council of governors 15 june 2017 · 2017-08-08 · 1/2 council of governors 15 june 2017...

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COUNCIL OF GOVERNORS 15 June 2017

12.30-2.30pm

Board Room, Aintree Lodge

AGENDA

d = document v = verbal p = presentation

No Item Reference

Preliminary Business – Chairman

12.30 1. Apologies for Absence

To note the apologies

CG17-18/001 (v)

2. Declarations of Interest

To receive declarations of interest in agenda items and/or any changes

to the register of governors’ declarations of interest pursuant to

Standing Orders

CG17-18/002 (v)

3. Minutes from the last meeting (15 March 2017)

To approve the minutes from the last meeting and discuss any matters arising:

Exit Interviews (Director of People & Corporate Affairs)

Annual Business Plan (Director of Finance)

Directors Dragons’ Den - Innovations Approved (Director of People & Corporate Affairs)

CG17-18/003 (d)

CG17-18/004 (d)

CG17-18/005 (d)

CG17-18/006 (d)

Overview

12.45 4. Strategic Update

Chairman/Chief Executive

To note

CG17-18/007 (p)

1.00 5. Lead Governor Report

To note

CG17-18/008 (d)

Quality & Performance Management

1.10 6. Assurance on Key Indicators:

Quality & Safety

Finance & Performance

Non-Executive Directors

CG17-18/009 (p)

Internal System of Control

1.40 7. Key Issues & Assurances

Audit

Non-Executive Director

CG17-18/010 (p)

Governance

1.50 8. PwC Long Form Report (External Assurance on QA)

PwC Representative

To approve

CG17-18/011 (d)

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Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors’ Meeting15 June 2017 2/2

2.05 9. Governor Committees:

Committee Chairs

Membership Committee (8 May 2017) for noting & approval of Terms of Reference

Quality of Care Committee (17 May 2017) for noting & approval of Terms of Reference

Nominations Committee approval of Terms of Reference

CG17-18/012 (d)

2.15 10. CoG Draft Objectives 2017/18

Chairman & Associate Director Corporate Governance/Board Secretary

To approve

CG17-18/013 (d)

2.20 11. Appointment of Lead Governor & Deputy Lead Governor

To approve the process

CG17-18/014 (d)

Concluding Business

2.25 12. Any Other Business

Chairman

CG17-18/015 (v)

13. Date and Time of Next Meeting:

Wednesday 18 October 2017 at 5.00-7.00pm

PRIVATE BUSINESS

No Item Reference

2.35 1. Appraisal of the Chairman

Senior Independent Director

CGP17-18/001 (d)

2. Appraisal of the Non-Executive Directors

Associate Director of Corporate Governance/Board Secretary

CGP17-18/002 (d)

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Council of Governors

Wednesday 15 March 2017 5:00pm

Board Room Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman

Steve Warburton - Chief Executive

Pamela Peel - Lead Governor

Sharon Bird - Public Governor

Mike Booth - Public Governor

Mike Bowker - Public Governor

Tony Byrne - Public Governor

John Johnson - Public Governor

Tony Kneebone - Pubic Governor

Julie Naybour - Public Governor

Stephen Thornhill - Public Governor

Rose Milnes - Public Governor

Tracey Barnes - Public Governor

Rosemary Urion - Public Governor

Lorraine Heaton - Staff Governor (AHPs)

John Wilding - Appointed Governor (University of Liverpool)

Kerry McManus - Staff Governor (Other)

Paul Cummins - Appointed Governor (Sefton Council)

-

In Attendance: David Fillingham Non-Executive Director

Michael Games - Corporate Governance Manager

Steve Evans - Medical Director

Sue Green - Director of People & Corporate Affairs

Tim Johnston - Non-Executive Director

Joanne Clague - Non-Executive Director

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Emily Kelso - Corporate Governance Officer

Kevan Ryan - Non-Executive Director

Andrea Thomas - Acting Director of Nursing & Quality

Beth Weston - Deputy Chief Operating Officer

Apologies: Gerry Hill - Public Governor

Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)

Brian Lawless - Public Governor

Andrew Swift - Staff Governor (Medical)

Helen Frankland - Staff Governor (Nursing)

Ian Jones - Director of Finance & Business Services

Angie Smithson - Deputy Chief Executive/Chief Operating Officer

Mandy Wearne - Non-Executive Director

Paul Fitzpatrick - Director of Estates & Facilities

Juliet Herzog - Non-Executive Director

5 members of the public were in attendance

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Minutes: Council of Governors’ Meeting 15 March 2017 2/7

Ref Minute

Preliminary Business

CG16-17/033 Apologies for Absence

The apologies were noted as above.

CG16-17/034 Declarations of Interest

There were no declarations of interest.

CG16-17/035 Minutes from the last meeting (8 December 2016)

The minutes from the previous meeting held on 8 December 2016 were approved as an

accurate record.

CG16-17/036 Exit Interviews

Sue Green, Director of People & Corporate Affairs, presented the report which provided

details on the development of a Trust wide approach to exit interviews to enable trends

and themes to be more easily identified and remedial action to be initiated in a more

timely way. She advised that by using the data provided, and through close working

between HR and the Divisions, the Trust could identify if there were any particular

actions required to improve retention in key areas.

Governors welcomed the initiative and sought and received confirmation that improved

processes would be in place by the end of Q1 2017/18 and that bespoke training would

be provided for areas identified within the Divisions. A further update was to be

provided to Governors in June 2017.

The Council noted the report

Overview

CG16-17/037 Strategic Update

The Chairman and Chief Executive advised the meeting of the following matters:

Budget Statement – no additional financial assistance was to be provided to the

NHS but there was money to be made available for social care

Annual Plan – the Trust was awaiting formal feedback from NHS Improvement

(NHSI) on its submitted financial plan and Governors would be kept informed

accordingly

Sustainability & Transformation Plan (STP) – the Trust continued to work within

the North Mersey footprint of the wider Cheshire & Merseyside STP. There

continued to be negative media coverage but the local delivery plan was considered

to be credible and the proposed merger with the Royal Liverpool (RLBUHT) formed

a significant part of those plans

Aintree/Royal Merger – work continued on the development of the outline

business case and a recent meeting with NHSI had discussed the detail required

for inclusion within the document alongside the clinical work. Governors would

continue to be kept informed of developments in this regard

Community Health Services – some concerns had been raised locally with NHSI

in regard to the awarding of the contract for community services within Liverpool

through the Bridgewater consortium. The outcome was awaited but the Trust

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remained committed to the vertical integration of services

Contracts – the Trust had received agreement from Liverpool, Sefton and

Knowsley Commissioning Groups to move to a block contract arrangement for

2017/18.

Members of the Council then sought and received clarification in relation to the following

matters:

The use of charitable funds by Aintree and the Royal Liverpool Hospital to look for

opportunities and innovations that NHS funding cannot provide. Reference was

made to the Trust’s recent initiative for the use of Dementia Pods which was funded

by the Charitable Funds Committee

It remained the intention for the proposed merger between Aintree and RLBUHT to

be in place by 1 April 2018. However, there were a number of external factors that

could impact including the potential scrutiny by the Competitions & Markets Authority.

The Council noted the update.

CG16-17/038 Lead Governor Report

The Lead Governor made reference to the report and highlighted the following matters:

Aintree Volunteer Inductions – Governors were encouraged to attend these

sessions to recruit new members who were already committed to the Trust.

Governor Activity – there had been positive involvement by Governors at recent

events including Aintree Volunteer Inductions, Catering and Food Quality work

stream, Multi-disciplinary Accelerated Discharge Event (MADE) sessions, Well-Led

Governance Review Governor focus group, Aintree Champions Excellence Panel,

Focus on Kidney Event, prospective new Governor information session, staff

inductions and the helipad turf cutting

Governor Development – arrangements had been made for a Media Awareness

session which would cover a wider remit than that previously presented to

Governors. Other topics for future Governor sessions had been identified and

arrangements would be made in this regard

Induction/Development of New Governors – arrangements were to be made for

newly elected Governors to receive an induction session from the Board Secretary

and for current Governors to meet and assist in their development.

The Council noted the update.

Quality & Performance Management

CG16-17/039 Emergency & Acute Care Programme

Beth Weston, Deputy Chief Operating Officer, gave a presentation which covered the

following matters:

the progress made within the Medical Assessment Unit

the revised processes within AED with particular emphasis on patient streaming and

the rapid assessment and treatment process

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an overview of the Frailty Model including the improvement in discharge home rate

performance

the improved SAFER ward processes also linked to the safe discharge of patients

before noon and at weekends

the changes introduced to delayed transfers of care through the rapid improvement

event.

The key themes arising from the questions posed by members of the Council were as

follows:

the assurance gained from sustained performance that systems and processes

were embedded within certain areas and the continued work being undertaken to

embed consistency in other areas

the EAC programme being the biggest change project undertaken by the Trust with

a suite of metrics in place to monitor performance

the performance of the various teams to improve A&E performance, the accolades

given to the Frailty Unit for the service it provides and the significantly improved

ambulance handover processes put in place

the significant reduction in the number of long waits for those patients classed as

Ready for Discharge but further improvements were required to reduce the levels

and improve patient flow. Any failed discharges resulting in readmission were

reviewed by the Discharge Matron with lessons learned cascaded accordingly

the involvement of the consultant leads, registrars, nursing staff and site team as

part of the Acute Medical Scrums to speed up assessments

the inclusion of information relating to patient experience metrics within future

presentations and the possibility of providing patient/staff stories to Governors.

The Council note the presentation.

CG16-17/039 Assurance on Key Indicators

Quality & Safety Kevan Ryan (Non-Executive Director), member of the Quality & Safety Committee, gave

a presentation which covered assurance on key indicators relevant to quality and safety

including the key areas of focus, where on-going assurance was received and where

assurance was sought on areas of concern. He highlighted the main areas of focus

including serious incidents, mortality, infection prevention & control, the Quality Strategy

delivery plan and the risk register. He also referred to the ongoing assurance sought on

workforce, patient experience and pressure ulcer prevention as well areas of concern on

the Advancing Quality programme, ophthalmology and improvement in emergency

laparotomy. An overview was also provided on the Trust’s performance against the main

clinical quality indicators.


follows:

The recording of falls and their severity. It was explained that the majority of falls

were occurring between 4.30pm and 10.30pm. Work was being undertaken to

understand the reasons for this and make the necessary improvements.

The Trust was treating a more elderly population with a noticeable increase in the

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number of patients with co-morbidities, frailty, dementia and confusion. This tended

to lend itself to patient falls due to being in unfamiliar surroundings. Every effort

was made to reduce the risk of falls through the assessments undertaken

The concerns raised by the Trust with the Governor of HM Prisons in Liverpool on

the security of prisoners attending the Trust for treatment and the potential impact

on safety for the Trust’s staff, the prison guards and the general public

The commitment of the Trust to reduce the level of pressure ulcers and the work

being undertaken with the community and training of Health Care Assistants on

early detection and management of pressure ulcers. It was agreed that details of

aspirational targets for pressure ulcers for 2017/18 and trends for 2016/17

would be provided at the next meeting.

The Council noted the presentation. Finance & Performance Joanne Clague (Non-Executive Director), Chair of the Finance & Performance

Committee, gave a similar presentation on assurance on key indicators relevant to

finance and performance. This covered the Referral to Treatment recovery plan,

divisional deep dives, theatre productivity & efficiency and plans for closures. She also

highlighted the areas of on-going assurance in relation to emergency & acute care,

operational & financial performance, transformation and progress against the annual

business plan priorities. Reference was also made to the areas of concern relating to

A&E data quality and agency staffing. An overview was also provided on performance

against the financial and activity indicators, including access to services and workforce

targets.


follows:

The intention to repeat the Dragons Den initiative during the course of the year. It

was agreed that Governors would be provided with information in relation to

the return on investment received from previous innovations at the next

meeting

The use of agency staff and the impact it has on quality and safety. Governors

were advised that changes had been implemented on block booking agency staff

where appropriate and providing them with the necessary training on the systems

and processes to undertake other duties within the Trust

The Trust’s sickness absence rate was good compared to the benchmark across

North Mersey with the level of other acute Trusts over 2% higher. The Trust now

provided Occupational Health services to other Trusts and the implementation and

delivery of the Health & Wellbeing Strategy should reduce absenteeism levels

further.

The Council noted the presentation.

Internal System of Control

CG16-17/040 Key Issues & Assurance (Audit)

Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a

presentation which covered the key areas of assurance obtained from the Committee’s

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deliberations which included internal audit reports on car parking concessions and

incident reporting, together with assurance sought on areas of concern relating to Bank,

Agency & Locum staff and Trust Policy compliance.

The Council was informed that the Trust was due to receive a CQC inspection anytime

from April 2017 and it was noted that Governors would be involved where appropriate.

The Council noted the presentation

Governance

CG16-17/041 Appointment of External Auditor

Tim Johnston, Non-Executive Director, advised the Council of the audit tender process

undertaken by the Audit Committee and Governor representatives. He provided a brief

overview of the work that would be undertaken by the External Auditors and explained

that the Committee had followed the prescribed framework to invite firms to tender. The

Trust had only received one response from PricewaterhouseCoopers (PwC) but still went

through a proper process via an assessment panel. Tony Byrne, Public Governor,

advised that he and Gerry Hill, Public Governor, had been the Governor representatives

and explained that he had been part of the panel assessment which had gone through a

robust Q&A session and PwC had answered proactively. He stated that he fully

supported the recommendation to appoint PwC.

