board of directors board/trust... · diane halsey, director of governance and compliance . andrew...

Board of Directors Tuesday 28 July 2015, 8:45am

Flintoff Room, Holiday Inn

Board of Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Flintoff Suite, Holiday Inn, Bamber Bridge, Preston

Date Tuesday, 28 July 2015

Time 8.45am – 2.00pm

PART ONE:

Reference Item Lead Action Enc FOIA Exempt

PROCEDURAL ITEMS TB 055/15 Welcome and opening comments Chair Verbal

TB 056/15 Patient Story Chair Verbal

TB 057/15 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 058/15 Declarations of Interest Chair Verbal

TB 059/15 Minutes of the previous meeting Chair Decision Paper

TB 060/15 Action Tracker Chair Decision Paper

BOARD DEVELOPMENT TB 061/15 Devolution in Greater Manchester Graham Urwin Discussion Verbal

CHAIR AND CHIEF EXECUTIVES REPORT TB 062/15 Trust Chairs Report Chair Noting Paper

TB 063/15 Chief Executive’s Briefing Chief Executive Discussion Paper

TB 064/15 Audit Committee Chairs Report Committee Chair Decision Paper

TB 065/15 Quality Committee Chairs Report Committee Chair Noting Paper

TB 066/15 Finance and Performance Committee Chairs Report

Committee Chair Noting Paper

QUALITY AND SAFETY TB 067/15 Safer Staffing Report Director of

Nursing and Quality

Discussion Paper

FINANCE AND PERFORMANCE TB 068/15 Finance Report Chief Finance

Officer Noting Paper

PEOPLE AND LEADERSHIP TB 069/15 Quarterly Workforce Report Director of HR Noting Paper

TB 070/15 Living Wage Salary Proposal Director of HR Decision Paper

GOVERNANCE AND ASSURANCE TB 071/15 Board of Directors Terms of Director of

Governance and Decision Paper

PART TWO:

Reference Compliance

TB 072/15 Board Assurance Framework 2015/16 – Quarter One review

Associate Director of Compliance and Business Assurance

Decision Paper

TB 073/15 Academic Health Science Network (AHSN) North West quarter one performance report

LCFT Chief Executive

Noting Paper

TB 074/15 Use of the Common Seal Director of Governance and Compliance

Noting Paper

TB 075/15 Pennine Lancashire Update Chief Executive Discussion Verbal

TB 076/15 Red Rose Corporate Services (RRCS) Performance Update including Pay Change Proposal and Change to the Informed Client Reporting Arrangements

RRCS Board Directors

Noting Paper

TB 077/15 Any other business Chair Noting Verbal

TB 078/15 Date and time of next meeting Chair Noting Verbal

TB 079/15 Clinical quality visits Board members

CONFIRMED

BOARD OF DIRECTORS Minutes of the meeting of the Board of Directors (Part One) held on

Thursday 28 May 2015

PRESENT: Derek Brown, ChairPeter Ballard, Deputy Chair David Curtis, Non-Executive Director Louise Dickinson, Non-Executive Director Gwynne Furlong, Non-Executive Director Bill Gregory, Chief Finance Officer Naseem Malik, Senior Independent Director Max Marshall, Medical DirectorSue Moore, Chief Operating OfficerDee Roach, Director of Nursing and QualityHeather Tierney-Moore, Chief Executive

IN ATTENDANCE: Jo Alker, Deputy Company Secretary Diane Halsey, Director of Governance and Compliance Andrew Pennington, Associate Director of Research & Development Tim Cutler, External Audit, KPMG

TB 045/15 WELCOME AND OPENING COMMENTS

The Chair welcomed everyone to the meeting which would predominantly focus on the year-end reporting requirements.

TB 046/18 APOLOGIES FOR ABSENCE AND CONFIRMATION OF QUORACY

No apologies for absence had been received and confirmation of quoracy was given.

TB 047/18 DECLARATIONS OF INTEREST

No declarations of interest were made.

TB 048/15 MINUTES OF THE LAST MEETING

The meetings of the meeting held on 24 April 2015 were confirmed as a true and accurate record.

TB 049/15 ACTION TRACKER

The action tracker was reviewed and updated as necessary.

TB 050/15 RECOMMENDATION FROM THE AUDIT COMMITTEE CHAIR

The Audit Committee Chair opened the discussion explaining that she would be recommending the formal sign off of the Trust’s Annual Report and Accounts and Quality Account on behalf of the Audit Committee. She asked Executive colleagues to discuss their specific areas and asked the External Audit representative, Tim Cutler to discuss the audit findings.

The Chief Finance Officer outlined the process that supported the sign off of the Trust’s Annual Accounts. A key area of scrutiny this year had been around

CONFIRMED

the revaluation of the Trust’s properties and a technical adjustment to accurately reflect how the revaluation of assets was declared in the notes to the accounts.

The Director of Nursing and Quality highlighted the longstanding process developed to support the production of the Quality Account that supported gaining significant input from stakeholders, service users and Governors. The work undertaken around data quality improvement had allowed for a more streamline approach to its development this year. Of particular note was the feedback from commissioners included and articulated work to support further improvements.

The External Audit representative, Tim Culter confirmed a clean conclusion to the audit undertaken against the Trust’s year-end reporting. In relation to the accounts, assurance was gained from the co-ordination of the draft accounts. A change was made following the revaluation of Trust properties which led to a small unadjusted change. There was some challenge around this change, auditors did not disagree with the non-adjustment but highlighted it to Audit Committee for discussion and the proposition made by the financial team was approved. In terms of the Quality Account, there had been no issues around data quality. The two mandated indicators and the Governor chosen indicator had a clean conclusion however two minor concerns were raised to Audit Committee around the Board assurance in totality around data quality improvements and how the organisation records whether a patient is medically fit enough to be discharged. The Board noted the minor concerns.

The Chief Executive drew the Boards attention to the Annual Governance Statement contained with the Annual Report. This has been reviewed in detail and also reviewed by External Audit.

The Board approved the recommendation made by the Audit Committee Chair on behalf Audit Committee to formally sign the Annual Report and Accounts and the Quality Account.

Thanks was formally recorded to those involved in the collation of the year-end documentation particularly KPMG as this would be their final year as the Trust’s External Auditors under the current contract arrangements.

TB 051/15 CHIEF EXECUTIVE’S REPORT The Chief Executive introduced her report and noted the conclusion of the CQC inspection although visits and requests for data were still ongoing. The Trust now awaits the reports for factual accuracy check which is anticipated towards the end of summer.

In relation to the current financial position, financial assumptions had been discussed with the Chair outside of the meeting and as a result had now decreased from £4.4m to £3m. A CoSSR of 3 was anticipated for the whole year rather than the originally recorded first three quarters. A tariff deflator of

CONFIRMED

0.8% had been agreed with Commissioners however the Mental Health contract had still not been formally signed. In terms of Month One, pressures around OATS and bank and agency spend remained a concern and these risks were reflected in the BAF.

The Chief Executive drew the Boards attention to the update provided on the Vanguard sites. National teams were pushing sites to be radical and good progress had been made in Blackpool. Learning was now being taken from that to embed in other parts of Lancashire.

An update was provided around the Offender Health bid in Staffordshire.

Minute extract removed - FOIA Exempt Under Section 43 Commercial Interest

TB 052/15 PERFORMANCE REPORTING SUPPLIER

Chief Operating Officer introduced the item and reminded the Board of the proposal that was brought previously around implementing a blended approach to the management of performance data reporting. This was put out to tender and two bids were received. The Trust had been naïve in the specification given and the costs put forward were in excess of what the Trust could budget for. As a result, no decision was able to be reached and the contract with Ernst & Young was extended to support quarter one performance reporting. The two bids that were submitted confirmed that both companies could provide the level of service requirements outlined by the Trust. During scrutiny of the costings and despite some robust questioning, no assurance could be provided around how both had costed their service. Ernest Young, who had put forward a bid, were 22% less than the second candidate, Capgemini. What was included in the costings was the month on month reporting of the performance report. As the Networks move towards producing their own performance data and reports it provides the opportunity to review the structure and the requirements of the performance team. It had become evident in the organisation that teams were now using data to drive the business. The Business Intelligence and Analytical team had been developed significantly and changes to the culture in Networks had allowed them to understand their businesses in more detail.

A proposal was discussed around extending the contract with Ernest Young for a further 12 months. In relation to the overall budget, c£900k per annum had been approved by the Board and this had been costed at £330k per annum. Starting the new arrangement on 1 June 2015 also provides one

CONFIRMED

month at this rate which was not included in the plan. This cost also includes the development of the Board Balanced Scorecard and the development of a performance app to give Networks access to live data.

The original scope included work around the data warehouse but this has been taken on by the IT team and the other component was the provision of the Network based performance manager. This has been removed and the Networks have now identified their own performance leads. The Trust will extract the performance data and Ernst & Young will review and analyse that data for reporting through to the Board. The Associate Director of Performance is responsible for the line management of all this activity. As the data warehouse is developed, it will provide a resource and time to support Networks. A data dictionary had been developed along with Standard Operating Procedures to ensure continued sustainability.

In response to a question around next steps moving on from the top 50, the Chief Operating Officer explained that she had commissioned a piece of work to code performance data being reported. That coding would fall into three categories, what is mandated, what is legislative and what is nice to see but has little effect on the services provided by the Trust. The link between the Board Balanced Scorecard and the performance reporting to the Board were noted.

A conversation followed around other data streams and how they come together both in presentation and how they are viewed in totality by the Board to allow triangulation of performance data at Board level. This action would be added to the action tracker for continual monitoring by the Board.

Although the Trust is red in terms of seven day follow, there were no concerns around getting this back on track prior to the quarter end.

The Board approved the awarding of a contract for a further 12 months to Earnst & Young.

TB 053/15 ANY OTHER BUSINESS There was no other business to be discussed.

TB 054/15 TIME AND DATE OF THE NEXT MEETING The time and date of the next meeting was scheduled to take place on 23 June 2015 at 9.30am.

CONFIRMED

BOARD OF DIRECTORS

Minutes of the meeting of the Board of Directors (Part One) held on Tuesday 23 June 2015

PRESENT: Derek Brown, Chair Heather Tierney-Moore, Chief ExecutiveDavid Curtis, Non-Executive Director Louise Dickinson, Non-Executive Director Gwynne Furlong, Non-Executive Director Naseem Malik, Senior Independent Director Bill Gregory, Chief Finance Officer Max Marshall, Medical DirectorDee Roach, Director of NursingTanya Hibbert (deputising for Sue Moore)

IN ATTENDANCE: Diane Halsey, Director of Governance and Compliance Sue Tighe, Network Director Specialist Services (agenda item TB 060/15 only) Umme Batan, Corporate Governance Support (Minutes)

OBSERVERS: None

TB 057/15 WELCOME AND OPENING COMMENTS The Trust Chair welcomed everyone to the meeting.

TB 058/15 APOLOGIES FOR ABSENCE Apologies were received from Peter Ballard, Deputy Chair and Sue Moore, Chief Operating Officer and confirmation of quoracy was given.

TB 059/15 DECLARATIONS OF INTEREST There were no declarations of interest.

TB 060/15 PRISON TENDERS/BUSINESS OPPORTUNITIES The Chief Finance Officer introduced his report and outlined recommendations for LCFT Prisons Procurement Priorities. The Network Director for Specialist Services provided further details on this paper.

There are 29 prisons undergoing procurement, across 13 Lots released and available for LCFT to bid for. The Lots available provide LCFT an opportunity to commence service provision in Women’s and Young Offenders institution, whereas most of LCFT’s existing service provision is male prisons.

Strategically LCFT has targeted growth in service provision, revenue and geographical footprint as an organisation. Supporting this the Trust has recently won the contract for HMP Liverpool and HMP Kennet prisons, which provides Specialist Services Network with a platform for further expansion.

Discussion followed relating to the Commissioner approach to leading on a prime provider model,

CONFIRMED

TB 061/15 CORPORATE GOVERNANCE STATEMENT AND SUPPORTING DECLARATIONS The Director of Governance and Compliance presented her paper and provided the Board with the Corporate Governance Statement and supporting declaration for approval prior to submission to Monitor on 30 June 2015.

The Chair of the Corporate Governance and Compliance Sub-Committee confirmed that evidence in support of the statement had been scrutinised by the Committee. The Committee recommend the approval of the statement and supporting declaration.

The Board approved the Corporate Governance Statement, the Compliance with Provider Licence: Governor Training Declaration and the Certificate on Academic Health Science Centre and Governance.

TB 062/15 ANY OTHER BUSINESS There was no other business to be discussed.

TB 063/15 TIME AND DATE OF THE NEXT MEETING The next meeting is scheduled to take place on 28 July 2015 at 9.00am.

Minute extract removed - FOIA Exempt Under Section 43 Commercial Interest

Board of Directors

Agenda Item TB 062/15 Date: 28/07/2015 Report Title Trust Chairs Report

FOIA Exemption No Exemption

Prepared by Umme Batan, Corporate Governance Support

Presented by Derek Brown, Trust Chair

Action required Noting

Supporting Executive Director Executive Director of Governance and Compliance

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by Non-Executive Directors outside of the Board members

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence

CQC domain Well-led

1.0 INFORMAL & FORMAL BOARD SESSIONS

Since the formal Board meeting held on 28 April 2015, Board members attended a Board Away Day on 23 June 2015. The away day focussed on the Trust’s strategic direction and planning for the future.

2.0 DIRECTOR ACTIVITY

In addition to the usual Board business, Non-Executive Directors have been involved in their areas of special interest during the period of April-July 2015:

All Non-Executive Directors have been attending the programme of quality board visits following the Board meetings. They have also been attending the Board sub-committee meetings which they are a member of. All Non-Executive Directors had their appraisal with the Chair and the Chair had his appraisal with the Senior Independent Director. A meeting was arranged for all NEDs and the Chair to discuss the recruitment for the Chair and they also met to review the Appreciative Leadership Programme, apologies were received from David Curtis as he was on annual leave.

The CQC Inspection took place week commencing 27th April and all Non-Executive Directors met with CQC Inspectors for group and individual interviews.

Louise met with both the Internal and External Auditors and had individual meetings with the Director of Governance and Compliance. She also had her monthly meetings with The Chief Executive. She also met with the Medical Director. She attended a Good Practice Visit in June at The Innovation Centre to visit the Chronic Obstructive Pulmonary Disease Rehab Team BwD. Louise met with the Chief Exec, Chief Finance Officer and the Director of Governance. She has had tele-calls with Executive Directors and meeting with senior managers. Naseem attended a Good Practice Visit in Leyland to the Safeguarding team. She also met individually with the Director of Governance and Compliance and the Deputy Chair to discuss the Chair’s appraisal

process and procedure as this was her first appraisal of the Chair. She attended the Engage event and met individually with the Equality and Diversity Project Manager. David attended a Dare to Share event at the Acorn centre in Accrington. He met with the Director of Nursing to discuss the Quality Committee agenda and papers. He also attended a Good Practice Visit in Leyland at the Crisis Resolution Home Team. He had a meeting with the Network and Clinical Director from Children & Families and carried out a visit at Daniels Lane Centre with them. As part of recruitment for the new Chair Peter Ballard has been attending drop in session at various Trust sites and also attending Network Governance meetings and providing presentations. Gwynne Furlong attended an Appeal Hearing and also attended the Out of Hospital Steering Group meeting in June and July. He met with the Chief Finance Officer to discuss the RRCS accounts. He also had a meeting with internal Directors.

Louise and David attended the Council of Governors meeting in May and June. Naseem, Gwynne, Louise and Peter have been attending the Appreciative Leadership workshops.

3.0 CHAIRS ACTIVITY The Chair met with Chair of the CQC Inspection and attended the close out meeting with the Executive team. He has attended July’s Engage and the Rising Stars events. He continues to visit the Trust’s services on a weekly basis. The Chair has met with the Chief Executive and the Director of Governance and Compliance.

4.0 RE-APPOINTMENT OF NON-EXECUTIVE DIRECTOR Gwynne Furlong joined the Trust as a Non-Executive Director on 1st October 2012. Following the annual appraisal process for Non-Executive Directors, a recommendation was made to the Council of Governors in June that Gwynne be re-appointed for a second term of office until 1st October 31st September 2018. This recommendation was approved.

5.0 RE-APPOINTMENT OF CHAIR, DEREK BROWN Prepared by Naseem Malik, Senior Independent Director.

Derek Brown’s Non-Executive Director post took effect in 2007 when the Trust became an authorised Foundation Trust and he was subsequently re-appointed in 2010 for a further three year term of office.

Following the resignation of the previous Chair, the Council of Governors Nomination/Remuneration Committee held on 26 June 2013 considered the proposal to appoint Derek as the Trust Chair for the term of office unserved by the previous Chair. The full Council of Governors agreed the recommendation and appointed Derek Brown as Trust Chair until 31 March 2016 subject to annual re-appointment.

At the 11 June 2015 Council of Governors meeting the deputy Chair on behalf of the Senior Independent Director made a recommendation to the Council to formally approve the final re-appointment of the Trust Chair, Derek Brown until 31 March 2016. This was approved by the Council of Governors.

6.0 APPOINTMENT OF EXTERNAL AUDITOR Following a robust procurement process for the appointment of the Trust’s External Auditors, the Council of Governors working group will be making a recommendation to the full Council of Governors on 6th August 2015 for KMPG to continue to provide the External Audit function for three years.

7.0 COUNCIL OF GOVERNORS MINUTES Attached for information are the confirmed Council of Governor minutes from the meetings held on May and June 2015.

Council of Governors

COUNCIL OF GOVERNORS

Minutes of the formal meeting of the Council of Governors held on 07 May 2015

Present Derek Brown (Chair) Public Governors Alan Ravenscroft Bill Coulton Brian Spencer Brian Taylor Lin Jones John MacLeod Mike Marsden Tahir Khan Staff Governors Paul Morris Linda Ravenscroft Lynne Bax James Harper Graham Ash

In Attendance Bill Gregory, Chief Finance Officer Diane Halsey, Director of Governance & Compliance Damian Gallagher, Director of Workforce David Curtis, Non-Executive Director Louise Dickinson, Non-Executive Director Steve Winterson, Engagement Director Ashley Christian, Corporate Governance Officer (minutes) Paul Aspden, Blackpool Teaching Hospitals (observer)

CG018.15 WELCOME AND OPENING COMMENTS The Chair welcomed everyone and in particular Staff Governor Paul Aspden from Blackpool Teaching Hospital who was attending to observe the meeting.

The Chair gave a brief update on the recent CQC visit, the formal feedback report for which would not be issued until July.

CG019.15 APOLOGIES AND DECLARATIONS OF INTEREST Governor apologies were received from David Jackson, Mike Wedgeworth, Tom Lawman, Jacqui Sutton and Max Oosman. Trust Board apologies were received from Heather Tierney-Moore, Max Marshall, Naseem Malik and Gwynne Furlong. The Chief Finance Officer would be deputising for the Chief Executive.

It was noted that Nigel Harrison had also sent apologies, the Nomination Remuneration Chairs Report would be taken by the Lead Governor.

Confirmation of quoracy was given.

CG020.15 MINUTES OF THE COUNCIL OF GOVERNOR MEETING HELD ON 15 JANUARY 2015The minutes of the meeting held on 15 January 2015 were confirmed as a true and accurate record.

CG021.15 MATTERS ARISING & ACTION TRACKER UPDATES There were no open items on the action tracker.

Confirmed


CG022.15 CHAIRS REPORT The Trust Chair introduced his report and highlighted the recommendation for the Council of Governors to appoint a representative from Young Lancashire to fulfil one of two vacant Appointed Governor positions on the Council. The Council of Governors approved the recommendation which would allow the formal appointment process to continue.

There were no further questions on the Chairs Report.

CG023.15 REACh PROGRAMME The Chair introduced the Clinical Director for Children and Families, Warren Larkin who introduced the presentation into the Routine Enquiry of Adversity in Children (REACh) Programme and provided the background into his clinical interest in childhood adversity. The Council noted that the World Health Organisation (WHO) considers adversity as a global public health imperative and heard the most common Adverse Childhood Experiences (ACEs) noted in adults through research studies.

The Clinical Director provided an overview of studies which have looked in depth at the causal and proportionate relationship between ACEs and poor physical health, mental health and social outcomes. An overview of the statistics around ACEs and health harming behaviour was provided alongside an understanding of how questionnaires are used for enquiry into adversity in adults. The benefits of understanding the background of a patient with adversity in terms of their clinical therapy was described amongst other notable benefits.

The support from Public Health England and the multi-agency organisation model was described further and the process to gain funding in order to pursue research into childhood enquiry was described. The Council noted that more work was needed to establish best practice in routine enquiry with children and the Clinical Director outlined the significant potential to break the intergenerational impact of ACEs. The Clinical Director described how the REACh programme, if rolled out could be implemented across a range of clinical contact opportunities including GPs, IAPT and CAMHS once research has concluded.

Following a Governor question the Clinical Director described the process for research outcomes to be translated into best practice and influencing factors were explained in more detail. It was confirmed that the REACh research sits with the Trust’s Making Every Contact Count initiative as a Public Health opportunity. An explanation was also given of how grants would fund initial research into areas of poverty but also diversity of population.

A discussion took place around the effects of bullying on children’s mental health as a factor which is not reflected in the list of established Adverse Childhood Experiences identified through this research.

The Chair thanked the Clinical Director on behalf of the Council and advised any further questions could be submitted outside of the meeting.


Warren Larkin left the meeting.

CG024.15 OPERATIONAL PLAN 2015/16 The Chief Finance Officer, attending on behalf of the Chief Executive presented the Operational Plan 2015/16. The purpose of the Plan and Monitor requirements were described and the Council noted that the current Trust strategy had been reflected within the Plan.

The Council understood the Operational Plan had been recently reported to the Board of Directors and was presented to Governors for noting. The Chief Finance Officer referred to detailed outlines of Trust’s the financial position and described the Continuity of Service Risk Rating and other key areas in more detail.

Following a Staff Governor query the detail around the Risk Management Policy within the Plan would be reviewed to ensure it remained accurate and reflected the current position at the date of submission.

The Director of Governance & Compliance agreed to check the accuracy of the reporting of the Risk Management Strategy within the Operational Plan, it appears it is still out for consultation and so should be checking prior to submission if this work will not be completed in time.

A query was raised around the signing of specific service contracts which was addressed by the Chief Finance Officer. The Council noted the current position was not uncommon for Trust’s preparing to submit operational plans.

CG025.15 FORMAL AMENDMENTS TO THE CONSTITUTION The Director of Governance & Compliance reminded the Governors of the resignation of the Director of Strategy and Transformation in February 2015, following which, as part of good governance practice, the Board utilised the opportunity to review the effectiveness of the Board and considered the reduction of the Executive Team. The Council were satisfied that there was no overriding financial driver behind the decision to reduce the number of Executive Management Team members although a relative cost saving would be realised through absorbing the vacant post.

The Council heard that the Trust Board Nomination Remuneration Committee considered a wide range of issues, challenged appropriately and were subsequently assured by the responses provided. The implication arising from the recommendation to reduce the number of Executive Directors also requires an amendment to the Constitution to reflect a reduction in the number of Non-Executive Directors on the Board. The Council noted that approval of changes to the Constitution affecting Non-Executive Directors is the remit of the full Council of Governors.

The Lead Governor reflected on the discussion held at the Council of Governor Nomination Remuneration Committee to consider the changes to the composition of the Non-Executive Directors on the Board. The recommendation to enact a flexible


amendment was detailed within the paper. The Lead Governor provided an overview of the challenge put forward by the Committee around the removal of the Executive Director role and were assured that the decision was not only based on finances but also standards of service delivery.

The Nomination Remuneration Committee recommended the acceptance of changes to the Constitution in reducing the Non-Executive Director community of the Board and the Council of Governors approved the changes to theConstitution by majority vote.

CG026.15 NOMINATION REMUNERATION COMMITTEE CHAIRS REPORT This item was covered in preceding discussions CG025.15

CG027.15 PROGRESS OF EXTERNAL AUDIT CONTRACT The Chief Finance Officer reminded the Council of the decision to prioritise the internal audit contract and confirmed the recent award to Mersey Internal Audit Agency (MIAA). The Council noted the process to appoint external auditors would re-commence using the tender documentation reviewed and approved by the Audit Tender Working Group. The Chief Finance Officer outlined the stages of the process including shortlisting of potential suppliers and tender presentations.

It is expected that the Audit Tender Working Group will make a recommendation on preferred supplier to the full Council of Governors at the August meeting.

CG028.15 SUB COMMITTEE CYCLE OF BUSINESS 2015/16 The Director of Governance & Compliance introduced the sub-committee Cycles of Business 2015/16 presented to the Governors for noting. The Council were reminded of the process around membership of sub-committees and should submit any comments around the Cycles of Business for further consideration.

The Director of Governance & Compliance outlined the plans to undertake a review of the Council’s effectiveness and governance systems later in the year, which may affect the Cycles of Business endorsed by the Council.

CG029.15 NHS PROVIDERS CONFERENCE FEEDBACK The Lead Governor provided an overview of the NHS Providers recent conference attended by himself and fellow Public Governor Mike Wedgeworth. Topics covered during the conference plenary sessions and breakout sessions held especially for Governors were outlined, including Lead Governors and holding Non-Executive Directors to account which were particularly helpful.

The Lead Governor invited Governors to request further information on topics from the conference agenda and the presentations would be shared with Governors as required.

CG030.15 CHIEF EXECUTIVE ASSURANCE REPORT Q4 The Chief Finance Officer provided an overview of the assurance report and referred to the update provided by the Chair on the recent CQC visit. An updated position was provided around The Harbour and the tendering for service contracts,


in particular the successful tender for the provision of health and social care at HMP Liverpool and Kennet prisons.

The Council also received updates relating to the appointment of a new Adult Mental Health Network Director, the Quality Visits by Board members and the financial position.

The Council noted the external activity around the Vanguard sites for the development of new care models programme. The Public Governor for Blackpool requested more detail on how the scheme will affect the Fylde coast as it becomes available to Governors.

CG031.15 QUARTERLY WORKFORCE REPORT Q3 & Q4 The Workforce Reports were taken as read. The Council challenged the disciplinary figures contained within the report and the Director of Workforce discussed the new controls implemented to assist in DBS compliance checking for staff which have affected disciplinary figures as the process now involves triggering early stage disciplinary action for non-response.

The data provided around staff suspensions was also discussed further and the Council heard in more detail the Trust policy to re-check the DBS certificate of staff working in eligible roles every three years. A discussion took place around the controls to prevent suspended staff undertaking other paid work whilst on suspension with salary.

CG032.15 SUB COMMITTEE CHAIRS REPORTS The Sub-Committee Chair’s Reports were taken as read and there were no questions raised.

CG033.15 ANY OTHER BUSINESS The Trust Chair outlined the process for appraising the Non-Executive Directors and the Director of Governance & Compliance explained the format and basis of appraising Non-Executives Directors. The Council noted that the outcome of the appraisal process would be reviewed by the CoG Nomination Remuneration Committee before being reported back to the full Council once complete.

CG034.15 DATE AND TIME OF NEXT MEETING Council of Governors Informal, 11 June 2015, 10:00am. Holiday Inn Express, Walton Summit, PR5 8AA


COUNCIL OF GOVERNORS

Minutes of the formal meeting of the Council of Governors held on Thursday 11 June 2015

Present Derek Brown (Chair) Alan Ravenscroft Bill Coulton Brian Spencer Brian Taylor Lin Jones John MacLeod Mike Marsden Tahir Khan Graham Ash Paul Morris Linda Ravenscroft Tom Lawman

In Attendance Diane Halsey, Director of Governance & Compliance Peter Ballard, Deputy Chair Jo Alker, Deputy Company Secretary Ashley Christian, Corporate Governance Officer (minutes)

CG035.15 WELCOME AND OPENING COMMENTS The Chair welcomed everyone to the meeting and set out the format of the part-Formal meeting which would be followed by an Informal session.

CG036.15 APOLOGIES AND DECLARATIONS OF INTEREST Apologies were received from David Jackson, Mike Wedgeworth, Jacqui Sutton, James Harper and Lynne Bax. It was noted that Nigel Harrison had also sent apologies and so the Nomination Remuneration Chairs Report would be taken by the Lead Governor.

Confirmation of quoracy was given.

The Trust Chair declared an interest in item CG 037.15 Report of the Nomination Remuneration Committee in relation to his re-appointment. The Council noted that the Trust Chair would leave the meeting for this discussion and the Trust’s Deputy Chair would assume the chair.

The Trust Chair left the meeting.

CG037.15 NOMINATION REMUNERATION COMMITTEE CHAIRS REPORT The Lead Governor introduced the item and outlined the discussion undertaken by the Nomination Remuneration Committee in considering the re-appointment of the Trust Chair as part of the annual re-appointment process necessary for his extended term of office, previously agreed by the Council of Governors, until 31 March 2016.

The Lead Governor discussed in more detail the items considered by the Nomination Remuneration Committee in support of the Trust Chair’s annual re-appointment including the very satisfactory appraisal undertaken by the Senior Independent Director. The Council agreed that the Trust Chair had undertaken his duties thoroughly well. The Lead Governor formally presented the Committee’s

Confirmed


recommendation to approve the re-appointment of the Trust Chair until 31 March 2016. Comments from Governors were received and supported the recommendation for re-appointment.

The Trust’s Deputy Chair requested a Governor vote and the Council of Governors unanimously approved the re-appointment of the Trust Chair until 31 March 2016.

The Trust Chair re-joined the meeting.

The Trust Chair invited the Council to consider the re-appointment of Non-Executive Director, Gwynne Furlong. The Lead Governor provided an overview of the discussions undertaken at the Nomination Remuneration Committee in relation to the positive appraisal outcome and notable contribution to the Board during the Non-Executive Directors first term of office. The Lead Governor noted that full appraisal outcomes for all Non-Executive Directors would be presented at a later date.

The Lead Governor formally presented the Committee’s recommendation to approve the re-appointment of Non-Executive Director, Gwynne Furlong for a second term of office, commencing on 1 October 2015 – 30 September 2018.

The Trust Chair requested a Governor vote and the Council of Governors unanimously approved the re-appointment of Gwynne Furlong for a second term of office.

There was no further business to conduct and the Chair concluded the Formal meeting.

CG038.15 DATE AND TIME OF NEXT MEETING Formal Council of Governors 06 August 2015, 10:00am. Holiday Inn Express, Walton Summit, PR5 8AA

Board of Directors

Agenda Item TB 063/15 Date: 28/07/2015 Report Title Chief Executive’s Briefing FOIA Exemption Part Exemption FOIA Exempt Under Section 43Prepared by Heather Tierney-Moore, Chief Executive Presented by Heather Tierney-Moore, Chief Executive Action required Discussion Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT: Report purpose The purpose of this report is to provide Board members with

an overall summary of the Trust position and highlight areas for further discussion.


To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality.

CQC domain Well-led

Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.

The development of the Board Balanced Scorecard has been progressing at pace which involved major rework of the design, to provide greater clarity and assurance against the trusts strategic priorities. Attached at appendix one is the Board Balanced Scorecard reporting data for quarter one, highlighting areas of achievement and areas which warrants attention or escalation.

Post CQC Inspection update The Trust’s CQC Inspection took place at the end of April and following that we anticipated receiving the draft reports in July. This date has been pushed back and we now expect to receive the 16 service line reports and one overarching report on 11th August 2015. The Quality Summit was tentatively scheduled for 1st September 2015 and I am now able to confirm that date. At the Quality Summit the CQC will present the report and the Trust will then respond with our initial action plan. The action plan will then be further developed with stakeholders attending the summit, the report will be published the following week.

Culture Assessment Tool Board members will recall the presentation given by Professor Michael West at the formal Board meeting in April where he outlined the approach to assessing the Trust’s culture, how he would help to further develop a collective leadership approach to support high quality care. This included the use of the Culture Assessment Tool (CAT), a survey that had been circulated to randomly chosen members of staff across the organisation. The six areas of culture that the tool assessed were:

Values and vision Goals and performance Support and compassion Learning and innovation Team working Collective leadership

The results of the CAT were shared at the last Board session and have since been disseminated within the organisation. Michael will be joining the Board again in September to provide feedback on the

outcome of the diagnostic phase of our joint work, of which the CAT was one component and our plans for the design and delivery phases to strengthen our leadership and culture in response to the findings.

Financial position The Five Year Forward View (5YFV) sets out the overall challenge facing the NHS with an estimated gap of £30bn over the next five years. This includes a proposition that £22bn is required to be delivered in efficiency savings, with an additional real time funding requirement of £8bn. The July Budget reaffirmed the government’s backing of the 5YFV.

Within the budget, a national pay restraint of 1% over the next four years was announced. Lord Carter’s review of procurement is a national lead enabler to support the NHS in delivering some of that efficiency. An early focus of this work relates to the workforce and adopting a national approach to reducing the cost of agency staff. Locally, Healthier Lancashire is leading a programme of work to quantify the nature and scale of the collective challenge facing health and social care pan Lancashire and identify potential solutions. These solutions will be over and above those already planned at local economy and individual organisational level. Our own approach within LCFT through Delivering the Strategy is set out later in this report. The national context serves to emphasise the importance of the successful delivery these programmes.

Vanguard sites The Trust has recently contributed to three joint new bids, to establish urgent care vanguards, spanning physical and mental health which will support our pan Lancashire work on the crisis concordat. A further bid is being developed in relation to hyper stroke services as a Lancashire wide acute care vanguard.

