council of governors - aintree university hospital...jun 15, 2016 · which the council of...

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COUNCIL OF GOVERNORS 15 June 2016

12.30pm – 2pm 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

CG16-17/001 (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

CG16-17/002 (v)

3. Minutes from the last meeting (16 March 2016)

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

CG16-17/003 (d)

Overview

12.35 4. Strategic Update

Deputy Chairman/Chief Executive

To note

CG16-17/004 (p)

12.45 5. Lead Governor Report

To note

CG16-17/005 (d)

Quality & Performance Management

12.50 6. Assurance on Key Indicators:

Quality & Safety

Finance & Performance

Non-Executive Directors

CG16-17/006 (p)

Internal System of Control

1.25 7. Key Issues & Assurances (Audit)

Non-Executive Director

CG16-17/007 (p)

1.30 8. External Auditors Report on the Quality Account

PricewaterhouseCoopers LLP

To note

CG16-17/008 (d)

Governance

1.40 9. Governor Committees:

Membership Committee (3 May 2016) for noting

Quality of Care Committee (18 May 2016) for noting

Nominations Committee (15 June 2016) for approval

CG16-17/009 (d/v)

1.45 10. Council of Governors’ Objectives 2016/17

To approve

CG16-17/010 (d)

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Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors’ Meeting 15 June 2016 2/2

1.50 11. Appointments:

Lead Governor – to approve

Deputy Lead Governor – to elect

CG16-17/011 (d)

Concluding Business

2.00 12. Any Other Business

Chairman

CG16-17/012 (v)

13. Date and Time of Next Meeting:

Thursday 13 October 2016 at 5.30pm

PRIVATE BUSINESS

No Item Reference

2.05 1. Appraisal of the Chairman

Senior Independent Director

CGP16-17/001 (d)

2.10 2. Appraisal of the Non-Executive Directors

Associate Director of Corporate Governance/Board Secretary

CGP16-17/002 (d)

Council of Governors – Objectives 2016/17

To further develop skills and knowledge base in order to collectively understand and constructively challenge and support the quality of care agenda provided by the Trust

To improve communication and engagement with members of the Trust in line with the membership strategy objectives

To monitor the performance of the Board of Directors through holding the Non-Executive Directors individually and collectively to account

To deliver its statutory duties in line with regulatory requirements

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Council of Governors

Wednesday 16 March 2016 5.30pm

Board Room Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman

Pamela Peel - Lead Governor

Tracey Barnes - Public Governor

Sharon Bird - Public Governor

Mike Booth - Public Governor

Tony Byrne - Public Governor

Gerry Hill - Public Governor

John Johnson - Public Governor

Tony Kneebone - Pubic Governor

Brian Lawless - Public Governor

Julie Naybour - Public Governor

Stephen Thornhill - Public Governor

Rosemary Urion - Public Governor

Helen Frankland - Staff Governor (Nursing)

Lorraine Heaton - Staff Governor (AHPs)

Andrew Swift - Staff Governor (Medical)

Paul Cummins - Appointed Governor (Sefton Council)

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

John Wilding - Appointed Governor (University of Liverpool)

In Attendance: Steve Warburton - Chief Executive

Joanne Clague - Non-Executive Director

Steve Evans - Medical Director

David Fillingham - Non-Executive Director

Nicola Firth - Director of Nursing & Quality

Michael Games - Corporate Governance Manager

Sue Green - Director of People and Corporate Affairs

Juliet Herzog - Non-Executive Director

Tim Johnston - Non-Executive Director

Ian Jones - Director of Finance & Business Services

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Colin Maloney - Non-Executive Director

Kevan Ryan - Non-Executive Director

Angie Smithson - Chief Operating Officer

Nicola Allen - Corporate Governance Officer

Elaine Carter - Member of the Public

Apologies: Mike Bowker - Public Governor

Rose Milnes - Public Governor

Kerry McManus - Staff Governor (Other)

Colin Maloney - Non-Executive Director

Paul Fitzpatrick - Director of Estates & Facilities

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Minutes: Council of Governors’ Meeting 16 March 2016 2/6

Ref Minute

Preliminary Business

CG15-16/043 Apologies for Absence

The apologies were noted as above.

CG15-16/044 Declarations of Interest

There were no declarations of interest.

CG15-16/045 Minutes from the last meeting (9 December 2015)

The minutes from the previous meeting held on 9 December 2015 were approved as an

accurate record.

The Chairman made reference to the Governor workshop held on 24 February 2016 at

which the Council of Governors agreed the following Quality Indicator for the purpose of

External Audit:

Emergency Re-admissions to Hospital within 28 days of Discharge.

Where are we going as an Organisation?

CG15-16/046 Strategic Update

The Chief Executive advised the meeting of the following matters:

Strategic Vision: at the Governor Workshop on 24 February 2016 the Trust’s

refreshed strategic vision & objectives were shared, following discussions held by the

Board to have a vision that accurately reflected the Trust’s ambitions and aspirations.

Governors accepted the refreshed vision and objectives.

Partnerships: the Trust continued to hold discussions with the Royal Liverpool &

Broadgreen University Hospitals NHS Trust (RLBUHT) on the proposed merger of

clinical services. A meeting of the two Trusts had taken place with the regulators and

local commissioners and there had been a clear steer from the Liverpool Clinical

Commissioning Group (CCG) on the case for the strategic transformation plan and

the impetus behind that proposal would need to be worked through appropriately.

Liverpool Health Community (LCH) Services: the tenders for the transaction and

transformation of the community services provided in Liverpool and South Sefton by

LCH were being progressed. The Trust was actively reviewing the commissioned

provisions with particular input being sought from specialist community services.

Financial Position: contract negotiations were yet to be agreed with commissioners

but this was being pursued. Nationally, the Trust had been offered the opportunity to

access £9.5m but this was predicated on the Trust achieving a surplus control of

£1.2m. However, on reviewing the Trust’s financial forecasts for 2016/17 and

assuming that the cost improvement plans were met, it was anticipated that there

would be a deficit of £7.4m which would mean that the Trust would not be able

access the funds being made available. The Trust had received a site visit in

February 2016 from Monitor to assess the financial plans and assumptions and

feedback from the visit was awaited.

A&E Performance: the Trust had been invited to meet with Monitor in January 2016

to discuss its poor performance and to outline its plans to improve the situation. A

summit meeting subsequently took place in February 2016 with Trusts who were in a

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similar position in order to discuss and review best practice. However, nothing had

been raised that was not already factored into the Trust’s framework and plans for

improvement. The Trust was now focussed on the delivery and implementation of its

plans to improve its A&E performance which had been developed in conjunction with

the clinical teams. The Trust would also continue to focus on working with its

external partners on the prevention of patients coming to the Hospital and

appropriately discharging patients into the community.

The Council of Governors requested clarification on the following matters:

Concerns over the Trust’s financial position and its A&E performance and

questioned whether appropriate and the right actions had been taken at an

early stage. The Chief Executive commented that the Trust’s deficit position would

be carried over into the next financial year with the cumulative effect of a reduced

tariff and the increased costs of services being the main contributors. However, the

Trust was committed to maintaining quality and safety standards within its services

and would compromise on this regardless of cost. The Chairman advised that the

Board was to undertake a review during March/April 2016 to understand how it got to

this position and reflect on the learning from the experience.

The Council being equally responsible for the poor performance of the Trust.

The Chairman advised that the Board was clear on its responsibility to manage the

business and performance of the Trust and for the Council of Governors to represent

the interests of public and staff members, and local partner organisations in the

governance of the Trust as well as hold the Non-Executive Directors to account. He

believed that the Board had been more open and transparent with the Council but

was more than happy to hear any views on further engagement to ensure that

Governors felt more assured where appropriate.

How was the Trust performing compared to its peers? The Trust was at the

lower end in terms of performance but this was expected to improve once the

approved Emergency and Acute Care Plans had been implemented.

The Council noted the update.

How are we performing?

CG15-16/047 Finance & Performance – Report on Key Issues & Assurance Received

David Fillingham (Non-Executive Director), Chair of the Finance & Performance

Committee, gave a presentation covering the progress and achievements made and the

key challenges faced for December 2015 to February 2016. Particular mention was

made of the deteriorating performance in A&E and the development of a key set of

principles as a framework for implementation to improve the position, together with the

revised governance structure. Reference was also made to the presentations received

from the Divisions on their financial and clinical performance together with plans for

improvements going forward. The scrutiny of the Trust’s challenging financial position

continued to be a major factor in the Committee’s deliberations with particular emphasis

on progress against the achievement of the Cost Improvement Programme as well as

the financial planning and budgets for 2016/17.

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What were the contributing factors to the Trust’s deficit? The cost of agency

staff has been one of the factors but rigorous controls had been put in place to limit

the amount of agency staff used when other options may be more efficient. The

Trust’s financial position also been impacted by a change made to the tariff by

Commissioners on non-elective admissions which was unforeseen at the time the

budget and revenue setting process was undertaken. There continued to be plenty

of rigour and challenge from the Committee on the robustness of the financial

planning and budget process. However, it was anticipated that future savings would

be more difficult to achieve particularly as the tariff received by the hospital was likely

to become insufficient to cover costs at some point.

Has theatre productivity improved? Unfortunately a number of operations had to

be cancelled during January 2016 due to the Junior Doctors strike and any further

strikes would also have an impact on productivity levels. It was noted that the

Committee was to receive a presentation from the Surgery Division at the end of

March which would include information relating to theatre productivity.