The Council approved the recommendation to appoint PwC for external audit services for

3 years with the option to extend for a further 2 years.

CG16-17/041 Reports of Governor Committee Chairs

Membership Committee – 1 February 2017

The Council of Governors received the report of the Committee which was taken as read

and noted.

Quality of Care Committee – 9 February 2017

The Council of Governors received the report of the Committee which was taken as read

and noted.

Nominations Committee –15 March 2017

The Council of Governors noted that the Committee had met to discuss the re-

appointment of the Chairman.

Concluding Business

CG15-16/032 Any Other Business

Re-appointment of Chairman

The Chairman left the meeting at this point and Tim Johnston, Non-Executive Director

and Senior Independent Director, chaired the remainder of the meeting.

TJ advised the Council that the Nominations Committee had met to discuss the re-

appointment of the Chairman for a second term of office. Committee members provided

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a brief overview of their deliberations in relation to the performance and leadership

qualities of the Chairman. The Committee sought and received approval by the Council

of Governors that Dr Neil Goodwin, Chairman, be appointed for a second 3 year term of

office concluding on 30 September 2020.

Date and Time of Next Meeting:

Wednesday 15th June 2017 in the Board Room Aintree Lodge at

The meeting closed at 7.00pm Chair’s Signature: Date:

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Agenda Item (Ref) CG17-18/004 Date of Meeting: 15 June 2017

Report to Council of Governors

Report Title Exit Interviews

Executive Lead Sue Green, Director of People and Corporate Affairs

Lead Officer Steven Richardson, Acting Head of Business HR

Action Required Progress Update

Substantial assurance

High level of confidence

in delivery of existing

mechanisms / objectives

Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in

delivery of existing

mechanisms /

objectives

No

assurance

No

confidence

in delivery

Key Messages of this Report (2/3 headlines only)

A Trust-wide approach to exit interviews is being developed to enable trends and themes to be

more easily identified and remedial action to be initiated in a more timely way.

By using the data provided and through close working between HR and the Divisions the Trust

can identify if there are particular actions required to improve retention in key areas.

Impact (is there an impact arising from the report on the following?)

Quality

Finance

Workforce

Equality

Risk

Compliance

Legal

Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must

accompany the report)

Strategy Policy Service Change

Strategic Objective(s)

Deliver outstanding care

Achieve best patient outcomes

Promote research and education

Deliver sustainable healthcare to meet people’s needs

Provide strong system leadership

Be a well-governed and clinically-led organisation

Governance (is the report a……?)

Statutory requirement

Annual Business Plan Priority

Key Risk

Service Change

Other

rationale for Board submission required:

Next Steps (actions following agreement by Board/Committee of recommendation/s)

Review the outputs from the current Nursing Retention Review underway;

Engage key stakeholders in reviewing the Policy/toolkit

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Exit Interviews: Council of Governors 15 June 2017 2/5

REPORT HISTORY

Committee / Group Name

Agenda Ref

Report Title Date of submission

Brief summary of key issues raised and actions

Council of

Governors

CG16-17/

036

Exit Interviews 15 March

2017 A Trust-wide approach

to exit interviews is

being developed

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Exit Interviews

Executive Summary

1. The purpose of this report is to update the Council of Governors on progress made on exit

process and interviews and how the Trust uses these and will use these to gain an

understanding of the main themes of reasons for staff leaving the Trust. This is an update of

the previous report submitted to the Council of Governors in March 2017.

Key Issues / Proposals

2. The previous report identified that a more effective Trust wide approach and process is

necessary in order to gain a better understanding of why staff choose to leave; this will help

to provide legitimate intelligence around issues or interventions that can be deployed to

change outcomes and improve retention

3. Key Actions identified were as follows:

To identify how many staff have left the Trust, broken down by Division, job role, and

grade and identify what the reasons for leaving have been and whether or not the

reason for leaving was voluntary or as a result of action taken by the Trust

To identify the destination of leavers, and to understand how many of our leavers left

the organisation to work elsewhere within the NHS; and how this level compares to the

number leaving to further their education and/ or training and the number of leavers

exiting the NHS altogether.

Review in detail the reason groups – Work Life Balance, Better Reward Package and

the Other/Not Known

Develop an exit interview template and process to be used as a consistent approach to

be applied across the Trust; Divisions will be encouraged to carry out exit interviews on

every leaver following the new structured process

Current Positon

4. An Exit Review Policy and framework is in development which will look to provide a structure

for managing the exit process for staff. This is due to be presented to WELG later this

month; it will look to address the issue of retention on 3 levels.

i. Through good management practice; implementing an approach for managers to speak

to leavers to gain valuable information as to the reasons (exit interviews)

ii. Identification of unusual changes in exit information; triggering conversations between

HR Teams and Managers to understand the reasons for spikes for early intervention

iii. Trend analysis; focussed pieces of work where significant trends are identified for

gathering in depth understanding and developing tailored interventions

5. A number of initiatives have already been implemented to support the delivery of the Policy

and framework.

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6. A detailed data set and information has been produced to provide a more in depth

quantitative understanding of attrition rates; this information has also now been incorporated

as standard into the monthly pipeline report for Divisions and reviewed at NSSG. This report

provides a specific focus on band 5 nursing leavers as a starting point, as this is the key area

of concern with one of our biggest vacancy gaps.

7. This intelligence has identified some significant trends that are now being investigated in

more detail, for example, AED and MAU accounts for approximately 50% of all leavers within

the Division of Medicine over the last 12 months; moreover it has shown that of these almost

50% are staff whose service is less than 2 years. At the moment the vast majority of newly

qualified nurses are deployed to these departments and there is a concern that something is

happening that is resulting in these staff exiting. More focussed intervention has

commenced and will be concluded by the end of June; this will identify if there is an issue

with the loss of NQNs, the causes and interventions to drive change and improvement.

8. The Business HR Team are working closely with the respective Divisions on the

development of Resource Plans; these will incorporate the same data and intelligence on exit

for all staff groups, to ensure that the Policy and processes are embedded, data analysed,

areas for intervention identified and activity initiated and monitored.

9. In addition to this, a Trust Exit interview template has been developed that will shortly be

presented to the Divisions for review, comment and implementation; this will look to provide a

more structured approach to undertaking exit interviews.

10. It is recognised that an exit interview process in itself may not provide a complete picture of

the reasons for leaving, particularly if the reasons are of a sensitive nature or relate to

relationship issues with colleagues. Consequently, a process has already been put in place

to give every leaver the opportunity to provide confidential feedback, completely separate to

the exit interview process, which will look to address this gap.

Additional Strategies

11. A QEP initiative has been identified that will look to review the current shift patterns and skill

mix to identify improvements; the exit process and information will provide valuable data and

intelligence to inform that review.

Implications / Impact

Quality

12. Retention of trained, qualification and professional staff will improve the quality of care our

patients receive.

Finance

13. It is widely acknowledged that the cost of retaining staff is much lower than the cost of

recruiting new staff, so improvements in retention rates will support effective use of

resources.

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Workforce

14. Maintaining a stable, committed workforce is a key objective within the 2017 / 2018 strategic

plan. A reduction in staff turnover will likely have a positive impact on staff morale and

therefore staff survey results, and will likely have a positive impact of sickness absence rates

and ultimately will help the Trust develop a workforce capable of meeting the challenges

faced by the organisation over the coming years.

Equality & Diversity

15. The revised process and Policy will be subject to an Equality Impact Assessment. In addition,

Exit Interviews will include an assessment of any opportunities to promote Equality and

Diversity as well as ensuring no detrimental impact on people within the protected

characteristic groups.

Legal

16. The provisions of the Data Protection Act will apply in relation to data produced and stored

as a result of exit interviews.

Conclusion

17. The development of the Exit Review Policy and framework will provide a clear structure and

methodology to drive improvement.

18. The steps implemented so far have started to drive a better understanding of retention issues

and hotspot areas.

19. Focussed interventions have already commenced or are about to begin to address some

initial identified hotspots.

Recommendation

20. To note the contents of this report and support the proposed methodology.

Author: Alan Evans; Head of Workforce and Payroll Systems

Date: 7 June 2017

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Report Title Annual Business Plan 2017/18

Executive Lead Ian Jones, Director of Finance

Lead Officer Alistair Leinster, Head of Corporate Planning and Performance

Angela Whittaker, Associate Director of Strategy, Service Development

and BI

Action Required To approve





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


This report gives and overview of the annual business planning considerations for the Trust and

approach taken to the planning process.

It summarises the priorities that have been included in the Annual Business Plan for 2017/18


Quality

Finance

Workforce

Equality

Risk

Compliance

Legal














Key Risk

Service Change

Other



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Annual Business Plan 2017/18: Council of Governors 15 June 2017 Page 2

REPORT HISTORY


Agenda Ref



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Annual Business Plan 2017/18

Executive Summary

1. This report summarises the priorities that have been identified for inclusion in the Trust’s

2017/18 Annual Business Plan.

2. The Annual Business Plan outlines the Trust priorities in delivery of its strategic vision and how

it aims to contribute to the wider emerging strategic vision for the health economy. It should be

considered alongside other Trust assurance processes and reporting mechanisms including a

range of business as usual activities.

3. In order to ensure that the Annual Business Plan represents a manageable overview of Trust

priorities, schemes are divided into those reported at Trust level and those reported at

Divisional / Executive Led Group level. A total of 33 schemes are prioritised to be reported in

the Trust level report, with a further 19 schemes to reported at Divisional and Executive Led

Group level (total = 52 schemes).

Introduction/Background

4. The Trust’s Annual Business Plan for 2017/18 outlines how Aintree aims to; (i) achieve its

strategic vision, (ii) contribute to the delivery of the emerging strategic vision for the health

economy and (iii) deliver against its mandated operational performance targets and quality

standards.

5. Divisions and Corporate Services Departments have identified their priorities for inclusion

within the 2017/18 Annual Business Plan.

6. The emerging business plan priorities have been aligned to the Trust’s strategic objectives and

also triangulated against the Quality Strategy and QEP programme.

National Priorities / Planning Guidance

7. National policy signals a further move towards system-based working with a key focus being

the requirement for Trust plans to align with Sustainability and Transformation Plans (STP).

Within Cheshire and Merseyside the main themes of the STP are; hospital reconfiguration,

demand management, population health and digital first. The Trust continues to progress the

acute merger with the Royal Liverpool and Broadgreen University Hospitals NHS Trust as a

strategic priority.

8. Finance, activity and workforce plans are required to be consistent with the wider STP plans,

with all organisations being held accountable for delivery of their own and system STP

financial control totals.

9. Local commissioners are unequivocal in their approach to service developments for 2017 -

2019, stating that CCGs will not agree to any service development where there is a net

increase in costs to commissioners.

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10. Local commissioner and national priorities both look to outpatients as an area of focus

through; new to follow ratios, mandating the use of e-referral system, requirement to develop

‘advice and guidance’ services as well as a shift from daycase procedure to outpatient setting.

Local Strategic Priorities

11. During 2016/17 the Trust focused on a number of work programmes that support the principles

set out in the emerging Sustainability and Transformation Plans and are central to delivery of

Local Delivery System plans. A number of these issues remains as key priorities for the Trust

in 2017/18:

Working towards acute provider merger, delivering horizontal integration. Clinical teams

are developing integrated models of care to deliver patient benefits across the city.

Active engagement in the Healthy Liverpool and Shaping Sefton programmes to

improve pathways and support demand management. This has included working on

city-wide pathways that offer the potential to reduce demand for acute services, as well

as exploring opportunities to reduce duplication of support services.

Progression of shared electronic patient record system across three of the acute

providers within the city. This will support future organisational reconfiguration as well

as offer benefits of additional functionality and record sharing capabilities.

Working collaboratively with partners across health and social care to resolve some of

the key challenges facing the Trust. This includes a multi-professional workshop with

partners, including social care, focused on accelerating discharge and addressing

delays.

Maintain a focus on the delivery of high quality community services through

collaboration with others.

Trust Planning Considerations

12. In developing its Annual Business Plan the Trust has to ensure that it is aligned to the Trust’s

overarching strategic plan, the priorities set out in National Planning guidance and the

priorities set out by our local Commissioners in the emerging Sustainability and

Transformation Plan.

13. The Trust’s strategic vision and objectives are included in the diagram below;

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14. In identifying key priorities for action, Divisions were asked to ensure their key priorities align

with the strategic direction for the Trust and the wider NHS, and support of one of the following

key principles:

Support delivery of the Sustainability and Transformation Plans;

Related to existing redesign workstream (e.g. CVD, Ortho, Trauma, Stroke, Respiratory,

IV therapy, Community Services);

Support delivery of operational standards / address operational pressures or risk /

address clinical risk;

Support delivery of CIP;

Support delivery of the Trust Quality Strategy.

15. In reviewing potential priorities, account was taken of progress against schemes agreed as

part of the 2016/17 business plan (i.e. consider inclusion of schemes not delivered by end of

2016/17). Plans should also reflect delivery of key operational targets.