LCFT is a partner within the bid as we provide stroke pathways into the community. The Board will be kept informed of progress should these bids be successful.

Making healthcare more human-centred and not system-centred The Secretary of State made a number of announcements in his statement to the House of Commons and his speech at the Kings Fund on the 16th July 2015. They related to:

Changes to the regulatory architecture, a renewed focus on improvement; Changes to consultant contracts; Leadership capacity; Proposals relating to patient safety, quality and choice.

A briefing provided by NHS Providers is attached FOIA Exempt

Monitor Quarterly Declaration The Monitor Quarterly Declaration for Q1 has required additional activity and workforce data to be collated, validated and prepared for submission on the required template. The Monitor submission was completed on Thursday 23rd July 2015 and the Board declaration to be signed off can be accessed h FOIA Exempt the main content of the submission has been scrutinised by the Corporate Governance and Compliance sub-committee and through the approved process, and has also been validated by the relevant Executive Director. Once approved, this submission will be uploaded to the Monitor Portal.

Business Development Report – FOIA Exempt under Section 43

Operational Performance There are no regulatory non-compliance performance issues for the Trust.

The Trust has achieved full compliance of its Monitor measures for Q1 2015/16.

MR03, Delayed Transfers of Care (DTOC) has shown a 2% plus movement from May to June that indicates deterioration in performance, however full compliance in month and quarter has been achieved.

Two new indicators will be introduced during 2015/16, Improving Access to Psychological Therapies (IAPT) and Early Intervention Services (EIS). The IAPT indicator will be reported in Q3 and the EIS indicator in Q4 as per the Monitor guidance.

The internal audit of monitor indicators will commence in July 15 in line with the agreed programme, with an initial focus on DTOC and seven day follow ups. The Adult Community Services Network is currently refreshing their DTOC Action Plan to ensure ongoing delivery of the DTOC measure. Delivery against this measure will be closely and jointly monitored in Q2 by the Network and the performance team.

The Trust’s performance report for Month 3 can be viewed FOIA Exempt

Additionally, Delivering the Strategy is the primary focus for Networks with alignment of business plans underway and fully developed proposals being finalised for the five year plan. Included with this summary is an update on the progress, structure and governance of the Delivering the Strategy programme which can be seen FOIA Exempt

Serious Incident FOIA Exempt, Section 40 Personal Information

Corporate Services

Corporate Services

Board Balanced Scorecard

(BSC) Quarter 1

Board of Directors 28th July 2015

Appendix 1

Corporate Services

Submission – Quarter 1

Continuity of Services Risk Rating (COSRR)

PEOPLE AND LEADERSHIP FINANCE

QUALITY AND SAFETY SERVICE DELIVERY

Staff Survey

Business Gained – Business LostMental health community survey

Serious Incidents

Friends & Family Test

(FFT)

National Audits & Accred

Schemes

Violence Reduction

Research Studies

Harm Free Care

Out of Area Treatments

(OATS)

Monitor Compliance

Contract Performance

CQC Outstanding

Actions

Staff Friends and Family Test (FFT)

Sickness Absence

Induction Attendance

Time to Recruit

Capital Servicing Capacity

Liquidity

Cost Improvement Programme

Capital Expenditure

(CAPEX)

Annual benchmarked FFT

Green – Target Achieved Red – Target not Achieved Blank – No Data

Corporate Services

Quality and Safety - Executive Director of Nursing & Quality

Mental Health Comm Survey Nationally reported mental health community (CQC)

Target - top 25% of other trusts

National Audits and Accreditation Schemes No. of National Audits and Accreditation Schemes we

achieved top 50% of performance Target 80% of the time

Annual Benchmarked FFT Annual benchmarked (FFT) position

Target - top 25% of other trusts

Fieldwork closes 17/7/15 – response rate was 27% (average response rate for all Trusts 27%) as of 15/6/15. Initial findings will be sent to the Trust by Quality Health 28/7/15. Lancashire Care will be nationally benchmarked

mid September 2015

Currently there are 8 national audits in progress. It is anticipated that 2 will be reported during Q2, 3 during Q3 and 2 during Q4. The remaining audit is scheduled for completion in Q1 2016/17. It is anticipated that 5 audits

will provide sufficient data so the organisation can benchmark itself relative to the other participating organisations. These will be the Diabetes, Intermediate care, COPD, Stroke and Parkinson projects.

Harm Free Care (Safety Thermometer Tool) Physical Health - keep patients safe from the 4 harms

(falls, catheter acquired urinary tract infections, pressure ulcers, venous thromboembolisms). The

Trust measures the % of patients who are free from all of the harms listed.

Target 95%

Performance April May June

92% 96% 94%

94% of the 1172 people seen in June were free from all respective harms. A slight increase in recorded falls and VTE are being investigated

Harm Free Care (Safety Thermometer Tool) Mental Health - keep patients safe from 5 harms (medication omissions, violence and aggression,

restraint, feeling safe, self-harm). Target 70%

No. people recruited to Research studies Number of people recruited to National Institute for

Health Research (NIHR) portfolio studies. Target 100 participants monthly


42% 68% 63%

63% of the 27 patient’s seen in June in the 4 PICUs were free from harm. The achievement Harm Free Care continues to be progressed


46 85 85

Whilst monthly recruitment rate is currently short of the annual target, monthly rates are improving and we anticipate that we will hit the overall target in year due to additional studies

currently in the pipeline.

Violence Reduction % reduction in the levels of physical violence to staff

compared to the benchmark average month for 14-15 Target 10% reduction


+17% +75% +19%

The significant majority of incidents were low level incidents of physical violence. The current average for 2015/16 is a 37% increase.

Serious Incidents The number of serious incidents reported.

Target 10% reduction

Friends and Family Test (FFT) Our monthly score on the Friends and Family Test.

Target 95%


+11% -50% -82%

Performance April May June 97% 97% 94%

Reduced average for June reflects a reduction in the average positive score this is reflective of the early stage of data collection

The data provided is the % difference on those reported in the same month last year. The current average for 2015/16 is a 40% decrease.

The FFT is not being used as a benchmarking tool but as a quality improvement tool. It is proposed that this indicator will be replaced by another strategic indicator by Quarter 2.

Corporate Services

Contract Performance Measure 3 Top contract performance indicator valued by

commissionersTarget IAPT Prevalence 1.25%

Service Delivery – Chief Operating Officer

CQC outstanding actions from inspections Number of outstanding actions in progress following

any CQC inspection. Target - No outstanding actions exceeding

the agreed timescales.

LCFT have been successful in four bids, which total an annual value of £6.9m for 15/16. These bids have been commissioned by Lancashire CCG’s and NHS England for Community IV, Diabetes and Offender Health.

All these bids have constituted new business for LCFT, with no existing contracts lost.

The Trust does not presently have a centralised system to monitor the completion of actions arising from CQC inspections (including CQC Mental Health Act Monitoring Visits). The current system is based on local ownership

and monitoring. A new centralised system is being developed within Datix and shall be implemented by September 2015 at which point this data will be available.

Out of Area Treatments (OATS) The number of patients placed in out of area beds

(outside of the 10 contracted beds). Target 10 contracted beds

Monitor Compliance Monitor operational Performance measures currently reported to Board and Executive in line with national

monitor definitions. Target 100% compliance in each quarter

Contract Performance Measure 1 Top contract performance indicators valued by

commissioners which include CQUIN, IAPT, MAS, flu uptake & activity levels

Target CQUIN 100%


45 47 48


99.8% 99.8% 100%

April May June

78.4% 75.3% 76.3%

Actual OAT beds in month were 48 (including 9 PICU) against contracted activity of 10 acute OAT beds. This figure has risen and is 4 above the Trust monthly trajectory of 35 acute OAT beds. The bulk of the patients occupying these beds are male (75% of the Acute and all the

PICU).

Contract Performance Measure 2 Top contract performance indicator valued by

commissionersTarget MAS Waiting Time 70%

Monthly Target Met

April May June

1.45% 2.73% 3.73%

Monthly Target Met

This target is an accumulative target. Q1 position is on target


<100% 100% *100%

Monthly Target Met

Business Gained – Business Lost The business gained in £’s minus the contracts that we

have attempted to retain and have lost Target – the Trusts growth target for the next

12 months is %

Corporate Services

Finance - Chief Finance Officer

Capital Expenditure (CAPEX)Measures Capital Expenditure against Planned Capital

expenditure. Target 85%


83% 83% 88%


75% 88% 98%

LiquidityRisk assessment score - Measures the ability to meet

short term obligations and compares to plan. Target 4

Capital Servicing Capacity (CAPEX)Risk assessment score - Measures the degree to

which generated income covers financing obligations and compares to plan.

Target 2

Continuity of Services Risk Rating (COSRR)

Risk assessment score - Monitors overall measurement of risk to continuity of services,

calculated using an average of Liquidity and Capital Service Cover ratings.

Target 3

Cost Improvement Program Measures percentage performance of CIPs against

plan. Target 100%


3 3 3

I&E forecasts are slightly behind plan, but forecasts indicate performance on CoSRR will achieve the planned rating of 3.


2 2 2

Current projections maintain a debt service of 2 against a plan of 2 at the end of the year.


4 4 4

Cash is ahead of plan and based on current forecasts and assumptions is now expected to be remain so.

Overall Capital Expenditure is broadly in line with plan.

Performance against monitored and approved schemes is broadly in line with plan. Unallocated CIP programmes are managed through reserves with £0.7m yet to be fully

transacted. Programme is expected to be achieved.

Corporate Services

People and Leadership – HR Director Staff Survey

This is the annual staff survey which is sent out to all staff.

Target - Top 25% of other trusts

Staff Friends and Family Test (FFT) A sample of staff who have responded to the FFT

questionnaire in the current month Target - The average score of the sample is

at or above the score that would have achieved upper quartile performance in the

previous years Staff Survey

“In Touch” communication sessions have been completed and a further round planned for July / August 2015. Senior HR BP's are working in partnership with Network Directors to embed the plans.

The Friends and Family Test (FFT) will be conducted in partnership with the Nursing and Quality Directorate using the same software in order to enhance the current process. This will offer the benefits of shared

marketing of the survey and familiarity with the software. The current process will continue until implementation of the new system.

Sickness Absence % of working hours lost due to staff sickness.

Target 4.50%

Induction Attendance % staff who attended the Trust induction within 4 weeks

of starting employment with the Trust. Target 95%

Time to Recruit Working days it takes from the identification of a

confirmed recruitment need to appointment. Target 60 working days


5.60% 5.52% 6.12%

Sickness absence has increased this month. We have implemented a specific sickness absence project under the Delivering the Strategy Programme.


60.5% 60.7% 55.6% This will improve further as we move to a new induction process.


65.4 64.6 67.5

Electronic solutions will be implemented (EDBS and TRAC is being reviewed) both systems will support a reduction in recruitment time within HR. We are also able to

track where delays in recruitment are (e.g. finance networks, recruitment)

Board of Directors

Agenda Item TB 064/15 Date: 28/05/2015 Report Title Audit Committee Chairs Report


Prepared by Ashley Christian, Corporate Governance Officer

Presented by Louise Dickinson, Non-Executive Director

Action required Decision

Supporting Executive Director Chief Executive


Report purpose To provide an outline of the activity undertaken by the Audit Committee, highlight assurance received and risks identified.




CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Audit Committee on 29 April 2015, 20 May 2015 and 15 July 2015.

This Chair’s Report excludes Committee activity relating to the year-end processes and sign off of the Annual Report & Accounts which was reported through to the Board via a special Chair’s Report to the May Trust Board meeting and was supported by a verbal update from the Audit Committee Chair immediately prior to the Board sign off of the Annual Report & Accounts 2014/15.

The Chair’s Report is also accompanied by the Annual Report of the Audit Committee 2014/15 which was endorsed by the Audit Committee for presentation to the Council of Governors at its meeting on 06 August 2015.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance, and approve the terms of reference submitted for Board approval.

CHAIRS REPORT

CHAIRS REPORT OF: Audit Committee

DATE OF MEETING: 29 April 2015, 20 May 2015, 15 July 2015

ASSURANCE:

BAF Risk: 7.1

Breaches and Waivers Report The Committee received the strengthened report which detailed one avoidable waiver in quarter one. The Director of Financial Services provided a verbal update of processes which are being formalised with the Procurement Team to prevent any further avoidable breaches and waivers occurring in future. This activity is being reviewed by the Finance Sub-Committee.

BAF Risk: 7.1

Losses and Special Payments The Committee considered the losses and special payments report which highlighted a weakness in the recovery of money from leavers. The Committee has noted a number of HR related control failures has requested that assurance be brought back to the Audit Committee around how HR controls from recruitment to the leavers’ pathway are being strengthened.

BAF Risk: 2.1

Declaration of Interest & Gifts and Hospitality Registers The Committee noted the robust process in place for Declarations of Interests and received assurance that there have been no conflicts of interest highlighted by management arising from the declarations.

BAF Risk: 7.1

Contracts Register The Committee received an update around the review process of the Contracts Register, the reduction of risk and noted the limited assurance currently available. Further progress updates will be provided as the Contracts Register is developed and further reviews undertaken.

BAF Risk: 7.1

Internal Audit Plan 2015/18 Assurance was provided that a systematic review of the National Internal Audit standards had been undertaken and there are no other gaps relating to recommendations. The Committee noted the Chief Executive’s recommendation to ask Internal Audit to support the work being undertaken to improve the quality of HR data The Committee received assurance on the progress of the Internal Audit Plan and the progress of recommendations. A discussion was instigated which arose from a recommendation within the Compliance with the Provider Licence audit report around the arrangements for AHSN board members and requirement to comply with the Fit and Proper Person requirements. The Committee recommends discussion at Trust Board to reassess whether the Fit and Proper Person process should be applied to AHSN non-executive directors.

BAF Risk: Appointment of Internal & External Auditors

7.1 The Committee received assurance on the progress of the External Audit tender process and appropriate engagement of the CoG and other stakeholders. Assurance was provided that a robust procurement process had been followed and a recommendation was made by the Committee in support of the outcome.

BAF Risk: 7.4

Data Quality Plan The Committee received assurance that all actions had been assimilated into the revised performance improvement plan.

BAF Risk: 7.4

Governance Documentation The Committee endorsed refreshed Terms of Reference and Cycle of Business 2015/16.

The Committee are formally recommending the terms of reference for approval to the Board of Directors which are attached at appendix one.

BAF Risk: 7.4

Clinical Audit Programme 2015/16 The Committee received assurance that the final Clinical Audit Programme 2015/16 had been aligned to the Board Assurance Framework. The newly abbreviated clinical audit report delivered at the July meeting was received by the Committee. The Committee requested the abbreviated report highlights control gaps or risk areas which are identified by clinical audits, in particular, any non-clinical control gaps. Assurance was provided around progress with National Audits and Pharmacy audits.

BAF Risk: 7.1

Corporate Governance & Compliance Sub-Committee Chair’s Report The Committee received an update on the Information Governance risk identified by Corporate Governance & Compliance sub-committee which continues to remain at a high level until stronger assurance can be provided that improvements are being delivered and the results of the ICO audit have been received.

BAF Risk: 7.1

Value For Money The Committee discussed the appropriate reporting pathway and scrutiny of the VFM agenda within the governance structure, including the significance of ensuring overall monitoring of outcomes was in place. The Committee agreed the Finance & Business Performance Committee would scrutinise the value for money programme and produce an Annual Report to the Audit Committee on its activity. An action was taken away to consider the functional monitoring of the plan for VFM outside of the meeting to ensure provision of evidence based assurance to Audit Committee in support of approving the Annual Governance Statement. The Committee asked for its terms of reference to be reviewed in this context.

BAF Risk: 7.1

Governance Structure Change Request: Year-End Reporting The Audit Committee endorsed a proposed change request around delegation of year-end reports to the Corporate Governance & Compliance sub-committee for in depth scrutiny, and the provision of a specific year-end assurance report to the Audit Committee on the outcomes. The Committee received confirmation that the topic of ‘fair pay’ had been added to the agenda for consideration at the Board of Directors Nomination

Remuneration Committee. BAF Risk: 7.1

Risk Management & Assurance – Workforce The Committee received a verbal report around the ongoing work within the HR department to embed risk management arrangements, and the challenges faced around staff understanding of risk in general.

BAF Risk: 7.1

Effective Internal Controls In Relation To Risk Management The Committee received assurance that risk assurance systems are improving. Assurance was provided evidencing the improving and enhanced risk management arrangements. Assurance was also provided around the improvement in structure of processes and continuing development of intelligence within the framework. The Committee also heard about the development of an assurance quality matrix to assess the quality of the assurance put forward to the Board of Directors. The Committee has requested a framework be established to enable it to monitor further progress, particularly quantitively, in relation to Network and Corporate Directorate reports to the Committee.

BAF Risk: 7.1

Annual Report Of The Audit Committee The Annual Report of the Audit Committee was endorsed by Committee members for submission to the Board of Directors and Council of Governors. The final version of the Annual Report of the Audit Committee is appended to the Chair’s Report for assurance.

BAF Risk: 7.1

Harbour Staffing Model & Shift System Assurance was provided that the management of governance decisions reflected the relevant control frameworks at the time decisions were made. However, it was recognised that the Board should have had greater visibility of the proposal and its implications. The new governance framework should mitigate this gap going forward. Further assurance was sought around a number of risks raised within the paper to determine that the scrutiny of risks and mitigating actions are being dealt with appropriately and a report will come back to the Committee.

The Director of Governance & Compliance agreed to revisit the Decision Rights Framework and Matters Reserved for the Board to ensure material matters (>£2M) are escalated for Board approval. The Committee recommends the Board seeks assurance that the necessary visibility exists within the governance structure in terms of the wider risk profile identified by Audit Committee paper;

The funding deficit for the Harbour and its impact on financial sustainability Safer staffing and the application of the model at the Harbour and beyond Future decisions regarding the reprovision of inpatient facilities Value for money of services provided by the Trust Relationships with commissioners

The Committee raised the critical importance of high quality chairs reports and the key role of committee chairs in setting a consistently high standard of reporting throughout the governance structure. This message is being

escalated within the Audit Committee Chair’s Report to the Board to reflect the recognition that the governance system design is satisfactory but there is risk around implementation in terms of visibility of risk information and assurance to the Board. The Committee has requested consideration be given to the development and training needs of those involved in the Board’s Committees and Sub-Committees.

RISKS:

New Governance Framework A potential risk was raised around the key role of committee chairs within the new governance structure to appropriately and diligently escalate risk and provide assurances to the Board. The Board is asked to consider the risk around implementation of effective controls around visibility of risk information and assurance to the Board. A review of the effectiveness of the new governance framework has been included in the internal audit plan for quarter 1 2016/17. This audit will be key in providing the assurance to the Board that the design of the new framework has been robustly implemented.

Datix ID Ref: 6592

ACTION REQUIRED: Decision

Fuller discussion requested

Report provided for assurance

AUDIT COMMITTEE

TERMS OF REFERENCE VERSION 1.0

PURPOSE The Trust Board has set up an Audit Committee as a Committee of the Board to support them in their responsibilities for issues of risk, control and governance and associated assurance. The Committee’s activities will cover the whole of the organisation’s governance agenda, including finance, risk and clinical audit.

The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference.

The Committee will act consistently with the principles outlined in HM Treasury’s Audit Committee Handbook April 2013. NHS Audit Committee Handbook 2014, the UK Corporate Governance Code (FRC) 2014, the NHS Foundation Trust Code of Governance 2014 and other relevant guidance.

The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to look for any information it needs from any employee and all employees are required to co-operate with any request made by the Committee. The Committee is authorised by the Board to get outside legal or other independent professional advice and to ask advisers to attend meetings if it considers this necessary.

Where the Audit Committee thinks that there is evidence of improper acts or if there are other important matters that the Committee wish to raise, the Chair of the Audit Committee will raise this at a full meeting of the Trust Board.

The principal duties of the Committee are to review the adequacy and effectiveness of:

All risk and control related disclosure statements (in particular the Statement onInternal Control), together with any accompanying Head of Internal Audit statement,external audit opinion or other appropriate independent assurances, prior toendorsement by the Board

The underlying assurance processes that indicate the degree of achievement orcorporate objectives, the effectiveness of the management of principal risks and theappropriateness of the above disclosure statements

The policies for ensuring compliance with relevant regulatory, legal and code ofconduct requirements and related reporting and self-certification

The policies and procedures for all work related to fraud and corruption as set out inSecretary of State Directions and as required by the NHS Counter Fraud and SecurityManagement Service.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also look for reports and assurance from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

This will be evidenced through the Committee’s use of an effective Assurance Framework to

guide its work and that of the audit and assurance functions that report to it.

NB Throughout these terms of reference, the term ‘Internal Audit’ should be taken to incorporate the provision of Counter Fraud Services, though this should not be seen to imply that both services will be delivered by the same body.

DUTIES AND RESPONSIBILITIES

1. To review the adequacy of all risk and control related disclosure statements and receivepositive assurances from directors and managers on the overall arrangements forgovernance, risk management and internal control.

2. To review the internal audit strategy and plan.3. To review the Head of Internal Audit Opinion and other Internal Audit reports.4. To review the annual report of the Chief Internal Auditor.5. To review the effectiveness of the provision of the Internal Audit service; the cost of audit

adequacy of resource and any questions over resignation or dismissal and to ensure thatInternal Audit has the appropriate standing in the organisation.

6. To discuss the external audit plan with the External Auditor before the external auditcommences and the extent of reliance to be placed on internal audit.

7. To discuss problems and reservations arising from the External Auditor’s work and anymatters the External Auditor may wish to discuss (in the absence of the Trust’s Chair andother officers if necessary).

8. To review all External Audit reports, including the report to those charged with Governanceand the annual audit letter and management’s response and other reports during the yearas may be relevant.

9. To develop and implement a policy on the engagement of the external auditor to supplynon-audit services

10. To consider the content of any report involving the Trust issued by the Government PublicAccounts Committee, the Controller and Auditor General and any reviews by Departmentof Health, regulation/inspection and professional bodies with responsibilities for theperformance of staff or functions and to review management’s proposed response beforepresentation to the Trust Board.

11. To examine the circumstances associated with each occasion when Standing Orders andStanding Financial Instructions are waived.

12. To review schedules of losses and compensations and make recommendations to theTrust Board.

13. To receive assurance around compliance with the policy on standards of business conductfor members of staff thus offering assurance to the Board of probity in the conduct ofbusiness.

14. To monitor the integrity of the financial statements and to review the annual financialstatements prior to submission to the Board, focusing particularly on changes in andcompliance with, accounting policies and practices, and significant adjustments resultingfrom the audit. To review any announcements relating to the Trusts financial performance.

15. To make recommendations to the Council of Governors on the appointment and selectionof the External Auditor.

16. To approve any change in Internal Audit service provider.17. To review the adequacy of the policies and procedures for all work related to fraud and

corruption as set out in Secretary of State Directions and as required by the CounterFraud and Security Management Service.

18. To review the work of other committees within the organisation, whose work can providerelevant assurance to the Audit Committee’s own scope of work.

19. To review the adequacy of the Trust’s arrangements by which foundation trust staff may, inconfidence, raise concerns about possible improprieties in matters of financial reportingand control and related matters or any other matters of concern.

20. To receive assurance around the production of the clinical audit programme test

methodology used to undertake the audits. 21. Receive the Value for Money report22. To review the Trust’s Annual Report, Quality Account and Annual Governance Statement

for consistency and make a recommendation for approval to the Board of Directors23. To receive and approve the Corporate Governance & Compliance sub-committee Terms of

Reference24. To receive the Chair’s report from the Corporate Governance & Compliance sub-

committee following each meeting that provides assurance around the Trust’s corporategovernance arrangements and compliance with regulatory requirements and escalaterisks where necessary

REPORTING ARRANGEMENTS

Report to Activity Lead When Link to

Cycle of Business

Board of Directors

Report changes to the Audit Committee Terms of Reference

Chair As required AC 025

Board of Directors & Council of Governors

Produce an Audit Committee Annual Report commenting on the Trusts system of internal control

Chair Annually AC 028

Board of Directors

Produce a Chair’s Report to the Board of Directors following each meeting, directing as to where minutes can be accessed

Chair After each meeting

AC 027

Board of Directors

Evaluate any assurances received during the meeting which may impact on risk scores

Chair After each meeting

AC 027

Board of Directors

Present the Head of Internal Audit Opinion


Board of Directors

Recommend Annual Report & Financial Statements, Quality Account and Annual Governance Statement for sign off


Board of Directors

Conduct a review of effectiveness of the work of the Committee and report the outcome



Present the External Auditors Assurance Report on the Annual Report



Make a recommendation on the appointment of External Auditors

Chair As required AC 020

MEMBERSHIP AND QUORUMThere will be at least 3 members one of whom shall act as Chairperson. No business will be completed unless at least two Non-Executive Directors including the Chair are present at a

meeting. At least one Member of the Committee will have recent and relevant financial experience.

Sub-Committee Member

Name Title

Louise Dickinson Non-Executive Director (Chair)

Gwynne Furlong Non-Executive Director

David Curtis Non-Executive Director

Quoracy will be two of the above members. All members should attend at least half of all meetings in each financial year.

The Chief Finance Officer and appropriate internal/external, clinical audit and Local Counter Fraud representatives will normally attend meetings.

The Chief Executive, other Executive Directors and accountable managers may be invited to attend when the Committee is discussing areas of risk or operation that are the responsibility of that Director or manager.

FREQUENCY OF MEETINGS The Audit Committee will meet at least three four times a year. One of the meetings will consider the proposed internal and external audit plans and the final meeting of the calendar year will review the annual reports of the Auditors.

The Head of Internal Audit or the External Auditor may ask for a meeting to be called if they think it is necessary.

REVIEW The detail of how and when these functions are discharged can be found in the Cycle of Business. This represents the planned work of the committee and is the basis for the agenda setting process, allowing contributors opportunity to plan ahead and meet information expectations.

LANCASHIRE CARE NHS FOUNDATION TRUST

Annual Report of the Audit Committee April 2014 – March 2015

FOREWORD

Having been a member of the Audit Committee since October 2013, and appointed as Chair on 1 July 2014, I am pleased to present the Annual Report of the Audit Committee which covers the activities of the Trust for the period 1st April 2014 to 31st March 2015. I believe this report demonstrates a successful year in providing a forum for monitoring the Trust’s governance arrangements, supporting the production and approval of the Annual Governance Statement, and monitoring the integrity of the Annual Report and Financial Statements.

This year has seen considerable progress in the review and monitoring of the Clinical Audit Programme, under the leadership of the Medical Director. The improvements seen in the quality of the audits has been supported by robust clinical audit arrangements, notably the Clinical Audit Protocol, which was produced in close consultation with the Audit Committee and strengthens clinical engagement and the impact on improving practices.

The development and progress of a two year programme by the Audit Committee to review the risk management arrangements across the service Networks and Corporate directorates has been a valuable process of assurance for the Committee. Clinical & Network Directors attend the Committee on a rotational basis to report risk management and governance arrangements, and this enables the Committee to monitor and assess the risk culture across the organisation. The enhancement of our internal audit Network Audits has been well received by the Networks and seen as a helpful input into their continuous improvement activity.

The Audit Committee has worked closely with the Council of Governors to prepare for the appointment and award of a new external audit contract and will continue to oversee a fair and transparent tender process to ensure the appointment meets the needs of the Trust and the Governors.

As we look to the coming year, our priorities as a Committee will continue to be the oversight of the Trust’s risk management programme and holding the Trust to account for embedding an effective governance structure and systemic risk management arrangements. We will also focus on developing a more holistic planning approach to the audit and assurance environment and embedding our partnership with a new internal audit firm, Mersey Internal Audit Agency (MIAA).

Finally, on behalf of the Committee, I extend my thanks to Teresa Whittaker, the outgoing Audit Committee Chair, for her significant contribution to the activity of the Committee over a number of years.

Louise Dickinson Chair of Audit Committee

1. Audit Committee Overview

The Audit Committee is required to report annually to the Trust Board of Directors and tothe Council of Governors outlining the work it has undertaken during the year and wherenecessary, highlighting any areas of concern.

The Audit Committee is responsible on behalf of the Board of Directors for independentlyreviewing the Trust’s systems of governance, control, risk management and assurance.The Committee’s activities cover the whole of the organisation’s governance agenda, andnot just finance. The Committee also has a duty to monitor the integrity of the financialstatements and related reporting.

The Committee membership consists of independent Non-Executive Directors. The tablebelow details the membership during the reporting period. During the year, the Chair of theCommittee, Teresa Whittaker stepped down (in the ordinary course of Board succession)and the table below reflects the rotation of members following the recruitment of new Non-Executive Directors for the Trust.

Member Meetings Attended

Louise Dickinson FCA BA (Hons) (Chair) (appointed as Chair on 01 July 2014)

6/6

Teresa Whittaker BA FCMA (stepped down in June 2014)

3/3

Chris Heginbotham OBE, FRSPH (stepped down in September 2014)

4/4

Gwynne Furlong FRICS 6/6

Naseem Malik (interim appointment to replace Chris Heginbotham between 01 October 2014 – 01 December 2014)

1/1

David Curtis (replaced Naseem Malik in December 2014)

1/1

The External Auditors, Internal Auditors, Local Counter Fraud Service, Clinical Audit, Chief Executive, Chief Operating Officer, Director of Governance & Compliance and Medical Director all have a standing invitation to attend meetings and do so on a regular basis.

The Committee met on six occasions during the period which was in accordance with its planned schedule.

The Trust attendance record demonstrates the Committee continued to reach into the organisation. Attendance has included Executive Directors, Network and Clinical Directors and other senior managers, depending on the subject under review. We also accept regular requests from staff who wish to attend the Committee as observers, as part of their own professional development.

2. Work of the Committee in 2014/15Throughout 2014/15, the Committee reported on the nature and outcomes of its work to theBoard of Directors highlighting any areas that should be brought to its attention.

Other key development themes featured at meetings included:

• ensuring that audit arrangements are sufficient to meet the futurerequirements of the Trust, particularly in respect of quality and capitalprogrammes;

• the further development of the Trust’s risk management and assuranceframework;

• the development and application of change controls, in particular HRfunctions;

• the clinical audit programme;• development of local management systems as a first line of assurance

and general strengthening of the control environment;• changes to the regulator environment and compliance;• the continuation of ‘deep-dive’ Network audits;• asset management;• the development of Value for Money reporting;• the on-going monitoring of improvement actions; and• monitoring of the tender process and appointment of internal and external

audit.

Further detail on the scope of work performed by the Audit Committee can be found in the appendices to this report.

Appendix One sets out the Committee’s Terms of Reference and the Annual Schedule of planned work for 2014/15.

Appendix Two sets out the programmes of work in relation to the Internal Audit Plan and the Clinical Audit Plan for 2014/15.

In my role as Audit Committee Chair, I undertake a number of activities outside of the formal meetings on matters relating to the Committee; such as meetings with the Chief Executive, members of the Executive Management Team and other Non-Executive Directors. I have attended meetings of the Council of Governors to provide advice around the role of Audit Committee and presented on the role of external auditors in providing key assurances to the Council. In partnership with the Director of Governance & Compliance, I have advised and supported the Audit Working Group established by the Council of Governors to appoint a suitable external audit partner continues. Similarly, I have been involved in the tender process to appoint a new internal audit partner for 2015/18. I have hosted external technical update training session for the Non-Executives Directors and other members of the Board and I have regularly met informally with the internal and external auditors throughout the year. This additional activity facilitates the triangulation of information and allows the Committee to have greater reach into the organisation.

3. Financial & Business ReportingThe Audit Committee takes a holistic approach to discharging its accountability in relation tothe Annual Report, Financial Statements and the Quality Account with its reach across thewhole of the system of risk and internal control focussing on clinical systems and qualityalongside the traditional domains of finance and business systems.

Examples of specific activity undertaken by the Audit Committee to facilitate an informedidentification, review and assessment of any significant issues in relation to the 2014-15Annual Financial Statements include the following:

• the Chief Finance Officer is required to bring to the attention of the Committee, onan ongoing basis, any changes to accounting policy, significant financial reportingissues, estimates and judgements, and significant transactions;

• at the start of the year, External Audit provide their view on the risk profile and areasof focus in its audit planning, and updates the Committee on an ongoing basis;

• a technical update session open to all members of the Board was delivered by theExternal Auditor on 20 March 2015. At this session, the External Auditors providedtheir updated view on their risk based audit approach and their key areas of focus inthe year end audit, enabling the Non-Executive Directors to ask questions and seekadvice as necessary. The key risks identified that might impact the financialstatements included:

• recognition of NHS & non-NHS income;• management override of controls;• valuation and ownership of tangible assets;• cash controls and application cut-off;• robustness of payroll processes;• capital developments;

• the production of the Quality Account 2014/15 was supported by David Curtis, aNon-Executive Director member of Audit Committee and Chair of the Board’sQuality Committee providing additional oversight on behalf of the Board of Directors.

• the draft Annual Report, Financial Statements and Quality Account were tabled forthe April 2015 Committee meeting in good time to ask questions and seek advice onany issues;

• the Committee reviewed the Annual Report and Annual Financial Statements toprovide a consistency and reasonableness check;

• the Chief Finance Officer provided a detailed variance analysis between 2013/14and 2014/15 accounts and 2014/15 plan to actual out-turn. This enabled theCommittee to carry out a high level review and triangulate this against other sourcesof information, to ensure that all items of a significant nature had been captured anddiscussed;

• the Chief Finance Officer provided a detailed report to the committee on 20 May2015, confirming all previous verbal representations on areas of estimate andjudgement, and provided further information on the basis of estimates and keysensitivities, including responses to specific enquires made by Audit Committeemembers. The Committee reviewed the key judgements applied by management inassessing contingent liabilities, revaluation, asset carrying values and provisions;

• the Committee checked that the accounts presented were consistent with thefigures reported to Monitor in year;

• the Committee considered the Head of Internal Audit opinion which provided overallsubstantial assurance; and

• the Committee considered the External Auditors ISA260 report and unmodified auditopinion. No differences of opinion with the key management judgements werehighlighted.

