board of directors - royal berkshire hospital...1 board of directors thursday 28 may 2015 11.00am...

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Board of Directors Thursday 28 May 2015 11.00am – 1.20pm Boardroom, Level 4, Royal Berkshire Hospital We are here to provide a comprehensive service, based on clinical need, not an individual’s ability to pay. We aspire to the highest standards of excellence and professionalism and to put patients at the heart of everything we do. We are committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. We are accountable to the public, communities and patients that we serve.

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

Caroline Ainslie

11.00 – 11.10

1. Apologies for Absence

Janet Rutherford -

2. Minutes: 28 April 2015 (Attached to approve)

Janet Rutherford 11.10 – 11.15

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


4. Declarations of Interest (Verbal to note)

Janet Rutherford -

Strategy & Partnerships 5. a) Chief Executive’s Report

(Attached) b) Strategy Developments (Attached)

Jean O’Callaghan

11.20 – 11.40

6. Corporate Risk Register and Board Assurance Framework (Attached)

Caroline Ainslie 11.40 – 11.50

Integrated Performance 7. a) Integrated Performance Report

(Attached) b) Finance Report (Attached)

Executive Team

11.50 – 12.10

8. Monitor Action Plan (Attached)

Jean O’Callaghan 12.10 – 12.20

Agenda

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9. Monitor Annual Self-Certification (Attached)

Craig Anderson 12.20 – 12.30

Culture, Workforce & Infrastructure 10. Monthly Workforce Report

(Attached)

Paul Beal 12.30 – 12.40

11. Trust Improvement Programme (Attached)

Bernie Bluhm 12.40 – 12.50

12. Review of Standing Financial Instructions (Attached)

Craig Anderson 12.50 – 12.55

13. Board Committee Review (Attached)


Minutes of Board Committee Meetings 14. To note and agree recommendations

a) Operational Performance & Finance Committee 28 April 2015 b) Resources Committee 11 May 2015 c) Clinical Governance Committee 14 May 2015 d) Audit & Risk Committee 18 May 2015 (Verbal)

Janet Rutherford Sue Hunt Janet Rutherford Brian Hendon

1.00 – 1.10

Other Items

15. Board Work Plan (Attached)

Caroline Lynch -

16. Date of Next Meeting Monday 29 June 2015 (Verbal)

Janet Rutherford -

17. Exclusion of the Press and Public (Verbal)

Janet Rutherford -

Coffee Break 1.10 – 1.25 Closed Board Meeting - Part 2 The following section of the meeting will be closed to the press and public as the material to be discussed discloses exempt information as defined by the Freedom of Information Act.

Agenda Item 2

Minutes of the Board – 28 April 2015 1

Board Tuesday 28 April 2015 11.00am – 2.45pm Boardroom, Royal Berkshire Hospital, Reading Members Present Mrs. Janet Rutherford (Non-Executive Director and Acting Chair) Mrs. Jean O’Callaghan (Chief Executive) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance and Interim Deputy Chief Executive) Dr. Lindsey Barker (Medical Director) Mr. Paul Beal (Director of Workforce & Organisational Development) Ms. Bernie Bluhm (Interim Chief Operating Officer) Mr. Julian Dixon (Non-Executive Director) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Ms. Sue Hunt (Non-Executive Director) In attendance Mrs. Caroline Lynch (Interim Trust Secretary) Mrs. Heather Allan (Director of IM&T) (for minute 70/15) Mr. John Taylor (Director of Strategy) (for minute 63/15) Apologies There were five governors, three members of staff and one member of the public present. The meeting commenced with a patient story from the Director of Nursing. The Director of Nursing gave an overview of patient feedback submitted to the NHS Choices website from a maternity patient. The patient, a first time mother, had reported that she had experienced a difficult labour which had resulted in an emergency Caesarean section being performed. However, the patient had reported that the care, compassion and support provided by midwives had made this difficult experience easier to cope with. The Board noted that patient comments on the NHS Choices website were monitored and fed back to relevant department. In addition, the Trust responded to comments within 48 hours. The Board congratulated Dr. Lindsey Barker on her recent appointment as Medical Director. 58/15 Minutes: 30 March 2015 The minutes of the meeting held on 30 March 2015 were approved as a correct record and

signed by the Chair.

Minutes


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59/15 Schedule of Matters Arising and Outstanding Decisions The interim Trust Secretary submitted the schedule of matters arising from the last meeting

and outstanding issues from previous meetings. Progress against each decision was noted. Minutes 36/15 and 44/15: Matters Arising: Review of the Meeting: 44/15: Trust

Improvement Programme: The Acting Chair advised that a recommendation in respect of the Operational Performance & Finance Committee would be submitted to the May Board.

Action: J Rutherford/C Lynch 60/15 Declarations of Interests

There were no declarations of interest. 61/15 Minutes of Meetings

The Board received the draft minutes of the following meetings:

Audit & Risk Committee 19 March 2015 Clinical Governance Committee 26 March 2015 Charity Committee 30 March 2015 Operational Performance and Finance Committee 30 March 2015 Resources Committee 13 April 2015 The Chair of the Charity Committee advised that the Committee were continuing to review developments in respect of the proposed merger with the Reading & District Hospitals Charity. A due diligence exercise was ongoing. The Chair of the Resources Committee gave a verbal update on the outcome of the meeting on 13 April 2015. The Chair advised that the Committee had reviewed the IT Strategy, approved two business cases and had received the monthly workforce report. The Committee had also received an update in respect of the Pathology Business Case and had recommended that the full business case be submitted to the May meeting ahead of submission to the May Board. The Chair of Operational Performance & Finance Committee gave a verbal update on the outcome of the meeting held on 30 March 2015. The Chair advised that the Committee had reviewed the quality performance dashboard including ED performance and cancer wait treatment targets. The Committee had also received and endorsed the newly developed performance dashboard which would be in use from May onwards. Resolved: that the minutes of the meetings be received and the recommendations therein endorsed.

62/15 Chief Executive Report

The Chief Executive submitted a report summarising key strategic and other issues since the February Board meeting. The Chief Executive advised that following the recent appointments of Dr. Lindsey Barker as Medical Director and, Ms. Mary Sherry as Chief Operating Officer, who would be joining the Trust in June, the recruitment of the Executive team, was now completed.


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The Chief Executive reported that future options for the Trust’s pathology services had been discussed at the Resources Committee and the business case for the preferred option would be presented to the Board in May. The Chief Executive reported that the preferred option to create a new NHS Joint Venture Berkshire Surrey Pathology Services would be presented to the Board in May. The Chief Executive reported that she had been invited to attend a two day Chief Officers Group for the local health economy along with the Director of Finance and the Medical Director. The Board noted that the Executive had agreed a number of measures for tightening pay control. Clarification was sought as to what new measures had been introduced. The Director of Workforce & Organisational Development advised that vacancy control meetings were held each week and the workforce productivity programme would introduce a focussed change to drive recruitment plans in order to further reduce agency spend. It was noted that there were ‘hotspot’ areas, particularly in respect of ward based nursing, which presented challenges to recruitment. There continued to be a shortage of nurses in the UK and overseas recruitment was not as successful as it had been in the past. The Director of Workforce & Organisational Development advised that work was ongoing to make NHSP a more attractive option for agency nurses. It was agreed that a stretch target for nursing recruitment would be submitted to the Board. Action: P Beal The Board noted that the NHS England ‘Sign up to Safety’ campaign had been launched across the Trust during April. The Director of Nursing advised that a series of information seminars had been held covering a wide range of patient safety topics. The Quality Strategy would also be refreshed during 2015 taking into account the Quality Account priorities for 2015/16. The Board discussed the Clinical Administration review programme. The interim Chief Operating Officer advised that the interview process for staff affected had concluded the previous week. The review had proven difficult and challenging for staff. Training would be provided throughout May to enable the Clinical Admin teams to begin their new ways of working from 1 June 2015. The Director of Workforce & Organisational Development advised that staff affected by the review had been supported throughout the process by the HR team and individual meetings had been held at the beginning and the end of the process. There had been lessons learned identified from the review which would be taken forward with any future workforce reviews. The Board noted that the Clinical Admin review had been implemented as a result of the significant number of complaints received relating to clinical admin processes and the review would result in a standardised and improved process for patients. Resolved: that (a) a stretch target for nursing recruitment be submitted to the Board (b) the report be noted.

63/15 Strategy Developments The Chief Executive introduced the report and advised that following the Strategy

Workshop held on 23 and 24 March a road map had been developed. The Trust’s vision was to achieve seamless delivery and excellence in patient care outcomes. Collaborative working with other organisations, in particular, improving links between acute and primary care to deliver integrated care were also planned.


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The Director of Strategy advised that the two day workshop had been extremely beneficial. The Director of Strategy advised that clinical teams were fully engaged with the development of the strategy and each clinical strategy had been reviewed against the overall road map. The Chief Executive advised that a communications plan would be developed to ensure the strategy would be successfully implemented and links with other organisations developed. Each strategic objective would have an Executive lead to ensure ownership and progress would be regularly reviewed as the strategic plan was developed further. It was agreed that the strategic plan would need to be flexible and linked with the Clinical Commissioning Groups (CCGs).

Resolved: that

(a) the Strategic Road Map for the Trust be approved and progressed for discussion with staff and stakeholders. (b) the update be noted

64/15 Quality Performance Report

The Director of Nursing and the interim Chief Operating Officer submitted the quality performance report.

The interim Chief Operating Officer advised that the year to date position in respect of ED performance was 94.44%. As a result the Trust had not achieved compliance with the standard. The interim Chief Operating Officer advised that a significant amount of work had been undertaken two months previously in order to better manage patient flow which had resulted in reduced length of stay and improved patient pathway. However, ‘out of hours’ performance in ED remained an issue. The interim Chief Operating Officer advised that two hourly progress reviews were being undertaken in ED and an increased focus on the out of hours service would be maintained. A further progress report would be provided at the next meeting. Action: B Bluhm The interim Chief Operating Officer gave an update on the 18 week Referral to Treatment Standards (RTT). The Board noted that RTT performance was either on track or exceeding recovery plans agreed with the CCG and Monitor. The interim Chief Operating Officer advised that March had proved a challenging month in respect of cancer waiting times. The 62 day performance had deteriorated mainly due to capacity constraints and delays in reaching a ‘decision to treat’. Acute capacity and demand pressures in gastroenterology had contributed to the 62 day position. This was also a significant factor in the two week wait position. The interim Chief Operating Officer advised that although the independent sector was being used there was limited resource in respect of locum cover availability in this speciality. The interim Chief Operating Officer advised that the CCG had been notified of the situation. A further progress report would be provided at the next meeting. Action: B Bluhm The Director of Nursing advised that the CQC had advised the Trust that it would be placed in a numerical band a year after its CQC Inspection. However, the recent fifth draft of the CQC Intelligent Monitoring Report had banded the Trust as ‘recently inspected’ overall. The Board noted that within the April report there was one ‘elevated risk’ and four ‘risks’ all of which were predicted within the Quality Performance report submitted to the March Board.


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The Chief Executive advised that there had been three cases of C. Diff. reported by the Trust in March which were linked to the increase in Norovirus. The interim Chief Operating Officer advised that the response from the infection control team had been excellent. Overall, the Trust had had a total of 29 cases against a national annual target of 40, and the Trust’s quality target of 30. The Board expressed their thanks to staff in infection control for the excellent achievement during 2014/15 in respect of C. Diff. The Director of Nursing advised that the level of harm free care had increased slightly to 95.53% during March. The Director of Nursing reported that there had been no Grade 3 or 4 hospital acquired pressure ulcers reported in March and the Trust continued to demonstrate improved performance with falls prevention. The Director of Nursing highlighted that the new Serious Incident Reporting Framework had been published in March 2015 which replaced the National Patient Safety Agency National Framework for Reporting and Learning from Serious incidents Requiring Investigation. As a result the Trust’s policy for Serious Incidents Requiring Investigation was being updated to ensure current processes reflected the updated guidance. The Director of Nursing advised that inpatient recommendation rate for Friends and Family was 99%. The Trust was therefore in the top 10 acute hospitals nationally with 0% of patients stating that they would not recommend. The Trust therefore exceeded the target of 40% at the end of March 2015 and therefore achieved the national CQUIN for Friends and Family. Resolved: that the report be noted

65/15 Finance Report

The Director of Finance submitted a report on the financial performance of the Trust for March 2015. The Director of Finance advised that the year end position was an £8.96m deficit which included contract retentions. The closing cash balance was £13.4m. The Director of Finance advised that it was anticipated that the Trust’s cash position would deteriorate further during June 2015 in respect of the CCG contract retentions. It was noted that one Craven Road property sale had been completed and a further sale was due to complete shortly. The Director of Finance advised that actions in respect of reducing pay spend were being reviewed. However, additional work to clear backlogs in three specialties had been required therefore there had been additional pay costs as a result of the additional activity. The Director of Finance advised that the additional activity and costs had been included in the operational plan for 2015/16. The Director of Finance advised that the implementation of service line reporting had been discussed with Care Groups and specialties had been identified as areas in which efficiency opportunities could be achieved. It was anticipated that monthly service line reporting could be introduced towards the end of 2015 which could then be used for budget planning for


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2016/17. It was noted that a Steering Group had been developed to roll out service line reporting across the organisation. Resolved: that the report be noted.

66/15 Monthly Workforce Report

The Director of Workforce & Organisational Development introduced the report and advised that the workforce planning process had begun and would report to the Board at the end of June 2015. This would ensure a strategic approach was undertaken to workforce planning. The Director of Workforce & Organisational Development advised that the workforce productivity work stream had reviewed attendance management and targets had been set for each cost centre. The Director of Workforce & Organisational Development advised that all budgeted establishments would be entered onto the ESR system once budgets had been agreed. During 2015/16 this would ensure that more precise data was available on budgeted whole time equivalents and vacancies. Resolved: that the report be noted.

67/15 Trust Improvement Programme

The interim Chief Operating Officer introduced the report and drew attention to the phasing of delivery of the improvement programmes. Each phased and forecast savings would be reviewed each month as part of the PMO assessment. The interim Chief Operating Officer advised that there was one programme, medical records, which was RAG rated red in terms of overall progress this month. Key issues included the need to relocate the medical records team due to the environmental issues within the records library and the need for IT support to deliver some of the improvement changes. The interim Chief Operating Officer advised that there had been a positive response in respect of the need to return medical records to the records library. However, this had caused an issue with storage and, as a short term measure; more records were being moved to offsite storage.

The Board noted that the medical records department and improvement project sat within

the Planned Care Group even though the issue was Trust wide. The Board recommended that the Executive should review and agree the ownership of the Medical records improvement programme.

Resolved: that (a) the Executive review and agree the ownership of the Medical Records improvement programme (b) the report be noted.

68/15 Monitor Quarterly Return

The Director of Finance submitted a report in respect of the quarter 4 return to Monitor. The Director of Finance explained that the Risk Assessment Framework required the submission of a quarterly financial and governance combined return, comprising a number


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of declarations. The Director of Finance advised that the quarterly return required the Board to certify confirmed or not confirmed in respect of three statements

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

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

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

The Board was recommended to mark the statement in respect of the continuity of service rating as “not confirmed”. This was on the basis that the Trust’s latest submission to Monitor for 2015/16 showed a CoSRR of 1 with a possibility of moving to a 2. The Board was recommended to mark the statement in respect of the compliance with targets going forward as “not confirmed”. This was on the basis that there was sufficient concern to believe that there was a significant risk of systematic underperformance in respect of the A&E target and subject to validation, the cancer 62 day target, the two week wait target and overall RTT performance. With regard to exception reporting, the Board was recommended to mark this as ‘confirmed’ on the basis that there were no known issues requiring an exception report, which had not already been reported. Resolved: that (a) the Chief Executive and Director of Finance be authorised to sign the quarter 4 Monitor return (b) the statement that the Board anticipated that the Trust would continue to maintain a continuity of risk rating of at least 3 over the next 12 months be marked as ‘not confirmed’ (c) the statement that the Board was satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds); and a commitment to comply with all known targets going forwards be marked as ‘not confirmed’ (d) the statement that the Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which had not already been reported be marked as ‘confirmed’ (e) the submission of the full return to Monitor be approved


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69/15 Board Agenda Proposal The Chief Executive introduced the proposal to revise Board agendas and Board report

cover sheets in order to better ensure dedicated time to strategic debate, the key risks to the Trust’s strategic objectives in line with the Board Assurance Framework and reflection on the impact of the Well Led Framework on Board business.

The Board agreed that the Executive should implement the proposal and this would be

reviewed in October 2015. Resolved: that

(a) the revised agenda and Board report cover sheets be implemented by the Executive

b) the proposal be reviewed in October 2015. 70/15 IT Strategy The Director of IM&T introduced the report and advised that the IM&T strategy aimed to

address key risks and then to position the Trust to exploit technology that would benefit patients, staff and the organisation.

The Director of IM&T advised that a key focus for the strategy over the last few months had

been to start to address four key areas; data quality, optimising IT systems ‘uptime’; IT infrastructure and the inability to provide adequate services, either clinically or financially, due to the lack of ability to exploit technology.

The Board noted that funding options for the IM&T strategy were based on a ‘must do’,

‘should do’, or ‘could do’ basis over the next four years. The Director of IM&T advised that the Resources Committee had reviewed the strategy in details at its April meeting. The Resources Committee would review the strategy on a quarterly basis in the future.

Resolved: that the IM&T strategy be approved 71/15 Information Item: Audit & Risk Committee Annual Report The Board received, for information, the annual report for 2014/15 of the Audit & Risk

Committee. Resolved: that the Audit & Risk Committee Annual Report be noted. 72/15 Information Item: Board Work Plan The Board received, for information, the work plan for the year. The work plan would be

updated ahead of the next meeting. Resolved: that the work plan be noted. 73/15 Date of Next Meeting

Resolved: that the next meeting of the Board be held at 9.30am on Tuesday 26 May 2015.


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74/15 Exclusion the Press and Public Resolved: that the press and public be excluded from the remainder of the meeting

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

Chairman Date 28 May 2015

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 3

May 2015 Board 1

Board Date Board Minute

Subject Decision Owner Expected Submission

Update

February 2015

25/15 Finance Report Future reports include clear trajectory for reduction of agency spend

Craig Anderson Due May.

February 2015 26/15 Trust Improvement Programme

An update on estates maintenance issues be reviewed by the Resources Committee

Philip Holmes/ Craig Anderson

Item scheduled for the Resources Committee in June.

February 2015 33/15 Monitor Operational Plan Assumptions 2015/16

The Board emphasised the need for robust headcount data to support the financial savings plan.

Craig Anderson

Indicative headcount savings to support QiPP have been developed but full Workforce Plan due to come to the Board in June/July.

March 2015 48/15 Monitor Action Plan In response to a query regarding the ongoing work in respect of the Board Assurance Framework and Corporate Risk Register the Chief Executive confirmed that these reports were due to be discussed in private by the Board that day but would be added to the public section of the agenda at some point in the future.

Jean O’Callaghan/ Caroline Ainslie

An overview report on the BAF & CRR will go to the public May Board and periodically to the public section of the Board). Any detailed Board review of the BAF and CRR may still be subject to redaction and/or discussion in the private section of the Board.

March 2015 56/15 Corporate Risk Register The Chairs of the Clinical Governance and Resources Committee to highlight any issues requiring detailed review to the Chair of the Audit & Risk Committee where appropriate

Janet Rutherford/ Sue Hunt

Ongoing

April 2015 59/15 Matters Arising: Trust Improvement Programme:

A recommendation in respect of the Operational Performance & Finance Committee to be submitted to the May Board.

Janet Rutherford/ Caroline Lynch

Item on the Agenda

April 2015 62/15 Chief Executive Report A stretch target for nursing recruitment to be submitted to the Board.

Paul Beal Time to recruit target from 12 weeks to 10 weeks initially


May 2015 Board 2

April 2015 63/15 Strategic Developments The Strategic Road Map for the Trust be approved and progressed for discussion with staff and stakeholders.

Jean O’Callaghan/ J Taylor

An engagement & communication plan to support the development of the strategic plan has been drafted and will be discussed at SMT prior to being implemented during June (and subsequent months). Progress on engagement and feedback from stakeholders will be update as part of the Strategic Developments Report to Board.

April 2015 64/15 Quality Performance Report

A further progress report on ED and cancer waiting times to be reported at the next meeting.

Bernadette Bluhm

May 2015 Exception report on the agenda as an appendix to the Quality Performance report. No ED progress report submitted this month as target achieved during April 2015.

April 2015 67/15 Trust Improvement Programme

The Executive Team to review and agree the ownership of the Medical Records improvement programme.

Executive Team Item on the agenda.

April 2015 68/15 Monitor Quarterly Return

The Chief Executive and Director of Finance to sign the quarter 4 Monitor return. The statement that the Board anticipated that the Trust would continue to maintain a continuity of risk rating of at least 3 over the next 12 months be marked as ‘not confirmed’. The statement that the Board was satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds); and a

Jean O’Callaghan/ Craig Anderson Craig Anderson Craig Anderson

Completed Completed Completed


May 2015 Board 3

commitment to comply with all known targets going forwards be marked as ‘not confirmed’. The statement that the Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which had not already been reported be marked as ‘confirmed’.

Craig Anderson

Completed

April 2015 69/15 Board Agenda Proposal The revised agenda and Board report cover sheets be implemented by the Executive The proposal to be reviewed in October 2015.

Jean O’Callaghan

Revised board report cover sheets have been implemented. Item added to the work plan.

April 2015 78/15 Draft Monitor Operational Plan Budget 2015/16

A report highlighting the prioritisation of the five year capital programme and any associated risks to be submitted to the Resources Committee for review. The Director of Finance to discuss the contingency fund further with the Chief Executive.

Craig Anderson Craig Anderson

Completed. Completed. Contingency allocated to both QiPP and Planned Care Growth as reported to May Resources Committee.

Title: Chief Executive’s Report Agenda item no: 5a Meeting: Board of Directors Date: 28 May 2015 Presented by: Jean O’Callaghan, Chief Executive Prepared by: Jean O’Callaghan, Chief Executive Purpose of the Report • To update the Board with an overview of key performance,

operational and regulatory issues since the previous Board meeting. • This includes items that may impact on policy, quality and financial

risks to the Trust.

Report History N/A

What action is required? For information and discussion: the Board is asked to note the report.

Assurance Information Discussion/input Decision/approval

Resource Impact: None

Relationship to Risk in BAF:

• Failure to maintain and improve quality of care. • Failure to maintain standards required to maintain licence to

operate. • Failure to sustainably achieve financial targets and CIPs.

Strategic objectives. This report impacts on (tick all that apply)::

Deliver the Trust’s strategic ambitions and intentions. Quality care and operational excellence Achieve and maintain financial sustainability A highly skilled and flexible workforce, demonstrating leadership at all levels Growing partnerships and collaborative working relationships based on trust. Maintain a fit for purpose estates infrastructure and IM&T systems

Well Led Framework applicability: Not applicable 1.Strategy & planning 2. Risk

Management 3. Board capability

4. Culture 5. Learning & development

6. Roles & accountabilities

7. Performance management

8. Stakeholder engagement

9. Information analysis

10. Robust information

• Implications of all local health economy factors are incorporated into planning. • Information is used to improve quality performance. • Processes provide the board with the insight and foresight to manage the performance of the

trust now and into the future. Publication Published on website Confidentiality (FoI): Private Public This report will be made available on request.

1 Overview 1.1 The Trust performance in March for the 18 week referral to treatment time (RTT)

indicators was:

• Non-admitted patients - 96.8% treated in 18 weeks compared to the 95% standard

• Admitted patients – 75.5% treated in 18 weeks compared to the admitted plan of 78%. The underperformance in April was due to reduced admitted activity during the April Easter holiday despite forward planning. The Trust expects to be back on plan for this standard in May.

• Incomplete pathway patients - 93.2% treated in 18 weeks compared to the 92% target.

1 1.2 52 week waits - In April 12 patients waited longer than 52 weeks. All remain on the waiting list through patient choice. All have dates for surgery or out-patient review.

1.3 The Trust achieved the 4 hour Emergency Access standard for April and 95.1% of

patients were treated in 4 hours. The Emergency Department has developed an internal improvement plan to minimise internal delays. 2 hourly “safe huddle” escalation board rounds have also been introduced.

1.4 Cancer performance is not expected to meet the 2 week or 62 day standard for April.

Performance is expected to improve with final validation. The Trust has submitted a recovery plan to the CCG.

1.5 In April we reported 6 serious incidents on STEIS and no never events.

2 Key Issues

2.1 As in previous months, our monthly meeting with Monitor focused on our ability to recover our financial position. Monitor explained the disadvantage of seeking "distress funding" and that this would put a severe constraint on our ability to make decisions without reference to them.

2.2 Interviews have been held for the new Clinical Admin Teams; following a second round of interviews, a small number of vacancies remain and these will be re-advertised. Staff training has taken place throughout May to enable commencement of new ways of working in June. Refurbishment of office accommodation is in progress for the new teams.

2.3 Craig Anderson, Lindsey Barker and I attended a two-day workshop for Chief Officers and senior staff in West Berkshire. The objectives were to:

• develop more effective working relationships and agree a shared vision.

• develop deeper and more effective relationships

• share vision and agree shared purpose for integrated care

• agree values and behaviours underpinning leadership

• review progress and identify areas for further development

• review governance and meeting arrangements and propose changes to fit our

purpose

• agree future direction and next steps

• produce a narrative for the wider system. 2.4 I am pleased to welcome Ayshea (Surraya) Richards and Pat Rubin to the Trust.

Ayshea will cover the head of communications role on an interim basis and Pat is acting as Director of Operations in Planned Care.

3 Other Issues

3.1 Caroline Ainslie and I attended the Reading Health and Wellbeing Board in April last. We provided an update on our progress against the CQC action plan and assurance that we will continue to improve. I was also invited to the North West Reading CCG Council to give a brief presentation on the Trust strategic direction.

3.3 The Trust held a ‘thank you afternoon tea’ in the Education Centre to celebrate International Nurses’ Day. Director of Nursing Caroline Ainslie spoke of her pride of our nurses and the outcomes they have achieved for our patients.

3.4 Quality improvements for the discharge for women, who have experienced the loss of a baby, are being led by Amy Wood-Blagrove. The project aligns well with everything we want to achieve as a trust by improving patient-centred and compassionate care.

3.5 The Catering department have raised £4212.37 for the Nepalese earthquake relief efforts by holding a staff curry lunch. The money will be used to buy urgent medical equipment for the Tribhuvan University Teaching Hospital.

3.6 Dr Bruno Holthof has been appointed as the new Chief Executive at Oxford

University Hospitals from on 1 October 2015. For the past ten years Bruno has been Chief Executive of ZNA, a network of general and specialised hospitals in and around Antwerp. Under his leadership, ZNA has come to be recognised as one of the best performing healthcare systems in

4 Key Reports

Europe.

How is the NHS performing?

4.1 The Kings Fund Quarterly Monitoring Report April 2015 uses a small group of 2014/15 national performance statistics to illustrate the challenges currently confronting the NHS:

• The number of C Difficile infections in Q4 reduced slightly to 424 (previous quarter 442).

• Since 2009, there has been an increase in all staff groups except managers. Consultant numbers have increased by 19%; scientific, therapeutic and technical staff by 6%; nurses, midwives and health visitors by 3%. The number of managers has decreased by more than 16.5%.

• Waiting times for the 18 week RTT were breached in February with 13% admitted patients waiting longer than 18 weeks and 5.3% of non admitted patients.

• In Q4 8.2% patients waiting longer than 4 hours in A&E from arrival to

discharge or admission. Overall less than 12% providers achieved the A/E target in Q4.

• Delayed transfers of care reduced in February compared to the previous month but remained high at 4,950 in the hospital setting.

4.2 On the financial side, the Kings Fund’s survey of finance directors (carried out in February/March) confirms growing pessimism about the current financial state of health organisations and deep worries about the coming financial year.

• With an estimated need for increased funding of 4 to 5 per cent each year from 2011/12 to 2014/15 to meet growing demands, the NHS has been under constant pressure to close the funding gap with increases in productivity. Trusts have on average set themselves cost improvement programme targets of around 5 per cent each year. The latest survey suggests that only 45 per cent of trusts are confident of achieving their cost improvement targets for 2014/15 – a decline in confidence compared to previous years.

• Nearly 70 per cent of providers and 40 per cent of commissioners are concerned about staying within budget in 2015/16. More than 90 per cent of providers and 85 per cent of commissioners are concerned about the overall financial state of their local health economies

4.3 The full report is available via the following link: http://qmr.kingsfund.org.uk/2015/15/

Uses and abuses of performance data in healthcare 4.4 A report by Dr Foster outlines five steps that seek to address weaknesses in the

generation and use of data and metrics that impact on improving healthcare through better measurement and the use of information. The report makes a series of recommendations to tackle practices that distort the reliability of the information used to manage the standards of care delivered to patients:

• Make data quality as important as hitting targets

•

: Failure to tackle data quality risks undermining the entire enterprise of performance management. There should be a long term audit programme to assure data integrity. Where possible, data should be drawn from information sources shared with patients and used in other contexts, to support consistency and accuracy.

Measure the context not just the indicator:

•

Performance measures need to be monitored along with sets of counterbalancing metrics that can identify issues such as pathway distortion. Measures need to be constantly monitored and reviewed in the light of experience. This task could be undertaken by multi-disciplinary specialist groups, including royal colleges and patient organisations.

Consider the potential to incentivise gaming in the design of metrics: Performance management metrics are often designed with a view to simplicity of implementation and communication, and with insufficient thought to the likely negative consequences. Performance measures should be assessed against these risks.

http://qmr.kingsfund.org.uk/2015/15/�

• Be more open:

•

Make data underlying performance management widely available and promote ongoing assessment of the degree to which metrics are being gamed. Build in regular reviews of performance management regimes. Expect to make annual refinements to the way in which performance is measured to minimise fine tuning of systems to meet targets rather than achieving the desired benefit for patients.

Apply measures fairly:

4.5 The full report is available via the following link:

Performance management in the NHS has been seen as a form of arbitrary justice which fails to recognise legitimate mitigating factors such as resources and pressures outside the control of the organisation. The most serious issue is the creation of conflicts between the requirements of performance management and the needs of individual patients. Performance management regimes must explicitly allow for the possibility of breaches in patient interests.

http://www.drfoster.com/wp-content/uploads/2015/04/Uses-and-abuses-of-performance-data-April-2015-FINAL-DIGITAL-with-cover1.pdf

Duty of Candour Supports Good Surgical Practice 4.6 The Royal College of Surgeons recent guidance on the professional and statutory

duty of candour for surgeons and their employers will also be applicable to medical specialties. It provides helpful advice on talking to patients who have suffered harm and suggests how to support them. The guidance emphasises the importance of providing early support to surgeons and surgical teams who have been involved in harm. It includes an outline of a proposed disclosure process covering the requirements of the duty of candour for both individuals and organisations.

4.7 The full report is available via the following link: http://www.rcseng.ac.uk/news/docs/1-duty-of-candour-web-final.pdf Monitor Business Plan 2015-16

4.8 Monitor has published its business plan for the coming year. Although there is no significant change to the challenges set out in its strategy and reflected in last year’s business plan there is reflection of the developments over 2014/15; in particular, the publication of the Five Year Forward View. Therefore there is a response to the system’s collective view of how it needs to develop, and also to the sharp deterioration in the operational and financial performance of the provider sector.

4.9 Monitor will therefore focus its role in helping the NHS address its two main priorities – short-term operational improvement and longer-term sustainability and also set out its own operational actions.

4.10 Drive and support provider operational improvement

• Establishing a Provider Sustainability Directorate

. Monitor highlights that the providers will need to achieve significant further improvements in operational efficiency. These need to be achieved at pace and, therefore, will need to be developed mostly within the current care models and then translated into the new care models as they are implemented. Monitor will support this through:

• Develop preferred approach to supporting provider improvement

• Ensure adequate improvement support is available

http://www.drfoster.com/wp-content/uploads/2015/04/Uses-and-abuses-of-performance-data-April-2015-FINAL-DIGITAL-with-cover1.pdf�



http://www.rcseng.ac.uk/news/docs/1-duty-of-candour-web-final.pdf�

• Improve the availability of critical managerial talent

• Find more effective ways to turn around challenged and failing foundation trusts

• Help commissioners use best practice procurement to drive significant improvements in provider quality and efficiency

• Ensure the 2015/16 and 2016/17 payment systems optimise incentives for provider and commissioner efficiency improvements

4.11 Drive and support long-term sustainability.

• Support the reconfiguration of services particularly through the vanguard of implementing the new care models and on the economics of different care models and on the future of smaller hospitals.

In parallel with improving its current operational performance, the NHS must also redesign the way it delivers care if the opportunity to provide better care for more people is to be seized. Monitor will respond to this challenge through the following:

• Continue to support long-term capability development at providers. This will have a particular focus on leadership and change management.

• Adapt Monitor’s regime to the changing provider landscape 4.12 Operate effectively.

• Complete the restructuring of Monitor’s organisation: the creation of the Provider Sustainability Directorate, the expansion of the Clinical and Patient Engagement Directorate and the restructuring of the Provider Regulation Directorate.

Reflecting the expansion of its role following the Health and Social Care Act 2012 Monitor expects to bring in more people with clinical and frontline operational experience, and work to improve its own operational efficiency.

• Insource as much activity as feasible and achieve a step change in our rate of recruitment.

• Accelerate cultural change. Ensure a focus on professional rigour is combined with an appropriate degree of nimbleness and pragmatism.

• Seek alignment of our powers, resources, regulatory regime and accountabilities. Recognising that there is a mismatch between Monitor’s powers, resources and the regulatory regime within which they operate, and that for which we are de facto being held to account.

4.7 The full report is available via the following link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425392/Monitor_Business_plan_2015_16.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425392/Monitor_Business_plan_2015_16.pdf�

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425392/Monitor_Business_plan_2015_16.pdf�

Title: Strategic Developments Report Agenda item no: 5b Meeting: Board of Directors Date: 28 May 2015 Presented by: Jean O’Callaghan, Chief Executive Prepared by: John Taylor, Director of Strategy Purpose of the Report • To update the Board with an overview of key national and local

strategic environment and planning developments. • To support the development of our Strategic Plan and the Clinical

Services Strategy.

