council of governors - royal berkshire hospital...lindsey barker philip holmes 6.15 – 6.30 holding...

1

Council of Governors Thursday 29 January 2015 6.00pm – 7.40pm Seminar Room, Trust Education Centre Item Lead Time

1. Apologies for Absence

Stephen Billingham -

2. Minutes for Approval: 29 October 2014 (Attached to approve)

Stephen Billingham 6.00 – 6.05

3. Matters Arising Schedule (Attached to note)


4. Questions from the Public (Verbal)


5. Changes to Council Membership (Verbal to note)

Caroline Lynch -

6. Items from Governors: What are the Trust’s plans in respect of innovation, research and development in order to take advantage of the benefits of best practice across the NHS? (Jonathan Mason) Can the Council be advised whether the Trust has been consulted by Reading Borough Council’s with regard to their plans to introduce a pay and display for on road parking around the hospital? (Tony Lloyd)

Lindsey Barker Philip Holmes

6.15 – 6.30

Holding the Board to Account

7. Draft Quarterly Return to Monitor (Attached to review) To review the quarterly return, considered by the Board on 29 January 2015, to gain assurance in respect of actions being taken by the Board to address areas of concern

Jean O’Callaghan

6.30 – 6.45

8. Minutes of the Clinical Assurance Committee: 8 December 2014 (Attached)

Tony Skuse 6.45 – 6.50

Agenda

Agenda - Council of Governors 2

Agenda – Council of Governors

a) To review issues of concern to, or escalated by, the Assurance Committees requiring consideration by the full Council (b) To gain assurance from the Board Directors in respect of issues of concern

9. Minutes of the Business Assurance Committee: 8 January 2015 (Attached) (a) To review issues of concern to, or escalated by, the Assurance Committees requiring consideration by the full Council (b) To gain assurance from the Board Directors in respect of issues of concern

Bob Pitts

6.50 – 6.55

10. Minutes of the Strategy Committee: 20 January 2015 (Attached) (a) To review issues of concern to, or escalated by, the Assurance Committees requiring consideration by the full Council (b) To gain assurance from the Board Directors in respect of issues of concern

Peter Dooley 6.55 – 7.00

11. Update on Monitor Actions (Verbal to note)

Jean O’Callaghan

7.00 – 7.20

Items of Council Business

12. Minutes of Membership Committee: 14 January 2015 (Attached to note)

Tom Bune

7.20 – 7.25

Representing the Views of Members and the Public

13. Quarterly Survey of Members (Verbal to note)

Tom Bune

7.25 – 7.35

14. Questions from the Public (Verbal)


15. Date of Next Meeting Thursday 28 May 2015 6.00pm

- -

Close 7.40

Agenda Item 2

1

Council of Governors 6.00pm – 7.00pm Seminar Room, Trust Education Centre Thursday 29 October 2014 Present Mr. Stephen Billingham (Chairman) Mr. David Cooper (Public Governor, Reading) (Lead Governor) Mrs. Carol Bolderson (Public Governor, West Berkshire) Ms. Wendy Bower (Partner Governor, West Berkshire Federation CCG’s) Mr. Tom Bune (Public Governor, Southern Oxfordshire) Mr. Jeremy Butler (Public Governor, East Berkshire) Mr. Ross Carroll (Public Governor, East Berkshire) Mr. Ian Clay (Volunteer Governor) Mr. Peter Dooley (Partner Governor, Berkshire Carers Service) Ms. Jennie Ford (Partner Governor, East Berkshire Federation CCG’s) Mr. Colin Lee MBE (Public Governor, West Berkshire) Mr. Tony Lloyd (Public Governor, Wokingham) Mr. Jonathan Mason (Staff Governor, Allied Health Professionals/Scientific) Mr. David Mihell (Public Governor, East Berkshire) Dr. Charles McKenna (Staff Governor, Medical/ Dental) Cllr. Bob Pitts (Partner Governor, Wokingham Borough Council) Ms. Anne-Marie Probert (Staff Governor, Nursing/Midwifery) Ms. Deborah Sander (Public Governor, Reading) Mr. Tony Skuse (Public Governor, Wokingham) In attendance Ms. Caroline Ainslie (Director of Nursing) (from minute 52/14) Mrs. Heather Allan (Director of IM&T) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Care Group Director, Networked Care) Mr. Paul Beal (Director of Workforce & OD) Mr. Keith Eales (Director of Corporate Affairs & Secretary) Dr. Sue Edees (Care Group Director, Urgent Care) Mr. Alistair Flowerdew (Medical Director) (from minute 52/14) Mr. Brian Hendon (Non Executive Director) Dr. Alison Hill (Non Executive Director) Ms. Sue Hunt (Non Executive Director) Mrs. Caroline Lynch (Deputy Company Secretary) Ms. Jane May (Associate Non Executive Director) Jean O’Callaghan (Chief Executive) Mrs. Janet Rutherford (Non Executive Director) Miss. Emma Sampson (Corporate Governance Officer) Apologies Mr. Martyn Cooper (Public Governor, Reading) Mr. Sanusi Koroma (Partner Governor, Reading CRE)

Minutes

Council of Governors 2

Council of Governors 29 October 2014

Mr. Dave Dymond (Public Governor, Reading) Cllr. Gordon Lundie (Partner Governor, West Berkshire) Mr. John McKenzie (Public Governor, Wokingham) Ms. Pamela Simmons (Staff Governor, HCA/Ancillary) Cllr. Bet Tickner (Partner Governor, Reading Borough Council) Ms. Maria Walker (Staff Governor, Admin/ Management) The Chairman welcomed Mrs. Sue Hunt to her first meeting as Non Executive Director, and Mr Paul Beal, to his first meeting as Director of Workforce & Organisational Development. 48/14 Minutes: 31 July 2014 and 30 September 2014

The minutes of the meetings held on 31 July 2014 and September 2014 were agreed as a correct record and signed by the Chair.

49/14 Matters Arising Schedule

The Council noted the matters arising schedule setting out updates on actions from the previous meeting. Resolved: that the matters arising schedule be noted

50/14 Changes to Council Membership The Council noted that there had been no changes to Council Membership since the last

meeting.

The Director of Corporate Affairs & Secretary advised that elections were ongoing at present for two vacant seats in Reading and West Berkshire and the closing date for nominations was Friday 31 October 2014.

Resolved: that the Council note that no changes had been made to Council Membership.

51/14 Items from Governors

The Care Group Director, Networked Care provided an overview in relation to the Trust’s discharge process. The Care Group Director, Networked Care, advised that a new discharge protocol had been developed and a staff communications plan had been undertaken to ensure staff were aware of the new protocol. A patient leaflet was also provided to patients to ensure there were aware of the process. The Care Group Director, Networked Care advised that discharge planning began on the patient’s first day of admission. Patients were reviewed daily, with the decision to discharge being made after consultant ward rounds. Improvements such as a ward based pharmacy with a satellite dispensary, use of the discharge lounge, hospital based transport and a social worker on site had been introduced. It was noted that a project was currently being undertaken by patient leaders who were reviewing the discharge process.



52/14 Board Performance Reports The Chief Executive introduced the Chief Executive’s Report and drew attention to the NHS

Five Year Forward View document published by NHS England in October 2014.

The Chief Executive advised that that the ED target for Quarter 2 had been narrowly missed with the Trust achieving 94.8% against a target of 95%. The Council noted that an external data team had been engaged to revalidate 18 week data and the team would be sited on site with existing staff. The Chief Executive advised that an external review of maternity services had been commissioned. It was noted that recruitment of midwives remained an issue and sickness absence levels had exacerbated this issue. The Chief Executive advised that diversions had been put in place on occasions in addition to reduced use of the midwifery led unit in order to ensure a safe service was provided for women.

The Council requested whether a briefing on 18 week pathway could be provided. The Chief Executive confirmed that this would be arranged. Action: Jean O’Callaghan The Council noted the increase in complaints received. It was queried whether customer service training for staff was still provided. The Director of Workforce & OD undertook to confirm this. Action: Paul Beal The Director of Finance introduced the finance update and advised that a deficit of £5.6m had been declared in September which was in line with the budget. The Trust had however maintained a Continuity of Service Risk Rating (CoSRR) of 2. The Director of Finance advised that that cash was ahead of budget at £14.32m. The Director of Finance submitted the latest forecast for 2014/15. The Council noted a forecast deficit of £3.2m, which included £2.2m of non recurrent spend. In response to a query the Director of Finance advised that the QIPPs target was £18.5m and the current Programme Management Office risk assessment was £14.5m. In response to a query the Director of Finance advised that budget figures would be presented to the Board in December and February before being submitted for final confirmation in March. Further actions were being implemented in an attempt to reduce costs and the Executive was reviewing agency expenditure and headcount reductions. Centralised approval of discretionary spend had also been put in place. In response to a query the Care Group Director, Networked Care, advised that drug costs had reduced this year and the Trust was now using direct prescriptions. The Director of Finance added that the Trust’s drug costs were £0.5m below budget. The Council noted that the new theatres would be in use by January 2015. The Chairman advised the Council that the Board, at its meeting earlier that day, had confirmed that two out of the three statements submitted as part of the Monitor quarterly



return had been marked as ‘not confirmed’. The Chairman advised that this was likely to heighten Monitor’s scrutiny of the Trust. Resolved: that the report be noted.