From its work the Audit Committee was able to conclude that:

• the Annual Report and Financial Statements represent a fair and reasonable viewof the Trust’s financial position;

• there were no significant accounting policy changes;• asset values are considered fair and reasonable;• the Trust undertook a revaluation exercise resulting in some significant changes to

the valuation of the Trust estate;• there were no significant or unusual transactions in the year; and• a prudent approach has been taken to establishing provisions in line with the

Trust’s policies.

4. Governance, Internal Control and Risk ManagementThe Committee consider emerging regulatory requirements and best practice, in order toensure that the scope of Trust work in response is appropriate, a planned approach toconsidering issues is taken and the provision of support and training is made available tothe Committee members.

The Committee encourages frank, open and regular dialogue with the Trust’s internal andexternal audit teams and a risk and assurance approach runs through all the planningactivity and the development of annual audit programmes.

Throughout the year, the Committee receives reports from the internal audit, clinical auditand the external audit teams on both their audit findings and updates on actionimplementation. Additional reporting was received from both Corporate and Network riskowners on the progress in embedding a risk management regime across the organisation.Similarly the Finance Directorate provided assurances against a Trust control improvementplan around procurement processes. The Committee has continued to promote theimportance of the clinical audit function as a key element of the Trust’s quality improvementactivity. We have been pleased to receive, in addition to the results of the clinical auditwork, regular updates on the clinical audit development plan and approved a Clinical Audit

Protocol to support consistency of compliance targets and methodology for data interpretation and ratings.

The Committee is fully committed to reviewing and monitoring the Trust’s systems of internal control and wider assurance mechanisms to ensure there are systemic risk management processes fully embedded across the organisation, and the necessary culture shift required to achieve a fully integrated governance framework remains on the agenda at both Audit Committee and Trust Board meetings. The development of the risk management programme allows the Committee to monitor progress directly through Corporate and Network risk owners. Risk owners attend the Audit Committee to provide assurance on effectiveness of local systems and processes to manage risk, attending on a cyclical basis to provide evidence based assurance.

5. External AuditThe external audit services contract was awarded to KPMG LLP in April 2010 following arigorous competitive tendering process for three years with an option to extend for a furthertwo until completion of work for financial year 2014/15. A declaration of auditorindependence and objectivity is provided to the Committee on an annual basis, and as partof the tendering process we test how the professional firms manage this process internally.

There are clear policy guidelines in place around the provision of non-audit services by theExternal Auditor. Safeguards are in place that ensure the Committee are kept informed ofthe scope and value of work commissioned from the External Auditor. During the year,KPMG conducted additional non-audit work relating to the data quality review, the fee forthis work was £18,500.

The Committee has reviewed the work of external audit and is satisfied that the externalaudit service is of a sufficiently high standard and that KMPG’s fees are appropriate andreasonable.

6. Internal Audit including Counter Fraud ServicesThe Committee is required to ensure that the Trust has an effective Internal Audit function.This is achieved through the review and approval of the risk based Internal Audit andCounter Fraud plan and regular progress meetings with internal audit, the Chief Executiveand Chair of Audit Committee.

During 2014/15, all reasonable steps have been taken to address key counter fraudmeasures. The Audit Committee remains mindful of the need to continuously improve andenhance counter fraud measures and has continued to build on work undertaken with theLancashire Care NHS Foundation Trust Specialist Counter Fraud Service during thereporting period to raise awareness of fraud potential and address fraud issues.

The Audit Committee has reviewed the work undertaken by Deloitte within their internalaudit and Specialist Counter Fraud Services and is of the opinion that it is of a sufficientlyhigh standard and that their fees are appropriate and reasonable.

7. Re-Appointment Of Auditors And Audit TenderingExternal AuditThe current External Audit contract expires with the completion of the work programme forthe current financial year and as such a robust procurement process led by the Council ofGovernors audit working group has been initiated to award a new contract in consultationwith Finance colleagues and the Chair of the Audit Committee. It is expected that an awardwill be made in August 2015 and a full report will be disclosed in the Committee’s AnnualReport for 2015/16.

Internal AuditThe current Internal Audit contract expires with completion of the work programme for thecurrent financial year and thereafter the delivering of the Head of Internal Audit Opinion.The Trust has consulted with the outgoing Internal Audit service provider in thedevelopment of a charter to govern the internal management of the Internal Audit servicewhich was approved by the Committee. The transparent tender process to identify andaward a new internal audit contract was undertaken in consultation with the ChiefExecutive, Finance colleagues and with advice from the outgoing internal audit providerDeloitte, who had declared preclusion in tendering for the new contract and as such werenot part of the tender process. The contract was awarded in April to a new internal auditpartner, Mersey Internal Audit Agency (MIAA) for a period of three years.

8. Value for MoneyThe Committee continues to challenge and encourage the organisation to further improveits approach to demonstrating value for money. The Trust is in the process of reviewing theoptions for carrying out an integrated approach to measuring efficiency using readilyavailable information, benchmarking with similar organisations and also the availability ofthird party performance comparison services that cover the healthcare services the Trustprovides.

9. Raising Concerns (Whistleblowing)The Trust aims to create an environment where employees feel it is safe to raise anddiscuss concerns and weaknesses openly so that the appropriate action plans can beestablished and monitored. The Audit Committee reviews the system for raising concernsas part of its normal cycle of business. During 2014/15, the Committee monitored thereview of the Whistleblowing Policy following an independent review of arrangements forraising concerns commissioned by the Chief Executive in response to the Francis andKeogh Reviews. Given the important nature of this work the Audit Committee referred thisback to the Board for consideration. An action plan was implemented for a policy reviewand a communication plan to embed the Raising Concerns process including theintroduction of ‘Dear Derek’ to allow staff to raise concerns directly with the Trust’s ChairDerek Brown and the specific work with the Counter Fraud Team. The Board oversight ofthe cultural shift within the organisation around raising concerns and the embedding ofquality governance into the Trust is now monitored on a quarterly basis and the Trust hasimplemented a refreshed Raising Concerns Policy which has been shared with the Boardand Council of Governors.

10. Engagement with the Council of GovernorsGovernors have a statutory duty to hold Non-Executive Directors to account for theperformance of the Board and the Trust. As Chair of the Audit Committee, I have aresponsibility to ensure Governors are kept informed of the work of the Committee and howwe have discharged our responsibilities. During the year, I have attended a number offormal and informal Council of Governors meetings. I have delivered a presentation on theRole of the External & Internal Audit Function and will formally present the Annual Report ofthe Audit Committee in August 2015.

11. Moving to ISA 700 RequirementsThe main implications of adopting the ISA 700 standard for 2014/15 are the requirementsfor auditors to include details of materiality, risks and the External Auditors response tothese risks within their opinion. The enhanced reporting requires the External Auditors togive a view on whether the Annual Report and Accounts are fair, balanced andunderstandable and also describe the audit risks which had the most significant impact onthe audit and how these have been addressed.

Louise DickinsonChair of the Audit CommitteeMay 2015

AUDIT COMMITTEE

TERMS OF REFERENCE

1. AUTHORITYThe Trust Board has set up an Audit Committee as a Committee of the Board to support them in their responsibilities for issues of risk, control and governance and associated assurance. The Committee’s activities will cover the whole of the organisation’s governance agenda, not just finance.

The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference.

The Committee will act consistently with the principles outlined in HM Treasury’s Audit Committee Handbook March 2007. NHS Audit Committee Handbook 2011, the UK Corporate Governance Code (FRC) 2010, the NHS Foundation Trust Code of Governance 2010 and other relevant guidance.

2. PURPOSEThe Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to look for any information it needs from any employee and all employees are required to co-operate with any request made by the Committee. The Committee is authorised by the board to get outside legal or other independent professional advice and to ask advisers to attend meetings if it considers this necessary,

Where the Audit Committee thinks that there is evidence of improper acts or if there are other important matters that the Committee wish to raise, the Chair of the Audit Committee will raise this at a full meeting of the Trust Board.

The principal duties of the Committee are to review the adequacy and effectiveness of:

2.1 All risk and control related disclosure statements (in particular the Statement on Internal Control), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board

2.2 The underlying assurance processes that indicate the degree of achievement or corporate objectives, the effectiveness of the management principal risks and the appropriateness of the above disclosure statements

2.3 The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification

2.4 The policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud and Security Management Service.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also look for reports and assurance from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

NB Throughout these terms of reference, the term ‘Internal Audit’ should be taken to incorporate the provision of Counter Fraud Services, though this should not be seen to imply that both services will be delivered by the same body.

3. FUNCTIONS

3.1 To review the adequacy of all risk and control related disclosure statements and receive positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.

3.2 To review the internal audit strategy and plan.

3.3 To review the Head of Internal Audit Opinion and other Internal Audit reports.

3.4 To review the annual report of the Chief Internal Auditor.

3.5 To review the effectiveness of the provision of the Internal Audit service; the cost of audit adequacy of resource and any questions over resignation or dismissal and to ensure that Internal Audit has the appropriate standing in the organisation.

3.6 To discuss the external audit plan with the External Auditor before the external audit commences and the extent of reliance to be placed on internal audit.

3.7 To discuss problems and reservations arising from the External Auditor’s work and any matters the External Auditor may wish to discuss (in the absence of the Trust’s Chairman and other officers if necessary).

3.8 To review all External Audit reports, including the report to those charged with Governance and the annual audit letter and

management’s response and other reports during the year as may be relevant.

3.9 To develop and implement a policy on the engagement of the external auditor to supply non-audit services

3.10 To consider the content of any report involving the Trust issued by the Public Accounts Committee or the Controller and Auditor General and any reviews by Department of Health, arms length bodies or regulation/inspection and professional bodies with responsibilities for the performance of staff or functions and to review management’s proposed response before presentation to the Trust Board.

3.11 To review proposed changes to Standing Orders and Standing Financial Instructions.

3.12 To examine the circumstances associated with each occasion when Standing Orders and Standing Financial Instructions are waived.

3.13 To review schedules of losses and compensations and make recommendations to the Trust Board.

3.14 To review the scheme of delegation

3.15 To monitor the implementation of policy on standards of business conduct for members and staff (the Codes of Conduct and Accountability), thus offering assurance to the Board of probity in the conduct of business.

3.16 To monitor the integrity of the financial statements and to review the annual financial statements prior to submission to the Board, focusing particularly on changes in and compliance with, accounting policies and practices, and significant adjustments resulting from the audit. To review any announcements relating to the Trusts financial performance.

3.17 To make recommendations to the Council of Governors on the appointment and selection of the External Auditor.

3.18 To approve any change in Internal Audit service provider.

3.19 To review the adequacy of the policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the Counter Fraud and Security Management Service.

3.20 To review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own scope of work.

3.21 To review the adequacy of the Trust’s arrangements by which foundation trust staff may, in confidence, raise concerns about possible

improprieties in matters of financial reporting and control and related matters or any other matters of concern.

4. MEETINGSThe Audit Committee will meet at least three times a year. One of the meetings will consider the proposed internal and external audit plans and the final meeting of the calendar year will review the annual reports of the Auditors.

The Head of Internal Audit or the External Auditor may ask for a meeting to be called if they think it is necessary.

5. MEMBERSHIP AND ATTENDANCEMembers of the Audit Committee will be appointed by the Board from amongst the Non-Executive Directors. There will be at least 4 members one of whom shall act as Chairperson. No business will be completed unless at least three Non-Executive Directors including the Chair are present at a meeting. At least one Member of the Committee will have recent and relevant financial experience.

The Trust Chair, Chief Executive and Director of Finance will not be members of the Committee.

All members should attend at least half of all meetings in each financial year.

The Director of Finance and appropriate internal/external and clinical audit representatives will normally attend meetings.

The Chief Executive, other Executive Directors and accountable managers may be invited to attend when the Committee is discussing areas of risk or operation that are the responsibility of that Director or manager.

At least once a year the Committee will meet with external and internal auditors without management representatives present.

6. AGENDA6.1 The agenda will be determined by the Committee Chair.

6.2 Items for inclusion on the agenda will be submitted 2 weeks prior to the meeting.

6.3 The agenda will be circulated one week prior to the meeting.

6.4 The Company Secretary will be Secretary to the Committee and shall attend to ensure minutes of the meeting are accurately recorded and provide appropriate support to the Chairman and Committee members.

7. REPORTING MECHANISMS7.1 The Audit Committee will produce an Annual Report on its work to the

Trust Board and the Council of Governors specifically commenting on

the fitness for purpose of the Assurance Framework, the completeness and ‘embeddedness’ of risk management in the organisation, the integration of governance arrangements, the appropriateness of the evidence complied to demonstrate fitness to register with the CQC and the robustness of the processes behind the quality accounts. The Committee Chair will attend a Council of Governors meeting annually to present the report and answer any questions that may arise.

7.2 The minutes of the Audit Committee will be sent to the Trust Board.

8. REVIEWThe functioning of the Audit Committee shall be reviewed at least once every two years.

9. RELATIONSHIP WITH INTERNAL AUDITThe Audit committee must be able to assure the Trust Board that the systems of internal control are operating effectively and for this they will rely on the work of the Internal and External Auditors amongst others.

A report on the Internal Auditor’s findings on internal control is required by the Committee. Provided that the work is of a satisfactory standard and the coverage is adequate, then these reports should form the basis of the Committee’s conclusions and recommendations. It is the responsibility of the Director of Finance to manage the internal audit service, and for the professional conduct of the internal auditors. The Audit Committee will approve any change in internal audit service provider.

There will be a direct line from Internal Audit to the Audit Committee which is independent of the Chair, Chief Executive and other Executive Directors. Members of the Audit Committee will ensure a professional relationship with Internal and External Auditors is maintained to ensure that the reporting lines can be effectively used.

10. RELATIONSHIP WITH EXTERNAL AUDITThe External Auditor provides an independent assurance of financial stewardship including value for money, probity, accuracy, compliance with guidelines and accepted accounting practice of NHS accounts. External Auditors may be instructed to carry out specific work related to the use of resources by Monitor.

The External Auditor’s primary task is to certify that the statement of accounts presents fairly the financial activities of the Trust. Through this process the External Auditor confirms, within the Code of Audit Practice limits, the accuracy, probity and legality of the accounts.

The Audit Committee’s relationship with the External Auditor provides a forum whereby Non-Executive Directors can secure an independent view of any major activity within the External Auditor’s remit.

The External Auditor is appointed by the Council of Governors and is paid for by the Trust. The Audit Committee must ensure that a cost effective service is obtained and should do this by seeking the views of senior managers, finance managers and internal audit on the approach and quality of external audit work. It should seek to establish the extent of co-operation and joint planning with Internal Audit. Should there appear to be a problem then this should be raised with the External and Internal Auditors.

11. CONDUCT OF COMMITTEE MEETINGSMeetings of the Committee will be conducted in line with the Standing Orders (Section 4), which refer to setting the Agenda, recording of Minutes, attendance and papers being issued in advance for consideration.

AUDIT COMMITTEE SCHEDULE OF ANNUAL BUSINESS 2014/15

Committee Activities to Gain Assurance

The ‘WHAT’

Mee

ting

1

Mee

ting

2

Mee

ting

3

Mee

ting

4

Mee

ting

5

Mee

ting

6

The WHEN:

30th

Ap

ril

21st M

ay

28th

May

29rd

Ju

ly

20th

Oct

22nd

Jan

I Financial Matters and Related Reporting

Financial Issues impacting objectives (as required)

Monitor Submissions (as required)

Annual Report & Accounts process/ plan X

Annual Accounts & Related Reporting X X X

Delegated Authorities SoD X

Waivers and Breaches Report X X X X

Losses and Special Payments Report X X X X X

Accounting Policies X X

II General Controls & Compliance

Review Assurance Environment in LCFT

(Risks, Internal Controls & assurance)

X X X X

Review overarching Risks Management

Process, policy etc

X

Review Management Arrangements Process /Risk Owner E.g.

• Information Governance• IT Governance• Service Lines• Functional risk owners, FM HR etc

Others –E.g. major change projects -as defined in assurance mapping risk assessment

X X X

Special Reports – identified control failures (as required)

Annual Governance Statement (SIC) Review X X

Finance Directors Exception Report (as required)

Whistle-blowing arrangements & Serious Concerns Reporting

VfM Report X

Committee Activities to Gain Assurance

The ‘WHAT’

Mee

ting

1

Mee

ting

2

Mee

ting

3

Mee

ting

4

Mee

ting

5

Mee

ting

6

The WHEN:

30th

Ap

ril

21st M

ay

28th

May

29rd

Ju

ly

20th

Oct

22nd

Jan

III Internal Audit / Clinical Audit

Audit Remit / Approach / Approve Plan / Resources X

Report of Internal Audit findings X X X X X X

Report progress vs Plan X X X X X X

HIA Opinion X X

Counter Fraud Measures & Reporting X X X X X X

Internal Auditor Effectiveness X

Clinical Audit Findings X X X X

Clinical Audit Annual Programme X X

Internal Audit progress against data management improvement plan X X

IV External Audit

Meeting with Audit Committee without mgt. X X X X X X

Audit approach / Plan / Fees X

External Audit Effectiveness X

Appointment of External Auditors X

Policy non audit services X

External Auditors Report / Update X X X X X

Management Letter /Opinion X X

Auditor co-operation with assurance functions X

V Other Committee Activities

Review of Audit Committee Terms of Reference X

Audit Committee Effectiveness Review X

Reports to the Board & CoG’s (as required) X X X X X X

Annual Report of the Audit Committee X X

Committee Development / Briefings (as required)

Annual schedule of business X

Internal Audit Programme 2014/15

Ref. Audit review Review area

01.15 IT and Network Security IM&T

02.15 Management of Vacancies, Sickness and Absence Workforce

03.15 Communication of Policies & Procedures Governance

04.15 Management of Capital Assets Finance & Business

05.15 Network Audits: Adult Community & Adult Mental Health Cross-Cutting

06.15 Management of Service Providers and Consultants Cross-Cutting

07.15 Quality SEEL Service Quality

08.15 Business Continuity Planning: Corporate Systems IM&T

09.15 Information Governance IM&T

10.15 Information & Performance Improvement Plan (incorporating Data Warehouse follow up)

IM&T

11.15 Cost Improvement Programme (CIP) Finance & Business

12.15 Assurance Framework and Risk Management Governance

13.15 Follow-Up of 2013/14 Specialist Assignment: Procurement, Purchasing and Related Party Transactions

Governance

Clinical Audit Programme 2014/15

Audit review Review Quarter

Specialist Services (SS)

QS 10 COPD 2

QS 8 Depression 2

QS 28 Hypertension 2

LCFT Seclusion re audit 2

QS 53 Anxiety Disorder 4

QS 43 Smoking Cessation 4

CG178 Psychosis 3

Mental Capacity Act (MCA) 3 Adult Community (AC)

LCFT Falls Assessment Policy 2 LCFT Physical Health Policy 2 MCA – Consent to Medication 2

QS 3 Venous Thromboembolism (VTE) 2 QS 13 End of Life re-audit 4 LCFT **Observation levels Policy 4

QS 24 Nutrition at Longridge Hospital 3

LCFT guideline for the Assessment and Management of Patients with Lower Limb Conditions

4

Adult Mental Health (AMH)

QS 3 Venous Thromboembolism (VTE) 2

QS 53 Anxiety Disorders 2 CG 26 Post Traumatic Stress Disorder 2

CG 25 Quality of Debrief re Restraint Incidents 2

QS 14 Service User Experience 4

Mental Health Act Consent to Treatment 3

LCFT Care Plans Policy re-audit 4

Quality of 5P Risk Formulation 4 Children & Families (CFS)

Consent To Treatment 2

LCFT Vitamin D Policy 2 QS 48 Depression 2

QS 39 ADHD 2

CG 145 Spasticity 4

QS 34 Self Harm 4

QS 51 Autism 4

MHA, S17 4

� � � �

�

� ��

BOARD OF DIRECTORS

Agenda Item TB 065/15 Date: 28/07/2015

Report Title Quality Committee Chairs Report


Prepared by Jo Alker, Deputy Company Secretary

Presented by David Curtis, Non-Executive Director


Supporting Executive Director Executive Director of Nursing �


Report purpose To provide outline the activity undertaken by the Quality Committee



Board Assurance Framework risk 1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services. 1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. 3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider,

CQC domain Well-led

1.0 INTRODUCTION This Chair’s Report outlines the activity undertaken by the Quality Committee held on 16th July 2015.

� � � �

�

� ��

CHAIRS REPORT

CHAIRS REPORT OF: Quality Committee

DATE OF MEETING: 16th July 2015

ASSURANCE:

BAF Risk: 1.2

Friends and Family Test The Committee received an outline of the early findings of the Friends and Family Test and assurance was provided around the Trust’s compliance with national guidance. A new system had been in place since April 2015 to collate feedback and work was currently being undertaken to review how the system might be used to measure and record other patient experience feedback to provide a holistic view. It was noted that this information would begin to be reported to the Commissioners from Q2.

BAF Risk: 1.1

Serious Incidents The Committee received the six monthly report on serious incidents across the Trust. Assurance was received around the decrease of serious incidents. The Committee noted that due to the very low number of incidents it was difficult to identify meaningful trends.

BAF Risk: 1.2

Safeguarding Annual Report It is a national requirement to annually report on safeguarding activity across the organisation and the Committee received and considered the Safeguarding Annual Report. Conversations around additional training requirements being included in future were discussed and noted. Assurance was received that the Trust is compliant with the safeguarding requirements detailed in the Care Act 2014.

BAF Risk: 1.1

Appraisal and Revalidation Annual Report The Committee received the Appraisal and Revalidation Annual Report for review and noted the action to recommend approval to the Board in July. Assurance was received around doctors receiving the appropriate appraisals and that the appropriate information supports that appraisal. The Trust is meeting the required national standards are doctors appraisals and revalidation. Board members can view the full report. FOIA Exempt

BAF Risk: 1.2

Raising Concerns: Freedom to Speak Up The Committee received its six monthly update on the embedding of raising concerns across the organisation in particular, the action being taken to review the Freedom to Speak Up review. Assurance was provided around the actions being addressed to implement the Freedom to Speak Up recommendations.

BAF Risk: 1.1

Ribble Ward investigation The Committee received an update on the investigation that took place following an incident at Ribble

� � �

�

Ward in Blackburn. It was noted that the investigation had been delayed due to police investigations. Additional work was being done to review the initial investigation. The Committee received assurance that a robust investigation had taken place to address the concern around the quality of care a patient received at Ribble Ward and that this was currently being reviewed.

BAF Risk: 1.1, 1.2, 3.1

Chairs Reports The Committee received an update on the work undertaken by the following sub-committees for information and assurance:

- Quality & Safety sub-committee - Mental Health Law sub-committee - People sub-committee

RISKS:

Opening comments The Committee Chair raised concerns around the lack of compliance with the standards set within the new governance framework in relation to one late paper and one omission, the Safer Staffing paper. He noted the amount of narrative in the papers which was informative but lacked the level of assurance required to support the Committee in discharging its role within the governance structure. It was recognised that work to develop robust assurance papers has begun but that the assurance process needed to be enhanced in other areas. Work to strengthen the reporting requirements was commissioned and the Committee Chair requested that the Safer Staffing report be circulated to the Chair outside of the meeting.

Risk Ref: 6592

Friends and Family Test Following consideration of the outcome Q1 Friends and Family Test, further assurance was requested around the themes of responses, lessons being learnt and as a result the improvements being made.

Risk Ref: 5060

Safer Staffing The Committee received no assurance from the Safer Staffing Report as this was not available for the meeting. The Committee noted that action was being taken to address the issue around the production of this paper. The paper would be made available to the Chair of the Committee as soon as possible and would form part of the July Board meeting agenda.

Risk Ref: 6336, 6296

Serious incidents In relation to admissions of children to adult wards currently being recorded as serious incidents, a further discussion would be held with the Executive Management Team around how this is monitored operational, recognising that this should be removed from the formal serious incident reporting.

Risk Ref: 5160

� � �

�

Assurance around this monitoring would be brought back to the next meeting.

Safeguarding Annual Report Further assurance was requested following the consideration of the Safeguarding Annual Report around the impact that safeguarding compliance is having on the organisation.

Risk Ref: 6026, 5822, 5148

Raising Concerns: Freedom to speak up The Committee discussed the Dear Derek function as part of this item particularly how well understood the process is across the organisation. Further assurance was commissioned around the embedding of the Dear Derek function and confirmation of this would be brought back to the next meeting.

Risk Ref: No risk currently recorded

Ribble Ward investigation Further assurance requested around the outcome of the investigation into the incident at Ribble Ward.

Risk Ref:

ACTION REQUIRED:

Decision


Report provided for information �

�

Board of Directors

Agenda Item TB 066/15 Date: 28/07/2015 Report Title Finance and Performance Committee Chairs Report


Prepared by Judith Hough, Executive Personal Assistant

Presented by Peter Ballard, Deputy Trust Chair


Supporting Executive Director Chief Finance Officer


Report purpose To provide an outline of the activity undertaken by the Finance & Performance Committee




CQC domain Well-led

1.0 INTRODUCTION This chairs reports outlines the activity undertaken by the Board level, Finance & Performance Committee held in July 2015.

CHAIRS REPORT CHAIRS REPORT OF: Finance and Performance Committee

DATE OF MEETING: 20 July 2015

BAF Risk 2.1

Development of the Committee and Agenda The Committee considered the development of the committee and its agenda throughout the meeting and concluded that the assurance process needed to be enhanced by the provision of summary papers on key issues. There were a number of other concerns raised and the Committee requested further work to strengthen the assurance provided within the meetings including: Making sure changes in risk rating is explained Embedding the maturity of the Committee with the current governance structure Reviewing the frequency of meetings Further work to strengthen the level of scrutiny and underlying information provided and assurance

within Chairs report

ASSURANCE:

BAF Risk: 7.4

Board assurance risks relative to the Committees Remit The committee considered the Board Assurance Risks relating to the Committee : 5992 – Trust not achieving financial performance sufficient to retain resilience and sustainability had decreased at the end of Q1. The Committee challenged the rationale for this reduction which was explained as relating to the improved position in 2015/16 (resilience) but acknowledging the continuing risks longer term (sustainability). The Committee emphasised that it was still a significant risk and that the granularity in relation to CIPs and costing level detail was now providing more assurance. 5995 - The Committee challenged risk around the implementation of the EPR system and queried that there were only two risks of 15 and above linked to BAF Risk 6.2. The Committee requested further assurance and scrutiny to enable the Committee to feel confident of the risk profile.

BAF Risk: 2.2, 6.1

Business Planning & Transformation Sub-Committee Chairs report Commissioner Contracts – The Committee noted a risk relating to reduction in contract value for older adult community liaison which could potentially impact upon quality of service. The Committee noted the control against this risk is a paper to commissioners setting out the levels of service available for the new contract value. The Committee requested a one page narrative in relation to the business development hotspots including contract summary to be attached to the Chairs reports prospectively.

BAF Risk: 6.1

Health Informatics Sub-Committee Chairs Report The Committee raised concerns that the Chairs report did not provide the necessary assurance on progress with the EPR programme. Additional assurance was requested around the Legacy system and mitigating the risk by migrating five existing systems into one to bring down the costs. The Committee highlighted that the risks associated with consolidation of these systems within a suitable timeframe remains quite high.

The Committee noted the escalation in relation to the staff call system failures at The Harbour noting the issue is how good we are at managing external contracts and holding suppliers to account.

BAF Risk: 5.2

Estates Sub-Committee Chairs Report To enhance assurance, the Committee received the Estates Sub-Committee Chairs Report and suggested that a post go-live review of The Harbour would be appropriate later this year taking account of various operational issues.

BAF Risk: Operational Delivery & Performance Sub-Committee Chairs Report The Committee received assurance in relation to the process for reviewing risks at this Sub-committee. Further assurance was requested in a number of areas including the new Monitor requirements for EIS and a progress report was requested for the next meeting. The Committee received assurance around OATS and that a joint scrutiny group has been established with commissioners. The networks will be providing an update at the next Operational Delivery & Performance Sub-Committee on 20.7.15. In addition, assurance will be provided at the next meeting of the Finance & Performance Committee in October 2015. The Committee requested an update in relation to the timescales and plan for development of the executive dashboard which will provide additional assurance.

BAF Risk: 5.1, 5.3

Finance Sub-Committee Chairs Report The Committee noted that Delivering the Strategy (DTS) reporting is well progressed. The requested additional assurance through the DTS reporting into the next meeting of the Finance & Performance Committee.

BAF Risk: 5.1

Significant transaction Assurance was received that there were no gaps in the Decision Rights Framework regarding significant transactions. Additional assurance was requested in relation to Business Case and Case for Change processes within the Decision Rights Framework.

RISKS:

Reduction of Older Adult Community Liaison Contract It was recognised that the reduction in contract value will impact upon service quality and a report had been prepared for commissioners around continuing service provision at the lower contract value.

BAF Risk Ref: 2.2

ACTION REQUIRED: Decision


Report provided for information

Nursing & Quality Directorate - Safer Staffing Report – 20th

July 2015

Board of Directors

Agenda Item TB 067/15 Date: 28/07/2015 Report Title Safer Staffing, Executive Director of Nursing and Quality /

National Quality Board Report


Prepared by Tracy Fennell, Associate Director of Nursing

Presented by Dee Roach, Executive Director of Nursing and Quality

Action required Discussion

Supporting Executive Director Executive Director of Nursing and Quality


Report purpose The Trust Board have full responsibility for the quality of care provided to patients and as a key determinant of quality, take full and collective responsibility for nursing and care staffing capacity and capability.

This report provides an update on the progress of work being undertaken to ensure appropriate systems and processes are in place to manage staffing establishments in line with national guidance.

Background papers relevant:

“How to Ensure the Right People with the Right Skill are in the Right Place at the Right Time.” Published by the National Quality Board (NQB) with support from other partners (2013).



Board Assurance Framework risk 4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care.

CQC domain Safe

1.0 Introduction

There are established and evidenced links between staffing levels, skill mix, and capability and patient outcomes. Recent reviews and publications, Francis, Keogh and Berwick detail the impact on quality and patient safety, and the importance of getting this right.

The publication “How to Ensure the Right People with the Right Skills, are in the Right Place at theRight Time” (National Quality Board and Chief Nursing Officer of England, November 2013) sets out 10 expectations for nursing, midwifery and care staffing capacity and capability. It is a guide aimed to


July 2015

support Providers and Commissioners to meet the expectations of the people using their services. These expectations are set out in section 2.

National guidance does not determine minimum staffing ratios but suggests the use of evidence based tools; where available; professional judgement and triangulation of information to determine safe staffing levels.

Following an announcement by Simon Stephens at the NHS Confederation Conference 2015, the Chief Nursing Officer (CNO) has written to all Nurse Directors to inform that the work being led by National Institute for Health and Care Excellence (NICE) in relation to mental health and community staffing would cease. The letter sets out the future approach to review staffing requirements in line with the vision of The Five Year Forward View. The reviews will take a multi professional approach to staffing rather than nursing alone. The vision to outline clear progression for non-registered staff, nurse retention and flexible working remains a strong focus for the future.

2.0 National Quality Board 10 Expectations

An action plan is in place to ensure delivery against the 10 expectations and progress is monitored through the Safer Staffing Group. Assurance is provided to the Quality and Safety Sub-Committee. Risks against the delivery plan are reported and mitigating actions agreed.

Expectation 1: Boards take full responsibility for the quality of care provided to patients and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing and capability.

Trust Progress / Actions

Monthly reports detailing actual staff numbers compared to planned staffing numbers are reported to the Quality and Safety Sub-Committee. Safer Staffing reports are accessible through the Public Board discussions and are displayed on the Trust website to maintain openness and transparency. The Executive Director of Nursing and Quality will present the Safer Staffing Report twice a year to the Executive Quality Committee and Trust Board.

Progress against staffing reviews will be reported in January and July of each year based on evidence based tools where available. To date the Board has received a number of papers outlining staffing establishments for services including reviews of the Harbour, Longridge and Guild staffing levels. The impact of staffing levels on quality is reviewed on a monthly basis considering Friends and Family testing, themes of incidents and any serious incidents, Quality Safety, Effectiveness, Experience and Leadership (SEEL), complaint reviews and intelligence from the wards and care experience workers. This is analysed and has been presented monthly to the Quality and Safety Sub-Committee.

This triangulation provides a more detailed picture of the standards of quality in inpatient areas and reporting will be strengthened by the introduction of Safe Care, the Integrated Quality Reports and the development of ambitious quality goals as part of the Trusts quality plan.

Expectation 2: Processes are in place to enable staffing establishments to be met on a shift by shift basis.


The Safer Staffing Action Plan details the implementation of the Electronic Roster system, the temporary staffing improvement work, development of the Safe Care electronic tool, HR recruitment


July 2015

improvement plan, escalation policy development and associated processes and reviews of staffing establishments. Slippage of some elements of the plan has occurred due to absence and changes of key personnel. This is now resolved and recovery plans will be presented to the August Safer Staffing Group.

