key issues and assurance report audit committee …to note the progress report from the internal...

KEY ISSUES AND ASSURANCE REPORT Audit Committee

February 2021

The Committee draws the following matters to the Board’s attention-

Issue Committee Update Assurance received Action Timescale

Annual Report and Accounts

The Committee considered the arrangements for the 2020-2021 process

The Committee agreed the process to be undertaken

Draft Accounts, and final draft Annual Report, to be submitted to auditors no later than 24th April 2021

24th April 2021

Board consideration in May 2021 May 2021

Provisional Audit Committee meeting to be arranged for early June 2021, in the event of any late guidance being issued.

March 2021

External Audit update The Committee received the technical update

The Committee considered the audit plan for the year

There was positive assurance that the plan was appropriate, and the Committee approved the plan.

Local Counter-Fraud service

The Committee received the regular update

There was positive assurance that the plan continued to be appropriately implemented

The Committee noted the awareness sessions with local teams

All Non-Executive Directors to be invited to attend an awareness session

April 2021

Declarations of Interest The Committee were updated on the progress of colleagues making the necessary declarations

The Committee welcomed the escalation of the remaining colleagues to the Executive team for support and noted the impact of the pandemic on the process.

Continued engagement to the end of the year

March 2021

Issue Committee Update Assurance received Action Timescale

Board Assurance Framework

The Committee agreed with a proposal that each Board Committee with oversight of a risk should, at each meeting, identify any items discussed that could significantly impact on the BAF risk

Agenda item to be added to each relevant Committee's agenda

March 2021

Internal Audit update The Committee received an update on the progress of the Internal Audit work.

There was positive assurance that the revised plan would be completed and would be able to support the Head of Internal Audit opinion for the year-end process

The Committee welcomed the High Assurance rating from the review of Key Financial Controls.

The Committee noted the positive outcomes of the Internal Audit service's re-validation exercise.

Assurance gained includes the Committee receiving evidence that:

i. The extent of the issue has been quantified;

ii. The impact is included in all internal and external reporting

iii. There are processes in place to learn from the occurrence, and measures have been put into place to prevent them happening again

Audit Committee, November 2020 Page 8 of 8

Tameside and Glossop Integrated Care NHS Foundation Trust

Minutes of a meeting of the Audit Committee of the Board of Directors, held on Wednesday, 18th November 2020 at 2pm via videoconference.

Present Andrew Light AL In the Chair

Peter Noble PNo

Martyn Taylor MT

In attendance Michelle Hurst MH Assistant Head of Financial Services

Jakira Motala JK KPMG

Neil McQueen NMcQ LCFS Specialist (MIAA)

Ruth Parker RP MIAA

Steve Parsons SIP Trust Secretary

Sam Simpson SS Director of Finance

Peter Weller PW Director of Nursing and Integrated Governance

73/2020 Welcome and apologies

The Chair welcomed colleagues to the meeting.

Apologies for absence were received from Debra Chamberlain and Lindsey Hulme.

74/2020 Declarations of Interest

It was noted that KPMG would declare their interest in the item related to appointment of external auditors, and withdraw from the meeting at that point.

75/2020 Minutes of the meeting held on 8th September, 2020

The minutes of the Committee’s meeting held on 8th September, 2020 were approved as an accurate record.

76/2020 Matters Arising from the minutes

The Committee noted the updates on the matters on the Action Log, and that both actions were now completed or discharged.

In respect of the action on developing a reporting template for the BAF (17/2020), AL noted that he had discussed a draft with SIP and Kim Smith; if the proposals were approved by the Board, it could then be used as a standard across the Board Committees. The Committee directed that the draft template be immediately circulated to the Chairs of Board Committees.

PW noted that he would also pick up any related changes to the Risk Management strategy with the Trust Secretary outside of the meeting.

ACTION-


a. SIP to immediately circulate the draft reporting template to Chairs of Board Committees.

77/2020 Internal Audit progress report

RP presented the circulated report, and drew attention to the following points-

a. A number of reviews were in progress, but there were no reports to the Committee at this meeting

b. The report proposed a substantial change to the programme of reviews for the remainder of the 2020-2021 year, reflecting the impact of COVID-19 and the continuing engagement with Executive colleagues about the key and emergent risks facing the Trust. The proposal was to undertake a major review of infection prevention and control arrangements at the Trust, reflecting the current key operational risk; to achieve this, the following were proposed to be postponed- i. Emergency Preparedness, Resilience and Response (EPRR) ii. Stock Management & Control iii. Completeness of Patient Records iv. Patient Property v. Allied Health Professionals’ job planning

c. These reviews had been identified as impacted by the COVID-19 situation, as either requiring attendance on site and/ or significant work by clinical staff who had greater priorities at present. It was noted that this was an issue being seen more widely across MIAA’s client base, and with a number of Trusts proposing changes to their programmes as a result.

The Committee discussed the following points from the report-

a. The Committee were broadly supportive of the proposed changes to the programme, and understanding of the reasoning behind the proposal.

b. A query was raised regarding the postponement of the review of completeness of patient records, which had been raised as a concern in the past in terms of the quality of care through the Quality and Governance Committee. The Committee noted that this would be a particularly hands-on review requiring clinical staff to support; there were also a number of changes to record-keeping, including moving to digital records and changes in community record-keeping, that meant a delay was desirable. It was confirmed that, if a ‘deep dive’ review into particular aspects was desired, that could be arranged through the Quality and Governance Committee.

The Committee then agreed-

a. To note the progress report from the Internal Audit service; b. To agree the proposed changes in the Internal Audit programme for the

remainder of 2020-2021.

78/2020 External Audit update

JM referred the Committee to the circulated technical update, noting the following-

a. In line with the guidance from the National Audit Office, the auditors were starting the work required for the new and more detailed Value for Money process. The Trust had been provided with an initial questionnaire, which would form the basis for planning and executing the necessary audit review.


b. To date, there had not been national confirmation of the requirements to be put into place for Foundation Trusts in respect of audit work on Quality Reports (Accounts) for the year ending on 31st March 2021. The current basis of planning was that the requirements would be similar to previous years, but that was subject to change.