16. Teams were advised that the business planning processes should not be considered as a

means of bidding for new money. The aim was to set out Divisional business plans which are

financially balanced at Clinical Business Unit and departmental level. Potential service

developments or business opportunities will need to have Commissioner Support and be

funded through:

Internal service redesign to release efficiency savings.

Approval of a business including financial approval.

Securing a new funded service through competitive tender.

17. Divisions were encouraged to engage with operational teams and develop plans at

departmental and specialty level to support their alignment with wider Trust plans.

Annual Business Plan Priorities

18. Work has been undertaken with Divisional and Corporate leads to identify schemes for

inclusion in the 2017/18 Annual Business Plan, and to provide details including proposals and

quarterly milestones for each. Currently the business plan consists of 52 reporting lines; with a

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proposal to report 33 at Trust level (see section ‘Annual Business Plan Reporting’ below for

details).

19. Annual Business Plan schemes are summarised in Appendix 1, by Trust strategic objective

and in Appendix 2 by the Executive Led Group they report to. In addition they are listed in

Table 1 and Table 2 below.

20. Detailed proposals relating to each Annual Business Plan priority for 2017/18 are presented in

Appendix 3. Here details of each scheme for inclusion in the business plan are included,

noting the Division they are associated with, details of the proposal, its quarterly milestones,

reporting theme and whether the scheme will be reported at Trust or Divisional / Executive Led

Group level.

Annual Business Plan Reporting

21. The planning process for 2017/18 has focused on ensuring that the annual business plan

represents a manageable overview of Trust priorities. The aim is to give an overview of the

extent of schemes undertaken to support Trust objectives, without presenting a level of detail

that is overwhelming. In order to achieve this, and to manage the number of schemes reported

at Trust level, the following steps have been taken when developing the Annual Business

Plan:

Schemes are grouped into themes (‘Joint working’, ‘Workforce redesign’, ‘Efficiency’,

‘Clinical / Operational practice’, ‘Quality’) in order to support the interpretation of

reports.

Reporting of the Quality Strategy progress against the four high level themes included

in the strategy; ‘Care that is safe: reducing harm’, ‘Care that is safe: reducing avoidable

mortality’, ‘Care that is clinically effective’ and ‘Care that provides a positive experience

for patients and their families’ – with full progress reporting of each Quality Strategy

initiative provided through a quarterly Quality Strategy update.

Overall Quality and Efficiency Programme (QEP) progress will be reported in the

Annual Business Plan as delivery of savings against plan – with full progress reporting

delivered through the QEP programme via the Transformation Steering Group.

Where appropriate, related schemes are grouped for Trust level reporting, with detailed

progress monitored on Divisional basis – quarterly Divisional progress reports will be

produced alongside the Trust level report.

A number of schemes to be reported at Divisional and Executive Led Group level,

rather than as part of Trust level report (see Table 1 and 2 below) – as above quarterly

Divisional and Executive Led Group progress reports will be produced alongside the

Trust level report, maintaining a focus on delivery of those schemes.

22. Reporting will be undertaken on a quarterly basis. The process for completion of reports will be

largely based on that which was in place during 2016/17, in that it will rely on the reporting

lead updating on progress via a centralised template, against each scheme. The one notable

change for 2017/18 will be the additional production of Divisional level annual business plan

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quarterly update reports. This will not require any more work from those providing quarterly

update, with a smaller overall number of reporting lines seen in 2017/18.

23. Table 1 contains the 33 x Trust reported lines in the Annual Business, and Table 2 list the

further 19 x schemes that are only reported at Divisional and Executive Led Group level.

Table 1: Trust Level Reported Schemes

Theme ABP Ref Priority description

1 Proposed Merger Transaction

3 Maintain a focus on the delivery of high quality community services through collaboration with

others

15 Work with Merseycare to improve crisis care for people with mental health problems who

present to AED.

16 Collaborative working with the stroke network and other local providers in implementing new

stroke pathways

17 Contribution to Cardiology city wide service reconfiguration

18 Contribution to Respiratory and City-wide Service Reconfiguration

19 Haemato-Oncology Transfer of Services

42 North Mersey Orthopaedic & Trauma Service (MOATS)

6 Cancer Services Support - Radiology

7 IT EPR Implementation

23 AED flow measures: improving access to GP, primary care at front door, maximise patient

flow to ambulatory emergency care (combined reporting line see ABP Ref 15, 25, 26)

24 Deliver Stroke standards for all of our patients and to deliver sustainability across the clinical

teams.

45 To develop safe and sustainable Dermatology services for Aintree university Hospital in

partnership with local provider or providers

46 Improving Acute Surgery flow, in the surgical assessment unit and across the Surgical

Division.

47 To continue to reduce risks to Ophthalmology patients due to insufficient capacity to see

patients in a timely way.

14 Outpatient productivity

40 Delivery of Quality of Efficiency Programme savings against plan

49 To improve Theatre productivity and efficiency, by increasing the number of theatre sessions

running and increasing the use of theatre time in session.

2 Working collaboratively with partners across health and social care to resolve some of the

key challenges facing the Trust

36 Care that is Safe: Reducing Harm

37 Care that is Safe: Reducing Avoidable Mortality

38 Care that is Clinically Effective

39 Care That Provides a Positive Experience for Patients and their Families

41 Consideration of case for increased capacity within the Intravenous (IV) Team

50 Implementation of ‘National Guidance on Learning from Deaths’ from the National Quality

Board on structured review of deaths

51 Seven day services – Diagnostics and Support Services

52 Seven day services – Medicine

53 Seven day services – Surgery

31 People and Corporate Affairs High Impact Improvement Plan - Culture

32 People and Corporate Affairs High Impact Improvement Plan – Capacity

33 People and Corporate Affairs High Impact Improvement Plan – Competence

34 People and Corporate Affairs High Impact Improvement Plan - Communication

43 Seven Day working - Acute Surgery flow

Joint working

Quality

Workforce

Clinical /

operational

practice

Efficiency

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Table 2: Divisional Level / Executive Led Group Reported Schemes

Financial Considerations

24. Under the ‘Acting as One’ agreement, the Trust along with all other provider organisations in

the North Mersey Local Delivery System (NMLDS), have agreed a block contract for 2017/18

and 2018/19 with our four main commissioners, Liverpool CCG; South Sefton CCG (incl

Southport & Formby CCG); Knowsley CCG; and NHS England Specialised Commissioning.

25. This agreement has been put in place to support the delivery of the NMLDS plans, providing

the required financial stability for implementation of the system transformation considered

necessary to deliver a clinically and financially sustainable future, in line with the aspirations of

the Healthy Liverpool Programme and Shaping Sefton.

26. The ‘Acting as One’ financial envelope has been developed on the basis of no anticipated

changes to activity levels. In order to support this on-going monitoring will take place with

material movements reported to allow corrective action to be formulated.

27. A more detailed briefing has been circulated to senior management teams for wider

dissemination within the organisation. It is intended to help guide management and

operational teams in decision making in relation to financial management and service

developments / change, in response to changes in the contracting environment.


28. Completion of the business planning process will support the delivery of quality, finance and

workforce development across the Trust.

Theme ABP Ref Priority description

4 Divisional Orthopaedic Service Re-design

5 Hydrotherapy Pool / Facilities

20 Deliver sustainable Respiratory outpatient services in a community setting for Knowsley

CCG

8 Imaging of Stroke Patients

9 Cardiac Imaging Service

10 Inpatient Demand - Radiology

11 MCAS Sefton /Liverpool

12 Early Supported Discharge (Stroke)

13 Out of Hours MRI Imaging

25 Improving access to GP/primary care services at the ‘front door’ of the ED

26 Maximise patient flow to ambulatory emergency care

27 Implement dialysis service changes

28 Outpatients - address existing pressures through provision of capacity and redesign

48 Increasing outpatient access through exploration of advice and guidance and telephone

follow ups to reduce the number of outpatient attendances

29 Review of the medical daycase unit

30 Cardiology diagnostics utilisation service review

21 Implement medicine workforce strategy linked to medical workforce

22 Reduce pay costs from premium rate and agency sessions across Divisional footprint

44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia Division

Clinical /

operational

practice

Efficiency

Joint working

Workforce

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Conclusion

29. The annual business planning process represents an opportunity to support the organisation in

focusing on achievement of its strategic and operational objectives. The annual business

planning process for 2017/18 has focused on delivery of a list of schemes that represent

organisational priorities in achievement of these objectives.

30. Divisional and Corporate leads have provided detail related to proposed annual business plan

schemes related to their area for inclusion in the Trust business plan. The outputs from this

exercise have been collated and presented here as the Trust Annual Business Plan for

2017/18.

31. Reporting will be undertaken on a quarterly basis providing a progress update against each

scheme at Divisional and Executive Led Group, as well as Trust level.

Recommendation

32. The Council of Governors is asked to note the proposed Annual Business Plan for 2017/18 as

set out in this paper and outlined in Appendices 1 and 2

Author: Alistair Leinster, Head of Corporate Planning and Performance

Date: 9th May 2017

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Appendix 1 – List of Annual Business Plan Schemes by Strategic Objective

ABP Ref Scheme Title Executive Led Group

1 Proposed Merger Transaction HMB

15 Work with Merseycare to improve crisis care for people with mental health

problems who present to AED.

Ops and Performance

21 Implement medicine workforce strategy linked to medical workforce Workforce

24 Deliver Stroke standards for all of our patients and to deliver sustainability

across the clinical teams.

Clinical Effectiveness

27 Implement dialysis service changes Ops and Performance

32 People and Corporate Affairs High Impact Improvement Plan – Capacity Workforce

36 Care that is Safe: Reducing Harm Safety and Risk

39 Care That Provides a Positive Experience for Patients and their Families Patient Experience

41 Consideration of case for increased capacity within the Intravenous (IV)

Team


44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia

Division

Workforce

45 To develop safe and sustainable Dermatology services for Aintree university

Hospital in partnership with local provider or providers

Ops and Performance


8 Imaging of Stroke Patients Clinical Effectiveness

9 Cardiac Imaging Service Clinical Effectiveness

24 Deliver Stroke standards for all of our patients and to deliver sustainability

across the clinical teams.


33 People and Corporate Affairs High Impact Improvement Plan – Competence Workforce

37 Care that is Safe: Reducing Avoidable Mortality Clinical Effectiveness

38 Care that is Clinically Effective Clinical Effectiveness

43 Seven Day working - Acute Surgery flow Ops and Performance

50 Implementation of ‘National Guidance on Learning from Deaths’ from the

National Quality Board on structured review of deaths


51 Seven day services – Diagnostics and Support Services Ops and Performance

52 Seven day services – Medicine Ops and Performance

53 Seven day services – Surgery Ops and Performance

1 Proposed Merger Transaction* HMB

1. Deliver outstanding care - by being a patient-centred organisation that provides high quality, safe and compassionate

services

2. Achieve best patient outcomes - by providing effective treatment to achieve best possible patient outcomes and promote

quality of life

3. Promote research and education - by delivering the benefits of education, research and innovation for our patients and staff

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ABP Ref Scheme Title


6 Cancer Services Support - Radiology Ops and Performance

10 Inpatient Demand - Radiology Clinical Effectiveness

13 Out of Hours MRI Imaging Ops and Performance

14 Outpatient productivity Ops and Performance

16 Collaborative working with the stroke network and other local providers in

implementing new stroke pathways

Ops and Performance

22 Reduce pay costs from premium rate and agency sessions across

Divisional footprint

Workforce

23 AED flow measures: improving access to GP, primary care at front door,

maximise patient flow to ambulatory emergency care (combined reporting

line see ABP Ref 15, 25, 26)

Ops and Performance

25 Improving access to GP/primary care services at the ‘front door’ of the ED Ops and Performance

26 Maximise patient flow to ambulatory emergency care Ops and Performance

28 Outpatients - address existing pressures through provision of capacity and

redesign

Ops and Performance

29 Review of the medical daycase unit Ops and Performance

30 Cardiology diagnostics utilisation service review Ops and Performance

40 Delivery of Quality of Efficiency Programme savings against plan Ops and Performance

46 Improving Acute Surgery flow, in the surgical assessment unit and across

the Surgical Division.

Ops and Performance

47 To continue to reduce risks to Ophthalmology patients due to insufficient

capacity to see patients in a timely way.

Safety and Risk

48 Increasing outpatient access through exploration of advice and guidance and

telephone follow ups to reduce the number of outpatient attendances

Ops and Performance

49 To improve Theatre productivity and efficiency , by increasing the number of

theatre sessions running and increasing the use of theatre time in session.

