Council of Governors
22 January 2019, 17:30 to 19:30Trust HQ Boardroom, Royal Albert Edward
Infirmary, Wigan Lane, Wigan, WN1 2NN
Agenda1. Chair and quorum
Information
Robert Armstrong
2. Apologies for absenceInformation
Robert Armstrong
3. Declarations of interestInformation
Robert Armstrong
4. Minutes of previous meetingApproval
Robert Armstrong
Minutes - CoG - 15 Oct 2018.pdf (8 pages)
5. Chair and Deputy Chief Executive's report
(Presentation) Discussion
R Armstrong/R Forster
Strategy and planning6. Development of WWL strategy
(Presentation) Discussion
Richard Mundon
7. Council of Governors' cycle of businessApproval
Paul Howard
CoG cycle of business.pdf (3 pages)
Holding to account
8. Non-Executive Directors' updatesDiscussion
NEDs
9. Board assurance frameworkInformation
Robert Armstrong
BAF - Patients - Dec 2018.pdf (2 pages)
BAF - People - Dec 2018.pdf (3 pages)
BAF - Performance - Dec 2018.pdf (2 pages)
BAF - Partnerships - Dec 2018.pdf (2 pages)
10. Leadership safety walkaround reportInformation
Paul Howard
Leadership Safety COG Quarterly Report.pdf (7 pages)
Other items11. Items requested by governors
11.1. Governors volunteering on wardsDiscussion
Bill Anderton
11.2. Progress with addressing nursing vacanciesDiscussion
Alan Baybutt
11.3. Staff engagement updateDiscussion
Mustapha Koriba
11.4. Update on fundingDiscussion
Rob Forster
12. Resolution to exclude press and public
Approval
Robert Armstrong
13. Date, time and venue of next meeting30 January 2019, 5.00pm for 5.30pm, MacDonald Kilhey CourtHotel
Information
Robert Armstrong
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WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST
MINUTES OF A MEETING OF THE COUNCIL OF GOVERNORS
HELD AT 5.30PM ON 15 OCTOBER 2018
AT ROYAL ALBERT EDWARD INFIRMARY, WIGAN LANE, WIGAN, WN1 2NN
Members’ attendance record 2018-19:
16 A
pr 2
018
16 J
ul 2
018
15 O
ct 2
018
22 J
an 2
019
30 J
an 2
019
Atte
ndan
ce
Robert Armstrong Chair (in the Chair)
Imran Alam Staff Governor, Medical and Dental --- --- A
Bill Anderton Public Governor, Wigan
Helen Ash Public Governor, Makerfield ---
Alan Baybutt Public Governor, Wigan --- ---
Tim Board Staff Governor, Medical and Dental A ---
John Cavanagh Appointed Governor, FT volunteers --- --- ---
Les Chamberlain Public Governor, Makerfield
Jean Coates-Topping Public Governor, Makerfield --- ---
Kathryn Drury Public Governor, Makerfield A ✗ ---
Tom Frost Public Governor, Rest of England and Wales A ---
Howard Gallimore Public Governor, Makerfield
Bill Greenwood Public Governor, Wigan A A ---
Pauline Gregory Public Governor, Wigan
Dawne Gurbutt Appointed Governor, UCLAN A
Marie Hart Staff Governor, Nursing and Midwifery A ✗ ---
Andrew Haworth Public Governor, Leigh
Jean Heyes Appointed Governor, Staff Side A ✗ ---
Alex Hilton Staff Governor, Other staff A
Sarah Howard Staff Governor, Nursing and Midwifery --- ---
Jackie Hylton Staff Governor, Nursing and Midwifery --- ---
Mustapha Koriba Public Governor, Rest of England and Wales A A
Hazel Leatherbarrow Staff Governor, Other staff --- ---
James Lee Public Governor, Makerfield A
Lisa Lymath Public Governor, Rest of England and Wales A
Renée Mellis Public Governor, Rest of England and Wales --- ---
Reg Nash Appointed Governor, Age UK
Syed Shah Appointed Governor, Local Medical Committee
Maggie Skilling Public Governor, Wigan
Veronika Stevens Public Governor, Rest of England and Wales --- ---
Linda Sykes Public Governor, Leigh
Corinne Taylor-Smith Public Governor, Leigh A A A
David Thompson Public Governor, Rest of England and Wales ---
Fred Walker Appointed Governor, Wigan Council
Mavis Welsh Public Governor, Leigh
Gen Wong Appointed Governor, Wigan Borough CCG A ✗ ---
James Yates Staff Governor, Other Staff A ✗ ---
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
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In attendance: Steven Elliot Non-Executive Director Andrew Foster Chief Executive Mick Guymer Non-Executive Director Ian Haythornthwaite Non-Executive Director Carole Hudson Non-Executive Director Paul Howard Company Secretary and Data Protection Officer Tony Warne Non-Executive Director Julie Critchley Integration Programme Director (to item 55/18 only) Jo Goodfellow Bolton, Salford and Wigan Partnership (for item 56/18 only) One member of the public was also in attendance. 50/18 Chair and quorum
Robert Armstrong took the chair and noted that due notice had been given to all governors and that a quorum was present. He therefore declared the meeting duly convened and constituted.
51/18 Apologies
Apologies for absence were received as shown in the members’ attendance record, above.
52/18 Declarations of interest
Prof T Warne declared an interest in minute reference 59/18 (Proposal to extend non-executive director term of office) and 60/18 (Appointment of Senior Independent Director).