Report History N/A





• Failure to respond appropriately to changes in the external environment impacts on viability.

• Failure to develop the organisation to support the delivery of the Trust’s vision











• Implications of all local health economy factors are incorporated into planning. • Board members are knowledgeable about quality issues and priorities • Board promotes a strong focus on continuous learning and improvement at all levels of the

organisation. Publication Published on website Confidentiality (FoI): Private Public This report will be made available on request.

1 Five Year Forward View

1.1 Simon Stevens has announced an expansion of the vanguard programme which includes application to smaller acute hospitals and a separate strand of work that will include a wider review of urgent and emergency care including, potentially, the metrics used to measure performance. It is suggested that this may involve a broader focus on measuring and reducing emergency admissions and on the number of bed days lost to delayed transfers of care.

1.2 Mr Stevens also drew attention to trusts needing to set limits on what they pay for agency staff and to act collectively. NHS England is understood to be putting forward proposals on this shortly.

1.3 In response to what is seen as too much focus on individual institutions, there will be moves to create a “success regime”, which will aim to help struggling areas move towards the new care models in the NHS Five Year Forward View. This will apply primarily to two areas

• those where services are under “very substantial pressure” and “struggling both financially and operationally”. They will be put into a new intervention process to be called a “success regime”. For these areas NHS England, Monitor and the NHS Trust Development Authority will be “directive in terms of the support that will be provided” – indicating they will be instructed where necessary on what changes need to be made. They are expected to be identified by the national bodies early in the new year.

• those which can move quickly to new models because they have the right “conditions for transformation”. They are performing strongly and have good relationships. The focus of national bodies will be on removing obstacles to progress to allow trusts to “co-create” the new models. The areas will be identified as part of the planning process for 2015-16 under guidance to be published before Christmas.

2 The Practice of System Leadership 2.1 A report by the Kings Fund has sought to look in depth at the skills needed to be a

system leader that can achieve system change that meets the needs of the Five Year Forward View. The report identifies that, given the unprecedented challenges facing the NHS (its sub-title is Being comfortable with chaos), the system needs leaders who can motivate staff and managers to work differently, across service and organisational boundaries. It identifies four key themes for trust to concentrate on:

• Start with a coalition of the willing, build an evidence base, and build outwards; it is vital to engage clinicians in understanding the need for change and to lead efforts to achieve that change.

• Involve patients, service users and carers because they have an invaluable role to play in helping to identify which services need to be redesigned.

• Strike the right balance between constancy of purpose and flexibility by facilitating conversations about what needs to change and how; being flexible about how that might be achieved; and ensuring the momentum is there to deliver change despite the inevitable opposition.

• Pursue stability of leadership, something that has proved difficult in a context of

frequent reorganisation of the provider and commissioning landscape. 2.2 The full report can be read here:

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/System-leadership-Kings-Fund-May-2015.pdf

3 Urgent and Emergency Care 3.1 The NHS Confederation has published a report Rip off the sticking plaster now:

Enabling the local implementation of sustainable urgent and emergency care models in 2015/16. This report highlights that, without immediate action, the NHS is set for a winter crisis in 2015/16 and that NHS organisations need to take rapid action now to implement solutions that will prevent this from happening. It also raises the concern that the issue of planning and policy guidance has been affected by the electoral cycle.

3.2 This report collates the guidance and urges immediate action from NHS

organisations, national bodies and the incoming Government. It makes a number of recommendations for a sustainable urgent and emergency care system including:

• Change must be locally led, with national-level support that is tailored locally

• Direct investment towards the right services to have the most impact on overall sustainability - improving access to care in the community must be prioritised

• Ensure access to a multi-disciplinary workforce, supported to work across primary, community, acute and social care

• Embrace joint working between the NHS, social care and the independent and voluntary sectors, for a truly whole-system response.

• Avoid hitting the target and missing the point – system-wide, outcomes-focused measures must be the focus.

3.3 The full report can be read here:

http://nhsconfed.org/~/media/Confederation/Files/Publications/Documents/rip_off_sticking_plaster_now0515.pdf

4 Workforce Planning in the NHS 4.1 Another report from the Kings Fund Workforce Planning in the NHS, focuses on three

key areas of the NHS workforce – mental health, general practice and community nursing. It argues that shortages and other critical pressures could jeopardise plans outlined in the NHS Five Year Forward View to deliver new models of care.

4.2 The report highlights that the NHS workforce is the primary driver of future health

costs and given the substantial changes in population demographics and health care needs, the workforce needs to be fit for purpose. The workforce needs to respond to immediate needs and financial pressures while adapting to deliver the future care models outlined in the NHS five year forward view. Getting the right balance requires a robust understanding of the nature of workforce pressures locally and nationally and what can be done to address them in the short and the long term.

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/System-leadership-Kings-Fund-May-2015.pdf�

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/System-leadership-Kings-Fund-May-2015.pdf�

http://nhsconfed.org/~/media/Confederation/Files/Publications/Documents/rip_off_sticking_plaster_now0515.pdf�

http://nhsconfed.org/~/media/Confederation/Files/Publications/Documents/rip_off_sticking_plaster_now0515.pdf�

4.3 The analysis in the report is presented alongside data that highlights providers’

reliance on agency staff. It looks at how workforce issues have been addressed across the system so far, explores the main challenges including major disconnects between strategic goals and workforce trends, and makes recommendations to improve workforce planning:

• The greater strategic priority given to mental health has not translated into staff numbers on the ground.

• The rate of increase in the number of GPs has been dramatically outstripped by increases in the medical workforce in secondary care – a trend at odds with the ambition to deliver more care in the community.

• Despite long-standing ambitions to raise the level and range of community services provided, it is difficult to see any increases among key staff groups. Any such increases have been limited to areas with specific national targets.

• The information needed to guide workforce planning locally and nationally has not kept pace with the growing plurality of providers delivering NHS-commissioned services. There are large data gaps on primary and community care, use of agency and bank staff, vacancy rates, and independent and voluntary sector providers

4.4 The full report can be read here: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforce-

planning-NHS-Kings-Fund-Apr-15.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforce-planning-NHS-Kings-Fund-Apr-15.pdf�

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforce-planning-NHS-Kings-Fund-Apr-15.pdf�

Title: Board Assurance Framework and Corporate Risk Register Report Agenda item no: 6 Meeting: Board of Directors Date: 28 May 2015 Presented by: Caroline Ainslie, Director of Nursing Prepared by: John Taylor Director of Strategy; James Brind Head of Risk Purpose of the Report • This paper presents an update on the Trust Corporate Risk

Register and the Board Assurance Framework development

Report History N/A





• Failure to respond appropriately to changes in the internal and external environment impacts on viability.











• Board understands the internal and external factors affecting delivery of the plan. • Main risks are identified. No significant control issues/gaps and clear responsibilities. • Effective process in place to monitor, understand and address current & future risks

Publication Published on website Confidentiality (FoI): Private Public This report will be made available on request.

BAF and CRR Report Agenda item 6

Page 1

1 Introduction

1.1 This report presents the next development stage of the Board Assurance Framework in aligning the strategic objectives of the Trust with the risks identified in the Corporate Risk Register. This is the main tool the Board should use in discharging its overall responsibility for internal control. It is the key source of evidence that links strategic objectives to strategic risks and assurances, rather than primarily focussing on residual operational risks.

1.2 The BAF will continue to be developed through four distinct elements: a) final alignment to the Corporate Objectives b) Board and Executive assessment of the quality and level of assurance in place c) Board input of horizon-scanning and future risk impact d) development of new action plans or alignment to current action plans. These inputs will be completed in June 2015. However, the current version of the BAF is attached at Appendix A for the scrutiny of the principal risks and debate.

2 The Board Assurance Framework

2.1 The benefits of a working BAF is that it encourages individuals and groups to think about and plan for the achievement of their strategic objectives in a proactive manner - with Board agendas focussed on the strategic and reputational risks rather than operational issues.

2.2 It highlights any gaps in control and assurances that may hinder the achievement of these objectives which are escalated to the Board and can be traced through the Board agenda including follow up arrangements to address these gaps

2.3 The BAF seeks to provide a clear status report on the controls in place and the quality and reliability of assurances on how well these risks are being managed and supports the Board in making a declaration on the effectiveness of the Trusts system of internal control in the Annual Governance statement

2.4 The nature of a strategic risk means that the consequence is known to be catastrophic so the focus needs to be on the factors that impact upon the likelihood, rather than the traditional approach to risk management - where the severity of the risk is calculated using likelihood of a risk occurring in combination with the consequence.

2.5 For the BAF to be more than a tick box exercise, the Board must engage in developing, maintaining, reviewing and challenging its content. In order to do this the Board members should ask the following questions:

• What is the difference between the BAF and the Board Agenda? • Does the BAF cover all activity and relationships? • Does the Board receive assurances that risks and controls that are the

responsibility of partners will not compromise the Trust • Are assurances evidence based


Page 2

2.6 The BAF is designed to provide the Board with an easily digestible overview of the principal risks relating to the strategic aims of the organisation, ownership and accountability through identification of the Executive Lead and of the Non-executive by inference from indication of the associated Board Committee. It shows for each of the principal risks: the key controls and assurance over the effectiveness of the controls; identification of gaps in controls and actions plans designed to address these gaps. The proposed direction of change in the risk rating since the previous presentation will be highlighted in the form of a heat map (Figure 1).

Figure 1: Draft Ratings of Principal Risks in the Board Assurance Framework

2.7 From the information presented, the Board will be able to form a view of its satisfaction with the assurance(s) provided and identify any gaps and actions they consider necessary to better treat the identified risks and /or strengthen the assurance that the risks are under appropriate control. The details of such action are added into columns for identified gaps, action to be taken, the assigned owner of the action and a date for completion.

2.8 Full and iterative population of the document will ensure that the Board has at all times, an awareness of the current state and progress made in managing these principal risks to a position in accord with the Board appetite.

2.9 Assurances are time limited and should only be relied upon if current. All assurance should be targeted and scored so as to be weighted by its quality and relevance. Examples include:

• Regulator reports and feedback


Page 3

• Independent assurance relevant to the controls which is commissioned by the Board

• Independent assurance – internal auditors • Internal assurances by Trust staff - performance reports are one strong

way of evidencing the relationship between effective performance and effective controls and actions plans where required.

2.10 The Trust is in the process of agreeing its Corporate Objectives for 2015/16. Although the detailed measures behind these have yet to be finalised, Figure 2 below sets out the draft headline objectives. Once finalised these will be aligned to the BAF set out in Appendix 1 and the risks to achievement assessed.


Page 4

Figure 2: Draft Corporate Objectives 2015/16


Page 5

3 BAF development and support

3.1 Management ownership and support of the BAF will be led by the Company Secretary working with the Board Chair. It is important that there is a separation between the responsibility for the BAF and for the CRR to avoid overt duplication and to ensure that strategic and operational risks are differentiated. However, close alignment will be required between those responsible for the two sources of assurance.

3.2 Care Boards, Corporate equivalents and certain themes such as Safeguarding, infection Control will have their own risk register. Therefore a process is in place to identify common themes / risks across these risk registers as individually these may not seem of concern but together these risks may threaten a single or multiple objectives. Therefore a common risk can be entered on the BAF and cross referenced to these lower level risks

4 The Corporate Risk Register

4.1 The Corporate Risk Register (Appendix 2) is in the process of being updated to reflect:

• The risks from the Care Groups and Estates and Facilities Risk Registers have been entered onto the Datix risk management module.

• Quarterly review of risk entries on the Corporate Risk Register are being undertaken with risk leads for presentation at the June Integrated Risk Management Committee.

• All risks entered onto Datix are required to be linked to the Trusts 6 strategic objectives. This will allow for risk themes and horizon scanning to start and be developed.

• The Head of Risk Management has reformatted all Care Group risk registers to match the Corporate Risk Register, and is arranging to present these and the risk management policy changes to the Care Boards in June.

• Attendees of the first risk assessment training are being followed up so departmental and ward risks can start to be entered onto Datix, and so starting to create a Trust risk which reflects risks from the ward to the board.

4.2 With the Corporate Risk Register being in place and being subject to scrutiny by the Executive Risk Committee and the Audit and Risk Committee, the key corporate risks have now been included within the BAF. This will allow triangulation of the operational and Executive owned risks with the top down strategic risks. This triangulation will allow on-going identification of potential omissions to risks.

5 The Audit and Risk Committee

5.1 To ensure that the BAF is working as a tool to drive the Trust it is considered best practice for the Audit and Risk Committee:


Page 6

• to undertake an annual review to ensure appropriate spread of strategic and operational risks and to ensure no significant omissions.

• independently review the BAF to challenge and assure the Committee that the identified managers and directors have been involved and take responsibility for their entries.

• monitor the action plans to cover gaps in controls and assurance by directors and managers and follow up via audit.

• identify areas eg specific to a risk or objective for further investigation and attention

6 Next Steps

6.1 As referred to above, the BAF will continue to be developed:

• Once finalised the corporate objectives will be fully aligned to the BAF – June 2015

• The Executive will further develop its assessment of the quality and level of assurance in place – June 2015

• A Board development workshop will be put in place to allow Board input in relation to horizon-scanning and future risk impact. The Executive will respond to any additional risks identified. July 2015

• Finalised development and agreement of any new action plans required or alignment to current action plans. July 2015.

• Bi-monthly Board review and maintenance of the BAF and develop this as a key driver for the agenda of Board Meetings. July 2015 onwards

• BAF will be updated after performance reviews and Executive Risk Committee meetings – July 2015 onwards

• Development of arrangement to share BAF with strategic partners with a view to agreeing a LHE assurance framework. September 2015.

7 Attachments

7.1 The following are attached to this report:

(a) Appendix 1 - Draft BAF

(b) Appendix 2 – Corporate Risk Register

Appendix A _ BAF Agenda item 6

Page 7

Draft Strategic Objective 1 – To deliver the Trust’s strategic intentions effectively and efficiently ensuring financially sustainable quality care.

Principal Risk

Executive Lead Board Sub Committee Enablers Key Controls (Existing)

Assurances

Gaps in controls or assurances

Action plan including owner

and due date

CEO

DoN

CO

O

MD

DoW

OD

DoF

Boar

d of

Dire

ctor

s

Perfo

rman

ce &

Fin

ance

Audi

t and

Ris

k

Res

ourc

es

Clin

ical

Gov

erna

nce

Failure to communicate, engage and involve stakeholders during period of significant change.

X

X

Strategic Plan

Regular engagement with stakeholders Chief Officers Group Joint Senior Governance Governor updates

• Meetings with Monitor • • Monitoring by the

Executive • • Updates to the Board •

Engagement Plan

Development of comprehensive engagement framework. Clinical Services Strategy

Failure to maintain focus and delivery of CIPs.

X

X

Improvement Programme

PMO Improvement Board

• Meetings with Monitor • QIPP Program Board • Monitoring by the

Executive • Financial Recovery

Action Plan

Failure to attract and retain high calibre leaders – clincial and management.

X

X

Workforce Plan

• Appraisals levels • Sickness levels • Mandatory training

compliance • Trust Board Papers

Failure to maintain focus on operational standards.

X

X

Improvement Programme Operational Plan

PMO Improvement Board

• Monthly reporting to Board

• Quality Assurance and Learning Committee

• Clinical Governance Committee Minutes


Page 8

Draft Strategic Objective 2 - Achieve and maintain financial sustainability

Will impact on all risks on the risk register if realised

Executive Lead Board Sub Committee Enablers Key Controls (Existing)

Assurances

Gaps in controls or assurances

Action plan including owner

and due date

CEO

DoN

CO

O

MD

DoW

OD

DoF

Boar

d of

Dire

ctor

s

Perfo

rman

ce &

Fin

ance

Audi

t and

Ris

k

Res

ourc

es

Clin

ical

Gov

erna

nce

Datix Risk number 385 The Trust is in risk of becoming insolvent in 2015/16 This Impacts on the Trust Through Monitor intervention Negative reputational impact The ability to suitably respond/ address other risks Inability to take advantage of business opportunities

X

X

Executive plan to maintain financial stability

QIPP Plans Presentation of financial forecasts and performance to the Executive Capital projects reviewed and approved by the Capital Investment Group Financial Recovery Plan

Meetings with Monitor QIPP Program Board Monitoring by the Executive Financial Recovery Action Plan


Page 9

Strategic Objective 3 - A highly skilled and flexible workforce, demonstrating leadership at all levels

Will also impact on the strategic objective Quality care and operational excellence if realised

Executive Lead Board Sub Committee Enablers Key Controls Potential sources of assurance Gaps in controls or assurances

Action plan including owner and due date

CEO

DoN

CO

O

MD

DoW

OD

DoF

Boar

d of

Dire

ctor

s

Perfo

rman

ce &

Fin

ance

Audi

t and

Ris

k

Res

ourc

es

Clin

ical

Gov

erna

nce

Datix Risk number 386 The inability of the Trust to recruit to substantive nursing or medical vacancies and or supply of suitable temporary staff in some areas of the Trust

X

X Workforce plan Workforce productivity plan

Daily controls include reallocation of staff, reviewing skills mixes Recruitment Initiatives

• Appraisals levels • Sickness levels • Mandatory training compliance • Care group board minutes,

papers/reports on recruitment / vacancy rates level of turnover

• Nursing board minutes, papers/reports

• Trust Board Papers

• Staff attendance at mandatory training

X

X Mandatory training policy Appraisal policy

• Workforce and Education Committee minutes, papers/reports

• Care group board minutes, papers/reports

• Leadership

X

X Leadership program Training for Board member

• Trust Board Papers • Leadership program take up


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Strategic Objective 4 - Quality care and operational excellence



CEO

DoN

CO

O

MD

DoW

OD

DoF

Boar

d of

Dire

ctor

s

Perfo

rman

ce &

Fin

ance

Audi

t and

Ris

k

Res

ourc

es

Clin

ical

Gov

erna

nce

Datix Risk number 390 Principal risk: Failure to reduce the number of ‘Never Events’ Never events when they occur will impact on patient safety and lead to a review of process by the Trust and commissioners. May also lead to Civil litigation and Regulatory action

X

X Serious Incident Policy

Trust has a Quality Improvement Lead for Never Events

WHO Checklist

Quality Improvement Program

• Investigations into Never Event are signed off by Executives

• Investigation findings are communicated and action plans where required are produced and implemented

• Theatre Safety Group Minutes • Quality Assurance and Learning

Committee • Clinical Governance Committee Minutes • Count days between Never Events


Page 11

Datix Risk number 391 (Linked to 386) The CQC has identified a number of issues regarding the Trusts maternity service provision

X

X Maternity Action Plan

Two birthing rooms have been closed on Rushey To consolidate workforce staff implement a closure of MLU when levels of demand dictate Staffing levels and patient admissions monitored on a daily basis Funding for 2 consultant posts Findings from the Midwifery staffing assessment being implemented

• UCG Board and the Improvement Project Board Minutes and papers

• Birth-rate plus findings • Feedback from open staff forums

undertaken • Care group board minutes,

papers/reports on recruitment / vacancy rates level of turnover

• Nursing board minutes, papers/reports • Trust Board Papers • Workforce and Education Committee

minutes, papers/reports • CQC reporting / monitoring

Datix Risk number 392 (Linked to 395) Failure to meet A&E clinical standards of 95% for patient admittance, transfer or discharge

X

X

Recovery and Improvement Plan

COO appointed Launch of Trust transformation patient flow program Agreement that the RBFT ‘single point of entry’ for all NEL admissions Additional space in ED, a new observation area and MH assessment room GP referrals to Medicine now being diverted direct to GPU avoiding ED

• Berkshire West CCG Urgent Care Programme Board Minutes and papers

• Audit, monitored through the LOS steering group.

• Trust Board Papers • UCG Board Minutes and papers • Meetings with Monitor


Page 12

Datix Risk number 393 The demand for ICU beds has been increasing and the Trusts ability to meet this demand is constrained due to the Trust having lower average number of beds per head of population 2.6 to 7:4

X

X

Bed space utilise in HDU area SOP for transfer of patients with colonised multi-resistant Refurbishment of areas eg Haygroves

• UCG Board Minutes and papers

Datix Risk number 394 Medical Records work environment places staff and individuals at risk.Failure to suitably manage the health records within the Trust may lead to non delivery or loss of records or incomplete or unavailable records. This ultimately may impact on patient care.

X

X

Recruitment Initiatives

• UCG Board. Planned and Network Minutes and papers

• Monmouth Audit

Datix Risk number 395 Failure to meet the 18 week RTT pathway. Length of patient wait may be longer than reported due to inability to produce accurate data. This may impact upon revenues streams.

X

X

Recovery plan

• Operation Recovery Board Minutes and papers

• Cancer, Speciality and Weekly PTL Minutes

• Monitor reporting / monitoring


Page 13

Strategic Objective 5 - Maintain a fit for purpose estates infrastructure and IMT systems

Datix Risk number



CEO

DoN

CO

O

MD

DoW

OD

DoF

Boar

d of

Dire

ctor

s

Perfo

rman

ce &

Fin

ance

Audi

t and

Ris

k

Res

ourc

es

Clin

ical

Gov

erna

nce

Datix Risk number 387 Inadequate IT infrastructure

X

X

Funding for Wi-fi networking has been confirmed and committed

• Installation wi-fi network • Trust Board Papers

Datix Risk number 388 Inadequate operation uptime of key IT systems including - 1. EPR Hardware,

operational, technical support & DR

2. Workforce to

support operational use of EPR

3. Many stand alone

IT systems

X

X

Complete implementation of the move to Cerner Hosting to be completed by end Q.4 2015/16 Complete upgrade of EPR Radnet Radiology module so it is intrinsic part of Trust integrated EPR and covered by same support processes/staff. To be completed by end March 2015 Cross train resulting IM&T support team to provide resilience in IT application support skills and knowledge of key IT applications. To be completed during 2015/16

• Trust Board Papers


Page 14

Datix Risk number 389 Inadequate data quality

The Trust is not assured that it is able to accurately collate its clinical activity and performance data. There is inconsistency in reporting of performance & quality data between the Care Group and Board reports.

X

X

The three Head of Informatics posts have been relocated from Care Groups into the Informatics team. Restructure of the Trust Informatics team and Trust Data Assurance Team Research and scoping required to review business intelligence and information tools A Ward to Board review of KPI requirements and data gathering processes to optimise production and alignment of Care Group Performance and Board Reports

•

Appendix B _ Corporate Risk Register Agenda item 6

Page 15

Lead Executive Director for risk: Director of Finance Present Risk Rating = High Risk (20) Risk Id 385 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating

Cons L’hood Risk Rating

Cons L’hood Cons L’hood Risk Rating

Principal risk: The Trust is in risk of becoming insolvent in 2015/16 The Trust has been drawing down on its cash reserves in 2014/15 affecting the Trusts financial position. It will now have a much reduced cash reserve entering the financial period 2015/16. The potential impact to the Trust if not addressed now, is for it to run out of money leading to Monitor intervention and enforcement action being taken.

5

5

25

• Monthly Review of financial performance by Executive and Board.

• Quarterly re-forecasts completed to assess current delivery.

• Weekly, monthly and 18 monthly cash forecasting. • Payment runs reviewed by DoF. • All capital projects are reviewed and approved by Capital

Investment Group. • Executive plan to maintain financial stability. • Monitoring by Executive and QIPP program board • Capital spend halted except for projects underway and

for statutory compliance • Q3 Forecast to January Board Meeting • New Headcount requires Exec sign off • Identified discretionary spending signed of by the Exec • Reduced spend sums that require non exec sign off

5

4

• Budget and actions to be taken agreed by the board

• Monitoring of risks through quarterly re-forecasting

• Identify additional projects to address shortfall

• Deliver 18.5M QUIPP Savings • Financial recovery plan for next two years

being developed for sign off at March 2015 Board meeting

4

2

8

Lead Executive Director for risk: Director of Workforce and OD Present Risk Rating = Medium Risk (9) Risk Id 386 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating



Principal risk: Staffing levels Inability to recruit to substantive nursing and medical vacancies and or supply of suitable temporary staff in some areas of the Trust Effect 1 Patient Care Staff may have less time to spend with each patient, and complete documentation records etc. This has the potential to reduce operational efficiency and create a detrimental experience for the patient and so adversely impacting on the delivering of safe care

3

4

12

• Daily controls – Matrons reallocate staff to wards to ensure safe staffing levels and skill mixes.

• Ward managers review skills mix to ensure senior cover on every shift to support junior staff.

• Matrons are more visible • Recruitment initiatives in place • Monitoring by the Trust executive team • Overseas recruitment initiative

3

3

• Development of Workforce plan • Nursing Programme board to be

established • Monitoring by the Care Group

Board • Work streams to be established

to review through the workforce productivity program

2

2

4

Effect 2 Attendance at Training Due to staffing levels there may be an inability to release staff for mandatory training. This has the potential to increase risks in safe patient care through staff competencies not being reviewed, and successful civil claims if staff are injured outside the Trust stipulated periods to attend refresher training

• Mandatory Training Policy • Training can be accessed via training days or e-

learning • Monitoring by the Care Group Board • Monitoring by the Trust executive team • UK skills framework for statutory and mandatory

training now followed • Incremental pay increase linked to completion of

S&M training

• Additional training sessions to be arranged

• Monitoring by the Workforce and Education Committee

• Review of the delivery of training


Page 16

Lead Executive Director for risk: Chief Executive via the IM&T Director Present Risk Rating = High Risk (16) Risk Id 387 Initial Risk Rating Present controls Present Risk

Rating Mitigating action to be taken Target Risk Rating by


Cons L’hood Cons L’hood

Risk Rating

Principal risk: Inadequate IT infrastructure The Trust has an IT infrastructure (firewalls, servers, wireless and fixed networks, pc, laptops etc) which is inadequate for its current and future operational needs. The present financial position and outsourcing contractual commitments constrains the Trust to invest short and medium in its infrastructure. There is potential for inefficient clinical staff data recording which may affect patient safety and efficient care due to the lack of computer access and the requirement to have to access various applications to record and retrieve information (slow log on and need to log on to multiple systems). Without additional investment to address its present requirements and the Trust identifying and committing to a long term investment solution the failing infrastructure will negatively impact upon the Trusts present and future operational and financial performance, as well as limit its capability to participate in future e-patient pathways being led by the CCGs etc.

4

4

16

• AD Infrastructure recruited on fixed term contract to give continuity

• Funding for Wi-fi networking has been confirmed and committed

4

4

• Scoping work to install wi-fi network commenced with network to be installed by end of Q1 2015/16 – lead Mike Robinson

• Production of hi level options paper regarding the end of the CSC contract in 2016 (To be presented to the Executive in May 2015) – lead Heather Allan.

• Infrastructure review to be undertaken in sections across the estate identifying essential infrastructure improvements with report to be shared with the Exec (end Q.1 2015)This will include possible shortfall in license cover. – lead Mike Robinson

• Review the residual Trust risks following the completion of Transformation work by CSC. These include reviewing Trust IT systems which have not been transformed and cannot continue to run on the Trusts evolving infrastructure. Paper to be presented to the Executive in Q.2 2015 – lead Mike Robinson

• Review options for speed of log on/access to multiple systems (e.g. single sign on to allow clinicians to switch between applications without using multiple system logins). Paper to be presented to the Exec in Q.2 2015 on how the Trust will address and mitigate – lead Mike Robinson.

2

2

4


Page 17

Lead Executive Director for risk: Chief Executive via the M&T Director Present Risk Rating = High Risk (20) Risk Id 388 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating by



Principal risk: Inadequate operation uptime of key IT systems

EPR Hardware, operational, technical support & DR

The EPR system is running on 6 year old hardware which gives increased reliability risk and incurs increased maintenance expense. It is housed in a third party location with support supplied by multiple vendors adding complexity if problems occur. There is inadequate disaster recovery. The Trust relies on two IT technical contractors and a third-party service to provide technical and operational expertise with a lack of proactive “housekeeping” and no resilience in the skills provided. The combination of the above leave the Trust significantly at risk of extended downtime incidents.

Workforce to support operational use of EPR

The support of EPR as an application divides into: a) Front line support covering help desk, configuration

changes including clinic changes, correspondence problems, new user set up, management of requests and changes.

b) Third line support where there needs to be deep knowledge of the processes and use of EPR by the Trust and of the EPR application itself.

c) Integration engine support with new functionality delivery. The integration engine is a complex piece of software which supports the EPR link with other IT systems.

Areas a) and b) give risk with their numbers depleted due to freezing of vacancies and retirement of a key long term

5

4

20

• AD Architecture & Application Support recruited

• Best endeavours by IM&T

5

4

EPR Hardware, operational, technical support & DR

• A business case is being written to move to Cerner hosted EPR environment, including renewal of associated hardware and a full operational management service. The EPR application and Trust associated processes will still need to be supported by internal IM&T staff (see below) but they will no longer perform operational management of the hardware and databases. Proposal and Business Case will be presented to the Exec before end April 2015 – lead Heather Allan

• Complete implementation of the move to Cerner Hosting to be completed by end Q.4 2015/16 – lead Heather Allan

• Complete upgrade of EPR Radnet Radiology module so it is intrinsic part of Trust integrated EPR and covered by same support processes/staff. To be completed by end March 2015 – lead Heather Skevington

Workforce to support use of EPR

a), b) Review depth and capacity of internal EPR IT Support ensuring continuity/resilience. To be completed by end of Q.4 2014/15, earlier if possible, with a proposal to the Exec – lead Heather Allen Implement agreed recommendations ASAP and provide internal contract cover.

c) Make a case to recruit an integration engine contractor for 9 months to deliver backlog and provide resilience. Cross-

2

2

4


Page 18

senior staff member taking with her significant Trust EPR knowledge. Implementation of a large central module of EPR, Order Comms, has increased this risk. This staff shortfall impacts on the Trust gaining the optimal benefit from EPR and leaves too few staff able to provide adequate out of hours/in hours cover. This provides a major risk. Area c) is support by 1 contractor with no resilience.

Many stand alone IT systems

d) The Care Groups through the Trusts previous and present arrangements are responsible, including software support and emergency response, for all IT applications/systems outside of the EPR system.

Price Waterhouse, the Trust internal auditors, have highlighted that this decentralised approach has left the Trust at risk in the area of operational management controls e.g. leavers/joiners/access management, supplier license agreements, DR and back up arrangements. A combination of these can result in information governance issues (patient confidentiality), legal license compliance and excessive downtime occurrences. e) IM&T also has a small team who have developed up to

30 internal IT systems over 20 years. The trust strategy is to replace these systems with supplier product based solutions which will provide less risk longer term and remove dependency on individuals.

train two current development staff and review if this gives adequate solution.

Many stand alone IT systems

d) Complete review of operations management and support of top priority IT systems and take appropriate action to regularise/strengthen supplier management on the ground, IT support and Disaster Recovery - lead Mike Robinson/Nigel Uwins Implement findings of this review which may mean moving IT support responsibility (and any associated IT staffing) to IM&T for key Trust systems during 2015/16 – lead Nigel Uwins

e) Cross train resulting IM&T support team to provide resilience in IT application support skills and knowledge of key IT applications. To be completed during 2015/16 – lead Heather Allen Review of out of hours IT applications support cover and strengthen, spreading load wider and ensuring adequate cover and remuneration To be completed during 2015/16 – lead Heather Allen


Page 19

Lead Executive Director for risk: Chief Executive via the IM&T Director Present Risk Rating = High Risk (20) Risk Id 389 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating



Principal risk: Inadequate data quality The Trust is not assured that it is able to accurately collate its clinical activity and performance data. There is inconsistency in reporting of performance & quality data between the Care Group and Board reports. Successive external audits have highlighted the lack of documented processes for the collection of data for performance and quality data and activity data. Monmouth audit has highlighted accuracy of coding to be adversely affected by: a) Lack of ability to locate case notes b) The discharge note IT system being a freestanding

Trust developed IT system separate from the Trust EPR PAS giving non aligned data with the EPR.

c) Clinical coding being supported by and stored in a Trust developed IT system, separate from the EPR PAS and with inadequate data validation functionality.

The Trust data warehouse is 14 years old and extremely difficult to maintain and modifications give a very high risk of corrupting data. The Trust has multiple IT systems and multiple entry needs making analysis and assurance more complex and less robust than having a single source. The Trust has not yet integrated these systems to support data being entered once. Therefore the Trust is not able to monitor with confidence its performance and productivity through KPI operational performance reports The impact also is that the Trust may not be accurately invoicing for its work and therefore potentially not being paid for work that has been undertaken. The risk of data accuracy has been identified by Monitor

4

5

20

• Associate Director for informatics recruited

• Review undertaken and proposed restructuring of informatics team was approved by the Trust Executive meeting 03.11.2014

• The three Head of Informatics posts have been relocated from Care Groups into the Informatics team.

4

5

• Implement the restructure of the Trust Informatics team. To be completed by end of Q.2 2015/16 - lead Eghosa Bazuaye.

• Review and implement restructuring, if required, of the Trust Data Assurance Team including a review of working practices – lead Eghosa Bazuaye.

• Replace old data warehouse with product based, supportable software. Phase 1 to be completed by end Q.2 2015/16, Pahse 2 to be completed by end Q.4 2015/16 – lead Eghosa Bazuaye.

• Research and scoping required to review business intelligence and information tools that can be used within the Trust. To be completed by late 2015-16 – Eghosa Bazuaye.

• A Ward to Board review of KPI requirements and data gathering processes to optimise production and alignment of Care Group Performance and Board Reports has commenced This will lead to the development of a multi phased action and implementation plan – lead Eghosa Bazuaye.

• Review collections processes from speciality collection through to EPR, data warehouse, clinical coding/data assurance to finance for all inpatient and outpatient/day case activity and recommend an action plan to identify missing data and improve data accuracy. Implement action plan – lead Eghosa Bazuaye

2

2

4


Page 20

and action is required to comply with the Monitor 18 week RRT Recovery Plan There are two outstanding data quality breaches (CCG and NHS England)

Lead Executive Director for risk: Medical Director Present Risk Rating = Medium Risk (15) Risk Id 390 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating



Principal risk: Failure to reduce the number of ‘Never Events’ These incidents should never occur but an increase may be due to improved reporting and a culture of openness Never events when they occur will impact on patient safety and lead to a review of process by the Trust and commissioners.