The Committee discussed the following points from the External Auditor’s update-

a. Whilst the changes to the Value for Money process had been expected, the challenges had been increased by the impacts of COVID-19; of particular note was that the financial arrangements for supporting Trusts had changed fundamentally twice within the financial year, and at this stage there was no clarity on the expected processes for the 2021-2022 financial year.

b. The Committee noted that there were continuing discussions with the external auditors on the most appropriate way to respond to the national changes in Value for Money work: this included reference to the impact of COVID-19 on financial sustainability across the North-West region, and the uncertainties about financial arrangements for the 2021-2022 year.

c. The Committee discussed whether there could be a change in the Value for Money approach given the continuing pressure on services being exerted by COVID-19; it noted that the National Audit Office continued to set out the changed expectations, but re-consideration remained a possibility and the Committee would be kept informed. It was also important to note that the Trust had complied with all the requirements related to 2019-2020, and at this stage there were not significant concerns although it would depend on how the various processes developed.

d. It was suggested that the Trust should, in concert with other providers and interested parties, be making national representations about the limited amount of value provided by undertaking the statutory Quality Accounts process and the additional requirements on Foundation Trusts, which was a particular strain when the NHS was managing a long-term national incident at Level 4 of the EPRR framework. The Committee agreed that representations should be made through all appropriate forums.

e. An enquiry was raised regarding the current thinking on arrangements for the 2021-2022 year; SS advised that there was currently significant uncertainty at a national level as to what funding structure would be operating. The key factors were likely to be the run rate (affected by COVID-19, which could be expected to have a significant continuing effect) for both the NHS and individual organisations; there was a regional piece of work underway to address those questions.

The Committee then noted the technical update from the external auditors.

79/2020 National Audit Office guidelines

The Committee noted the circulated briefing note, together with the assurances provided against the various questions suggested by the National Audit Office for Audit Committees to ask of management during the COVID-19 period.

No questions were raised on the briefing, which the Committee welcomed.

80/2020 Local Counter-Fraud Service update

NMcQ drew attention to the following points from the written report-


a. The key message was the continuing identification and prevention of attempted frauds related to COVID-19; it was very pleasing that, whilst a number of attempts had been made on the Trust, no successful attempts had been identified.

b. The data submissions for the National Fraud Initiative had been sent in accordance with the national deadline; it was anticipated that any matches for investigation would be received early in 2021.

c. There had been two new referrals received since the previous meeting, which were being investigated.

d. In respect of the case that had been referred to the Crown Prosecution Service, a process of providing further information for consideration was continuing.

The Committee discussed the following points-

a. There was nothing in particular to draw to the Committee's attention regarding the attempted fraud approaches being seen; the process of identification and reporting was broadly working as expected.

b. An enquiry was made as to whether some organisations were seeing under-reporting of possible frauds during this period. NMcQ was not able to give a more general comment, but noted that there was a continuing stream of cases being drawn to his attention through the various reporting routes.

The Committee then noted the update from the Local Counter-Fraud Specialist.

81/2020 Board Assurance Framework

SIP presented the paper, which invited the Audit Committee to consider the matters referred by the Board to Committee consideration in September 2020; it also set out, for consideration, an outline methodology for the formation and oversight of the BAF through the remainder of the 2019-2020 year and the 2020-2021 year.

The following comments were made-

a. The Committee noted that its proper focus was on the control systems in place, rather than the assurances and judgements that were undertaken by other Committees. This was an important nuance, which would ensure that each focused appropriately on the area delegated to it by the Board.

b. The Committee welcomed and supported the outline methodology given in the paper.

c. The Committee considered the question, discussed at the Board, of possibly sub-dividing the four current BAF risks against the key themes agreed by each Committee. It noted that the draft template might enable the other Board Committees to map against those themes; this would be further discussed with relevant Chairs after the meeting.

d. The Committee noted that, whilst its role was assessing assurance regarding the control systems in place at other Committees, overall oversight and assurance remained a matter for the Board.

The Committee then-

a. Noted the paper on the Board Assurance Framework; b. Agreed to the outline methodology, and recommended its approval by the

Board;


c. Requested the Secretary to schedule in presentations by Chairs of Committees to this Committee, as per the outline methodology;

d. Confirmed that it expressed no view to the Board on the question of possibly sub-dividing the current BAF risks.

ACTION-

a. Outline methodology to be considered by the Board at the November 2020 meeting.

b. SIP to schedule presentations to the Committee by Chairs of other Board Committees, as per the outline methodology.

82/2020 Update on preparation of the Annual Report

SIP presented the circulated update, which advised on current preparations for the Annual Report and Accounts process for the year ending 31st March 2021. He noted that, whilst the Annual Reporting Manual had not yet been published, the Department’s manual indicated 5-year trend data was required for the Departmental accounting group, and so was likely to be in the ARM; appropriate preparations were being made for that.

The following points were discussed-

a. It was confirmed that, based on current understandings, the implementation of IFRS would be proceeding; however, it was possible that HM Treasury might further delay implementation given the circumstances of COVID-19.

b. The Committee welcomed the confirmation that there were good reporting systems in place that could support the move to long-term trend reporting, which the Committee would wish to see implemented in any event.

c. Attention was drawn to the potential impact on front-line colleagues of the timing and substantial content of the process, which might expect to revert to the 6-7 week timetable following the year-end (submission by end May 2021). The Trust would seek to minimise the impact on colleagues.

d. Attention was also drawn to the operation of the EPRR architecture during the year, when (at Level 4) the Trust had been required to take decisions that aligned with regional and national directions; and the appropriate way for that restriction on the Board’s judgement to be reflected in the Annual Governance Statement. It was suggested that this would also be an area where representation should be made to national bodies, in conjunction with other providers.

The Committee then noted the update on progress towards preparing the Annual Report and Accounts.

83/2020 Control documents

SS introduced this item, which invited the Committee to approve some minor wording changes to the Standing Financial Instructions and the Schedule of Delegations; and provided the index to those plus the Schedule of Matters Reserved to the Board of Directors, and the specific delegations agreed by the Board in respect of COVID-19.

She also took the opportunity, in light of some concerns raised prior to the meeting, to confirm that the Standing Financial Instructions provided appropriate authority for the Deputy Chief Executive to utilise the delegations of the Chief Executive whilst

Audit Committee, November 2020 of 8

Karen James was seconded to Stockport FT. She drew attention, in this regard, to the delegation provision within SFI 1.2.2.

The following points were discussed in relation to the documents-

a. Minor possible errors were noted for addressing after the meeting. b. The Committee accepted that SFI 1.2.2 provided a basis for the Deputy

CEO to undertake CEO delegated powers; however, some members felt that, given the long-term nature of the arrangement with Stockport, it would be more appropriate for the Board to put in place a specific authorisation; and also that the Board should very specifically record its acceptance of that approach.

c. It was confirmed that the control systems would not permit the Deputy Chief Executive to sign both as Acting Chief Executive and in another capacity; two different individuals would be required. RP noted that the Internal Audit service would be able to review relevant documentation to ensure that the controls were respected and observed.

