Revenue and Customs

PO Purchase Order

Employee An officer who is paid through the Trust payroll system

Officer All employees, temporary staff, agency staff or self-employed consultants of the Trust, including nursing and medical staff, and consultants practising upon Trust premises for whatever reason.

Scheme of Delegation The system of delegated powers from the Board of Directors to enable appropriate officers of the Trust to manage the day to day activities.

Trust Approved Procurement Systems

Oracle i-procurement; JAC; Ingenica; NHS Supplies; NHS Professionals

Wherever the title CEO, DOF, or other nominated officer is used in these instructions, it should be deemed to include such other officers who have been duly authorised to represent them. However, it is a fundamental tenet of these instructions that no officer of the Trust is empowered in any way to provide authorisation to represent themselves to persons who are not under their organisational control, unless specifically authorised within these SFIs.

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Powers of Authority and Delegation

Principles of delegated powers of authority and Schemes of Delegation The Board of Directors will delegate responsibility for the performance of its functions in accordance with the Scheme of Delegation adopted by the Trust. The Board of Directors have determined that they shall reserve for their sole approval certain financial transactions based around types or values as set out in the Scheme of Delegation. Those aside, all executive powers are vested in the CEO, who in turn will provide delegated powers to relevant officers. The CEO and DOF will, where appropriate, delegate their detailed responsibilities but will remain accountable for financial control. The Scheme of Delegation is a collection of schedules setting out various powers of authority delegated to a post holder. The first schedule sets out Board of Directors powers and the extent to which they are delegated to the CEO and other Executive Directors. Separate schedules will be retained by the DOF setting out the powers delegated to identified post holders. A full record of each scheme of delegation will be reviewed at least annually to ensure all authorised individuals understand and are fulfilling their responsibilities. Board of Directors The Board of Directors have retained sole rights to approve all financial transactions with a value in excess of the level specified for this purpose in the Scheme of Delegation, subject to the exclusion of any item covered by specific delegated authority. This applies to individual transactions and to term contracts for the provision of goods, services or capital works over a period of time. The only exception to this instruction is on the extremely rare occasions where time is a critical factor. Then the Board of Directors can instruct the CEO to approve specified transactions that are required in the interest of the Trust. In such circumstances the CEO must provide a full report to the Board of Directors at the next available opportunity. The Board of Directors acts as corporate trustee for all charitable funds. The Board of Directors delegates the management of the charitable funds to the Charity Committee. The Board of Directors are responsible for ensuring appropriate governance arrangements are in place for the Trust’s wholly owned subsidiary company, Healthcare Facilities Management Services Limited. The Board of Directors will maintain adequate policies and safeguards to prevent bribery and ensure compliance with the requirements of the Bribery Act 2010. (nb. The key policies affected are those relating to gifts/hospitality/sponsorship; staff recruitment and disciplinary; conflict of interests and declaration of interests).

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Chief Executive Within the SFIs, it is acknowledged that the Board of Directors is responsible for ensuring that the Trust meets its obligation to perform its functions within the available financial resources. The CEO has overall executive responsibility for the Trust’s activities and is responsible to the Board of Directors for ensuring that its financial obligations and targets are met. Further, the CEO is recognised by Statute as the Accounting Officer of the Trust and as such can be called upon to report to Parliament for all actions undertaken by the Trust. Save for the requirements under Board of Directors powers, the CEO is provided with full operational powers to approve financial transactions within the Trust and to delegate such powers as per the Scheme of Delegation. Director of Finance The CEO delegates powers to the DOF in his/her role as a first line budget holder responsible for the Finance Directorate. In addition to these, the DOF is provided with further powers to manage the approval of financial transactions initiated by other directorates across the Trust, and other financial transactions on behalf of the Trust. The Board of Directors instruct that the DOF is required to implement the Trust’s financial policies, ensure that detailed financial procedures and systems are established, incorporating the principles of separation of duties and internal control to supplement these instructions, and ensure that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose the financial position of the Trust at any time. In relation to any officer who is involved in a financial or procurement process or function, the DOF shall set out the requirements, the manner in which the officer discharges his/her duties and the form in which financial records are kept. All finance and procurement processes must be to the standard and satisfaction of the DOF.

In addition to these, the DOF is provided with further powers to control the approval of financial transactions relating to the Trust capital programmes, in accordance with the Schemes of Delegation.

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Corporate Responsibilities of all Trust employees and staff The SFIs set out specific Trust policies and procedures across a number of areas and all officers must comply with these requirements in all cases. Where exceptions are deemed necessary, prior approval from the DOF must be obtained, as set out in the SFIs It is not possible to govern all the financial affairs of the entire Trust through a single set of instructions. Therefore, these Instructions make reference in a number of areas where it is considered appropriate for the CEO or the DOF to develop, on behalf of the Trust, a series of detailed policies, procedures and processes, which are not included in these Instructions. In such cases it is the responsibility of all employees of the Trust to ensure they understand fully the existence, contents and requirements of all such policies and procedures and to comply with them on the basis that they have received full authority from the Board of Directors. Guidance on the existence and relevance of policies and procedures to specific situations is available on the Trusts internal website or is available from the CEO, the DOF or the Deputy DOF. If you are unsure as to the most appropriate course of action in a particular situation then consult one of these sources, especially so if you are about to make a financial commitment on behalf of the Trust, because breach of these requirements will be regarded as a disciplinary offence.

You must comply with principles of Public Sector Values You should be committed to the highest standards of corporate and personal conduct in all aspects of their work within the Trust, based on recognition of public service values. There are three crucial public service values which must be understood and accepted by everyone working in the Trust:

Accountability - everything done by those who work in the Trust must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct. Probity - there is a requirement for an absolute standard of honesty in dealing with the income, assets and financial interests of the Trust. Integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of Trust duties. Openness - there must be sufficient transparency about Trust activities to promote confidence between the Trust and its staff, patients and the public. All staff must disclose possible conflicts of interest.

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You have a duty of stewardship Proper stewardship requires value for money to be high on the agenda of the Board of Directors and all officers, so

You must - Safeguard the Trust’s financial resources.

Financial resources may take the obvious tangible form of fixed assets, income and cash as well as others that are less clear, such as lost or foregone income through failure to notify income sources or lost opportunities to earn or recover income due to the Trust.

- Conduct Trust business as efficiently, effectively and economically as possible.

- Comply with the Trust’s policies and processes covering all aspects of money, assets and other Trust resources.

- Avoid unauthorised acts that may result in the Trust incurring liabilities (directly or indirectly) or which may diminish the value of any of the Trust’s assets (including the Trust’s brand or reputation).

- Report all new income sources immediately to the DOF.

- report damage to or losses of the Trust’s premises, assets, supplies or other resources must be reported to the DOF immediately in accordance with procedures of Losses and Special Payments

- Inform either the DOF or the Local Counter Fraud Officer if you discover or suspect a loss that you think may be fraud. You should fully understand the Trust’s Human Resources and Local Counter Fraud Policy (CG155)

- Send all signed copies of contracts (however described) are lodged with Procurement within one month of formal approval.

- Only order goods and services through the Trust’s Approved Procurement Systems (unless authorised in writing by the DOF to do otherwise).

- Upon delivery of goods or services immediately record the receipt on the relevant Trust Approved Procurement System.

- Quote a valid Trust PO number to suppliers when placing an order for goods or services.

- comply with the Trust’s Guidance on Hospitality,

You must not - Incur expenditure for which there is not an

approved budget, unless authorised to do so by the DOF, CEO, or Board of Directors, as appropriate.

- Use a budget for a purpose other than that for which it was provided, unless authorised to do so by the DOF, or CEO, as appropriate.

- Approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers.

- Order any goods or services, including agency staff, other than by using one of the Trust Approved Procurement Systems, unless previously authorised to do so by the DOF.

- Order goods or services directly from suppliers. Procurement will negotiate contracts which will provide catalogues of goods and services, from which orders may be raised. These instructions provide clear guidance on purchasing and contract tendering and these must be followed. In exceptional circumstances, where senior officers of the Trust wish to operate direct ordering procedures, the approval of the CEO and DOF must be obtained.

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Gifts & Commercial Sponsorship

Compliance with rules of delegated powers of authority The Board of Directors has absolute authority for the conduct of the financial affairs of the Trust, but has established a system of delegated powers to enable appropriate officers of the Trust to manage the day to day activities. This system of delegated powers is referred to throughout these Instructions as the Scheme of Delegation. The high level Scheme of Delegation is included as Appendix A to these Instructions. The detailed scheme of delegation, including lower level authorities, must be approved by the DOF and a full register will be maintained by the DOF.

The principles of the Scheme of Delegation

• Approval limits will be determined based on an assessment of need in each specific area. • An Officer who is not Staff cannot hold responsibility for approvals unless pre-authorised by the

DOF • All delegated powers must remain within the limits set out in Scheme of Delegation. • An officer must not approve a transaction outside their written delegated power. • A power is delegated on condition that it cannot be further delegated at that same level of

power, except in cases of temporary holiday cover, when it can be delegated to another officer who already holds delegated power at that level. Delegation over and above this must be requested in writing in advance to the DOF.

• Only the DOF may delegate powers to officers outside of his/her direct control. • All proposed powers, or variation to powers, of delegation, other than temporary holiday cover,

must be provided in writing and duly authorised by the DOF. • Officers with delegated authority on iproc must set up in advance a vacation rule for period they

will be absent from the office • Applications for other short term powers must be requested in writing by the delegating officer,

and approved by the Director of Finance prior to the period for which approval is sought. • Only the CEO and DOF are authorised to sign and authorise extensions to supplier contracts. • Where a member of the Board of Directors is through incapacity unable to utilise their authority

or appropriate delegation, the CEO and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

• If the CEO is incapacitated the Chairman and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

The DOF may reject any delegation of powers if in his opinion, there is a financial risk to the organisation or it may result in a reduction of financial control or it may affect the Trust reputation with respect to counter-fraud.

Failure to comply with these principles, or a material breach thereof, will be recognised as a disciplinary offence. Where such a breach results in clear financial loss, the employee may be personally liable to compensate the Trust.

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Responsibilities of the Chief Executive

Annual Plan The CEO, with the assistance of the Commercial Director and DOF, shall compile and submit to the Board of Directors strategic plans and operational plans as required by the Board of Directors and which meet the requirements of the Independent Regulator (as described in Monitors published Guidance, Directions and Risk Assessment Framework). The operational plan shall be reconcilable with the annual submission of Monitor’s Operational, Strategic and Financial proforma in its Annual Plan Review The CEO shall require the DOF to report to the Board of Directors any significant in-year variance from the budget and to advise the Board of Directors on action to be taken. The DOF shall also be required to compile and submit to the Board of Directors, any and all such financial estimates and forecasts, of both revenue and capital nature as may be required from time to time. As a consequence, the DOF shall have full and complete right of access to all budget holders on financial related matters. All Officers shall provide the DOF with all financial, statistical and other relevant information as necessary for the compilation of such budgets, estimates and forecasts, in accordance with the timetable required by the DOF.