53/18 Minutes of the previous meeting
The minutes of the previous meeting held on 16 July 2018 were agreed as a true and accurate record, subject to one minor amendment. Mr A Hilton advised that, at minute reference 41/18, his question had related to the total setup costs for WWL Solutions prior to the decision not to proceed, rather than just those paid to QE Facilities. The Chief Executive agreed to provide the revised information.
ACTION: Chief Executive
54/18 Chief Executive’s report
The Chief Executive delivered a presentation which covered the following key areas:
(a) a summary of his highlights and lowlights;
(b) an overview of the foundation trust’s performance across a number of metrics; and
(c) a summary of concerns and those areas of particular positivity.
Cllr F Walker noted the recent reintroduction of the Health Information System (HIS) into the Accident and Emergency Department and sought assurance that lessons had been learnt from the earlier adoption and that the reintroduction would be a smooth one. In
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
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response, the Chief Executive confirmed that the system had been in place within the department for around a month and that feedback from staff had been positive.
In response to a question from Mr B Anderton surrounding overseas nurses, the Chief Executive confirmed that some of the nurses in question now reside in the UK and are therefore likely to take on permanent roles within the organisation and that others will return to their home countries after a period of time, in accordance with the “learn, earn, return” model. In response to a question from Dr S Shah, the Chief Executive advised that overseas nurses from India had been targeted as a result of the strong relationship between the foundation trust and organisations in India, and the ability to provide effective pastoral care due to the size of the Indian clinical cohort within the organisation. Notwithstanding, the Chief Executive confirmed that nurses from other overseas countries would be welcomed within the foundation trust.
In response to a supplementary question from Cllr F Walker regarding nurse vacancies, the Chief Executive provided a summary of how the foundation trust seeks to address rota gaps, including the use of bank and agency staff.
In response to a question from Mr A Hilton surrounding orthopaedics, the Chief Executive noted that NHS Improvement had acknowledged that a number of procedures are loss making and wished to avoid creating a disincentive for specialist providers to undertake complicated procedures. Further information on the tariff for 2018-19 was currently awaited.
The Council received the presentation and noted the content.
55/18 Strategic item: transfer of community services
The Chief Executive delivered a presentation to update the Council of Governors on progress with the proposed transfer of Wigan-based community services from Bridgewater Community Healthcare NHS FT into the foundation trust. Confirmation was provided that commissioners had agreed to fund some of the costs of the due diligence exercise along with some of the transaction costs.
In response to a question from Mrs L Sykes, the Chief Executive advised that the potential care hotel on the Leigh Infirmary site did not fall within the scope of the project but confirmed that the proposal for an 80-bed facility is still being considered.
In response to a question from Mrs M Skilling surrounding the need for the Council of Governors to approve significant transactions, the Company Secretary reminded governors that a dedicated session run by an independent legal firm on the role of the Council of Governors in significant transactions had been scheduled as part of the North West Governors’ Forum that had been organised by the foundation trust, and confirmed that a number of governors would be attending the event. He also noted that a further update on progress would be provided to the council at its workshop on 6 December 2018.
Mr A Howarth commented that communication would be important throughout the project, to which the Chief Executive confirmed that communications were about to commence with staff and that the next step would be for information to be provided to the public, although the Chair reminded the council that, as the process is led by Wigan Borough Clinical Commissioning Group, communications would be undertaken by them rather than the through the foundation trust.
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
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The Council received the presentation and noted the content.
The Chief Executive left the meeting.
56/18 Strategic item: update on Bolton, Salford and Wigan Partnership
Ms J Goodfellow joined the meeting and delivered a presentation to update the Council on the work of the Bolton, Salford and Wigan Partnership. She provided an overview of the Healthier Together programme and the proposed acute developments, as well as highlighting the intended arrangements for general surgery. She also outlined the investments that had been allocated to Bolton, Salford and Wigan and gave a summary of the key timescales associated with the transformation of services. The Council’s attention was also drawn to the key achievements to date and the plans for surgical ambulatory care and dermatology in the future.
Copies of the consultation document entitled “The development of a future, sustainable dermatology service for Bolton, Salford and Wigan” were distributed and the presentation outlined ways in which individuals can get involved.
A discussion was held around the capital investment and note was made of the increased costs associated with the building of facilities on the Salford Royal Hospital site. Confirmation was provided that the increased costs would be met by Salford Royal NHS FT and would not therefore impact on other organisations. Dr S Shah commented of the need for General Practitioners to be able to easily refer into Salford under the new model.
In response to a question from Mr A Hilton, Ms J Goodfellow summarised the work that has been undertaken to address the need for ambulance transfers between the various sites and particularly in relation to high needs patients. As a result, an additional £800k will be provided to commission additional ambulance activity from North West Ambulance Service NHS Trust.
The Chair summarised this item by thanking Ms J Goodfellow for her attendance and requested that she return at an appropriate point in time with an update, including how equity of access will be ensured, how a patient’s care record will follow them to different sites and updates on clinical leads, ambulance transfers and GP involvement.
The Council received the presentation and noted the content.
Ms J Goodfellow left the meeting.
57/18 Holding to account: performance and finance reports
Copies of the performance and finance reports as at 31 August 2018 had been circulated with the agenda to inform the Council of the foundation trust’s current performance and to allow governors the opportunity to seek assurances from those non-executive directors present. The Chair reminded the Council of the scrutiny arrangements in place within the foundation trust, with scrutiny of clinical matters taking place at the Quality and Safety Committee, scrutiny of financial and operational matters taking place at the Finance and Performance Committee and workforce matters being scrutinised by the Workforce Committee.