Concerns have been raised regarding the lack of clinical engagement in the development of the Electronic Rostering system resulting in implementation issues, delays, the necessity to use manual reporting and the inability to optimise the systems’ full functionality in a timely way. This has been addressed by securing the involvement of Senior Nurses and the Executive Director of Nursing and Quality taking responsibility for the completion of the project. Progress against delivery will be monitored by the Safer Staffing Group and reported to the Quality and Safety Sub-Committee.

Matrons have an integral role in supporting Ward Sisters and Charge Nurses to ensure wards are safely staffed. The skill mix on each ward includes additional support roles to make sure nursing staff are able to deliver direct patient care. These roles include the Ward Clerk, Occupational Therapists, Psychologists, Advanced Practitioners and Violence Reduction staff.

A daily review of nurse staffing is undertaken by the Ward Sister in conjunction with the Matrons to determine whether a ward is staffed to meet the patient’s needs. Where shortages are identified, teams work together to identify a solution based on clinical and nursing need. Staff may be deployed from one clinical area to another or alternatively bank or agency staff will be secured to mitigate risk to ensure patient safety.

In Adult Mental Health wards there have been concerns raised in relation to staffing numbers, staff skills and competences. In response and to assist the mitigation of any risks a Red, Amber Green (RAG) rating tool has been developed by Senior Nurses in the Network to grade the safety of each ward in relation to staff skill mix. The tool also allows identification of high risk areas so that experienced nurse cover can be deployed where possible.

Staffing levels are also reported on a shift by shift basis. This process does not focus wholly on staffing numbers, but relies heavily on the professional judgement of the nurse in charge who is required to determine whether the staffing levels and skill mix is safe. A Nurse Escalation Policy is currently in development and is due to be implemented from September 2015. When there are concerns about staffing levels, this is reported through the operational and nurse leadership structures and detailed in the daily situation report which is communicated to Senior Managers, the Senior Manager On Call and the Executive On Call. Mitigating actions can include reducing bed capacity, diverting admissions to other areas, moving staff, and reviewing appropriate allocation of patients based on current staffing levels.

Formal reporting is extrapolated from data in Electronic Roster to provide detailed data of actual verses planned staffing.

Challenges continue with the ability to fill registered nurse bank shifts, it is estimated that 75% of bank shifts are downgraded to Care Support Worker (CSW) level due to the lack of availability of registered bank nurses. A recruitment drive has resulted in 326 bank staff being recruited since August 2014. A recent recruitment event at the Harbour also initiated a further 67 CSW going through the recruitment process and a further 97 candidates have been contacted for interviews. Recruitment in a day processes have speeded up Disclosure and Barring Service (DBS) and pre-employment checks. The availability of face to face mandatory training has caused delays in bank staff commencing work. New trainers have now been recruited and a plan is in place to ensure all bank staff meet their mandatory training requirements.


July 2015

The use of bank and agency remains high due to patient acuity, sickness and absence. The Delivering the Strategy (DTS) project to reduce the use of bank and agency has been aligned to the Safer Staffing Action Plan to ensure any decisions around bank and agency reduction does not impact on the ability to deliver clinical services safely.

Expectation 3: Evidence based tools are used to inform nursing, midwifery and care staffing and capability.


It is recognised that no single nursing workforce planning method is suitable for all care services however, the adoption of a tool ensures consistency of data and supports safer decision making processes.

The Safe Care software tool is currently being piloted within the Children’s and Families wards. The Safe Care software will allow more effective Ward to Board visibility on a shift by shift basis, allowing an organisational overview of risks to inform the effective deployment of nurses across the whole organisation. The software will also enable the development of individual acuity and dependency tools and support future establishment reviews based on live evidence. The initial pilot highlighted the need for increased clinical involvement in the ongoing development. This has now been put in place and as previously stated is further enhanced by the transferring of responsibility for delivery to the Executive Director of Nursing and Quality to enhance clinical input and ensure robust monitoring and reporting processes. It is anticipated that a roll out plan will commence on the remaining inpatient wards from Quarter 3, 2015. The date for completion is currently being reviewed in light of capacity challenges within the E-Rostering Team.

Expectation 4: Clinical and managerial leaders foster a culture of professionalism and responsiveness where staff felt able to raise concerns. Staff work in well-structured teams and can practice effectively though the supporting infrastructure of the organisation i.e. IT, Ward Clerks and Housekeepers.


The organisation is promoting a culture of responsiveness and professionalism through a variety of mechanisms such as the Values, In Touch sessions, Appreciative Leadership and the Blue Waves of Change programmes. In response to the “Raising Concerns agenda” the Trust has a number of routes to enable staff to raise concerns that include:

Dear Derek Raising Concerns Policy Clinical and Professional Leadership Teams Manager, Network Directors and the Executive Team Trade Unions Human Resources (HR) processes and supporting policies.

Work is ongoing to further expand staff opportunities to raise concerns by adopting the Red Flag Events drawn up by NICE. Nurses will be able to report events such as a lack of patient checks, omissions in providing medications and delays in issuing pain relief, which will act as a trigger for considering increasing staff numbers. Another warning sign will be if there are fewer than two Registered Nurses on a ward during a shift. The Trust is developing the system within DATIX to support the reporting of Red Flag Events which will enable Ward Sisters to identify hot spots in real


July 2015

time which will allow immediate action to be taken to mitigate against the identified risks. It is planned that this will be fully embedded during Quarter 3.

Expectation 5: A multi-professional approach is taken when setting nursing, midwifery and care staffing establishments. Expectation 6: Nurses, midwives and care staff have sufficient time to fulfil care responsibilities that are additional to their direct caring duties.


The needs of each area are taken into consideration when reviewing staffing requirements. This includes consideration of other inter-professional relationships and dependencies to ensure that relevant medical and allied health professional workforce skill mix and staffing levels are taken into account.

The interdependent nature of this work is reliant on support services and Networks working together to ensure implementation deadlines are met. All parties are represented at the Safer Staffing Group and will be held to account for delivery by the Quality and Safety Sub-Committee.

Establishments have been reviewed at Longridge Hospital utilising the Royal College of Nursing Acute Hospitals, Safer Staffing Model. Following the review, Longridge is staffed above funded establishment in line with the model. Discussions are currently underway with Commissioners to secure permanent funding.

Bleasdale, Winfell, Langdon and Hermitage wards at Guild Lodge have been reviewed in line with the Dependency and Staffing Scale. Additional funding was agreed at Board to enable increased staffing. Reviews are ongoing for Mallowdale, Elmridge and Forest Beck wards in anticipation to move towards becoming a long stay service from October 2105. Discussions are continuing with Commissioners to support funding to increase staffing in line with requirements.

Recruitment is currently ongoing to support these increased staffing establishments. Despite several successful recruitment events the Network continues to face challenges around large numbers of staff not commencing post after accepting initial offers of employment. This is currently being managed by over-recruiting.

A review of staffing establishments is also underway at Guild for Dutton, Calder, Marshaw, Greensnape, Fairsnape, Fairoak and Greenside wards. The outcome of the review is expected to be presented in Quarter 3, 2015. In the absence of an accredited staffing model all establishments for wards outside the Harbour have been reviewed against current funded establishments and will require a full establishment review taking account of quality, safety and experience factors which affect patient care. These reviews will be completed before the end of Quarter 4, 2015.

The three shift system is currently being implemented at the Harbour, it is expected that this will be fully implemented by mid-August 2015. Issues relating to the internal capacity to process high volumes of recruitment and a significant number of new starters giving back word following formal offers are the main reason for this position. This has necessitated a continued need for high numbers of bank and agency staff and a requirement to continue with the two shift system in the short term.

The ward establishments require sufficient flexibility to ensure safe nurse staffing levels whilst ensuring planned and unplanned staff leave is accommodated. Effective rostering of annual leave and study leave in line with ‘rostering rules’ assists the wards to run at optimum quality and capacity. Plans are in


July 2015

place to utilise the performance tools within Electronic Roster to identify where staff require support to implement effective rostering practices.

A review is currently underway to assess the headroom requirements for nurse staffing. Currently Adult Mental Health has 23.03% headroom. This comprises of 15.73% (33 days + Bank Holidays) annual leave 2.30% (6 days) training and 5% (13 days) sickness per Whole Time Equivalent (WTE). It is known that sickness has collectively run overall between 7.84% during January and rising to 9.77% in June across inpatient areas. This is not known to be attributed to one identifiable cause.

Training and professional development is in excess of the allocated 6 days training. The review of the current headroom requirement will take into account opportunities presented by the review of mandatory training requirements and plans to deliver education and training in different ways across the organisation.

The expectation within the Mid Staffordshire “Hard Truths” report was that Ward Managers should operate in a supervisory capacity, the minimum time set for supervisory status of Ward Managers according to Chief Nursing Officer for England & National Quality Board Report is two days per week and all inpatient wards at Lancashire Care exceed this standard.

Ward Managers within inpatient environments all have a full time supervisory role. The rationale for exceeding two days per week supervisory status within Lancashire Care was carefully considered and based on the evidence that effective leadership and clear roles and responsibilities supported the Trust’s vision and values. It was recognised that Ward Managers positions were pivotal to facilitate the accountability for the quality of care at the point of access to their clinical areas and strengthen the relationship with Board.

Expectation 7: Boards receive monthly updates on workforce information and staffing capacity is discussed at public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review.


Monthly updates are presented to the Quality and Safety Sub-Committee and Commissioner Contract meetings. These reports are available on the Trust website and NHS Choices. They are also reported through the Chairs Report to the formal Board meetings quarterly.

The Executive Director of Nursing and Quality provides a six monthly report to Trust Board detailing progress against the National Quality Board (NQB) 10 expectations.

Children and Families wards consistently continue to maintain safer staffing figures above the desired 80% fill rate utilising very low numbers of bank staff. Longridge Hospital also continually reports appropriate staffing numbers. The lower reported UNIFY fill rates at Longridge Hospital are reflective of the ward closure in April and May for the completion of building works.

Areas experiencing consistent staffing challenges include Harbour wards, East Lancashire wards, and Guild wards due to the inability to recruit and retain experienced nurses. These issues are being addressed through the ongoing recruitment drives led by the recruitment workstream and are reported monthly via the Quality and Safety Sub-Committee. Scarisbrick and Orchard also continue to require higher levels of staff due to the continued use of contingency beds. This is being addressed by work within the Networks around Delayed Transfers of Care (DTOC) and Out of Area Treatments (OATs).


July 2015

Expectation 8: NHS Providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift.


Each inpatient ward area displays each day the staffing establishment on each shift compared to the actual. The Ward Sister/Charge Nurse is responsible for ensuring these are accurate and updated. Compliance against this standard is monitored by the Quality SEEL and during Quality Visits.

The named Consultant and Nurse are displayed both on Team Information Boards (TIBs) and in the majority of areas in the patient bed areas. Named Clinicians are also detailed identifying clearly who has responsibility for care provision.

Expectation 9: Providers of NHS services take an active role in securing staff in line with their workforce requirements.


The Trust has submitted its 5 year projections for Workforce Planning to Health Education Northwest. Work is also underway to enable staff to undertake appropriate training and professional development to meet their needs. The development of Bands 1 - 4 and Advanced Practitioner roles and additional skills such as prescribing are planned in order to best utilise the workforce to deliver quality care using a multidisciplinary approach.

The recruitment process has been reviewed and HR support is essential to facilitate a proactive approach to nurse recruitment and retention strategies. In some inpatient areas recruitment has been streamlined and recruitment in “a day” strategies have been employed with good effect. The implications of recruitment on retention of new staff are yet to be fully realised.

Plans are underway to forward plan 6 - 8 weekly recruitment events at various locations aligned with workforce planning initiatives to ensure effective sustainable workforce can be recruited more timely. Challenges continue in recruiting experienced nurses as described in expectation 5.

The challenges we face are reflective of the national picture in relation to the recruitment of registered nurses. This will be addressed in the future by workforce planning and the work driven by the Education, Training and Professional Department.

Expectation 10: Commissioners actively seek assurance that the right people, with the right skills are in the right place at the right time within the providers with whom they contract.


Safer Staffing papers are presented monthly to the Commissioner led Quality & Performance meetings. Commissioners are able to actively seek assurance on the Trusts work in this area and respective progress and issues.

3.0 Conclusion

The Trust continues to make progress against the ten expectations set out by the NQB.


July 2015

Regular and consistent review of day to day staffing levels is undertaken as an integral part of the Trust’s daily capacity planning, risk management and escalation process. This includes consistent oversight of staffing rotas and monitoring of compliance with quality standards in line with the Trust’s commitment to ensure safety, clinical effectiveness and patient experience.

The improved recruitment practices have made a notable impact, however, further work is required to improve recruitment in secure services and optimise retention.

4.0 Recommendations

The Board is requested to note:

Progress against the 10 expectations set out in the NQB Report Ongoing review of staffing establishments is underway The outcome of the headroom review across all services in conjunction with the establishment

reviews will be reported in future Board reports.

Board of Directors

Agenda Item TB 068/15 Date: 28/07/2015 Report Title Finance Board Report


Prepared by Shannon Carroll, Financial Services Director

Presented by Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Finance Officer


Report purpose To report Trust monthly financial position and forecast


To provide excellent value for money in a financially sustainable way

Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability.

CQC domain Well-led

1.0 INTRODUCTION

The Board is asked to review the attached report which outlines the current and forecast financial position of the Trust.

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 2 2,762 2,872 ‐110 2 11,284 11,595 ‐311 Surplus 2 ‐805 ‐795 ‐10 2 ‐3,455 ‐3,044 ‐411

CIPs 2 2,505 2,821 ‐316 3 11,610 11,792 ‐182 Cash and Liquidity 3 30,820 27,936 2,884 3 19,157 17,687 1,470Capex 3 1,613 1,650 ‐37 3 9,654 9,654 0CoSRR

Debt Service 2 2 2 2 2 2Liquidity 3 4 4 3 4 4Overall 3 3 3 4 3 3

Sustainability

CIPs

LiquidityCash is ahead of plan and based on current forecasts and assumptions is now expected to be remain so.

Capital and Financing

CoSRR

Key Actions

#

Current Out‐Turn

Performance against monitored and approved schemes is broadly in line with plan. Unallocated CIP programmes are managed through reserves with £0.7m identified but not yet fully transacted and phased across the year. Once fully transacted the in year position will improve with outturn position on track.

• Current position primarily due to improvements on working capital.

This month sees an operating deficit of ‐£805k, £10k behind plan after three months. The full year deficit is projected to be ‐£3.46m against a plan of ‐£3.04m, some c£0.4m behind plan. The position is hampered by OATs expenditure being in excess of the currently agreed funding, £572k over at month 3, which is anticipated to contribute a year end adverse variance of £1,294k. The Trust however believes further funding from commissioners of £871k has been secured, £217k at month 3. The Board Balanced Scorecard demonstrates an EBITDA (earnings before interest, taxes, depreciation and amortisation) of £2.8m against a plan of £2.9m. Full year projection is £11.3m against a plan of £11.6m. CoSRR is as forecast, 3.

• No significant overspends are currently expected on existing schemes.

Overall CoSRR 3 against Plan of 3 and expected to remain so. • Current I&E projections maintain a debt service of 2 against a plan of 2 at the end of the year.

• Forecast impact of I&E position is considered manageable within the short term.

Overall Capital Expenditure is broadly in line with plan. • Programme detail and forecasts are being worked up.

• Liquidity is expected to remain at 4

• Address the remaining balance of CIP schemes by DTS and PMO.

Note that the figures contained within this report form the basis of our quarterly return to Monitor.• Finalise the OATs contractual position and address the use of OATs.

Forecast ForecastYTD YTD Out‐turn Out‐turn

Jun 2015 May 2015 at Jun 2015 at May 20153 2 Note 12 12 Note

Plan ‐0.795 ‐0.530 Plan ‐3.044 ‐3.044

Major Variances Major VariancesCIP Slippage ‐0.316 ‐0.329 ‐ See CIP section CIP Slippage ‐0.182 0.124 ‐ See CIP sectionOATs ‐0.572 ‐0.318 ‐ See OATs Section OATs ‐1.294 ‐0.681 ‐ See OATs SectionOther Bud Vars 0.684 0.689 ‐ See Services section Other Bud Vars ‐0.509 ‐0.807 ‐ See Services sectionReserves 0.193 ‐0.181 ‐ See Reserves section Reserves 1.554 0.520 ‐ See Reserves sectionMinor Variances 0.000 0.030 Minor Variances 0.020 0.030

Variance ‐0.010 ‐0.109 Variance ‐0.411 ‐0.814

Actual ‐0.805 ‐0.639 Actual Forecast ‐3.455 ‐3.858

‐

‐

Surplus ‐ YTD (£m) Surplus ‐ Out‐turn (£m)

The full year projection is a deficit of ‐£3.5m. This is behind the financial plan of ‐£3.0m deficit., and assumes £0.8m of additional commissioner income, offset by a deterioration in the OATs position by £0.6m

This month sees an operating deficit of £0.8m, £0.01m behind plan, a slowing of the overspend trend.

‐6,000.0

‐5,000.0

‐4,000.0

‐3,000.0

‐2,000.0

‐1,000.0

0.0

Plan CIP Slippage OATs Other BudVars

Reserves Impairment MinorVariances

‐3,044.0 ‐181.6 ‐1,294.0 ‐508.5 1,554.2 0.0 20.4

‐1,800.0

‐1,600.0

‐1,400.0

‐1,200.0

‐1,000.0

‐800.0

‐600.0

‐400.0

‐200.0

0.0

Plan CIP Slippage OATs Other BudVars

Reserves Impairment MinorVariances

‐794.5 ‐315.6 ‐572.0 684.0 193.2 0.0 0.0



Plan 80.046 53.364 Plan 315.545 315.545

Major Variances Major VariancesCommunity Services 1.106 0.138 ‐ Note 1 Community Services 10.092 0.597 ‐ Note 1Mental Health 1.435 1.137 ‐ Note 2 Mental Health 2.868 2.513 ‐ Note 2Specialist Services 0.130 0.111 ‐ Note 3 Specialist Services 0.632 0.605 ‐ Note 3R&D 0.001 ‐0.001 R&D 0.049 ‐0.099ETR 0.227 0.137 ‐ Student Income ETR 0.653 0.525 ‐ Student IncomeMiscellaneous 0.236 0.244 ‐ Note 4 Miscellaneous 0.728 0.714 ‐ Note 4Contract phasing 0.174 Contract phasing

Minor Variances ‐0.001 ‐0.102 Minor Variances ‐0.001 0.000

Variance 3.133 1.838 Variance 15.022 4.855

Actual 83.179 55.202 Actual Forecast 330.567 320.400

1

234 Major increases is AHSN; major decreases are PIP/ATOS and MHRN ‐ see appendix for detailed impact.

Monthly Income Variances (£m) Cumulative Income Variances (£m)

Major increase is Liverpool and Kennet Prisons (£7m), Supported living and Family Nurse Partnership; major decrease is Offender Bedwatch ‐ see appendix for detailed impact.

Major increases include OATs and Contractual position reached with CCGs (see also reserves); no significant decreases ‐ see appendix for detailed impact.Major increases CAMHs Tier 4 and HIV; no significant decreases ‐ see appendix for detailed impact.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

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

Actual/Forecast

Plan

0.000

50.000

100.000

150.000

200.000

250.000

300.000

350.000


Actual/Forecast

Plan



Budget 73.300 48.881 Budget 289.541 283.529

Major Variances Major VariancesAdult Mental Health ‐0.411 ‐0.045 ‐ Note 1 Adult Mental Health ‐2.201 ‐1.568 ‐ Note 1Specialist Services ‐0.005 ‐0.001 ‐ Note 2 Specialist Services ‐0.014 ‐0.011 ‐ Note 2Property Services 0.002 ‐0.001 ‐ Note 3 Property Services 0.000 ‐0.004 ‐ Note 3Corporate ‐0.336 ‐0.356 ‐ Note 4 Corporate ‐1.001 ‐1.082 ‐ Note 4Adult Community 0.201 0.099 ‐ Note 5 Adult Community 0.372 0.211 ‐ Note 5Children & Family 0.289 0.308 ‐ Note 6 Children & Family 0.668 0.909 ‐ Note 6Other Clinical 0.056 0.038 Other Clinical 0.191 0.182

Variance ‐0.204 0.042 ‐1.984 ‐1.364

Actual 73.503 48.839 Actual Forecast 291.525 284.893

1

2

34

5

6 Children and Families have favourable positions on pay from vacancies in 0‐19 services and non pay in Sexual Health supporting the year to date position. The position is expected to remain positive for the year, particular driven by recruitment difficulties in Health Visitors.

Corporate Services forecast includes additional costs in Performance with regard to external support (£0.4m) but also sees pressures emerge in Workforce with regard to staffing in excess of budget (£0.4m).

Property Services are about breakeven and are expected to remain so.

YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)

Adult Mental Health overspend is driven by Out of Area Treatment (OATs) costs in excess of funding. The high level of OATs continued throughout April to June but is expected to be managed down during the summer, with additional PICU capacity opening in West Lancs in September. Actions to review the management of admissions and delayed discharges are in place. Pressures are being experience across most Step 4 services with regard to pay.

Specialist Services are about breakeven despite overspends from the high use of bank & agency on wards, particularly in male Medium Secure Services, this is compensated for by underspends in Offender Health.

Adult Community is currently delivering a slight underspend, and is anticipated to remain so for the year.

‐£2,500

‐£2,000

‐£1,500

‐£1,000

‐£500

£0

£500

£1,000

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family

OtherClinical Total

Service Forecast Variance

‐£500

‐£400

‐£300

‐£200

‐£100

£0

£100

£200

£300

£400

Adult MentalHealth

SpecialistServices

PropertyServices Corporate

AdultCommunityServices

Children &Family Other Clinical Total

Service Year to Date Variance

CIP Achievement (£)

NotesPerformance against monitored and approved schemes is broadly in line with plan.

Unallocated CIP programmes are being managed through reserves with £0 phased slippage accounted for to date. Annually £0.7m has yet to be transacted but is expected to be achieved (see reserves).

In addition to the £0.7m to be transacted, £0.4m re anticipated additional funding negotiated around Health Visitors (current offer from commissioners awaiting finalisation) is excluded and could either be considered a gain or be used to mitigate slippage.

Note mapping of individual schemes to projects and programmes may be subject to change.

Delivering the Strategy ‐ 2015/16 PROGRAMMES

Programme No.

Programmes Projects Annual Forecast Performance

Annual Plan Performance Var

Moss Vew ‐ ‐ ‐

Gateway ‐ ‐ ‐

Service Redesign 106,141 106,141 ‐

CRHT and liaison redesign ‐ ‐ ‐

Management on‐call 30,350 30,000 350

Structural Redesign 1,261,091 1,261,091 ‐

Substitute CIPs 885,000 885,000 ‐

Productivity 1,144,093 1,159,550 15,457‐

Burnley reconfiguration ‐ ‐ ‐

ECT single site 22,400 22,400 ‐

5 Out of Hospital 500,000 500,000 ‐

CAMHs Tier 3 and 4 redesign 201,884 269,884 68,000‐

Single Inpatient Site CAMHS tier 4 ‐ ‐ ‐

7 Estates 1,091,000 1,091,000 ‐

Increase annual leave purchase 138,248 138,248 ‐

Reduced travel costs assoc. with training ‐ ‐ ‐

Bank and Agency ‐ ‐ ‐

Medical Productivity ‐ ‐ ‐

Governance and Quality Business Plans 303,002 303,000 2

Workforce Business Plans 93,299 93,299 ‐

Workforce review Group ‐ ‐ ‐

Transformation and Innovation Business Plans 178,437 178,437 ‐

Working differently ‐ ‐ ‐

IM&T Business Plans 321,465 291,465 30,000

Trust Wide Admin 65,961 65,961 ‐

Petty Cash ‐ ‐ ‐

Leadership Development ‐ ‐ ‐

Consultancy Control 133,500 133,500 ‐

Mileage Claim Forms ‐ ‐ ‐

Medical Workforce Business Plans 42,074 50,579 8,505‐

Pharmacy Business Plans 140,000 140,000 ‐

ePMA benefits realisation ‐ ‐ ‐

Procurement ‐ ‐ ‐

Invoice Discrepancies ‐ ‐ ‐

Finance Business Plans 145,009 145,009 ‐

Adult Comm Business Plans 1,663,777 1,696,993 33,216‐

Adult MH Business Plans ‐ ‐ ‐

C & F Business Plans 1,555,166 1,547,682 7,484

SS Business Plans 790,056 790,056 ‐

Comms & engagement Business Plans 31,000 31,000 ‐

Successful Bids and Tenders ‐ ‐ ‐

Gov & Compliance Business Plans 47,279 47,279 ‐

16 Commissioning and Contracts Contract gains 200,000 200,000 ‐

11,090,232 11,177,573 87,341‐

CIPs to Be Transacted ‐ held in Reserves 724,000 724,000 ‐

Forecast Outturn 11,814,232 11,901,573 87,341

1 Specialist Mental Health Rehab

2 Unscheduled Care

3 Community MH Redesign

8 Workforce clinical

4 Excellence in In‐patient Care

6 CYP Emotional Health and Wellbeing

9 Workforce technical

10 Health Informatics

Administration11

15 Networks

12 Corporate

14 Procurement

13 Pharmacy

Month Month Month MonthJun 2015 May 2015 Jun 2015 May 2015

3 2 Note 3 2 Note

Agency Spend 1,065 835 Bank Spend 914 1,092

Network Analysis Network AnalysisAdult Network 346 262 ‐ Note 2 Adult Network 342 344 ‐ Note 2Adult Community 290 243 ‐ Note 3 Adult Community 239 324 ‐ Note 3Children & Families 62 36 ‐ Note 4 Children & Families 45 60 ‐ Note 4Specialist Services 146 128 ‐ Note 5 Specialist Services 285 305 ‐ Note 5Corporate Services 221 166 ‐ Note 6 Corporate Services 2 59 ‐ Note 6

Actual 1,065 835 ‐ Note 1 Actual 914 1,092 ‐ Note 1

12

3

4

5

6

Specialist Services Network bank and agency costs are partly due to the contract for Liverpool and Kennet Prisons and partly due to acuity on inpatient wards. Secure wards have seen bank and agency use reduce from previous months.Corporate Services bank and agency costs have decreased in June. Significant agency costs are still being incurred in Human Resources.

Bank and Agency Costs (£'000) Bank and Agency Costs by Clinical Network (£'000)

A high level of vacancies is supported by bank and agency, total staffing deployed has remained below establishment year to date.Adult Networks bank and agency costs are primarily due to vacancies and acuity on inpatient wards above establishment. Increased Psychology and Medic agency within establishment.Adult Community bank and agency costs are almost exclusively driven by vacancies and acuity on Older Adult inpatient wards. Bank spend has increased across most Older Adult wards.Expenditure is fairly minor within Children and Families, impacting to some degree in most areas.

0

100

200

300

400

500

600

700

800

Apr 1

3

May 13

Jun 13

Jul 13

Aug 13

Sep 13

Oct 13

Nov

13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 1

4

May 14

Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov

14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 1

5

May 15

Jun 15

Adult MH Adult Community Specialist Children & Families Corporate

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2013/14 1341.911374.951541.161478.191438.591630.85 1470.2 1685.961631.951640.291763.091770.792014/15 1974.291763.551784.992032.262191.281974.121924.841877.422065.021837.281846.652258.662015/16 1787.181927.121978.21

0

500

1000

1500

2000

2500

Month Month YTD ForecastJun 2015 May 2015 Jun 2015 Out‐turn

3 2 Note 3 12 Note

Plan 0.9 1.4 Plan 27.9 17.7Major Variances Major Variances

I&E 0.0 0.2 ‐ Note 1 I&E ‐0.1 ‐0.3 ‐ Note 1Capital & financing ‐0.2 ‐0.5 ‐ Note 2 Capital & financing 0.0 0.8 ‐ Note 2PDC Adj 0.0 0.0 PDC Adj ‐0.7 0.0Contract phasing 0.2 ‐0.1 Contract phasing 0.0 0.0Contract Variations 0.9 ‐0.6 Contract Variations ‐0.3 0.0Debtors 2.3 1.8 ‐ Note 3 Debtors 1.5 ‐ Note 3Timing of settlements to suppliers ‐1.9 0.2 ‐ Note 4

Timing of settlements to suppliers 1.7 ‐ Note 4

Provisions and deferred income ‐0.4 0.7

Provisions and deferred income ‐0.1

Opening cash 0.0 0.0 Opening adjustment 1.1 1.1

Minor Variances 0.1 0.0 Minor Variances ‐0.2 ‐0.1


Actual 1.8 3.0 ForecastActual/Forecast 30.8 19.2 ‐ Note 5

123

4

5 Most of the timing issues relating to 14/15 were resolved in month 1.

Increases from Timing of settlements to suppliers has fallen but still contributes £1.8m more cash than plan. This largely relates to higher than expected uninvoiced goods and services, a substantial part of which relates to Property (£1m) and OATs (£0.4m), with remainder being due to recharges and AHSN.

Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)

Debtors have improved and are £0.5m lower than plan. This includes PDC due of £0.7m and further taking in to account uninvoiced contract variations indicates an underlying improvement in debtors of c£1.5m. This is largely attributable to actions in relation to the year end exercise.

The major risk to liquidity relates to the I&E position, which at current levels is manageable in the short term but is not sustainable in the longer term.Capital and financing are now broadly in line with plan.

‐3.000

‐2.000

‐1.000

0.000

1.000

2.000

3.000

4.000


Opening cash balance

Financing and Other

Capital and Investment Activities

Changes to WC

Non Cash Flows

Surplus/(deficit) after tax

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000


Forecast

Plan

Month Month YTD ForecastJun 2015 May 2015 Jun 2015 Out‐turn

3 2 Note 3 12 Note

Plan 0.6 0.6 Plan 1.7 9.7

Major Variances Major VariancesHarbour 0.0 0.0 ‐ Note 1 Harbour 0.0 0.0 ‐ Note 1PLMHU 0.0 0.0 Note 2 Pathfinders/Mossview 0.0 0.0 Note 2YPU 0.0 0.0 ‐ Note 3 YPU 0.0 0.0 ‐ Note 3IT Schemes 0.0 0.0 ‐ IT Schemes 0.0 0.0 ‐

Resource Centres 0.0 0.0 Resource Centres 0.0 0.0Min Improvements 0.0 0.1 ‐ Note 4 Min Improvements ‐0.1 0.0 ‐ Note 4Minor Variances 0.1 ‐0.1 Minor Variances 0.1 0.0


Actual 0.6 0.6 Actual Actual/Forecast 1.6 9.7

1

234

Monthly Capex Variance (£m) Forecast Capex (£m)

The Harbour building was opened on time in March. Slippage to 15/16 was allowed for in plan, but overall position is subject to negotiation of final account and commissioning constraints for outstanding work.

No expenditure is profiled in 15/16, commissioner support, and therefore the future of the scheme, is unclear.Further analysis will be incorporated as programme is developed.

PLMHU expenditure is expected to be minimal in 15/16

Expenditure to date is broadly in line with plan with forecasts replicating planned expenditure. Detailed programmes and forecasts are being worked up and more analysis will presented in future months.

‐5.000‐4.000‐3.000‐2.000‐1.0000.0001.0002.0003.0004.0005.000


The Harbour

PLMHU

YPU

IT Schemes

Minor Improvements

Maintenance

IT

Anti Ligature

Other 0.000

2.000

4.000

6.000

8.000

10.000

12.000


Actual

Plan

YTD Forecast YTD Forecast YTD ForecastJun 2015 Out‐turn Jun 2015 Out‐turn Jun 2015 Out‐turn

3 12 3 12 3 12

Plan 3 3 Plan 2 2 Plan 4 4

Actual/Forecast 3 3 Actual/Forecast 2 2 Actual/Forecast 4 4

Key Points ‐ I&E is the main driver for ratings at the moment. ‐ Overall CoSRR 3 against Plan of 3 and expected to remain so. ‐ Current I&E projections maintain a debt service of 2 against a plan of 2 at the end of the year. ‐

CONTINUITY OF SERVICE RISK RATINGS

Liquidity is expected to remain at 4

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Apr‐15 Jul‐15 Oct‐15 Jan‐16

CoSRR ‐ Overall

Actual/Forecast Plan

0.0

0.5

1.0

1.5

2.0

2.5

3.0


CoSRR ‐ Debt Service

Actual/Forecast 4 3 2 1

‐20.0

‐15.0

‐10.0

‐5.0

0.0

5.0

10.0

15.0


CoSRR ‐ Liquidity

Actual/Forecast 4 3 2 1

Reserves

Annual statement of Revenue Reserves

Budget Charge VarianceNon Recurrent Funds ‐1,500 ‐1,714 214 Note 1Contractual Gains 867 0 867 Note 2Non Pay Reserve 309 200 109 Balance of unallocated non‐pay inflationCIP Reserve ‐724 ‐724 0 Note 3

‐1,048 ‐2,238 1,190

Note 1 ‐ Non Recurrent Funds Note 2 ‐ Contractual Gains

Non Recurrent Reserve established at Plan 1,500ChangesAdditional GainsNon Recurrent Income re AHSN 80 Note 3 ‐ CIP ReserveHarvey House rents 50Supply Chain Credits 60PIP/ATOS rent 20Misc. 4

Variance 214

Total Charge 1,714

The negotiations with commissioners indicate a gain of £867k however this is not signed up to yet as lead commissioners need to finalise agreements with associates, and as such contains a degree of risk.