Budgets The DOF shall, on behalf of the CEO, and in advance of the financial year to which they refer, prepare and submit all revenue and capital budgets within the forecast limits of available resources and planning policies to the Board of Directors for its approval. The CEO shall require the DOF to devise and maintain systems of budgetary control. All officers shall comply with the requirements of those systems. The systems of budgetary control shall incorporate the reporting of, and investigation into, financial, activity or workforce variances from budget. The DOF shall be responsible for providing budgetary information and advice to enable the CEO and other officers to carry out their budgetary responsibilities. The CEO may delegate management of a budget or part of a budget to officers to permit the performance of defined activities. The Scheme of Delegation shall include a clear definition of

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individual and group responsibilities for control of expenditure, exercise of virement, achievement of planned levels of services and the provision of regular reports upon the discharge of those delegated functions to the CEO. In carrying out their duties no officers shall exceed the budgetary limits set them by the CEO. Except where otherwise approved by the CEO, taking account of advice of the DOF, budgets shall be used only for the purpose for which they were provided and any budgeted funds not required for their designated purpose shall revert to the immediate control of the Trust. Expenditure for which no provision has been made in an approved budget and which is not subject to funding under the delegated powers of virement shall only be incurred after authorisation by the CEO and DOF or the Board of Directors as appropriate. The DOF shall keep the CEO and the Board of Directors informed of the financial consequences of changes in policy, pay awards and other events and trends affecting budgets and shall advise on the financial and economic aspects of future plans and projects. Any in year changes to budgets must be approved in advance by the DOF, or by the Deputy DOF or a Care Group DOF, as set out separately in the delegation of authority for budget virements.

Contracts for the provision of Healthcare Services The Board of Directors will approve standard terms and conditions for legally binding contracts, on the basis of which the Trust will provide healthcare services. Any variations to the standard terms and conditions will be approved in accordance with the Scheme of Delegation. The CEO is responsible for negotiating contracts for the provision of services to patients in accordance with the budget. In carrying out these functions, the CEO should take into account the advice of the DOF regarding costing and pricing of services, and both the Commercial Director and Finance Director on matters relating to payment terms and conditions of service agreements. Contracts should be so devised as to achieve activity and performance targets, minimise risk, and to maximise the Trust's opportunity to generate income. The Trust will produce a reference cost tariff in accordance with NHS guidelines. The Trust will comply with the Department of Health Guidance on setting prices for the provision of NHS healthcare (i.e. Payment by Results Guidance) as far as this allows. Other prices and tariffs must be approved by the DOF with advice from the Commercial Director.

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The DOF shall ensure that a summary of the Trust’s contract income is reported annually to the Board of Directors. The DOF shall also produce regular reports detailing actual and forecast contract income with a detailed assessment of the impact of the variable elements of income. Any pricing of contracts at marginal cost should be undertaken by the DOF in accordance with a policy and tariff reported to the Board of Directors. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Capital Expenditure The CEO is ultimately responsible for all capital expenditure of the Trust, including expenditure on assets under construction. To discharge this duty, the CEO will arrange for the issue of a Scheme of Delegation for approval of capital commitments, and will arrange for the development of detailed policies and procedures covering all aspects of capital investment management, including scheme appraisals, contract awarding, contract management and financial control. The CEO shall provide executive delegation to the DOF to control programmes for capital expenditure, including assets under construction, within the restrictions of Scheme of Delegation. All expenditure on capital assets will be authorised in line with Scheme of Delegation. Any commitment in excess of the limits currently specified shall be referred to the Chief Executive and the Board of Directors respectively for approval before such commitment is made. Tendering and Contracting The CEO has overall responsibility to ensure that the Trust applies the principles of Value for Money in the procurement of goods, services and capital programmes. The CEO shall liaise with the DOF to develop processes and procedures for competitive selection in all procurement exercises. The CEO shall ensure that these procedures are open and clearly demonstrate fair and adequate competition. In particular, the processes and procedures will incorporate NHS and Trust requirements for disclosure of any commercial sponsorship or inducements offered by or received from actual or potential suppliers to the Trust. The CEO shall establish procedures covering the receipt, safe custody and formal opening of tenders received and appropriate records to be maintained in connection with the full tender exercise. All copies of signed contracts will be retained by Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval.

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Risk Management and Insurance The CEO shall ensure that the Trust has a programme of risk management which will be approved and monitored by the Board of Directors, by using the Trust Assurance Framework. The programme of risk management shall include:

a) processes for identifying and quantifying risks and potential liabilities; b) engendering among all levels of staff a positive attitude towards the control of risk; c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk; d) contingency plans to offset the impact of adverse events; e) audit arrangements including external audit, internal audit, clinical audit and health & safety review; f) arrangements to review the risk management programme. The existence, integration and evaluation of the above elements will provide a basis to make statements on the effectiveness of internal control within the Annual Report and Accounts as required by current guidance. The DOF shall ensure that appropriate insurance arrangements exist to mitigate the risks of the Trust across all areas, and that documented procedures cover these arrangements. Retention of Documents The CEO shall be responsible for maintaining archives for all documents required to be retained under the direction contained in HSC1999/053. A summary of the retention periods for key documents and records will be produced. A copy of the document will be available to all members of staff. The documents held in archives shall be capable of retrieval by authorised persons. Documents held under HSC1999/053 shall only be destroyed at the express instigation of the CEO; records shall be maintained of documents so destroyed. The DOF shall provide advice on the retention of financial records. Detailed policies covering money, assets and other Trust resources

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The CEO, in consultation with the DOF will develop, maintain and monitor detailed policies, procedures and instructions covering all aspects of the security of money, assets and other Trust resources Patients’ Property The Trust has a responsibility to provide safe custody for money and other personal property handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival. The CEO shall be responsible for ensuring patients or their guardians, as appropriate, are informed before or at admission that the Trust will not accept responsibility or liability for patients’ property brought into the Trust premises, unless it is handed in for safe custody and a copy of an official patients’ property record is obtained as a receipt. The CEO shall require the DOF, in conjunction with the Care Group Directors, to provide detailed written instructions on the collection, custody, investment, recording, safekeeping and disposal of patients’ property for all staff whose duty it is to administer the property of patients. Hospitality The CEO shall be responsible for maintaining comprehensive records of all offers of hospitality, both accepted and rejected. The record shall be in a form designed by the DOF and completed records shall be available for inspection by the designated auditors or DOF, at all reasonable times.

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Responsibilities of the Director of Finance General The DOF shall prepare, document and maintain detailed financial policies, procedures, processes and systems incorporating the principles of separation of duties and internal control to supplement these Instructions. The DOF shall require in relation to any officer who carries out a financial process, that the form in which the records are kept and the manner in which the officer discharges his/her duties shall be to the satisfaction of the DOF. The DOF shall ensure appropriate arrangements are in place to pay and recover tax, and shall be responsible for seeking professional advice in this regard, as necessary. Income The DOF is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and income coding of all monies due. The DOF is also responsible for ensuring the prompt banking of all monies received. The DOF is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary. All employees must inform the DOF promptly of any and all money due arising from transactions which they deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions. The DOF is responsible for the appropriate recovery action on all outstanding debts. Income not received should be dealt with in accordance with losses procedures. Overpayments should be detected (or preferably prevented) and recovery initiated. The DOF is responsible for approving the form of all receipt documents, agreement forms, or other means of officially acknowledging or recording monies received or receivable. The DOF is responsible for the provision of adequate facilities and systems for officers, whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys and for coin operated machines. The DOF is responsible for proscribing systems and procedures for handling cash and negotiable securities on behalf of the Trust. Official money shall not under any circumstances be used for the

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encashment of private cheques. All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the DOF.

The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss. No contract relating to the provision of Private Patient treatment should be signed without confirmation being provided to the DOF that the contract will not be actioned to the detriment of NHS patients. Annual Accounts and Reports The DOF, on behalf of the Trust, will prepare financial returns in accordance with the guidance given by the Independent Regulator and the Treasury, the Trust’s accounting policies, and International Financial Reporting Standards. The DOF, on behalf of the Trust, will prepare and certify Annual Report and Accounts, and submit them and any report of the auditor on them, for laying before Parliament. Following this, copies of the documents must be sent to the Independent Regulator. The Trust’s Annual Report and Accounts must be audited by an auditor approved by the Council of Governors in accordance with the appointment process agreed by the Trust. The Trust will publish an Annual Report and Accounts, in accordance with guidelines on local accountability, and present it at a public meeting. The document will include inter alia, the Audited Annual Accounts of the Trust. The Annual Report and Accounts will be sent to the Independent Regulator. Bank and GBS Accounts including charitable funds The DOF is responsible for managing the Trust’s banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance and directions issued from time to time by the Independent Regulator. The Board of Directors shall approve the banking arrangements. The DOF is responsible for all bank accounts and Government Banking Service (GBS) accounts. The DOF is responsible for ensuring payments made from bank or GBS accounts do not exceed the amount credited to the account except where arrangements have been made. Further he must report to the Board of Directors all arrangements made with the Trust’s bankers for accounts to be overdrawn.