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
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Mrs P Gregory suggested that it would be necessary to review the performance reports on a page-by-page basis, particularly given that there are a number of new governors now in post. The Chair commented that he felt this would be unnecessary as responsibility for performance rests with the Board of Directors and the purpose of providing the data to the Council is to allow governors to identify areas where it would wish to seek assurances from non-executive directors. It was therefore agreed that a workshop would be arranged to allow governors an opportunity to better understand the metrics used within the report.
ACTION: Company Secretary (to schedule)
It was also agreed that, for future meetings, copies of the board assurance framework would be provided rather than the detailed performance reports.
In response to a question from Mrs P Gregory surrounding the financial consequences of breaching the tumour pathway as shown on page 9 of the report, Mr M Guymer noted that financial consequences are determined based on the allocation of the breach but that the sums are minor in nature.
With regard to the wider process of holding non-executive directors to account, the Council considered it beneficial for the non-executive directors, on a rotational basis, to provide a summary of their recent activities to each meeting.
ACTION: Company Secretary (to schedule)
Mrs M Skilling noted that theatre effectiveness at Wrightington Hospital remained low, to which Mr M Guymer responded that the Finance and Performance Committee had scrutinised the Division of Specialist Services at its last meeting and confirmed that ongoing monitoring is undertaken by the committee. Mrs C Hudson also advised that work is ongoing to increase the number of cases that are undertaken on the Wrightington site.
Mrs P Gregory noted the reference in the finance report to the non-payment of fees by non-EU patients and Mr I Haythornthwaite confirmed that the matter had recently been discussed by the Audit Committee, where assurances had been provided that eligibility for treatment is being checked on arrival. The matter had been subject to internal audit and was now subject to a routine follow-up. Mr I Haythornthwaite noted that if there were a number of instances where concerns were raised, a re-audit would be arranged.
The Council received the reports and noted the content.
58/18 Non-Executive Director recruitment
The Chair noted that the recent death of Mr Neil Campbell had resulted in a non-executive director vacancy. He briefed the Council on the desire for the foundation trust to achieve University Hospital status in the future and the associated requirement for at least one non-executive director to be drawn from the faculty of an associated university. It was therefore recommended that this vacancy be filled by such a candidate.
Confirmation was provided that it was not intended for this to be an appointment by the university and that a selection process would still be undertaken, with the appointment remaining the responsibility of the Council of Governors.
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
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The Council of Governors APPROVED the proposal to seek candidates for the non-executive director vacancy that will satisfy the necessary requirements to enable the foundation trust to seek University Hospital status.
59/18 Proposal to extend non-executive director term of office
Prof T Warne withdrew from the meeting in light of his conflict of interest in this agenda item and in the following agenda item.
The Chair presented a report which had been circulated with the agenda to seek approval to extend the term of office of Prof T Warne by 12 months. He noted that Prof Warne would come to the end of his second term of office on 31 October 2019 and would normally not have been reappointed as he will have served six years as a non-executive director. Notwithstanding, he requested that the Council of Governors considers the exceptional nature of the presenting circumstances, as extending his term of office would facilitate stability and experience amongst the non-executive directors and allow a more progressive staggering of non-executive directors’ end dates.
Following consideration, the Council UNANIMOUSLY APPROVED the extension of Prof Warne’s appointment as non-executive director to 31 October 2020.
60/18 Appointment of Senior Independent Director
The Chair noted that the death of Mr Campbell had also left a vacancy for Senior Independent Director and recommended that Prof Warne be appointed to this role.
The Council of Governors UNANIMOUSLY APPROVED the appointment of Prof Warne as Senior Independent Director with immediate effect.
61/18 Approval of changes to the foundation trust’s constitution
The Company Secretary presented a report which had been circulated with the agenda to summarise the proposed changes to the foundation trust’s constitution. He reminded the Council that a working group had been established, comprising governors and non-executive directors, and that the group had recommended the changes.
Note was made of a typographical error within the draft constitution appended to the report and confirmation was provided that the reference at clause 11.7.2 of the constitution should be to the Local Medical Committee.
The Council of Governors UNANIMOUSLY APPROVED the amendments to the foundation trust’s constitution as presented.
62/18 Appointment of lead governor
The Company Secretary presented a report which had been circulated with the agenda to summarise the role of lead governor, which is one of being available to the regulator when the normal communication channels are not appropriate.
One nomination for the post was received from Mrs L Sykes and she was therefore ELECTED UNOPPOSED for a one-year term.
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63/18 Date, time and venue of next meeting
The next meeting of the Council of Governors will be held on 22 January 2019, 5.30pm at Royal Albert Edward Infirmary.
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Wrightington, Wigan and Leigh NHS Foundation Trust Minutes of a meeting of the Council of Governors held on 15 October 2018
Action log page 1
Action log Date of meeting
Minute ref. Item Action required Assigned to Target date Update
15 Oct 2018 53/18 Minutes of previous meeting
Provide updated information on the costs associated with WWL Solutions Chief Executive Jan 2019 A total of £300k was
paid. Action complete.
15 Oct 2018 57/18 Performance reports Arrange workshop for governors to outline the content of the performance report in more detail.
Company Secretary ASAP
Date being confirmed; update to be provided
at the meeting
15 Oct 2018 57/18 Performance reports Schedule NED updates on a rotational basis at future meetings.
Company Secretary Jan 2019 Action complete.