53/14 Minutes of Meetings

The Chairs of Council Committees introduced the minutes of the following sub-groups held and highlighted particular issues and recommendations

• Membership Committee 4 September 2014 • Clinical Assurance Committee 24 September 2014 • Nominations and Remuneration Committee 25 September 2014 • Business Assurance Committee 2 October 2014

Membership Committee The Chair advised that the survey to be undertaken in relation to the Annual Members Meeting had been delayed. Clinical Assurance Committee The Chair advised that the dates for the Committee had been rescheduled in order to align them with Board Clinical Governance Committee dates. The Chair reported that the new occupational health policy included a requirement that any new staff would not be declared fit for employment before they had confirmed their immunisation status.

Nominations and Remuneration Committee The Chair advised the Committee had recommended the appointment of the new Non Executive Directors. The Committee had also begun preparations for the appraisal of the Chairman.

Resolved: that the minutes of the above meetings be received and the recommendations therein endorsed.

54/14 Questions from the Public

There were no questions from the public. Date of Next Meeting

The next meeting would be held on Thursday 29 January 2015 at 6pm

SIGNED DATE

Council of Governors Matters Arising Schedule Agenda Item 3

1

Minute Ref

Subject

Matter Arising Owner Update

52/14 Board Performance Reports

The Council requested whether a briefing on 18 week pathway could be provided. The Chief Executive confirmed that this would be arranged. It was queried whether customer service training for staff was still provided. The Director of Workforce & OD undertook to confirm this.

Jean O’Callaghan Paul Beal

A briefing on the 18 week pathway was provided to governors at the Clinical Assurance Committee in December 2014. Customer service training is still provided for staff.

Agenda Item 7 Royal Berkshire NHS Foundation Trust Board of Directors

Date 29 January 2015 Lead Craig Anderson Title In-Year Quarterly Report to Monitor - Quarter 3 – 2014/15 Purpose: Approval of the Q3 Return for submission to Monitor by 30 January 2015. Key Points:

• Monitor’s Risk Assessment Framework requires the submission of a Quarterly Reporting Return (taking the form of standard templates and declarations) that has been assured by the Trust’s Board of Directors.

• The key issues of which the Board needs to be aware are included within this paper. Decision Required

The Board of Directors is asked to:

• APPROVE that the statement “The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.” should be marked as ‘Not Confirmed’

• APPROVE the Confirmation of the statement that “The board anticipates that the trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months”, should be marked as “

.

Not Confirmed

• APPROVE the Confirmation of the statement that “The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per Compliance Framework page 16 Diagram 8 and page 58, and the Risk Assessment Framework page 22, Diagram 6) which have not already been reported ” should be marked as “

”.

Confirmed”

• APPROVE the submission of the full Return to Monitor.

.

• AUTHORISE the Chief Executive Officer and the Director of Finance to sign the Q3 Monitor Return on behalf of the Board of Directors.

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

(a) Appendix 1 - Declaration of Risks against Healthcare Targets and Indicators (b) Appendix 2 - Detailed Financial Summary (c) Appendix 3 - In-year Governance Statement (d) Appendix 4 - Extracts from the Mandatory Guidance (e) Appendix 5 - Activity Information (f) Appendix 6 – Quality Governance Metrics – Executive Team Turnover

Contact: Craig Anderson – Director of Finance (Tel: 0118 322 8833)

Monitors Risk Assessment Framework (‘RAF’)

Monitor’s extant Risk Assessment Framework (‘RAF’) (as revised 1 April 2014) can be found on Monitor’s website under publications. Link: http://www.monitor.gov.uk/raf. All Board members should be conversant with its content.

Monitor uses a governance rating, incorporating information across a number of areas, to describe their views of the governance at a Foundation Trust. This governance rating will be generated by considering the following information regarding a Foundation Trust and whether it is indicative of a potential breach of the governance condition:

Governance Rating

• performance against selected national access and outcomes standards;

• CQC judgements on the quality of care provided;

• relevant information from third parties;

• a selection of information chosen to reflect quality governance at the organisation; the degree of risk to continuity of services and other aspects of risk relating to financial governance; and

• any other relevant information.

Monitor publishes governance ratings in the following form:

• A “GREEN” rating if no governance concerns evident; or

• The “GREEN” rating will be replaced with a description of the issue and the steps (formal or informal) Monitor is taking to address the concern; or

• A “RED” rating if regulatory action if being taken. To identify if there is a governance concern, Monitor have provided a number of examples of areas which would classify as governance concerns. One particular area identified as a governance concern is in respect to systematic underperformance in healthcare standards. The next table provides further details: Indicator Driver for Governance Concern Meeting the C-Difficile objective

• Has greater than 12 cases in the year to date and either: • breaches the cumulative year-to-date trajectory for successive quarters; or • breaches its full year objective • reports important or significant outbreaks of C-Difficile

Referral to treatment waiting times

• Breaches • The admitted patients 18 weeks waiting times measure for a third successive

quarter; • The non-admitted patients 18 weeks waiting times measures for a third

successive quarter; or • The incomplete pathway 18 weeks waiting time measure for a third

successive quarter. A&E indicator • Fails to meet the A&E target twice in any two quarters over a twelve month period

and fails the indicator in a quarter during the subsequent nine month period or the full year.

Cancer waiting times

• Breaches • the 31 day cancer waiting time target for a third successive quarter; or

http://www.monitor.gov.uk/raf�

• the 62 day cancer waiting time target for a third successive quarter. Any other indicator • Breaches the indicator for three successive quarters. In assigning an appropriate governance risk rating, Monitor will be informed by the:

• seriousness of the issue;

• information they already have concerning the situation;

• effectiveness of the Trust’s initial response to the issue; and

• time-critical nature of the situation.

Monitor may require additional information from the Foundation Trust. Depending on the assessment, Monitor may decide to investigate formally and/or address the issue through their application of their enforcement powers.

Monitor’s financial risk assessment considers the “Continuity of Services Risk Rating” (COSRR). This is a measure of the Trust’s financial ability to continue to deliver Requested NHS Services to its Commissioners and looks at two, equally weighted, key measures:

Finance - Continuity of Services Risk Rating

• Liquidity: days of operating costs held in cash or cash equivalent forms; and

• Debt service cover rating: the degree to which the organisations generated income, that is EBITDA, covers its financing obligations such as interest and debt repayments.

Each metric is given a score of between 1 and 4, with 1 being high risk and 4 being low risk and a matrix used to arrive at the following COSRR (with associated potential action from Monitor.

Rating Explanation COSSR 4 “no evident concerns” with no further action from Monitor. COSSR 3 “emerging or minor concern potentially requiring scrutiny” so Monitor may ask the

Trust to provide a limited amount of financial information on a monthly basis. COSSR 2* “level of risk is material but stable”, that is, the Trust may have a COSRR of 2 but

Monitor feel that there is little likelihood of further financial deterioration. Monitor anticipates a limited number of Trusts in this position and this would generally be applicable to Trust’s with PFI schemes.

COSSR 2 “material risk” (potential breach of continuity of service license conditions) with Monitor either looking for immediate action or an increased level of monitoring with information being provided to Monitor on a monthly basis.

COSSR 1 “significant risk” resulting in Monitor either using its powers under the license to initiate contingency planning process or maintaining a closer degree of monitoring with formal enforcement action where necessary.

Healthcare Targets and Indicators Declaration

• The proposed Q3 completed template for Declaration of Risks against Healthcare Targets and Indicators is attached (Appendix 1). This discloses that the Trust is not able to confirm meeting the following targets:

Targets or Indicators Not Met Target Actual Comment RTT 18 weeks - Admitted 90% n/k Reporting holiday granted by Monitor.

Reported as not met in Q1 of 14/15 RTT 18 weeks - Non-admitted 95% n/k Reporting holiday granted by Monitor

RTT 18 weeks – incomplete pathways 92% n/k Reporting holiday granted by Monitor

A&E Wait < 4Hours 95% 94.5% Not met Q1, Q3 & Q4 of 13/14 and Q2 of 14/15

Cancer 62 Day Waits for first treatment (from urgent GP referral) 85% 83.6% Not met Q2 14/15

Cancer Two week (all cancers) 93% 91.9% Not met in Q1 and Q2 of 14/15

• At the time of publication some statistics are still subject to data validation checks being carried out by Care Groups: specifically Cancer waiting times. The final figures actually achieved for all indicators will be populated on the Return prior to submission. It is not expected that such changes will change the conclusion in terms of meeting any of the thresholds.