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The DOF has sole authority to open, operate and close accounts with banks, Building Societies and the Government Banking Service where Trust funds are received or expended. It shall be a disciplinary offence for any officer of the Trust outside the organisational control of the DOF to operate any such account. The DOF will report to the Audit and Risk Committee of any changes to the Trust bank accounts including the opening / closing of accounts and changes in signatory panel. The DOF will prepare detailed instructions on the operation of bank and GBS accounts which must include the conditions under which each bank and GBS account is to be operated, the limit to be applied to any overdraft, and those authorised to sign cheques or other orders drawn on the Trust's accounts. The DOF will advise the Trust’s bankers in writing of the conditions under which each account will be operated. The DOF will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business. Competitive tenders should be considered at least every 5 years. The results of the tendering exercise should be reported to the Board of Directors. The Audit and Risk Committee will review this on behalf of the Board of Directors. Where officers of the Trust wish to manage non-exchequer Trust funds such as ward funds or funds from donated sources, they are required to operate under the control of the Trust Charitable Funds who will operate the accounts on their behalf. All funds donated must be passed to Finance and only banked in the Trust Charitable Funds. No donations shall be passed to another charitable fund. It is not appropriate for any officer of the Trust to hold any such account in their own names as it creates a lack of openness in the handling of such funds and may allow that officer’s integrity to be called into question. The only exception to the above will be where the DOF has expressly issued written authorisation to officers to maintain accounts which have been deemed acceptable, such as accounts for social or sports clubs. The DOF will maintain a register of such accounts, and the details will be reported annually to the Audit and Risk Committee. Cash Management and Investments The DOF will produce cash management, treasury management and investment policy (Treasury Policy - CG401), in accordance with guidance received from the Independent Regulator, for approval by the Board of Directors. The investment may include investment by forming, or

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participating in forming, bodies corporate, and/or otherwise acquiring membership of bodies corporate. The Treasury policy (CG401) will set out the DOF’s responsibilities for advising the Board of Directors on investments and reporting periodically to the Board of Directors concerning the performance of investments held. The DOF will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained. External Borrowing and Public Dividend Capital The DOF will advise the Board of Directors concerning the Trust's ability to pay interest on, and repay the Public Dividend Capital and any proposed commercial borrowing, within the limits set by the Foundation Trust’s authorisation. The DOF will authorise and is also responsible for reporting periodically to the Board of Directors concerning the Public Dividend Capital and all loans and overdrafts. Any application for a loan or overdraft will only be made by the DOF or by an employee acting on his/ her behalf, and in accordance with the Scheme of Delegation, as appropriate. The DOF will prepare detailed procedural instructions concerning applications for loans and overdrafts. All short-term borrowings should be kept to the minimum period of time possible, consistent with the overall cash flow position. Any short term borrowing requirement in excess of one month must be authorised by the DOF. All long-term borrowing must be consistent with the plans outlined in the current budget. Capital Expenditure The DOF shall be responsible for preparing detailed procedural guides for the financial management and control of expenditure on capital assets, including the maintenance of an asset register in accordance with the minimum data set as specified in the Capital Accounting Manual. The DOF shall implement procedures to comply with guidance on valuation contained within the Capital Accounting Manual, depreciation and revaluation. The DOF shall establish procedures covering the identification and recording of capital additions. The financial cost of capital additions, including expenditure on assets under construction, must be clearly identified to the appropriate budget holder and be validated by reference to appropriate supporting documentation. The DOF shall also develop procedures covering the physical verification of assets on a periodic basis.

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The DOF shall develop policies and procedures for the management and documentation of asset disposals, whether by sale, part exchange, scrap, theft or other loss. Such procedures shall include the rules on evidence and supporting documentation, the application of sales proceeds and the amendment of financial records including the asset register. All capital schemes will be subject to the procedures as set out in the Capital Investment Manual, Concode and Concise guidelines governing control of capital programmes in the NHS (available on the Department of Health website) , together with approved local guidelines. Where appropriate, alternative measures of control deemed appropriate may be adopted by the Trust on the advice of the DOF, following discussion with the CEO. Where material these will be brought to the attention of the Board of Directors. Payment of Staff The DOF shall make arrangements for the provision of payroll services to the Trust, to ensure the accurate determination of pay entitlement and to enable prompt and accurate payment to employees. The DOF shall be responsible for establishing procedures covering advice to managers on the prompt and accurate submission of payroll data to support the determination of pay including, where appropriate, timetables and specifications for submission of properly authorised notification of new employees, amendments to standing pay data and terminations.

The DOF will issue detailed procedures covering payments to staff including rules on handling and security of bank credit payments. Tendering and Contracting for Goods and Services The instructions in this section concern purchasing decisions for goods and services required where the Trust needs to enter into formal tendering and contractual arrangements. All purchasing must be undertaken through one of the Trust Approved Purchasing Systems, unless explicit approval to alternative arrangements have been agreed in advance by the DOF. The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account legal requirements to comply with European Community and GATT rules on public procurement. These shall be set out within Schemes of Delegation. The DOF shall be responsible for establishing appropriate procedures to ensure that competitive tenders are invited for the supply of goods and services under contractual arrangements wherever possible. These shall include the procedures to be followed in the event of competitive tendering of

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in-house services. In such circumstances it must be ensured that no member of the in-house tender group may participate in the evaluation of the tender. The DOF shall maintain lists of firms from whom the Trust may invite tenders and quotations. These lists shall be kept under frequent review and shall include all firms who have applied for permission to tender. All firms will be assessed by Finance on their technical and financial competences. In this regard, the DOF shall be responsible for establishing procedures to carry out financial appraisals, and shall instruct the appropriate requisitioning directorate to provide evidence of technical competence. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, only after receipt of evidence as to their technical and financial competence will a contractor be invited to tender and be selected for inclusion on the list. The DOF shall be consulted as regards financial competence and a suitable officer within the Finance Directorate who will provide advice on financial status and recommended contract limits. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, any contractor invited to tender shall only be selected for invitation after receipt of evidence as to its technical and financial competence and inclusion on the approved list. All contract negotiations must be undertaken with the involvement of a member of the Procurement Team. All employees must demonstrate effective and efficient use of resources in awarding contracts, ideally through the use of competitive selection. Where by exception it is considered competitive selection to be inappropriate, undesirable or not possible, approval for single quote exercises in accordance with financial limits set out under the Scheme of Delegation may be requested in writing to the DOF. These powers are provided by the CEO and it is expected that they shall be exercised in exceptional cases only. The DOF shall advise the Board of Directors of circumstances where it would be appropriate for goods or services to be obtained under contract from sources that have not been subject to competitive selection. The outcome of the waiver process will be monitored by the Audit and Risk Committee on behalf of the Board of Directors.

The grounds where such single quote actions may

• Where the requirement is ordered under existing contracts which themselves were sourced under competitive selection.

be authorised are as follows, although approval is not to be regarded as automatic and each case shall be treated on its own merit:

• Where the estimated expenditure or income would not warrant formal tendering procedures or competition would not be practicable taking into account all the circumstances. The limits for such single quote exemptions are set out in Schemes of Delegation.

• Where in the opinion of the Director of Finance, or the Chief Executive if in excess of financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter

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into open competitive selection procedures. This may include procurement exercises where time is a critical factor in the interest of the Trust.

• For the supply of proprietary goods or services for which it is not possible or desirable to obtain competitive quotations.

• Where in the opinion of the Director of Finance, or the Chief Executive, according to the financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter into open competitive selection procedures. This may include procurement exercises where in the opinion of the Director of Finance time is a critical factor in the interest of the Trust.

• Separate authorisation arrangements, as set out in the Scheme of Delegation, shall apply to maintenance or other contracts for existing goods or assets where the Trust is contractually tied to specific companies. Details of such contracts shall be recorded in a register by Procurement.

• The extent to which relevant officers can exercise these powers is set out in the Scheme of Delegation. All officers of the Trust must be aware that single quote actions are to be the exception to the preferred procedures of competitive selection, and in all cases they must be able to fully explain their rationale before a decision is authorised. Records shall be maintained to enable the use of single quote and other non-competitive actions to be monitored and reported upon to the Audit and Risk Committee at least annually.

In all cases the DOF shall keep appropriate records of single quote actions including a full justification of the reasons why competitive selection procedures were not adopted. The CEO shall require the DOF to monitor the use of single quote actions in the awarding of contracts and to report to the Audit and Risk Committee on the extent of the use of single quote and other non-competitive actions. Procurement and Purchasing The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account the obligation on the Trust to comply with the European Union Procurement Directives, the Public Contract Regulations 2006 (as amended from time to time) and the GATT rules on public procurement. These shall be set out within the Scheme of Delegation. The DOF shall prepare procedural instructions on the obtaining of goods, services and works, incorporating the thresholds set by the Trust. The DOF shall determine that no goods, services or works, other than works and services executed in accordance with a contract and purchases from petty cash, shall be ordered except on an official order, raised following receipt by the ordering officer of a properly authorised requisition, and suppliers/contractors shall be notified that they should not accept orders unless on an official form. Official orders shall be consecutively numbered, in a form approved by the DOF and shall include such information concerning prices or costs as may be required. The order shall incorporate an

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obligation on the contractor to comply with the conditions thereon as regards delivery, carriage, documentation, variations, etc. Order requisitions shall only be issued to and approved by officers so authorised by the Scheme of Delegation. Lists of authorised officers shall be maintained by the DOF.

The DOF shall ensure that no order shall be issued for any item or items for which there is no budget provision, unless authorised by the DOF on behalf of the CEO. Goods and services for which Trust contracts are in place should be purchased within those contracts. Any purchasing request outside of such contracts must be referred in the first instance to the Head of Procurement for approval. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Payment of Suppliers The DOF shall be responsible for the proper payment of all supplier invoices and claims. The DOF shall establish and communicate procedures to ensure that all officers provide prompt notification of all money payable by the Trust arising from transactions which they initiate, including contracts, leases, tenancy agreements and other transactions. The DOF shall establish detailed procedures covering the approval of invoices for payment. The DOF shall develop procedures for the prompt payment of invoices once verified for settlement. Such procedures will include the taking of settlement discounts where offered, and rules covering independent control and security of payment transactions. The DOF will implement procedures to retain approval of all payments made in advance of receipt of the related goods or services. Stores and stocks All stores and stocks maintained by the Trust in wards, clinics or main stores must comply with the systems of control designated and approved by the DOF. Overall responsibility for the control of stores and stocks shall be delegated to the DOF by the CEO. The day-to-day responsibility may be delegated to departmental employees and stores managers/ keepers, subject to such delegation being entered in a record available to the DOF. The DOF shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses. All employees with day-to-day responsibility for stores must maintain such records to enable the value of the stockholding to be ascertained at

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any time. The DOF will ensure adequate physical stocktaking arrangements exist and there shall be a physical check covering all items in store at least once a year to confirm the value of the stockholdings with the system records. Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the DOF. All employees with day-to-day responsibility for stores shall ensure systems are in place to minimise any losses from obsolete, slow moving or unserviceable items. The DOF shall ensure a system is in place to review stockholdings for slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. All employees shall report to the DOF any evidence of significant overstocking and of any negligence or malpractice. Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods. All write offs must be approved by the DOF and reported to the Audit and Risk Committee at least annually. All managers must order and requisition all goods and services through the Trust’s Oracle i-Procurement System or such other systems as specified by the DOF. The only exception to this instruction is where managers have the express written permission from the DOF to do otherwise. As a part of this process managers are required to ensure the accurate and timely recording of the receipt of goods and services on the relevant approved Procurement System. Financial Systems The DOF shall be responsible for the accuracy and security of the computerised financial data of the Trust. This supplements the responsibility of the Director of Corporate affairs for Information Governance across the Trust in respect of non-financial data. In terms of the Trust’s financial systems, the DOF shall ensure that:

• Appropriate controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system.