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Approved by the Council of Governors: October 2017 (updated Jan 2019) 1
Council of Governors: cycle of business 2018-21
THE STATUTORY FUNCTIONS OF THE COUNCIL OF GOVERNORS
Under National Health Service Act 2006:
To appoint and, if appropriate, remove the Chair To appoint and, if appropriate, remove the other non-executive directors To decide the remuneration and allowances, and other terms and
conditions of office, of the Chair and other NEDs To approve the appointment of the Chief Executive To appoint and, if appropriate, remove the NHS Foundation Trust’s
external auditor To receive the NHS Foundation Trust’s annual accounts, any report of
the auditor on them and the annual report In preparing the NHS Foundation Trust’s forward plan, the board of directors must have regard to the views of the council of governors.
Under Health and Social Care Act 2012:
To hold the non-executive directors individually and collectively to account for the performance of the board of directors
To represent the interests of the members of the Trust as a whole and of the public
To approve “significant transactions” as defined within the constitution To approve any application by the Trust to enter into a merger, acquisition,
separation or dissolution To decide whether the FT’s private patient work would significantly interfere
with its principal purpose, i.e. the provision of goods and services for the health service in England or the performance of its other functions
To approve any proposed increase in private patient income of 5% or more in any financial year
Jointly with the board of directors, to approve amendments to the FT’s constitution
2018-19 2019-20 2020-21
Item Presenter Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan
GENERAL ITEMS
Apologies for absence Chair
Declaration of interests Chair
Minutes of previous meeting Chair
Review of action log Chair
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2
2018-19 2019-20 2020-21
Item Presenter Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan
HOLDING TO ACCOUNT
Board assurance framework (to inform discussions) Non-Executive Director
Non-Executive Director reports (on rotational basis) Non-Executive Director
Leadership safety walkabout report Non-Executive Director
Arrangements for winter Director of Ops and Performance
INFLUENCING STRATEGY
The forward plan (held as workshop) Director of Strategy and Planning
Feb
Agreement of local indicator for quality report Director of Governance
REPRESENTING THE INTERESTS OF MEMBERS AND THE PUBLIC
Approval of Membership Engagement Strategy Membership Engagement Group
Review of Membership Engagement Strategy Membership Engagement Group
RECEIVING THE ANNUAL REPORT AND ACCOUNTS
Annual report and accounts Chief Executive and auditor
APPOINTMENT, REMUNERATION AND TERMS OF SERVICE OF THE NON-EXECUTIVE DIRECTORS
Chair’s appraisal Senior Independent Director
Non-executive directors’ appraisals Chair
Review of terms and conditions of non-executive directors Company Secretary
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3
2018-19 2019-20 2020-21
Item Presenter Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan
Appointment of Chair Senior Independent Director
(Re)appointment of non-executive directors Chair TW
MG +3
APPOINTMENT OF EXTERNAL AUDITOR
Considering extension of contract for external auditor Chair of Sub-Group
ITEMS REQUIRED BY THE CONSTITUTION OF NHS FOUNDATION TRUST CODE OF GOVERNANCE
Review policy on the composition of the council of governors Company Secretary
Review policy on the composition of the non-executive directors Company Secretary
Review council/board engagement policy Company Secretary
Review of council effectiveness Company Secretary
Review of CoG Register of Interests Company Secretary
Appointment of lead governor Company Secretary
GOOD PRACTICE ITEMS
Review of constitution Company Secretary
Review of CoG Standing Orders Company Secretary
Review of code of conduct Company Secretary
Review of cycle of business Company Secretary
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Patients: Every patient receives the best possible care
Executive lead(s): Director of Nursing Medical Director
Reviewing committee: Quality and Safety Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD
Strategic importance: Provision of safe, effective, high-quality and evidence based care is at the heart of everything we do.
CURRENT MONTH: MONTH: YTD:
2.68
3.61
Sources of assurance: Scrutiny by Quality and Safety
Committee Scrutiny by Board of Directors Use of internal and external auditors
Escalation of emerging risks Divisional performance reviews REMC
ROLLING TREND: ROLLING TREND:
2.48
2.56
2.27
2.27
Nov 2018
Oct 2018
Sep 2018
Jul 2018
Nov 2018
Oct 2018
Sep 2018
Jul 2018
Individual risks Original
Score Mitigations Current score
Failure to document patient care through the production and maintenance of accurate and contemporaneous clinical records. 16 Risk escalated and subject to review by
REMC 16
There is a risk that patients with infectious conditions may not be able to be appropriately isolated in a timely manner due to a lack of side rooms 20 GM pipeline bid for additional beds
including side rooms 20
Inability to recruit to required staffing levels, in particular nurse staffing (numerous entries) 20 Board and Workforce Cttee briefed on this issue, various options being pursued 20
Risk of injury/equipment failure/fire cause by failure of celling pendants in ICH/HDU, as a result of excessive weight, beyond safe 16 Previously escalated to Q&S. Business
case and decant plan being prepared 20