Financial performance and Continuity of Service Risk Rating (‘CoSSR’)

• The Detailed Financial Summary from the Q3 financial templates is attached as Appendix 2, reflecting the Trust’s financial position for Quarter 3 ending 31 December 2014.

• The Trust had a Net Deficit at the end of Q3 of £6.9m against the Plan Net Deficit of £3.1m. Cash at the end of Q3 was £11.2m versus an Annual Plan of £13.2m.

• The Q3 Return reflects a COSRR achieved of ‘2’ versus an Annual Plan of ‘3’ as per table below:

Board Governance Statements required

The Quarterly Return requires the Trust’s Board of Directors to respond “Confirmed” or Not Confirmed” to the three statements below (see Appendix 3). In the case of the absence of full certification, the Board is required to set out in the Return the reasons for the absence and the action it proposes to take to address it.

(The extracts from the extant Risk Assessment Framework as referenced in the statements are attached at Appendix 4 for ease of reference). STATEMENT 1 - For Finance, that: “The board anticipates that the trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months.”

• It is proposed that the Board should mark this statement with “Not Confirmed”. Although, given that the Annual Plan expected us to be a COSRR of 3 at the end of March 2015, the latest forecast shows us achieving a CoSRR of ‘2’. Notwithstanding this, our expectation has been that we would be a CoSRR of 2 in Q1 and Q2 of 2015/16.

• Whilst the Trust is taking all reasonable steps to mitigate the deficit we do not expect that these will be sufficient to return us to a CoSRR of 3 this quarter.

Weighting Element Metric Rating for Element

Metric Rating for Element

50% Capital Service Cover (ratio) 1.79 times 3 1.31 times 250% Liquidiity -10.9 2 -16.2 1

Weighted CoS Risk Rating 3 2

YTD ENDED 31 DECEMBER 2014 CoSRR PLAN CoSRR ACTUAL

• A declaration of “not confirmed” should not be unexpected by Monitor being consistent with our response to the financial components of the “formal undertakings” and our discussions with them to date.

• The “Not Confirmed” status of the Finance Declaration requires the Trust to enter a commentary on the face of the Template. It is proposed that reference is made to our recent discussions re the formal undertakings and the latest forecast.

STATEMENT 2 - For Governance, that: “The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.”

It is proposed that the Board should declare this Governance statement with “Not Confirmed”. This is on the basis that there is sufficient concern to believe there is a significant risk of systematic underperformance triggering a potential governance concern. In coming to this conclusion, we have considered that:

• A&E <4 hour waits. Having narrowly missed the Q2 performance, achieving 94.86%, the Trust implemented a number of operational changes to strengthen the day to operational management and control of patient flow. Changes have resulted in an improved provision of executive and senior management support on a daily basis with structured operational meetings occurring 3 times a day. A strong focus on early discharge and the use of the discharge lounge improve flow and minimised breaches related to bed availability. The Trust saw improvements in both October and November’s performance with October achieving 97.2% and November 96.2%.

• December demand increased with both attendance and admission numbers increasing by 5%. The volume and complexity of admissions causing significant pressures on bed capacity. In particular, activity over the three weeks prior to Christmas the Trust saw 11 days with over 100 admissions and 10 days with over 300 attendances, this is a 9% increase on December 2013 for attendance and a 7% increase in admissions. The December performance reduced Q3 overall performance to 94.53%

• Further initiatives have included: 8 observation beds and ambulatory chairs opening in the Emergency Department (additional medical cover for the winter period to look after patients in both outlying wards) and ensuring timely clerking at the point of admission. Following the bed modelling carried out in quarter 2 and 3 we are planning a bed reconfiguration to ensure the emphasis on ambulatory care is maintained, particularly with the addition of a drop in unit to our acute medical unit allowing a sustained approach to ambulatory care.

• Cancer targets: Despite a marked improvement in Q3 performance across all 5 reported Cancer standards there is a strong likelihood that the Trust will fail to achieve 2 of these standards, namely the Cancer 62 day target (GP referrals) and the Cancer two week wait targets (all cancers). Performance against 62 day was compliant in both November (88.1%) and December (86% - this % is subject to final validation), however the ground lost in October (76.4%) could not be retrieved. The main reasons for October’s 26 breaches were diagnostics (10), patient availability (4) and tertiary provider breaches (3). The diagnostics issues were reporting delays, unable to book CTs before day 13-14, and delays in tertiary PET scans at Oxfords University Hospital. The remaining 9 were clinical safety and complexity related.

• The Cancer 2ww target failed October due to a high number of capacity related breaches, primarily in endoscopy. These have improved markedly in November and December, per our planned works to create an additional endoscopy room are underway and the gastro team are looking at the provision for 6 day working. December performance dipped largely as a result of patient choice over the Christmas period.

• 18 week RTT. Data reporting of 18 week RTT data is currently suspended due to ongoing validation processes in relation to its recording and reporting of RTT performance. A very challenging “data cleansing” plan was agreed with Monitor and commenced in November. All milestones within this plan have been achieved, the main impact being the reduction in the size of the Trust PTL from >80,000 patients to 26,000. Reporting resumes in January 2015..

• The Trust has secured the services of Planned Care and Informatics specialists to develop, implement and embed processes and disciplines, providing greater assurance to the Trust Board. During the quarter the management of “planned” lists was reviewed, this exercise uncovered 2 large cohorts of patients who had either been incorrectly assigned to the planned list or had not been managed in accordance with DH Guidance. These findings have both been declared as Serious Incidents and are currently being investigated. Applying the rules and guidance correctly to these cohorts has resulted in the declaration of 118 breaches of the 52 week RTT standard. Monitor, NHSE and the CCG have been informed, all of whom have supported the Trust in its response to these findings. These breaches will be uploaded and reported for December. The Trust is on track to report RTT performance in full for January. Once this is completed recovery plans will be shared and agreed with the CCG and Monitor.

• CQC Compliance: Following the inspection of the Trust by the Care Quality Commission (March 24 - 26 2014), the Trust continues to implement the actions identified in its post-inspection action plan, including action in relation to the 7 Compliance Actions and 27 specific actions within the CQC Quality Report of the inspection. The Trust is able to demonstrate progress against a number of areas and continues to drive towards compliance. This improvement programme is monitored by the CCG at the monthly Senior Joint Governance Meeting and bi-monthly at the Quality Review Group and by the CQC at regular quarterly meetings with the Chief Executive of the Trust.

It is proposed that the above Commentary is included within the Trust’s Q3 Return Commentary that is forwarded to Monitor in explaining the reason why this Governance Statement is not confirmed by the Board. STATEMENT 3- Otherwise, that: “The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per Risk Assessment Framework page 22, Diagram 6) which have not already been reported.” It is proposed that this statement is “Confirmed” on the basis that there are no known issues requiring an Exceptions report, which have not already been reported. Executive Team turnover

Under the RAF, Monitor uses Executive Team turnover as an indicator of potential quality governance concerns. The Trust return template for this is given in Appendix 6.

Activity Information

The Activity template for Q3 reflects the activity volumes which are consistent with Income reported for YTD Q3 (see Appendix 5).

List of Governors Elections

A ‘nil’ return is being made for List of Governors Elections on the basis that there were no elections in the reporting quarter.

`

APPENDIX 1

Declaration of risks against healthcare targets and indicators for 2014-15 by Royal BerkshireThese targets and indicators are set out in the Risk Assessment Framework Key: must complete

Definitions can be found in Appendix A of the Risk Assessment Framework may need to complete

Quarter 1 Quarter 2 Quarter 3

Threshold or target YTD

Scoring under RAF

Risk declared at Annual

Plan

Scoring under Risk

Assessment

Performance

Achieved/Not Met

Performance

Achieved/Not Met Performance Achieved/N

ot Met Any comments or explanations

Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 No 89.1% Not met 0.0% Not relevant 0.0% Not relevant Suspension of data reporting per email of 22 August 14 from Amrita Sidhu, Regional Manager

Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 No 99.8% Achieved 0.0% Not relevant 0.0% Not relevant Suspension of data reporting per email of 22 August 14 from Amrita Sidhu, Regional Manager

Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 No 0 94.2% Achieved 0.0% Not relevant 0.0% Not relevant Suspension of data reporting per email of 22 August 14 from Amrita Sidhu, Regional Manager

A&E Clinical Quality- Total Time in A&E under 4 hours 95% 1.0 Yes 1 95.8% Achieved 94.8% Not met 94.5% Not met See commentary

Cancer 62 Day Waits (from urgent GP referral) - post local breach re-allocation 85% 1.0 No 85.4% Achieved 76.1% Not met 83.6% Not met See commentary