• Adequate controls exist such that the computer operation is separated from development, maintenance and amendment.

• An adequate management (audit) trail exists through the computerised system and that such computer audit reviews as he/she may consider necessary are being carried out.

The DOF shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation. The DOF shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the

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security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes. Where another health organisation or any other agency provides a computer service for financial applications, the DOF shall periodically seek assurances that adequate controls are in operation.

The DOF shall satisfy himself / herself with regard to any computer systems which have an impact on corporate financial systems that:

• data produced for use with financial systems is adequate, accurate, complete, timely ,and appropriate for the requirements of the operation of the Trust financial systems;

• all systems are closed down with adequate cut off processes at each month end; • all processes occur in line with the Trust financial month end timetable • a management (audit) trail exists; • Finance staff have open and complete access to such data; and • such computer audit reviews as are considered necessary are being carried out. Audit The Board of Directors shall establish an Audit and Risk Committee which will provide an independent and objective view of internal control by examining Internal and External Audit reports, reviewing financial systems, ensuring compliance with Standing Financial Instructions and reviewing schedules of losses and compensations and making recommendations to the Board of Directors. Where the Audit and Risk Committee feel there is evidence of ultra-vires transactions, or of improper acts, or if there are other important matters that the Committee wish to raise, the chairman of the Committee should raise the matter at a full meeting of the Board of Directors. Exceptionally, the matter may need to be referred to the Independent Regulator. It is the responsibility of the DOF to ensure an adequate internal audit service is provided and the Audit and Risk Committee shall be involved in the selection process when an internal audit service provider is changed. In line with their responsibilities as set out in HSG(96)12, the CEO and DOF shall monitor and ensure compliance with Secretary of State Directions on fraud and corruption. The Trust shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist as specified by the NHS fraud and corruption manual and guidance. The Local Counter Fraud Specialist shall report to the DOF. The DOF is responsible for:

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• ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control by the establishment of an internal audit function;

• ensuring that the internal audit is adequate and meets the NHS mandatory audit standards; • deciding at what stage to involve the police in cases of misappropriation and other irregularities

(subject to earlier sections of these Instructions); • Ensuring that an annual audit report is prepared for the consideration of the Audit and Risk

Committee and the Board of Directors. The report must cover: o progress against plan over the previous year, o major internal financial control weaknesses discovered, o progress on the implementation of internal audit recommendations, o strategic audit plan covering the coming three years, o a detailed audit plan for the coming year.

The DOF or designated auditors are entitled without necessarily giving prior notice to require and receive:

• access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

• access at all reasonable times to any land, premises or employee of the Trust; • the production of any information, cash, stores or other property of the Trust under an

employee's control; and • Explanations concerning any matter under investigation. Any lack of co-operation in these matters, by any member of staff, will be considered a disciplinary matter and may result in dismissal. Whenever any matter arises which involves, or is thought to involve, irregularities concerning Information, cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature; the DOF must be notified immediately.

The Head of Internal Audit will normally attend Audit and Risk Committee meetings and has a right of access to all Audit and Risk Committee Members, the Chairman and CEO of the Trust. Staff Expenses The DOF shall be responsible for establishing procedures for the management of expense claims submitted by Trust employees. The DOF shall arrange for duly approved expense claims to be processed through the Trust payroll system, unless separately approved by the DOF or the Deputy Director of Finance (ensuring appropriate entries are made to the relevant cost centre. Expense claims shall be authorised in accordance with the Scheme of Delegation. The DOF shall refer to the Trust’s general policies on staff expenses and may reject expense claims where there are material breaches of Trust policies. In this regard the DOF shall liaise with the CEO where appropriate.

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Fraud

The Board of Directors recognises that in extreme cases financial loss may be the result of fraud (i.e. intentional deception to secure unlawful gain) or corruption. While the Board of Directors has every confidence in the integrity of Trust employees, it has a duty to put in place controls to minimise the opportunity for illegal appropriation of Trust resources. Accordingly, the DOF shall ensure appropriate compliance with the Secretary of State’s Directions to NHS Trusts regarding counter-fraud measures, which are referred to in these instructions. The DOF will ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the DOF will notify the Board of Directors. The DOF will also ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. The Trust Human Resources and Local Counter Fraud Policy (CG155) will be updated regularly by the DOF. Losses and special payments The DOF will establish a procedure for Losses and Special Payments. Credit Finance arrangements including leasing commitments There are no grounds where any employee of the Trust can approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers. The Board of Directors has provided the DOF with sole authority to enter into such commitments, although these powers can be delegated by him/her to appropriate officers under his/her organisational control. This instruction applies to potential or actual leasing agreements and Hire Purchase undertakings which must be sent to the DOF for prior approval. No officer of the Trust outside the organisational control of the DOF has any powers to approve such commitments. Failure to comply with this instruction shall be a prima facie breach of any officer’s contract of employment. Joint Finance Arrangements with Local Authorities Payments to and arrangements with local authorities made under the powers of the NHS Act 2012 shall comply with procedures laid down by the DOF which shall be in accordance with the Act.

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APPENDIX A RESERVATION OF POWERS TO THE BOARD OF DIRECTORS AND DELEGATION OF POWERS INTRODUCTION The Code of Accountability for NHS Boards requires the Board of Directors to draw up a schedule of decisions reserved to itself and to ensure that management arrangements are in place to enable the clear delegation of its other responsibilities. This document therefore sets out the powers reserved to the Board of Directors and the Scheme of Delegation, together with tables of financial limits and approval thresholds. However, the Board of Directors remains accountable for all of its functions, including those which have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. All powers of the Trust which have not been retained as reserved by the Board of Directors or specifically delegated, shall be exercised on behalf of the Board of Directors by the CEO. The Scheme of Delegation identifies any functions which the CEO shall perform personally and those delegated to other directors or officers. All powers delegated by the CEO can be re-assumed by him/her should the need arise. The Scheme of Delegation shows only the ‘top level’ of delegation within the Trust. The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust. POWERS RESERVED FOR THE BOARD OF DIRECTORS 1. General Enabling Provision 1.1 The Board of Directors may determine any matter it wishes in full session within its statutory

powers. 2. Regulation and Control 2.1 Approval, suspension, variation or amendment of Standing Orders, Standing Financial

Instructions, schedule of matters reserved to the Board of Directors, scheme of delegation of powers from the Board of Directors to officers, and other arrangements relating to standards of business conduct.

2.2 Specification of financial and performance reporting arrangements. 2.3 Approval of the Trust’s Treasury Policy (CG401) and authorisation of institutions with which

long term cash surpluses may be held.

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2.4 Requiring and receiving the declaration of directors’ interests which may conflict with those of the Trust and determining the extent to which that director may remain involved with the matter under consideration.

3. Appointments Subject to the relevant section of the Foundation Trust Constitution: 3.1 The appointment and agreement of the terms of reference of Board Committees. 3.2 The appointment of Deputy Chairman. 3.3 Through its Remuneration Committee, appraisal, disciplining and dismissal of Board Directors. 3.4 Through its Nominations Committee, the appointment of Board Executive Directors. 3.5 The appointment of consultant medical and dental staff. Ratification of unanimous

recommendations of Appointment Committees is delegated to the CEO. 4. Policy Determination 4.1 The approval of management policies including personnel policies incorporating the

arrangements for the appointment, removal and remuneration of staff. 4.2 The approval of strategy, annual plans, strategic plans and annual budgets. 5. Direct Operational Decisions 5.1 The approval of the acquisition, disposal or change of use of land and / or buildings (subject to

the Independent Regulator’s approval in the case of property designated as ‘protected’ in the Foundation Trust authorisation).

5.2 The approval of transactions with a value in excess of that currently specified in the table of financial limits as requiring Board of Directors approval, and which are not covered by any specific delegated authority.

5.3 The final approval of action on litigation against or on behalf of the Trust. 5.4 The approval of loans with repayment periods in excess of one year. 6. Financial and Performance Reporting Arrangements 6.1 Continuous appraisal of the affairs of the Trust by means of the receipt of reports as it sees fit

from directors, committees and officers of the Trust. 6.2 Approval of the Trust’s Annual Report and Account, including the annual accounts, prior to

submission to the Council of Governors.

Standing Financial Instructions (CG101) – updated May 2014


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TABLE 1: SCHEME OF DELEGATION OF POWERS FROM THE BOARD OF DIRECTORS TO OFFICERS OF THE TRUST 1.0 Capital & Asset Purchases (including

capital funded via lease finance or charitable grants)

Delegation Arrangements Additional Information

1.1 Approval of the overall Trust Capital Budget and any in-year variations

Board of Directors

1.2 Approval of overall budget allocation to individual capital projects and monitoring

Capital Investment Group (CEO, DoF, CGDs, CMO, CN, DoEF)

Monthly report to Board of Directors

1.3 Approval of individual capital projects within the overall Capital Budget (including approval of variations)

Up to £350,000 Between £350,000 - £700,000 Over £700,000

Director of Finance Chief Executive Officer Board of Directors

All asset leasing or financing arrangements (whatever value) must also be approved by the Director of Finance.

1.4 Management of individual capital projects Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.5 Management of assets under construction Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.6 Maintenance of Trust Asset register Director of Finance 1.7 Approval of Asset Disposals

Land & Buildings (any value) Other – where the asset has a residual value or there is a potential write off of value Other – where the asset has no residual value and there is no write off of value

Board of Directors Director of Finance Care Group Director after notification to the Head of Procurement

The Head of Procurement is responsible for ensuring the Trust receives best value from disposals and so must be notified of potential disposal where an asset may have any value. The Director of Finance must always be informed, by way of an Asset Disposal Form, of any asset disposals to enable the asset register to be updated. The Financial Controller must confirm on the Asset Disposal Form the residual book value of the asset.