This is the balance of CIP programmes as yet to be confirmed however confidence is high as Health Visiting contractual negotiations are likely to deliver c£400k and Children and Families are confident of c£300k further savings. These will only be transacted once confirmed.

MATTERS

ID Meeting DaPaper Status

02/01 Jul‐15 VerbalExcluded

02/02 Jun‐15 Verbal Included

02/03 Jun‐15 VerbalIncluded

02/04 Jun‐15 Verbal Excluded

02/05 Jun‐15 VerbalIncluded

02/06 Jun‐15 VerbalExcluded

02/07 Jul‐14 Verbal

Excluded

02/08 May‐14 VerbalExcluded

Invoices remain outstanding with regard to CAMHs Tier IV OATs recharges with Specialist Commissioners. Net exposure is c£200kbut the Trust considers its position robust. The situation will be resolved over the next couple of months

Subject

Contracted Out Services Changes‐ VAT COS remain an issue, though less so ‐ letter received from HRMC "we now appreciate that there are some areas where theguidance notes written for government departments are either not relevant to the NHS or can cause confusion for NHS bodies".COS are subject to roundtable discussion at DoH/HMRC. Guidance is still expected though timing is unknown.

On‐going Claims‐ Speculative VAT claims continue to be pursued in relation to older developments and changes in rulings. Up to £2m no gainassumed.

Settlements with regard to the Mental Health and Health Visiting contracts are still in discussion and the Trust believes that it hasmade prudent assessments of the likely outcome.

The Trust has made appropriate provision for additional redundancies as a result of the Harbour based on a workforce riskassessment.

A paper on agreements with regard to the Inpatient Programme was delivered in July.

The Trust has made appropriate provision for excess travel as a result of the Harbour workforce changes.

The OATs trajectory assumes a plateauing of OATs activity in the latter part of the financial year. If the previous two years activitypatterns are observed, there is a potential exposure of an additional £1.5m ‐ £2.0m.

OUT OF AREA ACTIVITY

12

345

The Networks have developed a trajectory which they believe is deliverable for 2015/16.We have already seen slippage against this.The Trust has provided £1.2m for OATs, which was the level deemed affordable at planning and not intended to remove all risk. The indications from commissioners are that this will be matched. Additionally, £50k per month is available until the PICU opens at West Lancs in September. This gives a funding envelope of £2.65m.This has been planned pro rata to the funding expenditure. The opening of the PICU will alleviate some of the pressure on OATs.The trajectory implies full year expenditure of £3.94m against funding of £2.65m, an overspend of £1.29mAt the end of month 3, costs are £2.34m against funding of £1.77m, an overspend of £0.57m.The trajectory assumes reduction and a plateauing of OATs activity in the latter part of the financial year. If the previous two years activity patterns are observed, there is a potential exposure of an additional £1.5m to £2.0m.

Appendix 1: Income ScheduleForecast Forecast

YTD YTD Out‐turn Out‐turnJun 2015 May 2015 at Jun 2015 at May 2015

3 2 12 12Community Services

Urgent Care Planning 0.000 0.000 ‐0.059 ‐0.179Chronic Fatigue Funding 0.012 0.008 0.050 0.050Supported Living 0.000 0.000 1.875 0.000BWD Council Service Reductions ‐0.012 ‐0.008 ‐0.084 ‐0.084Offender Health Bedwatch ‐0.216 ‐0.144 ‐0.864 ‐0.864Liverpool & Kennet Prisons 0.689 0.000 6.893 0.000Offender Health 0.022 0.015 0.121 0.088Family Nurse Partnership 0.195 0.130 0.781 0.781Health Visiting ‐0.063 ‐0.042 ‐0.250 ‐0.250CERS ‐0.013 0.033 0.067 0.041Beechwood 0.000 0.000 0.244 0.244Rheumatology 0.072 0.061 0.379 0.264Deflator Gain at 0.8% 0.085 0.000 0.339 0.000Other Community 0.333 0.085 0.600 0.506Total 1.106 0.138 10.092 0.597

Mental HealthOATS 1.350 1.037 1.450 1.450Contractual Settlement 0.217 0.000 0.866 0.000PICU Funding 0.000 0.000 0.350 0.000Community Dementia ‐0.052 ‐0.035 ‐0.207 ‐0.207Mental Health Resilience 0.074 0.009 0.298 0.518Other Mental Health ‐0.155 0.126 0.111 0.752Total 1.435 1.137 2.868 2.513

Specialist ServicesCAMHs Tier 4 0.090 0.059 0.334 0.334HIV 0.064 0.043 0.257 0.257Other ‐0.024 0.009 0.042 0.042Total 0.130 0.111 0.632 0.605

R&DTotal 0.001 ‐0.001 0.049 ‐0.099

ETRStudent Income 0.227 0.137 0.653 0.525Total 0.227 0.137 0.653 0.525

Other Non Healthcare IncomeAHSN 0.264 0.000 1.225 0.317MHRN ‐0.106 0.000 ‐0.424 ‐0.424PIP/ATOS ‐0.076 ‐0.086 ‐0.832 ‐0.618IT 0.081 0.049 ‐0.174 0.294HR 0.052 0.034 0.135 0.000Dental 0.005 0.000 0.040 0.000Secure Services 0.054 0.036 0.228 0.299Property Services 0.051 0.030 0.221 0.196Other Misc. ‐0.090 0.182 0.310 0.651Total 0.236 0.244 0.728 0.714

Total 3.134 1.766 15.023 4.855

Board of Directors

Agenda Item TB 069/15 Date: 28/07/2015 Report Title Quarterly Workforce Report – Q1 2015-16


Prepared by Damian Gallagher, Director of HR

Presented by Damian Gallagher, Director of HR




Report purpose To support and inform the Board’s Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staff and safe staffing levels, affecting quality of care and financial costs.

CQC domain Well-led

PAPER DEVELOPMENT PROCESS:

The format for the quarterly Workforce report for the Board of Directors has been amended and improved to reflect the recommendations made by director colleagues and to better reflect the needs of the networks and corporate services. It is proposed that the Board of Directors will receive a high level narrative summary of the quarterly report (click here for the link to the detailed report) with their regular Board papers prior to the Board of Directors’ meetings. Members of the Board are encouraged to ask any questions or make requests for further information with the Director of Human Resources prior to the meeting of the Board if possible.

The new format takes as its basis the business performance indicators that are relevant to People and Organisational Management Performance. These key performance indicators will help inform our progress towards mitigating the Board Assurance Framework risk 4.1 (The Trust is unable to attract,

recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels,

affecting quality of care and financial costs) as well as contributing to our objective to employ the best people. The metrics are integral to the CQC domain of well led. Each key performance indicator has a target and the results are RAG rated against that target for the quarter that is being measured (based on the previous quarter).

Vacancy Rate: the Trust has set a target of no more than a 5% establishment vacancy rate. We currently exceed that target with a quarterly figure of 11% but this is an improving figure. This relatively high figure represents the % difference between the Trust’s budgeted establishment and its actual spent establishment. An ‘active vacancy rate’ is also supplied – this figure supplements the

http://www.lancashirecare.nhs.uk/media/Jo_Alker/July%202015/LCFT%20Q1%20Workforce%20Board%20Report%202015%20v2.pdf

established vacancy rate figure by presenting the percentage of those positions in the budgeted

establishment that are being actively recruited to – this figure is currently just under 6%.

Operational Gap: this is a measure of absences other than sickness that affect operational

performance (e.g. career break, maternity leave, secondment etc). Our target is no more than 5% and

we currently have a rate of 3% but this has worsened (increased) when compared to the previous

quarter.

Sickness Absence: our short-term target is 4.5% and our results for the quarter are 6%. While this is

an improvement on the previous quarter there has been a slight increase between May 2015 and June

2015 that will need to be arrested. Our new occupational health provider will help us achieve this in

providing informative, timely and current best practice on how to proactively support our workforce to

attend work regularly and there is a specific workstream under the DTS programme with focused

activities to reduce sickness absence.

Agency & Bank % of Total Pay Spend: our target is no more than 6% and our current rate is a

disappointing 14% (although this is an improving position). There is a specific DTS workstream that is

working towards realising savings of £5m over 5 years with the first £1m this financial year. Extra

resources have been added to this programme in the past month and individual targets and trajectories

have been agreed with the networks and corporate services.

Turnover: our target (what we think is acceptable) is no more than 10% and our quarterly rate is 11%

which is an improving position based on the previous quarter.

Appraisal: There are two measures identified for monitoring appraisal performance within the Trust.

For Quarter 1 the number of appraisal that have been initiated and record in the performance

management system by the Employee across the Trust is just under 40%. Of those initiated in Q1

approximately 12% have been approved by Line Management.

Training: our target for mandatory training completion is 85% and we are currently under-performing

slightly at 76% compliance. The People sub-committee is monitoring this target closely and there are a

number of positive initiatives that will further improve this rate.

Induction: our current target is 85% completion and our results are a disappointing 58% for the

quarter.

Safer Employment: this indicator measures our performance against a number of standards for

recruiting staff safely and within the law. It measures compliance with specific standards to do with the

employee’s right to work in the country; professional registration where required, visas and work

permits; and criminal background checks. Our minimum target it 85% compliance within a given period

and our current performance is 89% and improving.

Damian Gallagher HR Director

Board of Directors

Agenda Item TB 070/15 Date: 28/07/2015 Report Title Living Wage Salary Proposal


Prepared by Damian Gallagher, Director of HR

Presented by Damian Gallagher, Director of HR




Report purpose To support and inform Board’s decision of the Living Wage


To employ the best people

Board Assurance Framework risk 4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staff and safe staffing levels, affecting quality of care and financial costs.

CQC domain Well-led

STAFF SALARY LEVELS – LIVING WAGE

1.0 INTRODUCTION At the Council of Governors meeting held on 10 July 2014 a discussion took place around staff salary levels particularly those that do not meet the current living wage salary level. The Chief Executive confirmed that she would enquire about the number of LCFT staff currently being paid below the living wage salary and consider how any changes to this could impact the organisation. The living wage salary is currently a minimum of £7.85 per hour and this would give a salary of £15,348, or below the second incremental point on band 2. There are currently circa 71 staff paid below the Living Wage hourly rate. These staff are predominantly Healthcare Assistants and clerical receptionists who are within their first year of service on band 2.

The calculation is based on the Minimum Income Standard for the United Kingdom, the product of research by CRSP (the Centre for Research in Social Policy), funded by the Joseph Rowntree Foundation. The research looks in detail at what households need in order to have a minimum acceptable standard of living. Decisions about what to include in this standard are made by groups comprising members of the public. The Living Wage is therefore rooted in social consensus about what people need to make ends meet.

The uprating of the Living Wage figure each year takes account of rises in living costs and any changes in what people define as a ‘minimum’. It also takes some account of what is happening to wages generally, to prevent a situation where Living Wage employers are required to give pay rises that are too far out of line with general pay trends.

However, the figure of £7.85 per hour taken on its own is misleading due to the way it is worked out each year. The true living wage for workers outside of London would be £9.20 at today’s prices if the full recommended increase took place within one year. There is a recognition that to get from where people are, in terms of pay, and where they ought to be, there needs to be stepped changes and so it has been agreed to limit increases to annual inflation plus 2%, but over time this gap will be bridged and each year the bar rises and covers more people. This means that the true impact of applying the Living Wage to our workforce would be an increase to the hourly rate of more than 1600 employees with an annual salary of £17,988 or below. This is currently just above the mid-point of band 3. The actual full year effect of implementing the Living Wage at today’s prices assuming we had reached the end of the capped increases would be £1.5M. This is a significant additional cost that would need to be factored in (added) to the requirements of our 5 year plan Delivering the Strategy.

1.1 TRUST VALUES

As a Trust we seek to be an employer of choice and we aspire to create a workplace where people want to work because they are supported, well led and able to reach their potential. To that end we publish our values and ask that our employees subscribe to them. In adopting the Living Wage it could be argued that we are demonstrating the values of respect, integrity and compassion mainly because not adopting it implies that we are not paying our staff enough for them to live in our current economic climate. However, the Living Wage is only an hourly rate and our employees enjoy many more benefits than their counterparts in the wider economy: When our generous pension scheme, almost automatic incremental progression, annual leave of 33 days plus 8 public holidays, and other benefits are taken into consideration the majority of our staff receive a total employment package far superior to the simple hourly rate of the Living Wage. For example, our lowest paid employees commence on a salary of £15,100 which is equivalent to £7.72 per hour – but when the employer’s pension contribution is added to this figure the equivalent hourly rate becomes £8.80 per hour, well above the current Living Wage rate. However it should be noted that accreditation for becoming a Living Wage employer will take no account of employer’s pension contributions as this is considered by them to be a deferred benefit not relevant to the contemporary situation facing lower paid workers.

1.2 REASONS FOR ADOPTING THE LIVING WAGE

This may give us a competitive advantage by enhancing our reputation and making ourrecruitment campaigns more successful.

It will enhance our reputation and make a statement about corporate social responsibility. It has political cross-party support. The Living Wage Foundation argues that it is good for business, good for the individual and

good for society. The Living Wage Foundation argues that in companies where staff are receiving the Living

Wage the quality of work is improved and absenteeism is reduced by 25%. PwC found that when it adopted the Living Wage the turnover of its contractors reduced

from 4% to 1%. The Living Wage Foundation argues that in companies where staff are receiving the Living

Wage 50% of staff feel more willing to implement changes in their working practices andseek fewer concessions when changes are being proposed.

1.3 REASONS AGAINST ADOPTING THE LIVING WAGE

Equal Pay for work of equal value – the current banding system of Agenda for Change waspartly created as a response to the threat of equal value pay claims within the NHS. Thecurrent system is regarded as ‘equal-pay proof’ in that it has successfully been used todefend such claims. This defence would be lost if we moved outside of Agenda for Change.For example there is now a clear difference between bands 1, 2 and 3 under Agenda forChange that would be lost with all 3 bands being paid equally for doing work that is notevaluated as being of equal value.

Almost certain risk of a backlash and possible grievances from people on slightly higherincrements aggrieved at the perceived unfair elevation of their colleagues if Living Wageadopted.

Risk of sex discrimination claims if Living Wage adopted – slight risk, but possible giventhose identified as affected currently are predominantly female.

Financial risk if Living Wage adopted of increased cost if the living wage increases morequickly than the NHS annual pay award (as is expected). Despite the claimed prime-ministerial backing for the Living Wage the government has restricted the cost of livingincreases in the NHS to 1% for some staff (i.e. it has raised the salaries but not moved tothe Living Wage despite some differential awards that favour the lower paid)

Risk to relationships with other Trusts if we implement and they don’t or vice versa. Thereare no plans in other Trusts in the Cumbria and Lancashire area.

2.0 RECOMMENDATION Further to the discussions at both the Council of Governors and the Board of Directors around consideration of implementing the Living Wage within the Trust, the Director of Strategy and Transformation was tasked with holding further discussions about this issue and reporting back to the Board with a recommendation for the Board to consider as to the proposed way forward.

After discussions with HR professionals both within and external to the Trust, and with the trade unions at the Partnership Forum the recommendation for the Board to consider is that we do not proceed with the adoption of the Living Wage at this point in time. The reasons for this recommendation are that we as an organisation wish to maintain the current collective bargaining arrangements that are in place nationally for the determination of employment terms and conditions of service. Currently NHS Employers gather evidence from all NHS organisations for the National Pay Review Bodies and negotiate collectively on our behalf with the trade unions nationally through the National Social Partnership Forum.

Any deviation from this process would involve a departure from the nationally agreed Agenda for Change terms and conditions and such a decision would likely prove problematic with trade unions at both national and regional level. It should also be noted that the current pay system in place for the number of staff that would be affected by the living wage proposal is based on the expectation of annual incremental progression following satisfactory performance that would take many of those individuals above the living wage threshold at some point (had they remained on Agenda for Change terms and conditions).

Should the Board decide not to adopt the Living Wage at this point in time there are other measures that could be considered that will be in keeping with the spirit of the Living Wage without attracting the disadvantages of leaving Agenda for Change and the national pay bargaining machinery. For example

the Trust could decide prospectively to appoint new starters to the second incremental point of band 2 and above only. This could be combined with the offer of a development programme for all those currently below this level with the aim of accreditation and subsequent pay increase similar to the approach we take with apprentices. Such an approach would meet the Living Wage hourly rate while remaining within Agenda for Change. Such an approach would mean that the only employees below the Living Wage hourly rate would be apprentices on an approved scheme who are exempt.

It should also be noted that, since the first draft of this paper was written, HM Government has announced its intention to introduce a National Living Wage from next year. This is different from the Living Wage Foundation and will see minimum hourly rates set at £7.20 from 2016 rising to £9.00 by 2020. As an employer we currently meet and exceed the proposed 2016 rate.

Damian Gallagher HR Director

BOARD OF DIRECTORS

Agenda Item TB 071/15 Date: 28/07/2015 Report Title Board of Directors Terms of Reference


Prepared by Jo Alker, Deputy Company Secretary

Presented by Diane Halsey, Director of Governance and Compliance




Report purpose To provide the Board of Directors with the draft Terms of Reference for approval



Board Assurance Framework risk 7.1 – The Trust does not comply with the Monitor Provider Licence

CQC domain Well-led

1.0 INTRODUCTION At the Board meeting held in July 2013, the Board approved its Terms of Reference. As considered best practice those terms of reference were scheduled for review in July 2014. This review was deferred following the commencement of the fundamental governance review. As we have now transitioned into the new governance structure and as terms of reference of the feeder committees have been approved, attached at appendix one are the draft terms of reference for the Board of Directors.

2.0 REVIEW OF THE TERMS OF REFERENCE The terms of reference have been reviewed and amended to align them to the previously approved Matters Reserved for the Board, the Standing Financial Instructions and the Decision Rights Framework.

As part of the governance review, the format of the Board agenda has been formatted to section agenda items under the following headings:

Quality and Safety Finance and Performance People and Leadership Governance and Assurance

The terms of reference have also been formatted to follow the same layout.

3.0 RECOMMENDATION The Board is asked to note the attached terms of reference for approval.

Board of Directors

DRAFT TERMS OF REFERENCE VERSION 1.0

PURPOSE The purpose of NHS boards is to govern effectively and in doing so build patient, public and stakeholder confidence that their health and healthcare is in safe hands. This fundamental accountability to the public and stakeholders is delivered by building confidence:

in the quality and safety of health services; that resources are invested in a way that delivers optimal health outcomes; in the accessibility and responsiveness of health services; that patients and the public can help to shape health services to meet their needs; and that public money is spent in a way that is fair, efficient, effective and economic.

DUTIES AND RESPONSIBILITIES The Board of Directors exercises all the powers of the Trust, it may delegate any of those powers to a committee of the Board or to an Executive Director. Arrangements for the reservation and delegation of powers are set out in the Trust’s Standing Orders, Standing Financial Instructions, Matters Reserved for the Board and the Decision Rights Frameworks.

The general responsibilities of the Board are:

Quality and Safety

The Board ensures that the Trust operates safely, effectively, efficiently andeconomically ensuring the proper management of resources and that a high quality of care is achieved.

The Board ensures that the Trust achieves the targets and requirements ofstakeholders within the available resources.

The Board ensures that there are sound processes and mechanisms in place to ensureeffective user and carer involvement with regard to development of care plans, the review of quality of services provided and the development of new services.

The Board approved the Quality Strategy and monitors its appropriate implementationand operation.

Finance and Performance

The Board ensures the continuing financial viability of the organisation. The Board is responsible for ensuring the financial strategy is in place and is monitored

appropriately understanding required action to maintain financially sustainable. The Board reviews performance, identifying opportunities for improvement and

ensuring those opportunities are taken. The Board monitors and reviews management performance to ensure the Trust’s

objectives are met and oversees both the delivery of planned services and theachievement of objectives, monitoring performance to ensure corrective action is takenwhen required.

People and Leadership

The Board is responsible for setting values, ensuring they are widely communicatedand that the behaviour of the Board is entirely consistent with those values.

The Board provides active leadership to the organisation by ensuring there is a clearvision and strategy for the Trust within a framework of prudent and effective control that enables risk to be assessed and managed.

The Board approves the People Strategy and monitors its appropriate implementation

and operation. The Board ensures there are appropriately constituted appointment arrangements for

senior positions such as consultant medical staff and executive directors.

Governance and assurance

The Board sets and maintains the Trust strategic vision; aims and objectives ensuringthe necessary financial and other resources are in place for it to meet those objectives.

The Board develops and maintains an annual business plan and ensures its delivery asa means of taking forward the strategy of the Trust to meet the expectations and requirements of stakeholders.

The Board ensures that national policies and strategies are effectively addressed andimplemented across the Trust.

The Board ensures that the Trust has comprehensive governance arrangements inplace that ensure that the resource vested in the Trust is appropriately managed and deployed, that key risks are identified and effectively managed and that the Trust fulfils its accountability and value for money requirements.

The Board ensures that the Trust complies with its governance and assuranceobligations in the delivery of clinically effective, personal and safe services taking account of patient and carer experiences.

The Board ensures compliance with the principles of corporate governance withappropriate codes of conduct, accountability and openness.

The Board formulates, implements and reviews its standing orders and standingfinancial instructions as a means of regulating the conduct and transactions of its business.

The Board ensures that the statutory duties of the Trust are effectively dischargedincluding compliance with the Monitor Provider Licence.

The Board maintains a schedule of matters reserved to itself. The Board safeguards the Trusts assets by ensuring that it has an effective system of

integrated governance, risk management and system of internal control across thewhole of the organisation.

REPORTING ARRANGEMENTS

Report to Activity Lead When

Formal Board meetings

Any activity undertaken outside of the formal Board meetings will be reported through the Trust Chairs report to the next formal Board meeting for ratification

Trust Chair As and when required


Chief Executive report to the formal Council of Governors meetings

Chief Executive

Quarterly

MEMBERSHIP AND QUORUM The Board of Directors will consist of the following members or their nominated deputies who will be required to attend should the Board member need to send apologies.

Board Member

Name Title

Derek Brown Trust Chair

Peter Ballard Deputy Chair

David Curtis Non-Executive Director

Louise Dickinson Non-Executive Director

Gwynne Furlong Non-Executive Director

Bill Gregory Chief Finance Officer

Naseem Malik Non-Executive Director (Senior Independent Director)

Sue Moore Chief Operating Officer

Dee Roach Director of Nursing

Max Marshall Medical Director

Heather Tierney-Moore Chief Executive

Non-Voting Member

Name Title

Diane Halsey Director of Governance and Compliance

Damian Gallagher Director of Human Resources

Members of the Senior Management Team and Professional Leads will be invited to as appropriate to the Board of Directors meetings as appropriate to the agenda.

Quorum for all Board of Directors meetings is seven directors including no fewer than two executive directors, one of whom is the Chief Executive or a nominated deputy, and no fewer than two Non-Executive Directors, one of whom is the Chair or a nominated deputy, is required to be quorate.

FREQUENCY OF MEETINGS The Board of Directors shall meet sufficiently regularly to discharge its duties effectively.

The Board of Directors holds its meetings in public. Matters that are confidential on the grounds of commercial sensitivity or involving personnel issues will be discussed in a separate closed session and members of the public and press will be required to leave the meeting.

In addition, the Board of Directors will hold regular informal briefing sessions/development workshops to develop and inform its thinking.

REVIEW The Terms of Reference for the Board of Directors shall be reviewed at least once a year to ensure it continues to operate effectively.

BOARD OF DIRECTORS

Agenda Item TB 072/15 Date: 28/07/2015 Report Title FOIA Exemption Prepared by

Board Assurance Framework

Part Exemption Appendix 2 FOIA Exempt under Section 40 & 43

Carrie Tomlinson, Compliance and Assurance Manager

Presented by Julie-Ann Bowden Associate Director: Compliance and Business Assurance




Report purpose To provide assurance to the Board of Directors in relation to the Q1 review of the BAF risks.



Board Assurance Framework risk This report contains an update relating to all 2015/16 BAF risks.

CQC domain Well-led


Meeting Presented Action Date

All sub-committees within the governance framework over the course of Q1 have reviewed BAF risks and 15 and above risks

NA NA NA

Governance and Compliance Sub-committee

Julie-Ann Bowden

For noting 20.07.15

1.0 INTRODUCTION 1.1 The Board Assurance Framework (BAF) has been reviewed for Quarter 1 in detail with each

Director Lead for 2015/16 supported by the review of BAF risks and 15 and above risks across the sub-committee governance environment.

In these discussions the following was considered: The need to review the strategic objectives against the key risk areas to reflect the

outputs from the strategic planning process. The need to considering the re-scoring of the BAF risks taking account of an assessment

of the assurances and controls and any gaps identified during Q1. The interdependency of risks scoring 15 and above with the BAF risks and the impact of

this in terms of risk profile which has been supported by the Q1 risk profiling exercise. Work to strengthen the analysis of mitigating actions required to close the gap between

the current risk score and the target risk score. Ensuring that systems and controls are in place that are adequate to mitigate any

significant strategic risks which threaten the achievement of the strategic objectives.

1.2 The report provides an opportunity for the Trust Board to review the position for 2015/16 BAF risk register at the end of the Q1 position.

2.0 RISK ASSURANCE PROCESS WITHIN THE GOVERNANCE FRAMEWORK 2.1 All Sub-Committees within the governance framework are now well established and they

receive reports outlining the BAF risks allocated against their area of responsibility as well as the 15 and above risks that are linked to the BAF risks under review.

2.2 The sub-committees seek to identify assurance through the meeting business that supports the management of the BAF risks and where gaps in controls or assurances are identified, the sub-committees commission additional assurance and escalate any risks in their Chair’s Reports.

2.3 The Chair’s Reports and the sub-committee agendas currently provide a valuable source of assurance when the BAF risks are reviewed. This will be further supported by the assurance mapping process currently underway and due to be reported to Audit Committee in October 2015.

3.0 BAF HEAT MAPS 2015/163.1 The first iteration of the BAF Heat Maps for 2015/16 can be viewed in Appendix 1. These

demonstrate our position as at 1st April 2015, Quarter 1 2015/16 and also provide the Risk Target for end of Q4, demonstrating the progression of the overall BAF risk profile and where we are aiming to be by the end of 2015/16.

3.2 The application of the principle of the Risk Appetite Statement can be observed in relation to the heat maps. There are currently 7 BAF risks appearing in Zone A which is classified as Unacceptable Risk therefore it is expected that the sub-committees will have a specific focus on commissioning assurance and controls in these areas.

4.0 BOARD ASSURANCE FRAMEWORK END OF QUARTER 1 4.1 A risk profiling exercise has been undertaken for Q1 as part of the review of the BAF risks.

This process is still currently led corporately as Datix risk module access is still limited across Directorates and Networks which prevents consistent sharing of risk information. A solution to this is being considered currently by the Associate Director of Patient Safety and Quality Governance.

4.2 The risk profiling process and the review of the BAF risks for the end of Q1 has been undertaken to ensure that an assured view is taken in assessing the current level of risk. Appendix 2 provides an overarching update for each BAF risk.

4.3 The BAF 2015/16 Risk Register final position for Q1 can be reviewed in Appendix 3. The 15 and above risks can be reviewed against each BAF risk with the caveat that these risks are dynamic in nature and those included in this report represent a risk profile snap shot at a point in time (that being 7 July 2015). It is important to note that the risk assurance process is still developing in maturity and that the governance system is facilitating discussions that are resulting in improvements in the risk profiling.

5.0 RECOMMENDATION 5.1 The Board are requested to:

a) Approve the BAF 2015/16 Risk Register at Q1.

Julie-Ann Bowden Associate Director: Compliance and Business Assurance

Appendix 1 – BAF Heat Maps 2015/16 (Q1 position)

Insignificant

Almost Certain

Likely

Possible

Unlikely

Rare

ZONE B

ZONE C

RISK APPETITE REFERENCE

ZONE A

Minor Moderate Major Catastrophic

7.1

5.2

6.1

7.2

2.1 4.1

1.2

1.14.2

2.2

5.1

3.1

Like

liho

od

Consequence

5

4

3

2

1

1 2 3 4 5

3.2

6.2

7.3

Insignificant

Almost Certain

Likely

Possible

Unlikely

Rare


ZONE A

ZONE B

ZONE C


3.2

7.3

7.1

5.2

6.1

7.2

2.1

4.11.2

6.2

1.14.2

2.2

5.1

3.1

Like

liho

od

Consequence

5

4

3

2

1

1 2 3 4 5

Insignificant

Almost Certain

Likely

Possible

Unlikely

Rare


ZONE A

ZONE B

ZONE C


3.2

7.37.1

5.2

6.1

7.2

2.1

4.1

1.2

6.2

1.1

4.2

2.2

5.1

3.1

Like

liho

od

Consequence

5

4

3

2

1

1 2 3 4 5

Q1 Review – as at 30 June 2015

Q4 Risk Target – for 31 March 2016

Q1 – as at 1 April 2015

Risk Appetite Statement

Zone A Unacceptable Risk

Zone B Balance Risk with Reward

Zone C Risk Positive

Appendix 2

FOIA Exempt under Section 40 and 43

BoardAssurance Framework

Q1 - 2015/16

Appendix 3

Executive Risk Lead:

Risk Appetite Reference CCO: Chief Operating Officer CFO: Chief Finance Officer HRD: HR Director

CoGC: Director of Governance and Compliance DoN: Director of Nursing MD: Medical Director ZONE A

ZONE B

ZONE C

Strategy Priority BAF Risk Sub-committee

Exec

Ris

k la

d

Risk Score 01 April 15

Risk Score End of Q1

Risk Appetite Position at Q1

Risk Target Risk Target Gap

O1 Quality 1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services. Quality & Safety DoN

16

Extreme

16

Extreme

Zone A 8

Significant

8

Close Monitoring

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. Quality & Safety DoN

16

Extreme

12

Significant

Zone B 8

Significant

4

Tolerable

O2 Outcomes 2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

Operational Delivery & Performance COO

12

Significant

12

Significant

Zone B 8

Significant

4

Tolerable

2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements. Finance CFO

15

Extreme

10

Significant

Zone B 5

Moderate

5

Tolerable

O3 Excellence 3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider Quality & Safety MD 12

Significant

16

Extreme

Zone A 8

Significant

8

Close Monitoring

3.2 The Trust does not build its communication and reputation with all stakeholders Operational Delivery & Performance COO

12

Significant

12

Significant

Zone B 8

Significant

4

Tolerable

O4 People 4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

People HRD 15

Extreme

15

Extreme

Zone A 10

Significant

5

Tolerable

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care People DoN 12

Significant

12

Significant

Zone B 9

Significant

3

Tolerable

O5 Money 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainibility. Finance CFO

25

Extreme

20

Extreme

Zone A 10

Significant

6 Close Monitoring

5.2 The Trust does not achieve the required efficiency savings whilst delivering and improving quality

Operational Delivery & Performance COO

16

Extreme

16

Extreme

Zone A 8

Significant

8

Close Monitoring

O6 Innovation 6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

Business Planning & Transformation CFO

16

Extreme

16

Extreme

Zone A 8

Significant

8

Close Monitoring

6.2 The Trust does not implement a transformational IT programme that ensures transition to a new intuitive clinical system across all services Health Informatics CFO 16

Extreme

16

Extreme

Zone A 12

Significant

4

Tolerable

O7 Compliance 7.1 The Trust does not comply with Monitor Licence. Governance & Compliance DoGC

10

Significant

10

Significant

Zone B 5

Moderate

5

Tolerable

7.2 The Trust does not comply with statutory legislative requirements Governance & Compliance DoGC

16

Extreme

16

Extreme

Zone A 4

Moderate

12

Serious

7.3 The Trust does not comply with Mental Health Legislation MH Legislation DoN 12

Significant

12

Significant

Zone B 4

Moderate

8 Close Monitoring

BOARD ASSURANCE FRAMEWORK 2015/16 1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC's standards for the quality and safety of services.

DIRECTOR LEAD: Director of Nursing DATIX NO: 5982

STRATEGIC PRIORITY: SO1 Quality ASSURANCE COMMITTEE TO REVIEW: Quality & Safety

GRAPH RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions.

RISK RATING: Original Score

01.04.15 Current Score

End of Q1 Target Score

16 16 8 4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE The Trust has in place established policies, procedures and systems for the reporting, investigation and management of risks and incidents that could impact on patient safety. A number of patient safety initiatives are underway such as the Harm Free Care Programme, Sign up to Safety Campaign and the Reducing Restrictive Practices Programme. However, additional work has been commissioned to improve the quality of complaint and incident investigations and the development of systematic learning and quality improvement. The Trust is experiencing high levels of acuity and throughput that requires service redesign.

CONTROLS 1. Risk Strategy, Safeguarding Strategy, Risk Policy, Incident Policy, Being Open Policy and

Complaints Policy2. Use and development of the Datix integrated risk management system3. Governance processes and oversight groups4. Engagement with commissioners5. Development of a centralised investigation function6. Patient safety initiatives - Harm Free Care, Reducing Restrictive Practices, Physical Health in

Mental Health, etc7. Systems to support and demonstrate compliance with CQC and monitor quality governance

requirements - Quality SEEL8. Effective management of new CQC registration processes9. Safer Staffing project and reporting

ASSURANCES 1. Six-monthly Serious Incident Report and quarterly Complaints Reports2. Network governance oversight of incidents, risks and complaints3. Serious Incident Advisory Group oversight4. Complaints Review Panel oversight5. Serious Incident Oversight Panel review of completed SI reports6. Safeguarding Committee oversight7. Quality Assurance and Quality Governance initiatives8. Quality Assurance Visits - LCFT and Commissioner9. Quality SEEL and Datix systems10. Team level Integrated Quality Reports/Team Information Boards11. Quality Tile and Quality Surveillance Reports12. Clinical Audit Programme and Internal Audit Programme

GAPS IN CONTROLS 1. Lack of integration between Quality SEEL and Datix systems2. Lack of a robust quality surveillance system

GAPS IN ASSURANCES 1. There is a lack of quality in relation to many incident and complaint

investigations, and concerns around data quality and reliability2. The Trust cannot centrally provide assurance that lessons have been

learned and associated quality improvements made from incidents, risksand complaints

3. The current model of quality surveillance is reactive with a range of qualitydata collected, reviewed and analysed across a range of systems resultingin theming or correlation being a manual task

05

10152025

April June Sept Dec Mar

RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services.