Cancer 62 Day Waits (from NHS Cancer Screening referral) - post local breach re-allocation 90% 1.0 No 0 90.5% Achieved 85.5% Not met 97.5% Achieved Cancer 62 Day Waits (from urgent GP referral) - pre local breach re-allocation 80.8% 76.1% 83.2%Cancer 62 Day Waits (from NHS Cancer Screening) - pre local breach re-allocation 90.5% 85.5% 97.5%Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No 94.1% Achieved 94.2% Achieved 95.9% Achieved Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No 100.0% Achieved 99.0% Achieved 99.4% Achieved Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No 0 97.3% Achieved 96.2% Achieved 99.0% Achieved Cancer 31 day wait from diagnosis to first treatment 96% 1.0 No 0 97.9% Achieved 98.3% Achieved 97.6% Achieved Cancer 2 week (all cancers) 93% 1.0 No 89.5% Not met 88.4% Not met 91.9% Not met See commentary

Cancer 2 week (breast symptoms) 93% 1.0 No 0 87.7% Not met 90.1% Not met 93.2% Achieved Care Programme Approach (CPA) follow up within 7 days of discharge 95% 1.0 No 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Care Programme Approach (CPA) formal review within 12 months 95% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Admissions had access to crisis resolution / home treatment teams 95% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Meeting commitment to serve new psychosis cases by early intervention teams 95% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Ambulance Category A 8 Minute Response Time - Red 1 Calls 75% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Ambulance Category A 8 Minute Response Time - Red 2 Calls 75% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Ambulance Category A 19 Minute Transportation Time 95% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant C.Diff due to lapses in care 30 1.0 No 0 0 Achieved 0 Achieved 3 Achieved Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) 4 8 12C.Diff cases under review 4 8 10Minimising MH delayed transfers of care <=7.5% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Data completeness, MH: identifiers 97% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Data completeness, MH: outcomes 50% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Compliance with requirements regarding access to healthcare for people with a learning disab N/A 1.0 No 0 0.0% Not relevant 0.0% Not relevant N/A Not relevant Community care - referral to treatment information completeness 50% 1.0 No 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Community care - referral information completeness 50% 1.0 No 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Community care - activity information completeness 50% 1.0 No 0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No No No

CQC compliance action outstanding (as at time of submission) N/A No Yes Yes Yes7 Compliance Actions - monitoring arrangements as per Q1 Return

CQC enforcement action within last 12 months (as at time of submission) N/A No No No No

CQC enforcement action (including notices) currently in effect (as at time of submission) N/A No No No No

Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time o N/A No No No No

Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of sub N/A No No No No

Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No No No

Results left to complete 0 0 0 0 0Total Score 1 1 2 3

Report by Exception

Target or Indicator (per Risk Assessment Framework)

APPENDIX 2

Financial Extract from Monitor Q2 Statement of Comprehensive IncomeAudited for Plan for Actual for Plan for Actual for Plan for Actual for Plan for Plan for Plan for Actual for Variance for

Operating

Yearending

31-Mar-14

Quarter ending 30-

Jun-14

Quarter ending 30-

Jun-14

Quarter ending 30-

Sep-14

Quarter ending 30-

Sep-14

Quarter ending 31-

Dec-14

Quarter ending 31-

Dec-14

Quarter ending 31-

Mar-15

Yearending

31-Mar-15

Year to date

ending

Year to date

ending

Year to date

endingNHS Clinical Revenue

NHS Community activity revenue, Total 2.00 0.44 0.49 0.44 0.49 0.44 0.49 0.44 1.75 1.31 1.47 0.16Elective activity revenue, Total 25.30 7.28 5.99 7.65 6.31 7.65 6.31 7.53 30.10 22.58 18.61 -3.97Elective Day Case activity revenue, Total 30.79 7.96 8.25 8.36 8.09 8.36 8.73 8.23 32.91 24.69 25.06 0.38Non-Elective activity revenue, Total 87.35 19.44 18.60 19.65 18.03 19.65 18.73 19.22 77.96 58.74 55.36 -3.38Outpatients activity revenue, Total 63.82 13.62 14.84 14.30 15.06 14.30 15.61 14.07 56.28 42.21 45.51 3.29A&E activity revenue, Total 12.99 3.35 3.40 3.39 3.43 3.39 3.44 3.31 13.44 10.13 10.27 0.14Other NHS Activity, Total 17.21 11.23 9.63 11.50 9.67 11.50 9.74 11.36 45.59 34.23 29.04 -5.18Non-Tariff revenue, Total 71.71 14.91 17.30 14.59 17.43 15.79 18.42 16.13 61.41 45.28 53.15 7.87CQUIN revenue 6.55 1.56 1.56 1.56 1.56 1.56 1.56 1.56 6.24 4.68 4.68 0.00NHS Clinical Revenue, Total 317.72 79.79 80.05 81.43 80.07 82.63 83.03 81.86 325.70 243.84 243.15 -0.69Non Mandatory/Non protected revenue, Total 4.13 1.00 0.96 1.00 0.82 1.00 0.99 1.00 4.00 3.00 2.76 -0.23

Other Operating revenue, Total 21.83 4.83 5.64 4.74 4.81 4.78 6.15 4.77 19.13 14.36 16.60 2.24Operating Revenue, IFRS, Total 343.68 85.62 86.65 87.17 85.69 88.41 90.16 87.63 348.83 261.20 262.51 1.31Operating Expenses

Drugs -33.52 -8.41 -9.15 -8.39 -7.35 -8.49 -9.19 -8.49 -33.78 -25.29 -25.69 -0.40Clinical supplies -40.32 -10.74 -10.59 -11.21 -10.35 -11.22 -11.29 -11.24 -44.40 -33.17 -32.23 0.94Non-clinical supplies -6.78 -1.77 -1.66 -1.78 -1.37 -1.75 -1.46 -1.75 -7.04 -5.30 -4.49 0.81Employee expenses, permanent staff -190.18 -50.87 -49.54 -50.29 -49.04 -48.01 -49.71 -47.84 -197.01 -149.18 -148.29 0.89Employee expenses, agency & contract staff -12.67 -1.39 -2.56 -1.30 -2.37 -1.32 -2.52 -1.32 -5.34 -4.02 -7.46 -3.44

Misc. other Operating expenses -43.81 -10.47 -10.78 -9.94 -11.38 -9.10 -11.16 -8.95 -38.47 -29.52 -33.31 -3.79Operating Expenses within EBITDA, Total -327.28 -83.65 -84.27 -82.92 -81.86 -79.89 -85.34 -79.58 -326.04 -246.46 -251.46 -5.00

Depreciation and Amortisation, Total -17.13 -4.36 -4.26 -4.44 -4.47 -4.44 -4.42 -4.44 -17.68 -13.24 -13.15 0.09

Operating Expenses IFRS, Total -344.42 -88.01 -88.53 -87.36 -86.32 -84.33 -89.76 -84.02 -343.73 -259.71 -264.61 -4.91

Surplus (Deficit) from Operations -0.74 -2.39 -1.88 -0.20 -0.63 4.08 0.40 3.61 5.11 1.49 -2.10 -3.59Non Operating

Non-Operating incomeInterest Income 0.11 0.02 0.02 0.01 0.00 0.00 0.05 0.05Gain/(loss) on asset disposals 0.09 -0.01 0.00 0.00 -0.01 -0.01

Non-Operating income, Total 0.20 0.00 0.02 0.00 0.02 0.00 0.01 0.00 0.00 0.00 0.05 0.05

Non-Operating expensesInterest Expense, Total -1.39 -0.27 -0.31 -0.25 -0.30 -0.25 -0.30 -0.24 -1.02 -0.78 -0.91 -0.12PDC dividend expense -4.82 -1.26 -1.27 -1.26 -1.27 -1.26 -1.27 -1.26 -5.06 -3.79 -3.80 0.00

Other Non-Operating expenses, Total -0.04 0.00 -0.01 0.00 -0.01 0.00 -0.01 0.00 0.00 0.00 -0.02 -0.02Non-Operating expenses, Total -6.25 -1.54 -1.59 -1.52 -1.57 -1.52 -1.57 -1.51 -6.08 -4.58 -4.72 -0.15

Surplus (Deficit) before Tax -6.79 -3.93 -3.44 -1.72 -2.18 2.56 -1.16 2.11 -0.98 -3.08 -6.78 -3.69

Income Tax (expense)/ refund -0.21 -0.08 0.00 0.00 -0.08 -0.08

Surplus (Deficit) After Tax -7.00 -3.93 -3.44 -1.72 -2.18 2.56 -1.24 2.11 -0.98 -3.08 -6.86 -3.78

Hist Gain/loss on relevant transfers (1st April) 0.18 0.00 0.00 0.00 0.00

Total Comprehensive Surplus/(Deficit) -6.83 -3.93 -3.44 -1.72 -2.18 2.56 -1.24 2.11 -0.98 -3.08 -6.86 -3.78