Ops and Performance

2 Working collaboratively with partners across health and social care to

resolve some of the key challenges facing the Trust

Ops and Performance

3 Maintain a focus on the delivery of high quality community services through

collaboration with others

HMB

4 Divisional Orthopaedic Service Re-design Ops and Performance

5 Hydrotherapy Pool / Facilities Ops and Performance

7 IT EPR Implementation Ops and Performance

11 MCAS Sefton /Liverpool Ops and Performance

12 Early Supported Discharge (Stroke) Ops and Performance

17 Contribution to Cardiology city wide service reconfiguration Ops and Performance

18 Contribution to Respiratory and City-wide Service Reconfiguration Ops and Performance

19 Haemato-Oncology Transfer of Services Ops and Performance

20 Deliver sustainable Respiratory outpatient services in a community setting

for Knowsley CCG

Ops and Performance

42 North Mersey Orthopaedic & Trauma Service (MOATS) Ops and Performance

31 People and Corporate Affairs High Impact Improvement Plan - Culture Workforce

34 People and Corporate Affairs High Impact Improvement Plan -

Communication

Workforce

6. Be a well-governed and clinically-led organisation - by developing and supporting effective leadership across the

organisation to enable our people to achieve our vision

4. Deliver sustainable healthcare to meet people’s needs - by delivering efficient, cost effective services to ensure their long-

term sustainability

5. Provide strong system leadership - by working together to support seamless pathways across all sectors

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Appendix 2 - List of Annual Business Plan Schemes by Executive Led Group

ABP

Ref Scheme Title Division

Trust

Reported

8 Imaging of Stroke PatientsDiagnostics and

SupportN

9 Cardiac Imaging ServiceDiagnostics and

SupportN

10 Inpatient Demand - RadiologyDiagnostics and

SupportN

24 Deliver Stroke standards for all of our patients and to deliver sustainability across the clinical teams. Medicine Y

37 Care that is Safe: Reducing Avoidable MortalityMedical Dir /

Nurse DirY

38 Care that is Clinically EffectiveMedical Dir /

Nurse DirY

41 Consideration of case for increased capacity within the Intravenous (IV) Team Medical Dir /

Nurse DirY

50Implementation of ‘National Guidance on Learning from Deaths’ from the National Quality Board on

structured review of deaths

Medical Dir /

Nurse DirY

1 Proposed Merger Transaction Corporate Y

3 Maintain a focus on the delivery of high quality community services through collaboration with othersCorporate

Y

2Working collaboratively with partners across health and social care to resolve some of the key

challenges facing the TrustCorporate Y

4 Divisional Orthopaedic Service Re-designDiagnostics and

SupportN

5 Hydrotherapy Pool / FacilitiesDiagnostics and

SupportN

6 Cancer Services Support - RadiologyDiagnostics and

SupportY

7 IT EPR ImplementationDiagnostics and

SupportY

11 MCAS Sefton /LiverpoolDiagnostics and

SupportN

12 Early Supported Discharge (Stroke)Diagnostics and

SupportN

13 Out of Hours MRI ImagingDiagnostics and

SupportN

14 Outpatient productivityDiagnostics and

SupportY

15Work with Merseycare to improve crisis care for people with mental health problems who present to

AED. Medicine Y

16Collaborative working with the stroke network and other local providers in implementing new stroke

pathwaysMedicine Y

17 Contribution to Cardiology city wide service reconfiguration Medicine Y

18 Contribution to Respiratory and City-wide Service Reconfiguration Medicine Y

19 Haemato-Oncology Transfer of Services Medicine Y

20 Deliver sustainable Respiratory outpatient services in a community setting for Knowsley CCG Medicine N

23AED flow measures: improving access to GP, primary care at front door, maximise patient flow to

ambulatory emergency care (combined reporting line see ABP Ref 15, 25, 26)Medicine Y

25 Improving access to GP/primary care services at the ‘front door’ of the ED Medicine N

26 Maximise patient flow to ambulatory emergency care Medicine N

27 Implement dialysis service changes Medicine N

Clinical Effectiveness (8 annual business plan reporting lines)

HMB ( 2 annual business plan reporting lines)

Ops and Performance (32 annual business plan reporting lines)

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ABP

Ref Scheme Title Division

Trust

Reported

28 Outpatients - address existing pressures through provision of capacity and redesign Medicine N

29 Review of the medical daycase unit Medicine N

30 Cardiology diagnostics utilisation service review Medicine N

40 Delivery of Quality of Efficiency Programme savings against plan Corporate Y

42 North Mersey Orthopaedic & Trauma Service (MOATS) Surgery Y

43 Seven Day working - Acute Surgery flow Surgery Y

45To develop safe and sustainable Dermatology services for Aintree university Hospital in partnership

with local provider or providers Surgery Y

46 Improving Acute Surgery flow, in the surgical assessment unit and across the Surgical Division. Surgery Y

48Increasing outpatient access through exploration of advice and guidance and telephone follow ups to

reduce the number of outpatient attendances Surgery N

49To improve Theatre productivity and efficiency , by increasing the number of theatre sessions running

and increasing the use of theatre time in session. Surgery Y

51 Seven day services – Diagnostics and Support ServicesDiagnostics and

SupportY

52 Seven day services – Medicine Medicine Y

53 Seven day services – Surgery Surgery Y

39 Care That Provides a Positive Experience for Patients and their FamiliesMedical Dir /

Nurse DirY

36 Care that is Safe: Reducing HarmMedical Dir /

Nurse DirY

47To continue to reduce risks to Ophthalmology patients due to insufficient capacity to see patients in a

timely way.Surgery Y

21 Implement medicine workforce strategy linked to medical workforce Medicine N

22 Reduce pay costs from premium rate and agency sessions across Divisional footprint Medicine N

31 People and Corporate Affairs High Impact Improvement Plan - Culture People and OD Y

32 People and Corporate Affairs High Impact Improvement Plan – Capacity People and OD Y

33 People and Corporate Affairs High Impact Improvement Plan – Competence People and OD Y

34 People and Corporate Affairs High Impact Improvement Plan - Communication People and OD Y

44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia Division Surgery N

Workforce Executive Led Group (7 annual business plan reporting lines)

Patient Experience Executive Led Group (1 annual business plan reporting line)

Safety and Risk Executive Led Group ( 2 annual business plan reporting lines)

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1/5



Report Title Directors Dragons Den – Review of approved schemes

Executive Lead Sue Green, director People & Corporate Affairs

Lead Officer Ruth Hoyte, Associate Director OD

Action Required To review & agree any actions arising





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


Provides a summary of schemes approved by Director Dragons Den

Outlines investment to date and completed schemes

Indicates benefits including return on investment, benefits and areas for improvement


Quality

Finance

Workforce

Equality

Risk

Compliance

Legal














Key Risk

Service Change

Other



To identify further reporting arrangements

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2/5

REPORT HISTORY


Agenda Ref



Page 29 of 78


Directors Dragons Den – Review of approved schemes: Council of Governors 15 June 2017 3/5

Directors Dragons Den – Review of approved schemes

Executive Summary

1. This report provides a summary of schemes which have been supported through Directors

Dragons Den since its inception in October 2014. It focusses only on those bids which

approved and provides an update on progress of the schemes. The report also outlines

returns on investment, benefits, learning points and areas to improve.

Key Issues / Proposal

2. The Directors Dragons Den (DDD) was created as a concept in October 2014 following

feedback from Listening into Action and other staff engagement the some improvements

require “start - up money” and there was commitment from the executive team at the time to

establish a process for this.

3. The DDD has evolved since then and is now composed of the Executive Team, Associate

Director OD, a non-executive Director and representative of the Academic healthcare

Science Network. The process is organised and supported by OD.

4. There are two rounds of DDD in each financial year when staffs at all levels are encouraged

to bid for financial support to support an improvement or innovation in their areas. There

are 6 steps to the process:

- Submission of proposal

- Shortlisting

- Presentation to the DDD

- Award of financial support and allocation of “Dragon”

- Completion of scheme

- Poster presentation

5. Staff or teams can bid for up to £25k including VAT for their idea and £250k is ring-fenced

for each round per year.

6. Bids are received from staff of all levels and representative of all roles in the organisation.

Summary of successful schemes

7. Appendix 1 provides an overview of all the approved schemes, funding allocated and

funding spent from October 2014 until the most recent DDD in March 2017.

8. Since October 2014 35 schemes have been approved with a total of £419k allocated to

support the schemes. The smallest amount allocated was £540 and some bids have been

allocated the full amount of £25k for their proposal.

9. The table indicates that 17 bids are fully completed, 13 are partially completed, 5 haven’t

started yet and 1 scheme has been withdrawn.

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10. Of the £419k allocated within the DDD £171k has been spent. This is due to numerous

reasons including bidders have spent less than allocated, some schemes have not yet

started and some have withdrawn. Also in allocating funds the DD will often commit to

funding up to a sum of money conditional on certain outcomes or delivery. Some bids will

not have been fully financially modelled so on occasions will require less or more to deliver.

There is flexibility to support this but the limit of £25k cannot be exceeded.

Benefits of DDD

11. A short summary of return on investment for the completed schemes is included in the

appendix 1. Returns can either be quantitative such as having financial or performance

benefit or qualitative in terms of patient experience or staff experience.

12. The benefits of DDD to our patients and staff are much wider and broader. The principles of

DDD help to deliver the trust mission, vision and values. Each of the schemes will meet at

least one of the strategic aims and supports the common purpose of “getting it right for

every patient every time”.

13. Benefits of the schemes to our patients will include:

- Delivering safer care

- Enhancing care or patient experience

- Improving access to services

- Reducing length of stay

- Preventing admission

- Reducing risks e.g. IPC

- Improving communication

14. In addition there are numerous benefits to staff:

- Encouraging a culture of improvement and generating ideas from frontline staff

- Developing proposals without the need to develop formal business cases

- Support to present and sell ideas

- Opportunity to meet and engage with executive

- Developing confidence that ideas will be held

- Developing financial awareness

- Project planning

- Use of improvement methodologies

Learning points & areas to improve

15. Each round of DDD has been a learning experience and it has evolved responding to

changes to the executive team and the needs of the organisation. Since it was conceived

other development such as AQUIS and QEP have emerge. DDD has been linked to these.

For example the DDD & AQUIS showcase events are now aligned and are one event to

celebrate success of either. Consistency in improvement methodologies and project

planning is encouraged.

16. Some proposals are easier to implement than others and the success of the schemes can

be influenced by factors other than finance. For the future more robust tracking of schemes

is required and consistency of support needs to be addressed.

Page 31 of 78



17. The process for allocation of funds has become easier and more transparent but further

review is needed to ensure funds are deployed successfully and meet the needs of the

scheme.

18. Where schemes are delayed there needs to be a clear decision making process on the

duration of the offer of funding support to avoid the process being open ended.


Quality – DDD has demonstrated a positive impact on quality both in terms of patient care and

experience

Finance –Positive impact of small non-recurring investment on patient and staff experience

Workforce – positive impact on staff engagement particularly in feeling valued and supported.

Promotes team working and innovation and learning.

Conclusion

19. In summary DDD has demonstrated that a relatively small financial commitment can result

in significant patient and staff benefits. There is also benefit for the organisation in

promoting innovation and improvement as well as reputation. DDD requires an approach of

continuous improvement to ensure its continued success including review of schemes and

ensuring delivery and return on investment.

Recommendation

20. It is recommended DDD continues to operate with 2 windows in the year for staff to bid for

non-recurring funds to support improvements

References and further reading

Author: Ruth Hoyte, Associate Director OD

Date: 2nd June 2017

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Page 34 of 78

1/2

Lead Governors Report


Date 15 June 2017

Committee Name Council of Governors

Chair’s Name & Title Pamela Peel, Lead Governor

Core Governor Activity

Attendance at Board meetings and Board Feedback sessions with the Chairman

Appraisals of the Non Executive Directors including the Chairman

Quality Accounts

Director Walkabouts

Quality of Care Committee

Membership Committee

Quarterly Informal Council of Governors – the meeting on 6 June was chaired by Lorraine Heaton

Governor Development

Media Awareness Session led by Fin McNicol, 3 April – attended by 10 Governors

Serious Incidents Session, led by Tristan Cope, 8 May – attended by 11 Governors

Wider Trust Activity

Staff Induction each month – Staff Governors are taking it in turn to make a brief presentation on

membership to new staff on their first day in the Trust

Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members

from amongst people who are already committed to the Trust, and also to engage with them, hear

their ‘stories’ and recognise the contribution they make to the smooth running of the hospital.

Workstream – Tony Kneebone continues to be involved in the Catering Food Quality Group. At the

last meeting the cost of patient meals was discussed. Aintree is in the middle range of costs

compared to other hospitals, spending £10 per day per patient, this figure includes food, staff and all

the associated costs. The Group then tasted the four full meals on offer that evening and discussed

the quality, they made some suggestions to improve things but generally were satisfied with the

menu.

PLACE Validation – Sharon Bird was a member of the team that undertook a review on 27 April 2017

External Activity

Healthwatch Sefton, 29 March – Pam Peel attended. A useful networking opportunity, particularly

interesting was the demo of the new online feedback centre, and how it is used to identify trends and

themes. There was a presentation by Southport & Ormskirk Hospital senior management team on

progress with their CQC report

Edge Hill Return to Nurse Practice Programme – Pam Peel attended a Seminar presentation on 20

April as a follow-up to the interview panel she participated in last November. The presentations take

the form of a 15 minute reflection on a critical incident from practice or taught session which the

5. C

G17

-18/

008

- Le

ad G

over

nor

Rep

ort

Page 35 of 78


2/2

student finds surprising, disturbing or puzzling. All were thought provoking. Pam Peel also attended

a networking lunch with the Nursing and Midwifery Council on 26 April when the assessment team

visited Aintree to speak with Return to Practice students and their mentors to evaluate their overall

experience.

