page 1 of 134 trust... · board action checklist ... eprr core standards compliance 2016/17 review...

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Public Agenda

Trust Board of Directors Board Room, Fairfield House, Fairfield General Hospital

24 November 2016 10.30am – 12.40pm

Owner Attached Time

1) Welcome and Apologies

JP Verbal 1030

2) Patient Story

Verbal

3) Declaration of Interests

JP Verbal

4)

Minute of Meeting held on 27 October 2016 JP Attached

5)

Chairman’s Remarks

JP Verbal 1035

6)

Chief Executive’s Report Integrated Performance Report

DD

Verbal Attached

1040

7)

Finance Report for the Period ending 31 October 2016

DF Attached

1130

8) Infection Prevention and Cleanliness Quarterly Report

MM Attached 1145

9) CQC Improvement Plan

JA To follow 1150

10) Board Assurance Framework and Corporate Risk Register

GB Attached 1200

11) a) b) c)

Board Sub-Committees and EARC Report Charitable Funds Committee – 19 October 2016 Audit Committee – 21 October 2016 Executive Assurance and Risk Committee – 22 November 2016

SD JW DD

Attached Attached To follow

1205

12) a) b) c) d) e)

Regulatory and Governance – Items for Approval or Noting Board Action Checklist Clinical Audit Annual Report 2015/16 EPRR Core Standards Compliance 2016/17 Review of Standing Orders and SFIs Appointment of External Auditors

GB MM JL GB GB

Attached Supp Pack Attached Attached Attached

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f) g)

Whistleblowing Policy Single Hospital Service Joint Committee Terms of Reference

JL KCT

Attached Attached

13) Date of Next Meeting Thursday 15 December 2016

JP Verbal 1220

14) Resolved That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

JP Verbal

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Minute

Trust Board of Directors Room F16 Education Centre The Royal Oldham Hospital

27 October 2016 10.30am

Owner Timescale

Present Mr J Potter, Chairman Mrs D Brown, Non-Executive Director Sir D Dalton, Chief Executive Mrs S Dixon, Non-Executive Director Mr D Finn, Director of Finance Mrs C Guereca, Non-Executive Director Mrs E Inglesby-Burke, Chief Nurse Mr J Lenney, Director of Workforce & OD Professor M Makin, Medical Director Mrs C Mayer, Non- Executive Director Mrs M Ollerenshaw, Non-Executive Director Mr J Willis, Non-Executive Director

In Attendance Mrs J Adams, Interim Director Mr G Barclay, Assistant Chief Executive / Board Secretary Ms K Calvin-Thomas, Director of Strategy Mrs J Byrne, Associate Chief Nurse Mrs J Downey, Director of Governance Mr P Downes, Director of Patient Safety Mr S Featherstone, Director of Nursing Mrs N Firth, Director of Nursing Mr A Lynn, Head of Communication Mrs L McCluskie, Director of Estates and Facilities

Public One member of the public

113/16 Welcome and Apologies The Chairman welcomed everyone to the meeting.

114/16 Patient Story Mr Lenney read the patient story which related to delays in referral and diagnosis.

115/16 Declaration of Interests There were no declarations of interest.

116/16 a)

Procedural Business Minute of the Trust Board of Directors’ Meeting held on 6 October 2016 The minute was submitted and approved.

117/16 Chairman’s Remarks The Chairman reported that he had met with Sir Richard Leese,

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Leader of Manchester City Council, to discuss the case for investment in the North Manchester estate and the work underway with the Single Hospital Service to provide as much certainty as possible for staff based at North Manchester General Hospital. The Chairman said it was increasingly important to be able to describe a positive future for North Manchester General Hospital in order to ensure retention and recruitment of staff.