What impact is the ageing population having on the Hospital? There continued

to be a huge demand on health services at a time when the Trust was not receiving

sufficient funding on a year by year basis. The ageing population placed a strain on

the Trust particularly as people were living longer despite having a number of co-

morbidities to contend with. The effect of GP closures locally placed further pressure

on the Trust as well as community services and the local authority. Furthermore, the

closure of residential homes for economic reasons also had an impact the health

economy within the City.

The Council noted the presentation.

How are we treating our patients?

CG15-16/048 Quality & Safety – Report on Key Issues & Assurance Received

Juliet Herzog (Non-Executive Director), Chair of the Quality & Safety Committee, gave a

presentation covering its key challenges, specific items presented during December

2015 to February 2016 and progress against the Quality Strategy objectives. Specific

mention was made of the degree of scrutiny undertaken by the Committee on serious

incidents and the challenges and concerns raised to receive assurance that appropriate

lessons had been learned, recommendations and actions identified and acted upon to

mitigate future incidents occurring; the continued monitoring of the Ophthalmology risk

and the monitoring of progress for mitigation; and the examination of performance of the

Trust’s infection prevention and control programme. Reference was also made to the

presentations received by the Committee on Assaults, Complaints, Laparotomy audit and

the quality of patient care in A&E.


Have the changes made to the recruitment process realised any benefits and

was there any confidence that the changes had not adversely affected patient

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care? The Trust had a level of vacancy control in place but following a review the

process had been tightened to provide Divisions with the opportunity to exhaust all

other options before putting their final recommendations to the panel. There was no

evidence to suggest that any delays in recruitment to genuine vacancies had

impacted on performance. The Trust’s vacancy rate was around 6% and further

recruitment drives were planned to reduce this further. It was noted that the Quality

& Safety Committee received a number of reports relating to staffing levels and

scrutinised the level of bank and agency staff being used to fill vacant posts. The

Staff Governor who raised the question was still concerned that the revised process

appeared to hinder the recruitment of staff into established posts. It was agreed that

the Staff Governor would meet with the Director of People & Corporate Affairs to

discuss this matter further.

What was the impact of using agency staff to fill gaps? The Trust was

committed to filling all its vacancies but there was national challenges being faced in

the recruitment of nursing and clinical staff. The intention was to only use agency

staff on an exception basis but this was not going to be achievable at this point in

time. However, one in place there would be a saving of around £2m.

What was the outcome of the Laparotomy Audit? A national audit had been

undertaken which highlighted that the Trust had not performed well compared to

national standards against the process indicators. An Emergency Laparotomy

Improvement Group had been established and was focussing on improvements to

data completion and lessons learnt. In addition a new Standard Operating Procedure

had been developed which conformed to the national guidelines.


How do we run ourselves? What do others think?

CG15-16/049 Report from Audit Committee

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

presentation covering the key items covered by the Committee and its main challenges

from December 2015 to February 2016. Specific mention was made to the review of the

clinical audit performance and the assurance received on the robust governance process

for project cancellation/abandonment. Reference was also made to the information

governance breach and request for a wider review to be undertaken to investigate

whether there were any other potential gaps or system issues.


CG15-16/050 Governor Activity

Governors provided an overview of the activities they had been involved in during the

last quarter with specific reference to the following:

Multi-Disciplinary Accelerated Discharge Events (MADE)

North West Governors’ Forum

North West Coast Academy Health Science Network event

Nutrition & Hydration Collaborative

Patient Led Assessments of the Care Environment (PLACE)

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The Council noted the update.

CG15-16/051 Reports of Governor Committee Chairs

Membership Committee – 2 February 2016

Pam Peel, Chair of the Committee, referred to the report and advised that it was the

intention to organise a World Café type event for Governors to discuss member

engagement. Further details would be issued in due course.

The Council noted the report.

Quality of Care Committee – 11 February 2016

Mike Booth, Chair of the Committee, referred to the report and advised that there had

been encouraging trends provided in the indicators. However, as the Medical Director

had been unable to attend the meeting, the Committee had experienced difficulty in

understanding the context of the data in relation to the Mortality Report.

The Council noted the report.

CG15-16/052 Terms of Reference for Governor Committee

The Council of Governors reviewed the revised terms of reference for the Quality of Care

Committee. It was noted that the change related to the attendance of deputies at the

meetings in the absence of the Director of Nursing & Quality and/or the Medical Director.

The Council approved the revised terms of reference.

Other items for Governors to be aware of

CG15-16/053

Council of Governors’ Forward Plan 2016/17

The Forward Plan for 2016/17 was approved by the Council.

Concluding Business

CG15-16/054 Any Other Business

No further business was raised.

Date and Time of Next Meeting:

Wednesday 15 June 2016 in the Board Room Aintree Lodge at 12.30pm.

The meeting closed at 7pm Chair’s Signature: Date:

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Lead Governors Report

Report to Council of Governors

Date 15 June 2016

Committee Name Council of Governors

Chair’s Name & Title Pamela Peel, Lead Governor

Core Governor Activity

Attendance at Board meetings

Director Walkabouts – considered a valuable and informative opportunity by Governors

Participation in annual NEDs appraisals

Quality of Care Committee

Membership Committee

Nominations Committee

Informal Council of Governors

Wider Trust Activity

Investors in People, 10 March – 6 Governors attended a session with the assessor and discussed

how the Council is able to influence and contributes to the success of Aintree

Quality Accounts, 13 April & 14 May – 2 Governors took part in the development and review of the

draft Quality Account,

Focus On...events. Two of four have taken place so far: 23 May Kidney 4 Governors attended;

Discharge 4 Governors attended

Celebration event for Aintree Volunteers (Volunteers’ Week 1-12 June) in the Chapel on 7 June –

Lead Governor attended and did the Thank you

PLACE assessments – a number of Governors have already been involved, and this is ongoing

Nutrition & Hydration Workstream – please see note from Mike Booth below

Infection Control Collaborative – both sessions were cancelled and no new dates have been issued

Integrated Clinical Network – please see note from Sharon Bird below

Falls – review event for the Falls Prevention Collaborative scheduled for earlier this year has not yet

taken place

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

Helipad Consultation – A number of Governors attended the Stakeholder event and several of us

also dropped into two events held for the local residents.

External Activity

Fazakerley Health & Wellbeing Forum, 10 March – Care-at-the-Chemist presentation and wider

discussion about alternatives to going to AED. Lead Governor attended.

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Healthy Liverpool event on Urgent & Emergency Care by Liverpool CCG, 17 March. Lead Governor

attended.

North West Coast Patient Safety Collaborative 8 March & 19 April – 2 Governors attended

MiAA Event on Mortality 5 May – 2 governors attended. The full note on the event is attached, but it

focussed on real people (rather than 'outcomes') and unexpected deaths, and getting all staff

involved in believing that they could make a difference to patient safety

Lead Governor Activity

Lead Governors conference call 26 April – nationally 12 Governors were involved. Feedback has

been provided to my colleagues and a follow-up virtual meeting via skype is scheduled later this

month

Meetings with Shadow Lead Governor of The Royal are ongoing though infrequent, most recent

meeting was 20 April

Meeting is scheduled later in June with Lead Governor of The Women’s Hospital.

Recommendation

The Council of Governors is asked to note the report.

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Note on Nutrition and Hydration (N&H) Workstream

N&H is included in the quality account, as a priority for improvement for 2016/2017. Aintree is

working towards at least 95% delivery 7 days/week for completion of Nutrition and Hydration Risk

Assessments. I note it dropped from 95% in 2014 to 87% last year. I also note that it is not in

Monitors Risk framework which is disappointing because it is such a fundamental issue.

Reference to N&H was made in the AAA framework update paper given to the QoC Committee on

the 18th May [QC16-17/005] AAA Standard 6 refers to N&H and the tables on page 9, 16 and 17 of

the paper were disappointing reading for the wards and division of medicine compared to the division

of surgery.

N&H group meets quarterly but because the members of the collaborative are all front line staff, they

have not met since December because of pressures from winter and industrial action. I am very

impressed with the focus and commitment of the group but there appears to be problems in

consistent delivery on the wards.

Mike Booth 120616

Note on Integrated Clinical Network

Held on 8 June and chaired by Dr Julie Raj. Those present were representatives of South Sefton LIT; Knowsley CRG, Liverpool End of Life Strategic Group; Woodlands; Community District Nurses; Woodlands; Walton Centre and AUH Clinical Nurse Specialists.

AUH is providing excellent education palliative care support for all areas across the network. These include

Palliative Care Advanced Care Planning Amber Care Bundle Locality audit Unified Do Not Attempt Cardio Pulmonary Resuscitation (uDNACPR)

The introduction of the Amber Care has resulted in a low re- admission rate of 4% at AUH.

AUH's programmes of Advanced Care Planning and Amber Care Bundle has had national recognition that it is leading the way with these initiatives.

Sharon Bird 130616

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Note on MiAA Event on Understanding Mortality There were 3 presentations: Dr Martin Farrier, Consultant Paediatrician and Corporate Clinical Director for Quality and Safety and Alison Unsworth, Coding Lead, Wrightington, Wigan and Leigh NHS FT. Alison introduced us to clinical coding and the key role this has in translating patient notes/ records into data codes that are used as the basis for payment, activity recording & performance management across the NHS. She explored the complexity of coding, the standards applied & the difficulties faced in translating notes. The accuracy of coding cannot be underestimated as it underpins all key decision making & payment mechanisms within the NHS. Martin shared his Trust’s story which started in 2007 when their HSMR was similar to Mid Staffs. He gave a number of examples using the following 4 step process which had achieved substantial change across the Trust. 1. Understanding data 2. Examining unexpected deaths 3. Engaging clinicians 4. Generating change The Trust has created about 200 Quality Champions all trained in the Institute for Health Improvements’ methodology. Martin referred to the often quoted figure that 3-5% of deaths that are believed to be preventable and the work of Helen Hogan under the Prism Programme to understand how these deaths can be avoided. Martin emphasised that it is important that each organisation understands and reviews the data and learns from that review process to consider what could have been done differently, so that changes and improvements are taken forward within each organisation. Paul Hawgood, Principal Business Intelligence Analyst at AQuA – his session ‘Mortality Insights & Myth busting’ took us through the 3 main methodologies to measure mortality: 1. SHMI or Summary Hospital Mortality Indicator 2. HSMR or Hospital Standardised Mortality Ratio 3. RAMI or Risk Adjusted Mortality Index. exploring the relative merits of each & busting some myths including whether adjustments should be made for deprivation, the impact of data coding accuracy, palliative care, auditing and learning lessons following every in hospital death and out of hospital deaths.