OTHER INFORMATIONRevenue Generation Programmes

Revenue Generation, net 5.40 1.55 0.00 0.00 1.55 1.55Cost Improvement Programmes

Pay Expense savings CIP, TOTAL 1.27 1.31 0.62 1.81 2.05 2.81 2.25 3.31 9.25 5.94 4.93 -1.00Drugs expense savings CIP, TOTAL 1.52 0.00 0.20 0.00 0.48 0.00 0.41 0.00 0.00 0.00 1.09 1.09Clinical Supplies expense savings CIP, TOTAL 3.70 0.00 0.56 0.00 0.98 0.00 1.32 0.00 0.00 0.00 2.86 2.86Non-clinical Supplies expense savings CIP, TOTAL 0.35 0.00 0.07 0.00 0.08 0.00 0.01 0.00 0.00 0.00 0.16 0.16Misc. Other Operating Expenses CIP, TOTAL 3.07 2.31 0.66 2.31 0.90 2.31 0.51 2.31 9.26 6.94 2.06 -4.89Other expense savings CIP, TOTAL 0.00 0.00 0.02 0.00 0.05 0.00 0.04 0.00 0.00 0.00 0.11 0.11

Cost Improvement Programmes, Total 9.92 3.63 2.13 4.13 4.54 5.13 4.54 5.63 18.50 12.88 11.20 -1.68

APPENDIX 3

In Year Governance Statement from the Board of Royal Berkshire

The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)

For finance, that: Board Response4 Not Confirmed

For governance, that:11 Not Confirmed

Otherwise:Confirmed

Consolidated subsidiaries:

1

Signed on behalf of the board of directors

Signature Signature

Name Jean O'Callaghan Name Craig Anderson

Capacity Chief Executive Officer Capacity Director of Finance and Interim Deputy CEO

Date 30 January 2015 Date 30 January 2015

0

Notes:

A

B

C

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 22, Diagram 6) which have not already been reported.

The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

For Finance: The latest forecast shows the Trust delivering a COSRR of 2 at the end of March 2015. Whilst the Trust is taking all reasonable steps to mitigate the current year deficit it is no longer expected that these will be sufficient to return the Trust to a COSRR of 3 at the end of March 15.

The details of the forecast along with the mitigating actions being taken is the subject of a separate report to Monitor as part of the formal undertakings.

Furthermore historical annual plans lead the Trust to believe that it will be a COSSR of 2 for the first two quarters of 2015/16 and is unlikely to return to a CoSRR of 3 until at least December 2015. The Operating Plan to be submitted to Monitor in the first week of April will verify this.

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the NHS foundation trust.

Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted to Monitor to arrive by the submission deadline.

In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed’ in the relevant box. It must provide a response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it. This may include include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance.

For Governance: Potential Governance concerns reflect the risks in reporting achievement of the following issues as described in the Commentary to the Q3 Return :

1. A&E - 4 hr target., 2. Cancer targets,3. 18 week RTT. (Reporting of 18 week RTT data is currently suspended due to ongoing validation process) 4. Following the inspection of the Trust by the Care Quality Commission (March 24 - 26 2014), the Trust continues to implement the actions identified in its post-inspection action plan, including action in relation to the 7 Compliance Actions and 27 specific actions within the CQC Quality Report of the inspection.

APPENDIX 4

EXTRACTS FROM THE MANDATORY GUIDANCE Appendix A of Risk Assessment Framework

APPENDIX 4 (cont’d) EXTRACTS FROM THE MANDATORY GUIDANCE (Contd.) Risk Assessment Framework - Exception Reporting

APPENDIX 4 (cont’d) EXTRACTS FROM THE MANDATORY GUIDANCE (Contd.) Risk Assessment Framework, page 22

APPENDIX 5

Activity Information for Royal Berkshire

Notes:Plan for Actual for Plan for Actual for Plan for Actual for Plan for Plan for Plan for Actual for Variance for

Quarter ending 30-

Jun-14

Quarter ending 30-

Jun-14

Quarter ending 30-

Sep-14

Quarter ending 30-

Sep-14

Quarter ending 31-

Dec-14

Quarter ending 31-

Dec-14

Quarter ending 31-

Mar-15

Yearending

31-Mar-15

Year to dateending

31-Dec-14

Year to dateending

31-Dec-14

Year to dateending

31-Dec-14

Acute & Specialist Activity MetricsElective inpatients Spells 2,299 1,788 2,414 1,833 2,414 1,817 2,375 9,502 7,127 5,438 (1,689) Elective day case patients (Same day) Cases 8,872 9,037 9,316 9,047 9,316 9,582 9,168 36,672 27,504 27,666 162 Non-Elective Spells 8,844 8,686 8,941 8,651 8,941 9,020 8,747 35,473 26,726 26,357 (369) Outpatients - first attendance Attendances 37,633 39,243 39,515 39,855 39,515 40,214 38,887 155,550 116,663 119,312 2,649 Outpatients - follow up Attendances 51,058 54,839 53,611 56,913 53,611 58,850 52,760 211,040 158,280 170,602 12,322 Outpatients - procedures Procedures 11,432 12,296 12,003 12,879 12,003 13,192 11,813 47,251 35,438 38,367 2,929 A&E Attendances 28,631 28,888 28,946 28,552 28,946 28,803 28,316 114,839 86,523 86,243 (280) Other NHS activity various 64,692,998 60,650,821 65,434,486 62,531,015 65,434,486 62,796,228 64,017,765 259,579,735 195,561,970 185,978,064 (9,583,906) Other various 7,192 8,045 7,551 7,576 7,551 7,717 7,432 29,726 22,294 23,338 1,044

Monitor will in future be devoting more attention to the activity

APPENDIX 6

In Year Quality Governance Metrics of Royal BerkshireActual for Actual for Actual for

The Risk Assessment Framework (diagram 13) sets out that Monitor will use executive team turnover as one of the potential indicators of quality governance concerns. Please provide the information requested below and ensure that any changes are explained in your commentary: units

Quarter ending 30-Jun-14

Quarter ending 30-Sep-14

Quarter ending 31-Dec-14

Executive DirectorsTotal number of Executive posts on the Board (voting) Posts 5 5 6 Number of posts currently vacant Posts 1 - -Number of posts currently filled by interim appointments Posts 2 - 2 Number of resignations in quarter Resignations - - -Number of appointments in quarter Appointments 1 - -

Agenda Item 8

1

Clinical Assurance Committee Monday 8 December 2014 5.30pm – 7.10pm Room 3, Level 4, Royal Berkshire Hospital Present Mr. Tony Skuse (Public Governor, Wokingham) (Chair) Mr. Jon Andrews (Public Governor, Reading) Ms. Wendy Bower (Partner Governor, West Berkshire CCGs) Mr. David Cooper (Public Governor, Reading, Lead Governor) Mr. Martyn Cooper (Public Governor, Reading) Dr. Charlie McKenna (Staff Governor, Medical and Dental) Mr. Tony Lloyd (Public Governor, Wokingham) Mr. John McKenzie (Public Governor, Wokingham) Ms. Anne-Marie Probert (Staff Governor, Nursing & Midwifery) Mr. Bob Pitts (Partner Governor, Wokingham Borough Council) Mr. David Rowark (Public Governor, West Berkshire & Borders) Ms. Deborah Sander (Public Governor, Reading) In attendance Ms. Bernie Bluhm (Interim Chief Operating Officer) (for minute 32/14) Mrs. Caroline Lynch (Deputy Company Secretary) Mrs. Jean O’Callaghan (Chief Executive) Ms. Emma Sampson (Corporate Governance Officer) Ms. Emma Vaux (Programme Director of Quality Improvement) (for minute

31/14) Apologies Mrs. Carol Bolderson (Public Governor, West Berkshire & Borders) Mr. Jeremy Butler (Public Governor, East Berkshire & Borders) Mr. Ian Clay (Volunteer Governor) Mr. Colin Lee (Public Governor, West Berkshire & Borders) Mr Jonathan Mason (Staff Governor, Allied Health Professionals/Scientific) Mrs. Janet Rutherford (Non Executive Director) Cllr. Bet Tickner (Partner Governor, Reading Borough Council) 29/14 Minutes: 24 September 2014

The minutes of the meeting held on 24 September 2014 were approved as a correct record and signed by the Chair subject to recording David Cooper’s attendance.

30/14 Matters Arising Schedule The Committee received the matters arising schedule.

Minutes

Clinical Assurance Committee 2

Clinical Assurance Committee 8 December 2014

In response to a query regarding the external review of Maternity the Chief Executive advised that the Clinical Governance Committee had received the Maternity action plan but had requested that the Executive review this to ensure a strong focus on outcomes. A revised action plan would be reviewed by the Board at a seminar arranged for 17 December 2014. The Chief Executive advised that two additional locum consultants had been appointed in Maternity and were due to start in March 2015. Other issues highlighted by the external review included culture, working relationships, the provision of obstetrics and gynaecology as a joint service, anaesthetic cover and nursing staffing. A further update on the maternity action plan would be provided at the next meeting. Action: C Ainslie

Resolved: that the schedule be noted 31/14 Mortality Rates

The Programme Director of Quality Improvement advised that mortality data used by the Trust was normally reviewed on a diagnosis basis. However, data had been reviewed on a speciality basis and as a result three outliers had been identified in critical care, midwifery and obstetrics. In respect of critical care only a few trusts used critical care as a specialty code and as a result data comparison presented a challenge. However, data was triangulated with the Intensive Care National Audit and Research Unit. All ICU Units in the UK submitted data to this registry which enabled the Trust to benchmark against other trusts. This demonstrated that the Trust was slightly above average.