118/16 Chief Executive’s Report Sir David reported that further work would be undertaken on the Integrated Performance Report to move beyond a narrative report and to develop SPC charts. This would take a further two to three months of work. Sir David reported that the Pennine Improvement Plan had been signed off by the CQC on 17 October 2016 and had been endorsed by the Greater Manchester Pennine Improvement Board. The CQC had requested a follow up visit with the Trust on 13 December 2016 to enable a detailed review of the Fragile Services Project Plan, the Mortality Review Project and an assessment of Winter Resilience. The Trust could anticipate a follow up inspection in the late spring which was likely to focus on those services / sites rated inadequate and the Well Led domain. There were a number of key risks relating to workforce availability, data quality and IT infrastructure, clinical leadership, the financial plan for 2017/18 and beyond and the development of the clinical services strategy. The Quality Improvement Strategy was in the final stages of development and would be submitted to the Trust Board in November 2016. In advance of the strategy being finalised the first learning collaborative had been established centred on the deteriorating patient including improved diagnosis and management of sepsis. Urgent Care performance in September had been 84.7%, below the externally agreed trajectory of 88.9%. This had implications both for the quality of patient care and for receipt of STP funding. A significant number of actions had been identified to improve performance and were included in the Pennine Improvement Plan. The Trust had also engaged with ECIP and the focus of improvement would centre around ambulatory pathways, frailty models and “discharge to assess”, and escalation. Mrs Mayer said that the “perfect week” held in 2005 had identified external factors as a major issue. Mrs Adams said that when “silver command” was in place there was movement with external bodies, but it was also the case that the Trust itself could undertake a number of further actions to improve patient flow. The next discussion with ECIP would focus on how to get traction on these issues. Mrs Dixon said that the Trust had been in this position many times before and she asked how learning would be embedded on this occasion. Mrs Adams said that clear measures would be introduced and used on a daily basis supported by sustainable leadership, in contrast to the significant leadership changes there had been over previous months and years.

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Sir David said that the Trust continued to achieve the referral to treatment target although he alerted the Board to deteriorating performance which had not yet breeched the targets. The main risks related to gastroenterology which had been reported at the previous Board meeting. The cancer targets had been achieved with the exception of the breast screening symptomatic target. It was expected that this standard would be achieved by November 2016. The Trust had reported 29 C-difficile cases for the year to date which was now only one above the trajectory target. Mrs McCluskie had met with the Director from G4S and had emphasised the requirement for improvements in cleaning. There had been inadequacies by both the Trust and G4S. Mrs McCluskie had noted that more robust contract monitoring was required. There were also a number of issues that the Trust needed to resolve. Trust HSMR remained at 102 compared to the previous month while the latest SHMI had increased to 1.115 which placed the Trust as a high outlier for the first time. A separate paper on mortality would follow later in the agenda. Sir David stated that the Trust remained on target with a six month year to date financial position of £8.2 million deficit against a planned deficit £8.2 million. However, activity remained lower than plan and agency use remained higher than planned due to the inability to recruit sufficient substantive staff. Sir David said that a full report on the Board Assurance Framework would be presented later in the agenda but as requested at the previous meeting all risks scored 12 and above had now been included within the Integrated Performance report. Mr Willis welcomed this change to presentational format. Sir David said further work remained to ensure reliable escalation between the Divisional Risk Registers and the Board Assurance Framework. Mr Willis noted that the Trust continued to experience single sex breeches. Sir David said that single sex breeches were isolated to critical care and related to the limited time within which step down patients should be transferred to another ward. Any breech in an inpatient ward would be highlighted separately. Sir David said that the Trust would not achieve the single sex accommodation standard in 2016/17 but breaches would be confined to step down from critical care areas. Mrs Inglesby-Burke said this matter had been discussed at the Executive Quality and Patient Experience Committee in relation to the data and also in relation to how patient transfers could be expedited. Sir David said that reducing the number of 12 hour trolley waits was a priority. Mrs Adams said that the policy on long waiters had been revised to focus attention on all long waiters. Mrs Brown asked about appraisals and Mr Lenney replied that progress was monitored through the Executive Workforce Governance Committee. He had asked Divisions for plans to