5

4

20

• Never Events covered in Serious Incident Policy and investigated as SIRIs

• Process for managing never events including communicating learning to areas exists and Executive sign off

• Trust has a Quality Improvement Lead for Never Events lead who is responsible for implementing the Never Events Action plan and learning

• Monitoring and implementation of learning from never events is the responsibility of the Theatre Safety Group

• Theatre Patient Safety Strategy Group • Count days between Never Events • Learning regarding the WHO Checklist • Part of the quality Improvement Program

5

3

• Once Never Event occurs the communication of learning and implementation of training as required

5

2

10

Lead Executive Director for risk: Director of Nursing Present Risk Rating = Medium Risk (15) Risk Id 391 Initial Risk Scoring Present controls Present Risk Scoring Mitigating action to be

taken Target Risk Rating



Principal risk: The CQC has identified a number of issues regarding the Trusts maternity service provision Due to: Inadequate clinical staffing levels and the standards of the working environment. Impact : Adverse impact on clinical standards, affecting patient safety and so potentially leading to serious incidents and non compliance to NHS standards. Ultimately leading to claims and reputational issues.

5

5

25

• Two birthing rooms have been closed on Rushey • To consolidate workforce staff implement a closure

of MLU when levels of demand dictate • Staffing levels and patient admissions monitored on

a daily basis • Post CCT posts used to keep levels at 60 hours • Funding for 2 consultant posts • Provision monitored by the UCG Board and the

Improvement Project Board • Maternity Action Plan presented and approved at

Trust Exec Meeting Q1 2015. • Work environment being addressed through

installation of ventilation, and Entonox levels being monitored.

5

3

• Recruitment of additional midwifery staff

2

2

4


Page 21

• Midwifery staffing assessment completed by Birth-rate plus – findings being addressed implemented

• Commencement of leadership programme for staff through Thames Valley University

• Open staff forums undertaken

Lead Executive Director for risk: Chief Operating Officer Present Risk Rating = Medium Risk (8) Risk Id 392 Initial Risk Rating

Present Risk Rating Mitigating action to be




Principal risk: Failure to meet A&E clinical standards of 95% for patient admittance, transfer or discharge Due to: Monitor Inspection Impact : Poor patient experience and safety that leads to regulatory action or reputational damage

5

4

20

• Trust appointment of an Interim Chief Operating Officer in April 2014 • Working as part of the multiagency Berkshire West CCG Urgent Care

Programme Board, The Care Group has agreed a trajectory for recovery for Q1 2014/15 (RBH Recovery and Improvement Plan)

• RBH A&E Recovery and Improvement Plan revised to include safe timely discharge informed by the audit, monitored through the LOS steering group.

• Agreement that the RBFT ‘single point of entry’ for all NEL admissions, regarded as best practice by ECIST and supported by our Commissioners, has been a contributing factor in the challenge to meet the A&E 4 hour standard

• Additional space in ED, a new observation area and MH assessment room

• Monitoring of actions by the UCG Board • Monitoring of actions by Trust Executive • Daily review of safe discharge by clinical teams in place • GP referrals to Medicine now being diverted direct to GPU avoiding

ED

4

2

Launch of Trust transformation patient flow program

2

2

4

Lead Executive Director for risk: Chief Operating Officer Present Risk Rating = Medium Risk (9) Risk Id 393 Initial Risk Rating

Present Risk Rating Mitigating action to be




Principal risk: The demand for ICU beds has been increasing and the Trusts ability to meet this demand is constrained due to the Trust having lower average number of beds per head of population 2.6 to 7:4 This can impact on the number of level 1,2,3

4

4

16

• Bed space utilise in HDU area • SOP for transfer of patients with

colonised multi-resistant • Refurbishment of areas eg Haygroves • A&E recovery plan • Recruitment of clinical staff

3

3

Business case reviewed and amended. To be presented at SMT on 23/03/15

2

2

4


Page 22

and impact on CQC findings and patient flow

Lead Executive Director for risk: Chief Operating Officer Present Risk Rating = Medium Risk (12) Risk Id 394 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating



Principal risk: Failure to suitably manage the health records within the Trust may lead to non delivery or loss of records or incomplete or unavailable records. This ultimately may impact on patient care.

4

5

20

• Health records work stream has been included in the over all Trust improvement programme with 5 established key work streams

• Extra staff employed to transport, file and repair notes • Monitoring by the Trust Executive • The risk around health records is monitored by the

Medical Records Improvement Programme Board • Quality audit taken place Dec 14/Jan 15 • Education programme delivered/being delivered • Successful trial of delivering patient notes in outpatients

3

4

• Trial for delivery of patient notes in inpatients

• Feasibility study and business case study to be undertaken around the purchase and implementation of an electronic records system

• Relocation of Medical Records dept to off site facility to allow for greater storage capacity so improved record management control

2

2

4


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Lead Executive Director for risk: Chief Operating Officer Present Risk Rating = Medium Risk (12) Risk Id 395 Initial Risk Rating Present controls Present Risk Rating Mitigating action to be taken Target Risk Rating



Principal risk: Failure to meet the 18 week RTT pathway. Impact : Length of patient wait may be longer than reported due to inability to produce accurate data. This may impact upon revenues streams.

4

4

16

• External consultant employed to develop an action plan, which included a check of all current data and training of staff

• Refresher training implemented • Weekly operation recovery board • Oct 2014 Data quality assurance exercise as part of the

recovery plan • Trust led IST workshop • 18 week access lead appointed • Weekly PTL meetings established

Speciality PTL meetings Cancer PTL meetings

• Recommenced reporting of all standards in Q4 • Monitoring of recovery trajectory agreed with Monitor to

achieve compliance Sept/Oct

4

3

• Action plan to be fully implemented with Monitor to confirm compliance

• Commenced capacity and demand modelling with NHS IMAS

2

2

4

Title: Integrated Performance Report Agenda item no: 7a Meeting: Board of Directors Date: 28 May 2015 Presented by: Caroline Ainslie, Director of Nursing

Bernadette Bluhm, Interim Chief Operating Officer

Prepared by: Lianne Mellor, Interim Head of Information

Purpose of the Report The purpose of this paper is to provide the Board of Directors with an

analysis of quality performance to the end of April 2015. The report covers performance against the Monitor Risk Assessment Framework as well as national and local key performance indicators.

Report History New report

What action is required?

Specification of what it is asking the Committee to do in relation to it e.g. review, approve, discuss etc – see below.


Resource Impact: Not applicable Relationship to Risk in BAF:

Failure to maintain quality and performance standards Failure to maintain standards required to maintain licence to operate











Improvement to processes for performance management. Processes for utilisation of information and its analysis to drive change. Assurance on the robustness of data quality. Publication Published on website Confidentiality (FoI): Private Public Available on request.

19th May 2015

Integrated Performance Report

The purpose of this paper is to provide the Board of Directors with an analysis of quality performance to the end of April 2015. The report covers performance against the Monitor Risk Assessment Framework as well as national and local key performance indicators. Contact: Caroline Ainslie Bernadette Bluhm Craig Anderson, Director of Finance Paul Beale, Direct of Workforce Lindsey Barker, Medical Director

Contents Introduction Page 3

Monitor Compliance Page 4

1. Access Page 5

Elective Waiting Times Page 5

Emergency Waiting Times Page 7

Inpatient Experience Page 8

Outpatient Experience Page 9

2. Patient Safety Page 10

Harm Free Care Page 10

Incidents Reporting Page 11

Patient Safety Thermometer Page 14

3. Patient Experience Page 15

4. Clinical Effectiveness Page 17

Mortality Page 17

Clinical Outcomes Page 18

5. Finance Page 22

6. Workforce Page 23

7. Staffing Data Page 24

8. Risk Log & Action Plan Page 27

21/05/2015 Quality Performance Report Page 2

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

Introduction


Monitor Compliance


• A&E o 95.1% of patients were treated in 4 hours in April 2015. This is a positive start to Q1 and the Trust is

expecting to continue to deliver above 95% through the quarter.

• Cancer Waiting Times – Un-validated position at the time of reporting o Cancer performance is a significantly challenged. Validation will improve performance figures included

within this report however the Trust is not expecting to deliver performance for 62 days or 2WW and a full exception report is provided with this report

• 18 weeks RTT Admitted Backlog Patients o The Trusts overall incomplete backlog reduced again in April by 297 , the total backlog now stands at

1,885. Significant validation work is still required ahead of upload to ensure that all clock stop activity is accurately reported.

• 18 Weeks RTT • The Trust’s 18 weeks performance for non-admitted exceeded the trajectory set for April 2015 and met the

national 95% target at 96.8%. The incomplete performance also met the national standard with 93.2% compliance against the 92% target. In April 2015 the Trust failed to meet the admitted plan of 78%. This was due to a reduction in activity leading to 75. 5%

1. Access

• 18 weeks RTT – Both non admitted and incomplete trajectories have exceed plan in April. Both also achieved the national standard ahead of trajectory. The admitted trajectory was not met in April. Failure to meet trajectory was almost entirely driven by a reduced admitted activity, despite planning for the April Easter holiday. Looking forward the Trust is back on plan for this standard in May.

• 52 week position - In April 12 patients have waited longer than 52 weeks. A further 3 patients had their 18 week clock stopped beyond 52 weeks. The 12 remaining patients were all identified in the breast list review that took place in November 2014 and remain on the waiting list through patient choice. All have dates for surgery or out-patient review. An additional 52 week indicator will be included as of May reporting.

• Diagnostics 6 Weeks Wait – a review of pathways and methodology is under way to ensure acute capture of information and reporting of performance.

Comments

21/05/2015 Integrated Performance Report Page 5

18 weeks RTT Monthly

variance

Waiting Times: 18 weeks RTT Nov Dec Jan Feb Mar Apr DoT Month +/-

Diagnostics in 6 weeks % 100.0% 100.0% 100.0% 99.8% 99.9% - ◄► > 99.0% 0.0%

18 Weeks: admitted patients - - 69.1% 71.5% 75.4% 75.5% ◄► > 90.0% -14.5%

18 Weeks: non-admitted patients - - 95.8% 93.3% 94.7% 96.8% ◄► > 95.0% 1.8%

18 Weeks: incomplete pathways - - 89.2% 91.4% 91.9% 93.2% ◄► > 92.0% 1.2%

18 weeks - Admitted backlog - - 1224 1264 1244 1321 ▲ - 0.0

Actual Target

1. Access


Outpatient Experience Monthly

variance Waiting Times: Cancer 1

Nov Dec Jan Feb Mar Apr DoT Month +/-

Cancer 2 week wait: cancer suspected 93.0% 92.5% 91.8% 93.9% 92.4% 84.5% ▼ > 93.0% -8.5%

Cancer 2 week wait: breast patients 96.0% 86.1% 96.6% 95.7% 93.0% 81.9% ▼ > 93.0% -11.1%

Cancer 31 day wait: to first treatment 97.8% 96.5% 94.0% 95.1% 98.0% 95.0% ▼ > 96.0% -1.0%

Cancer 31 day wait: drug treatments 100.0% 100.0% 98.6% 100.0% 84.4% 100.0% ▲ > 98.0% 2.0%

Cancer 31 day wait: surgery 96.4% 94.4% 94.4% 82.8% 94.6% 95.7% ◄► > 94.0% 1.7%

Cancer 31 day wait: radiotherapy 99.1% 98.3% 95.9% 95.0% 97.7% 100.0% ◄► > 94.0% 6.0%

62 day GP Ref re-allocation pre breach 87.9% 86.3% 79.1% 82.3% 75.8% 74.7% ◄► > 85.0% -10.3%

62 day GP Ref re-allocation post breach 87.9% 86.3% 79.1% 82.3% 75.8% 69.6% ▼ > 85.0% -15.4%

62 day screen Ref re-allocation pre breach 92.3% 95.0% 85.7% 73.7% 93.9% 74.7% ▼ > 90.0% -15.3%

62 day screen Ref re-allocation post breach 92.3% 95.0% 85.7% 73.7% 93.9% 69.6% ▼ > 90.0% -20.4%

62 day consultant upgrade: all cancers 40.0% 100.0% 100.0% 100.0% 0.0% 100.0% ▲ > 90.0% 10.0%

Actual Target

• Cancer performance remains un-validated at the time of this report. Performance in all standards is expected to improve with final validation, however the Trust is not expecting to meet the 2WW or 62 day standard for April.

• The Trust has submitted a recovery plan to the CCG. • A full exception is included as part of this report. The report identifies the key challenges and

remedial actions together with the improvement time line.

Comments

1. Access

• The Trust was compliant with the 4 hour Emergency Access standard for April. • The Emergency Department has developed an internal improvement plan aimed at

addressing specific risks / challenges that lead to internal delays. • A number of new actions have been agreed including the introduction 2 hourly “safe

huddle” escalation board rounds. • The plan will be monitored through the patient flow element of the Trusts transformation

programme. • The ambulance turnaround performance for the Trust will be included in reporting as of

May 2015.

Comments


A&E Experience Monthly

variance Waiting Times: A&E


A&E: 4hr Limit (type 1 &2) 96.3% 89.5% 92.6% 92.1% 92.5% 95.1% ▲ > 95.0% 0.1%

Seen within 4 hours - RBH site Type 1 only 95.8% 88.3% 91.6% 91.1% 91.5% 94.4% ▲ > 95.0% -0.6%

Actual Target

1. Access

• Cancelled Operations on day of surgery – there is an improvement on the March position with only 0.5% of patients being cancelled on the day of surgery for non clinical reasons. Overall activity in month was reduced due to the 2 week Easter holiday.

• RE-scheduled within 28 days – 2 of the 19 patients cancelled on the day were not re-scheduled within the required 28 days, both patients belong to Ophthalmology.

• The access steering group has agreed a standing operating procedure for on the day cancellations and all re-scheduling plans will be monitored through this forum to prevent subsequent failure of this standard.

Comments


Inpatient Experience Monthly

variance Cancellations and Delays


Delayed transfers of care 6.3% 4.8% 4.1% 4.6% 4.4% 4.4% ◄► < 3.5% 0.9%

Hosp Canc Ops day of surgery - non-clinical 0.8% 1.4% 0.9% 0.5% 0.9% 0.5% ▼ < 0.5% 0.0%

Cancelled Ops not re-scheduled < 28 days 0.0% 11.1% 5.4% 15.8% 0.0% 10.5% ▲ < 5.0% 5.5%

Theatre Utilisation 89.0% 91.0% 91.8% 94.0% 94.0% 94.6% ◄► > 91.0% 3.6%

Actual Target

1. Access

• The outpatient cancellation rate remains marginally over the agreed local standard. The Trust Clinical Admin Programme due to go live on 1st June is expected to deliver improvements in all the outpatient experience indicators. Although it should be noted that the Trust met the two local standards for Trust and Patient cancellations.

Comments


Outpatient Experience Monthly

variance Waiting Times: Outpatient


Outpatient cancellation rate 27.8% 28.5% 25.8% 27.6% 27.2% 27.1% ◄► < 25.8% 1.3%

% Appointments cancelled by RBFT 15.1% 14.7% 13.0% 14.9% 15.0% 15.1% ◄► < 15.5% -0.4%

% Appointments cancelled by patient 12.7% 13.8% 12.7% 12.7% 12.3% 12.1% ◄► < 12.3% -0.3%

Actual Target

2. Safety

• For 2015/16 the Trust has been assigned a target of 27 cases of C. difficile. In total 29 cases were reported for 2014/15 with an additional 40 non-reportable instances of C difficile being identified. Of the 29 reported cases 11 were identified as having lapses in care ( 2 remain outstanding) with common issues being associated with antimicrobial prescribing and appropriate stool sampling

• Improving hand hygiene compliance continues to be a focus of attention within the trust with 94.5 % compliance being reported for April.

Comments


Harm Free Care Monthly

variance Infection Control


Meeting the C.Diff objective5 3 2 0 3 3 ◄► < 2.3 0.8

MRSA0 0 0 0 0 0 ◄► = 0.0 0.0

MSSA surveillance (trust acquired)0 0 0 0 0 3 ▲ = - 0.0

Ecoli (trust acquired) infections 0 0 0 0 0 5 ▲ = - 0.0

Actual Target

2. Safety

• There were 3 falls resulting in serious harm which were assessed as avoidable

Comments


Incidents Reporting Monthly

variance Falls and Ulcers


Pressure Ulcer Incidence per 1,000 bed days 1.2 1.0 0.8 1.1 1.1 1.0 ▼ < 1.4 -0.4

Grade 3 or 4 avoidable pressure ulcers (SI)2 0 1 0 0 0 ◄► < 1.2 -1.2

Patient falls resulting in Harm (SI) 0 1 1 0 0 3 ▲ < 1.7 1.3

Patient Falls per 1,000 bed days3.9 4.8 4.2 3.2 5.1 5.0 ◄► < 5.0 0.0

Actual Target

2. Safety

• As of May 2015 reporting of the Patient Safety Incidents will be identified as approved and unapproved.

Comments


Incidents Reporting Monthly

variance Other Incidents


Patient Safety Incidents/100 Admissions 7.9 8.8 9.0 7.5 7.5 9.2 ▲ > 7.0 2.2

Number of patient safety incidents reported564 705 874 544 970 781 ▼ > 733.2 47.8

All serious incidents (SI)9 12 10 5 7 6 ▼ - 0.0

Duty of Candour breaches (SI) 0 0 0 0 0 0 ◄► = 0.0 0.0

Never Events0 1 0 0 0 0 ◄► = 0.0 0.0

CAS alerts overdue 0 0 0 0 0 0 ◄► = 0.0 0.0

Medication errors Resulting in Serious Harm- - - - - 0

◄►= - 0.0

Actual Target

2. Safety

Comments


Safety Improvement Monthly

variance Patient Safety Thermometer


Pressure Ulcers New (PST)0.8% 0.2% 0.2% 0.3% 0.3% 0.8% ▲ < 0.8% 0.0%

New catheters with a UTI (PST)0.5% 0.5% 0.2% 0.2% 0.8% 0.3% ▼ < 0.9% -0.6%

Harm Free Care - All Harms (PST) 96.1% 94.6% 95.3% 95.5% 95.5% 93.8% ◄► > 95.0% -1.2%

Harm Free Care - New Harms (PST) 99.2% 99.2% 99.0% 99.2% 98.3% 97.8% ◄► > 97.2% 0.6%

Actual Target

• The nutrition assessment in 24 hours has increased 6.7% from last month and the assessment in 48 hours 1.9%

Comments


2. Safety

Monitoring Clinical Outcomes Monthly

variance Other Clinical Indicators


Nutrition risk assessment in 24 hours 86.0% 77.0% 83.0% 82.0% 82.0% 88.7% ▲ > 90.0% -1.3%

Nutrition risk assessment in 48 hours 93.0% 85.0% 91.0% 90.0% 93.0% 94.9% ◄► > 90.0% 4.9%

Actual Target

3. Experience

•83% of complaints closed in April were responded to within 25 days. Of the complaints closed in April, the severity rating was: 1 Red (high), 1 Amber (moderate), 40 Green (low or very low). 15 were well founded, 5 partially and 9 were not founded. We are awaiting outcomes for 13 complaints these are being actively chased up The YTD figure for complaints closed within 25 days is 83%

Comments


Surveys and Feedback

Patient ComplaintsNov Dec Jan Feb Mar Apr DoT Month

Number of Complaints 43 26 30 37 42 24 ▼ < 33.3

Complaints avg response (days) 26 26 26 26 26 23 ▼ < 25.0

Number of PALS concerns 265 252 241 235 257 260 ◄► = -

Number of Complaints to Ombudsman - - - - - 0 ◄► = -

Number of Complaints upheld by Ombudsman - - - - - 0 ◄► = -

Actual Target

3. Experience

• The Trust Patient Survey has decreased 2.3%. This is the first time in the last year we have not achieved this standard.

• The inpatient survey patients being informed of drug side effects has increased by 3.4% .


Surveys and Feedback Monthly

variance Trust Patient Survey


Trust Patient Survey - overall rating 99.0% 98.0% 98.0% 97.0% 98.0% 95.7% ◄► > 97.0% -1.3%

FFT Response Inpatients 37.7% 32.5% 39.9% 41.3% 47.1% 36.6% ▼ > 30.0% 6.6%

FFT Reccomendation Rates Inpatients- - - - - 99.2%

▲> 98.0% 1.2%

FFT Response A&E 21.1% 23.8% 32.3% 28.3% 30.6% 19.8% ▼ > 16.0% 3.8%

FFT Reccomendation Rate A&E- - - - - 90.1%

▲> 90.0% 0.1%

FFT Response Maternity20.6% 25.2% 18.2% 14.5% 19.2% 21.9% ▲ > 12.0% 9.9%

FFT Reccomendation Rates Maternity- - - - - 96.4% ▲ > 95.0% 1.4%

Single sex accommodation - breaches0.0 0.0 0.0 0.0 0.0 0.0 ◄► = 0.0 0.0

Actual Target

4. Clinical

• Dr Foster Data is reported 3 months after the end of month reporting.

• The rolling 12 month HSMR from Dec 13 to Nov 14 was 90.65, below the national expected value of 100. The rolling HSMR on Saturdays is 90.65 and 95.96 on Sundays which is as expected (100 is the average value) when compared to other acute hospitals. The weekday HSMR value is 89.4 and is below the national average.

• The methodology for the weekend HSMR is currently under review, this indicator will be included in next months reporting.

Comments


Monitoring Clinical Outcomes Actual Target Monthly variance

Mortality Indicators


HSMR weekdays 86.3 - - - - -

◄► > 100.0 13.7

HSMR all days 91.9 - - - - -

◄► > 100.0 8.1

SHMI - - - - - -

◄► > 100.0 0.0

HSMR Elective - - - - - -

◄► > 100.0 0.0

HSMR Non-elective - - - - - -

◄► > 100.0 0.0

4. Clinical

• Average LOS - NEL length of stay currently includes all patients. With increasing use of ambulatory care pathways, these patients will be reported separately from admitted pathways going forward

Comments



variance Re-admissions and Re-attendances


Emergency re-admissions within 30 days 6.5% 7.7% 7.9% 8.3% - - ◄► < 7.3% 0.0%

Elective re-admissions within 30 days 4.2% 5.9% 4.4% 4.5% - - ◄► < 4.3% 0.0%

Average non-elective length of stay 4.7 4.4 4.4 4.8 4.3 4.1 ▼ < 4.7 -0.6

Average elective length of stay 2.5 2.4 2.2 2.4 2.4 2.4 ◄► < 2.7 -0.3

Clinical Coding Completeness 99.1% 99.1% 95.1% 96.0% - - ◄► > 100.0% 0.0%

NHS number coding (IP) 99.6% 99.2% 99.1% 99.2% 99.4% 99.2% ◄► > 99.0% 0.2%

Actual Target

4. Clinical

• The percentage number of caesarean sections has increased by 1.9% to 30% and the percentage of normal births has increased 1.1% to 57.6%

• Monthly review of all elective caesarean sections is completed by one of the Consultant Obstetricians. • The work on delivery suite for the ventilation system has not been conducive to an environment for

supporting normal birth. • The delivery of one to one care has increased to 100% • Midwife to birth ratio 1:30 • As of May 2015 reporting an additional indicator monitoring deliveries to Midwife ratio will be included

in the report.

Comments



variance Maternity Care


Percentage of ALL caesarean sections 27.4% 24.9% 22.1% 25.9% 28.1% 30.0% ▲ < 23.0% 7.0%

Percentage of normal births 55.5% 60.5% 61.9% 56.7% 56.5% 57.6% ◄► > 63.0% -5.4%

Women giving birth: 1:1 delivery of care 0.0% 98.0% 98.0% 98.0% 98.0% 100.0% ◄► > 95.0% 5.0%

Actual Target

4. Clinical

• The patients receiving surgery within 36 hours for #NOF has decreased from 84.8% to 57.6%. There were 33 patients admitted with #NOF . 27% of these patients were medically unfit for surgery, the other days were due to theatre space (over runs & other priority patients). The new Orthopaedic pathway has been introduced and May’s data is showing improvement

• VTE assessment and prophylaxis we continues to meet the quality standard

Comments



variance Other Clinical Indicators


Fractured Neck of Femur: Surg in 36 hours77.7% 69.3% 85.2% 89.2% 84.8% 57.6% ▼ > 74.7% -17.1%

VTE Risk Assessment 96.3% 95.8% 96.4% 95.9% 96.6% 97.1% ◄► > 95.0% 2.1%

Adult IP receive approp VTE prophylaxis 95.0% 90.0% 90.0% - 96.5% 97.0% ◄► > 85.0% 12.0%

Actual Target

4. Clinical

• The percentage of patients admitted to an Acute Stroke Unit within 4 hours has increased 17.9% this month and the number of patients scanned within 24 hours has increased to 0.3%.

• We continue to meet the quality standard of patients spending 90% of their time on a stroke unit.

• The target for admitted to stroke unit within 4 hours of arrival is currently under review as part of local negotiations.

Comments



variance Stroke Care


Pts spend 90% time on an acute stroke unit 86.0% 88.7% 93.3% 86.0% 81.6% 90.2% ▲ > 80.0% 10.2%

Admit to Acute Stroke Unit within 4 hours 92.0% 88.2% 80.0% 77.0% 55.0% 72.9% ▲ > 90.0% -17.1%

Stroke patients scanned within 24 hours 100.0% 96.6% 95.8% 97.9% 97.8% 98.1% ◄► = 100.0% -1.9%

Stroke: Discharged to normal residence 100.0% 88.9% 100.0% 100.0% 100.0% 93.5% ▼ > 92.5% 1.0%

Stroke: Average Length of Stay (days) 19 22 20 15 27 15 ▼ < 16.0 -1.0

Actual Target

5. Finance

• Deficit of £2.3m, which is £0.3m less than the budget deficit. • Income running £0.08m below budget, with income from CCG’s £0.3m below budget • Pay less than last month because last month included extra for the holiday pay accrual. • Cash £4.4m better than budget as a result of earlier than budgeted receipts from

commissioners and later than budgeted payments to suppliers as a result of timing of supplier payment runs.

• QIPP delivery figures not yet available.

Comments


Financial Proficiency Monthly

variance Financial Efficiency


Surplus/Deficit (£M)-0.6 -1.4 0.1 -1.1 -1.1 -2.3 ◄► > -2.6 0.3

Pay (£M)-17.2 -17.6 -17.7 -18.0 -18.3 -18.0 ◄► > -18.4 0.4

Cash(YTD) £M 11.2 11.2 8.2 10.0 13.5 14.3 ▲ > 8.9 5.4

QIPP Delivery (£M) 1.5 1.1 1.2 1.4 1.5 0.0 ◄► - 0.0

Actual Target

6. Workforce

• Appraisal Rate - Currently reviewing policy and approach. • Completed Mandatory Training - Continue to monitor compliance • Sickness / Absence - Some improvements made, review approach through workforce

productivity programme • Vacancy Rate - Reflects new budgets, further work on tackling hot spots through R&D group • Agency Spend as % of Total Staff Cost - Reduction from previous month. working with care

groups and corporate areas to reduce spend • Rolling 12 Month Workforce Turnover - Further work to address retention rates

Comments


Caring Culture Monthly

variance Workforce Indicators


Appraisal rate 90.0% 89.0% 88.0% 85.0% 84.0% 86.0% ◄► > 95.0% -0.1

Completed Mandatory Training 85.0% 87.0% 87.0% 87.0% 88.0% 88.8% ◄► > 90.0% 0.0

Sickness/absence 2.9% 3.1% 3.4% 3.7% 3.3% 3.2% ▼ < 2.8% 0.0

Vacancy rate8.5% 8.5% 8.4% 7.8% 8.0% 8.1% ◄► < 5.0% 3.1%

Agency spend % of total staff cost5.2% 6.9% 6.4% 6.8% 5.9% 5.7% ▼ < 5.0% 0.7%

Rolling 12 month Workforce turnover - - - - - 14.7%

▲< 12.0% 2.7%

Actual Target

7. Staffing Data


7. Staffing Data


Comments

Risk KPIs Impacted

8. Risk Log & Action Log


Action Plan Person Responsible Timeline Monitoring Body

SAMPLE RISK & ACTION PLAN LOG

Operational Performance – Exception Report Date: 7th May 2015 Author: Chris Lowrie & Mark Gatfield & Pat Rubin Subject: Cancer Access Targets 1.0 Issue The Trust is failing the Cancer Access Targets for patients (referred from GP, GDP or via the screening service) being treated within 62 days

2.0 Current performance against standard/ target Non achievement of the Cancer 62 day and 62 day screening access targets Cancer 62 Day performance for Q4

Speciality Total numbers of patients treated

Number of patients breaching 62 day standard

% meeting 62 day standard (target 85%)

Brain & CNS 0.0 0.0 Breast 41.0 3.0 92.7 Colorectal 22.5 10.5 53.3 Gynaecology 12.0 5.5 54.2 Haematology 10.0 2.0 80.0 Head & Neck 10.0 2.5 75.0 Lung 14.5 2.0 86.2 Sarcoma 0.5 0.5 0.0 Skin 34.0 1.5 95.6 Upper GI 10.5 2.5 76.2 Urology 68.0 13.0 80.9 Other 4.5 1.5 66.7 All Cancers 227.5 44.5 80.4

Cancer 62 Day Screening for Q4

Speciality Total numbers of patients treated

Number of patients breaching 62 day

standard

% meeting 62 day standard (target 90%)

Bowel 8.0 3.0 62.5 Breast 56.5 4.5 92.0 Cervical 1.5 1.5 0.0 All Cancers 66.0 9.0 86.4

Graph demonstrating performance –v- trajectory previously submitted

3.0 Root cause

• Medium term sickness and increasing demand within Gastroenterology, Endoscopy and the LGI surgical team. This is coupled with the lack of locum support nationally.

• Suitable Locum cover continues to be actively sought • Consultant sickness within Dermatology • Patient choice declining earlier dates / rescheduling appointments • Reduced resource within the MDT coordinator team and difficulty replacing with correct skills. • Increasing number of referrals is putting pressure at the start of the pathway, particularly

around diagnostic and outpatient services. The 31 day target continues to be achieved, when a decision to treat is made, the patient is consistently treated within target.

Cancer incidence has not changed appreciably despite the increase in referrals. In 2011/12 just over 10% of patients referred in as a 2ww had a confirmed cancer, 2014/15 YTD is just over 6%. National policy to diagnose cancers as early as possible seems to have translated into more referrals, which so far has driven down the cancer conversion rate. 4.0 Impact summary 55 patients were treated beyond the 62 day target, of these half were potentially avoidable. All breaches are reviewed by a clinician and the MDT leads are informed of the pathways. To ensure patients have not been subjected to clinical harm a breach analysis is undertaken for each one but this will be extended to a Root Cause Analysis in order that corrective action is taken.

62 day patients (excludes 100 day patients below)

Avoidable Unavoidable

Diagnostics 10 3

Capacity 4 1 Complex 1 2 Tertiary 2 2 Patient 0 3 Clinical 0 4 Tracking / Errors 0 0 Total 17 15

100 day patients Avoidable Unavoidable Diagnostics / capacity

5 4

Complex 0 6

Tracking / Errors 4 0 Patient 0 2 Tertiary 0 2 Total 9 14

Each breach has a negative impact on patient experience, Trust reputation and incurs a financial penalty. 5.0 Actions and expected outcomes The Trust has recently implemented a steering group to drive improvements in the pathway as a result of an IST review requested by the Trust. This is chaired by the Chief Operating Officer. The purpose of the group will be to identify key milestones within the pathway and supporting services to meet these. Radiology Mobile CT scanner use extended from June 2014, and remains in place as the Trust works towards 7 day services to expand capacity and reduce delays but it is proving challenging to recruit into these posts due to a national shortage in trained staff Regular additional weekend and evening scanning lists are now in place. Business case for an additional endoscopy room has been approved and building work commenced, equipment has been ordered and posts advertised. Provisional go live end of June 2015. Gastroenterology/Endoscopy Regular weekend and evening endoscopy lists undertaken by Nurse Endoscopists, Consultants, Associate Specialist and Tier 2 GPSis. 40 additional endoscopy slots created per week. Implementation in Q2 2015/16 Locum cover search extended to high cost agencies. Outsourcing routine endoscopy to the Tier 2 service commenced April 2015 Urology Agreed parallel Urology and Oncology clinics reducing waits for some Urology patients by 7-14 days. Additional building work required for this to go live. Breast Recruited a substantive pathologist April 2015 to support an additional triple assessment clinic for Breast patients thereby reducing waits for half of the patients by 4-7 days Recruiting an onco-plastic breast surgeon to meet rising demand of patients wanting immediate reconstruction – interviews scheduled in June 2015.

Skin Recruiting a locum to cover consultant vacancy. Additional clinics to meet seasonal 2ww demand Business case for additional consultants and nurses approved by Network Care Group. Cancer Pathways MDT coordinator recruitment is now complete. Will be fully established by the end of May. Training time for these roles is typically 3 months. Change the format of escalation and PTL meeting to give greater emphasis on accountability and responsibility Work towards internal milestones – first appointment by day 7, decision to treat by day 35

The trajectory is based on actual performance and the number of breeches for the period Oct ’14 to Mar ’15, this information has then been extrapolated to make predictions for the remainder of the calendar year to Dec ’15. In doing so the trajectory includes the effect of a number of planned improvements:-

1. Trust cancer PTL steering group milestones – May 2015 2. Recruitment of onco-plastic breast surgeon (Aug/Sept ’15) 3. New endoscopy room – Sept ‘15 4. Gastroenterologist recruitment – Sept ‘15 5. Radiologist recruitment – Sept ‘15 6. Radiology 7 day working – Sept ‘15 7. Dermatologist recruitment – Sept ‘15

6.0 Key risks to actions being delivered and identified mitigation

• Patients continue to exercise choice outside of 2 weeks • Continued sickness within gastroenterology team and inability to recruit suitable locum.