The Programme Director of Quality Improvement explained that Midwifery and Obstetrics did appear as an outlier. However, this was as a result of the way stillbirths were recorded. The Trust was, however, below average for the total number of stillbirths.

The Programme Director of Quality Improvement provided an overview of the National Bowel Cancer Audit data available on NHS choices. The number of procedures and patient deaths were recorded against individual surgeons. The Programme Director of Quality Improvement drew attention to the fact that this data was not risk adjusted and as a result this did not provide a complete picture as some surgeons carried out higher risk procedures than others. The Programme Director of Quality Improvement advised that all mortality cases were reviewed at specialty clinical governance meetings, the Data Quality Outlier Group and the Clinical Outcomes & Effectiveness Committee. In response to a query regarding the Hospital at Night programme the Programme Director of Quality Improvement advised that integrated working within the Trust had improved and representatives from ED and ICU now attended all handovers at night. In response to a query regarding unexpected deaths, the Programme Director of Quality Improvement advised that a root cause analysis was carried out in order to establish any lessons learned. In response to a query regarding data published on NHS choices the Programme Director of Quality Improvement advised that information published on the website was standard



information across the NHS and as a result trusts were unable to provide any context to the data published. In response to a query regarding the coding system the Programme Director of Quality Improvement advised that the consistency of coding had improved due to more information being provided in patient notes and detailed discussion between coders and clinicians. In response to a query regarding mortality alerts, the Programme Director of Quality Improvement advised that alerts were reviewed regularly by the Data Quality Outlier Group.

The Committee queried the length of time between an event occurring and alerts being raised. The Programme Director of Quality Improvement advised that data was reviewed monthly in retrospect. In response to a query regarding the timescale between deaths occurring and information being available the Programme Director of Quality Improvement advised that Dr Foster data was available approximately three months after a death had occurred and Summary Hospital-level Mortality Indicator (SHMI) data was made available six to nine months after a death had occurred.

32/14 18 Week Pathway Briefing

The Interim Chief Operating Officer introduced the report and gave an overview of the issues regarding 18 week referral to treatment data. A central 18 week team had been established in order to validate the 18 week pathways. A total of 41,846 pathway entries required validation and currently 12,000 pathways were still to be validated. The Committee noted that a number of these pathways did not represent ‘real patients’. This was largely due to the data migration exercise to the EPR system which had resulted in some patients showing as still awaiting treatment when this was not the case. However, some of the 18 week breaches were as a result of patients being entered incorrectly on to a planned care waiting list. In response to a query regarding the total number of patients affected the Interim Chief Operating Officer advised that an exact figure could not be provided until the validation exercise had been completed. It was estimated that the validation exercise would be completed by 8 January 2015. The Interim Chief Operating Officer provided detail on an additional cohort of patients whose waiting list management did not comply with the referral to treatment rules and guidance. These patients were on a planned breast list. The Interim Chief Operating Officer advised that all patients affected on this list would be written to by the Trust and a recovery plan was in place to address the position. The Interim Chief Operating Officer advised that the Trust had commenced detailed EPR training for all staff groups involved with booking and scheduling of appointments.

The Chief Executive advised that the Trust was holding weekly call conferences with Monitor and the local commissioners regarding the 18 week issue.

The Committee queried whether the treatment of new patients would be compromised as a result of the issues with the 18 week data. The interim Chief Operating Officer advised that patients would be prioritised according to clinical need and then by the length of wait time.



Resolved: that the update be noted.

33/14 Report from Clinical Governance Committee: Thursday 27 November

The Chief Executive reported that issues raised at the recent meeting included a lack of assurance in respect of the Maternity action plan and achievement of the Quality Account target in relation to the availability of medical records. Other issues reported to the Committee included a detailed updated on mortality rates, progress on the development of clinical governance systems and processes and medical revalidation. The Committee queried how the Executive were made aware of whether issues were present in respect of service provision, for example, in neurological services. The Chief Executive advised that a number of sources of information were utilised to ascertain whether services were running as they should be, for example, alerts, patient complaints and length of stay.

Resolved: that the update be noted. 34/14 Review of Terms of Reference The Deputy Company Secretary introduced the terms of reference which had been

submitted as part of the annual review cycle. The terms of reference of the Patient Experience Group had been reviewed and sections relating to patient experience had been added to the Committee’s terms of reference.

The Committee agreed the following changes:

The constitution and membership section be updated to read ‘any issues relating to patient safety, patient and staff experience’

The attendance section be updated to state ‘the Medical Director or Director of

Nursing, lead Non Executive and the Trust Secretary will attend meetings’.

The Committee agreed that, subject to the agreed changes, the terms of reference should be recommended to the Council of Governors for approval. Resolved: that, subject to the agreed changes, the terms of reference be recommended to the Council of Governors for approval.

35/14 Date of Next Meeting

It was agreed that the next meeting would take place on Thursday 9 April 2015 at 5.30pm. SIGNED

DATE

1

Clinical Assurance Committee

Terms of Reference Constitution and Membership The Committee will provide assurance to the Council of Governors in respect of the performance of the Trust, bringing to the attention of the Council, in particular, any matters likely to impact on

the Trust keeping within the Terms of Authorisation

the achievement of Care Quality Commission performance targets

the Monitor Risk Rating

any issues relating to patient safety, patient and staff experience The Committee will carry out this role through the review of the clinical assurance information submitted to the Board and from receiving responses from the Board on matters of interest or concern. The Committee membership will comprise any Governor wishing to serve. The Committee will be chaired by a Governor. The quorum of the Committee will be four members (one of whom must be a public Governor). Attendance The Medical Director or Director of Nursing, lead Non Executive and the Trust Secretary will attend meetings. Other Executive Directors will attend as required. The Trust Secretary, or their nominee, will act as secretary to the Committee. Frequency The Committee will meet quarterly. Monitoring The work of the Committee will be kept under review by the Council of Governors. Authority The Committee is authorised by the Council of Governors to review the assurance documents and information submitted to the Board and to bring appropriate matters to the attention of the Council.

2

Duties 1. The Committee will review the clinical assurance information submitted to the Board, and

bring significant matters of interest or concern, and the Board’s response, to the attention of the Council of Governors

2. The Committee will satisfy itself that the Board is reviewing, in a timely manner,

appropriate clinical information to ensure compliance with the Terms of Authorisation 3. The Committee will keep under review a range of assurance information submitted to the

Board including, as required

Complaints Statistics

Board Executive Report

Board Quality Performance Report indicators

Minutes of relevant Trust assurance committees

Trust registration documents with the Care Quality Commission

The quality and risk profile, issued by the Care Quality Commission, for the Trust Reporting The minutes of Committee meetings will be formally recorded and submitted to the Council of Governors. The Committee will review these terms of reference on an annual basis and report to the Council of Governors accordingly. Reviewed by the Committee Approved by the Council

Agenda Item 9

1

Business Assurance Committee Thursday 8 January 2015 5.30pm - 7.10pm Boardroom, Level 4, Royal Berkshire Hospital Members Mr. David Cooper (Public Governor, Reading) (Chair) Mr. Jon Andrews (Public Governor, Reading) Mr. Tom Bune (Public Governor, Southern Oxfordshire) Mr. Brian Hendon (Non-Executive Director) Mr. Jonathan Mason (Staff Governor, Allied Health Professionals/Scientific) Ms. Anne-Marie Probert (Staff Governor, Nursing /Midwifery) Mr. Tony Lloyd (Public Governor, Wokingham) Mr. David Rowark (Public Governor, West Berkshire & Borders) Cllr. Bob Pitts (Partner Governor, Wokingham Borough Council) In attendance Mr. Craig Anderson (Director of Finance) Mr. John Barrett (Non-Executive Director) Mrs. Caroline Lynch (Interim Trust Secretary) Mrs. Jean O’Callaghan (Chief Executive) (up to minute 38/14) Ms. Emma Sampson (Corporate Governance Officer) Apologies Ms. Carol Bolderson (Public Governor, West Berkshire) Mr. Jeremy Butler (Public Governor, East Berkshire) Mr. Peter Dooley (Partner Governor, Berkshire Carers Service) Mr. John McKenzie (Public Governor, Wokingham) Mr. David Mihell (Public Governor, East Berkshire & Borders) Mr. Tony Skuse (Public Governor, Wokingham) 01/15 Minutes: 8 October 2014

The minutes of the meeting held on 8 October 2014 were agreed as a correct record and signed by the Chair. The Committee queried whether staff turnover was related to the number of complaints regarding attitude and behaviour. The Director of Finance advised the high turnover of staff was considered largely due to the competitive market and staff often left for other reasons such as flexible working opportunities provided by agency work. The Committee queried whether the backlog of maintenance had an effect on Trust performance and reporting to Monitor. The Director of Finance advised that overall, this did

Minutes

2

Business Assurance Committee 8 January 2015

not have a significant effect. However, day to day performance may be affected in some areas but these issues were monitored on a regular basis. The Committee discussed staff data in the quality performance reports. In response to a query regarding whether staff experience data was reviewed the Chief Executive advised that the recent staff survey would provide a significant amount of information to the Board in respect of staff experience. The Director of Workforce Development and HR would be preparing an action plan after the results had been analysed which would then be submitted to the Resources Committee for review. In response to a query regarding the Trust’s disaster recovery plans, the Committee noted that the Trust’s disaster recovery plans were subject to external requirements and validation.