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recover the position so that the targets were achieved. Mrs Brown raised a specific issue about cancelled operations data reported at Site and Trust level which Mr Finn said he would review. Sir David reported that significant work was underway to set the Trust apart as a place to work. A differentiated approach to recruitment was being developed and would be delivered through an impactful recruitment scheme. Mrs Brown said that any recruitment scheme should focus on quality of life issues as well as any financial incentives within the Agenda for Change rules. Mrs Ollerenshaw said this was an exciting and positive approach but she asked that there was also a focus on retention of staff supported by good local leadership. Mr Lenney said there was now a sharper focus on retention with better information on why staff left and also earlier intervention to try to retain staff within the Trust. In advance of the impactful recruitment campaign and as a major step in improving the skill mix of staff across the Trust, the Executive Directors had agreed to a significant rebanding of 100 Band 5 nurse posts to Band 6 nurse posts across all wards and departments. It was anticipated that approximately half of these posts would be filled by existing staff who would be further developing their careers and skills, while at least half would be filled by new staff joining the Trust. Mrs Brown asked whether creating 100 further Band 6 posts would provide the right balance of staff. Mrs Inglesby-Burke said the ward review had identified significant skill and grade mix issues and there would be no surplus to requirement staff through the creation of these roles. Mrs Guereca asked about the Senior Leadership Development Programme. Mr Lenney said that the final session of the Transforming Leaders Programme would be held in December 2016 after which an evaluation would be carried out and the next steps would be planned with Salford Royal FT. The Nurse Leadership Programme continued and would now be further developed with Salford Royal FT. The Joint Programme Team for the Single Hospital Service had been established and significant work was underway to create the benefits cases which would be submitted to the Competition and Markets Authority later in the year. The new time table projected that UHSM and CMFT would formally create a new NHS Foundation Trust in September 2017 and that North Manchester General Hospital would be transferred into the new Foundation Trust some 12-18 months after (September 2018 - March 2019). The Chairman and Sir David had spent some time at the Single Hospital Service Programme Board emphasising that while the Trust fully supported the creation of the Single Hospital Service neither party could be subordinate to the other and there was a need to align and synchronise programmes and strategies across the organisations. A prospectus for the establishment of a local care organisation for Manchester would be considered by the Manchester Health and Wellbeing Board on 2 November 2016. The prospectus

DF

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detailed the Commissioners’ ambition for the delivery of community based out of hospital care through a local care organisation which would include the North Manchester Community Services provided by the Trust. An alliance agreement, the scope of which was yet to be determined, would be in place from 2017/18 with services provided collaboratively but by separate organisations. The intention was that there would be a single contract from April 2018 although the prospectus was silent as to whether this would be through a single provider. Work on the development of local care organisations / accountable care organisations was underway in Bury, Oldham and Rochdale and the Trust was working alongside the Local Authorities and CCGs in each of these areas. Sir David said that it was important that the Trust develop a clinical services strategy with a clear focus on the service portfolios to be provided on each site. The first Clinical Transformation Board had been held earlier in the month with CCG colleagues to engage on the journey and to support the strategy across the North East Sector. Local Authority colleagues would be invited to future meetings. Mrs Dixon commended the approach being taken to build on the significant work carried out within the Trust during 2014/15 which along with new work would lead to a business case and investment plan to allow the Trust to deliver effective and sustainable services. Work had commenced on a review of corporate and back office functions between the Trust and Salford Royal FT. A series of discussions had been held with managers across the Trust to outline and engage on the work to date on site management arrangements and group structures. Interviews for Site Managing Directors and Site Medical Directors would be held during November. The Integrated Performance Report was noted.

119/16 Finance Report for the Period ending 3 September 2016 Mr Finn reported at month six the Trust was on target reporting an £8.2 million deficit against a planned deficit of £8.2 million. Since the Board papers had been prepared NHS Improvement had confirmed the Trust’s control total would be amended from a £12.1 million deficit to a £15.2 million deficit. Mr Finn said that risks remained in relation to delivery of this new control total. £10 million of STP funding had factored in to the financial position but £400,000 was at risk due to the urgent care target being missed. Each month this target was not achieved would cost the Trust £200,000. Pay costs were £2.3 million higher than expected with agency spend for the six months being £20 million against a target of £14 million. Agency spend was however reducing and, with recent successful recruitment of midwives and AHPs, further reductions were expected. Productivity remained a key issue for the Trust. Two years ago the Trust was seeing 10% more patients than in the current