Currently down 1.2 WTE since March 2015. • Inability to recruit onco-plastic consultant, interviews are in June. • CCG project for parallel urology and oncology clinics not funded

• Endoscopy extra room has an issue with medical gases which needs to be addressed before go-live. Also dependent upon the 7 day working consultation being started with the nursing team

Title: Director of Finance Report Agenda item no: 7b Meeting: Board of Directors Date: 28 May 2015 Presented by: Craig Anderson, Director of Finance Prepared by: Graham Butler, Deputy Director of Finance Purpose of the Report To update the Trust Executive and Board on the financial results

of the Trust for April 2015

Report History

Executive Committee – 26 May 2015 Board of Directors – 28th May 2015






Failure to deliver the Trust’s financial budget.











Publication Published on website Confidentiality (FoI): Private Public

Finance Summary

• Deficit of £2.3m, which is £0.3m less than the budget deficit. • Income running £0.08m below budget, with income from CCG’s £0.3m below

budget • Pay less than last month because last month included extra for the holiday

pay accrual. • Cash £4.4m better than budget as a result of earlier than budgeted receipts

from commissioners and later than budgeted payments to suppliers as a result of timing of supplier payment runs.

• QIPP delivery figures not yet available.

Comments

26/05/2015

Financial Proficiency Monthly variance

Financial EfficiencyNov Dec Jan Feb Mar Apr DoT Month +/-

Surplus/Deficit (£M) -0.6 -1.4 0.1 -1.1 -1.1 -2.3 ◄► > -2.6 0.3

Pay (£M) -17.2 -17.6 -17.7 -18.0 -18.3 -18.0 ◄► > -18.4 0.4

Cash(YTD) £M 11.2 11.2 8.2 10.0 13.5 14.3 ▲ > 8.9 5.4

QIPP Delivery (£M) 1.5 1.1 1.2 1.4 1.5 0.0 ◄► - 0.0

Actual Target

2

Financial Position

Overall Financial Performance - £(2.30)m deficit in month, with favourable variance to budget of £0.29m. CoSRR of 1.

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

Key Messages: • Income down on budget driven by income from activities

£0.33m below budget, driven by low elective income

• Pay £0.41m less than budget with underspend in all areas except for COO.

• Non pay excluding drugs is an overspend against budget of £(0.20)m driven by clinical services in PCG and Miscellaneous services in UCG and PCG.

• Cash up £5.4m v budget due to earlier than expected receipt from commissioners and later than expected payment run to suppliers

Key Actions Arising: • Planned Care to ensure delivery of activity plan WF –

monthly

• Maintain controls over pay Exec

• Maintain controls over discretionary spend CAn • Deliver of QIPPs – all in SMT • Finalise year end position re contract retentions. CAn

£mActual Vs Budget Actual Vs Budget

Income 29.42 (0.09) 29.42 (0.09)

Pay (17.97) 0.41 (17.97) 0.41

Drugs (3.23) 0.17 (3.23) 0.17

Non Pay ex Drugs (9.98) (0.20) (9.98) (0.20)

Other (0.52) (0.00) (0.52) (0.00)

Exceptional Items (0.02) (0.02) (0.02) (0.02)

Surplus/(Deficit) (2.30) 0.29 (2.30) 0.29

COSRR 1.0

Actual Budget Actual Budget

Cashflow from Operations 0.81 (4.54)

Cash 14.37 8.95 14.37 8.95

EBITDA (0.27) (0.62) (0.27) (0.62)

EBDITDA margin -0.9% -2.1% -0.9% -2.1%

Net Surplus/(Deficit)

Actual £mVs Budget

£m Actual £mVs Budget

£mUrgent Care 2.33 0.07 2.33 0.07

Planned Care 1.33 (0.23) 1.33 (0.23)

Networked Care 0.80 0.04 0.80 0.04

E&F (1.81) 0.08 (1.81) 0.08

Corporate Services (4.96) 0.33 (4.96) 0.33

Total Trust (2.30) 0.29 (2.3) 0.29

MONTH YTD

MONTH YTD

MONTH YTD

3

Income from activities £(0.55)m down, partially off set by higher Other Operating Income resulting in overall unfavourable variance to budget of £(0.09)m.

Key Messages • Shortfall in Income from activities of £(0.33)m is entirely due to

elective activity. • Drug Income is down on budget by £(0.22)m but there is

associated savings in drug costs. • Other Operating income was ahead of budget due to

Education and Research and Development Income.

Action • Drive PCG elective activity, in particular through new theatres

–WF

Income

Actual £mVs Budget


£mIncome from Activities 24.24 (0.33) 24.24 (0.33)

Drug Income 2.59 (0.22) 2.59 (0.22)

Other Patient Care Income 0.45 0.08 0.45 0.08

Other Operating Income 2.15 0.38 2.15 0.38

Total Income 29.42 (0.09) 29.42 (0.09)Income per working day £k 1,102 (15) 1,102 (15)

MONTH YTD

23.00

25.00

27.00

29.00

31.00

33.00

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

Monthly Income £m

2014/15 Actual

2015/16 Actual

2015/16 Budget

4

Pay costs – £0.41m below Budget

Key Messages • Total Care Groups underspend of

£0.43m against budget is due to vacancies in UCG for Radiology and Maternity and in NCG for consultants vacancies.

• An adverse variance of £(0.18)m for COO catch up with contractors invoices.

• Spend down on last month because March included additional cost for holiday pay accrual

• £1.21m agency pay in month, of which £0.21m is bank, so agency premium being paid on £1.0m of cost.

Actions • Maintain exec controls over new hires,

non ward based agency spend and admin headcount freeze Exec

• Drive increase in % of total agency that is on bank and hence lower cost PB

Pay Costs £m

Group Description M10 2015 M11 2015 M12 2015 M01 2016 MoM var Month vs Budget

YTD vs Budget

Medical Staff (5.15) (5.04) (5.42) (5.07) 0.35 0.18 0.18

Nursing (7.09) (7.12) (7.04) (7.09) (0.05) 0.12 0.12

PAMs (0.94) (1.01) (1.01) (1.02) (0.01) 0.04 0.04

Scientist and PTBs (1.04) (1.04) (1.04) (1.00) 0.03 0.09 0.09

Pharmacists (0.18) (0.18) (0.19) (0.20) (0.01) 0.01 0.01

Admin & Management (2.40) (2.69) (2.78) (2.74) 0.04 (0.15) (0.15)

Ancil lary & Maintenance (0.79) (0.79) (0.75) (0.76) (0.01) 0.02 0.02

Other Pay (0.10) (0.10) (0.10) (0.09) 0.00 0.11 0.11 Pay (17.68) (17.97) (18.32) (17.97) 0.35 0.41 0.41

By Care Group/Directorate

UCG (5.68) (5.73) (5.50) (5.71) (0.21) 0.07 0.07

PCG (5.78) (5.76) (5.82) (5.78) 0.04 0.24 0.24

NCG (3.72) (3.80) (3.84) (3.71) 0.13 0.11 0.11

Total Care Group (15.17) (15.29) (15.17) (15.21) (0.04) 0.43 0.43

Estates & Facil ities (0.87) (0.87) (0.82) (0.84) 0.05 0.03 0.03

Chief Nursing Officer (0.32) (0.31) (0.30) (0.31) 0.01 0.02 0.02

Chief Medical Officer (0.26) (0.24) (0.24) (0.24) 0.00 (0.04) (0.04)

Corporate Affairs 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Commercial Directorate (0.01) (0.02) (0.02) (0.02) 0.00 0.01 0.01

Finance (0.30) (0.27) (0.28) (0.31) (0.01) (0.02) (0.02)

Chief Exec & Non-Execs (0.08) (0.11) (0.11) (0.05) 0.01 0.02 0.02

Workforce and Organisational Development (0.20) (0.23) (0.23) (0.22) 0.00 (0.02) (0.02)Corporate - Other 0.03 (0.12) (0.65) (0.11) (0.54) 0.18 0.18 Capital Charges & PDC Dividend 0.00 0.00 0.00 0.00 0.00 0.00 0.00 IT (0.26) (0.35) (0.24) (0.40) 0.11 (0.01) (0.01)

Chief Operating Officer (0.24) (0.15) (0.25) (0.28) (0.11) (0.18) (0.18)

TOTAL Other (2.51) (2.68) (3.16) (2.77) 0.39 (0.01) (0.01)Pay (17.68) (17.97) (18.32) (17.97) 0.35 0.41 0.41

VS BUDGET

5

Non Pay Costs – Drugs – Cost down this month by £0.17k

Key Messages • NCG adverse variance to budget of £(0.05)m is driven

by Alcura drugs for Sexual Health speciality. • Remaining underspend for dugs is driven by lower

Drugs Income in the month. • Drugs income as a percentage of cost is 75% which is

down on previous month of 87%.

Actions • QIPP projects on Waste management and aseptic unit

LB • The Chief Pharmacist is working on plans to reduce

prescribing cost. LB

Non Pay - Drugs

Actual £mVs Budget


£mUrgent Care (0.24) 0.02 (0.24) 0.02

Planned Care (1.55) 0.10 (1.55) 0.10

Networked Care (1.43) (0.05) (1.43) (0.05)

Other (0.02) 0.10 (0.02) 0.10

Total Drugs (3.23) 0.17 (3.23) 0.17

MONTH YTD

6

Non Pay Costs – Excluding Drugs £(0.20)m up on Budget.

Key messages • Clinical services is an overspend of £(0.15)m driven by

PCG Medical Physics and PCEU supplies, Ophthalmology and Orthopaedics outsourcing.

• General supplies is an underspend of £0.06m due to PCG synergy cost.

• Other establishment, Premises and Fixed Plant favourable variance of £0.16m is related to lower actual cost for Insurance in Corporate Other and credit note received from EDF.

• Miscellaneous services is an overspend of £(0.20)m more than budget driven by:

• £0.18m in UCG largely driven by underachieved QIPPs target

• £0.16m for PCG driven by spokes contracts

• £0.08m for NCG for underachieved QIPPs target

• Corporate includes budget allowance for contingency, restructure and reinvestment.

Actions • Drive delivery of cost QIPPs All exec directors

• Maintain controls over discretionary spend CA

Non Pay ex Drugs

Actual £mVs Budget


£mClinical Service & Supplies (3.81) (0.15) (3.81) (0.15)

General Supplies & Services (0.53) 0.06 (0.53) 0.06

Establishment Expenses (0.31) (0.01) (0.31) (0.01)

Other Establishment Expenses (1.12) 0.09 (1.12) 0.09

Prem, Trans & Fixed Plant (1.42) 0.07 (1.42) 0.07

Depreciation (1.50) (0.05) (1.50) (0.05)

Leases (0.16) (0.01) (0.16) (0.01)

Miscellaneous Services (1.12) (0.20) (1.12) (0.20)

Total Non Pay ex Drugs (9.98) (0.20) (9.98) (0.20)

MONTH YTD

Non Pay ex Drugs

Actual £mVs Budget


£mUrgent Care (1.09) (0.08) (1.09) (0.08)

Planned Care (2.60) (0.34) (2.60) (0.34)

Networked Care (1.45) (0.15) (1.45) (0.15)

Estates & Facilities (1.18) 0.06 (1.18) 0.06

HFMS 0.05 (0.06) 0.05 (0.06)

Other Corporate (3.71) 0.37 (3.71) 0.37

Total Non Pay ex Drugs (9.98) (0.20) (9.98) (0.20)

MONTH YTD

7

2014 / 15 QIPP Programme – Progress Report FY Cost QIPPs budgeted at £16.7m for FY 15-16

Downside Cash Position

No change versus Operating Plan (see below). Forecast to be updated for June Report.

9

Service Line Reporting Key Messages • Produced on a quarterly basis, figures shown are for YTD Q3. Full year Q4 will be available by the end of June • Changes made since Q2 SLR and overview of known issues shown

at the foot of this page • Three specialties that have not made a positive contribution to

overheads: Pathology, Stroke and Pain Management. Urgent Care – 0.9m surplus • Likely to have benefited from the income allocation known issue (see

below) which is likely to have contributed to the Radiology £1.2m surplus

• Maternity suffers high overheads because of weighted allocation of CNST costs

Networked Care – 0.6m surplus • Likely to have benefited from the income allocation known issue

(see below) which is likely to have contributed to the Renal £2.9m surplus.

• Pathology £(2)m deficit due largely to direct access path services namely Cytology, Microbiology and Haematology.

Planned Care - £(7.5)m loss • Likely to have been hurt by the income allocation known issue (see

below) which is likely to have contributed to the overall PCG loss • Urology and Gastro in surplus, but all other specialties loss making Changes made since Q2 include: • improvement in the allocation of income to specialty, so income

allocation now broadly in line with Care Group income • Paediatrics specialities (previously reported respective specialities

with Adult) reported in UCG under Paediatrics. • Stroke Medicine(from Rehabilitation) and Pain Management (from

Anaesthetics) have been recognised as Specialities. Known issues: • Systematic control over tracking of patient journey through the

hospital still needs to be put in place. Until then there is risk that cost is allocated to the wrong specialty as a result of ward clerks not updating PAS for patient moves. Action with Finance & Informatics.

• Anomalies in allocation of certain streams of income as yet unresolved. In particular Direct Access Radiology and Renal.

Care Group Specialty Group

Direct and Indirect Income [ A ] (£k)

Direct and Indirect Costs [ B ] (£k)

Contribution to Overheads [ A - B ] (£k)

Contribution % to Trust Overheads (£k)

Overhead Costs [ C ] (£k)

Net Surplus/Deficit (£k)

Total 262,513 207,660 54,853 20.9% 61,712 (6,859)

Networked Total 66,301 50,708 15,594 23.5% 14,954 640

Networked Allied Health Services 230 229 1 0.5% 84 (83)

Networked Audiological Medicine 2,346 2,205 141 6.0% 574 (433)

Networked Clinical Haematology 5,323 4,289 1,035 19.4% 988 47

Networked Dermatology 1,930 1,494 436 22.6% 360 75

Networked Endocrinology 2,452 1,868 584 23.8% 559 25

Networked General Medicine 2,225 1,238 987 44.4% 368 619

Networked Geriatric Medicine 13,573 11,036 2,537 18.7% 3,699 (1,163)

Networked GUM 4,075 2,606 1,468 36.0% 674 794

Networked Neurology 1,783 1,269 515 28.9% 322 193

Networked Orthotics 714 392 323 45.2% 116 207

Networked Pain Management 671 1,089 (418) (62.3%) 301 (719)

Networked Palliative Medicine 985 791 194 19.7% 193 1

Networked Pathology 5,827 6,072 (245) (4.2%) 1,762 (2,008)

Networked Rehabilitation 2,513 1,940 573 22.8% 609 (36)

Networked Renal 15,874 9,915 5,959 37.5% 2,962 2,997

Networked Rheumatology 5,150 3,704 1,446 28.1% 1,218 229

Networked Wheelchair Service 629 571 58 9.2% 163 (105)

Others Total 9,824 9,672 152 1.5% 1,046 (894)

Others Education and Training 0 0 0 0.0% 0 0

Others Home Delivered Drugs 4,537 4,562 (25) (0.6%) 25 (50)

Others Other Clinical Services 1 1 (1) (98.2%) 0 (1)

Others Other Services 833 530 303 36.4% 90 213

Others Research and Developm 0 0 0 0.0% 0 0

Others Unmatched Activity 4,454 4,579 (125) (2.8%) 931 (1,055)

Planned Total 104,157 85,139 19,019 18.3% 26,475 (7,456)

Planned Anaesthetics 1,180 1,178 1 0.1% 346 (345)

Planned Cancer 0 0 0 0.0% 0 0

Planned Clinical Oncology 17,063 13,882 3,182 18.6% 4,605 (1,423)

Planned ENT 4,190 3,833 357 8.5% 1,382 (1,026)

Planned Gastroenterology 8,804 6,508 2,295 26.1% 2,288 8

Planned General Surgery 14,786 12,746 2,040 13.8% 3,968 (1,928)

Planned Gynaecology 5,059 4,544 515 10.2% 1,328 (813)

Planned Ophthalmology 15,247 13,201 2,046 13.4% 3,592 (1,546)

Planned Oral Surgery 1,739 1,558 181 10.4% 454 (273)

Planned Plastic Surgery 651 541 110 16.9% 144 (34)

Planned Trauma & Orthopaedics 27,623 21,673 5,950 21.5% 6,630 (680)

Planned Urology 7,817 5,475 2,342 30.0% 1,738 604

Urgent Total 82,231 62,142 20,088 24.4% 19,237 851

Urgent Accident & Emergency 11,959 9,798 2,161 18.1% 2,613 (452)

Urgent Cardiology 12,246 8,235 4,010 32.8% 2,516 1,495

Urgent Critical Care Medicine 5,798 4,182 1,617 27.9% 1,547 70

Urgent Maternity 19,159 17,023 2,135 11.1% 4,727 (2,592)

Urgent Neo-Natal Critical Care 358 235 122 34.3% 103 19

Urgent Paediatric Medicine 18,314 12,856 5,458 29.8% 4,316 1,142

Urgent Radiology 6,512 3,799 2,713 41.7% 1,472 1,241

Urgent Respiratory Medicine 7,852 5,895 1,957 24.9% 1,919 38

Urgent Stroke Medicine 33 119 (85) (256.4%) 25 (110)

Title: Monitor Action Plan Agenda item no: 8 Meeting: Board of Directors Date: 28 May 2015 Presented by: Jean O’Callaghan, CEO Prepared by: Vanessa Harding, Head of PMO & Service Transformation Purpose of the Report The purpose of this paper is to update the Board on the

implementation of the Monitor Action Plan

Report History






Risk in relation to failure to maintain standards required to maintain licence to operate











Improved oversight of progress and delivery, as well as awareness of key risks Publication Published on website Confidentiality (FoI): Private Public [Insert as applicable the FoI exemption basis] N/A

1 Progress update

1.1 Good progress has been made in the last month. No actions are currently rated Red.

1.2 A number of actions have been delivered including:

o Revised Stakeholder engagement plan following the Strategy workshop

o The 2015/16 Operational Plan was completed and submitted to Monitor

o The review of Health & Safety was completed and a revised governance structure proposed. This is now out for consultation and will be taken to the next Policy Review Group for sign off

o The revised performance reporting suite was completed and the first formal report has been submitted to the Trust Board this month

o The Board approved the 2015/16 contract with the CCG subject to final terms in relation to specific items

o Q3 submission to Monitor on finance performance was completed

1.3 The full Plan is attached (Appendix A) detailing current status and rag rating of progress.

2 Contact

Contact: Jean O’Callaghan Phone: 0118 322 7230

Trust Response: ActionsExecutive

ResponsibilityExpected Date of Completion

Revised Date of Completion

Comments / Current StatusOutcome Expected Following

Implementation

Supporting Evidence Appendix ref no for full documentation / report

Governance and Reporting

Risks to Delivery Mitigation of Risks

Executive Directors portfolios reviewed and reallocated CEO 01/11/2014 Completed New portfolios in place

Weekly Executive Team meeting re-established CEO 01/11/2014 Completed Meets every Tuesday morningSenior Management Team membership revised to include Care Group Directors of Ops CEO 01/11/2014 Completed Meeting every two weeks

Care Group Directors report to the COO COO 01/11/2014 Completed

Care Group Directors of Ops report to the COO for Day to Day operational matters COO 01/11/2014 Completed

Role of Care Group Director of Operations changed to provide delegated authority to hold CDs, Matrons and Directorate Managers accountable for delivery of operational targets

COO 01/11/2014 Completed

Informatics staff centralised back to IM&T. Director IM&TConsultation Jan

2015Completed

HR Directors reporting in to Director of Workforce.Director Workforce

& ODConsultation Jan

2015Completed

HR to map structure, staff, and costs and benchmark against similar organisations by end March 2015

Director Workforce & OD

31/03/2015 Completed

Potential organisational redesign to present to Board July 2015 CEO 31/07/2015 On track

Identify clinical areas that can be better aligned within the Trust structure CEO 01/02/2015 01/07/2015To be completed as part of Trust wide structure & aligns with

above

Invest in specific areas to ensure risk is managed appropriately by appointing Deputy DON and Governance.

Director Nursing 28/02/2015 Completed Deputy DoN in place - further posts being recruited to.

1b. Quality Governance Framework action plan

Revised Quality Governance Framework action plan to be implemented, based on critical work streams (triangulated to responses to Deloitte QGF Recommendations) with Executive Leads (priority actions for Mar 15)

Director Nursing/ Director Workforce

&OD /Director S

01/03/2015 CompletedImplementation plan reviewed by Clinical Governance Committee

& Trust Board end of March - assurance progress being made

Stakeholder Engagement Plan developed Director Strategy 31/03/2015 CompletedRevised draft engagement plan complete. Circulate to SMT 1st

June. Implementation ongoing.Engagement Plan

Quality Strategy 15/16 priorities refreshed Director Nursing 31/03/2015 Completed Priorities agreed Quality Strategy document

15/16 Operational Plan completed Director Strategy 31/03/2015 Completed Submitted Operational Plan

Two day stakeholder workshop Director Strategy 31/03/2015 CompletedWorkshop took place with senior staff & key stakeholders - 23rd &

24th MarchWorkshop agenda

Clinical Audit Strategy Medical Director 31/03/2015 CompletedAudit plan mapped for approval at Clinical Outcomes &

Effectiveness Committee on 26th March, then sign off at QP&LCClinical Audit Strategy

Trust wide Structured Listening Exercise feedback Head of PMO 31/03/2015 CompletedTook place in February - triangulated with Staff Survey results -

action plan to be signed off by SMT in April

Listening Exercise template & analysis

Staff Survey results

Review of safe staffing levels Director Nursing 31/03/2015 Completed Paper to March resources Committee & then Board Skill mix review paper

Staff accountability framework to be implementedDirector Workforce

& OD31/03/2015 31/05/2015

Consulting on new Performance & Conduct Policy - during May & June

Effective Learning culture to be reviewed.Director Workforce

& OD31/03/2015 31/07/2015 Work being undertaken as part of wider OD programme Values

3. Well Led Framework transformation outline programme to be developed. Director Strategy 31/03/2015 Completed Taken to Board in March. Well Led Plan

4. Organisational culture, engagement, leadership development plan: work in progressDirector Workforce

& OD31/03/2015 31/07/2015 Work being undertaken as part of wider OD programme Engagement Plan

CRR & BAF reviewed, relaunchedDirector

Nursing/Director Strategy

31/03/2015 28th May Updated CRR & BAF being presented to Trust Board in May CRR & BAF

Assurance & Escalation Framework implementedDirector Nursing/ Director Strategy

31/03/2015 01/06/2015 Will follow on from above Ass & Esc Framework

Revised Risk Management Strategy completed Director Nursing 31/03/2015 30/04/2015Signed off by Exec Risk Committee - scheduled for Policy Approval

Group 27th MayRisk Management Strategy

Review of H&S systems and function Finance Director 31/03/2015 CompletedReview completed & revised governance structure proposed. Out

for consultation. To be approved at next Policy Review Group

Quality Governance Framework score of 3.5

Board mapping of Trust-wide committee structure, membership

and reporting framework to ensure full oversight by Trust

Board.

Risk register and BAF signed by Board quarterly.

Revised reporting to Board.

Effective assurance & escalation of operational & quality risks from

ward to Board.

Each work stream reporting fortnightly

to Senior Management Team meeting by way of exception report.

Board of Directors report review of RAG progress quarterly.

Clinical Governance Committee

monitoring QGF.

Trust Improvement Programme Steering

Group monitoring QIPP KPIs & Quality

Impact Assessments.

Board assurance

Project management.

Organisation/Care Group cascade and ownership.

Revised BAF and Corporate Risk Register

Dedicated lead and Executive time.

Engagement and communication plan.

Board development session.

Culture & Workforce:

Risk management:comprehensive risk management framework

Planning:

Revised QGF Plan

Monitor Action Plan - May 2015

1a. Quality Governance and Board Governance - revised management structure

Initial improvements made to structure but consideration of a wider restructure post HR mapping. Appointments to some key

positions still to be made.

Substantive COO appointed March 2015.

Benchmarking now completed - to be reviewed by Executive in April

Structure demonstrates lines of accountability.

Improved financial performance. Improvement in meeting

standards and targetsKey risk areas appropriately

staffed.

Structure Chart and Exec portfolios.

Management arrangements brief.

Executive review weekly

2 monthly report to Board

Capacity of Senior Management

Revised governance and reporting process.





Implementation





QIAs & KPIs completed for key QiPPs Head of PMO 31/03/2015 Completed Draft KPIs in place for all key QIPPs. Robust QIA process in place. QIPP PIDs

Risk Manager in post January 2015. Director Nursing 31/01/2015 Completed Role recruited & in place

Action plan developed to address short term issues (March 2015) and medium term issues (December 2015)

Director Nursing31/3/2015 & 31/12/2015

on track Short term actions delivered.Mediumterm actions on track. Action Plan

Plan to appoint Deputy Director of Nursing and Governance and Head of Governance. Recruitment process to commence February 2015.

Director Nursing 31/03/2015 CompletedDeputy DoN in place. Internal resource identified to cover Head of

Governance role.

Ongoing development of Risk Management Systems including Education Programme and Board Development.

Director Nursing 31/12/2015 OngoingBoard development session completed in January 15. Further actions being delivered. Further work to do post BAF sign off.

Comprehensive Risk Management Framework to be implemented over 2015/2016. Director Nursing 31/12/2015 Ongoing Ongoing and on track.Risk Management

Framework

Development of draft performance suite for reporting to Board - development of new integrated performance report & review of reporting cycle

Finance Director/COO

01/03/2015 Completed Formal report to May BoardPerformance Reports to

Board

Establishment of Internal Audit review of data quality assurance. Interim COO 01/03/2015 31/05/2015PwC appointed to undertake review. Scope has now been agreed

with Monitor. Work underwayInternal Audit report

Develop Performance Management Framework: including review of Care Group KPIs & performance management meetings (ensuring that actions are followed through)

Finance Director 31/05/2015Performance Management Framework remains in development.

Monthly performance meetings in place with Care GroupsPerformance meetings

notes & action log

Refresh Quality Governance committee structure & communicate expectations of each department to Board reporting lines

Director Nursing 01/04/2015 Completed Committee Structure

Review Terms of reference for Quality Performance & Learning Committee Director Nursing 01/04/2015 CompletedToR revised - name changed to 'Quality Assurance & Learning

Committee'.QPLC Terms of Reference

Standardisation of ward dashboards Director Nursing 01/04/2015 Completed Ward accreditation scheme implemented on all wards Ward dashboard

1c. Formulation of a Board Development Programme

Programme revised and aligned with Well Lead Framework, ensuring development in strategy and planning, capability and culture, processes and structure.

CEO / Trust Secretary

01/03/2015 In progressWell led outline plan complete. In process of commissioning

Leadership Academy to develop programme aligned to the WLF.

Improved Board Evaluation and assessment.

Higher rating. Programme brief Board

Board Time available to complete.

Prioritisation of commitments.

1d.Update Board Evaluation Plan

Monitor Board Evaluation Plan CEO / Chair In progress Plan reviewed and monitored regularly by BoardBoard evaluation plan

(latest signed off version) BoardReview and monitor

quarterly.

Organise re-evaluation via Independent review CEO/Chair 01/06/2015 on track External Review brief BoardReview and monitor

quarterly.

PMO / service transformation to transfer to COO COO 01/03/2015 Completed Transferred with effect from 1/11/2014Improved engagement &

ownership of programmes across Care groups

Organisational structure chart

Implementation of Trust Improvement Programme to oversee all major work programmes COO 01/03/2015 Completed In place - First Steering group meeting took place 2nd March 2015Single line of reporting for all

major work programmesSteering group notes &

actions

All programmes to have Executive sponsors and clinical leads Head of PMO 01/03/2015 CompletedExec leads in place for all programmes, with clnical leads as

appropriateExecutive ownership to drive

improvementProgramme brief

All progress to be measured and rag rated against achievements of monthly milestones with agreed KPIs

Head of PMO 01/03/2015 CompletedMonthly Highlight reports being completed. Monthly dashboard in

place for reporting to SMT / Board. PIDs completed for all programmes including KPIs

Transparent reporting of progress / clear escalation route for issues

& risks

Monthly dashboard / Highlight reports / PIDs

Communications plan to be implemented Head of PMO 01/03/2015 end JuneNew Interim Head of Comms started. Will develop comms plan

over next monthTrust wide engagement & shared

learningComms plan

1e. Commission an External review of Trust's Quality & Board governance

Agree brief with Monitor Chair 01/06/2015Briefing document &

external reportBoard

Self assessment by Board against both Chair 01/10/2015 Self assessment report Board

2a. Operational Plan development - financial component for 2015/16

Outline 2 year plan to be agreed by Exec Finance Director 05/01/2015 Completed

Outline plan to be agreed by Board Finance Director 26/01/2015 Completed

1.e. Ensure a process is in place to demonstrate Board sighted and assured action plan

Improved Board Evaluation Assessment.

Process demonstrates oversight and escalation of issues to the

Board

Information Management: ward to Board accountability


Group

Risk that programme leads will not provide robust plans

to give assurance that progress being made

capacity to deliver work programme

Requirement to complete PIDs to ensure plans are

captured in detail.

PMO resource now realigned to focus on transformational

programmes

Senior management buy in fi i l l

National deadlines have changed - will be metHigh level draft submitted 27th February.





Implementation





Agreement of key actions to deliver outline plan to be agreed by exec Finance Director 28/04/2015 Completed

CCG contract Heads of Terms to be agreed Finance Director 28/02/2015 n/a Commissioners requesting move to sign contract rather than HoT

Board sign off of two year operating plan Finance Director 31/03/2015 Completed Signed off by Resources Committee in May

Board sign off of 2015/16 CCG contract Finance Director 31/03/2105 CompletedBoard signed off contract subject to final negotiation of terms in

specific area

Independent review of operating plan Finance Director 31/05/2015 on trackInterim finance consultant commissioned to carry out 10 day

diagnostic - feedback to CEO on 26th May

Monthly monitoring of Operational Plan by Senior Management team Finance Director Ongoing ongoing

CEO / DOF discussions with CCG / BHFT CEO 01/03/2015 Ongoing Regular discussions taking place. Board to Board meeting with CCG.

Contracting response to Commissioning Intentions Finance Director 31/01/2015 OngoingDiscussions continuing as part of concluding 2015/16 contract (due

end April)

Consultation with CCG/BHFT/NHS England Director Strategy 31/01/2015 OngoingRobust planning process in place - realignment to CCG strategy

following strategy workshopEngagement Framework to be finalised 1st June

RBH strategic workshop Director Strategy23rd / 24th March 2015

Completed workshop held

Draft Strategic Plan revised and agreed by Board Director Strategy 20/07/2015 On track

Operational Plan Programme in place including milestones & engagement Finance Director 01/03/2015 Completed Activity assumptions being developed. Board seminars held.

Strategic Plan Programme to be in place with separate Engagement plan incorporating full system & consultation

Director Strategy 01/03/2015 CompletedClinical services plan at early draft & clinical engagement meetings

in place.

Dedicated intranet information point for strategic & operational planning Director Strategy 01/03/2015 CompletedMonthly Strategy newsletter sent to all staff since December 2014.

Intranet site up & running.Staff newsletter

Intranet site

Trust to return to reporting in Jan 2015 COO 31/01/2015 Completed Trust now reporting performance

RTT recovery plan & milestones submitted to Monitor COO 31/10/2014 Completed trajectory to achieve all 3 pathways in place & on track

Weekly submission of template returns capturing progress to Monitor & NHSE COO ongoing ongoing

Internal governance in place COO 31/01/2015 Completed

External validation resource commissioned to provide resilience to validation process whilst operational capability developed

COO 30/11/2014 30/06/2015External resource to continue until substantive appointments made

(expected June 2015)

Cerner functionality improvements made to enable accurate reporting COO 30/09/2014 14/05/2015 Initial work completed - final completion expected mid May

External recruitment programme for central 18 weeks function to be led by substantive Head of Access, team supervisor & 10 pathway co-ordinators

COO 31/03/2015 In progress

Head of Access appointed - starts 30/3/2015.Pathway coordinator posts will be allocated as part of Clinical

Admin teams (in place 1st June)In the meantime continue use of external validation team.

Weekly operational PTL meetings COO 31/10/2014 Completed

Implementation of weekly Care Group PTL meetings led by Head of Access to inform & ensure preparedness ahead of weekly corporate PTL meetings

COO 31/12/2014 Completed

As above

Recovery plan & trajectories submitted COO In progress Recovery plan

Non admitted pathways modelling COOfirst 7 due 29/3/2015

remainder due 27/05/2015

Modelling plan

Admitted pathways modelling COO 31/07/2015 Modelling plan

Will enable the Trust to meet the forecasted financial position

Operational Plan

Weekly review by exec team

Monthly review by Operations & Finance

Committee

Board

to financial recovery plan. Robustness of QIPP cost

actions by end March to give confidence of first yr

delivery. CCG longer term plans to substantially reduce activity may require further

cost actions & funding. Other external factors such as growth in insurance costs

may impact.

Weekly review by exec team

Monthly review by Operations & Finance

Committee

Board

2c. Operational Plan development - outline project plan including key milestones, stakeholder engagement & principle work streams

Delivery of operational plan by 10th April with CCG support.

Operational Plan - project plan

Board Feb & March. Resources Committee

Feb & March. Governors Jan &

March. Stakeholders 23rd/24th March.

Board to Board with CCG 27/2/2015

ResourcingBoard engagement with LHE

Clinical engagement in developing strategy

15/16 QIPP identification & workforce plan

Exec time earmarked for discussion

Additional Board time identified

Engagement plan to be signed off Jan 2015

2b. Operational Plan development - non financial component (engage with key stakeholders)

LHE alignment of assumptions & intentions / transparency &

agreement on gaps with development of plan to address

Meeting with external agency contacts.

Board to Board with CCG 27/2/2015

Reporting to Board Feb & March.

Resources Committee Feb & March.

Governors Feb & March.

Exec discussion / dissemination.

Co-ordination & management of engagement

plan& stakeholder involvement.

Clinical enagagement

Exec time to be earmarked for discussion.

Additional Board time identified.

Engagement plan to be developed.

3a. 18 week RTT Performance targets & data quality - reporting RTT

Return to full reporting.