02/15 Matters Arising The Committee noted the matters arising schedule.

Minute 29/14 (19/14, 11/14): Project Health Check: The Committee had received the CCG’s QIPPS plan. It was agreed that a copy would be provided to new members of the Committee. Action: C Lynch Minute 29/14 (19/14, 14/14): Audit & Risk Committee Minutes – 21 January 2014 and 25 March 2014: The Committee had received the internal audit programme. It was agreed that a copy would be provided to new members of the Committee. Action: C Lynch The Chief Executive provided an update on issues raised by Monitor. Key areas of concern related to finance, data quality, risk management and the management structure within the Trust. A prioritised action plan would be submitted to Monitor by 31 January 2015. In addition, a number of high priority actions would need to be completed by the end of March 2015. Monitor had also requested an external data quality review should be undertaken in March 2015. In response to a query regarding the validation exercise in respect of the 18 week data the Chief Executive reported that exercise was ongoing. However, 18 week data would be reported by the Trust for Quarter 4 in February. The Committee queried the financial position of the Trust. The Chief Executive advised that the original predicted £1m deficit had been optimistic one and the Trust would not be able to achieve the total £18m cost QIPPs. As part of the response to Monitor a budget re-forecast was being prepared. In response to a query regarding the ED service and whether the Trust would follow other trusts in declaring a major incident at times of extreme pressure the Chief Executive explained that the Trust would not do this. The Christmas period had been manageable and staff had worked extremely hard to free up capacity ahead of the holiday period. The Chief Executive advised that that the ED target for Quarter 3 had not been achieved by a small margin as the Trust had achieved 94.5% against a target of 95%.

03/15 Finance Performance to Date

The Director of Finance introduced the report which provided an update on the financial performance of the Trust for November 2014. The Committee noted that the Trust had

3


reported a deficit of £5.5m in the year to date which was £1.47m worse than forecast and £2.08m worse than budget.

The Director of Finance advised that cash was below budget at £11.19m. The Committee noted the Trust had maintained a Continuity of Service Risk Rating (CoSRR) of 2. The Director of Finance advised that a budget re-forecast was being prepared for submission to Monitor. It was noted that financial penalties which could be incurred as a result of the 18 week data issues had not been included. The Director of Finance advised that a meeting was scheduled with Monitor for 9 January 2015 to confirm the revised forecast and actions taken by the Trust in order to minimise the financial deficit. The Director of Finance advised that key issues had been identified and were being addressed, such as pay overspend. However, short term actions had also being taken including centralised authorisation of discretionary spend and enhanced vacancy control processes. In response to a query regarding one-off costs, the Director of Finance advised that one-off costs in the current financial year were £1.75m. The Committee sought assurance as to whether appropriate controls were in place to improve the current position of the Trust. The Non Executive lead advised that following the recent appointment of the Chief Executive more robust decisions were now being made and an improved focus on accountability had been achieved.

Resolved: that the report be noted 04/15 Audit & Risk Committee 18 November 2014

The Chair of the Audit & Risk Committee introduced the minutes from the Audit & Risk Committee in November.

The Chair of the Audit & Risk Committee gave an update on the number of outstanding recommendations from 2012/13 and 2013/14 internal audits. A number of recommendations were due for completion in December 2014 and a further update on would be provided to the January meeting of the Committee. A further update would be provided to governors at the next meeting. Action: B Hendon Resolved: that the report be noted

05/15 Resources Committee Minutes 11 November and 8 December 2014

The Director of Finance advised that the Resources Committee had reviewed a proposal in respect of capital replacement of the angiography suite and recommended this for approval by the Board. The Committee queried which Board committee would review staff experience issues in detail. The interim Trust Secretary advised that the Resources Committee reviewed workforce data but the Clinical Governance Committee had absorbed the remit of the Patient Experience Group and staff and patient experience had therefore been incorporated

4


into the terms of reference for both the Clinical Governance Committee and the Clinical Assurance Committee. In response to a query regarding the IT strategy the Committee noted that the draft IT strategy had been reviewed by the Resources Committee however final approval had not yet been made. The Committee queried whether a seminar on the IT strategy could be arranged and whether a copy of the draft strategy could be circulated to governors. It was agreed that this would be raised with the Director of IM&T. Action: C Lynch

Resolved: that the minutes be noted 06/15 Date of Next Meeting

Resolved: that the next meeting take place on Wednesday 22 April 2015 at 5.30pm.

SIGNED

DATE

Agenda Item 10

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Council Strategy Committee Tuesday 20 January 2015 5.35pm – 6.55pm Boardroom, Level 4, Royal Berkshire Hospital Present Mr. Peter Dooley (Partner Governor, Berkshire Carers Service) (Chair) Mr. Jon Andrews (Public Governor, Reading) Mr. Ian Clay (Volunteer Governor) Mr. Sanusi Koroma (Partner Governor, Reading CRE) Mr. Colin Lee MBE (Public Governor, West Berkshire) Mr. Tony Lloyd (Public Governor, Wokingham) Cllr. Gordon Lundie (Partner Governor, West Berkshire) (from minute 03/15) Ms. Anne-Marie Probert (Staff Governor, Nursing/Midwifery) Mr. David Rowark (Public Governor, West Berkshire & Borders) Mr. Tony Skuse (Public Governor, Wokingham) Ms. Bet Tickner (Partner Governor, Reading Borough Council) (from minute 03/15) In attendance Mrs. Caroline Lynch (Deputy Company Secretary) Mrs. Janet Rutherford (Non-Executive Director) Miss. Emma Sampson (Corporate Governance Officer) Mr. John Taylor (Associate Director of Strategy) Apologies Mrs. Carol Bolderson (Public Governor, West Berkshire & Borders) Mr. Jeremy Butler (Public Governor, East Berkshire & Borders) Mr. David Cooper (Public Governor, Reading) Mr. John McKenzie (Public Governor, Wokingham) Mr. David Mihell (Public Governor, East Berkshire & Borders) (Chair) Ms. Deborah Sander (Public Governor, Reading) 01/15 Minutes: 20 November 2014

The minutes of the meeting held on 20 November 2014 were agreed as correct record and signed by the Chair subject to the amendment of a minor typographical error.

02/15 Matters Arising

The Committee noted the matters arising schedule. Minute 25/14 (16/14): Car Parking Update: The Committee noted the update regarding Radiology intending to move towards provision of routine service at weekends. It was agreed that the Director of Organisational Development and HR would be asked to provide an update in respect of the level of staff consultation which had been undertaken.

Minutes

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Council Strategy Committee 20 January 2015

Action: J Rutherford The Committee queried local authority plans regarding car parking on streets adjacent to the Trust and whether the Trust had been involved in these discussions. It was agreed that this would be raised with the Director of Estates & Facilities and a verbal update be provided at the Council meeting on 29 January. Action: J Rutherford

Minute 26/14: Strategic & Monitor Annual Plan Update: The Committee noted that an organisational development strategy was being developed over the next three to four months. It was agreed that the Director of Organisational Development and HR would be asked to confirm the timescale when a briefing would be provided to governors.

Action: C Lynch

Resolved: that the matters arising schedule be noted.