8 out of 16 cardiac telemetry transmitters broken and out of service support period 20 Escalated to Q&S 20
Upgrade to Somerset cancer registry interface on PAS has potential to delay cancer diagnosis 20 New risk, further analysis being undertaken 20
Only 1 maternity theatre available for elective and emergency cases 20 New risk, further analysis being undertaken 20
NARRATIVE
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PATIENTS: WEIGHTED DASHBOARD
Performance Measure Result 1 (Green)
2 (Amber- Green)
3 (Amber)
4 (Amber-
Red) 5
(Red) Weight Month Year Source
Harm free care %VTE Assessments undertaken within 24 hours of admission (indicative data)
96.6% M 97.2% Y ≥95% 94% -
90% 89%-85% 84%-80% <80% 1 1 x 1 = 1 1 x 1 = 1 Perf. Report (Nov 2018)
Harm free care No. Serious Falls 1 Mth 6 YTD
0 1
(MTD) 2 or 3 >3 (YTD) 2 3 x 2 = 6 5 x 2 = 10 Perf. Report
(Nov 2018)
Patient Safety % of 'red sepsis' patients receiving antibiotics within 1 hour 87.2% ≥95% 94% -
90% 89%-85% 84%-80% <80% 1 3 x 1 = 3 --- A&E Monthly Audits
Patient Safety No. of Never Events 1 Mth 5 YTD 0 1 3 5 x 3 = 15 5 x 3 = 15 Perf. Report
(Nov 2018)
Patient Safety 100% compliance with appropriate frequency of observations 92.4% 100% 99-95% 94-90% 89-80% <80% 1 3 x 1 = 3 --- CCOT quarterly
Audits
Infection Control No. of MRSA 0 Month 1 YTD
0 (MTD) 1
(YTD) 3 1 x 3 = 3 5 x 3 = 15 Perf. Report (Nov 2018)
Infection Control No. of C. diff Lapses in Care 1 month 1 year 0 1 2 3 >4 2 2 x 2 = 4 2 x 2 = 4 Perf. Report
(Nov 2018)
Patient Experience % of patients recommending WWL for care 94% ≥95% 94% - 90% 89%-85% 84%-80% <80% 2 2 x 2 = 4 --- Monthly FFT
(Oct 2018)
Patient Experience % of patients feeling involved with decisions about their discharge 88.2% ≥95% 94% -
90% 89%-85% 84%-80% <80% 1 3 x 1 = 3 --- Perf. Report (Nov 2018)
Patient Experience % of complaints responded to within the timescale agreed with the patient
72.5% M 74.9% Y ≥95% 94% -
90% 89%-85% 84%-80% <80% 1 5 x 1 = 5 5 x 1 = 5 Perf. Report (Nov 2018)
Mortality HSMR 102% M 114% Y ≤100 101-105
(MTD) 106-110 111-115 (YTD) >115 3 2 x 3 = 6 4 x 3 = 12 Perf. Report
(Aug 2018)
Mortality SHMI 111.9% ≤100 101-105 106-110 111-115 >115 1 4 x 1 = 4 1 x 1 = 1 Perf. Report (June 2018)
Mortality No. of PFDs 0 0 1 2 3 >4 2 1 x 2 = 2 1 x 2 = 2 Perf. Report (Nov 2018)
Medicines Management
% of critical medicines prescribed within 24 hours of admission or before the patient is transferred to a new area
Not avail. 100% 99-95% 94-90% 89-80% <80% --- --- --- HIS
Medicines Management
% of completed medicines reconciliation within 24 hours 87.2% 100% 99-95% 94-90% 89-80% <80% 2 4 x 2 = 8 --- Pharmacy
(Oct 2018)
Total 67(/25) 65(/18)
Average 2.68 3.61
.
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People: Everyone has the opportunity to achieve their purpose
Executive lead(s): Director of Workforce Reviewing
committee: Workforce Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD
Strategic importance:
Every member of staff has the opportunity to achieve their purpose. Safe and effective workforce to meet service needs
MONTH: YTD:
4
4
Sources of assurance:
Scrutiny by Workforce Committee
Scrutiny by Board of Directors Use of internal and external
auditors
Escalation of emerging risks Exec-to-exec meetings REMC
ROLLING TREND: ROLLING TREND:
4
3.38
3.5
3.38
Nov 2018
Oct 2018
Sep 2018
Jul 2018
Nov 2018
Oct 2018
Sep 2018
Jul 2018
Individual risks Original
Score Mitigations Current score
HR 84 - Ability to recruit and retain to required staffing levels for service delivery and service development plans 20 International recruitment, nursing incentive schemes, return to practice
programmes, nursing pipeline 20
HR 86 - Lack of assurance around medical job plans will lead to both negative service and financial impacts for the Trust
12 E-job planning 16
HR93 – Breaching the NHSI agency ceiling 12 Temporary staffing protocols, nursing incentive schemes, international recruitment, Steps 4 Wellness programmes, regional collaboration 16
HR101 – Access to intranet (Wally) 16 Liaison between IT, system provider and staff engagement to resolve Active Directory problems. Single sign on implementation 16
HR102 - Re-building the relationship with E&F staff, the wider organisation and the Unions following WWL Solutions
20 Development of new recognition agreement. Commitment to partnership working. Early engagement regarding E&F CIP schemes and consultations. 1:1’s with new regional officer (Unison)
20
HR80 – meeting the Government Apprenticeship targets 10 Prioritisation programme. Workforce Committee discussions and agreement around the apprenticeship strategy – target will not be delivered
15
HR06 – sickness absence above target (and not delivering 20% reduction as specified in BIG scheme) 12 Escalation from divisional to corporate risk due to be discussed at
REMC. 15
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NARRATIVE The weighted dashboard overleaf has been updated and the month to which data relates has been included.
The October Pulse survey has seen a significant deterioration across almost all engagement enablers, behaviours and feelings. The recommendation as a place to work is at its lowest ever reported rate within the Trust and recommendation for treatment has also deteriorated significantly.
Sickness absence remains over the Trust target of 4% and bank / agency expenditure has increased significantly in October. Nursing vacancies within medicine are now 5% higher than 12 month ago.
Confidence in delivery has deteriorated to amber-red. A workforce summit has been proposed to help facilitate actions in response.