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year. Recovering this position would generate an additional £20 million. Mr Finn said that at any one time over 100 patients who were fit for discharge were occupying beds. That equated to costs of £20 million in a year. Every month the Trust cancelled and rebooked 20,000 patients. This provided a very poor patient experience and needed to be addressed and it would also generate a financial return. In response to a request from Mrs Mayer it was agreed to provide a report on the Booking and Scheduling review to a future meeting of the Board. Further reducing sickness absence to the same level as Salford Royal FT would generate a £5 million saving. It was anticipated that a review of corporate services could generate savings of £4 million. Transferring significant volumes of trauma and orthopaedic surgery to day-case would significantly improve productivity, patient experience and reduce costs. Mr Willis asked that the next finance report include a projected best, worse and most likely projected out turn for the year end. Mr Willis asked whether achieving the year-end CIP target was realistic with 60% of the savings still to be achieved. Mr Finn said that the CIP target would be achieved on a non-recurring basis but issues remained on achieving this recurrently. Sir David said that Divisions were unable to describe how recurrent savings would be achieved. In response to a request by Mr Willis it was agreed to include cash projection into 2017/18 in the next finance report. While the Capital Plan was underspent at month 6 Mrs McCluskie was taking action to ensure that the capital expenditure targets would be achieved by the year end. In response to a question from Mr Willis, Mrs Adams confirmed that the improvements required in the Improvement Plan were linked into the Capital Plan. The report was noted.

JA DF DF

Dec-16 Nov-16 Nov-16

120/16 Agency Trajectory and Mitigations Mr Lenney spoke to his paper which set out the forecast out turn on agency expenditure and the further actions planned to improve this. The mitigated spend forecast for the year was £34 million. Recruitment to substantive posts was the biggest single factor that would further mitigate the trajectory. All Divisional Directors had been asked to submit plans on further improvements to reduce agency spend. Further control measures had been implemented by NHS Improvement. Mrs Brown acknowledged that while monthly expenditure was reducing, the pace was not quick enough and she was concerned that there would be further slippage. Mrs Ollerenshaw asked about controls on non-clinical agency staff and Mr Lenney said that these were largely in place. It was agreed that a regular report on agency expenditure should be submitted to the Trust Board. The report was noted.

JL

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121/16 Mortality Reviews Professor Makin spoke his paper which set out the most recent mortality data, work on independent mortality reviews, morbidity and mortality meetings and special mortality reviews. He also set out proposed actions in terms of mortality reviews, coding and documentation, monitoring of information and education and training. Prof. Makin said that sharing a mortality timeline and being able to describe whether changes in practice had impacted on mortality would be key methods of achieving change. By the end of November the case note review on accuracy of coding would be completed. A coding validity tool would then be implemented. With regard to the external review of mortality at Fairfield General Hospital a comparative review would be carried out of six months when mortality was not rising and six months when it was. Prof. Makin had met with Clinical Directors to describe how directorate level mortality reviews should be carried out. Mrs Mayer said that the Board had paid close attention to mortality over recent years and when attention had been focussed on The Royal Oldham Hospital mortality had reduced. When rising mortality had been identified at Fairfield General Hospital the Board had asked for a review but this had been approximately 10 months ago and the review now proposed may take a further six months. She asked whether there were still potentially avoidable deaths which may occur during this period and whether enough action was being taken quickly enough. Prof. Makin said that work did need to proceed more quickly and the targeted review of a small number of deaths at Fairfield General Hospital would be carried out in advance of the wider review. Sir David said that Prof. Makin’s paper described the work underway. CQC would review this but would also want to know how the Board had responded and how it was monitoring effectiveness. He asked Prof. Makin to develop a single driver diagram of all the actions that would have an impact on mortality and then to monitor progress through a dash board with SPC charts. This report should be submitted to the next meeting of the Board. The report was noted.

MM

Nov-16

122/16 Patient Experience Quarterly Report Mrs Inglesby-Burke asked the Board to note the report and that future reports would include data on the Friends and Family Test. The report was noted.