Presence of a fully functional trust wide operational PTL.

In longer term, delivering compliance with all 3 RTT

standards.

Weekly evidence submitted to Monitor

Weekly specialty meetings.

Weekly corporate PTL meetings

Weekly operational meeting led by COO

& Head of Access

Corporate oversight & scrutiny of operationa RTT delivery reliant on interim

expertise. Substantive Head of Access commencing post

on 30/3/2015. Market availability of trained & knowledgable 18 week validators. Relaince on

external resource.Cerner testing requires pathway

expertise before switch over & PTL operational dashboard

is 1 month behind plan in development.

Performance management of operational management

roles.External resource to

continue until central team established.

3b. 18 week RTT Performance targets & data quality - full & accurate reporting within timescales

Non admitted - first 7 specialties completed end March with exception of ophthalmology (due by end April) Remainder due by

end May.Admitted - due to be completed by end of July

Specialty level recovery plans delivered to manage capacity &

demand variance to ensure achievement of RTT targets

Governance as above. Weekly site report

from ISTBi Weekly formal

reporting by COO to SMT / monthly to

Board

Needs to be corporately managed to ensure

consistency of approach & to feed into business planning cycle & delivery of activity

plans.Operational immaturity &

Performance management of operational management

roles.External resource to

continue until central team established.

3c. 18 week RTT Performance targets & data quality -capacity & demand models prepared to clinical specalty level to acceptable standard by DHIST

3d. 18 week RTT Performance targets & data quality -revise operational accountability & governance





Implementation





Recruitment of corporate central 18 week team COO 31/03/2015 In progress

Head of Access appointed - started 30/3/2015.Pathway coordinator posts will be allocated as part of Clinical

Admin teams (in place 1st June)In the meantime continue use of external validation team.

Delivery of RTT standards & proactive management.

Cleaner data for management of PTL & improved corporate

understanding of operational risks.

Organisational structure.RTT performance

Governance as above. Weekly site report

from ISTWeekly formal

reporting by COO to SMT / monthly to

Board

Failed to appoint 9 out of 10 pathway co-ordinator posts

& team supervisor in first round. Lack of overlap /

handover between outgoing interim resource & incoming

Head of Access

Further recruitment.lnternal training programme.

Discussions with Monitor regarding scope of review CEO 01/03/2015 Completed

Process to select external consultants with clinical input CEO 01/03/2015 Completed

External review completed CEO 01/03/2015 31/05/2015

Implementation of recommendations CEO 31/05/2015

Provide external assurance that actions implemented CEO 31/05/2015

Report monthly to Monitor on progress with implementing recommendations CEO ongoing

Initial Board review of likely range of outturn position Finance Director 31/12/2014 Completed

Q3F for intial non exec discussion Finance Director 19/01/2015 Completed

Board review of Q3F Finance Director 29/01/2015 Completed

Close monitoring of Q3F to ensure delivery Finance Director ongoing Completed

Q3F submission to Monitor Finance Director 23/01/2015 Completed

Discussion & potential agreement with commissioners re contract outturn for 2014/15 Finance Director 30/04/2015 Completed

As per 2a. Above

Removal of Compliance Actions & any 'unsafe / requires improvement ratings

CQC Action Plan

Assurance that actions to address issues in CQC report have been

addressed & being sustained

Peer review monthly reports

Evidence of Board assurance in place through Trust Quality Assurance & Learning Committee and Clinical Governance Committee

Medical Director / Director Nursing

31/03/2015 ongoing as above

Ensure sufficient programme management and governance arrangements in place to enable delivery

CEO 01/01/2015 CompletedDedicated project time in place but delivery support still to be

identified Delivery of Monitor Action Plan to

timePapers from exec & monthly

Board Exec & Board Capacity remians an issue

Monthly Monitor meetings and as requested Monitor 01/01/2015 ongoing All meetings being attended as requested

Notes:Priority actions in redOngoing transformational actions in green

6. Programme Management Meetings

4a. Financial Performance - revised 2014/15 range of likely financial outturn

3e. Liaise with Monitor to agree a timeline and commission a review of data quality

4b. Financial Performance - revised 2015/16 & 2016/17 plans incorporating recommendations from PWC Operating Plan review

5a. CQC - rectify 'must dos' as set out in CQC report

5b. CQC - Board assurance & assessment of CQC plan

QPLC monthly & Trust Clinical Governance.


Group monthly - reports to Finance &

Performance C itt

Operational pressures risk to capacity to deliver actions

Additional PMO resource in place to support programme

of work

Range of likely outturns submitted to Monitor 24/12/2014.

Robust action plan in place to address Compliance Actions & must dos & plan in place to test assurance

Director Nursing / Medical Director

31/03/2015

Year end review of plan being carried out & re-prioritisation of actions incorporating new CQC standards.

External review by Bournemouth NHS FT arranged for 15th June to test compliance

PWC appointed & scope of work & timings agreed. Commencing end of March to complete end of May.

Recommendations & actions arising from review.

PWC final report. Trust action plan.

1

Title: Monitor Self Certification Statements 2015/16 Agenda item no: 9 Meeting: Board of Directors Date: 28 May 2015 Presented by: Craig Anderson, Director of Finance Prepared by: Caroline Lynch, Interim Trust Secretary Purpose of the Report To approve self-certification statement for 2015/16.

Report History






Failure to maintain and improve quality of care. Failure to maintain standards required to maintain licence to operate











Publication Published on website Confidentiality (FoI): Private Public

1 Background

1.1 The Compliance Framework published by Monitor requires foundation trusts to submit an Annual Plan each year. The Plan is used by Monitor primarily to assess the risk that a foundation trust may breach its Licence in relation to finance and governance. Monitor will also assess the quality of the underlying planning processes. Part 2 will be submitted in June.

1.2 As part of the submission the Board is required to self certify against a number of prescribed statements as either ‘confirmed’ or ‘not confirmed’.

2

1.3 The position in respect of statements 1 and 2 must be submitted by 29 May. Statement 3 was submitted as part of the Operational Plan. Further statements 4, 5 and 6 must be submitted by 30 June.

1.4 If the Board feels it is unable to fully certify a particular statement, the guidance states that the Board

‘….should make an alternative declaration by amending the self certification as necessary and including an y significant prospective risks and concerns the FT has in respect of delivering quality services and effective quality governance and

…must provide a commentary explaining the reasons for the absence of a full self certification and the actions it proposes to take to address it.’

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the Trust.’

2 Comment

2.1 The Board statements are listed in the appendix to this report, together with a commentary supporting a ‘not confirmed’ declaration.

2.2 The Board is invited to consider whether it is able to certify each statement or whether further evidence is required. Should the Board be unable to fully certify then amendments to the appropriate statement and supporting commentary should be considered.

3 Recommendation

3.1 The Board is recommended to self certify that the two board statements for 2014/15 can be marked as ‘not confirmed’.

4 Attachments

4.1 The following is attached to this report:

(a) Self-Certification Statement for May

3

Appendix 1

Annual Plan Board Statements 2014/15 Statement Lead Commentary

1. Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution.

Craig Anderson Two significant events occurred during 2014/15; The CQC inspection which found the Trust as requiring improvement and the Monitor investigation which found the Trust in breach of its licence. Accordingly the Board is recommended to declare this statement as ‘not confirmed’ given the statements by the regulators above.

2. The board declares that the Licensee continues to meet the criteria for holding a licence.

Craig Anderson The Trust remains in breach of its licence as defined by Monitor. Whilst the Board is satisfied that the necessary steps are being taken to reverse the breach we remain technically in breach until otherwise advised by Monitor. The Board is therefore recommended to mark the statement as ‘not confirmed’ on the basis of the comments above.

1

Title: Monthly Workforce Report Agenda item no: 10 Meeting: Board of Directors Date: 28 May 2015 Presented by: Paul Beal, Director of Workforce and Organisational Development Prepared by: Workforce Team

Purpose of the Report • To highlight the key performance indicators for the workforce. • The report outlines the key workforce performance indicators for

the period April 2015 (March for sickness absence). • This report analyses the Trust’s current position, makes external

comparison, identifies risk and opportunities and management actions being undertaken to drive improvement.

Report History





Failure to develop the organisation to support the delivery of the Trust’s vision











Publication

Published on website Confidentiality (FoI): Private Public [Insert as applicable the FoI exemption basis] N/A

2

1 Introduction

1.1 This report outlines the current position relating to the staffing establishment, temporary workforce, sickness absence, mandatory and statutory training, and appraisals.

1.2 The report notes decreases to the staffing establishment and lower levels of spend on temporary staff. The report also identifies the action being undertaken to address the issues identified.

2 Staffing Establishment

2.1 Current Position

The M1 Trust staffing establishment reduced by 29 whole time equivalents (wte) however budgeted establishment remains 50wte higher than M1 2014/15 however. Further QIPP reductions have been identified by speciality level and included in the Trust workforce and financial planning through workforce planning process.

In M1 8.1% of establishment remained vacant, no change from M1 2014/15.

2.2 External Comparison The Trust is undertaking workforce planning for 2015/16 and 2016/17. This work will also help inform similar projects within the Thames Valley Health Education.

2.3 Financial The Trust now has all budgeted establishments in ESR. The budgets with QIPP applied provide clear financial envelopes for directorates to operate within to deliver their clinical and business objectives.

2.4 Management Actions

Considerable work is still required to ensure alignment of clinical, financial and workforce planning. The workforce specialty level plans under construction are being designed to be an iterative document and process so that performance and planning are bedded into the culture and direction of travel for the Trust.

3 Temporary Workforce

3.1 Current Situation

The Trust spent £1.2m in M1. This was £64,202 less than March 2015, however it was £241,839 more than April 2014. There was a reduction of expenditure in each Care Group in April 2015 compared to the preceding month. In total, this represented £169,220. This was offset however by rising costs in corporate expenditure of £58,138. Further analysis is provided in the attached highlight report.

3.2 External Comparison

Exact comparison for the same period is not possible. For March 2015 however, the Trust spent 5.87% of its salary bill on agency costs. Heatherwood and Wexham Park Hospital reported 20.38% and Frimley Park Hospital reported 13.4%.

3.3 Financial Implications and Risks

Whilst reduction in spend are anticipated in both the corporate areas and in the Care Groups, current expenditure is not sustainable at the current run rate.

3

3.4 Management Action

A cost reduction plan is in place that aims to reduce expenditure by £1.5m in 2015/16. Further information on management action can be found in the highlight report.

4 Sickness Absence 4.1 Current Situation

There has been a reduction in sickness absence rates from 3.35% (Feb 2015) to 3.20% for March 2015.

The primary reason for sickness absence in each organisational area in March 2015, regardless of whether it is short term or long term sickness is given as anxiety/stress/depression/other psychiatric illness.

The secondary reason (except long term absence in corporate areas) is back issues with other musculoskeletal issues being the tertiary reason given.Trust wide for March 2015 the short term/long term split is 54.90% (ST) and 45.10% (LT).

March 2015

Area In month Long Term Short Term

Corporate 2.4% 27.21% 72.79%

Estates and Facilities 4.43% 54.30% 45.70%

Planned Care 2.53% 41.0% 59.00%

Network Care 3.34% 40.99% 59.01%

Urgent Care 3.54% 43.09% 56.91%


The national median for sickness absence in the NHS is £3.3million per annum. This is dependent on measures such as staff mix, pay and deprivation. In 2014-2015 the Trust spent £3.7million which is comparable with Trusts of similar size and locality issues.


The total cost of absence for the month of March 2015 was £310,476. The highest area for absence costs was Urgent Care at £109,000. The lowest absence cost area was Facilities £23,000. The risk to the organisation with such high spend on sickness absence is that the reliance on agency to fill theses shifts will impact of patient care, quality and staff morale.

4.4 Management Action

Managers and HR are working closely to manage staff sickness absence issues. Support is provided across a range of interventions including formal procedures.

5 Mandatory and Statutory Training


Completion rates for mandatory and statutory training ended 2014/15 at 83.2%. Mandatory training was at 88.0% and statutory at 79.6%. By the end of April 15 this had risen to an overall completion rate of 84.2% with mandatory at 88.8% and statutory at 80.8%.

4

Overall some 38485 pieces of mandatory and statutory training are currently up to date for Trust staff with 7218 pieces outstanding.

Completion rates have improved in all three Care Groups, the corporate functions and Estates and Facilities, with the greatest increase being recorded in Estates and Facilities.


There is no nationally held comparison data available with which to compare Trust performance.


The primary risk is staff being unaware of key responsibilities which could affect the quality of patient care with a second risk being that the issue of poor completion rates was highlighted within the CQC inspection report. Whilst completion rates have continuously improved since our inspection we have not yet achieved our previous 85% target rate for combined mandatory and statutory training. With this now rising to 90% we are again some distance behind our own desired standard.

Training areas where completion is lowest are Conflict Resolution (65.7%), Moving and Handling for People Handlers – 3 year (68.4%) and Safeguarding Children Level 3 – 1 year (61.6%). Of these only Conflict Resolution has not seen an improvement.


All areas continue to promote the importance of mandatory and statutory training in the delivery of safe clinical care to our patients. This progress has been underpinned by the criteria contained within the Trust’s pay progression policy. The compliance rate for mandatory and statutory training is to be increased within this policy which will drive further improvements in compliance rates. A new approach to delivering Conflict Resolution training is now being put in place which should assist in improving completion rates.

6 Appraisal


Appraisal rates stand at 86.0% at the end of April 2015. This is an increase from 85.0% for the same time last year. The highest completion rates are in Networked Care at 91.0%, followed by Planned Care at 88.6% and Urgent Care at 86.3%. Estates and Facilities stand at 75% and the Corporate functions at 75.6%

3,589 staff had a current appraisal in place at the end of April with 585 outstanding.


There is no nationally held comparison data. In the National 2014 staff attitude survey however the national average completion rate for acute Trusts was 85%.


Failure to offer appraisal and a well-structured, meaningful set of objectives and individual development plans may affect levels of staff engagement, retention and performance. Poor engagement may affect our results in the Friends and Family test and have an adverse effect on retention of staff leading to increased turnover ultimately impacting on the delivery of care.


5

Improving appraisal completion rates continues to be a regular discussion point within Care Group Board meetings with areas asked to ensure completion and improvement of the current position remains a priority. Improvement in the quality of appraisals is part of the Trust wide action plan developed from the staff survey results.

Within the Corporate areas managers are being encouraged to update L&D with the information once the appraisals have been completed in a timely manner. Meetings are now underway with each line manager in these areas to ensure compliance rates are improved. Estates and Facilities are offering and undertaking both group and individual appraisals to staff.

As with Mandatory and Statutory training this has been underpinned by the criteria contained within the Trust’s pay progression policy.

7 Conclusion

7.1 The Performance Management and Workforce Productivity Group is looking at the management of all forms of absence including sickness absence.

7.2 The Temporary Worker Reduction Group is driving minimisation of agency usage.

7.3 The delivery of a robust workforce plan is essential to reduce our pay costs and maintain quality and safety. This will report to the Board end of June 2015

7.3 The Board is asked to: (a) Note the contents of this report (b) To agree/approve the area for detailed analysis in the next report in order to seek

assurance on workforce

8 Attachments

8.1 The following are attached to this report:

(a) Appendix 1 – Workforce Dashboard

(b) Appendix 2 – Workforce Data Charts

(c) Appendix 3 – Highlight Report Temporary Staffing

6

Appendix 1 – Workforce Dashboard

Apr 15 Performance Target Trajectory


Mandatory Training88.80% 90%

Employee Turnover (rolling 12 mths)14.74% 12%

Appraisal Completion85.98% 95%

Employee Turnover < 12 mths Service3.55%

Professional Registration Certified99.99% 100%

Employee Stability81.19% 80%

Friends and Family

% recommending RBFT as a place to care for family & friends 83.00% 60%

% recommending RBFT as a place to work58.00% 60%

Staff inoculations compliance100.00% 100%



Vacancies8.11% 5%

Staff costs as % budget 61.77% 60%

Sickness absence (Mar 15)3.16% 2.80%

Agency as of % spend 5.68% 5%

Flu Vaccination Uptake46.90% 65%

% Temp Staffing filled by NHSP40.33% 80%

Time to Hire Time (Data pending) 12 wks 12 wks

`

Workforce DashboardCapability Engagement

Capacity Productivity

7

Appendix 2 - Workforce Data Charts Staffing Establishment

Starters and Leavers

4300

4400

4500

4600

4700

4800

4900

5000

5100

5200

May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

WTE

Sta

ff N

umbe

rs

Staffing Establishment

Budget WTE Actual worked WTE Contracted WTE

0

50

100

150

200

250

May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

WTE

Sta

ff N

umbe

rs

Starters WTE Leavers WTE 52.58

8

Temporary Workforce

Sickness Absence

£0

£200,000

£400,000

£600,000

£800,000

£1,000,000

£1,200,000

NHSP Nursing Agency Nursing Medical Other Clinical staff

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15Trust - all 1,019,706£ 1,107,133£ 1,097,637£ 1,206,564£ 975,763£ 916,320£ 1,028,003£ 934,223£ 1,213,040£ 1,138,097£ 1,249,543£ 1,325,747£ 1,261,545£

Trust - all Nursing 381,403£ 481,264£ 405,945£ 394,524£ 437,834£ 399,805£ 351,334£ 409,422£ 407,632£ 421,544£ 494,268£ 550,485£ 426,256£ NHSP Nursing 154,194£ 286,480£ 219,842£ 208,313£ 266,372£ 233,685£ 230,003£ 212,051£ 209,044£ 212,425£ 218,988£ 250,691£ 192,988£ Agency Nursing 227,209£ 194,785£ 186,103£ 186,211£ 171,463£ 166,120£ 121,331£ 197,372£ 198,588£ 209,119£ 275,280£ 299,794£ 233,267£ Medical 186,312£ 217,395£ 185,797£ 223,848£ 195,262£ 143,410£ 263,136£ 165,603£ 244,636£ 323,792£ 258,261£ 299,155£ 279,824£ Other Clinical staff 128,598£ 111,880£ 104,747£ 127,400£ 44,237£ 84,958£ 76,195£ 95,869£ 84,135£ 42,324£ 92,655£ 105,281£ 128,655£ Ancil, Admin & Manageme 323,393£ 296,594£ 401,148£ 460,793£ 298,430£ 288,147£ 337,338£ 263,329£ 476,638£ 350,438£ 404,359£ 370,826£ 426,811£

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Absence % Absence %

Target %

9

Mandatory & Statutory Training and Appraisals – 2014/2015

£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

£350,000

£400,000

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Estimated Cost

End Q1 End Q2 End Q3 End Q4 End Q1 End Q2 End Q3 End Q4

Trust 75.1% 78.4% 81.3% 83.2% 85.6% 89.0% 88.3% 84.7%Networked CG 76.3% 78.4% 81.9% 83.4% 91.2% 88.0% 90.4% 89.9%Planned CG 74.0% 79.2% 83.1% 83.8% 83.4% 93.4% 90.4% 81.8%Urgent CG 74.8% 78.3% 79.7% 81.4% 89.9% 86.7% 86.0% 86.0%Estates and Facilities 73.0% 72.8% 77.5% 83.4% 73.9% 86.8% 91.6% 83.7%Corporate Directorates 84.8% 85.4% 85.1% 88.7% 89.6% 87.1% 85.3% 76.8%

Staff AppraisalCompletion

Mandatory & StatutoryTraining Compliance

10

Appendix 3 - Highlight Report Temporary Staffing

This report sets out greater detail on the Trust’s spending in 2014/15 on temporary staffing. It includes information on all staff groups and areas of the Trust and some external benchmarking.

Temporary staffing costs 2014/15 by staff group

The highest level of medical expenditure was in January 2015. NCG spent £71,684, PCG £183,614 and UCG £68,493. Within PCG, delayed submission of timesheets from work undertaken earlier in the year saw the increase in expenditure along with cover for vacant posts and higher sickness absence that required gaps in the junior doctor rota to be covered. Regular discussions are held within Care Groups to review activity and medical expenditure.

The highest level of nursing expenditure was in March 2015. NCG spent £122,446, PCG £152,195 and UCG £275,844.The increased bookings were logged for reasons of escalation, sickness and annual leave.

The Trust is monitoring annual leave patterns and is managing the allocation of leave to avoid the necessity for backfill. Accurate, timely and clear workforce information is circulated to those with responsibility with temporary worker procurement.

Within the Workforce Productivity Programme there is a dedicated work stream which is implementing measures to monitor expenditure. The temporary worker reduction work stream, which consists of representatives from clinical areas as well as finance, procurement and HR professionals, now meets on a weekly basis. There are monthly milestones set and progress is reviewed by the Workforce Productivity Board, chaired by the Director of Workforce and OD.

A cost reduction plan is in place so that £1.5m of savings can be realised in 2015/16. Phasing of the plan is spread across the financial year. Key performance indicators are set and progress is reviewed regularly.

11

12 Month total temporary staffing costs by Care Group and Corporate Services (May14 – April15)

Corporate Services saw high interim expenditure in the last financial year in the main due to the 18 week referral to treatment (RTT) recovery team. The RTT team had specialist skills and expensive and were necessarily composed of several consultants retained on day rates.

The Trust was obligated to engage these professionals, and others associated with business critical back office IT programmes, to ensure quality and efficiency of patient care are maintained. Monitor and the Care Quality Commission (CQC) were both aware of the plans the Trust put in place, and, in some cases, mandated the Trust to take these proportional and necessary steps. . Urgent Care saw the highest expenditure. This reflects particularly acute winter pressures and the capacity of the current workforce to meet service demand across the emergency, maternity and paediatrics areas. Increased recruitment, improved workforce information and improved controls on the most expensive nursing agency enhance delivery. Compared to 2013/14 Urgent Care spent £1.2m less on temporary staffing than it did in 2014/15.

Agency expenditure in 2014/15 as a percentage of salary costs

Agency Pay % RBH £10,507,252 £209,717,360 5.01% Urgent Care £2,734,631 £66,473,277 4.11% Planned Care £2,633,813 £67,715,349 3.89% Networked Care £1,666,563 £44,720,597 3.73% Estates & Facilities £75,816 £9,886,867 0.77% Corporate Services £3,396,428 £20,921,270 16.23%

External benchmarking – Agency expenditure in 2014/15 as a proportion of salary costs

• Frimley Park Hospital 7.2% • Heatherwood and Wexham Park Hospital 14.7

12

Agency expenditure in 2013/14 as a proportion of salary costs Agency Pay % RBH £7,984,610 £202,847,307 5.13% Urgent Care £3,457,037 £66,234,122 6.46% Planned Care £2,250,342 £66,589,219 5.29% Networked Care £1,444,321 £42,807,420 4.11% Estates & Facilities -£15,165 £9,944,233 -0.15% Corporate Services £848,076 £17,272,313 4.93%

Trust Improvement Programme – Report to Board – May 2015

Title: Trust Improvement Programme Agenda item no: 11 Meeting: Board of Directors Date: 28 May 2015 Presented by: Bernie Bluhm, Interim COO Prepared by: Vanessa Harding, Head of PMO & Service Transformation Purpose of the Report The purpose of this paper is to update the Board and to provide

oversight of the progress being made in the Trust Improvement Programme, including delivery of the Trust’s QIPP target.

Report History





Relationship to Risk in BAF: Risk to delivery of QIPP targets and impact on financial stability











Improved oversight of progress and delivery, as well as awareness of key risks Publication Published on website Confidentiality (FoI): Private Public [Insert as applicable the FoI exemption basis]


Key Points:

• The overall QIPP target is now set at £16.7m allowing for £1.5m contingency that was agreed at Trust Board in April. The contingency has been allocated against Planned Care (£1.2m) and Estates & Facilities (£0.3m).

• In year cost saving opportunities being tracked by the PMO currently total £17.8m with a risk assessment of £13.5m. This figure has reduced from last month by c£600 mainly due to removal of QIPPs in Urgent Care which are no longer feasible. Urgent Care are reviewing additional opportunities to remove the gap.

• Month 1 actual savings delivered totals £0.726m (including £0.425m of carry forward) against a forecast of £0.4m.

• The attached dashboard at Appendix A provides an update on the current status of the programme and current risks and issues known at the time of writing. The monthly milestones rag rating reflects delivery for April.

• 3 programmes are rag rated red in terms of overall progress this month. Exception reports are attached in Appendix B.

• The CQC programme has been removed as this is now managed and monitored through the Trust Quality Assurance & Learning Committee, and the Clinical Governance Committee.

1 Progress update

1.1 Good progress has been made in the last month in the majority of programmes. However 3 programmes are rag rated Red in terms of overall progress this month. See Exception Reports attached at Appendix B.

1.2 A number of actions have been delivered this month. Highlights include:-

o The procurement team have already taken action in month 1 that will deliver c£500k over the course of the next 12 months. The in-year opportunities have increased and now total the £3m target they were set.

o Medicines Management Programme is progressing well and have delivered £69k in Month 1 against a forecast of £11k.

o The HR re-structure is now out to consultation with implementation planned for September. The full year savings are expected to be c£150k, but will be achieved over this year and next.

o Maternity have completed benchmarking of other Trusts and following sessions with staff, have agreed operational and service improvements

o The Sign up for Safety Programme was successfully launched on 20th April with a week-long series of staff briefings


o The electronic workforce management system is out to tender – bids will be evaluated on 1st

o The clinical admin programme is at critical stage with logistics being finalised in relation to telephony, IT and capital works. Staff training is underway and the programme is on track for go live on 1

June with implementation due to complete in September

st

1.3 The full monthly Dashboard is attached (Appendix A) detailing current status, risk and issues and rag rating of progress.

June

2 Financial Delivery

2.1 Following the Board meeting in April, it was agreed that contingency of £1.5m would be set against the QIPP target. This has been allocated against Estates & Facilities (£0.3m) and Planned Care (£1.2m).

2.2 The current in year opportunities being tracked by the PMO total £17.8m with a risk assessment of £13.5m. This has reduced from last month mainly due to removal in QIPPs within Urgent Care in relation to reduced headcount to manage A&E growth and management of escalation costs. Since these were put forward as plans, the funding has been removed from the budget and therefore the savings are no longer valid as QIPPs.

The Care Group remain confident that they will still achieve their overall target by year end, although a proportion of this may be met by non-recurrent savings.

2.3 Month 1 cost savings delivered totalled £0.726m against forecast of £0.427m. The reason for the variation is that the forecast did not take account of carry forward savings from 2014/15 projects as these had not been profiled at the time.

2.4 In addition to cost savings, £3.2m of income efficiencies have been identified in-year with a risk assessment of £1.7m.

3 Exception Reports

3.1 3 Exception reports are attached this month – Medical Records, Ophthalmology and Radiology.

3.2 Medical Records – a number of issues have contributed to the current status, including lack of resourcing, previous lack of Care Group ownership, competing agendas and the need for additional IT support. Mitigating actions have been put in place to address these, however the need for additional IT resource is critical to the success of the programme going forward and funding of this will need to be considered as soon as possible.

3.3 Ophthalmology – the size and complexity of this Programme and competing agendas such as RTT validation and the clinical admin programme have impacted on the ability of the service to drive the planned improvements. However new leadership is now in place and the project team has been re-launched with a focus on taking immediate actions starting this month to improve operational performance and in parallel, moving forward on some of the transformational service redesign changes, such as implementation of a new IT system across all sites.


3.4 Radiology/ Order Comms – the Radiology and Order Comms Programmes have been rated Red this month due to on-going issues with implementation of the new Radnet system, and the subsequent impact of this on the implementation of Order Comms. All x-ray activity was moved onto the new Radnet system in April, however there has been a continuing issue with its operational use resulting in a delay in the roll out of other modalities.

3.5 The risks are being mitigated by increasing the IT resource and a revised approach to the roll out of the systems. Daily and weekly meetings are taking place to manage the situation.


Appendix B – Medical Records Exception Report

Programme: Medical Records Exec Sponsor: Bernie BluhmClinical lead: Lindsey Barker Project Lead: Clive Wewerka

Financial Savings target for 2015/16: (if applicable)

£100k Rag rating (Monthly Milestone):

Savings achieved this month:(if applicable)

0 Rag rating (Overall progress):

Summary of overall progress of Programme

Key issues contributing to the Programme's current RAG rating are:

1. Resourcing- lack of operational management, recent lack of PMO resource, need for additional IT/informatics support

2. Care Group contribution to the change programme - lack of ownership

3. Competing operational agendas - RTT validation / clinical admin etc

4. Clinical risks - lack of available notes leading to poor patient care

5. Financial risks - lack of available notes leading to cancelled clinics / theatres - loss of income & productivity, lack of storage impacting on archiving costs

6. Reputational risk - poor patient experience, CQC Compliance Action, Monitor Undertakings, Monmouth Audit

1. Decision to be made as to where the MR function sits within the organisation. The function may sit better within a corporate structure rather than in one Care Group.

2.A revised single Business Case is being developed to bring together different elements of the improvement programme, with a focus on resolving the current storage issues which is impacting on the ability to make progress. The Business Case includes an IT solution to enable availablity of notes and significant opportunity for reducing costs by reducing headcount and removing archiving/transport costs.

3. Resourcing - a proposal has been developed identifying an operational lead, and PMO resource has been agreed from 1st June. Many of the changes require an IT solution - whilst IM&T are supportive of the programme, we are now at the point of requiring a dedicated IT lead - however, this will require investment.

4. Some elements of the programme have progressed - such as security and quality of notes. Whilst there is still work to do in these areas, the Trust has improved the position from the previous CQC inspection & initial Monmouth Audit. The new CATs teams are being trained in the management of records, and this will be rolled out to wards, clinics areas in due course.

Improvement Programme - Exception Report

Whilst good progress was being made in this programme a number of risks and issues have materialised in the last couple of months preventing the programme from making further headway. Mitigating actions have been agreed and are underway, however decisions now need to be made such as future ownership of the MR function and the need for some short term investment for IT support, which is critical to the success of the programme. The previous short term actions to improve the physical environment of the records library have been completed but there is still a need for longer term solutions for location & storage of records.

Key risks & issues: Mitigation to be / being taken:


Appendix B – Ophthalmology Exception Report

Programme: Ophthalmology Exec Sponsor: Bernie BluhmClinical lead: Warren Fisher Project Lead: Simon Holmes


n/a Rag rating (Monthly Milestone):





The size and complexity of the Ophthalmology Programme has impacted on progress. However new leadership and a revised project team is now in place. Issues are understood and immediate and medium term actions have been agreed. The theatre programme has resulted in improved weekly admitted activity and overall there is improved support and engagement from the clinical team.


Key issues contributing to the Programme's current RAG rating are:

1. The sheer size and complexity of the programme and the number of competing issues has impacted on the ability to drive forward improvements and impacted on operational performance.

2. Resourcing - the need for ongoing dedicated operational management, PMO resource and admin and leadership resource at PCEU.

3. Pre-assessment processes, equipment and resource

4. Estates / environment - changes to the facilities at RBFT and PCEU to improve capacity and patient flow through the dept.

5. Pathways - the need to redesign some pathways to optimise productivity / achieve performance targets etc

6. RTT validation and ongoing training needs at PCEU

New leadership has been in place overseeing the department following the appointment of Warren Fisher as Care Group Director and Pat Rubin as Director of Operations.Planned Care are currently completing a Business Case for the appointment of a 12 month fixed term operational manager to oversee the operational actions and act as project lead for the Improvement Programme. Funding for this has been identified within the PC budget.

A project team has been established and has spent time in the last 2 weeks understanding the issues, the immediate actions and agreeing next steps. A senior Project Manager from the PMO has been seconded into ophthalmology for 3 days per week to take forward the service redesign work. Immediate and medium term actions for May, June and July, and have agreed the areas of improvements on which they will focus for the next 3-6 months, which are:

1. A proposal to strengthen nursing leadership at PCEU has been agreed to provide leadership & management of the site2. A weekly 18 week presence at PCEU and a training resource has been put in place at PCEU for the past 3 weeks3. A Task & finish group has been agreed to take forward pre - assessment resource, equipment and processes, including criteria / choice for which patients are treated on which site4. Re-location of the eye casualty dept within ophthalmology clinic to create additional capacity is being progressed5. Completion of the Lucentis room at PCEU creating capacity to see more patients (2-3 month timescale to complete)6. Agreement of the future IT strategy for the dept - implementation of one system across all sites following review by IT (will need additional resourcing within IT to implement)7. An external review of the glaucoma pathway has been commissioned across sites8. Longer term strategy to develop an integrated eye service across the health economy is being discussed with the CCG

The project team are meeting weekly to drive the above actions.


Appendix B – Radiology / Order Comms Exception Report

Programme: Order Comms and Radiology Improvement Programme Exec Sponsor: Lindsey Barker/Sue Edees

Clinical lead: Lindsey Barker Project Lead: Gary Curtis


£0.250m (tbc) Rag rating (Monthly Milestone):




All modalities except Xray at risk as team resource (0.6 wte PM and 0.5 wte radiology systems manager) overstretched to achieve radnet implementation and resolution of go live issues.

Project leads reviewing risks to identify where additional resource could be utilised Additional business analyst resource assigned to the projectAdditional testing resource required to support User acceptance and defect resolution


Issue was resolved in April. Contract resource was extended to complete the development.

Order Comms dependency on Radnet Upgrade:1. Regular review of build progress with workstream lead - Fenella Derbyshire.2. Finalise Radiology department cutover plans

Pathology link to Order CommsPathology lab systems (LIMs) development delay due to resource contention. Pathology IT have 1 contract resource who can enhance the Pathology LIMs system. He is also 3rd line support for when the LIMs system has issues. This has had an impact on the development timelines. (The LIMS system is very old & in need of replacement. This is delayed awaiting the outcome of the outsourcing pathology project).

The design of the Cerner/ICE to lab systems interface was chosen to be a longer term solution supporting this & future project needs. This requirement has taken a longer than expected development period.

Order comms Dependency on Radnet Upgrade: The Radnet upgrade project has impacted Order Comms Go live dates and ability to forward plan.

Pathology link to Order Comms:Path Mgmt have reassigned duties so resource is dedicated to the Project.Project Management, Developer and Software Development team lead assigned to bolster efforts and support the Pathology team.