Meeting with Shadow Lead Governor RLBUHT, 27 April

Lead Governor Network – topics under discussion include Governor Expenses and the

length/number of terms Governors are permitted to serve.

Recommendation

The Council of Governors is asked to note the report.

Page 36 of 78

Co

un

cil o

f G

ov

ern

ors

15 J

un

e2017

6 &

7. C

G17

-18/

009

& 0

10 -

Ass

uran

ce o

n K

ey In

dica

tors

: Qua

lity

& S

afet

y; F

inan

ce &

Per

form

ance

; A

udit

Page 37 of 78

Str

ate

gic

Up

da

te

•A

intr

ee

/Roya

l Liv

erp

ool m

erg

er

•C

are

Qualit

y C

om

mis

sio

n I

nspe

ctio

n

Page 38 of 78

Key A

rea

s o

f A

ssu

ran

ce

Inte

rnal

Syste

m o

f C

on

tro

l (A

ud

it)

Tim

Jo

hn

sto

n, N

on

Execu

tive D

irecto

r

Key

Are

as

of

Fo

cu

sO

n-g

oin

gA

ssu

ran

ce

As

su

ran

ce

so

ug

ht

on

are

as

of

co

ncern

Board

Assura

nce F

ram

ew

ork

2017-1

8

Bank,agency a

nd locum

sta

ffS

afe

guard

ing

Payro

ll

Annual A

ccounts

Appro

val and

Exte

rnal A

udit

Losses &

Com

pensations

Reduction in o

vera

ll score

report

ed

for

Info

rmation G

overn

ance

Inte

rnal A

udit -

Annual R

eport

and F

utu

re W

ork

pla

n

Tru

st P

olic

y C

om

plia

nce

Inte

rnal A

udit R

eport

s

-S

afe

guard

ing

-P

ayro

ll

-M

andato

ry T

rain

ing

Counte

r F

raud A

nnual R

eport

and

Futu

re W

ork

pla

n

Info

rmation G

overn

ance A

nnual

Report

6 &

7. C

G17

-18/

009

& 0

10 -

Ass

uran

ce o

n K

ey In

dica

tors

: Qua

lity

& S

afet

y; F

inan

ce &

Per

form

ance

; A

udit

Page 39 of 78

Qu

ality

& P

erf

orm

an

ce

Ma

na

ge

me

nt

As

su

ran

ce o

n K

ey I

nd

ica

tors

Kevan

Ryan

, N

on

Execu

tive D

irecto

r

Jo

an

ne C

lag

ue, N

on

Execu

tive D

irecto

r

Page 40 of 78

Key A

reas

of

Ass

ura

nce

Qu

ality

& S

afe

ty

Key

Are

as

of

Fo

cu

sO

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Page 50 of 78

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pec

ifie

din

dic

ato

rs”)

are

ma

rked

wit

hth

esy

mb

ol

inth

eQ

ua

lity

Rep

ort

an

dco

nsi

sto

f:

Sp

ec

ifie

dIn

dic

ato

rs

Sp

ec

ifie

din

dic

ato

rs

cr

ite

ria

(Mo

nit

or

sD

eta

ile

d

Gu

ida

nc

e)

Per

cen

tag

eo

fin

com

ple

te

pa

thw

ays

wit

hin

18w

eek

sfo

r

pa

tien

tso

nin

com

ple

tep

ath

wa

ys

at

the

end

of

the

rep

ort

ing

per

iod

An

nex

c–

Pa

ge

19

Per

cen

tag

eo

fp

ati

ents

wit

ha

tota

l

tim

ein

A&

Eo

ffo

ur

ho

urs

or

less

fro

ma

rriv

al

toa

dm

issi

on

,tr

ansf

er

or

dis

cha

rge

An

nex

C–

Pa

ge

20

Ou

rp

roce

du

res

incl

ud

ed:

o

bta

inin

ga

nu

nd

erst

an

din

go

fth

ed

esig

na

nd

op

era

tio

no

fth

eco

ntr

ols

inp

lace

inre

lati

on

toth

eco

lla

tio

na

nd

rep

ort

ing

of

the

spec

ifie

din

dic

ato

rs,

incl

ud

ing

con

tro

lso

ver

thir

dp

art

yin

form

ati

on

(if

ap

pli

cab

le)

an

dp

erfo

rmin

gw

alk

thro

ug

hs

toco

nfi

rmo

ur

un

der

sta

nd

ing

;

b

ase

do

no

ur

un

der

sta

nd

ing

,a

sses

sin

gth

eri

sks

tha

tth

ep

erfo

rma

nce

ag

ain

stth

esp

ecif

ied

ind

ica

tors

ma

yb

em

ate

ria

lly

mis

sta

ted

an

dd

eter

min

ing

the

na

ture

,ti

min

ga

nd

exte

nt

of

furt

her

pro

ced

ure

s;

m

ak

ing

enq

uir

ies

of

rele

van

tm

an

ag

emen

t,p

erso

nn

ela

nd

,w

her

ere

leva

nt,

thir

dp

art

ies;

co

nsi

der

ing

sig

nif

ica

nt

jud

gm

ents

ma

de

by

the

Tru

stin

pre

pa

rati

on

of

the

spec

ifie

din

dic

ato

rs;

an

d

p

erfo

rmin

gli

mit

edte

stin

g,

on

ase

lect

ive

ba

sis

of

evid

ence

sup

po

rtin

gth

ere

po

rted

per

form

an

cein

dic

ato

rs,

an

da

sses

sin

gth

ere

late

dd

iscl

osu

re.

Lo

cal

ind

ica

tor

We

are

als

ore

qu

ired

tou

nd

erta

ke

sub

sta

nti

ve

sam

ple

test

ing

of

on

efu

rth

erlo

cal

ind

ica

tor.

Th

isin

dic

ato

ris

no

tin

clu

ded

ino

ur

lim

ited

ass

ura

nce

rep

ort

.In

stea

d,

we

are

req

uir

edto

pro

vid

ea

det

ail

edre

po

rto

no

ur

fin

din

gs

an

dre

com

men

da

tio

ns

for

imp

rove

men

tsin

this

,o

ur

Go

ver

no

rsre

po

rt.

Th

eT

rust

’sG

ove

rno

rsse

lect

the

ind

ica

tor

tob

esu

bje

ctto

ou

rsu

bst

an

tive

sam

ple

test

ing

.T

he

ind

ica

tor

sele

cted

is:

Per

cen

tag

eo

fp

ati

ent

safe

tyin

cid

ence

sth

at

resu

ltin

sev

ere

ha

rmo

rd

eath

.

Page 52 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C3

Co

nte

nt

of

the

Qu

ali

tyR

epo

rt

No

issu

esh

ave

com

eto

ou

ra

tten

tio

nth

at

lea

du

sto

bel

ieve

tha

tth

eQ

ua

lity

Rep

ort

do

esn

ot

inco

rpo

rate

the

ma

tter

sre

qu

ired

tob

ere

po

rted

on

as

spec

ifie

din

the

FT

AR

Ma

nd

the

“Det

ail

edre

qu

irem

ents

for

qu

ali

tyre

po

rts

for

fou

nd

ati

on

tru

sts

20

16/1

7”:

Lim

ite

dA

ss

ur

an

ce

Re

po

rt

As

are

sult

of

ou

rw

ork

,w

ea

rea

ble

top

rov

ide

an

un

qu

ali

fied

lim

ited

ass

ura

nce

rep

ort

inre

spec

to

fth

eco

nte

nt

of

the

Qu

ali

tyR

epo

rt.

Co

nsi

sten

cyw

ith

Oth

erIn

form

ati

on

No

issu

esh

ave

com

eto

ou

ra

tten

tio

nth

at

lea

du

sto

bel

ieve

tha

tth

eQ

ua

lity

Rep

ort

isn

ot

con

sist

ent

wit

hth

eo

ther

info

rma

tio

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urc

esd

efin

edb

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HS

I’s

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ail

edre

qu

irem

ents

for

qu

ali

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po

rts

for

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nd

ati

on

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sts

20

16/1

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ite

dA

ss

ur

an

ce

Re

po

rt

As

are

sult

of

ou

rw

ork

,w

ea

rea

ble

top

rov

ide

an

un

qu

ali

fied

lim

ited

ass

ura

nce

rep

ort

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spec

to

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eco

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lity

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ort

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hth

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uir

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ort

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da

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ust

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ecte

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nce

ind

ica

tors

Ou

rfi

nd

ing

sre

lati

ng

toth

ep

erfo

rma

nce

ind

ica

tors

are

sum

ma

rise

da

sfo

llo

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mm

ar

yo

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nd

ing

s

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G17

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g F

orm

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ort (

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erna

l Ass

uran

ce o

n Q

A)

Page 53 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C4

Pe

rfo

rm

an

ce

ind

ica

tor

sin

clu

de

din

ou

rli

mit

ed

as

su

ra

nc

er

ep

or

tF

ind

ing

s

Per

cen

tag

eo

fin

com

ple

tep

ath

wa

ysw

ith

in18

wee

ks

for

pa

tien

tso

nin

com

ple

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ath

wa

ysa

tth

een

do

fth

ere

po

rtin

gp

erio

d

On

eis

sue

iden

tifi

ed;

No

imp

act

on

ou

rli

mit

eda

ssu

ran

ceo

pin

ion

.

Per

cen

tag

eo

fp

ati

ents

wit

ha

tota

lti

me

inA

&E

of

fou

rh

ou

rso

rle

ssfr

om

arr

iva

lto

ad

mis

sio

n,

tra

nsf

ero

rd

isch

arg

e

No

issu

esid

enti

fied

.

Lim

ite

dA

ss

ur

an

ce

Re

po

rt

As

ar

es

ult

of

ou

rw

or

k,

we

ar

ea

ble

top

ro

vid

ea

nu

nq

ua

lifi

ed

lim

ite

da

ss

ur

an

ce

re

po

rt

inr

es

pe

ct

of

the

ma

nd

ate

dp

er

for

ma

nc

ein

dic

ato

rs

.

Pe

rfo

rm

an

ce

ind

ica

tor

no

tin

clu

de

dw

ith

ino

ur

lim

ite

da

ss

ur

an

ce

re

po

rt

Fin

din

gs

Per

cen

tag

eo

fp

ati

ent

safe

tyin

cid

ence

sth

at

resu

ltin

seve

reh

arm

or

dea

th.

No

issu

esid

enti

fied

.

An

nu

al

Go

ver

na

nce

Sta

tem

ent

We

iden

tifi

edn

ois

sues

rele

van

tto

the

Qu

ali

tyR

epo

rt.

Page 54 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C5

Rev

iew

ag

ain

stth

eco

nte

nt

req

uir

emen

tsW

ere

view

edth

eco

nte

nt

of

the

Qu

ali

tyR

epo

rta

ga

inst

the

con

ten

tre

qu

irem

ents

wh

ich

are

spec

ifie

din

the

FT

AR

Ma

nd

the

“Det

ail

edre

qu

irem

ents

for

qu

ali

tyre

po

rts

for

fou

nd

ati

on

tru

sts

20

16/1

7”.

No

issu

esca

me

too

ur

att

enti

on

tha

tle

du

sto

bel

iev

eth

at

the

Qu

ali

tyR

epo

rth

as

no

tb

een

pre

pa

red

inli

ne

wit

hth

eF

TA

RM

an

dth

e“D

eta

iled

req

uir

emen

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rq

ua

lity

rep

ort

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un

da

tio

ntr

ust

s2

016

/17

”.

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iew

con

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ency

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ain

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ecif

ied

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rce

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cum

ents

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the

tim

eo

fw

riti

ng

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do

cum

ent,

we

wer

ein

the

pro

cess

of

fin

ali

sin

gth

isw

ork

.T

he

item

sli

sted

bel

ow

are

the

key

do

cum

ents

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e/

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nu

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oa

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the

da

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the

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ited

ass

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eed

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;

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20

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he

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are

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ali

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spec

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ted

06

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he

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al

Au

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nd

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ur

att

enti

on

tha

tle

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sto

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ieve

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ua

lity

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ort

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ot

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sist

ent

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ail

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Page 55 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C6

Per

form

an

cein

dic

ato

rso

nw

hic

hw

ea

rere

qu

ired

tois

sue

ali

mit

eda

ssu

ran

ceco

ncl

usi

on

As

req

uir

edb

yN

HS

Iw

eh

ave

un

der

tak

ensa

mp

lete

stin

go

ftw

op

erfo

rma

nce

ind

ica

tors

on

wh

ich

we

issu

edo

ur

lim

ited

ass

ura

nce

rep

ort

:

1.P

erce

nta

ge

of

inco

mp

lete

pa

thw

ays

wit

hin

18w

eek

sfo

rp

ati

ents

on

inco

mp

lete

pa

thw

ays

at

the

end

of

the

rep

ort

ing

per

iod

2.