123/16 Learning from Experience Quarterly Report Mrs Inglesby-Burke spoke to her report which provided a collective overview of the patient responsiveness, patient experience and adverse events and risk management reports. The full report had been considered by the Executive Quality and Patient Experience Governance Committee and Mrs Inglesby-Burke said that copies would be provided for Non-

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Executive Directors. Mrs Inglesby-Burke said that the level of harm described in the paper could be directly related to the paper on mortality. She commented on the level of harm recorded from patient falls. Two falls specialists were now in post and would have an impact in this area. Mrs Inglesby Burke also commented on the high number of patient absconds. The number of transfers from Neonatal Units was high but an external review had confirmed that the transfers were appropriate. A detailed review into blood transfusions was underway. There had been six surgical never events reported in the year against a zero tolerance. There were clinical, coding and financial risks related to the Evolve System. The IM&T department were currently identifying whether additional modules could address these issues. There had been 69 incidents categorised as death or severe harm associated with hospital acquired VTE. These incidents were under review to assess whether the patients had received appropriate prophylaxis. Further work was required on the duty of candour to ensure that each incident had a Family Liaison Officer and separately consideration was being given to whether the Family Liaison Officers were of sufficient seniority. There had been four prevention of future death reports issued by Coroners in the last six months. Mrs Brown said that it appeared that many of the issues raised by Mrs Inglesby-Burke had not been included in the Pennine Improvement Plan. Mrs Inglesby-Burke said that these were covered in the “review of governance and risk” and now that had been carried out specific actions would be included. Mrs Mayer said that staff were being asked to deliver on a significant number of priorities and she asked how these would be translated so that staff were clear what action need to be taken. Mrs Inglesby-Burke said that the Quality Improvement Strategy was being developed with staff and they would build up and implement their own plans. Mrs Inglesby-Burke said that there remained a significant back log of complaints and the focus was on reducing these. As soon as the backlog had been cleared the focus could switch to improving learning. The report was noted.

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124/16 Pennine Improvement Plan Mrs Adams spoke to her paper and said that the improvement plan had been signed off by CQC on 17 October 2016 and had also been endorsed by the Greater Manchester Pennine Improvement Board. Mrs Adams highlighted a number of key points:

15 additional consultant PAs would be implemented in North Manchester General Hospital A&E until the end of March 2017. The Trust would need to recruit substantive consultants to take over that work by that time or else request additional support.

Paediatric bed capacity had now been re-opened and the CQC and Greater Manchester were content for the Trust to use professional judgement and to operate on a 1:5 ratio rather a 1:4 ratio.

Progress against the improvement plan was monitored at a weekly meeting

A more detailed review of the dashboards and the impact of actions would be undertaken at the next meeting of the Board.

The report was noted.

JA

Nov-16

125/16 Corporate Risk Register and Board Assurance Framework Mr Barclay spoke to the Board Assurance Framework and said that since the previous Board meeting the Executive Assurance and Risk Committee had reviewed the BAF, all Executive Directors had reviewed and updated the risk scores and a number of changes had been made, and all controls, assurances and actions had been reviewed with some changes made. Two risks relating to data quality had been merged and the BAF and the Integrated Performance Report had been fully aligned. The next steps would include further work to review action plans and timescale, consideration of a separate risk on cleaning, addition of a risk related to Evolve and further work to ensure the full alignment of Risk Registers from Divisions which was being led by the Director of Governance. The report was noted.

126/16 Board Action Checklist Noted

127/16 a) b)

Annual Reports 2015/16 Cancer Services The Cancer Services Annual Report was noted. Mrs Mayer said that it would be helpful to include qualitative measures. The cancer strategy would be submitted to the Board in January 2017 and would include qualitative measures. Research and Development The Research and Development Annual Report 2015/16 was submitted and noted.

MM

Jan-17

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c)

Charitable Funds The Charitable Funds Annual Report and Accounts for 2015/16 was submitted and noted. Mr Finn said that the Dunwoody Foundation would be making a £250K donation to the charity to support a clinical education facility within the Trust. Mr Finn said that the Trust would provide matching exchequer funding.

128/16 Date and Time of Next Meeting It was agreed that the next meeting of the Board be held on Thursday 24 November 2016 in the Board Room, Fairfield House, Fairfield General Hospital at 10.30am.