1.8 Capital Budget Approval Process Director of Finance 2.0 Contracts for Expenditure Delegation Arrangements Additional Information 2.1 Financial appraisal of companies Director of Finance May be delegated to Head of Procurement



identified as potential tenderers 2.2 Maintenance of list of approved potential

suppliers Director of Finance Delegated to Heads of Procurement

2.3 Authorisation of less than the requisite number of quotes and/or tenders, including single tenders/quotes:

For individual contracts up to £350,000 For individual contracts between £350,000 and £700,000 For individual contracts over £700,000


Regular report to the Board of all recorded incidents of between £350,000 and £700,000

2.4 Authorisation of single tender/single quote action:

For individual contracts up to £350,000 For individual contracts between £350,000 and £700,000 For individual contracts over £700,000


Board notified of instances between £350,000 and £700,000

2.5 Single tender/single quote action for maintenance or other support contracts for existing goods or assets where the Trust is contractually tied to specific companies

Director of Finance

2.46 Monitoring the use of single tender/single quote action

Audit and Risk Committee on behalf of the Board of Directors

2.57 Receipt of Tenders Director of Finance 2.68 Opening of Tenders Any two from the list of trust Officers

authorised by the Director of Finance to open tenders”

As defined by Director of Finance, ensuring independence from Procurement Process

2.79 Permission to consider late tenders

Chief Executive With advice from Director of Finance

2.810 Tender ratification and award, including authorisation of any actions resulting from post tender clarification:

Up to £350,000 Between £350,000 and £700,000 Over £700,000


Post tender clarification will be led by Director of Finance or his delegate. Process overseen by Head of Procurement



2.911 Signing of Contracts (including letters of intent)

Chief Executive or Director of Finance All building/works projects above £500,000 should be sealed: Other contracts may be sealed if in the interest of the Trust

2.102 Approval of variation or extensions to the use of existing approved contract

Director of Finance

After taking advice from the Head of Procurement

All Contract Variations Variations of over 5% where the revised contract value is between £350,000 and £700,000 Variations of over 5% where the revised contract value is over £700,000

Director of Finance and if above limits the CEO or Board Chief Executive Officer Board of Directors

2.113 Sealing of Documents Chairman ( or Deputy Chairman in the absence of the Chairman) and one Executive Director of the Board

3.0 Contracts for Income Delegation Arrangements Additional Information 3.1 Approval of Healthcare Contracts Chief Executive or Director of Finance Following acceptance of commercial terms

by Director of Finance 3.2 Approval of all other income contracts

including research & development Chief Executive or Director of FinanceChief Executive

This may be delegated to the Director of Finance

3.3 Approval of variations to Acute healthcare and all income contracts

Chief Executive or Director of FinanceChief Executive

3.4 Authorisation of individual Credit Notes

relating to healthcare contracts

Invoicing adjustment to “on-account” invoicing under NHS Standard Contract. Otherwise: E.g. if relating to a pricing discount or loss of potential income then: Up to £350,000 Between £350,000 and £700,000 Over £700,000

Director of Finance Director of Finance Chief Executive Officer Board of Directors

Authorisation of Credit Notes below £5,000 may be delegated by the Director of Finance



3.5 Approval and variation of all contracts for recharges of costs and income generation

Director of Finance Training income and Training recharges will be managed in accordance with a policy approved by the Director of HROD

3.6 Submission of Tenders for new work 4.0 Purchasing and Payments (excluding

Capital) of Budgeted Expenditure Delegation Arrangements Additional Information

4.1 Authorisation of Requisitions for pre-contracted individual purchases (limits include irrecoverable VAT)

NOTE: Delegated authority to commit the Trust is only available where the proposed expenditure is within budget. Written authority is required from the Director of Finance before incurring expenditure above the budgeted limit.

Heads of Corporate Departments, Care Group Directors and Care Group Directors of Finance have key responsibilities for monitoring budgets and ensuring budget holders are aware of this limitation on approvals.

The maximum delegated limits which may be varied downwards by the CEO or DOF are: Up to £5,000 Up to £90,000 Up to £350,000 Up to £500,000 Above £500,000

Schemes of delegation within these limits may be determined by Care Group Directors, DoEF and Heads of Corporate Departments but such delegation must be approved by DoF before implementation. Executive Directors (including Care Group Directors) With restricted powers of delegation Director of Finance Chief Executive Board of Directors

Expenditure of £5k and above to be certified as being within budget by the Care Group DOF or by the Deputy Director of Finance To be notified to the Audit and Risk Committee Specific arrangements for delegating authority for amounts below £20,000 but only if agreed by the DOF and where it can be demonstrated that financial control will not be compromised. To be notified to the Audit Committee



4.2 Authorisation of Requisitions on non-contracted individual purchases

Limits include any irrecoverable VAT

These are the maximum delegated limits which may be varied downwards by the CEO or DOF are: Up to £5,000 Up to £90,000 Up to £350,000 Up to £500,000 Above £500,000

The maximum delegated limits will be determined by the CEO and DOF after taking into account the track record of Care Groups and Corporate Departments in meeting Trust’s business and financial objectives Schemes of delegation within these limits may be determined by Care Group Directors, DoEF and Heads of Corporate Departments. Such delegation must be formally documented and approved by DoF. Executive Directors (including Care Group Directors) With restricted powers of delegation Director of Finance Chief Executive Board of Directors

Details of the criteria used will be agreed by the Executive Directors To be notified to the Audit and Risk Committee Specific arrangements for delegating authority for amounts below £20,000 but only if agreed by the DOF and where it can be demonstrated that financial control will not be compromised. To be notified to the Audit and Risk Committee

4.23 Authorisation of individual invoices due for payment where the approved order process has not been followed

Not Allowed All purchases should be made via Trust i-proc ordering system. Only in extenuating circumstances should such invoices be presented for authorisation to the DOF or the Deputy Director of Finance

4.34 Authorisation of petty cash payments Authorisation by line manager (must be budget manager or have delegated authority)

4.45 Authorisation of expenses claims Authorisation by line manager (must be budget manager or have delegated authority)

Only via Trust On-line System



Formatted: Underline



4.57 Authorisation of time sheets Authorisation by line manager (must be

budget manager or have delegated authority)

4.68 Authorisation of Agency expenditure Non ward and non clinic based agency staff

: approval by any 2 of CEO, DOF, Chief Nursing Officer, Director of HR and Organisational Development, Chief Medical Officer and Chief Operating Officer

Ward and clinic based agency staff: ordered through NHS Professionals or iproc

Pre-Authorisation only via Trust On-line System

4.79 Authorisation of Overtime and additional hours

Pre-Authorisation only via Trust On-line System

5.0 Staff appointments Delegation Arrangements Additional Information 5.1 Clinical appointments To be approved by the Care Group Boards

and DOFany two of CEO, DOF, Chief Nursing Officer, Director of HR and Organisational Development, Chief Medical Officer and Chief Operating Officer

No appointment can be made unless it is within the budgeted establishment and the appointment has followed the process as established by the DoHROD

5.2

Non-clinical Appointments To be approved by any two of CEO, DOF, Chief Nursing Officer, Director of HR and Organisational Development, Chief Medical Officer and Chief Operating OfficerTo be approved by the Care Group Boards or Heads of Corporate Department

No appointment can be made unless it is within the budgeted establishment and appointment has followed the process as established by the DoHROD

6.0 Income and Debt write off Delegation Arrangements Additional Information 6.1 Invoicing Director of Finance All invoices to be raised by the Finance

Department 6.2 Requests for Invoicing to be raised Budget Managers may raise a request for

Finance to generate an invoice. For clarity no-one outside of Finance is authorised to raise an invoice.

All requests for invoicing should be passed to Finance.

6.3 Authorisation of discounts, credit notes (non healthcare income)

Director of Finance See under 3.4 for Credit Notes related to Healthcare income

6.4 Collection of Debts and use of Debt Director of Finance



Collection agencies 6.5 Authorisation of Individual Debt write off This delegation also applies to the effective

write off through lack of invoicing for income to which the Trust is entitled. Whether it occurs through action, lack of action or the passing of time

Less than £5,000 Less than £100,000 Between £100,000 and £200,000 Over £200,000

Financial Controller or Deputy Director of Finance Director of Finance Chief Executive Board of Directors

To be reported to the Audit and Risk Committee.

7.0 Losses and Special Payments Delegation Arrangements Additional Information 7.1 Authorisation of Individual Losses and

Special Payments

Less than £100,000 Between £100,000 and £200,000 Over £200,000

Director of Finance Chief Executive Board of Directors

Up to £100,000 delegated to the Head of Legal Services for payments resulting from legal claims. To be reported to the Audit and Risk Committee

7.2 Authorisation of Clinical Negligence Payments

Director of Finance To be reported to the Audit and Risk Committee

7.3 Monitoring of losses and Special Payments

Audit and Risk Committee On behalf of the Board of Directors

7.4 Authorisation of early retirement, redundancy and all other termination payments to staff

Less than £100,000 Between £100,000 and £200,000 Above £200,000

Director of Finance Chief Executive Board of Directors

Only after advice from the Director of HR

8.0 Budgetary Control Delegation Arrangements Additional Information 8.1 Delegation of Budgets Chief Executive and Director of Finance 8.2 Request for Budget Virement Initiator and recipient Budget Manager To be approved by CGDoFs 8.3 Authorisation of Budget Virement Director of Finance This may be delegated by the DoF to the

Deputy Director of Finance or the CGDoFs 8.4 Overall Trust Budget and planning Director of Finance



process

9.0 Stores and stock controls Delegation Arrangements Additional Information 9.1 Management and Control Systems for

Stores and stocks Director of Finance Delegated to Head of Procurement.

Orders may be generated automatically based on agreed minimum and maximum stock quantities.

10.0 Bank Account and Payment Methods Delegation Arrangements Additional Information 10.1 Opening of Bank Accounts Director of Finance 10.2 Signing of cheques, BACS schedules and

PGO authorisation Director of Finance This may be delegated within the Finance

Department.

11.0 Bank Account and working Capital Facilities Fees and Charges Delegation Arrangements Additional Information

11.1 Approval of Fees and Charges Director of Finance 12.0 Standards of Business Conduct Delegation Arrangements Additional Information 12.1 Maintenance of register of interests and

secondary employments

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

12.2 Maintenance of gifts and hospitality registers

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

13.0 Insurances Delegation Arrangements Additional Information 13.1 Insurance arrangements Director of Finance

4.0 Fraud and irregularity Delegation Arrangements Additional Information



14.1 Counter Fraud and corruption work Director of Finance It is expected that Internal Audit would be involved in any investigation.