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PEOPLE: WEIGHTED DASHBOARD
Performance Measure Result 1 (Green)
2 (Amber- Green)
3 (Amber)
4 (Amber-
Red) 5
(Red) Weight Month Year Source
Go Engage Friends and family test (work) 63.25% ≥95% 72-94% 68-71% 64-67% ≤63% 2 5 x 2 = 10 5 x 2 = 10 Workforce team
Employment Essentials Turnover 8.72% ≤8% 8.01-
8.5% 8.51-9% 9.01-9.9% ≥10% 1 2 x 1 = 2 2 x 1 = 2 Workforce team
Employment Essentials Leavers with less than 12 months’ service 17.12% ≤10% 11-14% 15-20% 21-24% ≥25% 1 3 x 1 = 3 3 x 1 = 3 Workforce team
Route Planner PDR completion 88.2% ≥95% 86-94% 78-85% 73-77% ≤72% 1 2 x 1 = 2 2 x 1 = 2 Workforce team
Steps 4 Wellness Energy levels 3.39 ≥4.00 3.7-3.99 3.61-3.69 3.47-3.6 ≤3.46 1 5 x 1 = 5 5 x 1 = 5 Workforce team
Go Engage Cultural enabler score 32.41 ≥36 35.01-35.9 34.01-35 33.61-34 ≤33.6 2 5 x 2 = 10 5 x 2 = 10 Workforce team
Total 8 32 32
Average 4 4
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Performance data as at 30 November 2018
Performance: We aim to be in the top 10%
Executive lead(s):
Director of Ops & Performance Director of Finance & Informatics
Reviewing committee:
Finance and Performance Committee DELIVERY CONFIDENCE WEIGHTED DASHBOARD
Strategic importance:
Delivery of operational and finance performance underpins clinical care, facilitates the patient journey and enhances the patient experience, and affects the organisation’s financial performance.
MONTH: YTD:
2.63
2.30
--Sources of assurance:
Scrutiny by Finance and Performance Committee
Scrutiny by Board of Directors Use of internal and external
auditors
Escalation of emerging risks Divisional performance reviews REMC
ROLLING TREND: ROLLING TREND:
2.20
2.09
2.61
2.79
Oct 2018
Sep 2018
Jul 2018
Jun 2018
Oct 2018
Sep 2018
Jul 2018
Jun 2018
Individual risks Original
Score Mitigations Current score
Risk of failure/vulnerability of back-end infrastructure resulting in no access to IT systems 20 Reviewed by REMC. Business case to be considered by F&P committee 20
Delivery of cost improvement programme 20 Reviewed by F&P committee regularly, focus on transformation programme 20
Risk of forecast and recurrent plans for 2018/19 not being achieved 20 Reviewed by F&P on a monthly basis. 20
Numerous IT-related risks 16 Reviewed by REMC. 16
Corroded copper pipe to water system 16 Reviewed by REMC 16
NARRATIVE **Please note that the weightings allocated to the metrics in the weighted dashboard were reviewed in September 2018 and therefore direct comparison with earlier periods is not possible. An additional metric relating to CIP performance was added to the dashboard in October 2018**
For the IT metric, this has been carried forward from November’s BAF due to the close proximity of the meetings. It should be noted that many of the projects not delivered on time were due to awaiting input from suppliers or input/authorisation from internal departments. All have been re-planned and there are only 2 projects in amber and one in red.
1/2 17/27
PERFORMANCE: WEIGHTED DASHBOARD Performance data as at: 30 NOVEMBER 2018
Performance Measure Result 1 (Green)
2 (Amber- Green)
3 (Amber)
4 (Amber-
Red) 5
(Red) Weight Month Year Source
4-hour standard 95% of patients should be admitted, transferred or discharged within 4 hours of arrival at A&E
80.80% Mth 87.13% YTD ≥95% 94.9-90% 89.9-80%
Mth & YTD 79.9-70% ≤70% 2 3 x 2 = 6 3 x 2 = 6 BI (Nov 2018)
12-hour operational standard
No patient requiring emergency admission will wait 12 hours in A&E
0 Mth 0 YTD
0 Mth & YTD 1 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)
Ambulance handover standard
All handovers between ambulance and A&E must take place within 15 mins with none waiting >60m
61 >60m Mth 623 >60m
YTD ≤ 15 mins 15-30
mins 30-59 mins
>60 mins mth & YTD 1 5 x 1 = 5 5 x 1 = 5 BI (Nov 2018)
Cancer treatment times
85% should wait no more than 62 days from urgent referrer to first definitive treatment
89.17% Mth 89.11% YTD
≥85% Mth & YTD ≤84.9% 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)
18-week RTT 92% on incomplete RTT pathways (yet to start treatment) should wait no more than 18 weeks
93.18% Mth 93.75% YTD
≥92% Mth & YTD ≤91.9% 1 1 x 1 = 1 1 x 1 = 1 BI (Nov 2018)
52-week RTT Zero tolerance for patient waits over 52 weeks on an incomplete pathway
0 Mth 0 YTD
0 Mth & YTD 1 2 1 x 2 = 2 1 x 2 = 2 BI (Nov 2018)
Diagnostic waiting times
99% of service users waiting for a diagnostic test should receive it within 6 weeks of referral
99.18% Mth 99.15% YTD
≥99% (mth) ≤98.9% 1 1 x 1 = 1 1 x 1 = 1 BI (Nov 2018)
Paper switch off programme
By 1 Oct 2018, NHS E-referral will be used for all relevant consultant-led first OPD appointments All using 100% ≤99.9% 1 1 x 1 = 1 1 x 1 = 1 Complete
Control total achievement
Forecast position: Achieve finance control total before STP
Forecast 3 quarters
Achieve 4 quarters
3 quarters
2 quarters 1 quarter 0
quarters 4 2 x 4 = 8 2 x 4 = 8 Forecast
Control total achievement
Forecast position: Achieve A&E control total trajectory
Forecast 2 quarters
Achieve 4 quarters
3 quarters
2 quarters 1 quarter 0