DIRECTOR LEAD: Director of Nursing DATIX NO: 5983

STRATEGIC PRIORITY: S01 Quality ASSURANCE COMMITTEE TO REVIEW: Quality & Safety



01.04.15

Current Score

End of Q1

Target Score

16 12 4 4x4 3x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Trust has in place a number of regular safety activities, and a number of environmental improvement initiatives such as ligature reduction capital works. New facilities such as the Orchard and the Harbour provide a significantly improved care environment. Additional challenges include high numbers of out of area treatments, delayed discharges and the admission of young people to adult wards was a result of a lack of CAMHS beds.

CONTROLS 1. Quarterly reporting to EMT in relation to Ligature Improvement Plan2. Estates linking into Network meetings in relation to ligatures3. Annual testing of anti-ligature environment through Hard FM contract4. Ligature Improvement Plan reviewed at Minor Capital Group5. Mintor Capital report to Property Services Governance Forum in relation ligatures6. Annual Health and Safety Audit of all Inpatient Wards7. Annual Ligature Audit of all Inpatient Wards8. PLACE Assessments of all Inpatient Wards9. Annual IPC Audits of all clinical areas not covered by PLACE Assessments10. Clinical policies and procedures11. Safer staffing project

ASSURANCES 1. Estates Sub-Committee oversight2. Quality and Safety Sub-committee oversight

GAPS IN CONTROLS 1. Lack of an electronic audit tool with action planning capabilities

GAPS IN ASSURANCES 1. Assurances around correct staffing levels

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality.

DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5984

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: Operational Delivery & Performance

GRAPH RATIONALE FOR RISK TARGET: The first phase of data improvement work addressed operational performance to enable regulatory compliance reporting. It is crucial that we are able to align workforce data with quality and financial metrics therefore the risk is assessed as above.

RISK RATING:

Original Score 01.04.15

Current Score End of Q1

Target Score

12 12 8 3x4 3x4 2x4

RATIONALE FOR CURRENT RISK SCORE Improvement in data quality was achieved during 2014/15 resulting in the delivery of the Top 50 operational performance indicators resulting in a greater understanding of actions and accountability. There remains a risk relating to the quality of data that impacts on the Trust's ability to receive accurate workforce information. The delivery of the Board Balanced Scorecard is impacted by the accuracy and timeliness of data.

CONTROLS 1. Operational Delivery Group established to performance manage emerging

performance breaches with agreed trajectories and recovery actions e.g. IAPTrecovery.

2. The reconfiguration of the BI and performance team in light of the PerformanceImprovement Plan will address this issue.

3. The consolidated data warehouse is now a key feature of the PerformanceImprovement Plan.

4. The revised performance structure will be presented to EMT in December 2014.

ASSURANCES 1. Top 50 indicators are being monitored by the Managed Services.2. Managed Service is now in place and providing core monthly reports to Exec, Board and

Commissioners.3. Strategic Performance Management function will commence the audit programme for

key measures to ensure compliance with the SOPS as of Q2.4. Managed Service is working with the Trusts Head of Performance to develop an

interactive App to support access and transparency of information.5. Networks now own their Operational Performance delivery within the Networks, thus

providing enhanced Operational grip of information.

GAPS IN CONTROLS 1. Improving data quality via the Performance Improvement Plan (i.e., reduction of

unallocated patients)

GAPS IN ASSURANCES 1. Undertake Network and Corporate reviews to ensure that full accountability and

system resilience is in place to minimise the likelihood of reoccurrence.2. Ensure that there is Trust Board scrutiny of performance with focus on corrective

actions plans and agreed improvement trajectories where there are regulatorycompliance failures.

3. Fully articulate the system requirements to deliver operational performance are in situand clearly articulate the external factors that are not within our control but that mayimpact on future reporting.

05

10152025


RiskScoreRiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16

2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements.

DIRECTOR LEAD: Chief Finance Officer DATIX NO: 5985

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: Business & Planning Transformation

GRAPH RATIONALE FOR RISK TARGET: The Trust Board wants the Trust to grow in-line with its strategic plans but failure to recognise the changing commissioning landscape and influence it, coupled with the Trusts inability to reposition itself in the market and adopt a market focused culture will lead to loss of income, market position and impact on the Trusts reputation.

RISK RATING: Original Score 01.04.15


Target Score

15 10 5

3x5 2x5 1x5

RATIONALE FOR CURRENT RISK SCORE Internal capacity and capability around business development/tendering has significantly increased and improved. This puts the Trust in a position to win and protect clinical services, and is illustrated by recent tender wins and successful progressing through tendering processes.

CONTROLS 1. Strategy & Transformation Business Plan2. Marketing Strategy3. Business Development Framework including Bib/No Bid Criteria, Opportunity Decision Point,

Review and Submission process4. Standard Operating Procedures5. Business Development Pipeline

ASSURANCES 1. Business Planning & Transformation Sub Committee2. Finance & Business Performance Committee3. Corporate Quarterly Review process4. TAS provide Business Development monthly contribution to Chief Executive

Officer Report5. TAS provide weekly Business Development update to EMT

GAPS IN CONTROLS 1. Alignment of plans across local health economy and Lancashire need further development.2. Trust's annual planning framework for 16/17 not yet approved.3. Market analysis for 16/17 not yet undertaken

GAPS IN ASSURANCES 1. Unknown commissioning intentions2. Signed Contracts not being completed on time3. Possibility of needing arbitration to agree current contracts around Mental

Health Contract

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider. DIRECTOR LEAD: Medical Director DATIX NO: 5986

STRATEGIC PRIORITY: S03 Excellence ASSURANCE COMMITTEE TO REVIEW: Quality & Safety

GRAPH RATIONALE FOR RISK TARGET: The Trust Board accepts a degree of risk when pursuing a programme which will lead to multiple benefits.




12 16 8

3x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE If we do not show that we are able to achieve the benefits of being a Health and Wellbeing Trust patients would be receiving a poorer quality of care than we could be delivery. We would be more likely to lose business as we would not be able to show that it is beneficial to have mental and physical health services in the same Trust.

CONTROLS 1. Public Health Strategy defined with component implementation plan2. Medical Director operational plan for 2015-16

ASSURANCES 1. Implementation of strategy monitored at Quality Committee2. Tracking of achievement of objectives and analysis of evidence. Quarterly

reporting to EMT3. MECC programme board4. NMP Clinical Leadership Group

GAPS IN CONTROLS 1. Areas of non-compliance impacting on achievement of operational plan (e.g. Smokefree)2. No clear pathways of care for inpatients with chronic conditions to ensure appropriate

management alongside mental health treatment. Similarly, no clear pathways for ensuringprovision of mental health support if patient is transferred to an acute hospital.

3. Staff training required to ensure competencies to manage physical health needs.

GAPS IN ASSURANCES 1. Further monitoring of inpatient units required to determine NMP implementation

status.2. Leadership of project for physical health care at the Harbour requires

clarification.

05

10152025


RiskScoreRiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 3.2 The Trust does not build its communication and reputation with all stakeholders. DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5987

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: Business Planning & Transformation

GRAPH RATIONALE FOR RISK TARGET: The Board will seek to ensure that the Trust strengthens relationships with key stakeholders through effective communication and engagement.




12 12 8

3x4 3x4 2x4

RATIONALE FOR CURRENT RISK SCORE Reputational risks arising from operational decisions, serious incidents or industrial action. Reduction in level of satisfaction in the staff survey for 2014/15. Includes adverse media coverage, litigation, implications on service provision and commissioning intentions. CQC impact on reputation from impending report.

CONTROLS 1. Monthly contract and performance meetings2. Transition oversight group to oversee inpatient transition programme3. Chorley Public Service Reform Board4. Mental Crisis Concordat Working Group5. Pennine Lancs Transformation Programme6. Central Lancs Clinical Senate7. Vanguard Programmes across Blackpool Fylde and Wyre8. North Lancs Better Care Together9. Developing engagement with the Third Sector.10. Communicating and engaging with GP Practices, Healthwatch, CCGs and MPs

ASSURANCES

1. Development of shared services with Chorley Council2. Part of the two Vanguard programmes that are listed in Controls.3. Won a number of tenders:

Childhood Flu Immunisation & Vaccination Framework Wave 2 Criminal Justice Liaison and Diversion Services Type 2 Diabetes Structured Education Services Midlands and East of England Prison in-patient review Offender Health-Merseyside (HMP Liverpool and HMP Kennet) Mental Health of Military Veterans

GAPS IN CONTROLS 1. Commissioners approach the middle management tier at locality level rather than using the

construction of the contract (physical health, GP&SR; mental health, BwD).

GAPS IN ASSURANCES 1. Process for service development by passes the main contractual route and is

developed at locality level which can potentially impact on consistency ofservice model development .

2. No communication with GPs at locality level. GPs aren’t federated so they areall individual practices within 7 CCGs.

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs.

DIRECTOR LEAD: Human Resources Director DATIX NO: 5988

STRATEGIC PRIORITY: S04 People ASSURANCE COMMITTEE TO REVIEW: People

GRAPH RATIONALE FOR RISK TARGET: The Trust Board wants appropriate staffing targets to be achieved and staff to be developed to the highest of standards of what would be expected of a top preforming Trust.




15 15 10

3x5 3x5 2x5

RATIONALE FOR CURRENT RISK SCORE The Directorate is currently reviewing all systems relating to safe and compliant recruitment including a review of all management information to allow sufficient assurance on service delivery.

CONTROLS 1. KPIs - Recruitment2. HR SMT3. Workforce Committee4. Process Mapping5. Appreciative Leadership program6. Performance management process7. HR Interim engaged to cover functional governance and MI data quality8. Data governance standard operating procedures9. Functional governance framework10. Employment Law11. Data Protection Act12. PSL for Temporary Staffing13. HR Transformation Programme

ASSURANCES 1. Workforce Governance2. Safer Staffing Executive Committee3. PMO Board4. People Sub-Committee5. Employee Staff Survey6. Compliance with Data Protection Act7. Compliance with Employment Law8. ESR Data Quality Working Group

GAPS IN CONTROLS 1. HR KPI framework agreed but not yet implemented2. HR governance framework phase 1 implemented, phase 2 in development3. HR systems and data governance procedures require update4. Having a fit for purpose PDR recording system for use in LCFT5. Recruitment team procedural compliance gaps6. Temporary Staffing procedural compliance gaps within HR and the wider business7. Lack of cross functional establishment control procedure

GAPS IN ASSURANCES 1. No SOP in place for Establishment Control2. No functional Internal Audit procedures3. No regular reconciliation between Finance Ledger and ESR4. There is a limited use of internal service performance KPIs to ensure

compliance with HR policy and procedure

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in

a workforce who are unable to deliver high quality, safe care. DIRECTOR LEAD: Director of Nursing DATIX NO: 5991

STRATEGIC PRIORITY: S02 Outcomes ASSURANCE COMMITTEE TO REVIEW: People

GRAPH RATIONALE FOR RISK TARGET: The Trust Board does not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions




12 12 9

4x3 4x3 3x3

RATIONALE FOR CURRENT RISK SCORE There remains a need to improve the evaluation of performance reviews, however plans are in development as part of the Organisational Development Strategy.

CONTROLS 1. Training policies and procedures2. Appraisal and performance processes3. Mandatory training requirements4. Revised clinical risk tool and training5. Individual professional development requirements

ASSURANCES 1. People Sub-committee2. Quality and Safety Sub-committee

GAPS IN CONTROLS 8. Lack of a clearly defined Organisational Development Strategy

GAPS IN ASSURANCES 1. Access to training and performance development data

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability.


STRATEGIC PRIORITY: S04 People ASSURANCE COMMITTEE TO REVIEW: Finance

GRAPH RATIONALE FOR RISK TARGET: The Trust must be sustainable and resilient to remain viable, but given the inherent uncertainties in the environment it is unlikely to eliminate all risks to the Trusts long term position.




25 20 10

5x5 4x5 2x5

RATIONALE FOR CURRENT RISK SCORE Draft plan and initial projections indicate that Trust is not sustainable financially. The Trust has enough resilience to allow some time to generate mitigating actions.

CONTROLS 1. Executive Accountability2. Board/EMT3. Regulatory Monitoring4. Planning and Budgetary Control (inc CIPs)5. Policy procedure and process controls

ASSURANCES 1. Monthly Board Reports2. Quarterly Monitoring Returns3. Management Accounts4. Budgetary and CIP Reporting System5. Audit and Review6. OATs Reporting

GAPS IN CONTROLS 1. Contract Agreements2. Signed and Validated CIPs

GAPS IN ASSURANCES 1. Controls over unfunded expenditure2. Network assurances on CIP robustness and achievement3. Signed Contracts

05

1015202530


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 5.2 The Trust does not achieve the required efficiency savings whilst delivering and improving quality. DIRECTOR LEAD: Chief Operating Officer DATIX NO: 5993

STRATEGIC PRIORITY: S05 Money ASSURANCE COMMITTEE TO REVIEW: Operational Delivery & Performance

GRAPH RATIONALE FOR RISK TARGET: The Board will seek to ensure that the Trust strengthens relationships with key stakeholders through effective communication and engagement.




16 16 8

4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE There is a robust governance structure in place to overview and manage the financial and quality improvements required as a result of DTS. QIA's are undertaken for each scheme identified within DTS and each programme has a clinical lead identified to ensure quality and finance efficiency safely balanced.

CONTROLS 1. Executive Accountability.2. Board/EMT.3. Regular Monitoring.4. Planning and Budgetary Control (inc CIPs).5. Policy procedure and process controls.6. Regular Network Accountant engagement with their Networks.

ASSURANCES 1. Quarterly reporting to the Business Planning and Transformation Sub-

Committee2. Monthly reporting to the Operational Delivery and Performance Sub-

Committee3. PMO Office4. Programme Management Group 2x monthly5. Quarterly reporting to the Finance Sub-Committee6. Devising the assurance Dashboard for Sub-Committees, Committees and

Board7. Programme specific highlight reports which are RAG rated and report into

PAGS and PMG8. All DTS risks are aligned within DATIX and linked as appropriate9. All DTS projects and programmes are linked to BAF risks

GAPS IN CONTROLS 1. Understanding of the impact on budgets with the delivery of CIPs YTD as reporting being developed

still in this area. i.e. CIPs are being extracted from budgets but are budgets overspent or balanced as a direct result of the CIP plan and actions

2. Reporting is being planned to accurately show the amount of recurrent vs non-recurrent savingsdelivering the CIP values for 2015/16. This will demonstrate what risk is attached to future years delivery.

3. Reporting is being devised to quantify the detailed quality benefits for each programme and it’sassociated project

GAPS IN ASSURANCES 1. Assurance reporting is currently being designed and planned for

implementation from Sept 2015 onwards to report through the subcommittees and ultimately to Board

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence.


STRATEGIC PRIORITY: S06 Innovation ASSURANCE COMMITTEE TO REVIEW: Business Planning & Transformation

GRAPH RATIONALE FOR RISK TARGET: The Trust Board while encouraging research and innovation will not sanction risky ventures that put the Trust reputation or finances in jeopardy.




16 16 8

4x4 4x4 2x4

RATIONALE FOR CURRENT RISK SCORE Current score reflects the change needed with the Trust to embrace increased competition for current and new services and to become more market aware.

CONTROLS 1. Running the Innovation Incubator as a focus for internally and externally sourced innovation ideas.2. Promoting the Innovation opportunity on demand to management teams across the Trust.3. Developing partnerships with commercial organisations on product development, research and

grants applications in collaboration with HEI’s or other third parties (e.g. Regenerate PennineLancashire, Lancashire Enterprise Partnership).

4. Identify funding opportunities for Innovation development.5. Working closely with the NWC AHSN to establish LCFT as a Trust that has embraced Innovation

and is actively setting the innovation agenda in its market.6. Refreshing LCFT’s Intellectual Property Management policies and procedures.

ASSURANCES 1. Annual Innovation Survey will determine the state of the Innovation Culture.2. Monitoring reports to the Workforce Committee.3. CQUIN reporting to Commissioners.4. Intellectual Property registered by LCFT and 3rd parties in collaboration with

LCFT.5. Monitoring cost savings and quality improvements from innovations.6. Business Planning & Transformation Sub Committee

GAPS IN CONTROLS 1. Alignment of plans across local health economy and Lancashire need further development.2. Market analysis for 16/17 not yet undertaken.3. Strategic alliance tools and methodologies to developed and tested with Network and Corporate

functions.

GAPS IN ASSURANCES 1. Developing Research Board and TAS Board.

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 6.2 The Trust does not implement an IT enabled transformational programme that ensures transition to a clinical system which is used across all services and supports the Trust in the realization of its strategic objectives.


STRATEGIC PRIORITY: S06 Innovation ASSURANCE COMMITTEE TO REVIEW: Business Planning & Transformation

GRAPH RATIONALE FOR RISK TARGET: Low risk appetite as this is strategically critical.



Target Score

16 16 12

4x4 4x4 3x4

RATIONALE FOR CURRENT RISK SCORE Robust programme and project management will ensure that short, medium and long term objectives are met and that any deviation from the planned course will be recognised and mitigated against.

CONTROLS 1. Programme management and Governance2. Project management approach and governance3. Stakeholder management and communication strategy and plan4. Data driven mechanism for assessing effectiveness of stakeholder management5. Business change strategy and implementation of approach6. Data migration strategy and plan7. Benefits realisation strategy and plan8. Information management strategy and plan9. Resource management strategy and plan10. Integration approach - with Partners / GP’s LA’s 3rd Sector etc11. Configuration of forms, workflows, protocols12. Testing of solutions

ASSURANCES 1. Documentation of vision and Blueprint -2. Agreed suite of MSP products3. Documentation resulting from management boards and other governance and

control mechanisms4. Programme plan with tranches and agreed ( targeted) capability5. Resource plans at Programme and project level6. Project plan for each project in the programme7. Initiation document for each project8. Hi-lite reports and end stage reports for each project9. Integration with partners embedded in PID and Programme Plan10. Detailed map of stakeholders, Mapped with influence, interest and key

messages11. Evidence of communication of messages12. Evidence of effectiveness of communication ( Data)13. Testing strategy and plan14. Documentation of test scripts and sign off by Networks / deployment teams15. Current and future state maps and gap analysis16. Benefits and dis benefits of the future state identified and documented17. Design, build and test of forms / workflows ect in response to agreed future

state and benefits matrix18. Documented Business Change Strategy

05

101520


RiskScore

RiskTarget

19. Documentation of benefits, owners and Measures20. Regular (quarterly) statistics / reporting on benefits realisation21. Information Management - Inputs mapped against outputs / gap analysis and

gaps addressed - evidence of this22. Reports tested and tests documented23. Documentation of DM Strategy and plan24. Approval of tested DM by Services / Networks

GAPS IN CONTROLS1. Follow procurement good practice2. Programme Management and Governance3. Project management approach and governance4. Stakeholder management can communications strategy and plan5. Data driven mechanism for assessing effectiveness of stakeholder management6. Business change strategy and implementation of approach7. Data migration strategy and plan8. Resource management strategy and plan9. Integration approach ( Partners, GP's, LA's, 3rd sector etc10. Configuration of forms, workflows, protocols11. Testing of solutions

GAPS IN ASSURANCES

BOARD ASSURANCE FRAMEWORK 2015/16 7.1 The Trust does not comply with the Monitor Licence. DIRECTOR LEAD: Director of Governance &

Compliance DATIX NO: 5996

STRATEGIC PRIORITY: S07 Compliance ASSURANCE COMMITTEE TO REVIEW: Governance & Compliance

GRAPH RATIONALE FOR RISK TARGET: The Trust must be able to evidence compliance with all conditions of the Provider Licence. It is unlikely to eliminate all risks as the impact of any non-compliance will be high.




10 10 5

2x5 2x5 1x5

RATIONALE FOR CURRENT RISK SCORE The compliance with key Monitor reportable targets is currently evidenced however, a range of licence conditions are not currently monitored for compliance and therefore we are unable to evidence the assurance in these areas at this stage.

CONTROLS 1. Executive Accountability - through agreed portfolios.2. Review and implement the revised governance and assurance framework – transition through Q4

into 2015/16.

ASSURANCES 1. Quarterly Governance Return2. Chief Executive Assurance Report3. Board Balanced Scorecard & Executive Dashboard4. Audit Committee5. Finance Report has been refreshed and Finance Sub-committee is

established6. Corporate Governance and Compliance Sub-committee is established7. Quality & Safety sub-committee is established

GAPS IN CONTROLS 1. Processes to monitor compliance with policy.2. Lack of robust system to identify and record assurance

GAPS IN ASSURANCES 1. Fit and Proper Persons Test and Duty of Candour require robust

management and governance processes to be implemented.2. Full Board evaluation scoping to be undertaken in preparation for the

evaluation to take place in 2015/16.3. Ensuring that reporting to the Board is robust – timely accurate and

supports effective decision making with risk driven agendas

0

5

10

15

20


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 7.2 The Trust does not comply with statutory legislative requirements. DIRECTOR LEAD: Director of Governance &

Compliance DATIX NO: 5997


GRAPH RATIONALE FOR RISK TARGET: There is an unsatisfactory assurance around statutory legislative requirements within LCFT which could result in our regulatory bodies, such as Monitor and CQC, taking action.

RISK RATING: Original Score Current Score Target Score 16 16 4

4x4 4x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Trust cannot provide evidence based assurance that meets all Statutory Legislative requirements across the organisation.

CONTROLS 1. Development of a Policy Framework and SOPs in place.2. Three year Health & Safety Improvement Plan now in place.

ASSURANCES 1. We have recently undertaken an audit by Deloitte and have receive assurance

that we are currently compliant and are awaiting a formal report.2. Annual organisational audit return to NHS England.3. Network governance oversight of health and safety incidents and risks.4. Oversight by Executive Quality Committee and Health and Safety.

GAPS IN CONTROLS 1. No IG Governance Structure in place.

GAPS IN ASSURANCES 1. There is a limited audit and inspection programme, and no self-assessment of

compliance - this means most health and safety performance measurement isreactive based on incident data.

2. Policies may not reflect the Statutory Legislative Requirements.3. No systematic evidence to support compliance with policy.4. No corporate assurance.

05

10152025


RiskScore

RiskTarget

BOARD ASSURANCE FRAMEWORK 2015/16 7.3 The Trust does not comply with Mental Health Legislation. DIRECTOR LEAD: Director of Nursing DATIX NO: 5998





Target Score

12 12 4

3x4 3x4 1x4

RATIONALE FOR CURRENT RISK SCORE The Mental Health Law Team have now been centralised into the Nursing and Quality Directorate and new governance arrangements have been implemented at Trust level and within Networks. A new Mental Health Law Manager has been appointed. A new Mental Health Law computerised system is being rolled out initially to be used by Mental Health Law Administrators. The risk score reflects the position that whilst improvements are being made to Mental Health Act governance, the new arrangements are not fully embedded and errors continue to occur or historical errors are being identified through new systems and processes. Additionally, concern has been raised around compliance with the Mental Capacity Act and this is being explored further.

CONTROLS 1. Mental Health Law Sub-committee oversight2. eLearning training for Practitioners3. Mental Health Law Administrators Group for standardisation and sharing learning4. Multi Agency Mental Health Oversight Group for collaborative working across the health economy5. Associate Managers Forum for engagement and sharing of learning6. Mental Health Act policies and procedures7. Local Authority Partnership Working8. Improved Engagement with Clinical Commissioning Groups9. Independent Mental Health Advocacy Services10. Locality Police Mental Health Champions11. Clear and consistent governance reporting systems across the Networks and within the Trust12. Network Mental Health Law Forums13. Clinical Audit Programme

ASSURANCES 1. Quality Committee oversight2. Mental Health Law Sub-committee scrutiny3. Network Mental Health Law Forums scrutiny4. Associate Managers Forum5. Mental health law data reports i.e. KP906. Clinical audit

GAPS IN CONTROLS 1. Lack of a computerised system for administration of the Mental Health Act

GAPS IN ASSURANCES 1. Delay in deploying the electronic Mental Health Act Module of ECR

05

10152025


RiskScoreRiskTarget

Board of Directors

Agenda Item TB 073/15 Date: 28/07/2015 Report Title Academic Health Science Network (AHSN) North West

quarter one performance report


Prepared by Dr Liz Mear, Chief Executive, North West Coast Academic Health Science Network

Presented by Heather Tierney-Moore, Chief Executive LCFT




Report purpose The attached report shows progress against key areas of AHSN 2015/16 Business Plan.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor licence

CQC domain Well-led


Meeting Presented Action Date

AHSN Board meeting Liz Mear Update to AHSN Board 08/07/2015

EMT EMT Draft paper to EMT 20/07/2015

1

REPORT TO THE AHSN BOARD 8th July 2015

Title Quarterly Business Performance and Finance Report

Sponsoring Director Name: Lisa Butland Title: Director of Innovation and Research

Author (s) Name: Lisa Butland / Lorna Green Title: Director of Innovation and Research / Commercial Director

Previously considered by: Finance & Business Performance Committee

Executive Summary

The attached report shows progress against key areas of AHSN 2015/16 Business Plan.

Fit with AHSN objectives The performance measures are included in accordance with the AHSN’s five year plan, which was agreed by a wide group of stakeholders.

What risks may be posed by this course of action?

Actions and overview areas established by the plan may not be completed

If there are any risks how will they be mitigated?

The Finance and Performance Committee will monitor data and quarterly reports supplied to NHS England and the host Board

Are there any associated legal implications

No

Are there any associated equality implications

No

Are there any associated financial implications

No

Action required by the Board

To note and discuss the performance data

Item 4

2

North West Coast Academic Health Science Network (AHSN) Finance and Performance Report

This paper includes:

Section Subject Page

Section one Safety/Clinical/Commercial programmes dashboard and update

3

Section two Detailed programme update for: Innovation Culture 29

Section three Financial performance 30

Section four Funded projects update 31

Section Five Corporate Risk and Mitigation Register 31

3

Section one: Safety/Clinical/Commercial programmes dashboard and update

Patient Safety Collaborative Medicines Optimisation Executive Lead Lisa Butland

Programme Lead Aly Hulme

Executive Lead Lisa Butland

Programme Lead Patricia Roberts

Commercial Atrial Fibrillation/Stroke Executive Lead Lorna Green

Programme Lead Brian Griffiths


Programme Lead Julia Reynolds

MSK Reducing Alcohol related attendances Executive Lead John Goodacre


Executive Lead Lisa Butland/ John Goodacre


Mental Health Precision MedicineExecutive Lead Lisa Butland/ John Goodacre

Programme Lead Gill Hamblin


Programme Lead Gill Hamblin

Explanation of red ratings:

Medicines Optimisation: Supporting the adoption of evidence into practice: two meetings scheduled to take place in quarter 1 were cancelled, they have now been scheduled to take place in quarter 2 and performance is on track.

4

Patient Safety Collaborative

Strategic Goal Project Details Indicative

budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome

Categorisation Code(s)

alignment with

NHSE Impact AHSN CC Themes

NHSE Licence objectives

Essential Programme 1 Patient Safety leadership and culture

Developing capacity and capability - Board level /equivalent development in patient safety leadership and culture to include: 1. Safety Culture baseline assessment 2. Human Factors &Error 3. Measurement4. Safety cases 5. Sign up to Safety Campaign Across the care delivery system - Break through collaboratives

£104K

Develop specification with PS Governance forum stakeholders

Commission programmes Agree provider

Develop safety leadership capability at Board level Improving Safety culture for safer care

I3 C3 C 7 C11 L3 L4


Patient leader for the PSC Recruit a patient leader to inform and work with the patient safety collaborative programmes of work.

TBA Associate

Undertaking Gap analysis -as part of stakeholder engagement & participation strategy development

Develop JD and go out to advert across the NWC system

Patient Leader for patient safety Improving Safety culture for safer care

I3 L3 L4


Sustain and embed patient safety networks and champions from 2014/15 programme of work Outreach model utilising existing PS infrastructure such as PS Champions and Q fellows to build on safety and learning network delivered at a local level - recruiting champions

£30k

Develop and agree programme of work with existing provider (AQuA)

TBA Sustaining and embedding Developing QI infrastructure

I3 C3 C7 L3 L4

5


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Essential Programme 2 A regional strategy for patient safety measurement

A NWC Measurement strategy Analysis of available data through a safety dashboard Peer review and capability building: Film Reports Capability building: Workshops

2014/15 Time Costs

Develop draft Measurement Strategy Develop dashboard and Film Measurement Event 9 June 2015

Disseminate final measurement products

Measuring for improvement through good practice and capability development a. A NWC AHSN Safety Measurement Strategy and measurement dashboard b. Informing the national measurement strategy c. Building upon previous PSC work d. Links to PSC Clinical Safety Priorities

I3 C3 C7 L3 L4

Essential Programme 2 A regional strategy for patient safety measurement

Building and sustaining P2a NWC regional strategy on patient safety measurement to relict Sign Up to Safety Campaign - Local improvement plans develop a patient safety dashboard ELearning and film Measurement Workshop

£25K TBA

Develop and agree programme of work with existing provider (Haelo)

TBA

Measuring for improvement through good practice and capability development Alignment with Su2S campaign

I3 C3 C7 L3 L4

Providing safety training and development to staff working at patient care level

Develop capability through E- learning package for each one of the four clinical safety priorities: 1. Medicine optimisation (professions focused) 2 Hydration including Acute Kidney Injury (Care worker focused) 3. Transition of Care (CAHMS to AMHS) 4. Sepsis ( care home focused)

2014/15 Time Costs

Develop ToRs for Clinical Advisory Groups Plan monthly meetings Agreeing and developing content and format Building E learning package technology

Testing and developing

Developing capability through E- learning for each of our four clinical safety priorities:

I3 C3 C7 L3 L4

6


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Setting up learning networks around safety improvement themes

NWC learning and improvement network NWC - Patient Safety Collaborative Network Events (up to 50 attendees) 1xCapability Building Module: Measurement (up to 40 attendees) 1x Capability Building Module: Human Factors (up to 40 attendees) 1xCapability Building Module: Culture (up to 40 attendees) Identify

2014/15 Time Costs

1 x NWC - Patient Safety Collaborative Network Event 1x Capability Building Module: Measurement 1x Capability Building Module: Human Factors 1x Capability Building Module: Culture

Impact report (AQuA)

Developing capability Learning and improving

I3 C3 C7 L3 L4


Sign up to Safety National Campaign Pledge Sign up to Safety -Lancashire Su2S collaborative - Explore developing Su2S collaboratives across other health economies

Time Costs

Disseminate through Webpage Webinars & E newsletter Collaborative working with Lancs 2u2S Plan monthly updates from Campaign Director

NWC Su2S workshop

Active engage, promote and support the national campaign

I3 C3 C7 L3 L4

7


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with




Acting for Patient Safety learning from Serious Incidents Consultation with PSGF for questionnaire development Academic input into Questionnaire design and impact & outcomes assessment Pilot of AfPS1 to test system and collect data for academic intervention Pilot new system in Women’s and some units in Royal

2014/15 Time Costs

Testing & developing questionnaire Design web questionnaire with CUBE

Pilot new system in Women’s and some units in Royal Need to determine timelines for roll out to other organisations

Improving safety and reducing avoidable harms through learning from Serious Incidents

I3 C3 C7 L3 L4


Q Initiative is part of the PSC programme -NHS England- organise a national system of NHS Improvement Fellowships, to recognise the talent of staff with improvement capability. Recruit 10 improvement fellows across the NW C

Time costs

Recruit 10 improvement fellows across the NW C Nominations to HF 15 May 15 Notify nominees outcome 22 June 15

Develop proposal to scope for funding of regional improvement work in partnership with AHSNs Attend HF workshops

Building and creating the improvement landscape for learning and improving

I3 C3 C7 C11 C12 L3 L4

Developing patient safety champions or leads in each organisations

Cross ref 1b and 1c Cross ref 1b and 1c

Cross ref 1b and 1c

Champion Safety across the NWC increase number of champions (need to agree number on commissioning)

I3 L3 L4

Technology reviews to identify solutions to safety issues

Sepsis technology review Reviewing the best technology and innovations to for patient safety solutions in Sepsis identification and management

£6K

Agree and commission a technology review for Sepsis

A evidence based Sepsis technology review to identify solutions to safety issues

I3 C3 C7 L1 L3 L4

8


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Clinical Safety Programme 1 Residential Care Homes safety

Cross ref P 1 leadership P3 E learning a. Building safety capability across the care home system b. Developing an integrated clinical risk assessment tool c. Evidence of usingLearning from health and social care from other countries d. Collaboratingwith small and medium enterprises to explore what supportive equipment is available for patients so they can live independently e. Exploring how we adopted telemedicine in the care home setting and develop implementation plan Lancashire CC QA programme Explore telemedicine in the residential care home setting ) Care home safety/inequalities event in partnership with St Helen's CCG Partnership working with EMASHN and learning from other countries (Maastricht)

£100k

Scoping exercise with Lancashire CC stakeholders Scoping care home networks Link up with teleswallowing lead , CWP NHS Trust , EMAHSN PSC lead

Scope with COO St Helen's CCG and Lancashire CCG/CC Scope with PSG forum member

Improving safety in residential & care homes through a. Building safety capability across the care home system b. Evidence of usingLearning from health and social care from other countries c. Collaborating with small and medium enterprises to explore what supportive equipment is available for patients so they can live independently d. Exploring how we adopted telemedicine in the care home setting and develop implementation plan e. Reducing avoidableharms, costs and avoidable admissions.