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are

su

mm

ari

sed

ag

ain

st

eac

h o

f th

e f

ive

pri

ori

ty a

rea

s (

see

Se

cti

on

3 f

or

furt

her

deta

ils):

-

Ris

ks

of

12 a

nd

ab

ove

Pri

ori

ty

An

nu

al

Pla

n O

bje

cti

ve

P

rin

cip

le R

isks

Sc

ore

1. P

urs

ue

Qualit

y

impro

vem

ent to

assure

safe

, re

liable

and

com

passio

nate

care

Sa

ve L

ives, assure

HS

MR

w

ith

in t

he t

op 1

0%

of

acute

Tru

sts

natio

na

lly

IF e

ffective m

ort

alit

y r

evie

w p

rocesses a

re n

ot in

pla

ce T

HE

N the T

rust w

ill b

e u

na

ble

to ide

ntify

death

s

attri

buta

ble

to c

are

and

take f

orw

ard

lessons learn

t 12

IF p

rocesses a

re n

ot in

pla

ce a

nd /

or

follo

we

d w

hen

caring f

or

patie

nts

with S

ep

sis

or

Recog

nis

ing a

dete

riora

ting p

atie

nt T

HE

N p

atient care

ma

y b

e c

om

pro

mis

ed

12

IF e

ffective, sup

port

ive

, cha

lleng

ing c

linic

al le

ad

ers

hip

is n

ot in

pla

ce a

cro

ss the T

rust T

HE

N C

linic

al vari

ation

will

contin

ue u

nchecked thu

s p

ote

ntia

lly lea

din

g t

o p

atient h

arm

12

Meet

CQ

C r

eq

uirem

ents

-

deliv

er

impro

vem

ents

w

ith

in t

imescale

s

If the T

rust fa

ils to e

nsure

Work

forc

e c

apacity, re

sili

en

ce a

nd f

un

din

g to

de

liver

the im

pro

vem

ent pla

n w

hils

t ensurin

g th

e o

ther

ke

y p

riori

ties o

f m

ain

tain

ing b

usin

ess a

s u

sual, d

eve

lop

ing a

nd d

eliv

erin

g o

n th

e c

linic

al

serv

ice s

trate

gy a

nd s

ignific

ant org

anis

atio

na

l re

-str

uctu

re a

re t

aken f

orw

ard

the

n the p

lan m

ay n

ot

be f

ully

and a

ppro

priate

ly im

ple

mente

d

12

IF the T

rust fa

ils to p

rovid

e s

afe

sta

ffin

g le

ve

ls in a

ll clin

ical are

as 2

4/7

TH

EN

th

is c

ould

le

ad t

o r

ed

uctio

n in

patient safe

ty a

nd q

ua

lity o

f care

alo

ng w

ith p

oor

sta

ff a

nd p

atient

experi

ence.

Sp

ecific

focus to b

e m

ade to

the f

ragile

serv

ices:

1. F

ragile

Serv

ices 2

. H

ard

to r

ecru

it a

reas 3

Clin

ica

l are

as w

ith s

ign

ific

ant sta

ff

short

ages

12

Impro

ve P

atie

nt

Experi

ence

IF

the tru

st fa

ils to m

easure

the Q

ualit

y s

tan

dard

s w

ith

in C

linic

al are

as T

HE

N it m

ay f

ail

to im

pro

ve t

he Q

ualit

y

and S

afe

ty o

f patien

t C

are

12

Item

6

of 134

4

Ris

ks

of

12 a

nd

ab

ove

Pri

ori

ty

An

nu

al

Pla

n O

bje

cti

ve

P

rin

cip

le R

isks

Sc

ore

2. D

eliv

er

financia

l p

lans

to a

ssure

susta

ina

bili

ty

Drive

eff

icie

ncy a

nd

pro

ductivity to d

eliv

er

financia

l contr

ol of

£39.7

m

deficit (

revis

ed t

o £

12.1

m

If the T

rust fa

ils to m

eet its f

inancia

l d

uties in 2

016/1

7 d

ue t

o incom

e a

nd e

xp

end

iture

issues a

nd f

ailu

re t

o

imple

ment C

IP p

lans t

hen t

he T

rust w

ill f

ail

its f

ina

ncia

l duties r

esultin

g in r

eg

ula

tory

action. (t

his

rela

tes t

o

Ris

k 6

. S

RR

)