quarters 2 3 x 2 = 6 3 x 2 = 6 Forecast
Use of resources risk rating
Forecast position: Achieve use of resources risk rating as per plan
Forecast 2 quarters
Achieve 4 quarters
3 quarters
2 quarters 1 quarter 0
quarters 4 3 x 4 = 12 3 x 4 = 12 Forecast
Transformation CIP delivery against target >30% Mth 7% YTD
Achieved (YTD)
Fail by <10%
Fail by 10-20%
Fail by 20-30%
Fail by >30% 3 5 x 3 = 15 2 x 3 = 6 Finance report
IT Completion of agreed IT priorities in line with plan 62% 100% 90-99% 80-89% 70-79% ≤70% 2 5 x 2 = 10 5 x 2 = 10 IT department
Total 27 71 62
Average 2.63 2.30
2/2 18/27
Partnerships: We work together for the best patient outcomes
Executive lead(s): Director of Strategy and Planning Reviewing
committee: Board of Directors DELIVERY CONFIDENCE WEIGHTED DASHBOARD
Strategic importance: Effective partnership working underpins our strategic direction
MONTH: YTD:
3.08
2.95
Sources of assurance:
Scrutiny by committee Scrutiny by Board of Directors Use of internal and external
auditors
Escalation of emerging risks Exec-to-exec meetings REMC
ROLLING TREND: ROLLING TREND:
2.92
2.58
3.00
2.91
Nov 2018
Oct 2018
Sep 2018
Jul 2018
Oct 2018
Sep 2018
Jul 2018
Jun 2018
Individual risks Original
Score Mitigations Current score
Lack of Tier 4 CAMHS beds 16 Escalated to Q&S 20
Transfer of community services from Bridgewater NHS FT to WWL 20 Risk assessment discussed and risk score agreed. Included on risk register 20
Non-achievement of KPIs relating to cellular pathology 16 Shared services board to be re-established 16
NARRATIVE Delivery confidence has reduced as a result of board discussions on Healthier Together and the potential consequences of this, together with the temporary suspension of the orthopaedic pilot with Bolton NHS FT.
1/2 19/27
PARTNERSHIPS: WEIGHTED DASHBOARD
Performance Measure Result 1 (Green)
2 (Amber- Green)
3 (Amber)
4 (Amber-
Red) 5
(Red) Weight Month Year Source
Transformation Support to BIG projects Mild problems Fully provided
Mostly provided
Mild problems
Moderate problems
Major problems 2 3 x 2 = 6 3 x 2 = 6 Self-assessment
Research Numbers recruited against target Ahead of target Target complete
Ahead of target On track Off target Way off
target 1 1 x 1 = 1 1 x 1 = 1 R&D report
Bolton partnership Progress on 8 key projects Mod. concern M Mild concerns Yr
Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 3 4 x 3 = 12 3 x 3 = 9 Self-assessment
Locality partnership Locality plan performance matrix Mild concerns Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 2 3 x 2 = 6 3 x 2 = 6 Self-assessment
Locality partnership Transformation of hospital care Mild concerns Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 3 3 x 3 = 9 3 x 3 = 9 Self-assessment
Locality partnership Healthier Wigan partnership score Almost on track Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 2 4 x 2 = 8 4 x 2 = 8 Self-assessment
Locality partnership Community services transfer Moderate concerns
Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 3 4 x 3 = 12 4 x 3 = 12 Self-assessment
NW Sector p/ship Highlight report for NWSP Moderate concerns
Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 1 5 x 1 = 5 5 x 1 = 5 Self-assessment
GM partnership Combined theme 3 status Mild concerns Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 2 4 x 2 = 8 4 x 2 = 8 Self-assessment
GM partnership Orthopaedic theme 3 status Almost on track Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 3 1 x 3 = 3 1 x 3 = 3 Self-assessment
GM partnership Cardiology theme 3 status Almost on track Fully on track
Almost on track
Mild concerns
Moderate concerns
Major concerns 2 2 x 2 = 4 2 x 2 = 4 Self-assessment
Total 24 74 71
Average 3.08 2.95
2/2 20/27
Leadership Safety Walkround
Quarterly Report Council of Governors Meeting
Carrie McManus - Patient Safety Manager
1/7 21/27
Introduction
Visible leadership is an essential part of an engaged organisation. It allows frontline staff to
see and interact with, executive and non-executive directors on a regular basis, therefore
breaking down those barriers to good communication including hierarchy and promoting an
open and honest culture. It is essential to walk the walk as well as talk the talk if culture is to
change.
Leadership safety walkrounds were first introduced in the USA and have proved to be a
useful tool in promoting a more proactive safety culture. They allow frontline staff access to
executives and it allows executives, non-executive directors and governors to experience
first-hand the safety concerns that staff have. They promote a culture of openness and
trust. Opportunities to improve safety will be identified and staff will be empowered to take
these opportunities and make them reality if this is possible, where it is not then an
explanation will be given and reasons as to why therefore creating a trusting and open
relationship. It will also signal to staff the importance that the senior team place on safety.
The walkrounds can take place in any area that impacts on patient care either directly or
indirectly, in other words any area of the hospital or outpatients sites.