The Committee then-

a. Approved the changes to the Schedule of Delegations and the Standing Financial Instructions, and recommended them to the Board for approval;

b. Welcomed the comprehensive cross-index for the four documents; c. Recommended that the Board consider and (if thought fit) record its

acceptance of the arrangements for the Deputy Chief Executive exercising the delegated authority of the Chief Executive under SFI 1.2.2, at the November 2020 Board meeting.

ACTIONS-

a. Board to consider approval of the changes to the Schedule of Delegations and Standing Financial Instructions, at the November 2020 meeting.

b. Board to be invited to express specific support for Deputy CEO undertaking Chief Executive’s delegated authority, at the November 2020 meeting.

84/2020 Declarations of Interests update

SIP presented the circulated update, which reported progress to date in the programme to ensure all ‘decision-making staff’ reviewed and reported any interests, as required by the national policy.

The Committee discussed the following points from the update-

a. Progress was better than in the 2018-2019 year, with a substantial proportion of colleagues having completed; but there remained room for improvement. Whilst the benefits of greater Exec team involvement were being seen, it was also important to take account of the circumstances and set a priority accordingly.

b. Concern was expressed that, whilst there had been progress and the circumstances had to be taken into account, most of those in the group required to declare had so far failed to do s. There was a serious reputational risks to both the individuals, and the Trust, if significant numbers had to be publicly reported as non-compliant: and also a risk of fraudulent activity being undertaken as declarations were not completed as required. It was suggested that a reserve plan for urgent escalation should


be in place, so that those who had not declared by the start of January 2021 had Executive Director involvement in their cases. The Committee were reminded of the escalation process previously agreed, which included involvement of the Executive team later in the process.

c. The Committee also noted the need to ensure that declarations were appropriately followed up, rather than simply lying on the file, to ensure that all risks arising were appropriately managed.

d. It was suggested that, in order to drive the required change in culture and behaviours, the Trust should institute a series of spot audits in local areas to ensure full compliance and provide assurance that no opportunities for fraud were present.

The Committee then noted the update on the Declaration of Interest round.

85/2020 Losses and Compensation payments

MH outlined the report as presented, noting that there were no trends to draw to the Committee’s attention. There had been a welcome drop in claims for lost patient property, which was particularly heartening. PW noted that this had in part been as a result of the different systems during the limited visiting under COVID-19: whilst there had been learning from those changes, the eventual move back to wider visiting might have a reversing impact on these figures.

SS drew attention to the additional information provided on Pharmacy, who had reduced their losses from the previous high levels through robust controls implemented by the Chief Pharmacist. Whilst there had been some impact from COVID-19 related pharmaceuticals that could not be re-sold to other providers, there continued to be good progress.

The Committee noted the losses and compensations payments for September and October 2020.

86/2020 Waiver of Tendering Requirements

The Committee received the report, and SS advised that there were no items to draw to the specific attention of the Committee.

There were no queries raised, and the Committee noted the report.

87/2020 Matters to be reported to the Board of Directors

The following matters would be drawn to the Board’s attention-

The changes agreed to the Internal Audit plan for the remainder of the year;

The desirability of seeking to change policy on Quality Reports/ Accounts and the related audit work; and on the appropriate form of the Annual Governance Statement;

The positive assurance regarding the queries suggested by the National Audit Office;

The positive assurance on the work of the LCFS;

The recommendation to approve the outline methodology for the Board Assurance Framework;

The recommendation to approve the changes to the Standing Financial Instructions and the Schedule of Delegations.


The Secretary would prepare the usual written report

JK declared the interest of KPMG, and withdrew from the meeting.

[AL left the meeting, and MT took the Chair.]

88/2020 Tender process for selection of external auditors

This minute has been withheld from publication, to protect the integrity of the tender process.

Finance Committee, January 2021 Page 1 of 4


Minutes of a meeting of the Finance Committee of the Board of Directors, held on Tuesday, 26th January 2021 at 9.30am, via videoconference.

Present Sallie Bridgen SB In the Chair

David Curtis DC

Andrew Light AL

Sam Simpson SS

In attendance Jane McCall JMc Trust Chair


Asif Umarji AU Deputy Director of Finance


The Chair welcomed colleagues to the first meeting of 2021.

Apologies for absence were received from Trish Cavanagh.

2/2021 Declarations of interest

No potential conflicts of interest were declared in the business expected to be considered at the meeting.

3/2021 Minutes of the meeting held on 22nd December 2020

The minutes of the Committee’s meeting held on 22nd December 2020 were approved as an accurate record, subject to the following corrections-

a. Attendance list, Sue Toal should be recorded as Chief Operating Officer b. Page 3, paragraph e, sentence should finish “and consideration was being

given to the appropriate actions to be taken.”


The Committee noted the following updates from the Action Log-

99/2020 Given the changed financial arrangements for the first half of the year, the action had been superseded. The Committee noted the need to ensure that the position at the end of the year was kept under close review.

92/2020 AU ran through a brief presentation, which showed that the difference in the Patient-Level Costings index is the PFI scheme was not included was about 2%. Completed.

5/2021 Finance Report, M9 (December 2020)

AU and SS drew the following to the attention of the Committee-


a. There was a £507k surplus for the month, after the GM funding for COVID-19 and growth was taken into account, which could be compared to the October forecast of a £1.1m deficit for the month. The Year-to-date position was £4m better than the initial plan.

b. The Trust was now forecasting a £3.1m deficit for the year-end, which represented a further small favourable movement. Attention was drawn to the various movements against the plan that were set out in detail in the report.

c. It was very positive that there had not been any significant increase in spending on bank and agency staffing, although there continued to be high pressure on workforce. COVID-related sickness, and sickness absence generally, had improved in December; it had also assisted that ICU had seen reduced demand in December, but it was now operating again at 100% of capacity.

d. Attention was also drawn to the impact of the start of the vaccination programme, which would show up in the figures for January 2021 and beyond. The Committee noted that the costs incurred in respect of the mass vaccination programme would be reimbursed to the Trust, as would the increased costs related to the vaccination of Trust staff.

e. For the remainder of the 2020-2021 year, GM had secured agreement with NHS England/ Improvement for an achievable target. This was (in part) a recognition that GM had been in a unique position, with only 25 days unrestricted during the financial year: and also a greater recognition of the challenge as other regions became more heavily affected. The Trust continued to exert grip and control on its costs, as standard practice, but recognised that there were different dynamics in play than might usually be the case.