I1 I3 C3 C5 C6 C7 C10 C11 C12 L1 L2 L3 L4

9


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Clinical Safety Programme 2 AHSNs PSC Sepsis Cluster

Cross ref P 2 ELearning P3 Measurement P6 technology reviews To undertake a technology review densify gaps in the body of knowledge and engage with local research networks and NIHR to determine the best way to close the gaps The cluster output will be a single set of clearly documented recommended actions and interventions

£15K

Form a Sepsis Clinical Advisory Group (AQuA, Patient rep, clinical and educational) links in with wider network -UK Sepsis Trust National Educational Forum) Produce cluster proposal paper DevelopToRs for cluster working Develop networks Secure membership with the UK Sepsis Trust National Educational Forum – met 20 April 2015

Agree ToRs for cluster working with AHSNs Develop and confirm contact database of AHSN PSCs and other partners organisations who lead on Sepsis and have related programmes of work National working at cross system sepsis programme board

Support existing programmes to reduce avoidable harms

Clinical Safety Programme 3 Establish and support of programmes on Medicine Optimisation

Cross ref P2 ELearning Disseminate outputs from Wessex AHSN PSC Cluster leads

£136K Please see breakdown below

Reducing harms—through medicine optimisation ,technology and developing capability:

I3 C7 L3 L4

10


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Clinical Safety Programme 4 Hydration including Acute Kidney Injury

Cross ref P3 ELearning PSC E Newsletter Contribute to AHSN PSC Cluster leads UCL AKI workshop & event for Commissioning and Primary Care

Time Costs

Save the date 9 September Collaboration with Renal Registry Think Kidney Campaign NHSE SCNs -develop draft programme

Agree and confirm speakers & programme

I3 C7 L3 L4

Clinical Safety Programme 4 Hydration including Acute Kidney Injury

Community Hospital – Hydration programme – Hydrate for Health

2014/15 Time Costs

Identification of teams participating in project train staff develop audit

Implementation

Improving safety and reducing avoidable harms through fluid management

I1 13 C4C7C9L1 L3 L4

Clinical Safety Programme 5 Transition of Care

Cross ref P 3 ELearning package CAHMS to AHMS

2014/15 Time Costs

Cross ref P3 I3 C4 C7 C10 L3 L4


E-referral systems to address patient flow in South Cumbria and North Lancashire, delivering co-ordinated and streamlined approach to patient transitions (Learning from Canada & expansion of interoperability across the Region

2014/15 Time Costs

E referral group Dolphin Lee (Care home group) resource matching group meet with John Roebuck project lead for Cumbria CCG

TBA Interoperability

I1 I3 C3 C5 C6 C7 C10 C11 C12 L1 L2 L3 L4

11


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with




Routine Enquiry into Adversity in Childhood

2014/15





Clinical Safety Programme 6 Staff Health and Wellbeing

Cross ref 1 a TBA based on a report commissioned by NWC AHSN findings- staff health and wellbeing

£20K TBA Associate

Exploratory meeting with Sue Henry

TBA I1 I3 C3 C4 C7 L2 L3

Active Engagement and Communication

Working Collaboratively Cross ref P4 NWC Patient Safety Collaborative E Newsletter Webpage Blogs Twitter Patient Safety Governance forum Clinical advisory groups AHSN Patient Safety Leads network Peer reviews Publications Conferences National working

Time costs

E newsletter x 2 PS Congress safety and innovation Judge PS leads meeting

Blog Newsletter re Q fellows , Pen picture & biography

Active engagement and involvement Collaborative working

I1 I3 C3 C5 C6 C7 C10 C11 C12 L1 L2 L3 L4

Active Engagement and Communication

On behalf of the NWC AHSN lead on developing a Stakeholder Engagement and Participation Strategy

2014/15 Time Costs

Commission programme of work to develop strategy 3 x Stakeholder listening events

? 1 x SME stakeholder event to take place Agreed NWC AHSN Strategy completed July/August

A NWC agreed Stakeholder Engagement & Participation Strategy

I1 I3 C3 C5 C6 C7 C10 C11 C12 L1 L2 L3 L4

12


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



PSC evaluation An evaluation of PSC 2014/15 programmes

2014/15 Time Costs

Work with Edge Hill University to agree areas for evaluation (level of evaluation is determined by previously agreed budget). Awaiting a revised proposal from EHU to deliver programme -agreed at PSG forum

Agree timelines and proposal

An completed evaluation to appraise PSC work and inform business plans 2015/16

Medicines Optimisation

Strategic Goal Project Details Indicative budget

Q1- Milestones - 5 stage RAG rating

Q2 - Milestones 5 stage RAG rating

Impact /Outcome

Categorisation Code (s) alignment with NHSE Impact AHSN CC Themes NHSE Licence objectives

Working collaboratively with stakeholders across health and social care

Expert group to provide high level direction, input and oversight.

£3K Meeting held

Meeting planned

WORKFORCE-Stakeholder engagement to focus on key priorities, developing an advocacy base to drive adoption

I2, C7, L3

13




Impact /Outcome


Supporting the adoption of evidence into practice

Development of a knowledge hub for sharing joint working initiatives between industry and NHS. Case studies approved by a multidisciplinary editorial board and endorsed by the AHSN. Details of the project / how it was implemented/ tools to implement/ barriers and enablers/ lessons learnt / impact and evaluation

£25k

Meeting with ABPI - agreement with the idea

Local SME commissioned to develop interface. Engagement meeting July 7th

CLINICAL Sharing of endorsed case studies to support uptake of medicines across the care pathway. Local, regional and national potential. WORKFORCE - endorsing the role of pharma in co- creating solutions to clinical challenges,

I1, I2. I3. C7.C9,C10,C11,L2,L3,L4

Identification and evaluation of innovation

Creating opportunities for industry to undertake proof of concept evaluations

£5K Liverpool Project on track

Application to innovation with impact competition

CLINICAL - Proof of concept studies in number of clinical settings. ECONOMIC - support international company to access NHS market and establish UK base

I2, C6,C7,C9,C12,L2,L3


Safe. Therapeutic, economic, pharmaceutical selection

£50k

Tentative commitment from Liverpool CCG

No interest from Lancashire. Other meetings planned NWCSU unsuccessful for lead provider - impact on engagement

WORKFORCE-changing role of pharmacy to clinical focus. ECONOMIC- Procurement to drive efficiency CLINICAL - Uptake of medicine to improve patient outcomes

i1,I2, I3, C8,C9.C10,L2,L3

Create a culture of innovation

Supporting Alistair Gray in region - Liverpool CCG scoping and feasibility study for transfer of patients from hospital to community pharmacy

£15k

Planning meeting with Liverpool CCG

Recruitment of project manager via Associate register

WORKFORCE- changing role of community pharmacy CLINICAL -optimise outcomes from hospital intervention ECONOMIC - prevent readmission into acute setting / reduce GP attendance

I1,L3,C3,C6,C7,C9,C11,L2,L3,L4

14




Impact /Outcome



Call to action. DVLA to provide clear guidance Empower people to go to their HCP for other therapies. HCP to ask patients with type 2 diabetes if the driving is part of their work and to consider this when prescribing Ambulance service to collect data Business Summit - LEPs/Health and Wellbeing Boards/ENWAS

£10

Planning meeting held with MSD and diary date with Diabetes UK

Follow on meeting with key project group to plan meeting. Spin out Programme plan with broader stakeholder group

Develop a co-ordinated plan with traditional and non-traditional stakeholders to support patients with diabetes who drive for a living to stay well and safe, remaining in work. Develop spin off activities

I1,I2,I3,C3,C7,,L3,L4


Supporting Medicines Management Solutions- local SME. Potential with Sefton and Wirral LA re digital adherence aids to support adherence

£5K

Meeting to discuss and development Innovation with Impact application Liaison with Rowlands pharmacy re the use of robotic dispensers

SBRI briefing for SMEs July 6th

ECONOMIC - supporting SME growth. CLINICAL - evaluation of innovation to inform commissioning decisions

I1,I2,I3,C3,C4,C5,C6,C9,C11,L1,L2,L3


Bone Health Campaign

£5k

Bone Health Campaign development - meeting cancelled

Meeting with stakeholders rearranged

CLINICAL - spread of best practice to optimise medicines across a care pathway ECONOMIC- pathway redesign , moving out of acute setting

I2,I3,C5,C11,L3,L4

Create a culture of Innovation

Pathway redesign for dressings

£3 Initial meeting June

CLINICAL - evidence based choice of dressings and supporting medication. Patient focused redesign of pathway ECONOMIC -rationalised use of NHS resources across the care pathway

I2,I3,C5,C11,L3,L4

15




Impact /Outcome



Presentation at ECHAlliance - Belfast - Support for LAMPS - Michael Martin

£2K Working closely with Prof Scott

Development of expert group

CLINICAL - import / export best practice. ECONOMIC - connected health across Europe

I2,C7,L3


Evaluation of Pharmacy First - minor ailments scheme

£5 Met with Fylde and Wyre CCG

Planning meeting with Lancaster University

ECONOMIC -evaluation of minor ailments scheme for community pharmacy to reduce GP attendance- inform commissioning decision

I2.C3,C7,C11,L3,L4


Evaluation of pathway redesign for ambulatory conditions

£2k

Meeting Dr Mehta and West Cheshire CCG - pending. Mat leave at CCG

Communication out to rearrange

CLINICAL - patient focused care pathway redesign to optimise the use of medicines ECONOMIC - reduced access to emergency care for ambulatory conditions

I3,C7,C12,L4


Market Access Plan - highlighted potential value in high cost drugs - scoping to determine potential

Time cost

Meeting with Graham Poston

Spec Comm - Malcolm Qualie - arrange follow on

CLINICAL /ECONOMIC Scoping - potential of Proteus for high cost drugs

I2,C6,C9,C12,L4


Spread of best practice to improve patient outcomes

Time cost

Meeting with MSD to discuss previous lack of engagement by key stakeholders

Follow up meeting - August

CLINCIAL /ECONOMIC Developing collaborative partnership with pharma. Improving access to medicines

I2,C7,L2,L4


Gilead Pharma in partnership with the RLH

£7k Initial meeting 19th June

Project initiation planned August

CLINICAL Developing collaborative partnership with pharma

I2.I3,C6,L3,L4


Ongoing collaboration between AHSNs and J&J

No cost

Boston Consultancy interview regarding home care for immunology

HIV care record feedback - Monthly call

WORKFORCE Developing collaborative partnership with pharma

I2,C7,L3

16




Impact /Outcome



TBC £5k Meeting August

CLINCIAL /ECONOMIC Developing collaborative partnership with pharma. Improving access to medicines

I2,C7,C10,L2,L3,L4


Alder Hey Children’s NHS Foundation Trust - evaluation of point of care testing for infection in partnership with Lancaster University

TBC Project planning meeting

TBC I2,C9,C12,L3

Commercial Programme


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Liverpool LEP Business Assist Programme

Support advice aligned with the New Markets programme in Liverpool City region

£30k

15 Companies engaged but limited conversion to contract phase

Final Delivery Report for the first phase needs to be complete by end Q2

Aligned with LEP targets on growth

Business Support, Effective Partnerships, Digital Data

Lancashire LEP Business Assist Programme

Business Support for SMEs in the areas of business. This includes any or all of the following: • Guidance for new product development programmes to ensure the product concept meets a clinical need and that regulatory requirements are, or can be, met • Evidence gathering • Designing studies that will provide

£100 19 Companies engaged

Multiple delivery workshops planned for Health Economics, Cost Consequence Modelling and Procurement

Aligned with LEP targets on growth


17


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



evidence for health economic analysis; • Health economics studies • Focus groups, customer / site visits and expert meetings to understand market and clinical needs • Access and introductions to potential customers and facilitation of meetings • Producing case studies to support future sales activities • Meetings with commissioners and / or procurement leads • Identifying and establishing collaboration partners within academia and / or the NHS for trials and evaluations, co-development and funding applications • Bid writingsupport and collaboration on bids if appropriate • Tender writingsupport

Stop & Go EU Project

The STOPandGO (Sustainable Technologies for Older People - Get Organised) consortium is a group of buyers and associated experts which offers an innovative procurement process aimed at securing cost-effective, care pathway oriented, sustainable and scale ICT-based telehealth and telecare services which will achieve clearly defined clinical and social outcomes. The target population to

£10k plus additional

£36k for LSE work packages

Recent TSA/CCG/AHSN event held at Alderley Park

Project enters regional procurement phase where each publish a local tender

Business Support, Effective Partnerships, Digital Data, Procurement

18


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



benefit from these products and services are frail and dependent elderly people, perhaps living with long term conditions such as Chronic Heart Failure and Diabetes, and their carers.

ENSAFE EU Project

ENSAFE envisages the creation of a supportive platform integrating the following different components, which were conventionally thought of as independent devices: • mobile communication and sensing through the GoLivephone device, developed by GoCiety • home environment monitoring through the CARDEAdomus system, developed by UniPR and distributed by I-cubo • tele-medicine products and physiological sensors, developed by METEDA.

£86k plus £86k as

match

Richard Harding in post (16 June)

Start date 1 July


General Business Engagement Activities

Ongoing enquiries from numerous business sources from within region, national and international

Ongoing Business Support

Procurement of Innovation

Keynote speech at national Procure4Health conference. Writing response to Lord Carter review on behalf of national AHSN network. Pilot

£20k Delivery phase

Procurement, C8 and spread of innovation L2

19


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



workshop for Trusts 15 July. Innovations with Impact competition in progress.

Excellence in Supply (EIS) Awards and Conference

Open Competition for NHS Suppliers in the Region together with a conference on procurement in November

Planning Phase

Judging

Procurement, Efficiency and supporting enterprise

Health Hubs Business Activities

AHSN has provided support to several of the Health Hubs in the Region

Invites for SMEs factored in for future meetings

Use of Technology

Red Rose Awards Acting as Judge on Awards

Planning Phase

Business Support

Bionow/Medilink Awards and Support

Sponsorship Planning Phase

Business Support

Alder Hey Hackathon

Business Support

20

AF/Stroke


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Deliver an awareness campaign for AF (Lancashire)

Public facing Campaign (9 events) Symposium for clinicians

£5K Events delivered

504 pulses taken, 34 irregular pulses identified. Media coverage over 100,000 through radio and local newspaper. Potential impact of identifying irregular pulses demonstrates possible strokes due to AF avoided both now and in the future. It is estimated that the UK spends £8.9 billion on stroke each year, 27% of this is direct care costs. • Every stroke prevented could save £23,315. In England during 2012/13 £103m was spent on AF Ischaemic Strokes which was 37.2% of all ischaemic stroke inpatient costs. • 30% of AF related stroke survivors are admitted to care homes. • 20% of strokes are caused by AF, but 75% of people affected do not know they have AF. People in their 40s have a 25% risk of developing AF. Strokes currently cost the public purse £20K in the first year and £6K every additional year the person survives. This is in addition to the £7,500 per year social care costs and costs borne by family and care-givers.

L4, L3, C12, C10, C9, C7, C5, I3

Support the development of genotype guided dosing for warfarin (Royal Liverpool, Countess, Arrowe Park, with University of Liverpool and LGC) Evaluation. Led by Professor Munir Pirmohamed

Project management and leadership support to a CLAHRC funded project

In kind support and a small budget £1,000 for travel and to support the events

Delays due to issues with the testing device

No impacts achieved yet, but potential

L3, L2, L1, C9, C7, C1,

21


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Support the development of telemedicine (Walton/Alder Hey) Management

Support for the development of a pilot system to look at telemedicine

£4K

Meetings delayed due to technical issues

Evaluation of delivering care differently. Costs identified in terms of travel time and patient outcomes and clinician and patient experience. Reduction of carbon footprint

L4, L3, L2, C10, C9, C8, C7, I3,

Support the improvement of identification and management in Primary Care (Wirral, West Lancs, South Sefton & Formby, and East Lancs).

Projects underway in both areas. Supported by industry

0 Training and audits are ongoing

Impacts will be demonstrated through the better identification and management of AF patients and the reduction of AF related strokes. Evaluation data will be provided

L4, L3, L2, C12, C9, C7,

Identify and support training for primary care (AF & anti-coagulation)

Piloting online training for AF

£5K

Identifying suitable people to pilot the online training has been problematic

Impacts will be identified through enhanced confidence in clinicians to identify and manage AF

L3, L2 L1, C12, C9, C7, C4

22


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Support self-management Management

Developing and evaluating Self Management

to be discussed

In development

Impacts will be demonstrated through improved outcomes for patients who are anti-coagulated on warfarin for AF. Less use of resources has been demonstrated elsewhere

L4, L3, L2, C10, C9, C7

Support for IAPT ADOPTs Study - Led by Professor Caroline Watkins

Identification and evaluation of the Access to Psychological Therapies for Stroke Survivors

Supported project in kind by leadership and project management

Support for scoping is ongoing

Impacts will be measured by better outcomes for stroke patients in terms of quality of life and use of resources. Commissioned IAPTs services by CCGs

L4, L3,L2, C10, C7, C5, C3, I3,

Support for Medtronics implantable loop Treatment

Working with C&M hospitals to pilot this loop device on patients who have had a stroke

Supporting discussions with CCGs

Support is ongoing

Impact will be, improved identification of AF following stroke

L4, L3, L2, L1, C12, C10, C8, C7, C4

My Stroke Guide – Stroke Association, Evaluation

Working with the Stroke Association, UCLAN, Countess, Research and Evaluation

£5 Support is ongoing

Impact will be trough improved outcomes through resources to support stroke survivors

L4, L3, L2, C10, C9, C7

Using MyDiagnostick in Primary Care, Care Homes and Community Pharmacy. Evaluation by UCLAN

Working with East Lancashire CCG to evaluate the roll-out of a technology to better identify AF in a range of community settings

£30K Project is on track

Impacts will be demonstrated in terms of improved outcomes for identification of AF in community settings

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

23


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Using Alive Cor in Primary Care to better identify AF patients

Deployment of Alive Cor devices to GPs across our area

£5K Project is on track

83 Devices were deployed. 90% of devices are in regular use. Outcomes are evaluated in terms of GP feedback (positive to date) and

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

Work on AF pathway with C&M SCN

Contribution to the electronic Care Pathway for C&M

£0 Project is on track

Pathway will be evaluated for impact and behaviour change. Ultimately to reduce the number of strokes

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

Work on AF took-kit with GM,L&SC SCN

£0 Delays due to staff changes

Tool-kit will help improved commissioning and promote consistent management of AF by clinicians

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

MSK


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Engage and develop partnerships

Expert group developed.

0 Establish the theme across stakeholders

L4, L3, L2, C10, C9, C7

24


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Introduction of effective medications, including biologic treatments, for inflammatory polyarthritis

Stakeholders identified and discussions in progress

tbd Introduce innovative and more effective treatments

L4, L3, L2, C10, C9, C7

A system to support improved management of back pain (StartBack),

Initial rollout in West Lancs and Halton CCGs. Other sites have partial use of it

£10K

More effective use of health care resources and improved patient outcomes

L4, L3, L2, C10, C9, C7

Alcohol


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Engagement & Partnerships

Developing a network of partners and engagement in the region

0 Foundation for development of engagement

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

25


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Identification and assessment of innovations

Examining and scoping innovations regarding evidence base

0 Ensuring a secure evidence base to future activities

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

Developing key partnerships to select innovations based on local issues

Highlighting scoping work and prioritising innovations. Developing focus and solutions through an Eco-system event

0 Ensuring stakeholder engagement

L4, L3, L2, LL1, C12, C10, C9, C7, I3,

Identifying industry/SME partners

Partners identified to develop joint working and mutually beneficial activities

0 Joint working identified L4, L3, L2, LL1, C12, C10, C9, C7, I3,

Support for national event in partnership with Drinkwise

Developing a series of workshops with feedback from national experts

£5K

26

Mental Health


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones

5 stage RAG rating

Impact /Outcome


alignment with



Work with Commissioners and Public Health, Build

a culture of partnership and

collaboration

MENTAL HEALTH-Zero Suicide - Innovate Depression

100K Initial workshop held

2nd workshop September 2015, agree project definition and scope

Zero Suicide for Merseycare inpatients (tbc), suicide prevention strategies, improvement in well-being,

L4, L3, L2, C12, C11, C10, C9, C7, C6, C5, I3

Rapid spread of Research and Innovation into Practice, Work with Commissioners and Public Health, Build a culture of partnership and collaboration

MENTAL HEALTH-REACh - Routine Enquiry into Adverse Events in Childhood

50K

Project Plan in place, Meetings dates agreed, approach for crown-sourcing agreed

Steering Committee date in place monthly

Training programme for staff to implement REACh, Earlier detection and prevention of MH conditions, Improved treatment, Improved awareness, engagement with service users

L4, L3, L2, C12, C10, C7

Rapid spread of Research and Innovation into Practice, Build a culture of partnership and collaboration, Cross Cutting with Innovation Culture workstream

MENTAL HEALTH-Innovation Scouts MH Forum, dedicated MH Action Learning Set for current MH Innovation Scouts

0

Spread and scaling up of innovations in Mental Health, improved care and integrated models of care,

L3, L2, C7, C3

Build a culture of partnership and collaboration

MH Transition CANMHS to AMHS, cross cutting with Patient Safety

Content supplied to Edge Hill to develop e module for signposting, improving capability and raising awareness

Testing of module, in line with Lay's timeline

Central module for access to signposting to other organisations, increasing capability and raising and improving awareness of Transitions issues

L4, L3, C11, C9, C7, C3, I2

27

Precision Medicine


budget

Q1- Milestones 5 stage RAG

rating

Q2 - Milestones 5 stage RAG

rating

Impact /Outcome


alignment with



Prime Action Plan Develop a medium term action plan (3 years)

0

Action Plan

completed to

determine

shot,

medium and

long term

goals for

next 3 years.

Awaiting sign

off at AHSN

Board July

2015.

TBC

Improved economic growth in the region. New partnerships with industry and Pharma. Improved capability.

L4, L3, L2, L1,

C13, C10, C9,

C7, C5, C3, C1,

I2, I1.

Cross cutting work stream- Precision Medicine: Implementation of the 100,000 Genomes Project - CANCERS

£56k year 2014/15 £56k year 2015/16

Pilot for Breast, Lung and Ovarian Cancers to commence August 2015 at RLBUHT, LWH AND LHCH ONLY

Pilot to be

completed

by 1st

October

2015 (

subject to

sufficient

numbers of

successfully

recruited

patients)

Improved health outcomes. Reducing inequalities in health. improved access to genetic testing. Innovation in diagnostic techniques. NHS Transformation- by Nov 2017 genetic testing will be embedded into diagnostic patient pathways for Rare Diseases. Well engaged public and professionals. Highly skilled workforce. Intelligence to enable longer term objective of development of new targeted drug therapies and screening programmes.

L4, L3, L2, C12, C11, C10, C9, C7, C5, C3, C1, I3 and I1

cross cutting work stream- precision Medicine: Implementation of the 100,000 Genome Project- RARE DISEASES

£56k year 2014/15 £56k year 2015/16

'Go live' Implemented in patients with a Rare Disease- patients being recruited since April 2015

Recruitment against agreed contracted trajectories with each Local Delivery Partner

Improved health outcomes. Reducing inequalities in health. improved access to genetic testing. Innovation in diagnostic techniques. NHS Transformation- by Nov 2017 genetic testing will be embedded into diagnostic patient pathways for Rare Diseases. Well engaged public and professionals.

L4, L3, L2, C12, C11, C10, C9, C7, C5, C3, C1, I3 and I1

28

Highly skilled workforce. Intelligence to enable longer term objective of development of new targeted drug therapies and screening programmes.

Diffusing of Innovation


budget

Q1- Milestones

5 stage RAG rating

Q2 - Milestones 5 stage RAG

rating Impact /Outcome


alignment with



To increase the capability & capacity within the NHS for diffusing innovation to maximise the impact for patients and carers

Establish an Innovation Forum

£250k

3rd core event taken place

Agreed set of values and behaviours

4th Core event to focus on industry engagement

Minimum of 3 core events pa with 60% attendance at each event

Evidence of increased uptake of innovations within partner organisations

Contribute to the evidence base

Celebration of innovators event

Participant satisfaction


Create an action learning set for mental health innovation scouts

Ongoing within MH

Arrange an initial meeting and agreed ToR

Evidence of increased uptake of innovations within partner organisations

MH


Collaborate Project with NHSE and CLAHRC

Ongoing

29


Design a workshop in collaboration with HNS IQ

Workshop co-designed and date set for Q2

Workshop Participant satisfaction

Partner in the National Innovation Accelerator Fellow Programme

Participated in all 3 national co-design owrkshops

Active participants in the recruitemtn process

Fellows announced on 6 July, contributing to national communications

Evidence of using national expertise to shape our local Innovation Scout Programme

IC

Progress against these targets is reported on a quarterly basis to NHS England, the AHSN’s representative Board, Finance and Performance Committee and Lancashire Care Board. RAG criteria can be found in Appendix 1.

Section two – Detailed programme update: Innovation Culture

2.1 Innovation Culture: Executive Lead: Lisa Butland, Programme Lead: Jen Gilroy-Cheetham

In December we launched the AHSN Innovation Scout Programme. The first cohort (of 37 members) is made up of NHS leads, nominated by their Chief Executive for being natural leaders, interested in innovation and prepared to try new things. We have since worked together to develop a set of shared values, and agreed on these:

The diversity of backgrounds and experience of our members, brought together with a shared vision to develop the capability for diffusing innovation across the North West Coast, provides us with a real opportunity.

We have committed to co-designing the programme going forward and at our third event, held last week, we explored the implications of the Five Year Forward View, what is happening in the region in respect of Vanguard sites and test beds, how knowledge

30

mobilisation systems can support innovators, a range of innovations in medicines optimisation and using open innovation approaches to engage with industry.

Measuring the impact of Innovation Scouts back in their organisations is notoriously difficult, how do you know if an introduction resulted in a new product further down the line? But the scouts have agreed to document their learning after each event and describe how they plan to contextualise that learning in their own organisation so we can review the impact of our programme.

We have also launched the ‘Innovation toolkit’, a suite of on-line templates/tools that an organisation can tailor for their own use. The toolkit was originally funded by RIF (the Regional Innovation Fund) and developed in collaboration with The Walton Centre, Lancashire Care, Southport and Ormskirk, St Helens and Knowsley, Liverpool Community Health, Cheshire and Wirral Partnership, Countess of Chester and the NWC AHSN.

A key element of the programme is to expose Scouts to innovations from other sectors; we are planning to see how lean methodology has informed the design of aircraft and a visit to 3M’s Innovation Centre. We have a comprehensive website with resources, development opportunities and tools which the Scouts can deploy in their organisations and an on-line forum where members can post the latest articles, details of events or seek help and support from the group.

We have been featured in the June Briefing produced by the NHS Confederation and The AHSN Network ‘Cracking the innovation Nut’ and were invited to share our approach at the NHS Confederation’s Annual conference earlier this month. Already, we are collaborating with Yorkshire and Humber and Oxford AHSNs to run joint events, and have sessions being planned on 3D printing, the NHS Change Model, Whiteboard Animation, IP, Innovation in Procurement and Thought Diversity, as well as a masterclass with Helen Bevan (this will be open to a wider group than the Scouts). All our events evaluate very well, with over 4 out of 5 stars.

Our immediate priorities are to: develop an approach to recognise the Innovation Scouts for their role; design the next session which will focus on how to engage with industry to develop your innovations, produce case studies of innovations that are already bringing benefits to patients in our geography, brand our successes to motivate others to join the cause and create an engagement strategy for our industry and academic colleagues.

If you want any further information on this programme please contact either Lisa Butland or Jen Gilroy-Cheetham

Section three: Financial Performance Executive Lead: Dr Liz Mear

As at Month 2, the AHSN is underspent by £435k, with a forecast full year position of £0.06k underspend, very near to breakeven. The Innovations for Impact Campaign is currently underway, with £500k of the budget allocated for this. Once the successful bids have materialised the current year to date underspend is expected to drastically reduce. The deferred income total of £317k has been deferred again into Month 3. Plans against the deferred income, still need to be confirmed and as they are materialised, the total of the deferred income should reduce from month to month.

A summary of financial issues, which has been prepared by the Lancashire Care Finance Department, is attached at Appendix 2.

31

Section four: Funded Projects Executive Lead: Lorna Green

The AHSN has funded a number of projects across the region. We are working closely with MIAA (Mersey Internal Audit Agency) to implement a robust monitoring system Detailed work has now been completed to introduce a programme verification process with a proforma system defined for progress capture; scheduling project by project and validation milestone agreed.

Future Board reports will include detailed progress updates from this system, a summary of the funded projects are included in Appendix 3.

Section five; Corporate Risk and Mitigation Register Executive Lead: Dr Liz Mear

Only one risk has been categorised as having a ‘high’ likelihood and ‘high’ impact, this is the annual funding cycle which creates a lack of confidence with stakeholders and potential job applicants, which makes it difficult for the AHSN to attract appropriate staff. As the NHS England funding structure unlikely to change, the AHSN is mitigating by strong communications and marketing of the valuable contribution of its work. Full details of all corporate risks can be found in Appendix 4.

32

Appendix 1 RAG Rating Definitions and Programme Updates


Impact categories AHSN cross-cutting themes NHSE Licence objectives

Efficiency an

d su

pp

ortin

g

enterp

rise

Develo

pin

g the eco

system

Patien

t and

po

pu

lation

be

nefits

Precisio

n m

edicin

e

Usin

g Gree

nsp

ace in h

ealth

Futu

re wo

rkforce

Bu

sine

ss sup

po

rt

Resid

en

t invo

lvemen

t

Digital H

ealth/d

ata inte

gration

Effective partn

ership

s

Pro

curem

ent

Use o

f techn

olo

gy

Red

ucin

g health

ineq

ualities

System in

tegration

Preven

tion

& early d

etectio

n o

f d

isease

Wealth

creation

thro

ugh

ado

ptio

n

of n

ew p

rod

ucts

Spread

of in

no

vation

Cu

lture o

f partn

ership

and

collab

oratio

n

Patien

t and

po

pu

lation

ne

eds

I2 I3 C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 L1 L2 L3 L4

Business Area Progress, Last period

R A/R A A/G G

Major issues are presently hindering progress of a deliverable or deliverables within the business area Or, a future threat or threats exist that are almost certain to have a major impact on the delivery of a deliverable or a number of deliverables in the business area. Immediate action is required to address these issues to ensure that work can proceed as planned.

Significant issues are present hindering progress of a deliverable or deliverables within the business area. Or, a future threat or threats exist that are likely to have a significant impact on the delivery of a deliverable or a number of deliverables in the business are Urgent action is required to address these issues to ensure that work can proceed as planned.

Moderate issues are present hindering progress of a deliverable or deliverables within the business area. Or, future threat or threats exist that are likely to have a moderate impact on the delivery of a deliverable or a number of deliverables in the business area. Short-term action is required to address these issues to ensure that work can proceed as planned.

Minor issues are present which are not yet hindering progress but, without attention in the medium to long term, will impact on overall achievement of a deliverable or deliverables within the business area.Or a future threat exists that is likely to have a minor impact on the delivery of a deliverable or a number of deliverables in the business area.

There are no issues currently present and all deliverables are on track to be achieved.

Business Area progress summary (inc. rationale for RAG status and key achievements)

Business Area Progress, Current Status

RAG definitions for PROGRESS

Provide a short narrative on the reason for the RAG, including actions to address present issues and ratings of amber through to and including red.

This information is populated by the rating from the last returned report.