14.2 Investigation of suspected cases of irregularity not related to fraud or corruption

Director of WOD

15.0 Investments Delegation Arrangements Additional Information 15.1 Approval of Treasury Policy (CG401) Board of Directors After review by the Audit and Risk Committee 15.2 Investment Decisions Director of Finance

16.0 Borrowings Delegation Arrangements Additional Information 16.1 Approval of Loans and Loan Facilities,

(including working capital facilities) Board of Directors

16.2 Use of Loans and Loan Facilities as approved by the Board of Directors

Director of Finance

16.3 Use of Leasing and non-conventional funding

Director of Finance

Feb 2014 Revision - Version 4.0 Page 38 of 38


Certification. I xxxxxxxxxxxxxxxxxxxxxx certify that I have read, understood and will comply with the Standing Financial Instructions dated xxxxxxxxx. Signature: _______________________________________ Date: ___________________________________________

Formatted: Left: 3 cm, Right: 1.8cm, Top: 3.4 cm, Bottom: 2.5 cm,Width: 21 cm, Height: 29.7 cm

Agenda Item 10a

1

Board Strategy Group Monday 12 May 2014 12.35pm – 1.50pm Boardroom, Level 4, Royal Berkshire Hospital Present Mrs. Janet Rutherford (Non-Executive Director) (Chair) Mr. Craig Anderson (Director of Finance) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Brian Hendon (Non-Executive Director) In attendance Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. John Barrett (Non-Executive Director) Mr. Stephen Billingham (Chairman) Mr. Matthew Chobbah (Business Development Manager) Dr. Sue Edees (Care Group Director, Urgent Care) Dr. Alison Hill (Non-Executive Director) Mr. Philip Holmes (Director of Estates & Facilities) Mrs. Caroline Lynch (Deputy Company Secretary) Mr. John Taylor (Interim Commercial Director) Apologies Ms. Caroline Ainslie (Director of Nursing) Mr. Paul Jones (Interim Director of Workforce & Organisational Development) Mr. Peter Malone (Care Group Director, Planned Care) Dr. Brian Reid (Interim Medical Director) 10/14 Integrated Business Plan The Chair advised that the purpose of the meeting was to discuss preparations for the

joint meeting with the Clinical Commissioning Group (CCG) to align IBPs and to receive an update on action taken by the Executive since the last meeting.

The interim Commercial Director advised that the Executive focus had been on

preparation of the Integrated Business Plan (IBP) for submission to Monitor on 30 June. Weekly Executive strategy meetings were ongoing and discussions with the Care Groups had been held in respect of core services and commissioning intentions. The Chair suggested that core services could be reviewed using a matrix scoring system to identify core services in preparation for the meeting with the CCG. This would assist in identifying those services which the Trust would wish to continue to provide and any services which may be better delivered by alternative providers.

Minutes

2

12 May 2014

The Group considered that it was important to ensure the IBP included potential areas for cost reduction although it was noted that there was uncertainty in respect of the CCG’s plans to reduce costs and subsequent demand on hospital services.

The Group recommended that the Executive should further review its services and

identify areas of potential market growth in preparation for proposals received from the CCG regarding future service provision. It was considered that the quality aspect of service provision should also be included as part of these discussions.

The interim Commercial Director would update the Chair after the joint meeting with the

CCG to prepare for the Board workshop scheduled for after the May Board meeting. Action: J Taylor 11/14 Date of Next Meeting

The next meeting of the Committee would be held on Thursday 5 June at 3pm. SIGNED

DATE

Agenda Item 10b

1

Resources Committee Monday, 12 May 2014 9.30 – 12.30pm Boardroom, Level 4, Royal Berkshire Hospital Members Mrs. Jane May (Non-Executive Director) (Chair) Mr. Craig Anderson (Director of Finance) Mr. Stephen Billingham (Chairman of the Trust) Mr. Alistair Flowerdew (Acting Chief Executive) Mr. Brian Hendon (Non-Executive Director) Mr. Peter Malone (Care Group Director, Planned Care) In Attendance Mrs. Heather Allan (Director of IM&T) (for minute 57/14) Dr. Lindsey Barker (Care Group Director, Networked Care) (for minute 58/14) Mr. John Barrett (Non-Executive Director) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Dr. Sue Edees (Care Group Director, Urgent Care) (for minute 56/14) Mrs. Vanessa Harding (Head of Programme Management Office) (for minute 50/14) Dr. Alison Hill (Non-Executive Director) Mr. Philip Holmes (Director of Estates & Facilities) Mr. Stuart Johnstone (Head of Business Intelligence) (minute 57/14) Mr. Paul Jones (interim Director of Workforce & Organisational Development) Mr. Mark Robson (Director of Operations, Networked Care) (for minute 58/14) Mrs. Janet Rutherford (Non-Executive Director) Dr. Jon Swinburn (Consultant (for minute 57/14) Mr. Jez Tozer (Interim Chief Operating Officer) Mr Tim Warren (Interim Director of IM&T) (for minute 57/14) Apologies Ms. Caroline Ainslie (Director of Nursing) Mr. John Taylor (Interim Commercial Director) 47/14 Minutes: 16 April 2014

The minutes of the meeting held on 16 April 2014 were approved as a correct record and signed by the Chair.

48/14 Matters Arising Schedule The Committee noted the matters arising schedule.

Resources Committee

2

Resources Committee May 2014

Minute 40/14: Pathology Update

The Committee noted that, in respect of the proposed industrial action, a settlement offer had been made by the Trust.

Minute 43/14: Work Plan Review

The Committee noted that a detailed review of the work plan with each Director was to be completed.

49/14 Trust Banking Services

The Director of Finance submitted a report seeking an extension to the Trust banking facilities with Lloyds TSB Bank Plc for a further two years and the renewal of the existing £25m working capital facility to 31 July 2015. The Director of Finance explained that the banking facility contract ended on 31 May 2014 with an option to extend for a further two years. The principal cost was the arrangement fee, of £75,000, for the working capital facility. The Committee noted that the working capital facility was not guaranteed and that the covenants included a clause covering a material adverse change in the financial condition of the Trust. It was recognised that the options open to the Trust were to arrange the facility now or to seek support during the course of the year if this became necessary. The Committee concluded that, on balance, arranging the facility in advance was the preferred option given the heightened risk if it was not available to the Trust. The Committee noted that all financial institutions were likely to charge a similar fee for arranging the facility. However, it was considered that it would be appropriate to market test this in time for next year. Resolved: that (a) the Trust banking facilities provided by Lloyds TSB Bank PLC be extended for

two years to 31 May 2016

(b) the current working capital facility be extended from 1 August 2014 to 31 July 2015 at the existing level of £25m with an arrangement fee of £75,000

(c) the Director of Finance be authorised to sign and date the extension of the

banking and working capital facilities on behalf of the Trust. 50/14 Finance Update The Director of Finance explained that whilst early figures were not yet available the update

on the performance for April would be reported to the Non-Executive Director briefings in future starting with 19 May.

The Head of the Programme Management Office (PMO) submitted a report on progress

with the development and delivery of the 2014/15 QIPP programme. As of 9 May projects

3


to the value of £16m had been identified. The PMO risk rating was £5.4m. The gap between the programme value and risk rating largely reflected the fact that supporting documentation had not been prepared. The Committee sought clarification on the extent to which further action was required to address the position. The Acting Chief Executive explained that action was already being taken through streamlining the work of the QIPP Board, engaging with project leads and undertaking detailed assessments with each Care Group and Directorate.

The Director of Finance advised that the Executive would be considering the further

immediate cost actions that could be taken. These would be reported to the Non-Executive Director briefing on 19 May.

The Committee noted that the QIPP target had been increased to take account of

increased staffing in maternity. It was also noted that the business case had yet to be considered by the Executive. The Committee considered that it was not appropriate for the QIPP target to be increased to fund new expenditure. In addition, whilst the business case had yet to be discussed, the perception was that, by increasing the QIPP target, the additional staffing had been approved.

Clarification was sought with regard to progress in reducing agency expenditure. The

Director of Finance undertook to report this to the Non-Executive Director briefing on 19 May.

Resolved: that

(a) the report be noted

(b) the position in respect of performance in April, and progress in reducing agency expenditure, be reported to the Non-Executive Director briefing on 19 May

(c) the Executive ensure the adoption of the principle that expenditure on new

initiatives or projects should not be agreed prior to the identification of compensatory savings

51/14 Job planning Process Savings/Medical Pay Bill Review The Acting Chief Executive reported on progress with savings on the medical pay bill. The Acting Chief Executive advised that a key stage in achieving the savings would be

agreement of the new job planning policy. This would require agreement with the LNC. In response to a question, the Acting Chief Executive advised that the interim Medical

Director was leading on the project. Consideration was being given to identifying a project manager to support the interim Medical Director.

Resolved: that

(a) the interim Medical Director submit a report to the June meeting of the Resources Committee on the level of medical pay in each of the Care Groups

4


(b) the Acting Chief Executive confirm the timings of the review of the medical pay bill project and the reporting to the Committee.

52/14 Theatre Utilisation The Care Group Director, Planned Care submitted a report setting out the current utilisation

of the Trust theatres and plans in place to enhance this further.

The Committee noted that that the benchmark utilisation rate for the five theatre complexes was 88%. The Committee noted that there had been challenges in meeting this target in the early parts of 2013 and 2014 due to technical and estates issues. The Committee noted the seven project programme that was underway to enhance utilisation. It was suggested that ISO 9000 accreditation be considered as an eighth workstream in the programme. Resolved: that (a) the report be noted (b) the Care Group Director, Planned Care give consideration to including ISO

9000 accreditation as a further workstream in the theatre utilisation project (c) the Planned Care Group provide Governors with a presentation, in the light of

their continuing interest, on theatre utilisation (d) a progress report be made to the November 2014 meeting of the Committee (e) the thanks of the Committee be passed to Warren Fisher and Donna Rowell

for their work on the project 53/14 Quarterly Workforce Report The Director of Workforce & Organisational Development submitted the workforce report for

quarter four of 2013/14. The Committee noted that mandatory training and sickness absence was both below target.

Turnover was above 13% corporately and vacancy levels had reduced. The Committee identified a number of suggested improvements to be incorporated in future

reports

• it would beneficial to triangulate the data, in particular with quality and safety information

• targets and forecasts should be set for each of the indicators in the report

• an analysis of exit interviews should be added to the report.

5


It was noted that the staff survey and action plan had not yet been reported to the Committee. The Director of Workforce & Organisational Development undertook to provide this for the next meeting. Resolved: that (a) the report be noted (b) the Director of Workforce & Organisational Development include within future

reports

• triangulated data, linking particularly to quality and safety information • targets and forecasts for each of the indicators in the report

• an analysis of exit interviews.

(c) a report be made to the June 2014 meeting of the Committee on the staff

survey results and action plan.

54/14 NHS Litigation Authority (NHSLA) Update The Director of Finance submitted a report on the payments made to the NHSLA risk

pooling scheme. The Committee noted that the annual payment, after discount, was currently £8.211m. The

estimated value of outstanding clinical negligence claims against the Trust was £101.8m. Payments made by the scheme in respect of the Trust in the last five years amounted to £29.8m. During that period the Trust had paid £27.5m into the scheme.