f. NHS England/ Improvement had indicated that, in light of the continuing pressures from COVID-19, the statutory planning process would be delayed into the first quarter of 2021-2022; and that the current funding arrangements would be ‘rolled over’ to operate during that period. Internal work was being undertaken across GM, in conjunction with the regional finance team, to understand and forecast the run rate in place at the end of the 2020-2021 financial year, and the impact of that on the 2021-2022 year.

g. Some initial planning work had started within the Trust before the indication of the delay had been received; this had been positive, and would be used when the planning process was re-started. There were also positive improvements in how GM were working on planning matters and to influence the region.

h. The Trust’s cash position continued to be positive, and closely managed with appropriate work on the payment of suppliers in a timely manner.

i. The capital programme was on track for completion for the end of the year, and continued to be closely managed. Healthier Together was feeling significantly closer to being confirmed, but would now be beyond the year-end and had therefore been moved out of this year’s figures; there was no consequential impact from this. There had been considerably more capital work than usual on estates, equipment and IT, reflecting the additional funds that had been made available at short notice during the pandemic. The Trust’s performance in ensuring they were spent during the year reflected well in a GM context.

j. The Board noted the listed operational risks that supported the overall BAF risk AF3, which would be considered later.

k. It was noted that the consolidated report on locality finance had not yet been received; it would be circulated to Committee members when received.

Non-Executive Directors raised the following points from the report for discussion-

a. Clarification was sought on the forecast assumptions that had not eventuated; AU gave the Committee a brief summary of the key items.


b. It was enquired whether the Trust would be required to repay some of the monies received to support COVID-19 work, given the surpluses being seen. It was confirmed that the GM arrangements provided funding for both COVID-19 and growth as a single block to individual Trusts, and no claw-back arrangements applied to them.

c. A question was raised regarding the bank/ agency impact of shielding for staff who were extremely clinically vulnerable; and also whether they were being prioritised for vaccination, and re-risk-assessed following vaccination. The Committee noted that any re-assessment would need to be following a second vaccination; no significant bank/ agency impact was being identified from staff who were specifically shielding under the Government guidelines.

d. Confirmation was sought on the position for planning for the 2021-2022 year. SS confirmed that the national bodies had postponed the planning round into the first quarter of 2021-2022, with the current financial arrangements being extended into that quarter. There was already some discussion being undertaken about the planning round at a GM level, where (in association with the NHS E/I Region) work was being undertaken to understand the likely run rate at the end of the 2020-2021 financial year.

e. Concern was expressed regarding the planned £3.1 million deficit at the end of the financial year; SS confirmed that this was acceptable to NHS E/I, as part of the wider GM plan, reflecting that NHS E/I were now primarily looking at ICS-level performance. Whilst there were still some discussions within GM on some technical aspects, the region had accepted the GM plan. The Trust was continuing to work to reduce the deficit where possible: whilst the forecast had a deficit, this was not the aim and strong cost control measures continued to be applied.

f. Clarification was sought on the aim for run rate, and SS confirmed that no pressures were expected beyond those that the Committee had previously discussed. The focus remained on cost control, as there was not clarity on the future structure or level of income streams.

g. The Non-Executive Directors commented that a key challenge would be the work to recover elective activity, and the longer-term impact on that aim of continuing COVID-19 restrictions. There would also be a critical area around the use of the Trust’s workforce in the future, including allowing them time to recover from the pandemic.

h. Given the greater rigour on capital programme shown by the Trust, the score of 12 for the operational risk related to capital programme delivery was challenged. This would be looked at further; the Committee also noted the significant contribution to achieving the programme from SS and Paul Featherstone.

i. Information was sought on the financial situation of our locality partners, with reference being made to the financial pressures being faced by local authorities. The Committee noted that a range of different requirements and timescales were in place for partners, who operated in different systems.

The Committee then noted the Finance Report for month 9 (December 2020).

6/2021 Review of BAF Risk AF3

SIP presented the paper reviewing the risk, in accordance with the BAF procedures agreed by the Board. There were no changes proposed to the key risks or assurances. The Committee was invited to consider recommending to the Board that the score was reduced, reflecting the changes in funding systems and the greater clarity on future expectations.


No questions were raised on the paper.

The Committee then-

a. Noted the review; b. Agreed to recommend to the Board that the score for risk AF3 should be

reduced to 15 (from 25).

Quality and Governance Committee Page 1 of 8


Minutes of a meeting of the Quality and Governance Committee of the Board of Directors, held on Thursday, 14th January 2021 at 9.30am, via videoconference.

Present Martyn Taylor MT In the Chair

Sallie Bridgen SB

David Curtis DC

Peter Noble PNo

Brendan Ryan BR

Peter Weller PW

In attendance Lydia Briggs LB MacMillan Lead Cancer Nurse

Tracy Campbell TCa Deputy Chief Nurse

Rob Conyers RC Head of Patient Experience

Abdul Hamied AH Associate Non-Executive Director

Jane McCall JMc Trust Chair

Kerry Reede Field KRF Head of Midwifery and CYPF



The Chair welcomed colleagues to the meeting, and noted that LB and KRF would be joining at the appropriate points to present their items.

Apologies for absence were received from Karen James.


No conflicting interests were declared in the business expected to be considered at the meeting.

3/2021 Minutes of the meeting held on 3rd December, 2020

The minutes of the Committee’s meeting held on 3rd December 2020 were approved as an accurate record.


The Committee noted the following points arising from the Action Log-

92/2020 The question of the future of Quality Accounts had been raised with the Company Secretary Network and through the Chair’s contacts. Both actions completed.

5/2021 Service Quality and Organisational Governance Group minutes

The Committee noted the summary of the December meeting’s proceedings, and also the draft minutes that had been circulated after the pack. The Committee


welcomed the format of the summary, and requested that the draft minutes were included in the main circulation of papers for future meetings.

No queries were raised on the substance of the proceedings of the Group.

ACTION-

a. SQOGG draft minutes to be included in the main Committee circulation for future meetings.

[LB joined the meeting.]

6/2021 Patient Story

LB took the Committee through the patient story, which was outlined in the circulated papers and concerned the support provided to a patient who had undergone cancer treatment during the COVID-19 pandemic, and who had been reluctant to attend the hospital as a result.

LB outlined the relevant wider work of the cancer services team-

a. Whilst the national cancer survey had been postponed owing to COVID-19, the local team were undertaking monthly survey exercises. The October data had recently been analysed and had positive outcomes, and the team was taking learning to try to improve within the context of the current restrictions.

b. More broadly, it was a difficult period as patients were showing reluctance to attend the GP for an initial diagnosis, or to attend appointments at the hospital as part of their treatment. Some of the team had also been redeployed to other areas to assist with the significant pressures being caused by COVID-19. The team was internally re-deploying staff to support patient experience and provide assurance regarding attendance for treatment; the aim was to understand each case and give personalised support for individual situations. The response of the team had been outstanding.