Implementation of new Radnet:Radnet handling of x ray shows significant clinical and operational issues which are being monitored and managed daily to mitigate clinical risk.

Implementation of new Radnet:Halt further implementation until issues resolved in order to reduce clinical risk and operational impact.Focus on resolving remianing issues.Additional Cerner resource engaged to further assure the Radnet software.

Both Radiology Improvement programme and OC project have moved to Red this month due to on-going difficulties getting Radiology moved over to integrated Radnet and development of Pathology Lab system changes to accept electronic orders. Radiology have now moved all of their X-ray activity over to EPR radnet as at 20th April however a number of issues arising from operational use have necessitated the postponement of rolling out other modalities until these issues are resolved to minimise clinical risk.

Radiology and EPR project teams are now focused on resolving the issues and getting Radiology fully live by mid June so a Trust wide OC rollout of Radiology Requests and Results can take place end June.Full rollout of Pathology ordercomms has been impacted by more difficult than expected integration of electronic orders into Lab systems. Additional project management and business analysis support has been assigned to the work stream to further assure this delivery. Migration of code to Production environments is on track for w/c 11/5, followed by 4 weeks of Production Verification Testing and pilots.

The implementation approach has now changed due to the diverging deliveries between Radiology and Pathology. Radiology full implementation will be big bang across the organisation end June. Pathology has two rollout options: the first sees a fast phased approach from mid/end June to end of July. The second option sees a slower rollout from mid/end June to end August. The second approach is favoured for Pathology due to the more complex specimen collection processes and the need for these processes to bed into day to day processes. Option 2 allows for more support staff over a longer period.

Trust Improvement Programme - Dashboard - May 2015 (April Milestones)

Programme Area

Exec Lead

Current Status of Programme Current Risks / Issues

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Savings Opportunity for

2015/16 *

Current PMO Risk Assessment

**

Overall Programme

Progress

Maternity Director Nursing

Programme progressing with the majority of milestones completed in the month, including QI training for staff, agreement of the CQUIN with the CCG, initial review of the MCA role, the strategic review of the service, benchmarking work undertaken and improvements agreed.

However the ventilation project has been impacted by further issues. The completion date is now planned for mid June - no further delays are expected. Whilst the operational re-structure was not implemented in April, it is expected to be in place in the next 2 weeks.

Ventilation system - revised deadline is now mid May. No further delays are expected.

Amber

None identified to date

N/a

Ophthalmology Interim COO

Session held with management team to review all immediate, medium & long term actions.Agreement of actions required in May - now underway.Planned Care looking to recruit fixed term ops lead to focus on operational issues. PMO support in place to take forward improvement plans, including, eye casulaty relocation, Lucentis room at PCEU & implementation of a consistent IT system across sites.The project team will be meeting weekly to review progress.

Rag rated red due to number of issues to resolve. However, plan now in place with project team meeting weekly to drive progress.

See attached Exception report.None identified

to dateN/a

Order Comms Act. Medical Director

Timescales for delivery have slipped as a direct result of issues with implementation of the Radnet system in Radiology. A change notice will be issued to NHSE to advise re slippage - however they are aware of the issues & mitigation in place to recover the position.

Project impacted by roll out of Radnet. Implementation approach has been changed. Roll out of Radiology Order Comms now planned for end of June.The slippage will also impact on the forecasted savings - whilst the fy savings is £380k, the in year savings are now likely to reduce to c£250k. The PMO risk assessment will be amended to reflect this.See attached Exception Report

£0.38m £0.38m

Patient Flow Interim COO

Good progress being made. Process established for referral of patients for discharge, TTO/EDL CQUIN established, throughput targets by ward allocated & communicated with metrics in place to monitor progress, GP unit up & running.Good clinical engagement.Expecting to sign off bed plan shortly, with reviews underway of the trauma pathway, and of the Satellite Navigation Team.

Project may be impacted by non elective demand - this is being reviewed daily by the operational team.

£1.1m £0.802m

Radiology Care Grp Dir. UC

Whilst progress made in some areas, such as the admin review & the plan for 7 day working, there are key risks in the implementation of Radnet.There are a number of issues arising from operational use of the new system for x-ray, which has postponed the roll out of other modalities until these are resolved.Issues in realtion to admin resource have been resolved & recruitment is underway.

Issues with roll out of Radnet, which also impact on implementation of Order Comms.

See attached Exception Report.

Amber


N/a

Sign Up For Safety Director Nursing

Programme successfully launched on 20th April with week long series of staff briefings showcasing the national campaign & our local priorities.Safety Makers & Ambassador roles have been developed & job descriptions written.

NHSLA bid for funding was not successful (value of £800k). Review underway of how actions can still be delivered within existing resource. None identified

to dateN/a

Medical Records Interim COO

Progress has been very slow, impacted by lack of PMO resource, sickness absence from within the MR team and lack of engagement with Care Groups.The Steering Group is due to meet again on 20th May to review outstanding actions & agree next steps.

IM&T resource to support programmePhysical environment & storage capacity of current MR location

See attached Exception Report.

£0.1m £0.09m

Medical Productivity

Act. Medical Director

Good progress being made. Electronic workforce management system out to tender - bids will be evaluated 1st June with implementation between June & September. This, and the current manual job planning process is what will drive the planned savings.A review of current medical agency & locum use is underway - actions to be agreed.

Appetite to reduce medical spend versus potential negative impact on clinical engagement

£1.4m £1.05m

Workforce productivity

Director Workforce & OD

Work underway - KPIs have been signed off as has the PID.The Pay Progression Policy has been revised & with staff side for consultation.Absence targets have been allocated to each cost centre.

Whilst progress being made, the project currently lacks a level of granularity in order to provide assurance. The team will be presenting at the next Improvement Programme Steering Group in June.

£1.7m £1.269m

Theatre Efficiency Interim COO

The programme is coming to the end of the first 10 week phase. T&O and Ophthalmology have achieved ‘Quick Win’s and their overall monthly activity figures based on the ‘Magic Numbers’, have been exceeded for MayENT have achieved success with putting more cases for the lists targeted for the ‘Quick Wins’ however they are a slightly under on monthly activity figures due to needing to recruit to specialty doctor post and with one clinician currently unable to operateThe second phase will begin shortly focusing on 3 new specialties.

Clinical engagement is key to the programme - to date engagement has been good.Financial efficiencies shown are based on additional income - the project team are reviewing the equivalent / realistic cost savings would be.

£1.875m £1.875m

7 day working Act. Medical Director

5 priority standards have been agreed with the CCG which will be included in the 2015/16 contract. Work underway to confirm the baseline position & then improvements will be agreed in specific areas. In the meantime, the project is being scoped, and a request being made to Exec for additional project resource.

Funding of additional resource to implement 7 day working.Clinical engagement to drive the project will be critical.Trust operational lead to be identified to lead the programme of work.


N/a

Achievement of Milestones

Operational Effectiveness

Patient Safety

Productivity

Programme Area

Exec Lead

Current Status of Programme Current Risks / Issues

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Savings Opportunity for

2015/16 *

Current PMO Risk Assessment

**

Overall Programme

Progress

Clinical Admin Interim COO

Programme on track & all milestones delivered in April.Current work centred around logistics - ensuring telephony, capital works, IT are all in place for each CAT.All CATs have a location identified - teams will be moving into their new areas over the next 2 weeks.Recruitment is underway where there are current gaps in the new teams. Redeployment opportunities are being identified for those staff who were not successfully appointed to the CATs.Confirmation of the final costs & savings will be provided in the next few days.

There is still some clinical concerns from the medical staff - clarification of the exact concerns is being sought so the issues can be addressed.

£0.478m £0.386m

Corporate Services -general

Director Finance

2 specific actions agreed - reduction in discretionary spend & reducing commissioned reports. Both actions will deliver c£600k this year.

Will need continued focus on reducing discretionary spend to deliver the year end target.£0.61m £0.313m

Corporate Services - Finance

Director Finance

Specific QIPPs identified - PMO documentation completed & actions underway One action no longer feasible on original list - finance to identify additional savings of £86k in order to meet dept target. £0.364m £0.364m

Corporate Services - Estates

Director E&F

Target now reduced to £1.3m (following allocation of contingency). QIPP ideas on paper suggest opportunity of c£1m but very little progress made in the last month. Meeting to be held with Director E&F / FD to review QIPPs and agree next steps.

Concern over pace of delivery. Exec lead meeting Director to agree actions.

£1.056m £0.508m

Corporate Services - IM&T

Director IM&T

Target £800k but savings identified currently total c£225k. Team workshop to be arranged to identify further ideas.Review of current agency posts to be carried out to identify potential savings through converting to substantive posts.Agreement to transfer relevant budget to enable IT to take necessary actions to deliver QIPP savings.

Requires transfer of budgets into IM&T.Significant gap against target at the moment.

£0.225m £0.056m

Corporate Services - HR

Director Workforce &OD

Re- structure - consultation has commenced & due to complete July.Full year savings identified - but will only deliver 50% this year due to timing - therefore additional QIPPs to be found.

Confirmation of exact savings to be delivered and any shortfall against the target is still to be determined and therefore a risk. £0.088m £0.04m

Procurement Director Finance

Financial savings opportunities identified of £2.9m against target of £3m.Actions taken in month 1 will deliver c£500k savings over the course of the year.£64k delivered in Month 1

Staff engagement & buy in will be critical in order to deliver the actions across the Trust.£3.0m £2.253m

Medicines Management

Act Medical Director

Good progress being made. £69k of cost savings were delivered in Month 1 against a forecast of £11k.Work streams underway - delivery of QIPPs now incorporated into day to day work of the pharmacy team.

Assumption made that the gainshare of savings will continue as part of the contract this year - agreed in principle by the CCG but awaiting formal confirmation. £1.6m £1.2m

Pathology Integration

Act. Medical DirectorBusiness Case agreed by Board for integration of services with Frimley Partnership. Operational implementation plan to be developed.

Savings unlikely to deliver in 2015/16£0 £0

Urgent Care - BAU QIPPs

Care Group Director - UC

55k savings delivered in Month 1 against original forecast of £76k. Savings identified previously have now reduced due to changes in the Care Group budget vs assumptions made. FD / Head PMO investigating.

Shortfall of £962k against target (based on current risk rating)

£1.036m £0.663m

Planned Care - BAU QIPPs

Care Group Director - PC

Month 1 savings not confirmed due to resource issue in Care Group. Month 2 savings will be adjusted accordingly to include Month 1.

Contingency of £1.2m allocated to Care Group.£1.266m £0.818m

Networked Care - BAU QIPPs

Care Group Director - NC

£39k delivered in Month 1 against original forecast of £48k. Shortfall of £277k against target of £1m (based on current risk rating)£0.786m £0.723m

Carry Forward QIPPs from

2014/15

The carry forward figures for 2014/15 has now been confirmed and profiled. The in year total is £747k, of which £425k was delivered in Month 1. £0.747m £0.768m

£17.8m £13.5m

Notes:* = Programme Lead view of realistic savings opportunity** = PMO view based on current position (plans / actions taken)

Total QIPP (cost)

Financial Efficiency

Al l mi lestones achieved in the month Programme progress ing wel l / on track

Majori ty of mi lestones achieved Some concerns but mitigation in place

No mi lestones / majori ty not achieved Signi ficant concern re pace / i s sues / costs etc

Rag Rating Cri teria for Monthly mi lestones : Rag Rating Cri teria for overa l l progress :

May Jun Jul Aug Sep Oct Nov Dec

Ops Work Stream A: Microscopes in theatre B: Pre-Op Scheduling improvements C: Ops Mgr recruitment D: Call out in post (DNA) E: Surgical capacity short and long term F: Surgical capacity long term G: Lead nurse PCEU

RBHFT Service Improvement Work H: Eye casualty move I: Level 2 clinic redesign J: IT System standardisation

PCEU Service Improvement Work K: Admin team model/staff L: Lucentis room M: Med iSOFT upgrade

Care Pathway Developments N: Glaucoma pathway review O: Medical retina pathway P: CCG - Integrated pathway

A

B

C

D

E

F

G

J

H

I

K

L

M

N

O

P

OPHTHALMOLOGY 2015 DRAFT IMPROVEMENT PROGRAMME

RBFT Ophthalmology Improvement Programme Option

Care pathway Developments

Work Stream Lead: Simon Holmes

Key actions: N: Glaucoma pathway review O: Medical retina pathway P: CCG - Integrated pathway

Aim: To develop a one unit culture through identifying strategic service developments across all sites that deliver best patient experience & outcomes

PCEU Service Improvement Work

Work Stream Lead: Simon Holmes/Naomi Garnett

Key Actions: K: Admin team model/staff L: Lucentis room M: Med iSOFT upgrade

Aim: To improve PCEU operating model so that if becomes a flagship for eye services in East Berkshire.

Key actions: H: Eye casualty move I: Level 2 clinic redesign J: IT System standardisation

Aim: To improve RBHFT operating model as central hub for all RBHFT ophthalmology services.

RBHFT Service Improvement Work Ops work stream

Work Stream Lead: Naomi Garnett/Simon Holmes

Work Stream Lead: Tristram Mills Matron

Aim: To improve RBHFT operating model as central hub for all RBHFT ophthalmology services.

Key actions: A. Microscopes in theatre B: Pre-Op Scheduling improvements C: Ops Mgr post D: Call out in post E: Surgical capacity short term F: Surgical capacity long term G: Lead nurse PCEU

PROPOSED OPHTHALMOLOGY IMPROVEMENT PROGRAMME BOARD STRUCTURE Exec Sponsor Bernie Bluhm

Clinical lead Warren Fisher (Chair)

Programme Lead Simon Holmes

Board members Pat Rubin, Vanessa Harding, To be confirmed: Clinical staff, IT rep, Estates rep.

Work Streams Operational improvements

RBHFT Service Improvements

PCEU Service Improvements

Care pathway developments

Work Stream Lead Tristram Mills Simon Holmes Naomi Garnett

Simon Holmes Naomi Garnett

Simon Holmes

Project Leads A: Microscopes in theatre (WF)

H: Eye casualty move (NG)

K: Admin team model/staff (SH)

N: Glaucoma pathway review (SH)

B: Pre-Op Scheduling improvements (TM)

I: Level 2 clinic redesign (NG)

L: Lucentis room (NG) O: Medical retina pathway (SH)

C. Ops manager recruitment (PR)

J: IT System standardisation (NG)

M: Med iSOFT upgrade (NG)

P: CCG - Integrated pathway (VH/SH)

D Call out in post (re DNA) (SH)

E: Surgical capacity short term (SH)

F. Surgical capacity – long term (SH)

G: Lead Nurse PCEU (TM)

May Milestones

Project Owner Due

complete Actions

A: Microscopes in theatre

WF 1/6/15 Agree procurement process with PM to purchase selected microscopes asap.

B: Pre-Op Scheduling improvements

TM 1/9/15 Scope work and set up initial meeting.

C. Ops manager recruitment

PR 1/6/15 Prepare business case.

D Call out in post (re DNA)

SH 1/6/15 Recruit to post (?)

E: Surgical capacity short term

SH 1/6/15 Recruit to locum post.

H: Eye casualty move NG 1/6/15 Complete service requirements Po signed off for 10K outline design funding. Brief PB for outline design. Set up project team and draft proj mgt docs.

K: Admin team (PCEU) staff

SH 1/6/15 Identify admin team model and ensure staff in place and operational .

M: Med iSOFT upgrade (PCEU)

NG 1/9/15 NG to liaise with JN for project update.

Title: Review of Standing Financial Instructions Agenda item no: 12 Meeting: Board of Directors Date: 28 May 2015 Presented by: Craig Anderson, Director of Finance Prepared by: Graham Butler, Deputy Director of Finance Purpose of the Report To update the Board on the outcome of the review of the Trust Standing

Financial Instructions (SFI’s).

Report History Audit & Risk Committee - 18 May 2015 (Approved)






Failure to maintain standards required to maintain licence to operate











Publication Published on website Confidentiality (FoI): Private Public [Insert as applicable the FoI exemption basis]

1. Purpose and decision required To update the Board on the outcome of the review of the Trust Standing Financial Instructions (SFI’s).

2. Key points

(a) A copy of the SFI’s including tracked changes is attached to this paper.

(b) Nine minor changes have been made to the content of the SFI’s. These are summarised in appendix 1

(c) The approved document will be issued to all requisition approvers, requisitioners and senior managers for completion of the certification that they have read, understood and will comply to the SFI’s.

(d) The delegated authorities shown in the SFI’s show the maximum delegated authority. The Trust has reduced authority levels as part of the temporary measures taken to reduce spend, thus the only staff with approval authority above £25,000 are the Chief Executive, the Director of Finance, the Chief Operating Officer, the Medical Director, the Nursing Director and the Director of Workforce and Organisational Developments.

3. Recommendations The Board is asked to APPROVE the updated SFI’s.

4. Appendix 1 – Summary of changes

5. Attachment SFI document including tracked changes

Appendix 1 – Summary of changes

The following minor changes have been made to the content of the SFI’s:

(a) Page 12 – reference to the Public Contract Regulations 2015 has been inserted to ensure compliance with the appropriate regulations

(b) Page 12 – Slight wording change to clarify that Procurement will retain copies of all contracts.

(c) Page 19 – reference to tendering and contracting threshold table (Table 2) has been inserted.

(d) Page 20 – Sentence confirming that the Trust will undertake a vetting process for all suppliers

(e) Page 21 – An additional situation where a single tender would be authorised has been added in relation to waivers and Voluntary Ex-Ante Transparency notice (VEAT notice)

(f) Page 21 – reference to the Public Contract Regulations 2006 changed to current 2015 Regulations

(g) Page 27 – reference to tendering and contracting threshold table (Table 2) has been inserted

(h) Page 37 - Table of tendering and contracting thresholds have been added to provide guidance of the limits for the tendering process

(i) References to 2014 have been replaced with 2015 where appropriate

Standing Financial Instructions – updated May 20154 Page 1 of 38 1

Trust Standing Financial Instructions

Standing Financial Instructions of the

Royal Berkshire NHS Foundation Trust

As Revised in May 20154

Approved by the Trust Board 29 May 20154



Table of Contents

Table of Contents 2

Introduction including definitions 3

Powers of Authority and Delegation 5

Corporate Responsibilities of all Trust employees and staff 7

Responsibilities of the Chief Executive 10

Responsibilities of the Director of Finance 15

APPENDIX A - RESERVATION OF POWERS TO THE BOARD OF DIRECTORS

AND DELEGATION OF POWERS 27

Certification 37

Formatted: Heading 2, Adjust spacebetween Latin and Asian text, Adjustspace between Asian text and numbers



Introduction Purpose These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of the Foundation Trust (including its subsidiary and charity), its Directors, staff, officers and agents in relation to all financial matters. They explain the financial responsibilities, policies, processes and procedures adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law, Government policy and best practice in order to achieve probity, accuracy, economy, efficiency and effectiveness in the way in which the Trust manages its finances. They identify the financial responsibilities which apply to everyone working for or on behalf of the Trust. They do not provide all the detailed procedural advice. These statements must therefore be read in conjunction with the detailed financial procedure notes and other policies referred to within this document. All Trust policies are available on the Trust internal website or from the finance function. All financial responsibilities, policies, processes and procedures relating to the Trust and subsidiaries must be approved by the Director of Finance. Authority and Compliance These SFIs have been compiled under the authority of the Board of Directors of the Foundation Trust. They have been reviewed by the Trust Audit and Risk Committee and by the full Board of Directors and have their full approval. All staff employed by the Trust will comply with these instructions at all times. Failure to comply will result in disciplinary action up to and including dismissal. These SFIs supersede all previous editions. All breaches of these regulations, including evidence of fraud or irregularity will be investigated in accordance with the Trust’s Human Resources and Local Counter Fraud Policy (CG155). Any significant breaches of Financial Regulations will be referred to the Director of Finance and the Audit Committee. The Director of Finance will consider the necessary course of action, which may in certain circumstances include taking disciplinary action. In the event that a staff or Board member becomes aware of an irregularity or breach of any of the SFIs, or systematic breach or abuse of the levels of delegated authority, and is concerned about the reporting or notification of such actions through the normal management channels, the Trust has a clear ‘Raising Concerns at Work (Whistleblowing) Policy (CG055)’ on the intranet which should be followed in such circumstances. All such matters will be reported to Audit Committee by the Director of Finance.



Certification All Officers with iproc authority and all Officers who are cost centre managers will be required to certify that they have read, understood and will comply with these SFI’s. Definitions CEO Chief Executive Officer

DOF Director of Finance

HMRC Her Majesty’s Revenue and Customs PO Purchase Order

Employee An officer who is paid through the Trust payroll system

Officer All employees, temporary staff, agency staff or self-employed consultants of the Trust, including nursing and medical staff, and consultants practising upon Trust premises for whatever reason.

Scheme of Delegation The system of delegated powers from the Board of Directors to enable appropriate officers of the Trust to manage the day to day activities.

Trust Approved Procurement Systems

Oracle i-procurement; JAC; Ingenica; NHS Supplies; NHS Professionals

Wherever the title CEO, DOF, or other nominated officer is used in these instructions, it should be deemed to include such other officers who have been duly authorised to represent them. However, it is a fundamental tenet of these instructions that no officer of the Trust is empowered in any way to provide authorisation to represent themselves to persons who are not under their organisational control, unless specifically authorised within these SFIs.



Powers of Authority and Delegation

Principles of delegated powers of authority and Schemes of Delegation The Board of Directors will delegate responsibility for the performance of its functions in accordance with the Scheme of Delegation adopted by the Trust. The Board of Directors have determined that they shall reserve for their sole approval certain financial transactions based around types or values as set out in the Scheme of Delegation. Those aside, all executive powers are vested in the CEO, who in turn will provide delegated powers to relevant officers. The CEO and DOF will, where appropriate, delegate their detailed responsibilities but will remain accountable for financial control. The Scheme of Delegation is a collection of schedules setting out various powers of authority delegated to a post holder. The first schedule sets out Board of Directors powers and the extent to which they are delegated to the CEO and other Executive Directors. Separate schedules will be retained by the DOF setting out the powers delegated to identified post holders. A full record of each scheme of delegation will be reviewed at least annually to ensure all authorised individuals understand and are fulfilling their responsibilities. Board of Directors The Board of Directors have retained sole rights to approve all financial transactions with a value in excess of the level specified for this purpose in the Scheme of Delegation, subject to the exclusion of any item covered by specific delegated authority. This applies to individual transactions and to term contracts for the provision of goods, services or capital works over a period of time. The only exception to this instruction is on the extremely rare occasions where time is a critical factor. Then the Board of Directors can instruct the CEO to approve specified transactions that are required in the interest of the Trust. In such circumstances the CEO must provide a full report to the Board of Directors at the next available opportunity. The Board of Directors acts as corporate trustee for all charitable funds. The Board of Directors delegates the management of the charitable funds to the Charity Committee. The Board of Directors are responsible for ensuring appropriate governance arrangements are in place for the Trust’s wholly owned subsidiary company, Healthcare Facilities Management Services Limited. The Board of Directors will maintain adequate policies and safeguards to prevent bribery and ensure compliance with the requirements of the Bribery Act 2010. (nb. The key policies affected are those relating to gifts/hospitality/sponsorship; staff recruitment and disciplinary; conflict of interests and declaration of interests).



Chief Executive Within the SFIs, it is acknowledged that the Board of Directors is responsible for ensuring that the Trust meets its obligation to perform its functions within the available financial resources. The CEO has overall executive responsibility for the Trust’s activities and is responsible to the Board of Directors for ensuring that its financial obligations and targets are met. Further, the CEO is recognised by Statute as the Accounting Officer of the Trust and as such can be called upon to report to Parliament for all actions undertaken by the Trust. Save for the requirements under Board of Directors powers, the CEO is provided with full operational powers to approve financial transactions within the Trust and to delegate such powers as per the Scheme of Delegation. Director of Finance The CEO delegates powers to the DOF in his/her role as a first line budget holder responsible for the Finance Directorate. In addition to these, the DOF is provided with further powers to manage the approval of financial transactions initiated by other directorates across the Trust, and other financial transactions on behalf of the Trust. The Board of Directors instruct that the DOF is required to implement the Trust’s financial policies, ensure that detailed financial procedures and systems are established, incorporating the principles of separation of duties and internal control to supplement these instructions, and ensure that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose the financial position of the Trust at any time. In relation to any officer who is involved in a financial or procurement process or function, the DOF shall set out the requirements, the manner in which the officer discharges his/her duties and the form in which financial records are kept. All finance and procurement processes must be to the standard and satisfaction of the DOF.

In addition to these, the DOF is provided with further powers to control the approval of financial transactions relating to the Trust capital programmes, in accordance with the Schemes of Delegation.



Corporate Responsibilities of all Trust employees and staff The SFIs set out specific Trust policies and procedures across a number of areas and all officers must comply with these requirements in all cases. Where exceptions are deemed necessary, prior approval from the DOF must be obtained, as set out in the SFIs It is not possible to govern all the financial affairs of the entire Trust through a single set of instructions. Therefore, these Instructions make reference in a number of areas where it is considered appropriate for the CEO or the DOF to develop, on behalf of the Trust, a series of detailed policies, procedures and processes, which are not included in these Instructions. In such cases it is the responsibility of all employees of the Trust to ensure they understand fully the existence, contents and requirements of all such policies and procedures and to comply with them on the basis that they have received full authority from the Board of Directors. Guidance on the existence and relevance of policies and procedures to specific situations is available on the Trusts internal website or is available from the CEO, the DOF or the Deputy DOF. If you are unsure as to the most appropriate course of action in a particular situation then consult one of these sources, especially so if you are about to make a financial commitment on behalf of the Trust, because breach of these requirements will be regarded as a disciplinary offence.

You must comply with principles of Public Sector Values You should be committed to the highest standards of corporate and personal conduct in all aspects of their work within the Trust, based on recognition of public service values. There are three crucial public service values which must be understood and accepted by everyone working in the Trust:

Accountability - everything done by those who work in the Trust must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct. Probity - there is a requirement for an absolute standard of honesty in dealing with the income, assets and financial interests of the Trust. Integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of Trust duties. Openness - there must be sufficient transparency about Trust activities to promote confidence between the Trust and its staff, patients and the public. All staff must disclose possible conflicts of interest.



You have a duty of stewardship Proper stewardship requires value for money to be high on the agenda of the Board of Directors and all officers, so

You must - Safeguard the Trust’s financial resources.

Financial resources may take the obvious tangible form of fixed assets, income and cash as well as others that are less clear, such as lost or foregone income through failure to notify income sources or lost opportunities to earn or recover income due to the Trust.

- Conduct Trust business as efficiently, effectively and economically as possible.

- Comply with the Trust’s policies and processes covering all aspects of money, assets and other Trust resources.

- Avoid unauthorised acts that may result in may result in the Trust incurring liabilities (directly or indirectly) or which may diminish the value of any of the Trust’s assets (including the Trust’s brand or reputation).

- Report all new income sources immediately to the DOF.

- report damage to or losses of the Trust’s premises, assets, supplies or other resources must be reported to the DOF immediately in accordance with procedures of Losses and Special Payments

- Inform either the DOF or the Local Counter Fraud Officer if you discover or suspect a loss that you think may be fraud. You should fully understand the Trust’s Human Resources and Local Counter Fraud Policy (CG155)

- Send all signed copies of contracts (however described) are lodged with Procurement within one month of formal approval.

- Only order goods and services through the Trust’s Approved Procurement Systems (unless authorised in writing by the DOF to do otherwise).

- Upon delivery of goods or services immediately record the receipt on the relevant Trust Approved Procurement System.

- Quote a valid Trust PO number to suppliers when placing an order for goods or services.

- comply with the Trust’s Guidance on Hospitality, Gifts & Commercial Sponsorship

You must not - Incur expenditure for which there is not an

approved budget, unless authorised to do so by the DOF, CEO, or Board of Directors, as appropriate.

- Use a budget for a purpose other than that for which it was provided, unless authorised to do so by the DOF, or CEO, as appropriate.

- Approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers.

- Order any goods or services, including agency staff, other than by using one of the Trust Approved Procurement Systems, unless previously authorised to do so by the DOF.

- Order goods or services directly from suppliers. Procurement will negotiate contracts which will provide catalogues of goods and services, from which orders may be raised. These instructions provide clear guidance on purchasing and contract tendering and these must be followed. In exceptional circumstances, where senior officers of the Trust wish to operate direct ordering procedures, the approval of the CEO and DOF must be obtained.



Compliance with rules of delegated powers of authority The Board of Directors has absolute authority for the conduct of the financial affairs of the Trust, but has established a system of delegated powers to enable appropriate officers of the Trust to manage the day to day activities. This system of delegated powers is referred to throughout these Instructions as the Scheme of Delegation. The high level Scheme of Delegation is included as Appendix A to these Instructions. The detailed scheme of delegation, including lower level authorities, must be approved by the DOF and a full register will be maintained by the DOF.

The principles of the Scheme of Delegation

• Approval limits will be determined based on an assessment of need in each specific area. • An Officer who is not Staff cannot hold responsibility for approvals unless pre-authorised by the

DOF • All delegated powers must remain within the limits set out in Scheme of Delegation. • An officer must not approve a transaction outside their written delegated power. • A power is delegated on condition that it cannot be further delegated at that same level of

power, except in cases of temporary holiday cover, when it can be delegated to another officer who already holds delegated power at that level. Delegation over and above this must be requested in writing in advance to the DOF.

• Only the DOF may delegate powers to officers outside of his/her direct control. • All proposed powers, or variation to powers, of delegation, other than temporary holiday cover,

must be provided in writing and duly authorised by the DOF. • Officers with delegated authority on iproc must set up in advance a vacation rule for period they

will be absent from the office • Applications for other short term powers must be requested in writing by the delegating officer,

and approved by the Director of Finance prior to the period for which approval is sought. • Only the CEO and DOF are authorised to sign and authorise extensions to supplier contracts. • Where a member of the Board of Directors is through incapacity unable to utilise their authority

or appropriate delegation, the CEO and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

• If the CEO is incapacitated the Chairman and DOF will implement an interim arrangement until the next available Board Meeting. At that meeting a formal arrangement will be agreed.

The DOF may reject any delegation of powers if in his opinion, there is a financial risk to the organisation or it may result in a reduction of financial control or it may affect the Trust reputation with respect to counter-fraud.

Failure to comply with these principles, or a material breach thereof, will be recognised as a disciplinary offence. Where such a breach results in clear financial loss, the employee may be personally liable to compensate the Trust.



Responsibilities of the Chief Executive

Annual Plan The CEO, with the assistance of the Commercial Director and DOF, shall compile and submit to the Board of Directors strategic plans and operational plans as required by the Board of Directors and which meet the requirements of the Independent Regulator (as described in Monitors published Guidance, Directions and Risk Assessment Framework). The operational plan shall be reconcilable with the annual submission of Monitor’s Operational, Strategic and Financial proforma in its Annual Plan Review The CEO shall require the DOF to report to the Board of Directors any significant in-year variance from the budget and to advise the Board of Directors on action to be taken. The DOF shall also be required to compile and submit to the Board of Directors, any and all such financial estimates and forecasts, of both revenue and capital nature as may be required from time to time. As a consequence, the DOF shall have full and complete right of access to all budget holders on financial related matters. All Officers shall provide the DOF with all financial, statistical and other relevant information as necessary for the compilation of such budgets, estimates and forecasts, in accordance with the timetable required by the DOF.

Budgets The DOF shall, on behalf of the CEO, and in advance of the financial year to which they refer, prepare and submit all revenue and capital budgets within the forecast limits of available resources and planning policies to the Board of Directors for its approval. The CEO shall require the DOF to devise and maintain systems of budgetary control. All officers shall comply with the requirements of those systems. The systems of budgetary control shall incorporate the reporting of, and investigation into, financial, activity or workforce variances from budget. The DOF shall be responsible for providing budgetary information and advice to enable the CEO and other officers to carry out their budgetary responsibilities.

The CEO may delegate management of a budget or part of a budget to officers to permit the performance of defined activities. The Scheme of Delegation shall include a clear definition of individual and group responsibilities for control of expenditure, exercise of virement, achievement



of planned levels of services and the provision of regular reports upon the discharge of those delegated functions to the CEO. In carrying out their duties no officers shall exceed the budgetary limits set them by the CEO.

Except where otherwise approved by the CEO, taking account of advice of the DOF, budgets shall be used only for the purpose for which they were provided and any budgeted funds not required for their designated purpose shall revert to the immediate control of the Trust. Expenditure for which no provision has been made in an approved budget and which is not subject to funding under the delegated powers of virement shall only be incurred after authorisation by the CEO and DOF or the Board of Directors as appropriate. The DOF shall keep the CEO and the Board of Directors informed of the financial consequences of changes in policy, pay awards and other events and trends affecting budgets and shall advise on the financial and economic aspects of future plans and projects. Any in year changes to budgets must be approved in advance by the DOF, or by the Deputy DOF or a Care Group DOF, as set out separately in the delegation of authority for budget virements. Contracts for the provision of Healthcare Services The Board of Directors will approve standard terms and conditions for legally binding contracts, on the basis of which the Trust will provide healthcare services. Any variations to the standard terms and conditions will be approved in accordance with the Scheme of Delegation. The CEO is responsible for negotiating contracts for the provision of services to patients in accordance with the budget. In carrying out these functions, the CEO should take into account the advice of the DOF regarding costing and pricing of services, and both the Commercial Director and Finance Director on matters relating to payment terms and conditions of service agreements. Contracts should be so devised as to achieve activity and performance targets, minimise risk, and to maximise the Trust's opportunity to generate income. The Trust will produce a reference cost tariff in accordance with NHS guidelines. The Trust will comply with the Department of Health Guidance on setting prices for the provision of NHS healthcare (i.e. Payment by Results Guidance) as far as this allows. Other prices and tariffs must be approved by the DOF with advice from the Commercial Director.

The DOF shall ensure that a summary of the Trust’s contract income is reported annually to the Board of Directors. The DOF shall also produce regular reports detailing actual and forecast contract income with a detailed assessment of the impact of the variable elements of income.