Per

cen

tag

eo

fp

ati

ents

wit

ha

tota

lti

me

inA

&E

of

fou

rh

ou

rso

rle

ssfr

om

arr

iva

lto

ad

mis

sio

n,

tra

nsf

ero

rd

isch

arg

e

We

are

req

uir

edto

ob

tain

an

un

der

sta

nd

ing

of

the

key

pro

cess

esa

nd

con

tro

lsfo

rm

an

ag

ing

an

dre

po

rtin

gth

ein

dic

ato

rsa

nd

sam

ple

test

the

da

tau

sed

toca

lcu

late

the

ind

ica

tor.

Ou

rw

ork

isp

erfo

rmed

ina

cco

rda

nce

wit

hth

ed

eta

iled

gu

ida

nce

an

din

clu

ded

:

Id

enti

fica

tio

no

fth

ecr

iter

iau

sed

by

the

Tru

stfo

rm

easu

rin

gth

ein

dic

ato

r;

C

on

firm

ati

on

tha

tth

eT

rust

ha

dp

rese

nte

dth

ecr

iter

iaid

enti

fied

ab

ov

ein

the

Qu

ali

tyre

po

rtin

suff

icie

nt

det

ail

tha

tth

ecr

iter

iaa

rere

ad

ily

un

der

sta

nd

ab

leto

use

rso

fth

eQ

ua

lity

Rep

ort

;

U

pd

ati

ng

ou

ru

nd

erst

an

din

go

fth

ek

eyp

roce

sses

an

dco

ntr

ols

for

ma

na

gin

ga

nd

rep

ort

ing

the

ind

ica

tor

thro

ug

hm

ak

ing

enq

uir

ies

of

Tru

stst

aff

an

dth

rou

gh

per

form

ing

aw

alk

thro

ug

h;

C

hec

kin

gth

eT

rust

’sre

con

cili

ati

on

of

the

rep

ort

edp

erfo

rma

nce

inth

eQ

ua

lity

Rep

ort

toth

ed

ata

use

dto

calc

ula

teth

ein

dic

ato

rfr

om

the

Tru

st’s

un

der

lyin

gsy

stem

s;

T

esti

ng

asa

mp

leo

fre

leva

nt

da

tau

sed

toca

lcu

late

the

ind

ica

tor;

an

d

O

bta

inin

gre

pre

sen

tati

on

sth

at

the

da

tau

sed

toca

lcu

late

the

ind

ica

tor

isa

ccu

rate

lyca

ptu

red

at

sou

rce

an

dth

at

no

sou

rces

of

info

rma

tio

n/d

ata

rele

van

tto

the

ind

ica

tor

per

form

an

ceh

av

eb

een

excl

ud

ed.

We

on

lyte

sted

asa

mp

leo

fd

ata

,a

sst

ate

da

bo

ve,

tosu

pp

ort

ing

do

cum

enta

tio

n.

Th

eref

ore

,th

eer

rors

rep

ort

edb

elo

wa

reli

mit

edto

this

sam

ple

.

We

ha

vea

lso

no

tte

sted

the

un

der

lyin

gsy

stem

s,fo

rex

am

ple

the

pa

tien

ta

dm

inis

tra

tio

nsy

stem

an

dth

ed

ata

extr

act

ion

an

dre

cord

ing

syst

ems.

Ou

rfi

nd

ing

sa

rese

to

ut

bel

ow

.R

eco

mm

end

ati

on

sa

risi

ng

fro

mth

ese

fin

din

gs

are

pre

sen

ted

inA

pp

end

ixB

.

Page 56 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C7

Pe

rc

en

tag

eo

fin

co

mp

lete

pa

thw

ay

sw

ith

in18

we

ek

sfo

rp

ati

en

tso

nin

co

mp

lete

pa

thw

ay

s

Re

po

rte

dp

er

for

ma

nc

e:

20

16/1

7T

hr

es

ho

ld:

92

%2

016

/17

:9

1.2

%

Cr

ite

ria

ide

nti

fie

d:

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con

firm

edth

eT

rust

use

sth

efo

llo

win

gcr

iter

iafo

rm

easu

rin

gth

ein

dic

ato

rfo

rin

clu

sio

nin

the

Qu

ali

tyR

epo

rt:

T

he

ind

ica

tor

isex

pre

ssed

as

ap

erce

nta

ge

of

inco

mp

lete

pa

thw

ays

wit

hin

18w

eek

sfo

rp

ati

ents

on

inco

mp

lete

pa

thw

ays

at

the

end

of

the

per

iod

;

T

he

ind

ica

tor

isca

lcu

late

da

sth

ea

rith

met

ica

vera

ge

for

the

mo

nth

lyre

po

rted

per

form

an

cein

dic

ato

rsfo

rA

pri

l2

016

toM

arc

h2

017

;

T

he

clo

ckst

art

da

teis

def

ined

as

the

da

teth

at

the

refe

rra

lis

rece

ived

by

the

Fo

un

da

tio

nT

rust

,m

eeti

ng

the

crit

eria

set

ou

tb

yth

eD

epa

rtm

ent

of

Hea

lth

gu

ida

nce

;a

nd

T

he

ind

ica

tor

incl

ud

eso

nly

refe

rra

lsfo

rco

nsu

lta

nt-

led

serv

ice,

an

dm

eeti

ng

the

def

init

ion

of

the

serv

ice

wh

ereb

ya

con

sult

an

tre

tain

so

vera

llcl

inic

al

resp

on

sib

ilit

yfo

rth

ese

rvic

e,te

am

or

trea

tmen

t.

Iss

ue

sid

en

tifi

ed

thr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

.Is

su

eIm

pa

ct

on

lim

ite

da

ss

ur

an

ce

re

po

rt

1.F

or

on

ep

ati

ent

wit

hin

ou

rsa

mp

lew

en

ote

dth

at

the

clo

ckst

art

da

tew

as

dif

fere

nt

fro

mth

ed

ate

on

the

refe

rra

lle

tter

.H

ow

ever

,th

isd

idn

ot

ha

vea

nim

pa

cto

nth

ea

ctu

al

per

form

an

cea

sth

ep

ati

ent

wa

sst

ill

rep

ort

edin

the

corr

ect

per

iod

.

No

imp

act

on

ou

rli

mit

eda

ssu

ran

cere

po

rt.

Ov

er

all

Co

nc

lus

ion

:

Ou

rsu

bst

an

tiv

ete

stin

go

fth

ein

dic

ato

rid

enti

fied

on

eis

sue.

Th

eis

sue

no

ted

wa

sa

dif

fere

nce

an

da

ssu

chh

as

no

tim

pa

cted

the

calc

ula

tio

n.

Th

eref

ore

ther

eis

no

imp

act

on

ou

rli

mit

eda

ssu

ran

cere

po

rtre

sult

ing

ina

nu

nm

od

ifie

dre

po

rtin

resp

ect

of

this

ind

ica

tor.

8. C

G17

-18/

011

- P

wC

Lon

g F

orm

Rep

ort (

Ext

erna

l Ass

uran

ce o

n Q

A)

Page 57 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C8

Pe

rc

en

tag

eo

fp

ati

en

tsw

ith

ato

tal

tim

ein

A&

Eo

ffo

ur

ho

ur

so

rle

ss

fro

ma

rr

iva

lto

ad

mis

sio

n,

tra

ns

fer

or

dis

ch

ar

ge

Re

po

rte

dp

er

for

ma

nc

e:

20

16/1

7T

arg

et:

at

lea

st9

5%

each

qu

art

er2

016

/17

Act

ua

l:8

4.8

9%

Cr

ite

ria

ide

nti

fie

d:

We

con

firm

edth

eT

rust

use

sth

efo

llo

win

gcr

iter

iafo

rm

easu

rin

gth

ein

dic

ato

rfo

rin

clu

sio

nin

the

Qu

ali

tyR

epo

rt:

T

he

ind

ica

tor

isd

efin

edw

ith

inth

ete

chn

ica

ld

efin

itio

ns

tha

ta

cco

mp

an

yE

ver

yo

ne

cou

nts

:p

lan

nin

gfo

rp

ati

ents

20

14/1

5-

20

18/1

9a

nd

can

be

fou

nd

at

ww

w.e

ng

lan

d.n

hs.

uk

/wp

-co

nte

nt/

up

loa

ds/

20

14/0

1/ec

-tec

h-d

ef-1

415

-18

19.p

df

D

eta

iled

rule

sa

nd

gu

ida

nce

for

mea

suri

ng

A&

Ea

tten

da

nce

sa

nd

emer

gen

cya

dm

issi

on

sca

nb

efo

un

da

th

ttp

s://

ww

w.e

ng

lan

d.n

hs.

uk

/sta

tist

ics/

wp

-co

nte

nt/

up

loa

ds/

site

s/2

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13/0

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E-A

tten

da

nce

s-E

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gen

cy-

Def

init

ion

s-v2

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ina

l.p

df

Iss

ue

sid

en

tifi

ed

thr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

.Is

su

eIm

pa

ct

on

lim

ite

da

ss

ur

an

ce

re

po

rt

No

issu

esn

ote

d.

No

imp

act

on

ou

rli

mit

eda

ssu

ran

cere

po

rt.

Co

nc

lus

ion

:

Ou

rsu

bst

an

tiv

ete

stin

go

fth

ein

dic

ato

rid

enti

fied

no

issu

es.

No

imp

act

on

ou

rli

mit

eda

ssu

ran

cere

po

rtre

sult

ing

ina

nu

nm

od

ifie

dre

po

rtin

resp

ect

of

this

ind

ica

tor.

Page 58 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C9

Per

form

an

cein

dic

ato

rsn

ot

incl

ud

edw

ith

ino

ur

lim

ited

ass

ura

nce

rep

ort

NH

SI

als

ore

qu

ires

us

tou

nd

erta

ke

sub

sta

nti

ve

sam

ple

test

ing

of

alo

cal

ind

ica

tor

sele

cted

by

the

Go

ver

no

rs,

the

resu

lts

of

wh

ich

are

no

tin

clu

ded

wit

hin

ou

rli

mit

eda

ssu

ran

cere

po

rt.

We

ob

tain

an

un

der

sta

nd

ing

of

the

key

pro

cess

esa

nd

con

tro

lsfo

rm

an

ag

ing

an

dre

po

rtin

gth

ein

dic

ato

ra

nd

sam

ple

test

the

da

tau

sed

toca

lcu

late

the

ind

ica

tor

ba

ckto

sup

po

rtin

gd

ocu

men

tati

on

.

We

test

edo

nly

asa

mp

le,

as

sta

ted

ab

ove

.O

ur

rep

ort

eder

rors

bel

ow

are

lim

ited

toth

issa

mp

le.

Ou

rfi

nd

ing

sa

red

eta

iled

as

foll

ow

s:

Pa

tie

nt

sa

fety

inc

ide

nts

an

dth

ep

er

ce

nta

ge

tha

tr

es

ult

ed

ins

ev

er

eh

ar

mo

rd

ea

th

Re

po

rte

dp

er

for

ma

nc

e:

As

at

the

da

teo

fo

ur

test

ing

(Ma

y2

017

)N

HS

Ih

as

no

tfo

rma

lly

rep

ort

edth

ep

erfo

rma

nce

of

this

ind

ica

tor

for

20

16/1

7.

As

such

we

ha

vep

erfo

rmed

the

foll

ow

ing

pro

ced

ure

so

ver

this

ind

ica

tor:

1)W

eh

ave

reca

lcu

late

dth

ep

erfo

rma

nce

rep

ort

edin

the

20

16/1

7q

ua

lity

acc

ou

nt.

Th

isre

late

sto

the

pre

vio

us

yea

r’s

fig

ure

,a

sre

po

rtin

go

nto

NH

SI

ha

sa

tim

ela

g.

We

ha

ve

fou

nd

no

exce

pti

on

sin

the

reca

lcu

lati

on

of

this

per

form

an

ce.

2)

Ino

rder

top

rovi

de

com

fort

ove

rth

e2

016

/17

per

form

an

ceo

fth

etr

ust

,w

eh

ave

test

eda

sam

ple

of

15in

cid

ents

in2

016

/17

an

da

gre

edth

eyh

ave

bee

nco

rrec

tly

reco

rded

.N

ois

sues

wer

en

ote

dd

uri

ng

this

test

ing

.

Cr

ite

ria

ide

nti

fie

d:

We

con

firm

edth

eT

rust

use

sth

efo

llo

win

gcr

iter

iafo

rm

easu

rin

gth

ein

dic

ato

rfo

rin

clu

sio

nin

the

Qu

ali

tyR

epo

rt:

T

he

nu

mb

ero

fp

ati

ent

safe

tyin

cid

ents

resu

ltin

gin

seve

rh

arm

or

dea

tha

ta

tru

stre

po

rted

thro

ug

hth

eN

ati

on

al

Rep

ort

ing

an

dL

earn

ing

Ser

vice

(NR

LS

),d

ivid

edb

yth

en

um

ber

of

pa

tien

tsa

fety

inci

den

tsre

po

rted

at

this

tru

stth

rou

gh

the

NR

LS

.

In

cid

ents

are

rep

ort

eda

nd

revi

ewth

rou

gh

the

Da

trix

da

tab

ase

wh

ich

isth

enu

sed

toca

lcu

late

the

nu

mb

ero

fin

cid

ents

resu

ltin

gin

dea

tho

rse

ver

ha

rm.