The Committee discussed the following points from the presentation-

a. Whilst it could be challenging logistically given the other pressures being faced by the service, it was key that patients were being given personal contact. Many of the patients just wanted someone to talk to in the service, even in that individual wasn’t in a position to assist with specialist queries.

b. Funding for the colleagues who were providing the contact with patients had been confirmed until March 2022. The Committee noted that several funding streams for the team were blended between the NHS and the MacMillan Charity.

c. It was noted that the leadership being shown by the senior staff in the team, in delivering the key service priorities for the Board and for patients, was exceptional.

d. This was an important area for the Board in terms of delivering good patient experience in the current difficult circumstances; and it was positive to see a pro-active engagement with patients to address their concerns about attending for treatment.

The Committee then noted the patient story.


[LB left the meeting.]

7/2021 Quality Oversight report

The following points from the presentation were drawn to the Committee’s attention-

a. The flu vaccination campaign had concluded on the 31st December, to allow capacity for COVID-19 vaccinations. There had been good progress, notably with medical and dental staff; particular thanks were recorded to Dr New for her work with colleagues who had been hesitant to have the vaccination.

b. The COVID-19 vaccination programme had started on the 1st January, with over 3,400 staff colleagues being vaccinated in the first two weeks by the Trust; 95 patients had also been vaccinated as opportunities arose. This had been an exceptional effort by staff.

c. The Trust was working with locality partners to vaccinate their key staff, together with patients who were also front-line carers, in line with the national guidance. Support was also being provided to Pennine Care FT for vaccination of their staff, and discussions were being held for supporting North-West Ambulance in the area.

d. A particular area of support was vaccination of those in the community suffering from significant learning disabilities, who were a group presenting particular challenges around informed consent/ best interest decisions. In conjunction with locality partners, about 50% of those in this group had been vaccinated to date, and the remainder of the group were being worked through in an appropriate way. The Trust had received national congratulations for its work in this area, and was joining a national working group on the flu programme for 2021-2022 to share the learning.

e. There had been continuing changes to the guidance on COVID-19 vaccinations, which had presented challenges and were being worked through pro-actively with GM partners. Work was also being undertaken to ensure that all patients transferred to a care home since 20th December were vaccinated.

f. Attention was drawn to the current position on nosocomial infections and infection prevention and control, together with the benchmarking information against Greater Manchester provided in the report. Wards 40, 41 and 42 were the current subject of focus; these were medical wards, where patients could be asymptomatic and/ or uncooperative with the IPC regime, and so this focus was not a surprise.

g. The need to continue the policy of restricting physical visiting for patients across the hospital site was a source of pressure; as previously reported, there was pro-active work being undertaken to offer families and patients alternatives for contact, particularly through electronic devices. As detailed in the report, audit processes had been conducted and found about 90% compliance with expectations, but areas for improvement had been identified and were being taken forward, particularly in ensuring those patients who appeared to have their own devices were actually communicating with their families. The process had also demonstrated the good work undertaken in making electronic devices available for use.

h. A Medicines Improvement Board had been formed, which was looking across the Division for assurance and appropriate standards. It was also looking to provide support for leadership in medical and nursing positions within the Division.

i. The Medical Examiner system was now moving towards implementation, with the administrative support posts being filled and becoming active.


Additionally, a new appointment of a Lead Clinician for the Learning for Deaths process had been made, on a job-share basis.

j. A watching brief was being kept on excess mortality, bearing in mind that non-COVID excess mortality had previously risen as a result of patients being reluctant to engage with GP’s and hospitals during the COVID-19 period. There was a concern that this might be replicated, and (as discussed during the patient story) work was in place to pro-actively provide patients with assurance. The Trust was continuing to be actively involved in the work of the Greater Manchester Mortality Cell during the pandemic period.

k. The Service Quality and Operational Governance Group had drawn the Committee’s attention to the position regarding cared-for children (previously referred to as looked-after children), which was an expanding area of work with some challenges, where the Trust was working closely with partners. It was intended that a deeper review would be brought to the Committee in March or April 2021.

The Committee discussed the following points arising from the update-

a. Colleagues had been delivering fantastically in the local vaccination programme, as had colleagues across the locality. The national change in guidance for the timing of the second vaccination (from 21 days to 12 weeks) had caused some concern for patients, which were being actively addressed. It was also noted that the timing situation remained fluid, as further national reviews were undertaken from the greater evidence now available.

b. It was reported that the Trust’s work had been identified as showing a good practice organisation on a recent Regional call for Trust Chairs, which had also praised the very active engagement being shown by the Board during this period.

c. The Committee were reminded of the review of nosocomial mortality in September 2020; a similar report had been published by Manchester University FT earlier in the week, which had shown a similar pattern and referred back to this Trust’s review. More generally, a similar pattern was now being seen across a number of organisations.

d. The work with learning disability communities was welcomed; and an enquiry made whether there were identifiable communities not coming forward to be vaccinated. It was noted that information for wider community programmes would be with the Primary Care Networks, who were administering that programme. For Trust staff, the overall picture was positive, but there was some anecdotal evidence that BAME staff were more reluctant; this was being worked on and would be followed up.

e. It was confirmed that the Primary Care Networks hubs were providing vaccinations to the out-of-hospital population; anecdotal feedback was that engagement was good, but they could have some particular group that were a focus. Overall, the locality system was seen as very positive. A request was made that an enquiry regarding vaccination for the homeless was raised at an appropriate Chair’s meeting.

f. The Committee welcomed the benchmarking information on nosocomial infections, which provided a level of positive assurance. An enquiry was raised regarding when the level of outbreaks might be expected to reduce; it was advised that it was likely that outbreaks would continue to be seen, but the learning achieved so far was being used to better manage outbreaks when they arose. Whilst the fact that the Trust had been one of the first to see the start of the second/ third ‘spike’, the Trust was below the average for outbreaks and had significantly less beds being taken for COVID-19 than


other Greater Manchester and regional providers. g. The need to adjust services and staffing to meet the challenges of COVID-19

had led to individuals, teams and leaders being deployed around the Trust, and therefore having some instability in relationships particularly in medical wards. This was now a focus for the next period. More generally, there was continuing engagement with the Trust’s medical leadership, through the Clinical Advisory Group, a number of times each week.