03/15 Operational and Strategic Planning Process 2015/16

The Associate Director of Strategy introduced the report and advised that Monitor had updated its guidance on the Annual Planning Process in December 2014, in collaboration with NHS Trust Development Authority and NHS England. This had been as a result of significant deterioration in the overall financial performance of the Foundation Trust sector as a whole. The Associate Director of Strategy advised that all trusts were required to submit a one year Operational Plan focused on short term resilience, realistic planning assumptions and alignment with commissioners. The Trust was required to submit a high level summary of assumptions and alignment with commissioning intentions by 27 February 2015 and a final Operational Plan narrative by 10 April 2015. The Associate Director of Strategy advised that the Trust’s Strategic Plan which was submitted in Monitor in June 2014 was ‘red-rated’ by Monitor on the basis that it did not demonstrate sustainability. Whilst the new guidance issued by Monitor did not include a requirement to submit a Strategic Plan by June 2015 it emphasised that the one year Operational Plan must sit within the context of the Trust’s overarching strategy. Although no formal deadlines had been issued by Monitor for the Strategic Plan it was likely that a five year Strategic Plan would be requested in the latter half of the financial year in order to inform the 2016/17 Strategic Planning process. The Committee queried whether a more sustainable Strategic Plan would be produced in the current year and what different processes would be undertaken. The Associate Director of Strategy advised that a number of lessons had been learned from the previous exercise. In particular, the new guidance issued by Monitor reiterated the importance of ensuring that the Trust undertook the necessary engagement with stakeholders which was vital in the production of a sustainable Strategic Plan aligned with commissioning intentions. The Associate Director of Strategy drew attention to the timetable for the Strategic Planning Process and advised that the Clinical Services Strategy would form a critical input into the Trust’s Strategic Plan. A stakeholder strategy workshop had been scheduled for 23 March and members of the Committee had been invited to attend this. In addition, a programme of engagement with each of the clinical services had been developed and this was currently in progress. Each service plan would include a sustainability review highlighting key risks, opportunities and challenges and demonstrate

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Council Strategy Committee 20 January 2015

how these would be addressed. In addition, each service plan would need to identify how it would support the achievement of the Trust strategic goals and corporate objectives. The Associate Director of Strategy sought the views of the Committee as to their involvement in the Strategic Planning process, in particular, how governors wished to ensure the interests of members and the public were considered and how this feedback would be provided back to the Board. The Committee discussed various options for engagement with the public to seek their views such as a survey of members. It was agreed that a workshop session would be arranged to enable a more detailed discussion on how governors could canvass the opinions of members and of the public. It was agreed that this would be held on Tuesday 21 April 2015. Resolved: that the update be noted.

04/15 Date of Next Meeting

It was agreed that a further meeting of the Committee would be scheduled in the week commencing 16 March 2015 to enable the Committee to review and provide feedback on the Operational Plan for consideration by the Board at its meeting on 30 March 2015. Resolved: that the next meeting would be held in March to enable the Committee to review and provide feedback on the Operational Plan for consideration by the Board at its meeting on 30 March 2015. SIGNED

DATE

Agenda Item 12

Membership Committee 1

Membership Committee Wednesday 14 January 2015 4.00pm – 4.40pm Boardroom, Level 4, Royal Berkshire Hospital Present Mr. Tom Bune (Public Governor, Southern Oxfordshire) (Chair) Mr. Jon Andrews (Public Governor, Reading) Mr. Colin Lee (Public Governor, West Berkshire & Borders) Mr. David Rowark (Public Governor, West Berkshire & Borders) In attendance Mrs. Caroline Lynch (Deputy Company Secretary) Miss. Emma Sampson (Corporate Governance Officer) Ms. Nicola Wesson (Assistant Director of Public Relations) Apologies Mrs. Carol Bolderson (Public Governor, West Berkshire) Mr. David Mihell (Public Governor, East Berkshire) (Chair) 01/15 Minutes: 4 September 2014

The minutes of the meeting held on 4 September 2014 were approved as a correct record and signed by the Chair.

The Committee queried the lower than expected attendance figures at the Annual Members Meeting in 2014. The Assistant Director of Public Relations advised that attendance figures had been in decline over the past few years. However, the Committee it had not been possible to identify a specific reason for this decline. Attendance at membership engagement events remained high and these were often over-subscribed as a result. The Committee discussed the level of engagement between governors and members. It was recognised that it was a statutory duty of governors to represent the views of members and the public and the proposed quarterly survey of members would assist in enabling governors to carry out this duty. The Committee discussed the importance of governor attendance at membership events in order to provide feedback to the Council on a quarterly basis. It agreed that this would be highlighted at the next Council of Governors meeting. In addition, a request for governors to join the Committee would be made as the current membership was quite low in comparison with other governor Committees.

Membership Committee


Membership Committee 14 January 2015

02/15 Matters Arising Schedule

The Committee noted the matters arising schedule. Resolved: that the matters arising schedule be noted.

03/15 Annual Members Meeting Venue 2015

The Assistant Director of Public Relations introduced the report and advised that two dates were under consideration for the Annual Members Meeting in 2015; Thursday 2 July and Tuesday 14 July. It was noted that Henley Business School, Reading University which was the location used for the Annual Members Meeting 2014 was only available for Thursday 2 July. As a result, two other possible locations for the 2015 meeting were suggested. These options included the Trust Education Centre and the Penta Hotel, Reading. Both locations were available for the date of Tuesday 14 July.

The Committee noted that feedback received from members regarding the Henley Business School venue had been extremely positive. It was noted that use of the Penta Hotel would result in a higher cost than the University venue. The Committee agreed that this option was not appropriate in respect of the current financial situation of the Trust. It was agreed that a recommendation should be submitted to the Council that the Annual Members Meeting should be held at the Henley Business School, Reading University on Thursday 2 July.

Resolved that: a recommendation be submitted to the Council of Governors that the Annual Members Meeting 2015 be held on Thursday 2 July at the at the Henley Business School, Reading University.

04/15 Feedback of Governor Engagement and Quarterly Surveys of Members

The Assistant Director of Public Relations advised that a draft survey programme had been developed in order to introduce a rolling programme of members’ surveys in order to obtain the views of members in relation to Trust business proposals. The results of the quarterly surveys of members would be submitted to each meeting of the Council of Governors. It was agreed that draft survey programme would be initially circulated to members of the Committee for comments prior to submission to the Council as a whole. Action: N Wesson Resolved: that the report be noted.

05/15 Membership Report

The Assistant Director of Public Relations submitted the latest membership information report.

The Committee noted that membership stood at 23,638 as at 23 December 2014. Of this total 17,807 were public members. Total membership has decreased by 31 members since the last report was circulated in October. The Assistant Director of Public Relations advised that the database used for membership figures was regularly refreshed to ensure that figures remained up to date.


Membership Committee 14 January 2015

Resolved: that the report be noted.

06/15 Terms of Reference The Deputy Company Secretary introduced the terms of reference which had been

submitted for review as part of the annual review cycle.

The Committee agreed the following changes: The duties section be updated to include:

o To seek the views of members and the public on material issues or changes being discussed by the Trust

o To conduct arrangements for collecting and reviewing views of members and the public on key issues and their experience of the Trust in general

The composition section be updated to state ‘the Trust Secretary, and other Trust

Directors as appropriate, will be in attendance to advise the Committee’ .

Resolved: that, subject to the agreed changes, the terms of reference be recommended to the Council of Governors for approval.

07/15 Pulse Magazine Sponsorship Tom Bune gave an overview of previous attempts made to seek sponsorship in order to

reintroduce printed copies of the Pulse membership magazine. A total of £30,000 would be required on annual basis. Further approaches had been made to local commercial organisations but these approaches had not been successful.

The Committee considered that an approach to pharmaceutical companies may prove

more successful. It was agreed, however, that the Deputy Company Secretary would raise this with the Acting Medical Director to ascertain whether this approach would be appropriate.

Resolved: that the Committee be advised whether pharmaceutical companies could

be approached for sponsorship of the Pulse magazine. 08/15 Date of Next Meeting

Resolved: that the next meeting be held on Wednesday 13 May 2015, at 4pm.

SIGNED: DATE:

Membership Committee

Terms of Reference

Role of the Committee The Committee will, within the terms of the Constitution, develop, implement and keep under review a membership strategy for the Trust. It will also consider any dispute which arises with regard to membership of a constituency, of the Trust or the conduct of individual governors. Composition The Committee will be chaired by the Vice Chairman when undertaking the disciplinary elements of its terms of reference. Any Governor may chair the Committee at other times. The membership will comprise any Governor wishing to serve. The Trust Secretary, and other Trust Directors as appropriate, will be in attendance to advise the Committee. Quorum The quorum will be three members. Duties The Committee will, having regard to the views of the Board of Directors on appropriate resource levels, make recommendations to the Council of Governors on the following 1. To develop a policy, implement agreed proposals and keep under review the Trust

approach to engaging with the membership community 2. To recommend appropriate relationships and methods of communicating between

Governors and the membership 3. To develop, implement and review, annually, a membership strategy for the Trust 4. To keep under review the membership of the Trust to ensure that the actual membership

is representative of those eligible to be members of each constituency 5. To oversee preparations for the Annual Members Meeting 6. To prepare an annual report for the Council and the annual members meeting with

regard to the steps taken to secure representative membership, the progress of the membership strategy and any changes to the membership strategy

7. To consider any disputes concerning membership of a constituency, right to membership

of the Trust and the conduct of individual governors 8. To produce an annual work plan, for approval by the Council of Governors, setting out

how the Committee will discharge its responsibilities.

9. To seek the views of members and the public on material issues being discussed by the Trust

10. To conduct arrangements for collecting and reviewing views of members and the public

on key issues and their experience of the Trust in general Review The Committee will review these terms of reference annually, making recommendations to the Council of Governors as appropriate. Approved by the Committee: Approved by the Council:

council of governors - royal berkshire hospital...lindsey barker philip holmes 6.15 – 6.30 holding...

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