All presentations have been circulated to the Council of Governors.

Pamela Peel 120516

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DAT

OR

YTR

AIN

ING

24

.63

0.1

-AT

TEN

DA

NC

ER

ATE

95

.3%

96

.0%

6&7.

CG

16-1

7/00

6 &

007

- P

rese

ntat

ion

to C

ounc

il of

Gov

erno

rs

of 43

Ke

y A

rea

s o

f A

ss

ura

nc

e

Fin

an

ce &

Perf

orm

an

ce

•D

ee

p D

ive

s/

Ke

y D

iscu

ssio

ns

–S

urg

ery

–C

ost

Imp

rove

me

nt

Pla

n D

eliv

ery

20

16

/17

(W

ork

sh

op

an

d

De

ep

Div

e)

–F

ina

ncia

l P

lan

Re

ve

nu

e &

Bu

dg

ets

20

16

/17

–E

me

rge

ncy &

Acu

te C

are

Pro

gra

mm

e

–T

ran

sfo

rma

tio

n T

ask &

Fin

ish

Gro

up

•O

bse

rva

tio

ns f

rom

Dire

cto

r W

alk

rou

nd

s&

Bo

ard

Co

nve

rsa

tio

ns

of 43

Inte

rna

l S

ys

tem

of

Co

ntr

ol

Key Issu

es &

Assu

ran

ces

Ke

van

Ryan

, N

on

Execu

tive D

irecto

r

•B

oa

rd A

ssu

ran

ce

Fra

me

wo

rk

•In

form

atio

n G

ove

rna

nce B

rea

ch

(E

nd

osco

py)

•In

tern

al A

ud

it R

ep

ort

s

•A

nn

ua

l R

ep

ort

& A

cco

un

ts

•L

osse

s &

Co

mp

en

sa

tio

n

Ob

se

rva

tio

ns fro

m D

ire

cto

r W

alk

rou

nd

s&

Bo

ard

Co

nve

rsa

tio

ns

6&7.

CG

16-1

7/00

6 &

007

- P

rese

ntat

ion

to C

ounc

il of

Gov

erno

rs

of 43

ww

w.p

wc.

co.u

k

Ain

tre

e U

niv

er

sit

y

Ho

sp

ita

l N

HS

Fo

un

da

tio

n

Tr

us

t Q

ua

lity

Rep

ort

20

15/1

6

Go

ver

nm

ent

an

d

Pu

bli

c S

ecto

r

Ma

y 2

016

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 24 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

Co

nte

nts

Ba

ck

gr

ou

nd

an

d s

co

pe

1

Su

mm

ar

y o

f fi

nd

ing

s

3

De

tail

ed

fin

din

gs

7

Sc

op

e o

f th

is w

or

k

We

ha

ve

pe

rfo

rme

d t

his

wo

rk i

n a

cco

rda

nce

wit

h M

on

ito

r’s

Det

ail

ed g

uid

an

ce f

or

exte

rna

l a

ssu

ran

ce o

n q

ua

lity

rep

ort

s 2

015

/16

an

d

Mo

nit

or’

s D

eta

iled

req

uir

emen

ts f

or

qu

ali

ty r

epo

rts

20

15/1

6 w

hic

h w

ere

iss

ue

d i

n M

arc

h 2

016

an

d t

he

NH

S F

ou

nd

ati

on

Tru

st A

nn

ua

l R

ep

ort

ing

Ma

nu

al

20

15/1

6.

Re

po

rts

an

d l

ett

ers

pre

pa

red

by

ex

tern

al

au

dit

ors

an

d a

dd

ress

ed

to

go

ve

rno

rs,

dir

ect

ors

or

off

ice

rs a

re p

rep

are

d f

or

the

so

le u

se o

f th

e N

HS

F

ou

nd

ati

on

Tru

st,

an

d n

o r

esp

on

sib

ilit

y i

s ta

ken

by

au

dit

ors

to

an

y g

ov

ern

or,

dir

ect

or

or

off

ice

r in

th

eir

in

div

idu

al

cap

aci

ty,

or

to a

ny

th

ird

p

art

y.

Th

e m

att

ers

ra

ise

d i

n t

his

re

po

rt a

re o

nly

th

ose

wh

ich

ha

ve

co

me

to

ou

r a

tten

tio

n a

risi

ng

fro

m o

r re

lev

an

t to

ou

r w

ork

th

at

we

be

lie

ve

n

ee

d t

o b

e b

rou

gh

t to

yo

ur

att

en

tio

n.

Th

ey

are

no

t a

co

mp

reh

en

siv

e r

eco

rd o

f a

ll t

he

ma

tte

rs a

risi

ng

, a

nd

in

pa

rtic

ula

r w

e c

an

no

t b

e h

eld

re

spo

nsi

ble

fo

r re

po

rtin

g a

ll r

isk

s in

yo

ur

bu

sin

ess

or

all

in

tern

al

con

tro

l w

ea

kn

ess

es.

Th

is r

ep

ort

ha

s b

ee

n p

rep

are

d s

ole

ly f

or

yo

ur

use

in

a

cco

rda

nce

wit

h t

he

te

rms

of

ou

r e

ng

ag

em

en

t le

tte

r d

ate

d 1

9 A

pri

l 2

016

an

d f

or

no

oth

er

pu

rpo

se a

nd

sh

ou

ld n

ot

be

qu

ote

d i

n w

ho

le o

r in

p

art

wit

ho

ut

ou

r p

rio

r w

ritt

en

co

nse

nt.

No

re

spo

nsi

bil

ity

to

an

y t

hir

d p

art

y i

s a

cce

pte

d a

s th

e r

ep

ort

ha

s n

ot

be

en

pre

pa

red

fo

r, a

nd

is

no

t in

ten

de

d f

or,

an

y o

the

r p

urp

ose

.

Co

nte

nts

Page 25 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

1

Ba

ckg

rou

nd

N

HS

fo

un

da

tio

n t

rust

s a

re r

equ

ired

to

pre

pa

re a

nd

pu

bli

sh

a Q

ua

lity

Rep

ort

ea

ch y

ea

r.

Th

e Q

ua

lity

Rep

ort

ha

s to

be

pre

pa

red

in

acc

ord

an

ce w

ith

th

e N

HS

fo

un

da

tio

n t

rust

A

nn

ua

l R

epo

rtin

g M

an

ua

l (“

the

FT

AR

M”)

.

As

yo

ur

aud

ito

rs,

we

are

req

uir

ed t

o u

nd

erta

ke

wo

rk o

n y

ou

r Q

ua

lity

Rep

ort

un

der

Mo

nit

or’

s A

ud

it C

od

e a

nd

Mo

nit

or’

s ‘D

eta

iled

Gu

idan

ce f

or

Ex

tern

al

Ass

ura

nce

on

th

e Q

ua

lity

R

epo

rts

20

15/1

6’ (

‘th

e d

eta

iled

gu

ida

nce

’) w

hic

h w

as

pu

bli

shed

in

Ma

rch

20

16.

Th

e p

urp

ose

of

this

rep

ort

is

to p

rov

ide

the

Co

un

cil

of

Go

ver

no

rs o

f A

intr

ee U

niv

ersi

ty H

osp

ita

l N

HS

Fo

un

da

tio

n

Tru

st (

“th

e T

rust

”) w

ith

ou

r fi

nd

ing

s a

nd

rec

om

men

da

tio

ns

for

imp

rov

emen

ts,

in a

cco

rda

nce

wit

h M

on

ito

r’s

req

uir

emen

ts.

It i

s re

ferr

ed t

o b

y M

on

ito

r a

s th

e “G

ov

ern

ors

re

po

rt”.

Sco

pe

of

ou

r w

ork

W

e a

re r

equ

ired

by

Mo

nit

or

to r

evie

w t

he

con

ten

t o

f th

e

20

15/1

6

Qu

ali

ty R

epo

rt,

test

th

ree

per

form

an

ce i

nd

ica

tors

an

d p

rod

uce

tw

o r

epo

rts:

Lim

ited

ass

ura

nce

rep

ort

: T

his

rep

ort

is

a f

orm

al

do

cum

ent

tha

t re

qu

ires

us

to c

on

clu

de

wh

eth

er a

ny

thin

g

ha

s co

me

to o

ur

att

enti

on

th

at

wo

uld

lea

d u

s to

bel

iev

e

tha

t:

o

Th

e Q

ua

lity

Rep

ort

do

es n

ot

inco

rpo

rate

th

e m

att

ers

req

uir

ed t

o b

e re

po

rted

on

as

spec

ifie

d i

n A

nn

ex 2

to

C

ha

pte

r 7

of

the

FT

AR

M a

nd

Mo

nit

or’

s ‘D

eta

iled

re

qu

irem

ents

fo

r q

ua

lity

rep

ort

s 2

015

/16

’(“t

he

req

uir

emen

ts”)

;

o

Th

e Q

ua

lity

Rep

ort

is

con

sist

ent

in a

ll m

ate

ria

l a

spec

ts w

ith

so

urc

e d

ocu

men

ts s

pec

ifie

d b

y M

on

ito

r;

an

d

o

Th

e sp

ecif

ied

in

dic

ato

rs h

av

e n

ot

bee

n p

rep

are

d i

n a

ll

ma

teri

al

resp

ects

in

acc

ord

an

ce w

ith

th

e cr

iter

ia s

et

ou

t in

th

e d

eta

iled

gu

ida

nce

.