Any pricing of contracts at marginal cost should be undertaken by the DOF in accordance with a policy and tariff reported to the Board of Directors. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Capital Expenditure The CEO is ultimately responsible for all capital expenditure of the Trust, including expenditure on assets under construction. To discharge this duty, the CEO will arrange for the issue of a Scheme of Delegation for approval of capital commitments, and will arrange for the development of detailed policies and procedures covering all aspects of capital investment management, including scheme appraisals, contract awarding, contract management and financial control. The CEO shall provide executive delegation to the DOF to control programmes for capital expenditure, including assets under construction, within the restrictions of Scheme of Delegation. All expenditure on capital assets will be authorised in line with Scheme of Delegation. Any commitment in excess of the limits currently specified shall be referred to the Chief Executive and the Board of Directors respectively for approval before such commitment is made. Tendering and Contracting The CEO has overall responsibility to ensure that the Trust applies the principles of Value for Money in the procurement of goods, services and capital programmes. The CEO shall liaise with the DOF to develop processes and procedures for competitive selection in all procurement exercises. The CEO shall ensure that these procedures are open and clearly demonstrate fair and adequate competition. In particular, the processes and procedures will incorporate NHS and Trust requirements for disclosure of any commercial sponsorship or inducements offered by or received from actual or potential suppliers to the Trust. The CEO shall establish procedures in accordance with the Public Contract Regulations 2015 to ensure compliance regarding the issuing, receipt and covering the receipt, safe custody and formal opening of tenders received and appropriate records to be maintenance ained in connection with the full tender exercises. All cCopies of all signed contracts will be retained by Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval.



Risk Management and Insurance The CEO shall ensure that the Trust has a programme of risk management which will be approved and monitored by the Board of Directors, by using the Trust Assurance Framework. The programme of risk management shall include:

a) processes for identifying and quantifying risks and potential liabilities; b) engendering among all levels of staff a positive attitude towards the control of risk; c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk; d) contingency plans to offset the impact of adverse events; e) audit arrangements including external audit, internal audit, clinical audit and health & safety review; f) arrangements to review the risk management programme. The existence, integration and evaluation of the above elements will provide a basis to make statements on the effectiveness of internal control within the Annual Report and Accounts as required by current guidance. The DOF shall ensure that appropriate insurance arrangements exist to mitigate the risks of the Trust across all areas, and that documented procedures cover these arrangements. Retention of Documents The CEO shall be responsible for maintaining archives for all documents required to be retained under the direction contained in HSC1999/053. A summary of the retention periods for key documents and records will be produced. A copy of the document will be available to all members of staff. The documents held in archives shall be capable of retrieval by authorised persons. Documents held under HSC1999/053 shall only be destroyed at the express instigation of the CEO; records shall be maintained of documents so destroyed. The DOF shall provide advice on the retention of financial records. Detailed policies covering money, assets and other Trust resources The CEO, in consultation with the DOF will develop, maintain and monitor detailed policies, procedures and instructions covering all aspects of the security of money, assets and other Trust resources



Patients’ Property The Trust has a responsibility to provide safe custody for money and other personal property handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival. The CEO shall be responsible for ensuring patients or their guardians, as appropriate, are informed before or at admission that the Trust will not accept responsibility or liability for patients’ property brought into the Trust premises, unless it is handed in for safe custody and a copy of an official patients’ property record is obtained as a receipt. The CEO shall require the DOF, in conjunction with the Care Group Directors, to provide detailed written instructions on the collection, custody, investment, recording, safekeeping and disposal of patients’ property for all staff whose duty it is to administer the property of patients. Hospitality The CEO shall be responsible for maintaining comprehensive records of all offers of hospitality, both accepted and rejected. The record shall be in a form designed by the DOF and completed records shall be available for inspection by the designated auditors or DOF, at all reasonable times.



Responsibilities of the Director of Finance General The DOF shall prepare, document and maintain detailed financial policies, procedures, processes and systems incorporating the principles of separation of duties and internal control to supplement these Instructions. The DOF shall require in relation to any officer who carries out a financial process, that the form in which the records are kept and the manner in which the officer discharges his/her duties shall be to the satisfaction of the DOF. The DOF shall ensure appropriate arrangements are in place to pay and recover tax, and shall be responsible for seeking professional advice in this regard, as necessary. Income The DOF is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and income coding of all monies due. The DOF is also responsible for ensuring the prompt banking of all monies received. The DOF is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary. All employees must inform the DOF promptly of any and all money due arising from transactions which they deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions. The DOF is responsible for the appropriate recovery action on all outstanding debts. Income not received should be dealt with in accordance with losses procedures. Overpayments should be detected (or preferably prevented) and recovery initiated. The DOF is responsible for approving the form of all receipt documents, agreement forms, or other means of officially acknowledging or recording monies received or receivable. The DOF is responsible for the provision of adequate facilities and systems for officers, whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys and for coin operated machines. The DOF is responsible for proscribing systems and procedures for handling cash and negotiable securities on behalf of the Trust. Official money shall not under any circumstances be used for the



encashment of private cheques. All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the DOF.

The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss. No contract relating to the provision of Private Patient treatment should be signed without confirmation being provided to the DOF that the contract will not be actioned to the detriment of NHS patients. Annual Accounts and Reports The DOF, on behalf of the Trust, will prepare financial returns in accordance with the guidance given by the Independent Regulator and the Treasury, the Trust’s accounting policies, and International Financial Reporting Standards. The DOF, on behalf of the Trust, will prepare and certify Annual Report and Accounts, and submit them and any report of the auditor on them, for laying before Parliament. Following this, copies of the documents must be sent to the Independent Regulator. The Trust’s Annual Report and Accounts must be audited by an auditor approved by the Council of Governors in accordance with the appointment process agreed by the Trust. The Trust will publish an Annual Report and Accounts, in accordance with guidelines on local accountability, and present it at a public meeting. The document will include inter alia, the Audited Annual Accounts of the Trust. The Annual Report and Accounts will be sent to the Independent Regulator. Bank and GBS Accounts including charitable funds The DOF is responsible for managing the Trust’s banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance and directions issued from time to time by the Independent Regulator. The Board of Directors shall approve the banking arrangements. The DOF is responsible for all bank accounts and Government Banking Service (GBS) accounts. The DOF is responsible for ensuring payments made from bank or GBS accounts do not exceed the amount credited to the account except where arrangements have been made. Further he must report to the Board of Directors all arrangements made with the Trust’s bankers for accounts to be overdrawn.



The DOF has sole authority to open, operate and close accounts with banks, Building Societies and the Government Banking Service where Trust funds are received or expended. It shall be a disciplinary offence for any officer of the Trust outside the organisational control of the DOF to operate any such account. The DOF will report to the Audit and Risk Committee of any changes to the Trust bank accounts including the opening / closing of accounts and changes in signatory panel. The DOF will prepare detailed instructions on the operation of bank and GBS accounts which must include the conditions under which each bank and GBS account is to be operated, the limit to be applied to any overdraft, and those authorised to sign cheques or other orders drawn on the Trust's accounts. The DOF will advise the Trust’s bankers in writing of the conditions under which each account will be operated. The DOF will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business. Competitive tenders should be considered at least every 5 years. The results of the tendering exercise should be reported to the Board of Directors. The Audit and Risk Committee will review this on behalf of the Board of Directors. Where officers of the Trust wish to manage non-exchequer Trust funds such as ward funds or funds from donated sources, they are required to operate under the control of the Trust Charitable Funds who will operate the accounts on their behalf. All funds donated must be passed to Finance and only banked in the Trust Charitable Funds. No donations shall be passed to another charitable fund. It is not appropriate for any officer of the Trust to hold any such account in their own names as it creates a lack of openness in the handling of such funds and may allow that officer’s integrity to be called into question. The only exception to the above will be where the DOF has expressly issued written authorisation to officers to maintain accounts which have been deemed acceptable, such as accounts for social or sports clubs. The DOF will maintain a register of such accounts, and the details will be reported annually to the Audit and Risk Committee. Cash Management and Investments The DOF will produce cash management, treasury management and investment policy (Treasury Policy - CG401), in accordance with guidance received from the Independent Regulator, for approval by the Board of Directors. The investment may include investment by forming, or participating in forming, bodies corporate, and/or otherwise acquiring membership of bodies corporate.



The Treasury policy (CG401) will set out the DOF’s responsibilities for advising the Board of Directors on investments and reporting periodically to the Board of Directors concerning the performance of investments held. The DOF will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained. External Borrowing and Public Dividend Capital The DOF will advise the Board of Directors concerning the Trust's ability to pay interest on, and repay the Public Dividend Capital and any proposed commercial borrowing, within the limits set by the Foundation Trust’s authorisation. The DOF will authorise and is also responsible for reporting periodically to the Board of Directors concerning the Public Dividend Capital and all loans and overdrafts. Any application for a loan or overdraft will only be made by the DOF or by an employee acting on his/ her behalf, and in accordance with the Scheme of Delegation, as appropriate. The DOF will prepare detailed procedural instructions concerning applications for loans and overdrafts. All short-term borrowings should be kept to the minimum period of time possible, consistent with the overall cash flow position. Any short term borrowing requirement in excess of one month must be authorised by the DOF. All long-term borrowing must be consistent with the plans outlined in the current budget. Capital Expenditure The DOF shall be responsible for preparing detailed procedural guides for the financial management and control of expenditure on capital assets, including the maintenance of an asset register in accordance with the minimum data set as specified in the Capital Accounting Manual. The DOF shall implement procedures to comply with guidance on valuation contained within the Capital Accounting Manual, depreciation and revaluation. The DOF shall establish procedures covering the identification and recording of capital additions. The financial cost of capital additions, including expenditure on assets under construction, must be clearly identified to the appropriate budget holder and be validated by reference to appropriate supporting documentation. The DOF shall also develop procedures covering the physical verification of assets on a periodic basis. The DOF shall develop policies and procedures for the management and documentation of asset disposals, whether by sale, part exchange, scrap, theft or other loss. Such procedures shall include



the rules on evidence and supporting documentation, the application of sales proceeds and the amendment of financial records including the asset register. All capital schemes will be subject to the procedures as set out in the Capital Investment Manual, Concode and Concise guidelines governing control of capital programmes in the NHS (available on the Department of Health website) , together with approved local guidelines. Where appropriate, alternative measures of control deemed appropriate may be adopted by the Trust on the advice of the DOF, following discussion with the CEO. Where material these will be brought to the attention of the Board of Directors. Payment of Staff The DOF shall make arrangements for the provision of payroll services to the Trust, to ensure the accurate determination of pay entitlement and to enable prompt and accurate payment to employees.

The DOF shall be responsible for establishing procedures covering advice to managers on the prompt and accurate submission of payroll data to support the determination of pay including, where appropriate, timetables and specifications for submission of properly authorised notification of new employees, amendments to standing pay data and terminations. The DOF will issue detailed procedures covering payments to staff including rules on handling and security of bank credit payments. Tendering and Contracting for Goods and Services The instructions in this section concern purchasing decisions for goods and services required where the Trust needs to enter into formal tendering and contractual arrangements. All purchasing must be undertaken through one of the Trust Approved Purchasing Systems, unless explicit approval to alternative arrangements have been agreed in advance by the DOF. The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account legal requirements to comply with European Community and GATT rules on public procurement. These shall be set out within Schemes of Delegation (See Table 2). The DOF shall be responsible for establishing appropriate procedures to ensure that competitive tenders are invited for the supply of goods and services under contractual arrangements wherever possible. These shall include the procedures to be followed in the event of competitive tendering of in-house services. In such circumstances it must be ensured that no member of the in-house tender group may participate in the evaluation of the tender.



The DOF shall maintain lists of firms from whom the Trust may invite tenders and quotations. These lists shall be kept under frequent review and shall include all firms who have applied for permission to tender. The Trust will undertake appropriate compliance vetting of suppliers invited to supply goods and services to the Trust. In addition Aall firms will be assessed by Finance on their technical and financial competences. In this regard, the DOF shall be responsible for establishing procedures to carry out financial appraisals, and shall instruct the appropriate requisitioning directorate to provide evidence of technical competence. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, only after receipt of evidence as to their technical and financial competence will a contractor be invited to tender and be selected for inclusion on the list. The DOF shall be consulted as regards financial competence and a suitable officer within the Finance Directorate who will provide advice on financial status and recommended contract limits. Where there are no, or insufficient, contractors listed which are suitable to be invited to tender for a particular contract, any contractor invited to tender shall only be selected for invitation after receipt of evidence as to its technical and financial competence and inclusion on the approved list. All contract negotiations must be undertaken with the involvement of a member of the Procurement Team. All employees must demonstrate effective and efficient use of resources in awarding contracts, ideally through the use of competitive selection. Where by exception it is considered competitive selection to be inappropriate, undesirable or not possible, approval for single quote exercises in accordance with financial limits set out under the Scheme of Delegation may be requested in writing to the DOF. These powers are provided by the CEO and it is expected that they shall be exercised in exceptional cases only. The DOF shall advise the Board of Directors of circumstances where it would be appropriate for goods or services to be obtained under contract from sources that have not been subject to competitive selection. The outcome of the waiver process will be monitored by the Audit and Risk Committee on behalf of the Board of Directors.

The grounds where such single quote actions may be authorised are as follows, although approval is not to be regarded as automatic and each case shall be treated on its own merit:

• Where the requirement is ordered under existing contracts which themselves were sourced under competitive selection.

• Where the estimated expenditure or income would not warrant formal tendering procedures or competition would not be practicable taking into account all the circumstances. The limits for such single quote exemptions are set out in Schemes of Delegation.

• Where in the opinion of the Director of Finance, or the Chief Executive if in excess of financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter into open competitive selection procedures. This may include procurement exercises where time is a critical factor in the interest of the Trust.



• For the supply of proprietary goods or services for which it is not possible or desirable to obtain competitive quotations.

• Where in the opinion of the Director of Finance, or the Chief Executive, according to the financial limits set out in Schemes of Delegation, it is considered against the interest of the Trust to enter into open competitive selection procedures. This may include procurement exercises where in the opinion of the Director of Finance time is a critical factor in the interest of the Trust.

• Separate authorisation arrangements, as set out in the Scheme of Delegation, shall apply to maintenance or other contracts for existing goods or assets where the Trust is contractually tied to specific companies. Details of such contracts shall be recorded in a register by Procurement.

• The extent to which relevant officers can exercise these powers is set out in the Scheme of Delegation. All officers of the Trust must be aware that single quote actions are to be the exception to the preferred procedures of competitive selection, and in all cases they must be able to fully explain their rationale before a decision is authorised. Records shall be maintained to enable the use of single quote and other non-competitive actions to be monitored and reported upon to the Audit and Risk Committee at least annually.

• Where an approved waiver or Voluntary Ex-Ante Transparency notice (VEAT notice ) is in place.

In all cases the DOF shall keep appropriate records of single quote actions including a full justification of the reasons why competitive selection procedures were not adopted. The CEO shall require the DOF to monitor the use of single quote actions in the awarding of contracts and to report to the Audit and Risk Committee on the extent of the use of single quote and other non-competitive actions. Procurement and Purchasing The DOF shall advise the Board of Directors regarding the setting of thresholds above which quotations or formal tenders must be obtained. This will take into account the obligation on the Trust to comply with the European Union Procurement Directives, the Public Contract Regulations 201506 (as amended from time to time) and the GATT rules on public procurement. These shall be set out within the Scheme of Delegation. The DOF shall prepare procedural instructions on the obtaining of goods, services and works, incorporating the thresholds set by the Trust. The DOF shall determine that no goods, services or works, other than works and services executed in accordance with a contract and purchases from petty cash, shall be ordered except on an official order, raised following receipt by the ordering officer of a properly authorised requisition, and suppliers/contractors shall be notified that they should not accept orders unless on an official form. Official orders shall be consecutively numbered, in a form approved by the DOF and shall include such information concerning prices or costs as may be required. The order shall incorporate an



obligation on the contractor to comply with the conditions thereon as regards delivery, carriage, documentation, variations, etc. Order requisitions shall only be issued to and approved by officers so authorised by the Scheme of Delegation. Lists of authorised officers shall be maintained by the DOF.

The DOF shall ensure that no order shall be issued for any item or items for which there is no budget provision, unless authorised by the DOF on behalf of the CEO. Goods and services for which Trust contracts are in place should be purchased within those contracts. Any purchasing request outside of such contracts must be referred in the first instance to the Head of Procurement for approval. All copies of signed contracts will be retained by the Head of Procurement and registered on the Trust contract register. It is essential all staff ensure signed copies of all contracts (however described) are lodged with Procurement within 1 month of formal approval. Payment of Suppliers The DOF shall be responsible for the proper payment of all supplier invoices and claims. The DOF shall establish and communicate procedures to ensure that all officers provide prompt notification of all money payable by the Trust arising from transactions which they initiate, including contracts, leases, tenancy agreements and other transactions. The DOF shall establish detailed procedures covering the approval of invoices for payment. The DOF shall develop procedures for the prompt payment of invoices once verified for settlement. Such procedures will include the taking of settlement discounts where offered, and rules covering independent control and security of payment transactions. The DOF will implement procedures to retain approval of all payments made in advance of receipt of the related goods or services. Stores and stocks All stores and stocks maintained by the Trust in wards, clinics or main stores must comply with the systems of control designated and approved by the DOF. Overall responsibility for the control of stores and stocks shall be delegated to the DOF by the CEO. The day-to-day responsibility may be delegated to departmental employees and stores managers/ keepers, subject to such delegation being entered in a record available to the DOF. The DOF shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses. All employees with day-to-day responsibility for stores must maintain such records to enable the value of the stockholding to be ascertained at



any time. The DOF will ensure adequate physical stocktaking arrangements exist and there shall be a physical check covering all items in store at least once a year to confirm the value of the stockholdings with the system records. Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the DOF. All employees with day-to-day responsibility for stores shall ensure systems are in place to minimise any losses from obsolete, slow moving or unserviceable items. The DOF shall ensure a system is in place to review stockholdings for slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. All employees shall report to the DOF any evidence of significant overstocking and of any negligence or malpractice. Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods. All write offs must be approved by the DOF and reported to the Audit and Risk Committee at least annually. All managers must order and requisition all goods and services through the Trust’s Oracle i-Procurement System or such other systems as specified by the DOF. The only exception to this instruction is where managers have the express written permission from the DOF to do otherwise. As a part of this process managers are required to ensure the accurate and timely recording of the receipt of goods and services on the relevant approved Procurement System. Financial Systems The DOF shall be responsible for the accuracy and security of the computerised financial data of the Trust. This supplements the responsibility of the Director of Corporate affairs for Information Governance across the Trust in respect of non-financial data. In terms of the Trust’s financial systems, the DOF shall ensure that:

• Appropriate controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system.

• Adequate controls exist such that the computer operation is separated from development, maintenance and amendment.

• An adequate management (audit) trail exists through the computerised system and that such computer audit reviews as he/she may consider necessary are being carried out.

The DOF shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation. The DOF shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the



security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes. Where another health organisation or any other agency provides a computer service for financial applications, the DOF shall periodically seek assurances that adequate controls are in operation.

The DOF shall satisfy himself / herself with regard to any computer systems which have an impact on corporate financial systems that:

• data produced for use with financial systems is adequate, accurate, complete, timely ,and appropriate for the requirements of the operation of the Trust financial systems;

• all systems are closed down with adequate cut off processes at each month end; • all processes occur in line with the Trust financial month end timetable • a management (audit) trail exists; • Finance staff have open and complete access to such data; and • such computer audit reviews as are considered necessary are being carried out. Audit The Board of Directors shall establish an Audit and Risk Committee which will provide an independent and objective view of internal control by examining Internal and External Audit reports, reviewing financial systems, ensuring compliance with Standing Financial Instructions and reviewing schedules of losses and compensations and making recommendations to the Board of Directors. Where the Audit and Risk Committee feel there is evidence of ultra-vires transactions, or of improper acts, or if there are other important matters that the Committee wish to raise, the chairman of the Committee should raise the matter at a full meeting of the Board of Directors. Exceptionally, the matter may need to be referred to the Independent Regulator. It is the responsibility of the DOF to ensure an adequate internal audit service is provided and the Audit and Risk Committee shall be involved in the selection process when an internal audit service provider is changed. In line with their responsibilities as set out in HSG(96)12, the CEO and DOF shall monitor and ensure compliance with Secretary of State Directions on fraud and corruption. The Trust shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist as specified by the NHS fraud and corruption manual and guidance. The Local Counter Fraud Specialist shall report to the DOF. The DOF is responsible for:



• ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control by the establishment of an internal audit function;

• ensuring that the internal audit is adequate and meets the NHS mandatory audit standards; • deciding at what stage to involve the police in cases of misappropriation and other irregularities

(subject to earlier sections of these Instructions); • Ensuring that an annual audit report is prepared for the consideration of the Audit and Risk

Committee and the Board of Directors. The report must cover: o progress against plan over the previous year, o major internal financial control weaknesses discovered, o progress on the implementation of internal audit recommendations, o strategic audit plan covering the coming three years, o a detailed audit plan for the coming year.

The DOF or designated auditors are entitled without necessarily giving prior notice to require and receive:

• access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

• access at all reasonable times to any land, premises or employee of the Trust; • the production of any information, cash, stores or other property of the Trust under an

employee's control; and • Explanations concerning any matter under investigation. Any lack of co-operation in these matters, by any member of staff, will be considered a disciplinary matter and may result in dismissal. Whenever any matter arises which involves, or is thought to involve, irregularities concerning Information, cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature; the DOF must be notified immediately.

The Head of Internal Audit will normally attend Audit and Risk Committee meetings and has a right of access to all Audit and Risk Committee Members, the Chairman and CEO of the Trust. Staff Expenses The DOF shall be responsible for establishing procedures for the management of expense claims submitted by Trust employees. The DOF shall arrange for duly approved expense claims to be processed through the Trust payroll system, unless separately approved by the DOF or the Deputy Director of Finance (ensuring appropriate entries are made to the relevant cost centre. Expense claims shall be authorised in accordance with the Scheme of Delegation. The DOF shall refer to the Trust’s general policies on staff expenses and may reject expense claims where there are material breaches of Trust policies. In this regard the DOF shall liaise with the CEO where appropriate.



Fraud

The Board of Directors recognises that in extreme cases financial loss may be the result of fraud (i.e. intentional deception to secure unlawful gain) or corruption. While the Board of Directors has every confidence in the integrity of Trust employees, it has a duty to put in place controls to minimise the opportunity for illegal appropriation of Trust resources. Accordingly, the DOF shall ensure appropriate compliance with the Secretary of State’s Directions to NHS Trusts regarding counter-fraud measures, which are referred to in these instructions. The DOF will ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the DOF will notify the Board of Directors. The DOF will also ensure that procedures are in place that specify the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it. The Trust Human Resources and Local Counter Fraud Policy (CG155) will be updated regularly by the DOF. Losses and special payments The DOF will establish a procedure for Losses and Special Payments. Credit Finance arrangements including leasing commitments There are no grounds where any employee of the Trust can approve any contract or transaction which binds the Trust to credit finance commitments without the clear written prior authority of the DOF. This includes all Executive and Care Group Directors of the Trust and all other officers. The Board of Directors has provided the DOF with sole authority to enter into such commitments, although these powers can be delegated by him/her to appropriate officers under his/her organisational control. This instruction applies to potential or actual leasing agreements and Hire Purchase undertakings which must be sent to the DOF for prior approval. No officer of the Trust outside the organisational control of the DOF has any powers to approve such commitments. Failure to comply with this instruction shall be a prima facie breach of any officer’s contract of employment. Joint Finance Arrangements with Local Authorities Payments to and arrangements with local authorities made under the powers of the NHS Act 2012 shall comply with procedures laid down by the DOF which shall be in accordance with the Act.

Formatted: Centered



APPENDIX AA RESERVATION OF POWERS TO THE BOARD OF DIRECTORS AND DELEGATION OF POWERS INTRODUCTION The Code of Accountability for NHS Boards requires the Board of Directors to draw up a schedule of decisions reserved to itself and to ensure that management arrangements are in place to enable the clear delegation of its other responsibilities. This document therefore sets out the powers reserved to the Board of Directors and the Scheme of Delegation, together with tables of financial limits and approval thresholds. However, the Board of Directors remains accountable for all of its functions, including those which have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. All powers of the Trust which have not been retained as reserved by the Board of Directors or specifically delegated, shall be exercised on behalf of the Board of Directors by the CEO. The Scheme of Delegation identifies any functions which the CEO shall perform personally and those delegated to other directors or officers. All powers delegated by the CEO can be re-assumed by him/her should the need arise. The Scheme of Delegation shows only the ‘top level’ of delegation within the Trust. The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust. Table 2 indicates the tendering and contracting thresholds to be followed for all contracts for expenditure. POWERS RESERVED FOR THE BOARD OF DIRECTORS 1. General Enabling Provision 1.1 The Board of Directors may determine any matter it wishes in full session within its statutory

powers. 2. Regulation and Control 2.1 Approval, suspension, variation or amendment of Standing Orders, Standing Financial

Instructions, schedule of matters reserved to the Board of Directors, scheme of delegation of powers from the Board of Directors to officers, and other arrangements relating to standards of business conduct.

2.2 Specification of financial and performance reporting arrangements. 2.3 Approval of the Trust’s Treasury Policy (CG401) and authorisation of institutions with which

long term cash surpluses may be held.



2.4 Requiring and receiving the declaration of directors’ interests which may conflict with those of the Trust and determining the extent to which that director may remain involved with the matter under consideration.

3. Appointments Subject to the relevant section of the Foundation Trust Constitution: 3.1 The appointment and agreement of the terms of reference of Board Committees. 3.2 The appointment of Deputy Chairman. 3.3 Through its Remuneration Committee, appraisal, disciplining and dismissal of Board Directors. 3.4 Through its Nominations Committee, the appointment of Board Executive Directors. 3.5 The appointment of consultant medical and dental staff. Ratification of unanimous

recommendations of Appointment Committees is delegated to the CEO. 4. Policy Determination 4.1 The approval of management policies including personnel policies incorporating the

arrangements for the appointment, removal and remuneration of staff. 4.2 The approval of strategy, annual plans, strategic plans and annual budgets. 5. Direct Operational Decisions 5.1 The approval of the acquisition, disposal or change of use of land and / or buildings (subject to

the Independent Regulator’s approval in the case of property designated as ‘protected’ in the Foundation Trust authorisation).

5.2 The approval of transactions with a value in excess of that currently specified in the table of financial limits as requiring Board of Directors approval, and which are not covered by any specific delegated authority.

5.3 The final approval of action on litigation against or on behalf of the Trust. 5.4 The approval of loans with repayment periods in excess of one year. 6. Financial and Performance Reporting Arrangements 6.1 Continuous appraisal of the affairs of the Trust by means of the receipt of reports as it sees fit

from directors, committees and officers of the Trust. 6.2 Approval of the Trust’s Annual Report and Account, including the annual accounts, prior to

submission to the Council of Governors.

Standing Financial Instructions (CG101) – updated May 20154


TABLE 11: SCHEME OF DELEGATION OF POWERS FROM THE BOARD OF DIRECTORS TO OFFICERS OF THE TRUST 1.0 Capital & Asset Purchases (including

capital funded via lease finance or charitable grants)

Delegation Arrangements Additional Information

1.1 Approval of the overall Trust Capital Budget and any in-year variations

Board of Directors

1.2 Approval of overall budget allocation to individual capital projects and monitoring

Capital Investment Group (CEO, DoF, CGDs, MD, DoN, DoEF)

Monthly report to Board of Directors

1.3 Approval of individual capital projects within the overall Capital Budget (including approval of variations)

Up to £350,000 Between £350,000 - £700,000 Over £700,000

Director of Finance Chief Executive Officer Board of Directors

All asset leasing or financing arrangements (whatever value) must also be approved by the Director of Finance.

1.4 Management of individual capital projects Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.5 Management of assets under construction Allocated Capital Project Manager Project Monitoring by Capital Investment Group

1.6 Maintenance of Trust Asset register Director of Finance 1.7 Approval of Asset Disposals

Land & Buildings (any value) Other – where the asset has a residual value or there is a potential write off of value Other – where the asset has no residual value and there is no write off of value

Board of Directors Director of Finance Care Group Director after notification to the Head of Procurement

The Head of Procurement is responsible for ensuring the Trust receives best value from disposals and so must be notified of potential disposal where an asset may have any value. The Director of Finance must always be informed, by way of an Asset Disposal Form, of any asset disposals to enable the asset register to be updated. The Financial Controller must confirm on the Asset Disposal Form the residual book value of the asset.

1.8 Capital Budget Approval Process Director of Finance 2.0 Contracts for Expenditure Delegation Arrangements Additional Information 2.1 Financial appraisal of companies Director of Finance May be delegated to Head of Procurement

Formatted: Space After: 3 pt, Linespacing: Multiple 1.2 li



identified as potential tenderers 2.2 Maintenance of list of approved potential

suppliers Director of Finance Delegated to Heads of Procurement

2.3 Authorisation of less than the requisite number of quotes and/or tenders, including single tenders/quotes:

For individual contracts up to £350,000 For individual contracts between £350,000 and £700,000 For individual contracts over £700,000


Regular report to the Board of all recorded incidents of between £350,000 and £700,000

2.4 Monitoring the use of single tender/single quote action

Audit and Risk Committee on behalf of the Board of Directors

2.5 Receipt of Tenders Director of Finance 2.6 Opening of Tenders Any two from the list of trust Officers

authorised by the Director of Finance to open tenders”

As defined by Director of Finance, ensuring independence from Procurement Process

2.7 Permission to consider late tenders

Chief Executive With advice from Director of Finance

2.8 Tender ratification and award, including authorisation of any actions resulting from post tender clarification:

Up to £350,000 Between £350,000 and £700,000 Over £700,000


Post tender clarification will be led by Director of Finance or his delegate. Process overseen by Head of Procurement

2.9 Signing of Contracts (including letters of intent)

Chief Executive or Director of Finance All building/works projects above £500,000 should be sealed: Other contracts may be sealed if in the interest of the Trust

2.10 Approval of variation or extensions to the use of existing approved contract

After taking advice from the Head of Procurement

All Contract Variations Variations of over 5% where the revised contract value is between £350,000 and £700,000 Variations of over 5% where the revised contract value is over £700,000

Director of Finance and if above limits the CEO or Board Chief Executive Officer Board of Directors

2.11 Sealing of Documents Chairman ( or Deputy Chairman in the



absence of the Chairman) and one Executive Director of the Board

3.0 Contracts for Income Delegation Arrangements Additional Information 3.1 Approval of Healthcare Contracts Chief Executive or Director of Finance Following acceptance of commercial terms

by Director of Finance 3.2 Approval of all other income contracts

including research & development Chief Executive or Director of Finance This may be delegated to the Director of

Finance 3.3 Approval of variations to Acute healthcare

and all income contracts Chief Executive or Director of Finance

3.4 Authorisation of individual Credit Notes relating to healthcare contracts

Invoicing adjustment to “on-account” invoicing under NHS Standard Contract. Otherwise: E.g. if relating to a pricing discount or loss of potential income then: Up to £350,000 Between £350,000 and £700,000 Over £700,000

Director of Finance Director of Finance Chief Executive Officer Board of Directors

Authorisation of Credit Notes below £5,000 may be delegated by the Director of Finance

3.5 Approval and variation of all contracts for recharges of costs and income generation

Director of Finance Training income and Training recharges will be managed in accordance with a policy approved by the Director of HROD

4.0 Purchasing and Payments (excluding

Capital) of Budgeted Expenditure Delegation Arrangements Additional Information

4.1 Authorisation of Requisitions (limits include irrecoverable VAT)

NOTE: Delegated authority to commit the Trust is only available where the proposed expenditure is within budget. Written authority is required from the Director of Finance before incurring expenditure above the budgeted limit.

Heads of Corporate Departments, Care Group Directors and Care Group Directors of Finance have key responsibilities for monitoring budgets and ensuring budget holders are aware of this limitation on approvals.

The maximum delegated limits which may be varied downwards by the CEO or DOF are: Up to £5,000

Schemes of delegation within these limits

Expenditure of £5k and above to be certified as being within budget by the Care Group DOF or by the Deputy Director of Finance To be notified to the Audit and Risk



Up to £90,000 Up to £350,000 Up to £500,000 Above £500,000

may be determined by Care Group Directors, DoEF and Heads of Corporate Departments but such delegation must be approved by DoF before implementation. Executive Directors (including Care Group Directors) With restricted powers of delegation Director of Finance Chief Executive Board of Directors

Committee Specific arrangements for delegating authority for amounts below £20,000 but only if agreed by the DOF and where it can be demonstrated that financial control will not be compromised. To be notified to the Audit Committee

4.2 Authorisation of individual invoices due for payment where the approved order process has not been followed

Not Allowed All purchases should be made via Trust i-proc ordering system. Only in extenuating circumstances should such invoices be presented for authorisation to the DOF or the Deputy Director of Finance

4.3 Authorisation of petty cash payments Authorisation by line manager (must be budget manager or have delegated authority)

4.4 Authorisation of expenses claims Authorisation by line manager (must be budget manager or have delegated authority)

Only via Trust On-line System

4.5 Authorisation of time sheets Authorisation by line manager (must be budget manager or have delegated authority)

4.6 Authorisation of Agency expenditure Non ward and non clinic based agency staff: approval by any 2 of CEO, DOF, Director of Nursing, Director of Workforce and Organisational Development, Medical Director and Chief Operating Officer Ward and clinic based agency staff: ordered through NHS Professionals or iproc

4.7 Authorisation of Overtime and additional hours

Pre-Authorisation only via Trust On-line System

5.0 Staff appointments Delegation Arrangements Additional Information 5.1 Clinical appointments To be approved by any two of CEO, DOF,

Director of Nursing, Director of Workforce No appointment can be made unless it is within the budgeted establishment and the



and Organisational Development, Medical Director and Chief Operating Officer

appointment has followed the process as established by the Director of Workforce and Organisational Development

5.2

Non-clinical Appointments To be approved by any two of CEO, DOF, Director of Nursing, Director of Workforce and Organisational Development, Medical Director and Chief Operating Officer

No appointment can be made unless it is within the budgeted establishment and appointment has followed the process as established by the Director of Workforce and Organisational Development

6.0 Income and Debt write off Delegation Arrangements Additional Information 6.1 Invoicing Director of Finance All invoices to be raised by the Finance

Department 6.2 Requests for Invoicing to be raised Budget Managers may raise a request for

Finance to generate an invoice. For clarity no-one outside of Finance is authorised to raise an invoice.