Th

isis

then

rep

ort

edq

ua

rter

lyto

NR

LS

.

Iss

ue

sid

en

tifi

ed

thr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

.Is

su

eIm

pa

ct

No

issu

esn

ote

d.

No

imp

act

on

ou

rli

mit

eda

ssu

ran

cere

po

rt.

Co

nc

lus

ion

:

Ou

rsu

bst

an

tiv

ete

stin

go

fth

ein

dic

ato

rid

enti

fied

no

issu

es.

8. C

G17

-18/

011

- P

wC

Lon

g F

orm

Rep

ort (

Ext

erna

l Ass

uran

ce o

n Q

A)

Page 59 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C1

0

Th

ere

com

men

da

tio

ns

ass

oci

ate

dw

ith

thes

efi

nd

ing

sa

rep

rese

nte

din

Ap

pen

dix

B.

An

nu

al

Go

ver

na

nce

Sta

tem

ent

NH

SI

req

uir

eF

ou

nd

ati

on

Tru

sts

toin

clu

de

ab

rief

des

crip

tio

no

fth

ek

eyco

ntr

ols

inp

lace

top

rep

are

an

dp

ub

lish

aQ

ua

lity

Rep

ort

as

pa

rto

fth

eA

nn

ua

lG

ove

rna

nce

Sta

tem

ent

(“A

GS

”)in

the

20

16/1

7p

ub

lish

eda

cco

un

ts.

Th

ere

qu

irem

ents

for

the

con

ten

to

fth

eA

GS

are

set

ou

tin

An

nex

5o

fC

ha

pte

r2

of

the

NH

SF

ou

nd

ati

on

Tru

stA

nn

ua

lR

epo

rtin

gM

an

ua

l2

016

/17

.

Th

eA

nn

ua

lG

ov

ern

an

ceS

tate

men

t,w

ith

inth

eF

ou

nd

ati

on

Tru

st’s

20

16/1

7A

nn

ua

lR

epo

rt,

incl

ud

esth

efo

llo

win

gst

ate

men

tsp

ecif

icto

the

Qu

ali

tyR

epo

rt:

Th

ed

irec

tors

are

req

uir

edu

nd

erth

eH

ealt

hA

ct2

00

9a

nd

the

Na

tio

na

lH

ealt

hS

ervi

ce(Q

ua

lity

Acc

ou

nts

)R

egu

lati

on

s2

010

(as

am

end

ed)

top

rep

are

Qu

ali

tyA

cco

un

tsfo

rea

chfi

na

nci

al

yea

r.N

HS

Imp

rov

emen

t(i

nex

erci

seo

fth

ep

ow

ers

con

ferr

edo

nM

on

ito

r)h

as

issu

edg

uid

an

ceto

NH

Sfo

un

da

tio

ntr

ust

bo

ard

so

nth

efo

rma

nd

con

ten

to

fa

nn

ua

lQu

ali

tyR

epo

rts

wh

ich

inco

rpo

rate

the

ab

ove

leg

alr

equ

irem

ents

inth

eN

HS

Fo

un

da

tio

nT

rust

An

nu

al

Rep

ort

ing

Ma

nu

al.

Th

eT

rust

ha

sef

fect

ive

syst

ems,

pro

cess

esa

nd

mec

ha

nis

ms

inp

lace

top

rod

uce

the

Qu

ali

tyA

cco

un

ta

nd

toen

sure

tha

tit

isa

gen

era

la

nd

ba

lan

ced

vie

wa

nd

tha

ta

pp

rop

ria

teco

ntr

ols

are

inp

lace

toen

sure

the

acc

ura

cyo

fth

ed

ata

.T

he

Ex

ecu

tive

lea

dfo

rth

eQ

ua

lity

Acc

ou

nt

isth

eD

irec

tor

of

Nu

rsin

g&

Qu

ali

ty.

Th

eco

nte

nt

of

the

Qu

ali

tyre

po

rtre

flec

tsth

eT

rust

’so

vera

llQ

ua

lity

Str

ate

gy

an

dth

ep

rio

riti

esin

clu

ded

inth

isd

ocu

men

t.

Th

eG

ove

rno

rs,

sta

ffa

nd

exte

rna

lo

rga

nis

ati

on

ssu

cha

sth

eC

lin

ica

lC

om

mis

sio

nin

gG

rou

ps,

Lo

cal

Au

tho

rity

Ove

rvie

wa

nd

Scr

uti

ny/

Hea

lth

Sel

ect

Co

mm

itte

es,

the

thre

eH

ealt

hw

atc

ha

nd

the

Co

un

cil

of

Go

vern

ors

wer

eco

nsu

lted

on

the

pri

ori

ties

for

20

16/1

7in

det

erm

inin

gw

hic

ho

fth

elo

cal

ind

ica

tors

wa

sto

be

revi

ewed

by

exte

rna

la

ud

it.

As

pa

rto

fo

ur

rep

ort

on

the

fin

an

cia

lst

ate

men

tsw

ew

ere

req

uir

edto

:

R

evie

ww

het

her

the

An

nu

al

Go

vern

an

ceS

tate

men

tre

flec

tsco

mp

lia

nce

wit

hN

HS

I’s

gu

ida

nce

;a

nd

R

epo

rtif

itd

oes

no

tm

eet

the

req

uir

emen

tssp

ecif

ied

by

NH

SI

or

ifth

est

ate

men

tis

mis

lea

din

go

rin

con

sist

ent

wit

ho

ther

info

rma

tio

nw

ea

rea

wa

reo

ffr

om

ou

ra

ud

ito

fth

efi

na

nci

al

sta

tem

ents

.

Th

ew

ork

we

un

der

too

ko

nth

eA

nn

ua

lG

ove

rna

nce

Sta

tem

ent

as

pa

rto

fo

ur

wo

rko

nth

efi

na

nci

al

sta

tem

ents

no

issu

esre

leva

nt

toth

eQ

ua

lity

Rep

ort

.

Page 60 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C1

1

Ap

pe

nd

ice

s

8. C

G17

-18/

011

- P

wC

Lon

g F

orm

Rep

ort (

Ext

erna

l Ass

uran

ce o

n Q

A)

Page 61 of 78

Ain

tre

eU

niv

ers

ity

Ho

sp

ita

lN

HS

Fo

un

da

tio

nT

rust

Pw

C1

2

Ob

se

rv

ati

on

Re

co

mm

en

da

tio

n

Per

cen

tag

eo

fin

com

ple

tep

ath

wa

ysw

ith

in18

wee

ks

for

pa

tien

tso

nin

com

ple

tep

ath

wa

ysa

tth

een

do

fth

ere

po

rtin

gp

erio

d

1.F

or

on

eo

fo

ur

sam

ple

we

no

ted

tha

tth

ere

ferr

al

da

tea

sp

erth

eP

AS

syst

emw

as

the

15/0

1/2

016

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1/1

Membership Committee Report


Date 15 June 2017

Committee Name Membership Committee

Date of Committee Meeting 8 May 2017

Chair’s Name & Title Pamela Peel – Lead Governor

Summary of Meeting

A progress update was provided on the ‘Get Involved with Aintree’ group. Arrangements had been

made to host an informal, initial meeting with interested members on 18 May 2017 principally to

begin to form the group into a cohesive body and to discuss its remit. The meeting would be an

opportunity to begin to bridge the gap between Governors and the most engaged members. An

invitation had been extended to Kerry Higham, Lead Nurse Quality & Safety – Patient Experience, to

provide a short talk on her role and link with patients and members. The opportunity would also be

taken to obtain the views of members on the Governor Toolkit. An update on the meeting would be

provided at the formal Council meeting in June 2017

The Committee reviewed the Membership Strategy Implementation Plan and the tasks arising from

the Governor Development Day in September 2016. The Committee assessed the progress made to

date through the various initiatives and the key areas of focus going forward

Representation of Staff Governors at the monthly Corporate Induction with new staff had been

welcomed as it provided a great opportunity to present and promote membership. Overall, feedback

had been positive particularly with having the Chairman and Chief Executive in attendance as well as

a Staff Governor. Reference was made to the challenges being experienced in promoting the

benefits of membership to both staff and volunteers at Induction

The Committee discussed the promotion of membership and the possibility of more Governors being

involved in this regard within the public areas of the hospital. The Committee discussed the

possibility of having a stand in the Elective Care Centre so that Governors could speak directly with

members of the public in regard to their role and the hospital in general. It was agreed that the

membership leaflet be distributed again at the next Informal Governors meeting to remind colleagues

of the resources available and their responsibility for wider engagement with members

The Committee gave a vote of thanks to Lorraine Heaton for her sterling work and support in regard

to membership during her time on the Committee.

Recommendation


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Page 64 of 78

Council of Governors Membership Committee Terms of Reference – February 2017

Terms of Reference

Council of Governors – Membership Committee

Authority

1. The Membership Committee has been established as a formal committee of the Council of Governors and recommends processes and activities for the recruitment and engagement of members by or on behalf of the Council of Governors. This includes an overarching recruitment and engagement strategy.

2. The Membership Committee submits recommendations to the Council of

Governors for approval, but does not possess any delegated powers. 3. Governance and election issues are led by the Associate Director of

Corporate Governance and are not covered by this Committee.

Purpose

4. The Membership Committee has responsibility for developing and reviewing processes and activities for the recruitment and engagement of existing and new members of Aintree University Hospital NHS Foundation Trust.

Duties

5. Develop the Membership Strategy and provide strategic guidance on the communication and engagement activities undertaken by or on behalf of the Council of Governors.

6. Oversee the delivery of the action plan to support the Membership Strategy, including advising partners and stakeholders as appropriate.

7. Ensuring that the Membership Strategy is seeking a membership which is

representative of the patients and public served by the Trust.

8. In line with brand guidance, consider all aspects of communication relating to membership of the Trust including development of newsletters, digital and social communications, members’ meetings, media campaigns, membership forms and administration.

9. To advise on the organisation and promotion of the Annual Members’

Meeting. 10. Establish a developmental approach which encourages each Governor to

engage with the Membership as best suits his/her skills and time available.

11. The Committee aims to advise on and support focused recruitment and engagement of FT members. It will use the performance indicators outlined in its recruitment and engagement strategy to measure success.

Membership

12. The Committee will be comprised of 6 Governors.

13. The Chair of the Committee will be elected on an annual basis.

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Council of Governors Membership Committee Terms of Reference – February 2017

14. All Governors will be welcome to attend meetings of the Committee although voting

rights will be restricted to the 6 formal Governor members

Requirements of Membership

15. All members will contribute to and support the development and implementation of the recruitment and engagement strategy and support the wider Council of Governors and other partner agencies to participate in all related activities.

16. The Corporate Governance Team will provide administrative support to the

Committee and ensure that all papers and minutes are circulated promptly to

members.

17. In order for a meeting of the Membership Committee to make substantive decisions,

at least three Governors must be present. Any decisions made with fewer than three

Governors are subject to ratification at the next quorate meeting.

Reporting

18. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of the Council of Governors.

19. Minutes of the Committee meetings will be provided to the Council of Governors on

request. 20. The Deputy Chair of the Council of Governors/Lead Governor will attend the Annual

Members’ Meeting to report on activities of the Committee in the previous 12 months.

Administration of Meetings

21. The Committee will meet at least quarterly and then as required to fulfil its responsibilities, as determined by the Chair.

22. The Chair, with support from the Corporate Governance Team and Communications Team, will draft the agenda and enclosures.

23. The Corporate Governance Team will minute the meeting and duly record all decisions and actions. Minutes and related papers will be stored electronically in the Corporate Governance Team’s files.

24. The Committee will review its own performance and terms of reference at least once a year to ensure it is operating effectively. It will use the performance indicators outlined in the recruitment and engagement strategy to measure its effectiveness.

Review

25. Once approved, the Terms of Reference will be reviewed every 12 months. Next review date: February 2018.

Page 66 of 78

1/2

Quality of Care Committee Report


Date 15 June 2017

Committee Name Quality of Care Committee

Date of Committee Meeting 17 May 2017

Chair’s Name& Title Mike Booth

Summary of Meeting

The annual report on Infection Prevention and Control was provided which included an overview

of the Trust’s Healthcare Associated Infections (HCAIs) Reduction Plan for 2017/18. The main

points arising were:

The total level of CDifficile cases for 2016/17 was 46 with 19 cases successfully appealed by

theTrust as there were no lapses in care. This resulted in a net total of 28 cases at the year

end attributable to the Trust . This evidenced that the Trust was improving year on year in

reducing the number of cases

There had been one Trust attributable case of MRSA but the Trust continued to maintain its

90% standard in respect of patient screening. There had been increased staff training of

Asceptic Non-Touch Techniques (ANTT) and this would continue during 2017/18

The Trust continued with the process for peroxide fogging/deep cleaning programme to

eradicate infection cases.

The Committee had discussed the setting of achievable aspirational targets particularly given the

increased demand on the hospital’s services. The Committee also sought and received

clarification that the staff were informed of ANTT through monthly Divisional reports as well as

within team meetings with positive feedback provided where appropriate.