h. The Committee requested that, if available, contextual information for complaints management across GM was provided to ensure that the Trust’s performance was not an outlier.

i. It was confirmed that, following the review of TV provision, plans were in place and being implemented to ensure appropriate provision was in place.

j. The Trust was providing mutual assurance to other Trusts by accepting ICU transfers from other providers, both within and from outside the region. These patients, some of whom would be in our care for more extended periods, posed more acute challenges to ensure communication with their families, who were a lot further away from the Trust and not in the usual networks for staff.

k. There had been workforce challenges experienced, particularly in keeping rotas covered over the festive period. Junior and trainee medical colleagues had been operating for a number of months in high-stress areas which they would not usually be exposed; and there had been a national decision, where possible, to rotate staff (in the usual way) for their own welfare. It was also important to consider that the same staff would, in due course, be asked to make a further significant effort to address the backlogs of work that had inevitably accumulated as the NHS had focused on the management of the COVID-19 pandemic, which was likely to produce its own level of increased stress for staff. Attention was drawn to the fragility being seen amongst nursing staff, which would be addressed in reports to the Board in due course.

l. The Workforce Committee had been considering the issues related to staff welfare during the COVID-19 period, and had welcomed the provision that had been made for mental health support through the Manchester hub arrangements. The Workforce Committee was seeking assurance that staff were taking up the services when they would benefit from them.

m. There had been progress related to Equality, Diversity and Inclusion with clinical colleagues, although there remained some challenges. It was important to note that the high-risk areas for this Trust were almost completely staffed by BAME colleagues; there had been considerable focus in ensuring that they were supported to ensure that our services continued though this period.

n. The Committee noted that the detailed report on cared-for children, which would be brought to the Committee at a later date, would cover a complex area influenced by a wide range of factors. It was suggested that the review should reflect the wide spectrum of challenges from placed children, and also the resourcing required.

The Committee then noted the Quality Oversight report.

ACTION-

a. JMc to flag vaccination programme for homeless through Chair’s meetings. b. If possible, provide contextual information on complaints performance

compared to other GM bodies.


[KRF joined the meeting.]

8/2021 Ockenden review

KRF introduced the circulated paper, drawing attention to the following points-

a. This was an interim report from Professor Ockenden’s review of maternity services at Shrewsbury & Telford Trust; the final report was not expected for some time, and both reports were expected to have significant impact on the provision of maternity services across England.

b. As indicated in the paper, Professor Ockenden had identified 12 actions that all maternity providers should action with immediate effect, and these had been confirmed for action by NHS England/ Improvement and Ministers. Initial review by the Trust had identified that the Trust had full compliance with 8 of the actions, and partial compliance with four. Regional discussions had identified that different interpretations were being put on some actions; and if further clarification was issued, the relevant actions would be reviewed.

c. For the four actions where there was currently only partial compliance, work was being undertaken to identify the most appropriate way to move these forward; there would be implications both in costs and job-planning, and these were being reviewed. More widely, resourcing was an issue that was being raised as the resource demands of the standardised approach sought in the report would represent a significant challenge for smaller units such as the one in the Trust.

d. Funding for a review against the BirthRate Plus standards had been obtained via the Local Maternity System; KRF’s professional judgement for the present was that staffing was acceptable, although more midwifery assistants would be desirable. There was a bigger concern regarding the expectations in the report related to continuity of care for midwifery patients; the Greater Manchester region was not expecting to achieve this, and for this Trust it would require in the region of a further 15 midwives to be in place. This was subject to review at present, prior to being finalised with the Director of Nursing and Integrated Governance.

e. The requirement to ensure that the maternity incentive scheme rebate from the Clinical Negligence Scheme for Trusts (CNST) was being worked through by the Executive team, and would need to be reviewed and discussed by the Board.

f. The report recommended changes to ensure that Maternity was regularly and clearly considered at Board level, including the appointment of a Non-Executive Director as a Board Safety Champion to work in conjunction with the Executive Director Safety Champion. The Maternity dashboard would move into the Quality Oversight paper, with reporting aligning to the current structures; and the maternity champions meeting would be reviewed to facilitate appropriate participation by the NED lead. However, there remained some regional and national concern about the NED role, which appeared to be overlapping with that of the Executive Director lead.

The Committee discussed the following points arising from the Ockenden interim review and the circulated paper-

a. It was noted that there was a significant amount of disquiet nationally amongst Chairs regarding the boundaries of the proposed NED role, and this was something that the Board would need to consider when the paper was discussed at the end of the month. This was also an issue that was being


raised through Director of Nursing and Head of Midwifery forums. b. It was requested that the paper to the Board included, for those items where

the Trust was only partially compliant, an analysis of the implications of becoming compliant, together with the anticipated timeframes to do so.

c. The Committee welcomed the positive assurance that could be gained from the report, and the expectation that there would be a higher profile for maternity services at the Board in the future.

d. As the current NED Patient Safety Champion, PNo commented that he saw the role as supporting challenge and scrutiny; and also noted the role was also to being the voice of families and patients to the Board.

e. Whilst the expectations on the second ward round in the report had been noted, the Maternity team were exploring the options of this being done virtually, learning from the experience of COVID-19: whilst a physical round could improve quality, the very specific timing recommendations were not well adapted for how this Trust’s unit worked. Whilst taking forward the aims of the report, the Unit was seeking to be creative in its approach. It was noted that the regional networks had previously shared best local practice, and they could be a route to agree flexibility where it was appropriate.

f. The Committee noted that the sign-off of the Local Maternity System, as a non-statutory body, had been required for Trusts to be able to submit to Regional NHS England/ Improvement the assessment of compliance with the requirements. The Director of Nursing forums had raised concerns about this, and the logistical difficulties of getting their clearance; and it did also impact on the statutory responsibility of the Board for the Trust’s maternity service and relationship with the regulator.

The Committee then-

a. Noted the paper on the Ockenden interim report, and the Trust’s response to the 12 immediate actions from the report endorsed by NHS England/ Improvement;

b. Noted that there would be a further discussion, in accord with the requirements of NHS England/ Improvement, at the Board meeting at the end of January.

9/2021 Board Assurance Framework update

SIP presented the paper, which noted that no change was proposed for the key controls and assurances for Risk AF1, or to the score currently in place. He also confirmed that there were no matters to bring to the Committee’s attention for consideration as an additional strategic risk to add to the BAF.

The Chair suggested, and the Committee agreed, that a more detailed analysis of the risk, the underlying operational risks, and any changes since the last report, should be provided to support the Committee’s discussions. It was also agreed that future presentations should be supported by the full text of the relevant BAF risk, reflecting any changes proposed.