A l

imit

ed a

ssu

ran

ce e

ng

ag

emen

t is

les

s in

sco

pe

tha

n

a r

easo

na

ble

ass

ura

nce

en

ga

gem

ent

(su

ch a

s th

e ex

tern

al

au

dit

of

acc

ou

nts

). T

he

na

ture

, ti

min

g a

nd

ex

ten

t o

f p

roce

du

res

for

ga

ther

ing

su

ffic

ien

t a

pp

rop

ria

te e

vid

ence

are

del

iber

ate

ly l

imit

ed

com

pa

red

to

a r

easo

na

ble

ass

ura

nce

en

ga

gem

ent.

Go

ver

no

rs r

epo

rt:

A p

riv

ate

rep

ort

on

th

e o

utc

om

e o

f

ou

r w

ork

th

at

is m

ad

e a

va

ila

ble

to

th

e T

rust

’s G

ov

ern

ors

an

d t

o M

on

ito

r.

Ou

r li

mit

ed a

ssu

ran

ce r

epo

rt i

s re

stri

cted

, a

s re

qu

ired

by

Mo

nit

or,

to

th

e co

nte

nt

of

the

Qu

ali

ty R

epo

rt a

nd

tw

o

per

form

an

ce i

nd

ica

tors

on

ly.

Th

e G

ov

ern

ors

rep

ort

co

ver

s

all

of

ou

r w

ork

an

d,

ther

efo

re,

the

thir

d l

oca

l in

dic

ato

r w

hic

h

is c

ho

sen

by

th

e G

ov

ern

ors

.

Ba

ck

gr

ou

nd

an

d s

co

pe

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 26 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

2

Co

nte

nt

of

the

Qu

ali

ty R

epo

rt

We

are

req

uir

ed t

o i

ssu

e a

lim

ited

ass

ura

nce

re

po

rt i

n

rela

tio

n t

o t

he

con

ten

t o

f y

ou

r Q

ua

lity

Rep

ort

. T

his

in

vo

lves

:

Rev

iew

ing

th

e co

nte

nt

of

the

Qu

ali

ty R

epo

rt a

ga

inst

th

e re

qu

irem

ents

of

Mo

nit

or’

s p

ub

lish

ed g

uid

an

ce,

as

spec

ifie

d i

n A

nn

ex 2

to

Ch

ap

ter

7 o

f th

e F

T A

RM

an

d

Mo

nit

or’

s ‘D

eta

iled

req

uir

emen

ts f

or

qu

ali

ty r

epo

rts

20

15/1

6’;

an

d

Rev

iew

ing

th

e co

nte

nt

of

the

Qu

ali

ty R

epo

rt f

or

con

sist

ency

wit

h t

he

sou

rce

do

cum

ents

sp

ecif

ied

by

M

on

ito

r in

th

e d

eta

iled

gu

ida

nce

.

Per

form

an

ce i

nd

ica

tors

W

e a

re r

equ

ired

to

iss

ue

a l

imit

ed a

ssu

ran

ce r

epo

rt i

n r

esp

ect

of

two

ou

t o

f th

e th

ree

ind

ica

tors

sp

ecif

ied

by

Mo

nit

or.

Th

e in

dic

ato

rs f

or

the

yea

r en

ded

31

Ma

rch

20

16 s

ub

ject

to

li

mit

ed a

ssu

ran

ce (

the

“sp

ecif

ied

in

dic

ato

rs”)

; m

ark

ed w

ith

the

sym

bo

l

in

th

e Q

ua

lity

Rep

ort

, co

nsi

st o

f th

e fo

llo

win

g n

ati

on

al

pri

ori

ty i

nd

ica

tors

as

ma

nd

ate

d b

y

Mo

nit

or:

Sp

ec

ifie

d I

nd

ica

tor

s

Sp

ec

ifie

d i

nd

ica

tor

s

cr

ite

ria

(M

on

ito

r’s

D

eta

ile

d G

uid

an

ce

)

Per

cen

tag

e o

f in

com

ple

te

pa

thw

ays

wit

hin

18

wee

ks

for

pa

tien

ts o

n i

nco

mp

lete

p

ath

wa

ys a

t th

e en

d o

f th

e re

po

rtin

g p

erio

d

An

nex

C -

pa

ge

20

Per

cen

tag

e o

f p

ati

ents

wit

h

a t

ota

l ti

me

in A

&E

of

fou

r h

ou

rs o

r le

ss f

rom

arr

iva

l to

a

dm

issi

on

, tr

an

sfer

or

dis

cha

rge

An

nex

C –

pa

ge

21

Ou

r p

roce

du

res

incl

ud

ed:

ob

tain

ing

an

un

der

sta

nd

ing

of

the

des

ign

an

d o

per

ati

on

of

the

con

tro

ls i

n p

lace

in

rel

ati

on

to

th

e co

lla

tio

n a

nd

re

po

rtin

g o

f th

e sp

ecif

ied

in

dic

ato

rs,

incl

ud

ing

co

ntr

ols

o

ver

th

ird

pa

rty

in

form

ati

on

(if

ap

pli

cab

le)

an

d

per

form

ing

wa

lkth

rou

gh

s to

co

nfi

rm o

ur

un

der

sta

nd

ing

;

ba

sed

on

ou

r u

nd

erst

an

din

g,

ass

essi

ng

th

e ri

sks

tha

t th

e p

erfo

rma

nce

ag

ain

st t

he

spec

ifie

d i

nd

ica

tors

ma

y b

e m

ate

ria

lly

mis

sta

ted

an

d d

eter

min

ing

th

e n

atu

re,

tim

ing

a

nd

ex

ten

t o

f fu

rth

er p

roce

du

res;

ma

kin

g e

nq

uir

ies

of

rele

va

nt

ma

na

gem

en

t, p

ers

on

nel

a

nd

, w

her

e re

lev

an

t, t

hir

d p

art

ies;

con

sid

erin

g s

ign

ific

an

t ju

dg

men

ts m

ad

e b

y t

he

Tru

st i

n

pre

pa

rati

on

of

the

sp

ecif

ied

in

dic

ato

rs;

an

d

per

form

ing

lim

ited

tes

tin

g,

on

a s

elec

tiv

e b

asi

s o

f ev

iden

ce s

up

po

rtin

g t

he

rep

ort

ed p

erfo

rma

nce

in

dic

ato

rs,

an

d a

sses

sin

g t

he

rela

ted

dis

clo

sure

.

Lo

cal

ind

ica

tor

We

are

als

o r

equ

ired

to

un

der

tak

e su

bst

an

tiv

e sa

mp

le t

esti

ng

o

f o

ne

furt

her

lo

cal

ind

ica

tor.

Th

is i

nd

ica

tor

is n

ot

incl

ud

ed

in o

ur

lim

ited

ass

ura

nce

rep

ort

. In

stea

d,

we

are

req

uir

ed t

o

pro

vid

e a

det

ail

ed r

epo

rt o

n o

ur

fin

din

gs

an

d

reco

mm

end

ati

on

s fo

r im

pro

vem

ents

in

th

is,

ou

r G

ov

ern

ors

re

po

rt.

Th

e T

rust

’s G

ov

ern

ors

sel

ect

the

ind

icat

or

to b

e su

bje

ct t

o o

ur

sub

sta

nti

ve

sam

ple

tes

tin

g.

Th

e in

dic

ato

r se

lect

ed i

s em

erg

ency

rea

dm

issi

on

wit

hin

28

da

ys

of

dis

cha

rge

fro

m h

osp

ita

l.

Page 27 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

3

Co

nte

nt

of

the

Qu

ali

ty R

epo

rt

No

iss

ues

ha

ve

com

e to

ou

r a

tten

tio

n t

ha

t le

ad

us

to b

elie

ve

tha

t th

e Q

ua

lity

Rep

ort

do

es n

ot

inco

rpo

rate

th

e m

att

ers

req

uir

ed

to b

e re

po

rted

on

as

spec

ifie

d i

n A

nn

ex 2

to

Ch

ap

ter

7 o

f th

e F

T A

RM

an

d t

he

“Det

ail

ed r

equ

irem

ents

fo

r q

ua

lity

rep

ort

s 2

015

/16

.

Lim

ite

d A

ss

ur

an

ce

Re

po

rt

As

a r

es

ult

of

ou

r w

or

k,

we

are

ab

le t

o p

ro

vid

e a

n u

nq

ua

lifi

ed

lim

ite

d a

ss

ur

an

ce

re

po

rt

in r

es

pe

ct

of

the

c

on

ten

t o

f th

e Q

ua

lity

Re

po

rt.

Co

nsi

sten

cy w

ith

Oth

er I

nfo

rma

tio

n

No

iss

ues

ha

ve

com

e to

ou

r a

tten

tio

n t

ha

t le

ad

us

to b

elie

ve

tha

t th

e Q

ua

lity

Rep

ort

is

no

t co

nsi

sten

t w

ith

th

e o

ther

in

form

ati

on

so

urc

es d

efin

ed b

y M

on

ito

r’s

“Det

ail

ed r

equ

irem

ents

fo

r q

ua

lity

rep

ort

s 2

015

/16

”.