The Quality Strategy for 2017/18 together with the Delivery Plan was discussed. The main points

identified were:

A one year plan had been developed due to the possibility of the merger between Aintree

University Hospital and the Royal Liverpool Hospital. Discussion would take place between

the Trusts on developing a longer term quality strategy for the merged entity

Overall, 18 objectives had been developed which included a number of IPC projects, the

management of the deteriorating patient, falls, pressure ulcers and patient experience

projects

Medicines safety was a key focus as a number of errors had been reported . This had led to

the Trust relaunching the Medicines Safety Group.

The Committee reviewed the results of the Quality Strategy Delivery Plan for Q4 2016/17 and the

following matters were highlighted:

o The increased demand coupled with winter pressures had been challenging for the Trust but

it had demonstrated that, whilst not every objective had been met, there had been

improvements in a number of areas.

o There had been year on year improvement in the reduction of falls but there had been an

increase in moderate/severe cases and this would be taken forward during 2017/18

o Patient acuity and dependency had also increased particularly in relation to patients with co-

mobidities, dementia, confusion and those requiring help to maintain their deprivation of

liberties

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Page 67 of 78


Quality of Care Committee Report – 17 May 2017: Council of Governors 15 June 2017 2/2

o Pressure ulcers had also seen an improvement year on year but there were an umber that

had come through from the community which was being monitored

o The Trust was performing well against the Advancing Quality metrics across the North West

and was the top performer in a number of areas

o The palliative care work stream had performed well and there had been some good

improvements made in Acute Kidney Injury and the deteriorating patient. All this work

evidenced that the Trust was doing all it could to reduce the number of avoidable deaths

A report was presented on the Aintree Assessment & Accreditation Framework Q2 2016/17 and

it was highlighted that there were 12 Aintree Champions Excellence (ACE) Wards, 7 Green Wards

and 10 Amber Wards. No Wards/Departments were rated Red. The programme would continue to

be rolled out to other areas of the hospital such as theartes and outpatients during 2017/18.

A review of the Trust Mortality report highlighted the following:

HSMR remains in the expected range and was below 100%. .The SHMI had moved from

below expected into the as expected range but this was not considered ot be of concern.

Crude mortality had fallen to 2.83% on a rolling 12 month basis but was likely to be due to the

increased number of patients admitted against a decrease in the number of actual deaths.

Palliative Care was excluded from the HSMR figures but included in the SHMI which, when

excluded, give the Trust a SHMI rating of 98%.

A new process had been implemented to review the case notes for all deaths to learn lessons

and determine if any deaths could have been avoided.

Other matters raised at the meeting were:

The Trust’s reputation in the community had significantly improved

Recent PLACE inspection undertaken by Governors evidenced that the hospital was

extremely clean and that staff have a very positive attitude

There was evidence of overcrowding in Clinic G particularly when a number of clinics were

held on the same day and the overall environment within this clinic may need to be reviewed

Consideration would need to be given to the plans and future location of Clinic G going

forward.

All the matters raised would be discussed by the Executive Team.

Recommendation


Page 68 of 78

Quality of Care Committee: Terms of Reference February 2017 1/2

Quality of Care Committee

TERMS OF REFERENCE

Authority

1. The Quality of Care (QoC) Committee is authorised by the Council of Governors (CoG) and will

be Governor-led.

Purpose

2. To act as a focal point for work involving the care and safety of patients and to enable Governors

to become better informed on issues of concern to members and the public.

Membership

3. The QoC will be comprised of seven Governors.

4. The Chair of the Committee will be elected by the QoC Committee on an annual basis.

5. The Director of Nursing & Quality and the Medical Director or their respective deputies will be in

attendance. Other members of the Executive Team will be asked to attend as appropriate

6. Membership of the Committee will be reviewed annually at the first meeting of the Council of

Governors after the Annual Members Meeting. Governors will be invited to express an interest in

membership of the Committee prior to that meeting of the Council of Governors.

7. Vacancies will be filled by open self nomination and election by the Council of Governors if

necessary for the appropriate term.

8. All Governors will be welcome to attend meetings of the Committee although voting rights will be

restricted to the seven formal Governor members.

Quorum

9. A quorum shall be four members of the Committee.

10. Any decisions reached at an inquorate meeting shall be referred to the next quorate meeting for

approval.

Requirements of Membership

11. It is essential that all members participate in the meetings and punctuality must be observed.

12. The Chair will ensure that the key issues identified are highlighted as appropriate to the Hospital

Management Board and/or lead executive director/manager as required.

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Quality of Care Committee: Terms of Reference February 2017 2/2

Duties

13. In order to fulfil its role, the duties of the Committee will be:

To understand, support and be engaged with the Trust’s Quality Strategy

To receive reports on progress towards achieving the quality priorities, namely:

o care that is safe

o care that is clinically effective

o care that provides a positive experience for patients and their families

To receive and comment on indicators on safety, clinical effectiveness and patient

experience, in line with the national direction on quality. At present, these include:

Healthcare Associated Infections (HCAI), Mortality, Cleanliness and Patient Satisfaction. As

further indicators are developed or more detailed work is necessary, Governors may be

asked to contribute to additional working groups.

To review the results of patient satisfaction surveys, both national and local and to

understand the impact on patient care

To comment on the Trust’s declaration(s) to the Care Quality Commission on compliance with

its registration on behalf of the Council of Governors

Reporting

14. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of

the Council of Governors.

15. Minutes of the Committee meetings will be provided to the Council of Governors on request.

Administration of Meetings

16. The Committee will meet quarterly and the duration of each meeting shall be approximately 1.5

hours

17. The Associate Director Corporate Governance/Board Secretary will make arrangements to

ensure that the Committee is supported administratively. Duties in this respect will include

preparation of agendas and taking minutes of the meeting.

18. Agendas and papers will be circulated at least 4 working days (or 3 working days plus a

weekend) in advance of the meeting.

19. Minutes will be circulated to Committee members as soon as is reasonably practicable.

Review

20. The Terms of Reference shall be reviewed annually (next review date: February 2018) and

submitted to the Council of Governors for approval following a review by the QoC of its

performance against the terms of reference.

Page 70 of 78

Council of Governors

Nominations Committee

Terms of Reference

1. Purpose

A Nominations Committee (the Committee) is to be established for the purposes of identifying

appropriate candidates and for making recommendations to the Council of Governors on the terms

and conditions of office for non-executive directors of Aintree University Hospitals NHS Foundation

Trust (the Trust).

2. Membership

The standing membership of the Committee will be in accordance with the Trust’s Constitution and

will consist of:

The Chairman of the Trust (or Deputy-Chairman/Senior Independent Director in relation

to the appointment of the Chairman)

The Lead Governor

One Appointed Governor

Two Elected Governors

The Chief Executive of the Trust (where appropriate)

An external assessor, with appropriate skills and experience, may be appointed to advise the

Committee as and when required i.e. for each appointment process.

Members of the Committee may be required to undertake training and development commensurate

with the responsibilities outlined in Section 5.

3. Chairman of the Nominations Committee

The chair of the Committee will be the Chairman of the Trust, unless the discussion relates to the

appointment of the Chairman of the Trust, in which case, the Deputy Chairman will chair the

Committee. In the event that the Deputy Chairman or Senior Independent Director stands for the

appointment of Chairman, the Committee will be chaired by another non-executive director.

4. Support for the Nominations Committee

The Director of People & Corporate Affairs will provide advice to the Nominations Committee to

ensure that the recruitment and appointment processes are managed in accordance with best

practice and that the recommendations to the Council of Governors on terms and conditions of

office are appropriate and relevant to local circumstances.

The Associate Director of Corporate Governance/Board Secretary will make arrangements to

ensure that the Committee is supported administratively. Duties in this respect will include taking

minutes of the meeting and providing appropriate support to the Chairman and committee

members.

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Aintree University Hospital NHS Foundation Trust 5. Responsibilities of the Committee

Receive job descriptions and person specifications detailing the skills, knowledge and experience

required for non-executive directors, as approved by the Board of Directors.

Approve the recruitment and selection process for non-executive directors, elements of which are

likely to include:

Arrangements for advertising/raising of local awareness of the post(s).

Arrangements for shortlisting of candidates against agreed criteria.

Arrangements for formal interviews

Recommendation of the successful candidate(s) for approval by the Council of

Governors.

Receive reports in relation to the terms and conditions of office of current or newly appointed

Chairman and non executive directors and make recommendations to the Council of Governors.

Develop, monitor and seek feedback on a process for the evaluation of performance and

contribution on the part of Non-Executive Directors and the Chairman

Receive summarised reports as to the performance of the Non-Executive Directors (from the

Chairman) and the Chairman (from the Senior Independent Director) on an annual basis.

The Committee will provide assurance on these matters to the Council of Governors.

6. Quorum

The quorum necessary for the transaction of business will be three members of the Committee.

7. Frequency of Meetings

The standing membership of the Committee will meet at least annually and then as required to fulfil

its responsibilities, as determined by the Chairman.

8. Notice of Meetings

Meetings of the Committee will be called at the request of the Chairman.

Details of each meeting, including agenda and supporting papers will be forwarded to each

member of the Committee seven working days before the date of the meeting.

9. Minutes of Meetings

Minutes of the meetings will be circulated promptly to all members of the Committee and to all

other members of the Council of Governors as soon as reasonably practical.

10. Reporting Arrangements

The Chair of the Committee will report on the proceedings of each meeting to the next meeting of

the Council of Governors. This discussion will take place in a private session, i.e. not open to

members or the public, if the names and details of individuals are being discussed.

Page 72 of 78


The Chair will attend the Annual Members’ Meeting to report on the activities of the Committee in

the previous twelve months.

11. Authority

The Committee is authorised to seek information and advice either within the Trust or externally on

any matters within its terms of reference.

12. Review

The Committee will review its own performance, relevant sections of the constitution, and terms of

reference at least once a year to ensure it is operating effectively. Any proposed changes will be

submitted to the Council of Governors for approval.

These terms of reference will be approved by the Council of Governors and formally reviewed at

intervals not exceeding two years. [Next review: March 2019]

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Page 73 of 78

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Page 74 of 78

1/4



Report Title Appointment of Lead Governor and Deputy Lead Governor

Executive Lead Neil Goodwin, Chairman

Lead Officer Caroline Keating, Associate director of Corporate Governance/Board Secretary

Action Required To approve


High level of confidence in delivery of existing mechanisms / objectives

Acceptable assurance

General confidence in delivery of existing mechanisms/ objectives

Partial assurance

Some confidence in delivery of existing mechanisms / objectives

No assurance

No confidence in delivery


To agree the reprocess for the appointment of the Lead Governor and Deputy Lead Governor for

a term of 12 months


Quality

Finance

Workforce

Equality

Risk

Compliance

Legal

Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must accompany the report)












Key Risk

Service Change

Other



Board Secretary to seek expressions of interest from the Council of Governors for the roles and

undertake an election if necessary

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2/4

REPORT HISTORY


Agenda Ref



Page 76 of 78


Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2017 3/4

Executive Summary

1. The report provides the Council of Governors with a brief overview of the process to be undertaken

to source a Lead Governor and Deputy Lead Governor of the Trust

Background

Regulatory Requirements and the Trust Constitution

2. The NHS Foundation Trust Code of Governance, published by Monitor (now NHS Improvement),

contains a section relating to the role of the nominated lead governor which highlights that the role

is largely to facilitate direct communication between NHS Improvement and the Trust’s council of

governors.

3. Annex 5 of the Trust’s Constitution states the following:

The Council of Governors shall appoint one of the Governors to be Lead Governor of the

Council of Governors. The Lead Governor may be a Public Governor, an Appointed

Governor or a Staff Governor.

The term of office of the Lead Governor shall be 12 months. A Governor may be re-

appointed as the Lead Governor by the Council of Governors at the end of that term. Only

in exceptional circumstances would a Lead Governor serve for more than 2 years.

Key Issues / Proposals

4. In June 2015, the Council of Governors approved the appointment of Pamela Peel as Lead

Governor and Lorraine Heaton as Deputy Lead Governor for a term of 12 months. These two

individuals were reappointed into their respective roles in June 2016.

5. It is, therefore, now necessary to source nominations from the current Council of Governors for the

positions of Lead Governor and Deputy Lead Governor for a 12 month term of office. The Board

Secretary will write to the Council of Governors following this meeting to seek expressions of

interest for both roles. Nominations for both roles are to be submitted by close of play on Monday

19 July 2017

6. If only one nomination is received for either or both roles, the person(s) so nominated will be

automatically appointed and the Council of Governors informed accordingly.

7. If, however, more than one nomination is received for either or both roles, an election will be held

which will be undertaken by email the day after the closing date for nominations.

8. In terms of the process, each Governor will be emailed with the names of the nominated

candidates and will be asked to indicate their preferred candidate(s) only by return email.

9. The votes will be counted by the Board Secretary (acting as Returning Officer) and the result

provided by email. The candidates receiving the highest number of votes will be declared

appointed as the Lead Governor and Deputy Lead Governor.

Recommendation

10. Council of Governors to approve the process for the appointment of Lead Governor and Deputy

Lead Governor for a term of 12 months.

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Page 77 of 78


Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2017 4/4

Author: Michael Games, Corporate Governance Manager

Date: 12 June 2016

Page 78 of 78

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