A query was raised regarding BAF risks for the 2021-2022 year, and whether the current risks should be rolled over. It was noted that this was a decision for the Board, which might require discussion amongst the Executive team; and that the Committee had previously suggested some additional matters to be considered for inclusion.

The Committee then-


a. noted the BAF update; b. concurred that no change in the score should be recommended to the Board; c. requested that a more detailed analysis of changes, including the underliyng

operational risks, was presented for consideration at future reviews; d. requested that the full text of relevant risks from the BAF was presented for

future reviews.

ACTIONS-

a. Future BAF reviews to include detailed analysis of changes, including underlying operational risks.

b. Future BAF reviews to include full text of relevant BAF risks.

10/2021 CQC Strategy consultation

PW referred to the paper, and noted that the consultation was being drawn to the Committee’s attention for information. A copy of the consultation document would be circulated after the meeting.

ACTION-

a. Copy of the CQC consultation document on strategy 2021-2026 to be circulated to Committee members.

11/2021 Matters to be reported to the Board

The Committee noted the following matters would be reported-

The positive assurance from the patient story, including the pro-active work to contact and reassure patients during the COVID-19 period;

The successful ‘flu vaccination campaign, and the positive launch of the COVID-19 vaccination programme;

The positive benchmarking for infection prevention work;

The discussion on workforce welfare and it’s potential impacts on the quality of care and patient experience;

The discussion of the Ockenden interim report, noting the Board discussion to be held.

The Secretary would prepare the usual written report.

12/2021 Future Business

In light of the recent letter from the NHS England/ Improvement North-West Regional Director, calling on Boards to reduce their activities to a minimum and thereby release Executive time to focus on the pandemic, it was agreed that the formal meeting on the 4th February would not be held. An informal briefing for Non-Executive members of the Committee would be arranged, to keep them abreast of developments.

The Chair noted that this would be the last meeting of the Committee attended by PNo, who would be retiring from the Board. On behalf of the Committee, he thanked PNo for his contribution and work.

Workforce Committee, January 2021 Page 6 of 6


Minutes of a meeting of the Workforce Committee of the Board of Directors, held on Wednesday, 13th January 2021 at 2pm via videoconference.

Present Peter Noble PNo In the Chair

Sallie Bridgen SB

Andrew Light AL

Peter Weller PW

In attendance Amanda Bromley AB Director of Human Resources

David Curtis DC Non-Executive Director

Lucy Harmer LH Assistant Director of HR (Learning and Organisational Development)

Abdul Hamied AH Associate Non-Executive Director

Stuart McKenna SM Assistant Director of HR (Culture, Inclusion and Engagement)

Katheryn Mooney KM Assistant Director of HR (Business Partnering)


Mark White MW Deputy Director of HR


The Chair welcomed colleagues to the meeting; he thanked the team for the quality of the papers, with strong content coming through. He also noted that DC was observing this meeting, in preparation (subject to Board approval) for becoming the Chair of the Committee.

Apologies for absence were received from Trish Cavanagh, Brendan Ryan and Eleanor Devlin. It was note that AH would need to leave part-way through the meeting.


No potential conflicts of interest were declared in the business expected to be considered at the meeting.

3/2021 Temperature Check

AB drew attention to the following points- a. As in November, the Trust continued to be under immense pressure from the

combination of COVID-19 and the more usual winter pressures. Staff were dealing with a busy, relentless period and very difficult circumstances.

b. A programme to support the testing of staff for COVID-19, and their vaccination, had been rolled out successfully across the Trust, as covered in more detail in a later paper. The Trust was also involved, as Lead Employer for the mass vaccination site, at the Etihad in Greater Manchester.

c. The rates of absence continued broadly in line with those previously reported, reflecting the regional and national experience as COVID-19 continued to


impact through infection and the need for self-isolation. Further pressure was expected as the Trust worked through the third wave over the coming few weeks.


a. Progress on the vaccination programme for Trust staff had been very positive, and about 3,200 of about 4,500 individuals had now received the first dose. The programme was also being expanded to offer vaccination to colleagues from adult social care and primary care.

b. There were a range of options being provided for staff to support their mental health through these challenging time, many through the Greater Manchester hub arrangements. It was noted that the Resilience Hub had confirmed that staff from the Trust were accessing the services; a comment was made that it would be useful for the Committee to review take-up further, to gain assurance that it was accessed by all who could benefit from it.

c. The staff vaccination programme was some way ahead of plan, the Trust had been ensuring that the vaccine was utilised in full rather than having doses going to waste.

d. There was a continuing impact on teams from the pandemic and associated lockdown arrangements; staff colleagues were acutely aware of the impact on both patients and families. In some ways, it was more difficult now than in the first wave, when there had not been any expectations; however, the vaccination programme had given a degree of hope to colleagues. It was noted that some colleagues were now feeling tired and weary having been exposed on a continuing basis to the personal impacts of the pandemic for a number of months, and who were finding the position increasingly challenging.

4/2021 Minutes of the meeting held on 18th November, 2020

The minutes of the Committee’s meeting held on 18th November 2020 were approved as an accurate record.


The Committee noted that the due actions had been completed.

6/2021 Workforce Dashboard

AB presented the paper, noting that absence figures were covered in detail in the separate paper later on the agenda; and that mandatory training and appraisals were not being chased up, in line with the current national guidance.


a. Long-term absences from COVID-19 were being addressed in the usual way for all long-term absences, and access to the relevant clinics were available to colleagues through the Occupational Health service. The Trust would also address any working adjustments needed through the usual policy processes.

b. It was confirmed that the current national guidance was that, whilst new starters had to complete the required mandatory training, Trusts should not be pressing for refresher training to be completed at this stage.

c. The Executive team had discussed the position regarding colleagues taking annual leave during the year; although there had been a hiatus in the March/ April period, since then all colleagues had been encouraged to take leave for


their own well-being, including those who had been shielding for a period. A number of possibilities had been discussed in light of the national suggestion of allowing 20 days ‘roll-over’ over the next two years; in the result, the EMT had agreed to allow 5 days ‘roll-over’ into the 2021-2022 year, and would look at any teams which still had challenges on a case by case basis. The Committee requested an update on leave taken, rolled over and any exceptional cases was provided to the March 2021 meeting.

The Committee then noted the Workforce Dashboard as presented.

ACTION-

a. Update on leave taken, leave rolled over under the agreed approach, and any exceptional cases to be provided to the March 2021 meeting.