Lim

ite

d A

ss

ur

an

ce

Re

po

rt

As

a r

es

ult

of

ou

r w

or

k,

we

are

a

ble

to

pr

ov

ide

an

un

qu

ali

fie

d l

imit

ed

as

su

ra

nc

e r

ep

or

t in

re

sp

ec

t o

f th

e

co

ns

iste

nc

y o

f th

e Q

ua

lity

Re

po

rt

wit

h t

he

“D

eta

ile

d r

eq

uir

em

en

ts f

or

qu

ali

ty r

ep

or

ts 2

015

/16”

.

Su

mm

ar

y o

f fi

nd

ing

s

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 28 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

4

Sel

ecte

d P

erfo

rma

nce

in

dic

ato

rs

Ou

r fi

nd

ing

s re

lati

ng

to

th

e p

erfo

rma

nce

in

dic

ato

rs a

re s

um

ma

rise

d a

s fo

llo

ws:

Pe

rfo

rm

an

ce

in

dic

ato

rs i

nc

lud

ed

in

ou

r

lim

ite

d a

ss

ura

nc

e r

ep

or

t F

ind

ing

s

Per

cen

tag

e o

f in

com

ple

te p

ath

wa

ys

wit

hin

18

wee

ks

for

pa

tien

ts o

n i

nco

mp

lete

pa

thw

ays

at

the

end

of

the

rep

ort

ing

per

iod

On

e is

sue

iden

tifi

ed.

Th

is h

as n

o i

mp

act

on

ou

r li

mit

ed a

ssu

ran

ce o

pin

ion

.

Per

cen

tag

e o

f p

ati

ents

wit

h a

to

tal

tim

e in

A&

E o

f fo

ur

ho

urs

or

less

fro

m a

rriv

al

to a

dm

issi

on

, tr

an

sfer

or

dis

cha

rge

Tw

o i

ssu

es i

den

tifi

ed.

Th

is h

as

no

im

pa

ct o

n o

ur

lim

ited

ass

ura

nce

op

inio

n.

Lim

ite

d A

ss

ur

an

ce

Re

po

rt

As

a r

es

ult

of

ou

r w

or

k,

we

are

ab

le t

o p

ro

vid

e a

n u

nq

ua

lifi

ed

lim

ite

d a

ss

ur

an

ce

re

po

rt

in r

es

pe

ct

of

the

m

an

da

ted

pe

rfo

rm

an

ce

in

dic

ato

rs

.

Pe

rfo

rm

an

ce

in

dic

ato

r n

ot

inc

lud

ed

wit

hin

o

ur

lim

ite

d a

ss

ur

an

ce

re

po

rt

Fin

din

gs

Em

erg

ency

re

-ad

mis

sio

ns

wit

hin

28

day

s o

f d

isch

arg

e fr

om

ho

spit

al’

N

o i

ssu

es i

den

tifi

ed.

An

nu

al

Go

ver

na

nce

Sta

tem

ent

We

iden

tifi

ed n

o i

ssu

es r

elev

an

t to

th

e Q

ua

lity

Rep

ort

.

Page 29 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

5

Rev

iew

ag

ain

st t

he

con

ten

t re

qu

irem

ents

W

e re

vie

wed

th

e co

nte

nt

of

the

Qu

ali

ty R

epo

rt a

ga

inst

th

e co

nte

nt

req

uir

emen

ts w

hic

h a

re s

pec

ifie

d i

n A

nn

ex 2

to

C

ha

pte

r 7

of

the

FT

AR

M a

nd

th

e re

qu

irem

ents

.

No

iss

ues

ca

me

to o

ur

att

enti

on

th

at

led

us

to b

elie

ve

tha

t th

e Q

ua

lity

Rep

ort

ha

s n

ot

bee

n p

rep

are

d i

n l

ine

wit

h t

he

FT

A

RM

or

the

req

uir

emen

ts.

Rev

iew

co

nsi

sten

cy a

ga

inst

sp

ecif

ied

so

urc

e d

ocu

men

ts

Ou

r w

ork

in

rel

ati

on

to

rev

iew

ing

th

e co

nte

nt

of

the

20

15/1

6

Qu

ali

ty R

epo

rt f

or

con

sist

ency

ag

ain

st t

he

foll

ow

ing

so

urc

e

do

cum

ents

sp

ecif

ied

by

Mo

nit

or

is c

om

ple

te:

Bo

ard

min

ute

s fo

r th

e fi

na

nci

al

yea

r, A

pri

l 2

015

to

Ma

rch

2

016

(th

e p

erio

d);

Pa

per

s re

lati

ng

to

qu

ali

ty r

epo

rt r

epo

rted

to

th

e B

oa

rd

ov

er t

he

per

iod

Ap

ril

20

15 t

o t

he

da

te o

f si

gn

ing

th

is

lim

ited

ass

ura

nce

rep

ort

;

Fee

db

ack

fro

m t

he

Co

mm

issi

on

ers

So

uth

Sef

ton

CC

G

rece

ived

;

Fee

db

ack

fro

m G

ov

ern

ors

;

Fee

db

ack

fro

m L

oca

l H

ealt

hw

atc

h o

rga

nis

ati

on

s (K

no

wsl

ey C

ou

nci

l’s

Hea

lth

Scr

uti

ny

Su

b-C

om

mit

tee

an

d

Hea

lth

wa

tch

Kn

ow

sley

(jo

int

resp

on

se)

rece

ived

, H

ealt

hw

atc

h L

iver

po

ol

an

d H

ealt

hw

atc

h S

efto

n

rece

ived

);

Th

e T

rust

’s c

om

pla

ints

rep

ort

pu

bli

shed

un

der

re

gu

lati

on

18

of

the

Lo

cal

Au

tho

rity

So

cia

l S

erv

ices

an

d

NH

S C

om

pla

ints

Reg

ula

tio

ns

20

09

;

Th

e 2

015

na

tio

na

l a

nd

lo

cal

pa

tien

t su

rvey

;

Th

e 2

015

na

tio

na

l a

nd

lo

cal

sta

ff s

urv

ey;

Ca

re Q

ua

lity

Co

mm

issi

on

In

tell

igen

t M

on

ito

rin

g R

epo

rts

Th

e H

ead

of

Inte

rna

l A

ud

it’s

an

nu

al

op

inio

n o

ver

th

e T

rust

’s c

on

tro

l en

vir

on

men

t.

No

iss

ues

ha

ve

ari

sen

fro

m t

he

wo

rk p

erfo

rme

d.

Per

form

an

ce i

nd

ica

tors

on

wh

ich

we

are

re

qu

ired

to

iss

ue

a l

imit

ed a

ssu

ran

ce

con

clu

sio

n

As

req

uir

ed b

y M

on

ito

r w

e h

av

e u

nd

erta

ken

sa

mp

le t

esti

ng

o

f tw

o p

erfo

rma

nce

in

dic

ato

rs o

n w

hic

h w

e is

sued

ou

r li

mit

ed a

ssu

ran

ce r

epo

rt:

1. p

erce

nta

ge

of

inco

mp

lete

pa

thw

ay

s w

ith

in 1

8 w

eek

s fo

r p

ati

ents

on

in

com

ple

te p

ath

wa

ys a

t th

e en

d o

f th

e re

po

rtin

g p

erio

d;

2.

per

cen

tag

e o

f p

ati

ents

wit

h a

to

tal

tim

e in

A&

E o

f fo

ur

ho

urs

or

less

fro

m a

rriv

al

to a

dm

issi

on

, tr

an

sfer

o

r d

isch

arg

e

We

are

req

uir

ed t

o o

bta

in a

n u

nd

erst

an

din

g o

f th

e k

ey

pro

cess

es a

nd

co

ntr

ols

fo

r m

an

ag

ing

an

d r

epo

rtin

g t

he

in

dic

ato

rs a

nd

sa

mp

le t

est

the

da

ta u

sed

to

ca

lcu

late

th

e in

dic

ato

r b

ack

to

su

pp

ort

ing

do

cum

enta

tio

n. O

ur

wo

rk i

s p

erfo

rmed

in

acc

ord

an

ce w

ith

th

e d

eta

iled

gu

ida

nce

an

d

incl

ud

ed:

Iden

tifi

cati

on

of

the

crit

eria

use

d b

y t

he

Tru

st f

or

mea

suri

ng

th

e in

dic

ato

r;

Co

nfi

rma

tio

n t

ha

t th

e T

rust

ha

d p

rese

nte

d t

he

crit

eria

id

enti

fied

ab

ov

e in

th

e Q

ua

lity

rep

ort

in

su

ffic

ien

t d

eta

il

tha

t th

e cr

iter

ia a

re r

ead

ily

un

der

sta

nd

ab

le t

o u

sers

of

the

Qu

ali

ty R

epo

rt;

De

tail

ed

fin

din

gs

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 30 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

6

Ob

tain

ing

an

un

der

sta

nd

ing

of

the

key

pro

cess

es a

nd

co

ntr

ols

fo

r m

an

ag

ing

an

d r

epo

rtin

g t

he

ind

ica

tor

thro

ugh

ma

kin

g e

nq

uir

ies

of

Tru

st s

taff

an

d t

hro

ug

h

per

form

ing

a w

alk

thro

ug

h;

Ch

eck

ing

Tru

st’s

rec

on

cili

ati

on

of

the

rep

ort

ed

per

form

an

ce i

n t

he

Qu

ali

ty R

epo

rt t

o t

he

da

ta u

sed

to

ca

lcu

late

th

e in

dic

ato

r fr

om

th

e T

rust

’s u

nd

erly

ing

sy

stem

s;

Tes

tin

g a

sa

mp

le o

f re

lev

an

t d

ata

use

d t

o c

alc

ula

te t

he

ind

ica

tor

ba

ck t

o s

up

po

rtin

g d

ocu

men

tati

on

; a

nd

Ob

tain

ing

rep

rese

nta

tio

ns

tha

t th

e d

ata

use

d t

o c

alc

ula

te

the

ind

ica

tor

is a

ccu

rate

ly c

ap

ture

d a

t so

urc

e a

nd

th

at

no

so

urc

es o

f in

form

ati

on

/da

ta r

elev

an

t to

th

e in

dic

ato

r

per

form

an

ce h

av

e b

een

ex

clu

ded

.