Dates & Areas of Visit:
• 14 September Wrightington Main Theatres
• 16 October 2018 ICU
• 5 November 2018 Orrell Ward
Overall Summary
Wrightington Theatres
The tour of the Department was led by Theatre Matron, Wendy McNair and she provided
the team with an excellent walk through on the journey of a patient attending theatre.
During the interaction with staff there was a general consensus that they felt listened to and
well supported by senior staff and they would be happy for themselves or any member of
their family to be treated at Wrightington Hospital. The staff appeared to work well
together and communicated well within their team and within the division more widely.
They came across as energised, passionate and although they felt pressured due to the
2/7 22/27
operational demands this did not appear to faze them; they gave the impression that they
deal with pressures calmly and do not allow things to have too much of an effect on the
team dynamics.
Actions to take away:-
1. The first impression of the department was that aesthetically the department was
lacklustre and in need of some maintenance/redecoration (holes in doors & chipped
paint). – This action is currently still outstanding but will be addressed by the Estates
Walkaround that is scheduled to take place on the 14 January 2019.
2. The staff discussed the new Health Information System (HIS) and although it is now
integrated across the Trust and provides real time information across teams and
services, within theatre the system is only utilised for the prescribing and
administration of medication. The team have explained that HIS does have the
functionality to be able to improve theatre effectiveness yet currently they are
required to duplicate information on several systems which is proving time
consuming and non-productive. The team have highlighted that currently the
systems that are in theatre cannot be integrated which results in duplication and
unnecessary time spent by staff inputting this information into several systems. This
action has currently not been resolved.
ICU
The tour of the Department was led by Rebecca Worthington, ICU Quality Lead and she
provided an excellent explanation of a patient’s journey on ICU. The team observed
effective team working with clear visible leadership within the unit. Staff spoke positively
about the care and treatment provided, with all staff stating they would be happy for
themselves or a family member to be treated on the unit. The team were particularly
impressed with the cascade of information to staff working across the unit. Rebecca
explained the electronic screen in the staff room which delivers subtle key messages to
staff. Reassuringly, the most recent Internal Patient Safety Notice relating to the Air Flow
Never Event was clearly displayed, providing the appropriate information for staff without it
being overwhelming and losing the key message.
3/7 23/27
Actions to take away:-
1. One area of concern that was highlighted by the visiting team was the current
progression with the replacement of the HDU ceiling pendants. The team were
aware of the current risk assessment and requested an update on the progress of
the business case for replacement of this equipment. – This actions is still
outstanding, update still awaitied
2. ITU staff were asked what would be on their ‘wish list’. The general consensus was
for the Visitors Room to be more spacious with more amenities available for
relatives and also for their staff room to be redecorated with the old shabby chairs
replaced. – Chairs purchased through 3 wishes for the visitors room have been
replaced allowing some of the older furniture to be relocated to the staff room
3. The team found the role of Quality Lead very interesting and a role that was
proactive and not reactive in addressing concerns so to prevent errors/harm to
patients before they occurred. Tony (Non-Executive Director) asked Rebecca would
she present at a future Q&S meeting to share what her role entails within ITU. –
Rebecca presented at Q&S on 12 December 2018
4. The bitesize training facilitated by the Practice Educator was commended by the
team and the Company Secretary agreed to provide training for staff in relation to
GDPR. – This training has been scheduledto take place on the 15 January 2019
Orrell Ward
The tour of the Department was led by Kay MacDonald, Deputy Ward Manager and she
provided the team with an excellent explanation of the speciality of the patients nursed
here, she provided us with a commendable explanation of the patient flow process and how
this works effectively when the ward is being utilised as it was intended.
The team observed effective team working with clear visible leadership on the ward. Staff
spoke positively about the care and treatment provided, with all staff stating they would be
happy for themselves or a family member to be treated on the ward.
Actions to take away:-
1. The Ward staff were asked what would be on their ‘wish list’. There was general
consensus that since the introduction of the Trainee Nursing Associates (TNA) there
has been depletion in the wards establishment for Health Care Assistants. The staff
4/7 24/27
therefore, would like additional HCA for the ward to support the patient
dependency. – An update on progress is only due for February 2019
2. The staff explained that at times the job can be very emotional especially and can be
hard to stand back from the situation. All staff were interested to take part in the
current ongoing ‘Power Pause and Power to Recover’ pilot. This is an application that
gives staff permission to step away from what is going on and press the reset button.
– Staff Engagement have advised that if the pilot is to continue then Orrell Ward will
be contacted and involved. An update will be provided on progress in February
All actions identified via these visits are monitored via CQEC. The action plans developed for
ICU and Wrightingon Theatres are due to be tabled in January 2019 and the action plan for
Orrell will be discussed at CQEC in February 2019.
5/7 25/27
6/7 26/27
Issue Owner Feedback method Progress to date Completed
• Business case progress for replacement of HDU Pendants
• Sean Curran
DDOP Surgery
• Discussion at Risk
Management Group and feedback to CQEC in February 2019
• Feasibility for
replacement of staff chairs for staff room on ICU
• Sean Curran
DDOP Surgery
• For consideration
and update at CQEC in February 2019
• Quality Lead ICU to
attend Q&S to discuss role and current initiatives in ICU
• Rebecca
Worthington Quality Lead ICU
• To schedule
meeting with Nina Guymer (Deputy Company Secretary)
• Company Secretary to arrange training session on GDPR for staff on ITU
• Paul Howard
Company Secretary
• Training session to
be scheduled with Janet Enston (Practice Educator)
7/7 27/27