The Committee noted that the discount scheme used by NHSLA was to be replaced. The details of the scheme were not yet clear. However, it was likely to be more directly related to the individual claims history of member trusts. The Committee considered that summary information on claims against the Trust, and significant payments made should be reported to the Clinical Governance Committee. The Committee noted that there were limited alternatives to the scheme. The Trust was required to give notice if it wished to leave the scheme. The risk exposure to the Trust on exiting the scheme was £20.4m as at September 2013. Resolved: that (a) the report be noted (b) the Director of Corporate Affairs provide regular summary information on

claims against the Trust, and significant payments made, to the Clinical Governance Committee

(c) the payment of £8.211m to the NHSLA for 2014/15 be approved.

6


55/14 Nursing Turnover Rate Benchmarking The interim Director of Workforce & Organisational Development submitted a report on the

findings of a benchmarking exercise in respect of nursing turnover. The exercise had identified that the Trust turnover rate for qualified nursing was slightly

higher than other large acute trusts in the Wessex area but lower than small and medium sized trusts. It had also identified that recruitment was running at a higher rate than leavers.

Resolved: that the report be noted. 56/14 Maternity Block Briefing The Care Group Director, Urgent Care and the Director of Estates & facilities submitted a

report on the physical condition of the Maternity Block and options for the longer term. The Committee noted that whilst the upgrading of the fire protection to the block had been

completed issues remained in respect of inaccessible dead legs, asbestos, rubber insulated electric cabling, unreliable passenger lifts and sub-optimal ventilation systems. The backlog liabilities for the building amounted to £15m. Whilst short-term maintenance options were dealt with swiftly, they were becoming increasingly disruptive. As a result, proposals were being developed over 2014 for a seven to 10 year refurbishment programme.

In response to a question, the Director of Estates & Facilities explained that he anticipated

that the outline business case for the refurbishment of the building would be available for the September meeting of the Committee.

Resolved: that

(a) that the report be noted

(b) the outline business case for the refurbishment of the Maternity Block be submitted to the September meeting of the Committee.

57/14 Draft IT Quality Strategy The interim Director of IM&T gave a presentation of information quality in the Trust in the

context of the development of an information strategy. The presentation covered

• The current situation in respect of technology, data processing and presentation, the handling of data in the Trust and staff engagement

• The implications of the financial environment for the Trust

• The strategic vision

• recommendations and costs

7


In response to a question, the interim Director of IM&T advised that the key recommendations were in respect of the creation of a Deputy Director/business intelligence role, redeveloping the data warehouse and upgrading the data warehouse manager role. Resolved: that (a) the presentation be noted (b) the Director of IM&T submit a report to the June meeting of the Committee

setting out key actions to be taken and a possible implementation timetable. 58/14 Pathology Business Case The Care Group Director, Networked Care submitted a report on progress with the case for

a Berkshire and Surrey Pathology service. The Care Group Director, Networked Care advised that the Chief Executives and Finance

Directors of the five potential partners had met on 7 May to review progress. The meeting had endorsed the approach of creating a contractual joint venture and to establish a shadow integrated management group to take forward the development of the proposal. The intention was for the full business case to be submitted to the five Trust Boards in May.

The Committee considered that the analysis presented to the Board should include an

assessment of the options available to the Trust for the future of the Pathology service, including a stand-alone option, and the option of the Berkshire and Surrey Pathology service in this. The analysis would also need to address the implications of the joint option for the Trust, including the key risks.

Conformation was sought that it was appropriate for the Trust to continue participating in

the development of the contractual joint venture proposals. This was confirmed as being appropriate.

Confirmation was sought that commissioners were supportive of the joint service approach.

The Care Group Director, Networked Care confirmed that this was the case. Clarification was sought on progress with the short-term action agreed to improve the

working environment of the Trust Pathology staff. The Director of Estates & Facilities advised that the work was proceeding as planned.

Resolved: that

(a) the full business case for the Berkshire and Surrey Pathology service be submitted to the June meeting of the Committee

(b) the analysis submitted to the June meeting should include an assessment of

the stand-alone option for the Trust, the implications and impact of a joint service for the Trust and the key risks.

59/14 Pre-Op and Extra Ward Business Case The Care Group Director, Planned Care reported on the issues discussed at the Board

meeting on which further clarification had been sought.

8


The data underpinning the business case had been reviewed and was considered robust, Care would be provided by the consultant surgeon and, out-of-hours, the consultant

anaesthetist (separate from the on-call anaesthetist for NHS patients). Junior doctors would review private patients during ward rounds, as was the case as present. The Acting Chief Executive asked that a standard operating procedure be developed on the role for staff at all levels in supporting the unit.

With regard to practical implementation issues, these had been addressed as far as was

possible in advance of the business case being approved. The Committee discussed the possibility of utilising surplus capacity within the main site

rather than leasing new facilities for pre-op. It was considered that the potential for this should be reviewed before committing to leasing the new facility.

Resolved: that the business case be approved subject to Council of Governors

approval of the planned increase in private patient income. 60/14 Messages for the Trust Board The Committee considered that the following matters should be brought to the attention of

the Board

• the development of an implementation plan for the job planning QIPP project

• the update provided on theatre utilisation in the Trust and the project to enhance this

• the scope of the estates work required in the Maternity Block and the development of a refurbishment plan

• issues in respect of information quality in the Trust and the development of an action plan for the June meeting

• progress with the joint Pathology service and the submission of the full business case to the next meeting

• approval of the Pre-op and extra ward business case, subject to Council of Governors approval of the planned increase in private patient income.

61/14 Work Plan Review The Committee received the revised work plan. Resolved: that

(a) the work plan be updated to reflect the decisions of the Committee during the course of the meeting

9


(b) items listed on the schedule that had been referred by the Board be assigned to meeting dates

(c) discussions be held with each Director to identify any further amendments to

the work plan for meetings to be held in 2014. 62/14 Date of Next Meeting Resolved: that the next meeting be held at 9am on Tuesday, 17 June 2014. SIGNED DATE:

Agenda Item 10c

1

Audit & Risk Committee Thursday 15 May 2014 9.40am – 12.45pm Boardroom, Level 4, Royal Berkshire Hospital Members Mr. Brian Hendon (Non-Executive Director) (Chair) Mr. John Barrett (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) In attendance

Advisors

Ms. Debbie Kinch (Local Counter Fraud Specialist) (up to minute 70/14) Ms. Harriet Aldridge (Director, PwC) (up to minute 74/14) Mr. Clive Everest (Partner, PwC) (up to minute 74/14) Mr. Neil Thomas (Partner, KPMG) (up to minute 74/14)

Trust Staff

Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance) Mr. Graham Butler (Deputy Director of Finance) (up to minute 76/14) Dr. Keith Eales (Director of Corporate Affairs & Secretary) Mr. Mark Hughes (Risk Manager) (for minute 77/14 to 79/14) Mrs. Caroline Lynch (Deputy Company Secretary) Mr. Mike Robinson (Interim IT Manager) (for minute 67/14) Apologies Mrs. Kate Anderson (Senior Manager, KPMG) Mr. Alistair Flowerdew (Acting Chief Executive) 65/14 Minutes: 25 March 2014

The minutes of the meeting held on 25 March 2014 were approved as a correct record and signed by the Chair.

66/14 Matters Arising Schedule The Committee received the matters arising schedule. It was noted that all actions were

completed with the exception of: Minute 52/14: Non-NHS Debt

Action: C Anderson

: The Director of Finance would review the debt for which 50% provision had been made with the Planned Care Group Director.

Audit & Risk Committee

Audit Committee Minutes 2

Audit & Risk Committee Minutes 15 May 2014

Minute 57/14: Technical Update

Action: A Flowerdew

: The Acting Chief Executive would advise the Committee whether the name of a senior responsible doctor was displayed above patients’ beds.

Resolved: that the matters arising schedule be noted. 67/14 IT Update The Committee noted that, in respect of the recommendations following the PwC audit

report, 13 of the 21 had been completed and the remainder were in progress. The interim Head of IT advised that the nine outstanding actions would be addressed by the ongoing transformation programme and actions would be completed by the planned date.

The Committee sought clarification as to whether the outstanding actions could be completed earlier than the planned date. The Director of Finance confirmed that discussions would be held with the interim Head of IT to ascertain resources needed to support earlier completion of the outstanding actions. Action: C Anderson

A repeat audit of IT would be scheduled towards the end of 2014 and a report submitted to the Committee in January 2015. Action: C Everest

Resolved: that the update be noted.

68/14 QIPPs Update The Director of Finance introduced the report and advised that QIPPS totalling £14m had

been identified. However, the majority of these were in the early stage of development. The current Programme Management Office (PMO) risk rating for 2014/15 QIPPs was currently £5.7m which reflected the lack of robust plans for many of the projects.

The Committee sought clarification as to whether the meeting to identify leads for the

consultant productivity project, scheduled for week beginning 12 May, had taken place. The Director of Finance undertook to confirm this. Action: C Anderson

The Director of Finance advised that further discussion would be held with the Executive in

order to identify areas where immediate action could be taken. The Committee expressed concern due to the lack of robust plans for delivery and sought assurance that there was an organisation-wide focus on delivery of QIPPs. The Director of Finance would raise this with the Executive. Action: C Anderson

Resolved: that the update be noted. 69/14 Patient Safety and Experience Walkabouts

The Director of Nursing introduced the report and advised that currently different processes were in place for Patient Safety and Patient Experience Walkabouts as these were managed by different teams. The Director of Nursing advised that the Patient Experience Walkabouts were co-ordinated by the Director of Nursing, Networked Care supported by Practice Development leads. The template used for patient experience walkabouts had been redesigned in order to focus on the ’15 steps challenge’. Following each walkabout an action plan was developed



which was shared with ward areas, matrons and the Care Groups. The Patient Experience Committee reviewed all actions plan on a quarterly basis. The Director of Nursing advised that the clinical quality assurance team co-ordinated Patient Safety walkabouts and monitored completion of action plans. It was noted however that these findings were not currently formally reported to a committee. The Director of Nursing advised that quarterly reports to follow up outstanding actions and thematic analysis to share learning across the organisation were planned. However, due to the current capacity issues in the team and the ongoing review of quality governance this had not yet been put in place. It was agreed that a further update on the clinical quality review and alignment of the patient safety and patient experience walkabouts processes would be submitted to the November meeting of the Committee. Action: C Ainslie

Resolved: that the update be noted. 70/14 Counter Fraud Annual Report The Local Counter Fraud Specialist (LCFS) introduced the report and drew attention to the

proactive exercise to check whether Oracle approvers, Board members and Governors had declared their involvement in any secondary business they may be connected to. As part of this exercise it had been identified that a number of individuals registered as being involved with external businesses and some of these had not been declared on an associated Declaration of Interests. The Committee noted that there had been no adverse impact of this however the Director of Finance would discuss the issue and action to be taken with the interim Director of Workforce and OD and the Director of Corporate Affairs & Secretary An update would be provided the next meeting. Action: C Anderson

The LCFS gave an update on the investigation relating to an allegation that a Trust doctor

may have acquired medication through the Trust’s pharmacy which was then administered to a private patient. A final report would be submitted to the next meeting.