We

on

ly t

este

d a

sa

mp

le o

f d

ata

, a

s st

ate

d a

bo

ve,

to

su

pp

ort

ing

do

cum

enta

tio

n.

Th

eref

ore

, th

e er

rors

rep

ort

ed

bel

ow

are

lim

ited

to

th

is s

am

ple

. W

e h

av

e a

lso

no

t te

sted

th

e u

nd

erly

ing

sys

tem

s, f

or

exa

mp

le

the

pa

tien

t a

dm

inis

tra

tio

n s

yst

em a

nd

th

e d

ata

ex

tra

ctio

n

an

d r

eco

rdin

g s

yst

ems.

O

ur

fin

din

gs

are

set

ou

t b

elo

w.

Pe

rc

en

tag

e o

f in

co

mp

lete

pa

thw

ay

s w

ith

in 1

8 w

ee

ks

fo

r p

ati

en

ts o

n i

nc

om

ple

te p

ath

wa

ys

Re

po

rte

d p

er

for

ma

nc

e:

20

15/1

6 T

hre

sho

ld:

92

%

20

15/1

6 A

ctu

al:

95

.7%

Cr

ite

ria

id

en

tifi

ed

:

We

con

firm

ed t

he

Tru

st u

ses

the

foll

ow

ing

cri

teri

a f

or

mea

suri

ng

th

e in

dic

ato

r fo

r in

clu

sio

n i

n t

he

Qu

ali

ty R

epo

rt:

Th

e in

dic

ato

r is

ex

pre

ssed

as

a p

erce

nta

ge

of

inco

mp

lete

pa

thw

ays

wit

hin

18

wee

ks

for

pa

tien

ts o

n i

nco

mp

lete

p

ath

wa

ys a

t th

e en

d o

f th

e p

erio

d;

Th

e in

dic

ato

r is

ca

lcu

late

d a

s th

e a

rith

met

ic a

ver

ag

e fo

r th

e m

on

thly

rep

ort

ed p

erfo

rma

nce

in

dic

ato

rs f

or

Ap

ril

20

15

to M

arc

h 2

016

;

Th

e cl

ock

sta

rt d

ate

is

def

ined

as

the

da

te t

ha

t th

e re

ferr

al

is r

ecei

ved

by

th

e F

ou

nd

ati

on

Tru

st,

mee

tin

g t

he

crit

eria

se

t o

ut

by

th

e D

epa

rtm

ent

of

Hea

lth

gu

ida

nce

; a

nd

Th

e in

dic

ato

r in

clu

des

on

ly r

efer

rals

fo

r co

nsu

lta

nt-

led

ser

vic

e, a

nd

mee

tin

g t

he

def

init

ion

of

the

serv

ice

wh

ereb

y a

co

nsu

lta

nt

reta

ins

ov

era

ll c

lin

ica

l re

spo

nsi

bil

ity

fo

r th

e se

rvic

e, t

eam

or

tre

atm

ent.

Iss

ue

s i

de

nti

fie

d t

hr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

. Is

su

e

Imp

ac

t o

n l

imit

ed

as

su

ra

nc

e r

ep

or

t

1.

Fo

r o

ne

pa

tien

t w

ith

in o

ur

sam

ple

we

no

ted

th

at

the

clo

ck s

tart

da

te r

eco

rded

wa

s N

o i

mp

act

on

ou

r li

mit

ed a

ssu

ran

ce r

epo

rt.

Page 31 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

7

dif

fere

nt

fro

m t

he

da

te o

n t

he

refe

rra

l le

tte

r.

Ho

wev

er,

this

did

no

t h

av

e a

n i

mp

act

on

th

e a

ctu

al

per

form

an

ce a

s th

e p

ati

ent

wa

s st

ill

rep

ort

ed i

n t

he

corr

ect

mo

nth

.

Ov

er

all

Co

nc

lus

ion

:

Ou

r su

bst

an

tiv

e te

stin

g o

f th

e in

dic

ato

r id

enti

fied

on

e is

sue.

No

im

pa

ct o

n o

ur

lim

ited

ass

ura

nce

rep

ort

res

ult

ing

in

an

u

nm

od

ifie

d r

epo

rt i

n r

esp

ect

of

this

in

dic

ato

r.

Pe

rc

en

tag

e o

f p

ati

en

ts w

ith

a t

ota

l ti

me

in

A&

E o

f fo

ur

ho

ur

s o

r l

es

s f

ro

m a

rriv

al

to a

dm

iss

ion

, tr

an

sfe

r

or

dis

ch

ar

ge

Re

po

rte

d p

er

for

ma

nc

e:

20

15/1

6 T

arg

et:

at

lea

st 9

5%

ea

ch q

ua

rter

2

015

/16

Act

ua

l: 9

0.7

%

Cr

ite

ria

id

en

tifi

ed

:

We

con

firm

ed t

he

Tru

st u

ses

the

foll

ow

ing

cri

teri

a f

or

mea

suri

ng

th

e in

dic

ato

r fo

r in

clu

sio

n i

n t

he

Qu

ali

ty R

epo

rt:

Per

cen

tag

e o

f A

&E

att

end

an

ces

wh

ere

the

pa

tien

t sp

ent

4 h

ou

rs o

r le

ss i

n A

&E

fro

m a

rriv

al

to t

ran

sfer

, a

dm

issi

on

or

dis

cha

rge.

Th

e cl

ock

sta

rts

fro

m t

he

tim

e th

at

the

pa

tien

t a

rriv

es i

n A

&E

an

d s

top

s w

hen

th

e p

ati

ent

lea

ves

th

e d

epa

rtm

ent

on

a

dm

issi

on

, tr

an

sfer

fro

m t

he

ho

spit

al

or

dis

cha

rge

.

Pa

tien

ts s

ho

uld

be

cou

nte

d w

her

e th

eir

tota

l ti

me

in A

&E

is

04

:00

:01

ho

urs

or

gre

ate

r. P

ati

ents

wit

h a

to

tal

tim

e o

f 0

4:0

0:0

0 h

ou

rs o

r lo

wer

sh

ou

ld n

ot

be

cou

nte

d.

A&

E,

mea

ns

a T

ype

1, T

yp

e 2

or

Ty

pe

3 A

&E

dep

art

men

t.

Iss

ue

s i

de

nti

fie

d t

hr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

. Is

su

e

Imp

ac

t o

n l

imit

ed

as

su

ra

nc

e r

ep

or

t

1.

Fo

r tw

o p

ati

ents

wit

hin

ou

r sa

mp

le t

he

tim

e

per

th

e su

pp

ort

ing

do

cum

enta

tio

n v

iew

ed

wa

s d

iffe

ren

t to

th

e ti

me

reco

rded

in

th

e sy

stem

. H

ow

ever

th

is d

id n

ot

ha

ve

an

im

pa

ct

on

act

ua

l p

erfo

rma

nce

as

the

pa

tien

ts w

ere

stil

l re

po

rted

as

a b

rea

ch o

r n

on

bre

ach

co

rrec

tly

.

No

im

pa

ct o

n o

ur

lim

ited

ass

ura

nce

rep

ort

.

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 32 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

8

Co

nc

lus

ion

:

Ou

r su

bst

an

tiv

e te

stin

g o

f th

e in

dic

ato

r id

enti

fied

tw

o i

ssu

es.

No

ne

imp

act

on

ou

r li

mit

ed a

ssu

ran

ce r

epo

rt r

esu

ltin

g i

n

an

un

mo

dif

ied

rep

ort

in

res

pec

t o

f th

is i

nd

ica

tor.

Per

form

an

ce i

nd

ica

tors

no

t in

clu

ded

wit

hin

ou

r li

mit

ed a

ssu

ran

ce r

epo

rt

Mo

nit

or

als

o r

equ

ires

us

to u

nd

erta

ke

sub

sta

nti

ve

sam

ple

tes

tin

g o

f a

lo

cal

ind

ica

tor

sele

cted

by

th

e G

ov

ern

ors

, th

e re

sult

s o

f w

hic

h a

re n

ot

incl

ud

ed w

ith

in o

ur

lim

ited

ass

ura

nce

rep

ort

.

We

ob

tain

an

un

der

sta

nd

ing

of

the

key

pro

cess

es a

nd

co

ntr

ols

fo

r m

an

ag

ing

an

d r

epo

rtin

g t

he

ind

ica

tor

an

d s

am

ple

tes

t th

e d

ata

use

d t

o c

alc

ula

te t

he

ind

ica

tor

ba

ck t

o s

up

po

rtin

g d

ocu

men

tati

on

.

We

test

ed o

nly

a s

am

ple

, a

s st

ate

d a

bo

ve.

Ou

r re

po

rted

err

ors

be

low

are

lim

ited

to

th

is s

am

ple

.