33

Financial Performance Appendix 2

NWC AHSN Finance Performance Report 2015-16

Month 02 (May 2015)

Income & Expenditure

Budget Actual Variance Comments Budget Forecast Outturn Variance Comments

Non NHS Sundry Income 0 0 0 0 0 0

NHS Sundry Income (25,846) (13,010) (12,836) (155,075) (155,045) (30)

Membership Income (8,334) (6,667) (1,667) (50,000) (50,000) (0)

NHS England Funding (658,750) (658,750) 0 (3,952,500) (3,952,470) (30)

INCOME TOTAL (692,930) (678,427) (14,503) (4,157,575) (4,157,515) (60)


PAY TOTAL 241,504 191,797 49,707 1,449,022 1,384,191 64,831


Stroke AF 5,333 1,126 4,207 32,000 33,126 (1,126)

Procurement 10,000 0 10,000 60,000 60,000 0

Digital Health 0 (195) 195 0 (195) 195

Patient Safety Collaborative 72,667 175 72,492 436,000 436,175 (175)

Economic Growth 111,167 (30,800) 141,967 667,000 666,200 800

Innovation 62,887 8,128 54,759 377,324 385,288 (7,964)

Precision Meds 18,283 0 18,283 109,700 109,700 0

Workforce 0 0 0 0 0 0

Cancer 4,167 0 4,167 25,000 25,000 0

Mental Health 16,667 0 16,667 100,000 100,000 0

Msk 8,333 0 8,333 50,000 50,000 0

Alcohol 8,333 0 8,333 50,000 50,000 0

5 Year Forward View 33,333 0 33,333 200,000 328,847 (128,847)

CAMPAIGNS TOTAL 351,170 (21,566) 372,736 2,107,024 2,244,141 (137,117)


Drugs 0 (78) 78 0 (78) 78

Provisions & Kitchen 958 483 475 5,750 4,647 1,103

Printing & Stationery 1,917 773 1,144 11,500 1,810 9,690

Postage 333 56 277 2,000 370 1,630

Telephones 1,333 253 1,080 8,000 4,109 3,891

Advertising 19,877 (7,934) 27,811 119,261 12,066 107,195

Travel, Subsistent & Removal 16,667 16,858 (191) 100,000 112,611 (12,611)

Lease Cars 833 0 833 5,000 4,170 830

Training 8,127 5,545 2,582 48,760 31,360 17,400

Electricity 833 353 480 5,000 2,451 2,549

External Service Contract 3,167 3,351 (184) 19,000 18,351 649

Furniture, Office & Computing 2,167 678 1,489 13,000 1,077 11,923

Computer Maintenance 5,500 5,506 (6) 33,000 33,506 (506)

Rent 9,667 9,490 177 58,000 57,290 710

Building & Engineering Equipment 0 0 0 0 0

External Associates 15,210 5,928 9,282 91,258 144,828 (53,570)

Other Miscellaneous 333 19,076 (18,743) 2,000 20,672 (18,672)

Contribution to Overheads LCFT 13,333 13,333 0 80,000 80,000 (0)

NON PAY TOTAL 100,255 73,671 26,584 601,529 529,241 72,288


SURPLUS / (DEFICIT) (1) (434,525) 434,524 0 59 (59)

Year to Date - 2 Month 2015/16 Full Year





34

Month 02 May-15 Finance Report

L9060

Academic H'Lth Science Network

Type EST WTE Account Account Name Annual Budget Budget Actual Variance Budget Actual Variance

L9060 0 0 R220400 Nhs Trust -£40,000 -£3,333 -£3,333 £0 -£6,667 -£6,667 0

L9060 0 0 R221010 Nhs England Non Etr -£2,010,551 -£167,546 -£167,546 £0 -£335,092 -£335,092 £0

INCOME Subtotal -£2,050,551 -£170,879 -£170,879 £0 -£341,758 -£341,759 £0


PAY Subtotal £1,449,022 £124,397 £96,738 £27,659 £241,504 £191,797 £49,706


L9060 0 0 X201010 Drugs 0 0 0 0 0 -£78 £78

L9060 0 0 X212070 Beverages £250 £21 £59 -£38 £42 £110 -£69

L9060 0 0 X212100 Hospitality Provided £5,000 £417 £325 £92 £833 £373 £460

L9060 0 0 X212140 Catering Equipment £500 £42 0 £42 £83 £0 £83

L9060 0 0 X217010 Print & Stationery £6,000 £500 £36 £464 £1,000 £36 £964

L9060 0 0 X217030 Stationery 0 0 £76 -£76 0 £76 -£76

L9060 0 0 X217040 Photocopies And Scanning 0 0 0 0 0 -£1 £1

L9060 0 0 X217060 Books Journals Subscriptions £3,000 £250 £378 -£128 £500 £378 £122

L9060 0 0 X217080 Office Sundries £2,500 £208 £68 £141 £417 £284 £133

L9060 0 0 X218010 Postage £500 £42 £31 £10 £83 £31 £52

L9060 0 0 X218020 Franking £1,000 £83 0 £83 £167 0 £167

L9060 0 0 X218040 Carriage/Delivery Charges £500 £42 0 £42 £83 £25 £58

L9060 0 0 X219010 Telephones £500 £42 0 £42 £83 0 £83

L9060 0 0 X219040 Mobile Phones £7,500 £625 £386 £239 £1,250 £253 £997

L9060 0 0 X220020 Promotion & Marketing £119,261 £8,272 -£1,708 £9,979 £19,877 £399 £19,477

L9060 0 0 X220700 Misc 0 0 0 0 0 -£8,333 £8,333

L9060 0 0 X221020 Staff Travel £60,000 £5,000 £8,736 -£3,736 £10,000 £14,747 -£4,747

L9060 0 0 X221110 Travel - Bt+ £40,000 £2,917 £839 £2,077 £6,667 £2,111 £4,556

L9060 0 0 X222020 Lease Cars £5,000 £417 0 £417 £833 0 £833

L9060 0 0 X223030 Conferences/Courses £48,760 £3,230 £2,582 £649 £8,127 £5,545 £2,582

L9060 0 0 X224010 Electricity £5,000 £417 £210 £207 £833 £353 £481

L9060 0 0 X228010 External Service Contracts £19,000 £1,583 £2,104 -£521 £3,167 £3,351 -£185

L9060 0 0 X229020 Furniture, Fittings, Fixtures 0 £0 £616 -£616 £0 £616 -£616

L9060 0 0 X229030 Office Equipment £5,000 £417 £40 £377 £833 £40 £793

L9060 0 0 X229040 Computer Hardware £4,000 £333 0 £333 £667 0 £667

L9060 0 0 X229060 Computer Licenses £4,000 £333 0 £333 £667 £22 £645

L9060 0 0 X230010 Computer Maintenance 0 0 £6 -£6 0 £6 -£6

L9060 0 0 X230990 Computer Maintenance Recharges £33,000 £2,750 £2,750 £0 £5,500 £5,500 £0

L9060 0 0 X232010 Rent £58,000 £4,833 £4,756 £78 £9,667 £9,358 £309

L9060 0 0 X232030 Room Hire 0 £0 £132 -£132 £0 £132 -£132

L9060 0 0 X236030 Professional Fees £0 £0 0 £0 £0 0 £0

L9060 0 0 X236050 Consultancy £91,258 £6,876 £5,928 £948 £15,210 £5,928 £9,282

L9060 0 0 X238240 Insurance £2,000 £167 £165 £2 £333 £325 £9

L9060 0 0 X238310 Professional Membership Fees 0 0 £18,000 -£18,000 0 £18,000 -£18,000

L9060 0 0 X238340 Modernisation Initiatives 0 0 £0 £0 0 £0 £0

L9060 0 0 X238550 Other Consultancy 0 0 0 0 0 £751 -£751

L9060 0 0 X299010 Non Pay Reserve £80,000 £6,667 £6,667 0 £13,333 £13,333 0

NON PAY Subtotal £601,529 £46,482 £53,180 -£6,698 £100,255 £73,671 £26,584

Grand Total L9060 £0 £0 -£20,961 £20,961 £0 -£76,290 £76,290

----------------------Period-----------------------------------------------------Year to Date------------------

35

L9071

Ahsn - Modern Initiatives

L9071 EST WTE Account Account Name Annual Budget Budget Actual Variance Budget Actual Variance

L9071 0 0 R220100 Sundry Income -£155,075 -£12,923 -£13,010 £87 -£25,846 -£13,010 -£12,836

L9071 0 0 R220400 Nhs Trust -£10,000 -£833 0 -£833 -£1,667 0 -£1,667

L9071 0 0 R221010 Nhs England Non Etr -£1,941,949 -£161,829 -£161,829 £0 -£323,658 -£323,658 £0

PAY Subtotal -£2,107,024 -£175,585 -£174,839 -£746 -£351,171 -£336,668 -£14,503


L9071 0 0 X212100 Hospitality Provided 0 0 £135 -£135 0 £930 -£930

L9071 0 0 X238340 Modernisation Initiatives 0 0 £0 £0 0 £0 £0

L9071 0 0 X238341 Stroke Af £32,000 £2,667 £100 £2,567 £5,333 £1,126 £4,207

L9071 0 0 X238342 Procurement £60,000 £5,000 0 £5,000 £10,000 0 £10,000

L9071 0 0 X238345 Digital Health 0 0 -£215 £215 0 -£195 £195

L9071 0 0 X238346 Patient Safety Collaborative £436,000 £36,333 £175 £36,158 £72,667 £175 £72,492

L9071 0 0 X238347 Wealth Creation £667,000 £55,583 0 £55,583 £111,167 -£30,800 £141,967

L9071 0 0 X238349 Innovation £377,324 £31,444 £7,034 £24,410 £62,887 £7,198 £55,689

L9071 0 0 X238390 Precision Meds £109,700 £9,142 0 £9,142 £18,283 0 £18,283

L9071 0 0 X238392 Workforce 0 0 £5,400 -£5,400 0 0 0

L9071 0 0 X238393 Cancer £25,000 £2,083 0 £2,083 £4,167 0 £4,167

L9071 0 0 X238395 Mental Health £100,000 £8,333 0 £8,333 £16,667 0 £16,667

L9071 0 0 X238396 Msk £50,000 £4,167 0 £4,167 £8,333 0 £8,333

L9071 0 0 X238397 Alcohol £50,000 £4,167 0 £4,167 £8,333 0 £8,333

L9071 0 0 X238398 5 Year Forward View £200,000 £16,667 0 £16,667 £33,333 0 £33,333

CAMPAIGN Subtotal £2,107,024 £175,585 £12,629 £162,956 £351,171 -£21,565 £372,736

Grand Total L9071 0 £0 -£162,210 £162,210 £0 -£358,233 £358,233

TOTAL AHSN BUDGETS Annual Budget Budget Actual Variance Budget Actual Variance

Income -£4,157,575 -£346,464 -£345,718 -£746 -£692,929 -£678,427 -£14,502

Pay £1,449,022 £124,397 £96,738 £27,659 £241,504 £191,797 £49,707

Non Pay £2,708,553 £222,067 £65,809 £156,258 £451,426 £52,106 £399,320

£0 £0 -£183,171 £183,171 £1 -£434,524 £434,525

Plus Deferred Income Balance from 14-15 317508

Total YTD Underspend / (OverSpend) - Including Deferred Income £752,033

----------------------Period-----------------------------------------------------Year to Date------------------

36

Funded Projects Appendix 3 ** PLEASE NOTE AN UPDATE ON THE LATEST POSITION WILL BE SHARED WITH BOARD MEMBERS IN ADVANCE OF THE MEETING **

Funded Infrastructure and Investment Projects Investment Investment type Amount

(£) Year invested

Match funding (£)

Other investment secured as a result of initial investment

Short term ROI

Longer term ROI measures and impact

Annual ROI PM

2013 2014 2015 2016 2017

University of Lancaster

Infrastructure - sponsorship of an Entrepreneur in Residence for Lancaster University

£150,000 2013/14 £17m £17m received in 2014 from LEP and RGF 1 job created

Jobs created, business formed and relocated from outside NWC

£17m BG / auditor

Objectives and Outcomes

Funding enabled confidence in the project and support with the LEP to ultimately gain the £17m (£12m Regional Growth Funding and £5m LEP). Entrepreneur in Residence working with Commercial team to develop SME support in Lancashire in partnership with LEP and developing the offer for tenants in the innovation hub under development. Continue to track progress.

Liverpool BioInnovation Hub

Infrastructure - capital investment into Liverpool Bio-Innovation Hub

£150,000 2013/14 £15m £15m Jobs created, business formed and relocated from outside NWC

£15m Ended


Funding was capital into building as match funding for the £15m – now built

37

Alder Hey Training Centre

Infrastructure - capital investment into Alder Hey paediatric training centre

£150,000 2013/14 Training and development of future consultants, which includes innovation in the training pathway

Ended


Funding was capital into building – now built

Cheshire Innovation and Research Centre

Infrastructure - investment in new research and innovation hub for Cheshire

£26,000 2014/15 £26,000 from Countess of Chester

Future investment e.g. from LEP, research funding secured, SME collaborations, new products and jobs created

Auditor


Chorley digital health hub

Infrastructure - investment in new digital park

£25,000 2014/15 £25,000 Chorley Council

Jobs created, business formed and relocated from outside NWC

NWSIS / auditor


Not paid out- assessing input from IT consultant to scope the work

38

Bid Writing Research grants and programmes - funding of bid writing support

£50,000 2014/15 circa £2.85m from the £50k

Each will be tracked to measure specific / relevant outcomes including service transformation efficiencies and savings and associated jobs created

Tracker received monthly from GE / auditor to monitor progress of specific projects supported.


£765k for Liverpool City Region from Transformation Challenge Award, £1m from IDCF for LPRES (tender out for first tranche of work), 100,000 genomes (value to region?). Successful bids for RIF and SBRI (total tbc) Following the successful outcomes in 14/15 GE Finnamore have become Associate Partners within the core business plan to work with us and partners on future bids. Specific projects supported will continue to be reported on.

European collaborations

KIC (InnoLife) £25,000 2014/15 Funding secured by CLC – need to be included in specific applications to deliver part of the programmes in NWC; specific measures of impact to be developed for each element of the programme delivered

EU Associate Partner / auditor



AAL European grant £84,226 (in kind match)

£84,226k over 3 years

BG / auditor

39


ENSAFE Project (Elderly orientation, Network based services aimed at independent life) The overall objective of ENSAFE is to meet some of the societal and service provision related challenges posed by ageing society, and aims to support a more effective prevention and self-care strategy for both the elderly user and the caregiver. It is also expected that the project activity will create more room for inventive and flexible market actors, widening the possibility of SMEs by means of networking.


Stop and Go European Grant

£30k match (in kind) over 3 years £21k in 2014/15

£30k over 3 years £21k in 2014/15

BG / auditor


The STOPandGO (Sustainable Technologies for Older People - Get Organised) consortium is a group of buyers and associated experts which offers an innovative procurement process aimed at: - securing cost-effective care - care pathway oriented - creating a critical mass of innovative and sustainable ICT-based tele health and tele care services , which will achieve clearly defined clinical and social outcomes.

LEP support Economic Growth £50,000 2013/14 £30,000 from

LCR LEP

Inward investment (£,

jobs)

LG / AR

Objectives and

Outcomes

Marketing campaign to promote Liverpool City Region. Integrated with campaign for Health Enterprise Hub which brings together the LEP, NWC AHSN, LHP and the SCN. Website live, stage 2 in

progress

LEP support Post for sector growth £80,000 2014/15 £80,000 from

LCR LEP

1 job

created

Economic growth of

health and life sciences

sector, inward

investment,

jobs created

LG

Objectives and

Outcomes

A jointly funded post reporting to both LEP and AHSN to align activities of both organisations within Liverpool City Region. Awaiting start date from successful candidate.

LEP support Post for sector growth £50,000 2013/14 £50,000 from

C&W LEP

1 job

created

Auditor

Objectives and

Outcomes

Recruited and actions achieved

40

Infrastructure,

research and

economic

growth

RLBUHT Accelerator

Hub

£100,000 2013/14 £70,000 from

LCR LEP

Economic growth,

inward

investment, research

funding and

collaborations, jobs

created,

spin-out companies

AR /

auditor

Objectives and

Outcomes

Funds held at LCR LEP. Funding proposal going to 22 April Board

Infrastructure,

research and

economic

growth

Precision Medicine

strategy

£20,000 2013/14 £14,000 from

LCR LEP

Further

funding

from LEP

in

2015/16

from ESIF

funds

Economic growth,

inward

investment, research

funding and

collaborations, jobs

created,

spin-out companies

GH

Objectives and

Outcomes

PRiME document delivered

Infrastructure,

research and

economic

growth

Connected Health

Innovation Partnering

Platform - dedicated

N3 aggregator for

academia, NHS and

SMEs growing digital

economy by enabling

digital technologies to

link to and access NHS

IT infrastructure

£136,000 2014/15 £189,000

from

Liverpool

CCG and

commercial

partner

Growth in digital

economy / SMEs by

enabling digital

technologies to link to

and access NHS IT

infrastructure

NWSIS /

auditor

Objectives and

Outcomes

Connected Health Innovation Partnering Platform - dedicated N3 aggregator for use by academia, NHS and SMEs to support growing digital economy by enabling digital technologies to link to and

access NHS IT infrastructure.

Currently with new digital services typically need to provision an N3 connection from their service into the NHS, takes 6 months and IG accreditation. Collaborative N3 infrastructure will be based

41

at AIMES Grid Services, an ISOP27001 certified, NHS IG compliant facility and will be installed by BT. This will reduce the time for new services to connect, in accordance with HSCIC standards, to 1

month from 6 months.

Infrastructure,

research and

economic

growth

Employment and

Enterprise Hub within

Centre for Recovery

and Social Inclusion

£125,000 2014/15 £900,000

from

MerseyCare

Return to work and

new employment stats

GH /

auditor

Objectives and

Outcomes

Mersey Care is investing £0.9m into a physical Centre for Recovery and Social Inclusion that will incorporate a range of social health innovations supporting integrated recovery pathways. This

additional funding is to incorporate an Employment and Enterprise Hub within the centre.

The hub will be accessed by service users, carers, staff and the public so as to facilitate recovery and social inclusion and address public mental health needs.

It will integrate existing models of vocational support and engage local employers, entrepreneurs, the voluntary sector and the local community to design innovative solutions to social exclusion,

health inequality, unemployment and stigma.

Infrastructure,

research and

economic

growth

Innovation Hub for

healthcare sensor

technologies

£280,000 2014/15 £925,000 in

resource &

equipment

from industry

partners.

Potential for

£900k more

plus grant

opportunities

Inward investment,

jobs created, patents

filed, products

developed and

commercialised / spin-

outs

LG /

auditor

Objectives and

Outcomes

700 sqm of space identified in Phase 1 (main) building to house an innovation hub. Significant commitment from BT and Karl Storz, with interest from Philips and Sony. Our funding would be used

to fit out the concrete shell, walls, flooring, utilities etc. in order to show commitment to the project to secure other investment from corporates and charities.

Incorporating a hospital ‘living lab’ and co-creation space the hub will be used for testing, training and co-creation and has the potential to become a showcase for the region. Looking to

collaborate with Boston Children’s Hospital to become a key partner to industry for trials, co-creation and regulatory approvals work. Key focus will be sensor technologies developed in

collaboration with Sensor City and HPC at Daresbury

Infrastructure,

research and

economic

growth

City deal combined

service centres

£36,000 2014/15 £5k S. Ribble

Partnership,

£3k S.Ribble

Borough

Council

Auditor

42

(further £16k

tbc), £250k

City Deal

funding £50k

other

partners tbc

Objectives and

Outcomes

Research carried out for Lancashire LEP has shown that many organisations from different sectors are considering joint use of facilities and co-location of services primarily for financial, service

delivery and equality purposes.

A number of strategic partners including Chorley and South Ribble CCG, Lancashire County Council, Lancashire Fire and Rescue, North West Ambulance, South Ribble Borough Council, Enterprise

Lancashire, Lancashire Police and Progress Housing have already discussed the potential for a joint working/co-located facility as a result of South Ribble Partnership’s cross-sector approach.

Discussions underway to secure £250k City Deal monies from South Ribble Borough Council and Lancashire County Council (£6m pot available), keen to seek our support securing £50k match from

partners.

Infrastructure,

research and

economic

growth

Cheshire Learning and

Improvement

Academy

£100,000 2014/15 Establishment of the

academy, further

investment and

measures of key

activities and impact of

these

LB /

auditor

Objectives and

Outcomes

The pioneer programme brings together 2 councils and 4 CCGs to efficiently deliver integrated care. The proposal is for a Cheshire Learning and Improvement Academy (CLIA) – a scalable

education and training resource to assist Cheshire in achieving systematic quality and improvement. A self-improving institution underpinned by a recognised accredited training programme and

linked to the integration agenda and academic partners.

• Developing clinical/social care staff to meet the new challenges

• The development of new roles across boundaries, to meet the needs of the person

• Teaching a common quality/system improvement methodology

• Teaching common aspects of leadership approach at all levels

• Development of new skill sets such as those needed for person centred care, shared decision making, coaching for wellbeing and person activation

Funding is requested for 1 wte to scope learning needs, establish procedures across partners and plan the setup of the Academy.

43

Infrastructure,

research and

economic

growth

Leadership and project

support for 100,000

genomes project

£59,703

plus

£59,703 in

15/16

2014/15 Match

£59,703 by

RLBUHT,

£59,703 by

LWH

GH /

auditor

Objectives and

Outcomes

Infrastructure,

research and

economic

growth

Sefton Council/ Well

North/ Semitae

'Predict' - a digital

solution/ mobile

assessment tool that

can identify needs and

link to health and

social care

Infrastructure,

research and

economic growth

systems, building on

the Semitae

framework developed

in Stockport.

£88,000 2014/15 Free base

software

from Integro

Health improvement

and wellbeing of

individuals and families

in the most deprived

communities

Digital

Associat

e/

auditor

Objectives and

Outcomes

Semitae Predict – development of a digital tool based on the Semitae solution a framework technology for assessment and multi-agency support for troubled families already proven in Stockport

using key workers. Rather than this model Well North works with whole communities to support them to find solutions to problems based on their own community and personal assets. ‘Predict’

will enable mobile assessments and identification of needs to engage with resources / support services to deliver social prescribing.

Focus on some of the most deprived areas in the North: Sefton initially then Oldham and Doncaster proposed pilot sites – opportunity for AHSNs to collaborate

Infrastructure,

research and

economic

growth

Cumbria Rural Health

Forum - an integrated

approach to adoption

of digital technologies

that address rural

£15,000 2014/15 Match of

£15k from

NENC AHSN

NWSIS /

auditor

44

health and social care

issues

Objectives and

Outcomes

Second phase development of the Cumbria Rural Health Forum established to address rural health and social care issues – activities include think tank, website improvements, quarterly forums,

patient groups, SME engagement, conference, briefing papers and presentations / network events.

Patient Safety Acting for Patient

Safety - dissemination

of initial pilot of AfPS1

£38,854 2014/15 £66,554 from

LHP

AH /

auditor

Objectives and

Outcomes

Building on the Acting for Patient Safety educational package, funding is sought to further develop and disseminate more widely through improved IT infrastructure and evaluation to deliver a

robust learning package that could be utilised across the NHS.

Patient Safety Strata e-referral -

implementation of a

co-ordinated and

streamlined approach

to patient transitions.

£115,000 2014/15 Previously

had £220k

from NHSE

and £95k

from NENC

AHSN

AH /

auditor

Objectives and

Outcomes

Implementing the Strata e-referral and resource matching software to address patient flow problems in South Cumbria and North Lancashire, delivering a co-ordinated and streamlined approach to patient transitions. This is tried and tested, used comprehensively across Canada for the last 15years and builds on work undertaken in Cumbria over the past two years, with health and care organisations, including University Hospitals Of Morecambe Bay Foundation Trust (UHMB) and Cumbria County Council (CCC), with the aim of co-ordinating patient transitions between health and care organisations working across North Lancashire, who have signalled their support:

Lancashire County Council, Adult Social Care services Blackpool Foundation Trust, Community services Greater Manchester West FT, Drug and Alcohol services St John’s Hospice, Lancaster – Palliative care and end of life services Lancashire Care FT - Community and Mental Health services North Lancashire CCG – Joint commissioner of acute, community and mental health services

45

Patient Safety Restorative Integral

Support Infrastructure

for individuals with

high levels of Adverse

Childhood

Experiences. Scaling

up routine enquiry

(REACh), improving

interventions and

follow up.

£50,000 2014/15 £450,000 crowd

sourcing fundraise

GH /

auditor

Objectives and

Outcomes

Funding sought to kick start a crowd sourcing campaign to secure £500k to establish a Community Interest Company that will provide an agile platform to create and service the demand for

Adverse Childhood Events (ACE) and Routine Enquiry into Adversity in Childhood (REACh). Driving improvements in education, identification, response, evidence based interventions and

scalability to achieve a sustainable change in practice

46

Funded Innovation projects

Partner Organisation

Project Amount (£)

Year funding provided

Project summary and outcomes PM

LaSCA NHS Agency

Lancashire Patient Record Exchange Service

£250,000 2013/14 Establishment of a personal health Record

NWSIS


Objective: to develop an integrated patient record system for residents in Lancashire Further £1m funding secured from successful IDCF bid.

The Cumbrian Centre for Health Technologies CaCHeT

Tele health Adoption Study

£25, 000 2013/14 £25,000 from CSC

Tele health readiness adoption tool for future system use

Ended or PM/ auditor needed


Tool developed to test how ready regions are to adopt tele-health

Lancaster University

Health Economics Post-Doctoral Fellow

£140,000 2013/14 Post Doc fellow involved in developing health economic measures for NWC AHSN programmes and collaboration with Proteus Digital Health.

JR


Objective –

to support the health impact and evaluation process for new innovations and programmes that are being tested in the area and will help provide evidence for NICE and commissioners to support the delivery of advice, training and support to the business assist programme to develop health economic capacity and capability in the region

47

Update: A PhD student has been recruited and will start in October.

University of Liverpool

Innovation Framework

£72,000 2013/14 Working with Royal Liverpool and Broadgreen, Liverpool Heart and Chest, Lancashire Care and Lancashire Teaching Hospitals to develop a comprehensive NHS innovation framework for the NWC. The project will identify the core components, structurally and culturally, that enable good innovation within and between NHS Trusts, the framework is to be piloted in July and then rolled out more widely across the NW C by the end of 2014. Once the framework has been agreed it will be delivered by Professor Jiten Vora who will meet with trusts to identify opportunities for them to improve their innovation capability and capacity.

Ended


Not successful due to other organisations not accepting one approach to innovation. Innovation Scouts programme commenced, which so far has been successful.

Alder Hey Paediatric Neurology telemedicine service

£50,000 2013/14 The Health Foundation Bid was unsuccessful, but the project is moving forward with delivering an established telemedicine service to Leighton and the Countess with two additional sites identified in Jan 2015 and an economic evaluation developed with Lancaster University.

JR / auditor

Objectives and Outcomes To develop a telemedicine system for Paediatric Neurology at Alder Hey and deliver it across 2 key partners

Update: The technology has been deployed and is up and running with 2 sites at Leighton Hospital and the Countess of Chester. It has become part of routine practice. Further sites are under consideration at Stoke and Isle of Man

48

uMotif, Liverpool Heart & Chest and Lancs Teaching hospitals

Reducing re-admission through self-management (heart failure and head and neck cancer)

£50,000 2013/14 Reducing readmissions in Heart Failure Patients – Liverpool Heart and Chest – Lead Dr Jay Wright. The App has been developed with the team, including a patient representative and is now being used with patients. The evaluation has been built into the operating system and will be delivered by Lancaster University in February, 2015. The timelines have slipped by 2 months due to the summer break and the negotiation with Trusts relating to research ethics issues The evaluation will report in Spring 2015.

Reducing readmissions in Head and Neck cancer patients – Lancashire Teaching Hospital – Lead Dr Ligy Thomas. The App has been developed and is now being used by patients. The evaluation should be completed by Spring 2015.

Lead New

Objectives and Outcomes Update – both Apps have been developed and deployed. An evaluation will be delivered in May

Objectives: To develop Apps with clinical staff which are appropriate for patient use To evaluate the Apps to determine the impact on patient experience and outcomes

Liverpool Heart & Chest

Online pre-operative diabetes screening cardiothoracic surgery

£48,000 2013/14 70 devices purchased and agreement in place with supplier to provide secure network. Statisticians engaged and stakeholders informed. 5 patient pilots planned for July then roll out. The project has been delayed - current status: Staff has been trained on the study and is actively engaging with patients with regards to the study. To date there have been two screen fails and no one has entered the study proper as yet but set-up is complete and they actively trying to recruit.

Ended


Not successful – external investigation underway

49

Medipex Range of support activities for NWC AHSN

30,000 2013/14 NHS Expo SME engagement £6k - report received of all contacts for AHSN database and follow up by AHSN commercial manager once in post. Two-way CDA produced. Provision of SLAs for other projects and collaborations are planned. Remaining budget will be used to support activities for the procurement event in November and to support with the LEP business assist programme in Lancashire.

BG (Ended)


All delivered

Clatterbridge Centre for Oncology

Range of support activities for NWC AHSN

£25,000 2014/15 Clatterbridge in the Community – implementation of the Cancer Treatment at Home Service GH / auditor


To collaborate on the development and implementation of the transformation of chemotherapy service delivery. To improve the quality of patient experience and increase levels of patient satisfaction To improve patient outcomes To evaluate the cost effectiveness of delivering chemotherapy services at home To increase capacity in the delivery of chemotherapy To provide education and training to staff so that a highly skilled and competent workforce is utilised To engage with industry and promote AHSN collaboration

East Lancs Hospital and CCG

DM tele health solution

£35,000 2014/15 Roll out of a DM tele-health system across East Lancs. Access to computer or telephone line, literacy in English, or IT literacy, are not required. Patients receive reminder texts and treatment advice can be given by telephone, text or email.

Digital Associate / auditor


Promote and support telehealth solutions

50

East Lancs CCG and UCLAN

Evaluation of AF pilot extension

30,000 2014/15 NHS Expo SME engagement £6k - report received of all contacts for AHSN database and follow up by AHSN commercial manager once in post. Two-way CDA produced. Provision of SLAs for other projects and collaborations are planned. Remaining budget will be used to support activities for the procurement event in November and to support with the LEP business assist programme in Lancashire.

JR / auditor


Extension of AF detection pilot from 1 GP practice to 5 GPs, 16 residential and care homes and pharmacists. CCG will fund clinical service costs and devices and AHSN funding will be used to pay UCLAN to carry out an evaluation and resource dissemination activities.

Lancaster University

Researcher in Residence

£150,000 2014/15 Funding for a two year post JG / auditor


To embed a researcher into region wide projects and promote a culture of evidence base/ evaluation.

51

Section Five: Risks and Mitigation

Risk Likelihood Impact Mitigations

Annual funding cycle creates

lack of confidence with

stakeholders and potential job

applicants, which makes it

difficult for the AHSN to attract

appropriate staff.

H H NHS England funding structure

unlikely to change. AHSN will

mitigate by strong

communications and marketing

of the valuable contribution of its

work.

Lack of agreement across the

region on implementation of

annual plan.

L H Extensive engagement from the

start with all relevant stakeholder

organisations through the

Industry forum around position

statements.

Relevant stakeholders (e.g.

industry, academia, local

authorities) do not feel

sufficiently engaged in

determining the priority

improvement areas.

M M Extensive engagement around

selection of priority improvement

areas through a variety of

forums. Also other engagement

tools e.g. NHS Access, NW AHSN

Innovation Expo.

Trusts do not implement AHSN

approved innovations and

service improvements.

H M Extensive engagement

encouraging nominations for

AHSN approved innovations and

service improvements, as well as

concerning the evaluation and

selection of AHSN approved

innovations and service

improvements. Liaison with

CCGs as appropriate to

incorporate commitments within

contracts to incorporate the

implementation of approved


improvements.

Innovation scouts appointed in

Trusts do not have the

responsibilities capabilities and

skills to make sure NWC AHSN


improvements implemented.

L M NWC AHSN has supported

organisations to choose the most

appropriate staff to be Innovation

Scouts by providing a role

descriptor. Ongoing training is

supporting the Scouts

52

Risk Likelihood Impact Mitigations

Lack of integration with LEP

plans.

M H LEP representation on AHSN

board already and also helping to

shape business plan.

Lack of engagement from local

partners causing unco-

ordinated regional plans

M M Strong representative Board,

widely published stakeholder

events and various forums for

each sector of the triple helix

Delivery against some digital

health targets and systems

interoperability targets may

need support and may divert

attention from regional and

national spread of good

practice.

M H Mi project and the integrated IT

projects have dedicated teams

and AHSN will support via

Programme/ Project Leads

Conduct of one neighbouring

AHSN may affect the

performance of NWCAHSN/ the

reputation of Northern AHSNs

H M Strong work of NWC AHSN

Support of AHSN Network for a

collaborative way of working

AHSN staff on short term

contracts, lose motivation to

work on programmes and be

collegiate

H M Strong team spirit has been built

up with supportive policies and

procedures for staff in place

Board of Directors

Agenda Item TB 074/15 Date: 28/07/2015 Report Title Use of the Common Seal


Prepared by Umme Batan, Corporate Governance Support

Presented by Diane Halsey, Director of Governance and Compliance


Supporting Executive Director Executive Director of Governance and Compliance


Report purpose To note the Use of the Common Seal



Board Assurance Framework risk 7.2 the Trust does not comply with statutory legislative requirements

CQC domain Well-led

1.0 EXECUTIVE SUMMARY To inform the Board that the Common Seal has been used as follows since the Board meeting on 28th April 2015:

New Progress Housing Association & Lancashire Care NHS Foundation Trust - Lease relatingto The Oxford Annex Foundations Building, Oxford Street, Preston, PR1 3SG

Section 75 Agreement between Lancashire Care NHS Foundation Trust and Lancashire CountyCouncil of County Hall, Preston, PR1 8XJ (2 copies signed)

Derwent Holdings Limited and Lancashire Care NHS Foundation Trust - License to install acharging point beyond property demished. Office Building C, West Strand, Business Park, WestStrand Road, Prest9on, PR1 8UY

New Progress Housing Association & Lancashire Care NHS Foundation Trust - Lease relatingto The Oxford Annex Foundations Building, Oxford Street, Preston, PR1 3SG – Signing of plan

Lancashire County Council and Lancashire Care NHS Foundation Trust – Property Leaserenewal of Daniels Lane Centre, Daniels Lane, Skelmersdale, WN8 9NH (2 copies signed)

2.0 BOARD ACTIONTo note the use of the Common Seal.

board of directors board/trust... · diane halsey, director of governance and compliance . andrew...

Documents