Action: D Kinch Resolved: that the annual report be noted. 71/14 Internal Audit Progress Report The Director, PwC introduced the report and advised that final reports issued since the last

meeting included Quarter 3 QIPP review, Corporate Governance and Risk Management and Care Group Performance reporting.

The Director, PwC, drew attention to the Care Group Performance reporting audit. It was

noted that two medium and two low risk recommendations had been issued. The Committee expressed concern regarding the lack of documentation of Executive/Care Group performance meetings during 2013/14. The Director of Finance reported that arrangements for Care Group performance were currently being formalised. Separate performance meetings were being held on a weekly basis and work was ongoing to standardise performance reporting for all Care Groups. In addition the Executive was attending Care Group Board meetings. A follow up audit would be undertaken as part of the internal audit plan for 2014/15. The Committee recommended that this follow up should be undertaken earlier in the year than currently planned. The Director of Finance would confirm the timescale for this. Action: C Anderson



Resolved: that the report be noted. 72/14 Draft Head of Internal Audit Opinion The Partner, PwC, introduced the report and advised that although good progress had

been made in respect of IT risks there were a number of actions which had not yet been addressed. The Head of Internal Audit Opinion would therefore be a qualified opinion on the basis of non-IT work. However, with IT included an adverse opinion would have to be issued. It was agreed that the Director of Finance and the Partner, PwC, would further discuss whether to separate the final Head of Internal Audit Opinion and an updated report would be prepared for the meeting on 19 May. Action: C Everest/C Anderson


73/14 Internal Audit Plan 2014/15 The Partner, PwC introduced the internal audit plan for 2014/15. The Director of Finance

advised that it was proposed to increase the allocation for the 2014/15 plan to include additional work.

The Committee recommended that audit work on the QIPPs programme, payroll and

financial controls would be aligned to be undertaken in Quarter 3. Action: C Everest It was agreed that the Director of Finance would review whether the audit of complaints and

mandatory training should be included in the 2014/15 plan once the CQC formal report had been issued. Action: C Anderson

Resolved: that the report be noted. 74/14 External Audit Progress Report The Partner, KPMG, gave an update on work undertaken since the last meeting of the

Committee. It was noted that finalisation of the ISA 260 was ongoing in preparation for the special meeting of the Committee on 19 May.

Resolved that the update be noted. 75/14 Audit Recommendations Update The Deputy Director of Finance introduced the report and advised that six

recommendations from 2012/13 audits remained outstanding.

The Committee noted that recommendations outstanding from 2012/13 related to audits on estates strategy, consultant job plans, clinical data quality procedures, cost improvement plans (CIPs) and IT reviews.

The Committee discussed the recommendations relating to the Consultant Job Plans audit. It was noted that the job planning policy was currently being reviewed which would submitted to the Local Negotiating Committee (LNC) and it was anticipated this would be in place by September 2014. Work to review job plans however, in line with the existing policy, was ongoing. The Executive would continue to monitor the number of job plans which had been reviewed. Action: A Flowerdew/B Reid



The Committee requested that an update be provided to the next meeting in respect of the eight outstanding recommendations relating to the Clinical Data Quality procedures audit.

Action: A Flowerdew/B Reid The Deputy Director of Finance drew attention to the five outstanding recommendations

relating to the 2013/14 audits. These included rolling CIPs review, NHSP process review, pay arrangements for high earning interims, Monmouth audit and Reference cost audit.

Resolved: that the report be noted. 76/14 Implementation of Service Level Reporting The Deputy Director of Finance introduced the report and gave an overview of the

approach being taken to the implementation of Service Level Reporting (SLR). The Committee noted that data was currently being validated in addition to an ongoing ‘deep dive’ exercise which was being undertaken in conjunction with Care Groups.

The Director of Finance advised that the outcome of the ‘deep dive’ exercise would be

subsumed in QIPPs work. This would support a continued focus on Service Level Reporting (SLR). It was agreed that a verbal update on progress with implementation of SLR would be provided to the next meeting. Action: C Anderson

77/14 Corporate Risk Register The Director of Corporate Affairs & Secretary introduced the Corporate Risk Register. The Committee noted that the risk relating to poor patient experience and risk of regulatory

action as a result of failure to meet the A&E target, (CRR02) had been reviewed by the Urgent Care Group and remained a red risk although the risk score had been reduced.

The Committee noted the risk relating to data quality (CRR22) had been escalated to the

Corporate Risk Register. The Director of Finance confirmed that the risk relating to Monitor intervention through

failure to achieve a Continuity of Service Rating (COSRR) of 3 or above in the next four quarters (CRR06) had been amalgamated with the risk related to financial stability (CRR01). It was noted that the risk scoring had been reduced from 25 to 20 as a result of improvements in mitigating actions. The Committee recommended that the risk score should remain as 25 and appropriate narrative included to further clarify the mitigating actions taken. Action: C Anderson/K Eales The Committee noted that a number of risks had a completion date of April 2014. The Director of Corporate Affairs & Secretary advised that completion dates would be updated as part of the monthly review cycle however the current version had not yet been reviewed and updated by the Executive Risk Committee. Resolved: that (a) the Corporate Risk Register be reviewed and updated as discussed (b) completion dates for mitigating actions be updated (c) the register be noted.



78/14 Board Assurance Framework The Director of Corporate Affairs & Secretary introduced the Board Assurance Framework

(BAF) and advised that this would be updated once new strategic objectives had been developed.

The Committee discussed the risk related to improving market share (BAF 2). The Director

of Corporate Affairs & Secretary advised that key movement of this risk related to A&E performance.

The Director of Corporate Affairs & Secretary advised that discussions had been held with

PwC in respect of the Board recommendation to combine the Board Assurance Framework with the Corporate Risk Register who had advised that it was mandatory for trusts to have a Board Assurance Framework. Work to combine this with the Corporate Risk Register however would be pursued once new strategic objectives had been developed. Action: K Eales Resolved: that Board Assurance Framework be noted.

79/14 Risk Manager’s Report The Risk Manager introduced the report and advised that the Datix risk module would be

implemented during June 2014. This would enable more effective identification and evaluation of risks by teams across the organisation in addition to a clearly defined assurance process at corporate level.

The Committee noted actions taken following the 2013 staff survey results in respect of

staff undertaking health and safety training which included development of a health and safety matrix, training being introduced as part of the mandatory training programme and the introduction of Institute of Occupational Health and Safety (IOSH) Managing Safely Course being run in-house.

The Risk Manager drew attention to the action currently not on target for completion within

the timescale set out in the Health & Safety Action Plan. The Committee noted that in respect of conflict resolution training would be prioritised for ‘hot spot’ areas.

Resolved: that the report be noted. 80/14 Bank Account Authorisations The Committee noted there had been no bank authorisations since the last meeting of the

Committee and there had been one amendment to the Trust signatory panel which related to the removal of a member of staff no longer employed by the Trust.

Resolved: that the report be noted 81/14 Non-NHS Debt

The Committee received the report and noted that the non-NHS debt was currently £2.1m as at May 2014.




82/14 Losses and Special Payments

The Committee noted that since the last meeting, two special payments had been made to the value of £37,600.


83/14 Use of Single Tenders

The Committee noted that there had been no single tenders since the last meeting of the Committee.

84/14 Schedule of Significant Contracts

The Committee noted that there had been one significant contract since the last meeting of the Committee which related to a ‘call off contract’ to the value of £1m with employment agencies for temporary admin and clerical staff. Resolved: that the report be noted.

85/14 Non-Audit Services The Director of Finance introduced the report which outlined non-audit services which had

been completed or were currently being undertaken by KPMG. Resolved: that the report be noted. 86/14 Technical Update The item was deferred to the next meeting. 87/14 Audit Committee Timetable 2014/15 The Committee noted the timetable for 2014/15. Resolved: that the timetables be noted. 88/14 Date of Next Meeting Resolved: that the next meeting be held on Monday 19 May at 12.30pm 89/14 Private Meeting with External Audit A meeting with KPMG was held. 90/14 Private Meeting with the Internal Auditors A meeting with PwC was not held. 91/14 Private Meeting of the Committee A meeting of the Committee was held.



SIGNED

DATE

Agenda Item 11

Updated: 12 May 2014 1

Royal Berkshire NHS FT – Board Work Plan

Jan 2014 Feb

Mar Apr May June July September October

Regular business

Executive Report (ED) IPR (JT) Q&S (AF/CAi) Schedule of SIs (AF) DoF (CA) Minutes and actions (KE) Board Work Plan (KE)



Chief Executive Report (AF) Quality Performance Report (CAi/JT) Care Groups Performance (LB/SE/PM) Schedule of SIs (AF) DoF (CA) Minutes and actions (KE) Board Work Plan (KE)






Strategic/ Major

EPR (JT) TBC Final IBP Post Engagement (JT) Capital Programme Update TBC (CA)

Budget 2014/15 (CA)

Quality Strategy (CAi)

Annual Report and Accounts and quality Accounts) (CA/KE/AF)

Maternity Strategy (SE)

IM & T Strategy (TW

Estates Strategy (PH) TBC

Other

Nursing Recruitment plan (LL/CAi) Staff immunisation

Quarterly workforce report (LL)

Decon business case (PM)

Quarterly Budget forecast (CA) Maternity HDU (SE)

Bracknell Clinic Break even position (LB) Interventional radiology

Quarterly Budget forecast (CA)

Quarterly workforce report (PJ)

Quarterly Budget forecast (CA)

Agenda Item 11

Updated: 12 May 2014 2

Jan 2014 Feb

Mar Apr May June July September October

update (LL) Urgent care investment plan (SE)

Pre-op and extra ward business case (PM)

business case (SE)

Governance

Monitor Quarterly Return (CA) Board evaluation review (KE)

Corporate Risk Register and BAF (KE) Board evaluation review (KE)

Equality & Diversity (LL) Post-Francis Action Plan (CAi) Board evaluation review (KE)

Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)

SFI review (CA) Board evaluation review (KE)

Standing Orders Review (KE) Board evaluation review (KE)

Quality Governance Framework Action Plan (CAi) Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)

Quality Governance Framework Action Plan (CAi) Board evaluation review (KE)

Quality Governance Framework Action Plan (CAi) Corporate Risk Register and BAF (KE) Monitor Quarterly Return (CA) Board evaluation review (KE)