Ou

r fi

nd

ing

s a

re d

eta

iled

as

foll

ow

s:

Em

er

ge

nc

y r

e-a

dm

iss

ion

s w

ith

in 2

8 d

ay

s o

f d

isc

ha

rg

e f

ro

m h

os

pit

al

Re

po

rte

d p

er

for

ma

nc

e:

20

15/1

6 T

arg

et:

n/a

– n

o t

arg

et d

efin

ed

20

15/1

6 A

ctu

al:

8%

Cr

ite

ria

id

en

tifi

ed

:

We

con

firm

ed t

he

Tru

st u

ses

the

foll

ow

ing

cri

teri

a f

or

mea

suri

ng

th

e in

dic

ato

r fo

r in

clu

sio

n i

n t

he

Qu

ali

ty R

epo

rt:

Th

e in

dic

ato

r is

ex

pre

ssed

as

the

per

cen

tag

e o

f em

erg

ency

ad

mis

sio

ns

to t

he

Tru

st o

ccu

rrin

g w

ith

in 2

8 d

ays

of

the

last

, p

rev

iou

s d

isch

arg

e fr

om

ho

spit

al;

Th

e n

um

era

tor

incl

ud

es f

inis

hed

an

d u

nfi

nis

hed

in

pa

tien

t sp

ells

, in

clu

din

g w

her

e th

e p

ati

ent

die

s;

Th

e n

um

era

tor

excl

ud

es p

ati

ents

wit

h a

ma

in s

pec

iali

ty u

po

n r

ead

mis

sio

n c

od

ed u

nd

er o

bst

etri

c; a

nd

th

ose

wh

ere

the

rea

dm

itti

ng

sp

ell

ha

s a

dia

gn

osi

s o

f ca

nce

r (o

ther

th

an

ben

ign

or

in s

itu

) o

r ch

emo

ther

ap

y f

or

can

cer

cod

ed

an

yw

her

e in

th

e sp

ell;

Th

e d

eno

min

ato

r in

clu

des

all

fin

ish

ed c

on

tin

uo

us

inp

ati

ent

spel

ls w

ith

in s

elec

ted

med

ica

l a

nd

su

rgic

al

spec

iali

ties

, w

ith

a d

isch

arg

e d

ate

up

to

31

Ma

rch

;

Page 33 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

9

An

nu

al

Go

ver

na

nce

Sta

tem

ent

In t

he

req

uir

emen

ts

Mo

nit

or

ask

s F

ou

nd

ati

on

Tru

sts

to i

ncl

ud

e a

bri

ef d

escr

ipti

on

of

the

key

co

ntr

ols

in

pla

ce t

o p

rep

are

an

d

pu

bli

sh a

Qu

ali

ty R

epo

rt a

s p

art

of

the

An

nu

al

Go

ver

na

nce

Sta

tem

ent

in t

he

20

15/1

6 p

ub

lish

ed a

cco

un

ts.

Th

e A

nn

ua

l G

ov

ern

an

ce S

tate

men

t, w

ith

in t

he

Fo

un

da

tio

n T

rust

’s 2

015

/16

A

nn

ua

l R

epo

rt,

incl

ud

es t

he

foll

ow

ing

sta

tem

ent

spec

ific

to

th

e Q

ua

lity

Rep

ort

:

Th

e d

ire

cto

rs

are

re

qu

ire

d u

nd

er

th

e H

ea

lth

Ac

t 2

00

9 a

nd

th

e N

ati

on

al

He

alt

h S

er

vic

e (

Qu

ali

ty A

cc

ou

nts

)

Re

gu

lati

on

s 2

010

(a

s a

me

nd

ed

) to

pre

pa

re

Qu

ali

ty A

cc

ou

nts

fo

r e

ac

h f

ina

nc

ial

ye

ar

. M

on

ito

r h

as

is

su

ed

gu

ida

nc

e t

o N

HS

fo

un

da

tio

n t

ru

st

bo

ar

ds

on

th

e f

or

m a

nd

co

nte

nt

of

an

nu

al

Qu

ali

ty R

ep

or

ts w

hic

h

inc

orp

or

ate

th

e a

bo

ve

le

ga

l r

eq

uir

em

en

ts i

n t

he

NH

S F

ou

nd

ati

on

Tr

us

t A

nn

ua

l R

ep

or

tin

g M

an

ua

l.

Th

e T

rust

ha

s ef

fect

ive

syst

ems,

pro

cess

es a

nd

mec

ha

nis

ms

in p

lace

to

pro

du

ce t

he

Qu

ali

ty A

cco

un

t a

nd

to

en

sure

th

at

it

is a

gen

era

l a

nd

ba

lan

ced

vie

w a

nd

th

at

ap

pro

pri

ate

co

ntr

ols

are

in

pla

ce t

o e

nsu

re t

he

acc

ura

cy o

f th

e d

ata

. A

na

tio

na

l

rep

ort

on

th

e re

vie

w o

f th

e T

rust

’s R

efer

ral t

o T

rea

tmen

t (R

TT

) p

rov

ided

po

siti

ve

rein

forc

emen

t o

f th

e q

ua

lity

an

d a

ccu

racy

of

the

da

ta f

or

elec

tiv

e w

ait

ing

tim

es.

A n

um

ber

of

imp

rov

emen

ts w

ere

iden

tifi

ed a

nd

th

ese

ha

ve

bee

n t

ak

en f

orw

ard

fo

r

imp

lem

enta

tio

n b

y t

he

Tru

st.

Th

is r

epo

rt w

as

rece

ived

by

th

e A

ud

it C

om

mit

tee.

Th

e E

xec

uti

ve

lea

d f

or

the

Qu

ali

ty A

cco

un

t

is t

he

Dir

ecto

r o

f N

urs

ing

& Q

ua

lity

. T

he

con

ten

t o

f th

e Q

ua

lity

rep

ort

ref

lect

s th

e T

rust

’s o

vera

ll Q

ua

lity

Str

ate

gy

an

d t

he

pri

ori

ties

in

clu

ded

in

th

is d

ocu

men

t.

Th

e d

eno

min

ato

r ex

clu

des

da

y c

ase

s, s

pel

ls w

ith

a d

isch

arg

e co

ded

as

dea

th,

ma

tern

ity

sp

ells

(b

ase

d o

n s

pec

ialt

y,

epis

od

e ty

pe,

dia

gn

osi

s),

an

d t

ho

se w

ith

men

tio

n o

f a

dia

gn

osi

s o

f ca

nce

r o

r ch

emo

ther

ap

y f

or

can

cer

an

yw

her

e in

th

e sp

ell;

an

d

Pa

tien

ts w

ith

men

tio

n o

f a

dia

gn

osi

s o

f ca

nce

r o

r ch

emo

ther

ap

y f

or

can

cer

an

yw

her

e in

th

e 3

65

da

ys

pri

or

to

ad

mis

sio

n a

re e

xcl

ud

ed f

rom

th

e d

eno

min

ato

r.

Iss

ue

s i

de

nti

fie

d t

hr

ou

gh

wo

rk

pe

rfo

rm

ed

:

No

. Is

su

e

Imp

ac

t o

n l

imit

ed

as

su

ra

nc

e r

ep

or

t

1.

No

iss

ues

no

ted

. N

o i

mp

act

on

ou

r li

mit

ed a

ssu

ran

ce r

epo

rt.

Co

nc

lus

ion

:

Ou

r su

bst

an

tiv

e te

stin

g o

f th

e in

dic

ato

r id

enti

fied

no

iss

ues

. T

her

efo

re,

ther

e w

ou

ld h

av

e b

een

no

im

pa

ct o

n o

ur

lim

ited

a

ssu

ran

ce r

epo

rt h

ad

it

bee

n r

epo

rted

up

on

.

8. E

xter

nal A

udito

rs R

epor

t on

the

Qua

lity

Acc

ount

Page 34 of 43

Ain

tre

e U

niv

ers

ity H

osp

ita

l N

HS

Fo

und

ation

Tru

st

Pw

C

10

Th

e G

ov

ern

ors

, sta

ff a

nd

ex

tern

al

org

an

isa

tio

ns

such

as

the

Cli

nic

al

Co

mm

issi

on

ing

Gro

up

s, t

he

Lo

cal

Au

tho

rity

Ov

erv

iew

an

d S

cru

tin

y C

om

mit

tees

, th

e th

ree

Hea

lth

wa

tch

an

d t

he

Co

un

cil o

f G

ov

ern

ors

wer

e co

nsu

lted

on

th

e p

rio

riti

es f

or

20

15/1

6

in d

eter

min

ing

wh

ich

of

the

loca

l in

dic

ato

rs w

as

to b

e re

vie

wed

by

ex

tern

al

au

dit

.

As

pa

rt o

f o

ur

rep

ort

on

th

e fi

na

nci

al

sta

tem

ents

we

wer

e re

qu

ired

to

:

Rev

iew

wh

eth

er t

he

An

nu

al

Go

ver

na

nce

Sta

tem

ent

refl

ects

co

mp

lia

nce

wit

h M

on

ito

r’s

gu

ida

nce

; a

nd

Rep

ort

if

it d

oes

no

t m

eet

the

req

uir

emen

ts s

pec

ifie

d b

y M

on

ito

r o

r if

th

e st

ate

men

t is

mis

lea

din

g o

r in

con

sist

ent

wit

h

oth

er i

nfo

rma

tio

n w

e a

re a

wa

re o

f fr

om

ou

r a

ud

it o

f th

e fi

nan

cia

l st

ate

men

ts.

Th

e w

ork

we

un

der

too

k o

n t

he

An

nu

al

Go

ver

na

nce

Sta

tem

ent

as

pa

rt o

f o

ur

wo

rk o

n t

he

fin

an

cia

l st

ate

men

ts i

den

tifi

ed n

o

issu

es r

elev

an

t to

th

e Q

ua

lity

Rep

ort

.