All requests for invoicing should be passed to Finance.

6.3 Authorisation of discounts, credit notes (non healthcare income)

Director of Finance See under 3.4 for Credit Notes related to Healthcare income

6.4 Collection of Debts and use of Debt Collection agencies

Director of Finance

6.5 Authorisation of Individual Debt write off This delegation also applies to the effective write off through lack of invoicing for income to which the Trust is entitled. Whether it occurs through action, lack of action or the passing of time

Less than £5,000 Less than £100,000 Between £100,000 and £200,000 Over £200,000

Financial Controller or Deputy Director of Finance Director of Finance Chief Executive Board of Directors

To be reported to the Audit and Risk Committee.

7.0 Losses and Special Payments Delegation Arrangements Additional Information 7.1 Authorisation of Individual Losses and

Special Payments



Less than £100,000 Between £100,000 and £200,000 Over £200,000

Director of Finance Chief Executive Board of Directors

Up to £10,000 delegated to the Head of Legal Services for payments resulting from legal claims. To be reported to the Audit and Risk Committee

7.2 Authorisation of Clinical Negligence Payments

Director of Finance To be reported to the Audit and Risk Committee

7.3 Monitoring of losses and Special Payments

Audit and Risk Committee On behalf of the Board of Directors

7.4 Authorisation of early retirement, redundancy and all other termination payments to staff

Less than £100,000 Between £100,000 and £200,000 Above £200,000

Director of Finance Chief Executive Board of Directors

Only after advice from the Director of HR

8.0 Budgetary Control Delegation Arrangements Additional Information 8.1 Delegation of Budgets Chief Executive and Director of Finance 8.2 Request for Budget Virement Initiator and recipient Budget Manager To be approved by CGDoFs 8.3 Authorisation of Budget Virement Director of Finance This may be delegated by the DoF to the

Deputy Director of Finance or the CGDoFs 8.4 Overall Trust Budget and planning

process Director of Finance

9.0 Stores and stock controls Delegation Arrangements Additional Information 9.1 Management and Control Systems for

Stores and stocks Director of Finance Delegated to Head of Procurement.

Orders may be generated automatically based on agreed minimum and maximum stock quantities.

10.0 Bank Account and Payment Methods Delegation Arrangements Additional Information 10.1 Opening of Bank Accounts Director of Finance 10.2 Signing of cheques, BACS schedules and

PGO authorisation Director of Finance This may be delegated within the Finance

Department.



11.0 Bank Account and working Capital Facilities Fees and Charges Delegation Arrangements Additional Information

11.1 Approval of Fees and Charges Director of Finance 12.0 Standards of Business Conduct Delegation Arrangements Additional Information 12.1 Maintenance of register of interests and

secondary employments

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

12.2 Maintenance of gifts and hospitality registers

Board of Directors All other staff

Chief Executive Chief Executive

Maintained by the Director of Corporate Affairs

13.0 Insurances Delegation Arrangements Additional Information 13.1 Insurance arrangements Director of Finance

4.0 Fraud and irregularity Delegation Arrangements Additional Information 14.1 Counter Fraud and corruption work Director of Finance It is expected that Internal Audit would be

involved in any investigation. 14.2 Investigation of suspected cases of

irregularity not related to fraud or corruption

Director of Workforce and Organisational Development

15.0 Investments Delegation Arrangements Additional Information 15.1 Approval of Treasury Policy (CG401) Board of Directors After review by the Audit and Risk Committee 15.2 Investment Decisions Director of Finance

16.0 Borrowings Delegation Arrangements Additional Information 16.1 Approval of Loans and Loan Facilities,

(including working capital facilities) Board of Directors

16.2 Use of Loans and Loan Facilities as Director of Finance



approved by the Board of Directors 16.3 Use of Leasing and non-conventional

funding Director of Finance



TABLE 2 – TENDERING AND CONTRACTING THRESHOLDS

(a)

Up to £2,000

(b)

£2,001 - £5,000

(c)

£5,001 - £50,000

(d)

£50,001 – OJEC

Threshold (see column

g)

(e)

Over OJEC limit (See column g)

(f)

EC Journal Advertisement

(g)

Services & Supplies

Verbal quotation Single written quotation

3 written competitive quotations

3 formal tenders

Normally minimum of 5 tenders through OJEC

£93,896 and over* (£53,920 and over for small lots)*

Works Verbal quotation Single written quotation

3 written competitive quotations

3 formal tenders

Normally minimum of 5 tenders through OJEC

£3,611,395 and over (£674,000 and over for small lots)

• For tendering and contractual purposes, the Trust is a Governmental Procurement Authority (GPA) and the procurement thresholds shown for Services and Supplies are those for GPAs

• Even where estimated amounts are below the OJEC thresholds, quotes and tenders are to be conducted within the spirit of OJEC Tenders in terms of definitions of outputs required from the goods or services, pre-defined evaluation criteria should be defined with evaluation and awards conducted in a transparent and equitable manner capable of withstanding audit and challenge by unsuccessful suppliers

• For all levels the figures shown are those for the aggregate of the requirement. Artificial subdivision of lots into smaller lots to stay below thresholds is unacceptable for non-OJECT tenders and unlawful for OJEC ones.

• Where requirements are for a combination of supplies / services and works, the estimated value of the majority value within the total determines which procedure and, thereby, which threshold to apply

Formatted Table

Feb 2014 Revision - Version 4.0 Page 38 of 38


Certification. I xxxxxxxxxxxxxxxxxxxxxx ___________________ certify that I have read, understood and will comply with the Standing Financial Instructions dated xxxxxxxxx._________________ Signature: _______________________________________ Date: ___________________________________________

Title: Board Committee Review Agenda item no: 13 Meeting: Board of Directors Date: 28 May 2015 Presented by: Janet Rutherford, Acting Chair Prepared by: Caroline Lynch, Interim Trust Secretary Purpose of the Report To set out a proposal in respect of the Operational Performance &

Finance Committee and explain how its functions will be discharged.

Report History N/A






Failure to maintain and improve quality of care. Failure to maintain standards required to maintain licence to operate Failure to develop the organisation to support the delivery of the Trust’s

vision

Strategic objectives. This report impacts on (tick all that apply):: Deliver the Trust’s strategic ambitions and intentions. Quality care and operational excellence Achieve and maintain financial sustainability A highly skilled and flexible workforce, demonstrating leadership at all levels Growing partnerships and collaborative working relationships based on trust. Maintain a fit for purpose estates infrastructure and IM&T systems









The proposed changes will improve escalation of performance management issues to Board and ensure the Board receives timely information to support effective decision making. Publication Published on website Confidentiality (FoI): Private Public [Insert as applicable the FoI exemption basis] N/A

1 Background

1.1 The Board evaluation undertaken by Deloittes in 2013 recommended that a review of the Board Committee structure be undertaken as operational performance was not considered by a specific Board committee.

1.2 A review was undertaken during 2014 and a revised structure, which included the establishment of an Operational Performance & Finance Committee, was approved by the Board in December 2014.

1.3 This Committee has now met on four occasions. Meetings are held on the same day as the Board and the Committee reviews financial and operational performance in detail.

1.4 The Board provides considerable oversight and scrutiny of operational performance and finance at its monthly meetings. The Board has found that its discussions are a repeat from the earlier discussions at the Operational Performance and Finance Committee.

1.4 As a result, the Board recommended that the effectiveness of the Operational Performance & Finance Committee should be reviewed and discussions have been held between the Chair of the Resources Committee and the Chief Executive.

1.5 It is proposed that the Operational Performance & Finance Committee is disbanded and the remit of the Resources Committee expanded to incorporate review of financial performance and key performance where required. Should further in depth scrutiny be required task and finish groups could be established on a time limited basis. In addition, any specific performance risks would be escalated by the Chairs of Resources Committee or Clinical Governance Committee to Audit and Risk Committee for detailed review.

1.7 The remit of the Resources Committee currently covers workforce, IT, estates, business cases and oversight of contract negotiation. The terms of reference for the Resources Committee are attached. It is proposed that the duties of this Committee are expanded to review financial performance and the Chief Operating Officer is added to the membership of the Committee. This would enable a more in-depth discussion of issues of concern to the Board and/or the Executive. As a result the Committee will be renamed as the Finance & Resources Committee.

1.8 Consideration may need to be given to the timing of the dates of the Finance & Resources Committee as it has proved a challenge in the past for the Committee to review financial performance due to the timings of the meetings and the late availability of information. The timing of the Committee will be revised from July 2015 onwards.

1.9 The Resources Committee reviewed and updated its terms of reference at its meeting on 11 May 2015. The revised terms of reference for the Resources Committee are attached at appendix 1.

2 Recommendations

2.1 The Board is recommended to

(a) disband the Operational Performance and Finance Committee with effect from May 2015.

(b) incorporate the remit for financial performance into the terms of reference for the Resources Committee.

(c) consider the timing of Resources Committee to ensure financial performance information is available for review by Committee at each meeting.

3 Attachment

3.1 Appendix 1 – Revised Terms of Reference for the Finance & Resources Committee

Caroline Lynch

Interim Trust Secretary

Agenda Item 13 Appendix 1

Finance & Resources Committee - Terms of Reference Constitution and Membership The Committee will be appointed by the Board to give detailed consideration to financial performance, estates, investment, IT, Workforce, approval of business cases and approval of requisitions. It will provide assurance to the Board on issues to achieve the best value for money and use of resources. It will seek to ensure that agreed strategies for finance, estates and IT are developed, implemented, monitored and reviewed. The Committee is non executive in nature and will review and scrutinise papers and make recommendations to the Board as necessary. The Committee will be chaired by a non executive director. The membership will comprise at least two further non executive directors, the Chief Executive, Director of Finance and the Medical Director or the Director of Nursing and the Chief Operating Officer. The quorum of the Committee will be 3 members and will include at least two non-executive directors. Attendance The Director of Estates and Facilities, Director of Workforce & Organisational Development and Director of IM&T will be expected to attend to present quarterly updates to the Committee. The Trust Secretary (or their nominee) will act as secretary to the Committee. The Committee may invite other staff and external advisors to attend for all or part of any meeting. Frequency of Meetings The Committee is expected to meet monthly and at other times as may be required. Duties The main duties of the Committee will be: 1. To monitor the development of a broad and long-term Financial Strategy in

support of the wider integrated business plan and to review the overall financial performance of the Trust.

2. To monitor the performance of the Trust in respect of its key Financial

Performance targets, delivery of the Monitor RAF, the overall cost improvement programme (QIPPs) and contract negotiations.

Agenda Item 13 Appendix 1

3. To review the Trust’s Estates Strategy, its formulation, development and

implementation, its links to other related strategies and thus ensure that the Trust’s capital assets are properly and effectively utilised.

4. To review the Trust’s IT Strategy, its formulation, development and

implementation, its links to service and financial strategies. 5. To review the Trust’s Workforce & Organisational Development Strategy, its

formulation, development and implementation. To provide assurance to the Board on issues in relation to employment relations, workforce development, appraisal and mandatory training completion and equality and diversity matters.

6. To raise any issues of concern to the Board and to the Audit & Risk Committee of

appropriate actions required in respect of finance, estates, workforce and IT to ensure the Trust is operating effectively, efficiently and economically.

7. To review the progress of contract development with the organisation’s commissioners.

8. To consider recommendations in respect of business cases beyond the

delegated authority of the Executive.

9. Approve, on behalf of the Board, all purchase requisitions in excess of £500,000. 10. To review in detail any other relevant issue referred to it by the Board for more

detailed consideration. Reporting The work of the Committee will be kept under review by the Board. The minutes of meetings will be formally recorded and submitted to the Board after each meeting. Minutes will also be submitted to the Audit & Risk Committee for information.

Monitoring compliance The Committee will conduct an annual review of its effectiveness with its terms of reference and submit any findings and proposals for changes to the Board of Directors for consideration. Reviewed by the Committee: May 2015 Approved by the Board:

Agenda Item 14a

1

Operational Performance and Finance Committee Tuesday 28 April 2015 10.10am – 10.45am Boardroom, Royal Berkshire Hospital, Reading Members Present Mrs. Janet Rutherford (Non-Executive Director and Acting Chair) Mrs. Jean O’Callaghan (Chief Executive) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance and Interim Deputy Chief Executive) Dr. Lindsey Barker (Medical Director) Mr. Paul Beal (Director of Workforce & Organisational Development) Ms. Bernie Bluhm (Interim Chief Operating Officer) Mr. Julian Dixon (Non-Executive Director) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Ms. Sue Hunt (Non-Executive Director) In attendance Mrs. Caroline Lynch (Interim Trust Secretary) Mrs. Heather Allan (Director of IM&T) (for minute 70/15) Mr. John Taylor (Director of Strategy) (for minute 63/15) 13/15 Minutes: 30 March 2015 The minutes of the meeting held on 30 March 2015 were approved as a correct record and

signed by the Chair. 14/15 Quality Performance Report

The Director of Nursing and the interim Chief Operating Officer submitted the quality performance report. The interim Chief Operating Officer gave an update on the 18 week Referral to Treatment Standards (RTT). The Board noted that RTT performance was either on track or exceeding recovery plans agreed with the CCG and Monitor. The interim Chief Operating Officer advised that the year to date position in respect of ED performance was 94.44%. The Committee noted the exception report and actions being undertaken in respect of ED performance. The interim Chief Operating Officer gave an overview of issues in the gastroenterology department which had impacted on cancer waiting times. A combination of sickness absence of medical staff and demand pressures on the speciality had impacted on the both the 62 day position and the two week wait position. Mitigating actions included use of the

Minutes

2

independent sector in order to address the backlog situation. However, it was noted that it had proven difficult to engage locum staff for this particular speciality. Resolved: that the report be noted

15/15 Finance Report

The Director of Finance submitted a report on the financial performance of the Trust for March 2015. The Director of Finance gave an overview of contract negotiations with the CGG in respect of proposed contract penalties. The Director of Finance gave an overview of steps taken to secure funding in the situation of the anticipated negative cash position during 2015/16. The Director of Finance advised that an update on service line reporting would be submitted to the Resources Committee in May. Resolved: that the report be noted.

16/15 New Quality Performance Dashboard The interim Chief Operating Officer introduced the new integrated quality performance

dashboard. The new format would be used from May onwards and would ensure consistency of information. An exception report would be included for any performance areas which were not on target.

The Committee discussed the recent delay in data being available which had impacted on

the Board agenda despatch. The interim Chief Operating Officer advised that a new Head of Informatics was now in post and he was currently reviewing information feeds to ensure that quality assurance checks would be undertaken at appropriate stages to provide assurance that data was robust. It was agreed that any comments on the new integrated dashboard would be submitted to the interim Chief Operating Officer. Action: All

The Committee discussed the timing of the Board dates. It was agreed that a review

should be undertaken to ascertain if dates for September 2015 onwards could be changed so the Board met on the same day of each month. Proposed dates would be circulated to Board members for comments. Action: C Lynch

Resolved: that

(a) any comments on the new integrated dashboard would be submitted to the interim Chief Operating Officer. (b) the new integrated quality performance dashboard be noted.

17/15 Date of Next Meeting

Resolved: that the next meeting be held at 9.00am on Thursday 28 May 2015.

Chair

Date

Agenda Item 14b

1

Resources Committee Monday 12 May 2015 10.00am – 12.30pm Boardroom, Level 4, Royal Berkshire Hospital Members Ms. Sue Hunt (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Acting Medical Director) Mr. Brian Hendon (Non-Executive Director) Mrs. Janet Rutherford (Non-Executive Director and Acting Chair of the Trust) In Attendance Mrs. Jean O’Callaghan (Chief Executive) Ms. Angela Hughes (Networked Care Group Director of Finance) (for minute 46/15) Mrs. Caroline Lynch (Interim Trust Secretary) Mr. Geoff Pinney (Pathology Services Manager) (for minute 46/15) Mr. Mark Robson (Networked Care Group Director of Operations (for minute 46/15) Apologies Mr. Paul Beal (Director of Workforce and Organisational Development) Mr. Philip Holmes (Director of Estates & Facilities) 44/15 Minutes: 13 April 2015

The minutes of the meeting held on 13 April 2015 were approved as a correct record and signed by the Chair.

45/15 Matters Arising Schedule The Committee noted the matters arising schedule. Minute 32/15 (02/15, 117/14): Estates Strategy: The Director of Finance advised that an

update on North Block would be submitted to the June meeting. The Committee recommended that this update should clarify the timescales for any actions required to enable a decision to be undertaken in respect of North Block. Action: C Anderson

It was agreed that an estates maintenance update would be submitted to the June meeting.

The Director of Finance confirmed that this would set out prioritisation of the maintenance backlog in addition to estates maintenance plans over the next three to five years.

Action: C Anderson

Resources Committee

2

Resources Committee May 2015

Minute 32/15 (20/15, 02/15, 115/14, 108/14): Matters Arising: Theatre Efficiency: The Director of Finance advised that work being undertaken by Four Eyes would inform the theatre efficiency programme and included utilisation of the new theatres. A presentation on the Four Eyes work would be submitted to the June meeting. Action: C Anderson

It was noted that the Committee agenda would be revised in order to ensure a greater

focus on budget risks including performance. Action: C Anderson Minute 35/15: Workforce Report: It was noted that information regarding the significant

agency spend was to be circulated to the Committee. Action: P Beal Resolved: that the matters arising schedule be noted. 46/15 Pathology Business Case Update [s43 applied to this section] 47/15 Service Line Management The Director of Finance introduced the report and advised that implementation of monthly

service line reporting was planned. It was noted that Monitor were engaged in a pilot programme with circa ten trusts to identify good practice as to how trusts would move to monthly service line reporting with clinical accountability. The Trust has volunteered to participate in the project.

The Committee queried the level of clinical engagement in the project. The Medical

Director advised that some specialties were already using service line reporting and it was planned that these clinicians would assist with the roll out of the project to all specialties.

The Committee queried the timeline for implementation. The Director of Finance advised

that a system, iSLR, had been identified that would enable the Trust to deliver service line reporting in shadow form in six months with a review to being live from April 2016. The financial accounts would be prepared as normal using cost centres as well prepared using the service line reporting tool. A Steering Group had been set up to oversee the implementation.

Resolved: that the report be noted. 48/15 Financial Transactions Outsourcing [s43 applied to this section] 49/15 CCG Contract 2015/16 Update [s43 applied to this section]

3


50/15 Blood Transfusion Purchase Requisition The Committee received the report which sought approval for the purchase order for the

provision of blood components for 2015/16. NHS Blood and Transplant was the sole provider of blood components in England.

The Committee approved the purchase order of £1,306,137. Resolved: that the purchase order for provision of blood components for 2015/16 be

approved. 51/15 Five Year Capital Plan The Director of Finance introduced the report which set out the Trust’s capital expenditure

for 2015/16 of £12.5m. A further £1.5m of capital expenditure was predicted on charitable funding or third party grants. Capital expenditure for four years commencing in 2016/17 was also set out in the report.

The Director of Finance advised that the capital programme would be reviewed and funding options reviewed. A further report would be submitted to the Committee

Resolved: that (a) a further report be submitted to the Committee (b) the report be noted 52/15 Draft Monitor Operational Plan 2015/16 The Director of Finance introduced the draft Operational Plan 2015/16.

The Director of Finance advised that the plan had been updated in respect of re-phasing of capital expenditure. As a result the Trust would not achieve a negative cash position although cash would be low during December 2015.

The Director of Finance drew attention to the Board declarations required in the Operational Plan. The Director of Finance advised that the sustainability section would be declared as ‘not confirmed’. Whilst the Trust was confident that it would be operationally and clinically sustainable over one, three and five years, there was further work required by the Trust and the local health systems as a whole to confirm financial sustainability over this period. The Director of Finance advised that the resilience section would be declared as ‘confirmed’ as it was considered that the Trust would have the Required Resources available. However, an additional comment would be added that there was a high risk that a negative cash position could result at some point during the financial year. The Committee recommended that the Director of Finance should liaise with the interim Chief Operating Officer in order to include a statement regarding the risk associated with achievement of the ED access target. Action: C Anderson

4


It was agreed that further narrative would be included in the operational plan in respect of the mitigating actions being taken to address the risk of a downside cash scenario.

Action: C Anderson Resolved: that, subject to the agreed amendments, the draft Operational Plan

2015/16 be submitted to Monitor on 14 May. 53/15 Work Plan Review Resolved: that the work plan be noted. 54/15 Review of Terms of Reference The Chair advised that the terms of reference would be revised and updated prior to

submission to the May Board. Resolved: that the revised terms of reference be submitted to the May Board. 55/15 Date of Next Meeting Resolved: that the next meeting be held at 10am on Monday 15 June 2015. SIGNED: DATE:

Agenda Item 14c

1

Clinical Governance Committee Thursday 14 May 2015 1.00pm – 3.00pm Boardroom, Level 4, Royal Berkshire Hospital Members Ms. Janet Rutherford (Non-Executive Director and Acting Chair) (Chair) Ms. Caroline Ainslie (Director of Nursing) Dr. Lindsey Barker (Medical Director) Mr. Julian Dixon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) In Attendance Mrs. Caroline Lynch (Interim Trust Secretary) Ms. Gill Valentine (Director of Midwifery) (for minutes 35/15 and 36/15) Apologies Mrs. Jean O’Callaghan (Chief Executive) 31/15 Minutes: 26 March 2015

The minutes of the meeting held on 26 March 2015 were approved as a correct record and signed by the Chair.

32/15 Declarations of Interest

There were no declarations of interest. 33/15 Clinical Governance Committee Matters Arising Schedule The Committee received the matters arising schedule. Minute 20/15 (03/15, 55/14): Matters Arising Schedule: Quality Account Target Patient

Experience:

The Committee noted that complaints work was being led by the Planned Care Director of Nursing. A review of complaints relating to behaviour and attitude had been undertaken and a reflective process was now in place. Any complaints against medical staff were reviewed as part of the individual’s appraisal process. Planned Care had made good progress in complaints and had achieved a 93% response rate for complaints being responded to within 25 days. The Medical Director confirmed that there was also a focus on complaints with newly appointed consultants.

Minutes

Minutes of Clinical Governance Committee 2

Clinical Governance Committee 14 May 2015

Resolved: that the matters arising schedule be noted. 34/15 Items Referred from the Board There were no items referred from the Board 35/15 Maternity Response to Kirkup Report The Director of Midwifery introduced the report and advised that the Kirkup report on the

Morecambe Bay investigation was published in March 2015. The report made 44 recommendations, 25 of which related to the NHS as a whole. A full review of the report and its recommendations had been undertaken. A number of recommendations were already in place in the Trust and were being delivered through the Maternity Improvement Programme action plan.

The Committee discussed how to seek assurance in respect of some of the themes identified

in the report which had also been highlighted by the Royal College of Gynaecologists review of maternity services at the Trust. The Director of Midwifery advised that reporting and governance structures at the Trust were more robust than those at Morecambe Bay. In addition a number of staff at Morecambe Bay had multiple and conflicting roles. The Trust had clearer lines of accountability in its maternity staffing structure. The Director of Nursing advised that the Maternity Improvement Programme would be a key focus for the cultural and leadership themes outlined in the Kirkup report.

The Committee noted that the maternity dashboard was reviewed by the maternity clinical governance committee, Urgent Care Group Board and local commissioners. The Director of Nursing advised that the recent quality review of maternity by the CCG had provided assurance that the services provided were safe and of good quality. The Committee queried the processes in place to ensure lessons learned from incidents. The Director of Midwifery advised when incidents occurred an independent member of staff was appointed to carry out the investigation. An area of improvement was ensuring information was shared in a timely fashion with the correct staff and that staff involved in incidents were debriefed. It was agreed that a further update would be submitted to the Committee in respect of the work being undertaken with assistance from the NHS Leadership Academy.

Resolved: that the report be noted 36/15 Maternity Action Plan Update The Director of Midwifery gave a verbal update on the maternity action plan. The Committee noted the ventilation work was in progress and due to be completed in June.

Weekly monitoring of Entonox levels was being undertaken. The Director of Midwifery reported that a governance review had been undertaken which had

included incident reporting and processes were now aligned with those in place across the Trust. The Director of Midwifery confirmed this was the case and a high level validation of incidents was undertaken. The governance structure had also been reviewed which included the number of meetings, reporting lines and terms of reference had been reviewed.



The Committee noted that a new Clinical Director had been appointed, initially for a period of 6 months, and improvement in working relationships had already been achieved. The Committee queried if the CQC were to re-visit whether any issues would be highlighted. The Director of Midwifery advised that staffing levels had improved and the midwife to patient ratio was now to 1:30. The Committee noted that there had been no diversions during April.

Resolved: that the update be noted

Resolved: that the report be noted. 37/15 CQC Action Plan Exception Report The Director of Nursing introduced the report and advised that the Trust was required to

provide CQC compliance information as part of the 2015/16 annual return to Monitor. This included the projected compliance dates for the 7 compliance actions issued following the CQC inspection. The Director of Nursing advised that it was anticipated that the Trust would be fully compliant by Quarter 3 of 2015/16.

The Committee noted that the CQC action plan would now be managed by the Director of

Nursing and the Medical Director rather than the Programme Management Office. The action plan would be updated in order to encompass all CQC essential standards. An updated action plan would be submitted to the next meeting. Action: C Ainslie

The Director of Nursing advised that the Peer Review process had tested the majority of the key compliance actions. The Committee noted that approximately 30 staff, of all grades, were involved in the internal Peer Review process. A total of 15 wards had been reviewed during April in respect of access to information and interpreting to ensure that information was available on the wards. The Committee noted that in respect of the external Peer Review process a team of 15 would undertake an unannounced visit to the Trust and areas selected would be based on feedback obtained by the internal review process. The Director of Nursing advised that each of the CQC essential standards had an Executive lead and an Operational lead. Reports would be submitted to the Quality Assurance & Learning Committee and any exceptions would be monitored by the Care Groups. The Director of Nursing reported that in respect of serious incidents robust processes were in place. However, there was a lack of reporting in some areas. The Quality Strategy, the Sign Up to Safety campaign and the Quality Account all included a focus on open reporting. The Committee noted the template letter which would be sent to all patients involved in serious incidents along with a leaflet explaining the process to comply with the Duty of Candour. The Committee recommended that patient leaders should be asked to review the letter. Action: C Ainslie The Committee queried whether the CQC would re-inspect the Trust. The Director of Nursing advised that, at the last quarterly meeting with the CQC inspector, there had been no mentions of plans to re-inspect the Trust. It was noted that a number of trusts were yet to receive their first inspection from the CQC.

Resolved: that (a) an updated CQC action plan be submitted to the next meeting (b) patient leaders be asked to review the letter to patients involved in serious incidents



(c) the report be noted. 36/15 Safeguarding Report The Director of Nursing introduced the report and advised that key areas in respect of child

sexual exploitation and female genital mutilation required the Trust to work collaboratively with partner organisations.

The Director of Nursing drew attention to the review undertaken in respect of the Lampard/Saville report. It was noted that an initial gap analysis had identified a number of areas where action was required. It was agreed that the action plan would be submitted to the Board for discussion and agreement on implementation. Action: C Ainslie

The Director of Nursing advised that as a result of the Care Act 2014 a number of actions

were required by the Trust from April 2015. This would result in a significant impact on workforce for the adult safeguarding team including regular attendance at partnership meetings. The Medical Director advised that additional resource had been put in place in respect of adult safeguarding.

The Committee discussed the Child and Adolescent Mental Health service. It was noted that

work was ongoing with the CGG looking at access to mental health services for young people.

Resolved: (a) the Lampard action plan be submitted to the May Board (b) the report be noted 37/15 Executive Quality Assurance & Learning Committee Exception Report The Director of Nursing introduced the report and advised that key issues raised at the

meeting included allocation of estates issues and responsiveness to maintenance requests. The Director of Nursing advised that a target of 85% compliance for procedural documents had been set. Compliance in March had been 82%.

The Committee noted that the Medical Devices Committee was being reviewed and a new

Chair would be appointed. The Director of Nursing advised that the medical devices service was originally managed by Planned Care. However, governance arrangements were being reviewed in order to gain a corporate overview of medical device processes.

The Medical Director advised that a review of Clinical Audit had highlighted a lack of resource

to undertake national and local audits. Mitigating action had been implemented in order to reduce the risk. The Medical Director advised that a schedule of audits was being prepared and this would be shared with the CCG. It was agreed that the schedule would be circulated to the Committee. Action: L Barker

The Committee discussed the level of detail provided in the exception report. It was agreed that the minutes of the Quality Assurance & Learning Committee would be submitted to future meetings of the Committee. In addition, the exception report would ensure that key points were highlighted to the Committee.

Resolved: that

(a) minutes of the Quality Assurance & Learning Committee be submitted to future meetings (b) the update be noted.



38/15 Draft Quality Account 2014/15 The Director of Nursing introduced the draft Quality Account 2014/15 and drew attention to

the six priorities which had been selected. The Committee recommended that the Communications team should be asked to carry out a final proof read of the document.

The Committee discussed Research & Development. The Medical Director advised that

meetings of the Research & Development Committee had now been reinstated. The Committee recommended that updates on Research & Development should be submitted to the Board, initially, as part of the Chief Executive’s monthly report. Resolved: that (a) the Communications team be asked to proof read the final version of the Quality Account 2014/15 (b) Research & Development updates be submitted to the Board, initially, as part of the Chief Executive’s report (c) the draft Quality Account 2014/15 be noted.

39/15 Progress on the Development of Clinical Governance Systems and Processes The Medical Director gave a verbal update. The Medical Director advised that departmental

clinical governance reported into the Quality Assurance & Learning Committee. Clinical Governance Leads were identified in each speciality and local clinical governance meetings were ongoing. The Medical Director advised that work was being undertaken in conjunction with the Director of Nursing to appoint a Head of Governance. Action: L Barker/C Ainslie

Resolved: that the update be noted 40/15 Work Plan Review It was agreed that the Quality Account priority dashboard would be submitted to the next

meeting to ensure that the key indicators chosen were appropriate. In addition, two Quality Account priorities would be reviewed in detail. Action: C Ainslie

Resolved: that the work plan be noted. 41/15 Key Messages for the Board

The Committee reviewed the key issues to draw to the attention of the Board which included:-

• Committee had noted good progress achieved in Maternity • Safeguarding update received but noted impact on resources in respect of the Care

Act 2014 • Outcome of the Lampard review discussed • Estates issues highlighted by the Quality Assurance & Learning Committee included

responsiveness and prioritisation of maintenance requests • Quality Account 2014/15 received • Review of Clinical Audit which had highlighted lack of resource to undertake national

and local audits



42/15 Key Messages for Round Up

The Committee agreed the key issue to be cascaded to staff via Round Up

• Committee had noted good progress achieved in Maternity

43/15 Date of Next Meeting Resolved: that the next meeting be held on Thursday 23 July 2015 at 1.00pm.

SIGNED

DATE

Agenda Item 15

Updated: May 2015 1

Royal Berkshire NHS FT – Board Work Plan

Jan 2015 Feb 2015

Mar 2015 Apr 2015 May 2015 June 2015 July 2015 September 2015

October 2015 November 2015

Strategy & Partnerships

Chief Executive Report (JO’C)

Chief Executive Report (JO’C)

Chief Executive Report (JO’C) Corporate Risk Register and BAF (CAi)

Chief Executive Report (JO’C) Strategic Developments (JO’C)

Chief Executive Report (JO’C) Strategic Developments (JO’C) Corporate Risk Register and BAF (CAi)

Chief Executive Report (JO’C) Strategic Developments (JO’C) Draft Strategic Plan 2015-20 (JT) Quality Strategy (CAi)

Chief Executive Report (JO’C) Strategic Developments (JO’C) Corporate Risk Register and BAF (CAi) Clinical Services Strategy (JT)


Chief Executive Report (JO’C) Strategic Developments (JO’C) Corporate Risk Register and BAF (CAi)


Integrated Performance

Integrated Performance Report (CAi/BB) DoF (CA) Monitor Quarterly Return (CA)

Integrated Performance Report (CAi/BB) DoF (CA) Trust Improvement Programme (BB)

Integrated Performance Report (CAi/BB) DoF (CA) Trust Improvement Programme (BB) Budget 2015/16 (CA) Monitor Action Plan (JO’C)

Integrated Performance Report (CAi/BB) DoF (CA) Trust Improvement Programme (BB) Budget Approval (CA) Monitor Operational Plan (CA/JT)

Integrated Performance Report (CAi/BB) DoF (CA) Trust Improvement Programme (BB) Annual Report and Accounts and Quality Accounts) (CA/JO’C) Monitor Annual Self-Certification – Part I (CA/CL)

Integrated Performance Report (CAi/BB) DoF (CA) Trust Improvement Programme (BB) Monitor Self Certification – Part II (CA//CL)





Culture, Workforce & Infrastructure

Workforce Report (PB)










Agenda Item 15

Updated: May 2015 2

Jan 2015 Feb 2015

Mar 2015 Apr 2015 May 2015 June 2015 July 2015 September 2015

October 2015 November 2015

Trust Improvement Programme (BB) Schedule of SIs (CAi)


Trust Improvement Programme (BB) Schedule of SIs (CAi) Skill Mix Review (CAi) Quality Governance Framework Update (CAi)


Trust Improvement Programme (BB) Schedule of SIs (CAi) Monitor Action Plan (JO’C) Lampard’s Report Lessons Learned Review (CAi) SFI review (CA)

Trust Improvement Programme (BB) Schedule of SIs (CAi) Quality Governance Framework Update (CAi)


Trust Improvement Programme (BB) Schedule of SIs (CAi) Safeguarding Annual Report (CAi) Skill Mix Review (CAi)



Minutes of Board Committee meetings

Minutes and actions (CL)



Minutes and actions (CL) Monitor Quarterly Return (CA)







Other Items

Board Work Plan (CL)







Board Work Plan (CL) Standing Orders Review (CL)

Board Work Plan (CL) Board Agenda Proposal Review (CL)