7/2021 Agency and Bank staff usage

MW presented the report, noting the following-

a. The target figures shown in the paper reflected the official policy from NHS England/ Improvement, where a baseline was set in previous years with the intention that all providers would drive down the cost of agency staff by the amount any were allowed to pay being reduced. In the current labour market, where demand for qualified staff was outpacing supply, this was a difficult ask.

b. The demand for staff, both at the Trust and more generally, had also been increased by the need to create and staff a number of different pathways dependent on the COVID-19 status of the patient. Spend had accordingly increased as the Trust needed to use more agency staff, although maximum use of the available Bank staff had been undertaken first.

The Committee noted that the increased need for agency staff would have an impact on the Trust’s financial position, although the figures in this report reflected the NHS E/I aspiration rather than the financial plan. Demand was also being seen in less usual areas, such as Domestics and Portering, as COVID-19 impacted across all staff groups and cover proved challenging.

The Committee then noted the update on agency and bank staff usage.

8/2021 Staff absence update

MW presented the update, and drew attention to the following points-

a. Whilst COVID-19 was continuing to drive the above- expectations overall absence rates, both that and the non-COVID absences were following a similar pattern, with the non-COVID absences at what would be an acceptable level for this period of the year.

b. Total absence was currently running at about 300 colleagues each day, compared to about 200 for the same period in the previous year; and again about 520 at the previous COVID-19 peak. Currently it was predominantly short-term (less than 28 days) absence that was increasing.

c. Absence had shown similar patterns over the period of the previous three years, although there was a greater cross-over between absence types this year given the impact of COVID-19.

The Committee discussed the following arising from the report-


a. It was welcomed that the Trust was seeking to take learning from the experience of the first wave of the COVID-19 pandemic, and the Committee looked forward to this being evidenced in the response to the later stages of the pandemic.

b. Given the impact of shift patterns and other complexities, it was difficult to give an accurate figure of how many staff who would attend were absent on a given day; MW’s estimate was that it was in the region of 70 to 80 each day, which had a significant impact on a Trust of this size. There was very limited flexibility to meet a challenge such as this, which was reflected in the agency and bank use.

c. The Committee discussed the information required on absence to provide assurance: whilst recognising that it needed to avoid becoming operational, it was important that there was sufficient clarity on performance to provide assurance to the Board that the Trust could meet the challenges being seen.

The Committee then noted the update on staff absences.

9/2021 Update on staff testing for COVID-19

MW noted the following from the circulated report-

a. Whilst the Trust had started staff and patient testing testing from the start of the pandemic period, there had been very limited consumables for the first few months and testing had been concentrated on patients to start with. As more consumables had become available, staff testing had been expanded.

b. The Trust had now moved to a weekly testing schedule for all staff in the high-risk areas; about 18,000 tests had been completed with a positive rate of about 3%. This was higher than the national expectations, but did reflect that all those with symptoms were being tested.

c. The Trust had received about 3,500 lateral flow test kits in November 2020, which had been rolled out to about 2,500 staff colleagues to be self-test twice a week. If a colleague submitted a positive result through these, it would be confirmed through a lab-based test; currently the positive rate was showing as well below national expectations. These were likely to be phased out in February 2020 and replaced with alternative testing arrangements.

The Committee discussed the following that arose from the report-

a. It was agreed that MW would circulate information regarding the correspondence of a positive result from a lateral flow test to the subsequent lab test to members of the Committee after the meeting.

b. In response to a query, the Committee were advised that the LAMP test was saliva-based and had a relatively quick turnaround, but did require a lab to produce results. The Committee noted the appropriate application of the test, and the relative accuracy of the results achieved.

c. The challenges of conveying an appropriate message to staff who were asymptomatic were discussed, noting that these needed to be based on the need to have infection prevention, and the wider public health messages in place. It was also noted that a lack of compliance with the current legal requirements and related guidance by the wider public was causing some resentment for colleagues exposed to the difficult consequences of the pandemic.

The Committee then note the update on staff testing for COVID-19.


ACTION-

a. MW to circulate information on positive results from lateral flow tests and subsequent lab tests to Committee.

10/2021 North-West Black, Asian and Minority Ethnic Strategic Assembly

AB presented the circulated paper, noting the letter from the Assembly Co-Chairs and the Trust’s response, and drawing attention to the following points-

a. The paper came forward to the Committee so that it could be aware of both the requests in the letter and the Trust’s response. Owing to the required timings for the response to the letter, it had not been possible for the response to be considered by the Committee prior to the submission being made.

b. As part of the process, the several EDI groups that had been formed in the Trust had been linked into the more formal governance structures, with the chairs of the EDI groups now attending and contributing to the formal staff consultation meetings.

c. Brendan Ryan had been confirmed as the Executive Director lead for Equality, Diversity and Inclusion issues.

d. As the Committee knew, there was already an ambitious strategy in place for the Trust to develop in this area, which aligned with the national expectations and those of the Assembly. One of the key areas of current work was how to share information appropriately across colleagues in the Trust.


a. The Committee welcomed both the letter from the Assembly and the Trust’s response, which was felt to be a positive step towards responding to various matters that had an adverse impact on BAME colleagues and communities.

b. It was suggested that the Committee should review data regarding the take-up of various support options such as COVID-19 risk assessments, flu vaccinations, COVID-19 vaccinations and similar; so that any divergences in ethnic groups could be identified and actions to address them be put into place. The Committee were advised that there had been good levels of enthusiastic take-up for the COVID-19 vaccination programme from BAME groups within the Trust.

c. The focus of the Assembly on action, leadership and collaboration were particularly welcomed. The Committee noted that this was intended to be a long-term piece of work to change the culture of the NHS in the Region.

d. It was noted that the Board would also be invited to consider both the letter and the Trust’s response.

The Committee then noted the letter from the Co-Chairs of the North-West BAME Strategic Assembly, and the Trust’s response to the Assembly’s statement of vision, mission and priorities.

11/2021 Future Workplan

The Committee noted the current intended workplan as circulated, and that dependent on the pressures facing the Trust at that time some business might be re-arranged.

12/2021 Matters to be reported to the Board of Directors


The following would be drawn to the Board’s attention-

The continuing pressures on staff from the COVID-19 pandemic, together with the positive assurance regarding the roll-out of the related vaccination to staff and the other support being provided.

The position on staff taking annual leave, which the Committee would review in March 2021.

The positive assurances on use of agency staffing, the management of absences during this exceptional period, and the provision of staff testing for COVID-19.

The response to the North-West BAME Strategic Assembly’s statement, which would be considered separately by the Board.

The Secretary would prepare the usual written report.

key issues and assurance report audit committee …to note the progress report from the internal...

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