Page 35 of 43

In t

he

even

t th

at,

pu

rsu

an

t to

a r

equ

est

wh

ich

Ain

tree

Un

iver

sity

Ho

spit

al

NH

S F

ou

nd

atio

n T

rust

ha

s re

ceiv

ed u

nd

er t

he

Fre

edo

m o

f In

form

atio

n A

ct 2

00

0,

it i

s re

qu

ired

to

dis

clo

se a

ny

in

form

ati

on

co

nta

ined

in

th

is r

epo

rt,

it w

ill

no

tify

Pw

C p

rom

ptl

y a

nd

co

nsu

lt w

ith

Pw

C p

rio

r to

dis

clo

sin

g su

ch r

epo

rt.

Ain

tree

NH

S F

ou

nd

atio

n T

rust

ag

rees

to

pay

du

e re

gar

d t

o a

ny

rep

rese

nta

tio

ns

wh

ich

Pw

C m

ay m

ak

e in

co

nn

ecti

on

wit

h s

uch

dis

clo

sure

an

d

Ain

tree

Un

iver

sity

Ho

spit

al N

HS

Fo

un

dat

ion

Tru

st s

hal

l a

pp

ly a

ny

rel

eva

nt

exem

pti

on

s w

hic

h m

ay

exis

t u

nd

er t

he

Act

to

su

ch r

epo

rt.

If,

fo

llo

win

g c

on

sult

atio

n w

ith

Pw

C,

Ain

tree

Un

iver

sity

Ho

spit

al

NH

S F

ou

nd

ati

on

Tru

st d

iscl

ose

s th

is r

epo

rt o

r a

ny

pa

rt t

her

eof,

it

sha

ll e

nsu

re t

hat

an

y

dis

cla

imer

wh

ich

Pw

C h

as

incl

ud

ed o

r m

ay s

ub

seq

uen

tly

wis

h t

o i

ncl

ud

e in

th

e in

form

atio

n i

s re

pro

du

ced

in

fu

ll i

n a

ny

cop

ies

dis

clo

sed

.

Th

is d

ocu

men

t h

as

bee

n p

rep

ared

fo

r th

e in

ten

ded

rec

ipie

nts

on

ly.

To

th

e ex

ten

t p

erm

itte

d b

y l

aw,

Pri

cew

ate

rho

use

Co

op

ers

LL

P d

oes

no

t a

ccep

t o

r a

ssu

me

an

y l

iab

ilit

y,

resp

on

sib

ilit

y

or

du

ty o

f ca

re f

or

an

y u

se o

f o

r re

lia

nce

on

th

is d

ocu

men

t b

y a

ny

on

e, o

ther

th

an

(i)

th

e in

ten

ded

rec

ipie

nt

to t

he

exte

nt

ag

reed

in

th

e re

lev

an

t co

ntr

act

for

the

ma

tter

to

wh

ich

th

is

do

cum

ent

rela

tes

(if

an

y),

or

(ii)

as

exp

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Page 36 of 43

1/1

Membership Committee Report


Date 15 June 2016

Committee Name Membership Committee

Date of Committee Meeting 3 May 2016

Chair’s Name & Title Pam Peel, Lead Governor

Summary of Meeting

In reviewing the action from the previous meeting, the Committee considered the content of the

Aintree News and put forward some suggestions about the role of Governors for inclusion in the

forthcoming and future editions of the newsletter. This would help in promoting Governors and assist

in their engagement with members.

The meeting predominately reviewed the proposed programme for a World Café style event for

Governors on engagement. The Committee was provided with an overview of the objectives of the

session and the proposed questions to be issued in advance to aid discussion and debate at the

workshop.

In reviewing the questions, the Committee provided feedback and some suggested alterations to the

wording for consideration. The Committee was advised that the purpose of the preparatory

questions was to check that there was a common understanding of engagement amongst governors

and obtain a baseline for moving forward. The action plan arising from the workshop discussions

would effectively be owned by the Governors with an opportunity to pledge their commitment to

member engagement. It was acknowledged that there would be varying degrees amongst

Governors on the time they spend in this regard.

The Committee also considered the options in regard to the date for holding the workshop and

agreed that the afternoon of Wednesday15 June 2016, following the formal Council of Governors’

meeting, would be the most appropriate. It was agreed that a ‘Save the Date’ email was to be issued

to Governors to ensure that as many as possible were able to attend.

Recommendation


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Page 37 of 43

1/2

Quality of Care Committee Report


Date 15 June 2016

Committee Name Quality of Care Committee

Date of Committee Meeting 18 May 2016

Chair’s Name& Title Mike Booth

Summary of Meeting

A presentation was provided on the National Inpatient Survey Results 2015 which included details

of the process undertaken, the Trust’s previous yearly rankings. Detail was also provided on the

results of the survey with particular emphasis on the areas where the Trust had improved or

worsened compared to other Trusts. The Committee was advised that it had scored significantly

better than average on 11 questions and significantly worse than average in 0 questions. The Trust

had been ranked 16th out of 81 participating Trusts, with nine of the first 15 organisations classified

as specialist trusts. An overview was also provided on the key priorities for 2016/17 with specific

emphasis on flexible visiting, improving experiences on the use of the Bereavement service and

commence training in patient ‘shadowing’. The Committee welcomed the excellent results received

by the Trust and the improvements made to enhance patient experience within the Trust.

The Committee was presented with the report on the Aintree Assessment and Accreditation

Framework Q4 2015/16 and advised that there had been seven Aintree Champions Excellence

(ACE) rated wards during the year and that there were no Red rated wards at the year end. The

Committee was provided with an overview of the process undertaken for the assessment and how

wards were beginning to work together to learn best practice. The Committee noted that the

framework had been rolled out to Theatres, Critical Care and A&E and it was the intention to adapt

the framework for roll out in 2016/17 to Outpatients. Furthermore, the standards had been reviewed

with some amendments made to certain standards which had been communicated to the wards in

advance on the assessments for 2016/17. The Committee sought and received clarification the

reasons for red ratings in safeguarding noting that this predominately related to releasing staff to

undertake the necessary training. The Committee noted the report.

The Committee also discussed the Trust’s current mortality rates using the Standard Hospital

Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) methodologies.

The Committee was advised that the Trust’s SHMI was ranked 7th lowest of all 22 North West peers

which had been a vast improvement on the Trust’s position from two years ago. It was also

highlighted that the HSMR remained below expected and that the Trust’s crude mortality rate

continued to show a downward trend, particularly in regard to the winter months.

The Committee also received a report on the Quality Strategy Year 2 Improvement position and

noted that whilst not all the objectives had been achieved, there had been marked improvement in

the majority of quality goals set.

The Quality Strategy Year 3 Delivery Plan was also provided to the Committee and was advised that

the one of the key projects would be on the reduction of MSSA cases. Furthermore, the

collaborative work originally scheduled for 2015/16 would be progressed with more vigour during

2016/17.

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Page 38 of 43


Quality of Care Committee Report – 18 May 2016: Council of Governors 15 June 2016 2/2

Recommendation


Page 39 of 43

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Page 40 of 43

1/3

Agenda Item (Ref) CG15-16/011 Date of Meeting: 15 June 2016


Report Title Lead Governor and Deputy Lead Governor

Lead Neil Goodwin, Chairman

Lead Officer Caroline Keating, Associate Director of Corporate Governance/ Board

Secretary

Action Required Approval

Report purpose To inform the Council of Governors of the process undertaken to

source a Lead Governor and Deputy Lead Governor and seek approval

of the appointments.

Strategic Objective (s)

this work supports 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

Related Board

Assurance Framework

(BAF) risk

SR6 – Well-Led - governance

Business Priority N/A

Equality Impact

Assessment required?

No

Next Steps

REPORT HISTORY

Committee / Group Name

Agenda Ref

Report Title Date of submission

Brief summary of outcome

11. L

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Page 41 of 43


Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2016 2/3

Executive Summary

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

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

2. It confirms the proposed re-appointment of Pamela Peel as Lead Governor for a term of office of

12 months. In addition, an election is to be held at the Council of Governors’ meeting on 15 June

2016 for the appointment to the position of Deputy Lead Governor for a term of office of 12 months

with Lorraine Heaton and John Johnson putting their names forward for consideration by the

Council.

Background

Regulatory Requirements and the Trust Constitution

3. 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.

4. 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

5. 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. It has,

therefore, been 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. To that end,

the Board Secretary wrote to the Council of Governors on 27 May 2016 seeking expressions of

interest for both roles and the following nominations were received:

Lead Governor – Pamela Peel (Public)

Deputy Lead Governor – Lorraine Heaton (Staff) and John Johnson (Public)

6. As only one nomination was received for the Lead Governor role, it is proposed that the Council of

Governors re-appoints Pamela Peel.

7. In respect of the appointment of Deputy Lead Governor, an election will be held which will be

undertaken at the formal Council of Governors’ meeting on 15 June 2016.

8. In terms of the process, each Governor will be provided with a ballot slip containing the names of

both candidates and will be asked to place an X against their preferred candidate only and put their

ballot slip into the box provided. The votes will be counted by the Board Secretary (acting as

Page 42 of 43


Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2016 3/3

Returning Officer) and the result provided at the meeting. The candidate receiving the highest

number of votes will be declared appointed as the Deputy Lead Governor.

Recommendation

9. Council of Governors to approve the re-appointment of Pamela Peel as Lead Governor for a term

of 12 months.

10. The candidate receiving the highest number of votes to be appointed as Deputy Lead Governor

also for a term of 12 months.

Author: Michael Games, Corporate Governance Manager

Date: 9 June 2016

11. L

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Gov

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over

nor

Page 43 of 43

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