12

Reduce V

aca

ncy G

ap to

6%

If

sta

ff v

acancie

s d

o n

ot re

duce in

lin

e w

ith p

lan

the

n th

e q

ualit

y o

f care

will

not

impro

ve

an

d f

ina

ncia

l susta

ina

bili

ty w

ill n

ot

be d

eliv

ere

d.

12

If r

ecru

itm

ent does n

ot re

ach s

taff

ing e

sta

blis

hm

ent le

vels

th

en t

he q

ua

lity o

f care

will

be c

om

pro

mis

ed a

nd

mora

le / s

ickness issues w

ill c

ontinue

12

3: S

upp

ort

Hig

h

Perf

orm

ance

and

Impro

vem

ent

Impro

ve S

taff

Contr

ibution

to G

oa

ls a

nd V

alu

es

IF s

taff

do n

ot part

icip

ate

in

a g

ood q

ua

lity P

DR

the s

taff

rete

ntio

n m

ay r

educe

an

d the w

ork

forc

e c

apabilitie

s

of

Tru

st to

de

liver

hig

h p

erf

orm

ance a

nd im

pro

vem

ent m

ay b

e c

om

pro

mis

ed.

12

4:

Impro

ve C

are

and S

erv

ices

thro

ug

h

Inte

gra

tio

n a

nd

Colla

bora

tion

Pro

gre

ss S

ing

le H

osp

ita

l S

erv

ice in M

anch

este

r If

lack if

investm

ent in

NM

GH

esta

te c

ontinu

es d

ue

to n

atio

na

l short

age o

f public

div

iden

d c

ap

ita

l or

busin

ess

case n

ot

appro

ve

d a

t G

reate

r M

anch

este

r or

tre

asury

leve

ls T

HE

N tem

pora

ry w

ork

to a

llow

patie

nt care

in

curr

ent fa

cili

ties w

ill n

eed

to

continue

12

Impro

ve the U

rgent

Care

serv

ice in lin

e w

ith Q

1

aim

s a

nd d

eliv

era

ble

s

IF the T

rust is

un

able

to

sta

bili

se a

nd s

usta

in t

he m

edic

al w

ork

forc

e to s

upport

ED

and

AM

U T

HE

N th

ere

is a

risk that th

e T

rust on th

e N

MG

H s

ite c

ould

not pro

vid

e 2

4/7

em

erg

ency c

are

12

If the T

rust is u

nab

le t

o im

pro

ve

patie

nt

flo

w a

nd

redu

ce U

C d

em

and t

hro

ug

h a

ll sites w

ith e

merg

ency

depart

ments

the

n th

e n

atio

nal sta

nd

ard

s f

or

access w

ill n

ot

be m

et and p

atien

t ca

re w

ill b

e c

om

pro

mis

ed

13

5:

Dem

onstr

ate

C

om

plia

nce

with M

an

dato

ry

Sta

ndard

s

Achie

ve

the

follo

win

g k

ey

Access targ

ets

: A

&E

targ

et

Open R

TT

path

wa

y targ

et

Cancer

62 d

ay t

arg

et

D

iag

nostic t

arg

et

If e

ffective d

ata

qua

lity p

rocess a

re n

ot

in p

lace th

en d

ata

subm

issio

ns, d

ata

used

for

assura

nce a

nd

govern

ance p

rocesses a

nd

data

used t

o p

rogre

ss p

atient tr

eatm

ent m

ay b

e c

om

pro

mis

ed

13

If C

apacity a

nd D

em

and is n

ot m

atc

hed f

or

challe

nged

specia

litie

s th

en p

atien

ts m

ay n

ot

be t

reate

d w

ith

in

require

d t

imescale

s r

esultin

g in

pote

ntia

l harm

to p

atie

nts

, po

or

experi

ence a

nd

failu

re o

f nation

al dia

gn

ostic

sta

ndard

, R

TT

sta

ndard

an

d s

tand

ard

s f

or

pla

nne

d p

atients

12

Infe

ctions:

C

,Diff

MR

SA

IF the T

rust

fails

to m

eet m

anda

tory

sta

nd

ard

s f

or

infe

ction c

ontr

ol T

HE

N th

is c

ou

ld lea

d to p

atien

t harm

and /

or

the q

ua

lity o

f patient care

could

be a

ffecte

d w

hic

h c

ould

lead t

o r

egula

tory

involv

em

ent and

repu

tation

al

dam

age

13

Th

ere

are

23 i

nd

ivid

ua

l m

ea

su

res a

lig

ne

d t

o t

he f

ive

are

as w

hic

h a

re b

ein

g t

rac

ked

an

d r

ep

ort

ed

in

th

e I

nte

gra

ted

Sc

ore

ca

rd (

Se

cti

on

2).

T

heir

su

cce

ss

ful

deli

ve

ry w

ill

en

ab

le t

he T

rus

t to

ass

es

s a

nd

de

mo

nstr

ate

th

e e

xte

nt

to w

hic

h i

t is

me

eti

ng

its

key o

rga

nis

ati

on

al o

bje

cti

ve

s

an

d a

lso

pro

vid

e a

n o

pp

ort

un

ity t

o c

ros

s-r

efe

ren

ce a

gain

st

the r

isks

id

en

tifi

ed

in

th

e B

AF

. T

he p

erf

orm

an

ce e

xce

pti

on

s f

or

eac

h p

rio

rity

a

rea

an

d h

igh

lig

hts

of

oth

er

sig

nif

ican

t e

xc

ep

tio

ns a

re d

eta

ile

d o

ve

rle

af:

-

of 134

5 1.

Pu

rsu

e q

uality

im

pro

ve

me

nt

to a

ss

ure

safe

, re

lia

ble

an

d c

om

pa

ssio

na

te c

are

Th

e h

igh

ligh

ted m

etr

ics a

ga

inst th

e c

orp

ora

te o

bje

ctive

s a

re a

s f

ollo

ws:-

o

For

HS

MR

, ag

ain

st

an o

ve

rall

targ

et to

be w

ith

in t

he t

op

10%

perf

orm

ing

tru

sts

(8

7 o

r b

elo

w)

na

tion

ally

, th

e T

rust is

re

po

rtin

g a

sco

re o

f 1

02

.7

(Ju

l-1

5 t

o J

ul-

16).

Work

to

re

vie

w a

nd

im

pro

ve

mo

rta

lity w

ill b

e r

epo

rte

d b

ack t

o t

he

Tru

st B

oard

thro

ug

h g

ove

rna

nce s

tru

ctu

res.

o

F

or

the F

rie

nd

s a

nd

Fam

ily T

est

(FF

T) – th

e r

esp

on

se f

rom

pati

en

ts tre

ate

d a

t o

ur

Tru

st

- th

e T

rust h

as s

et itse

lf a

ta

rget to

ach

ieve

a s

co

re f

or

rec

om

me

nd

ati

on

as a

pla

ce

fo

r tr

eatm

en

t th

at is

, at

or

bett

er

than

th

e n

ati

on

al a

ve

rag

e. T

he T

rus

t is

belo

w a

ve

rag

e fo

r: (

1)

A&

E, (2

) M

ate

rnity b

irth

; (3

) M

ate

rnity p

ostn

ata

l w

ard

, a

nd

in

th

e l

ow

er

qu

inti

le (

20%

) fo

r (4

) in

pa

tien

t ca

re, (5

) O

utp

atie

nt care

, (6

) M

ate

rnity p

ostn

ata

l co

mm

unity. T

he T

rus

t is

bett

er

than

ave

rag

e fo

r (7

) C

om

mu

nity c

are

and (

8)

Ma

tern

ity a

nte

nata

l.

Oth

er

exce

ptio

ns h

igh

lighte

d fo

r su

pp

ort

ing

me

tric

s a

re a

s f

ollo

ws:-

o

F

or

the S

um

mary

Ho

spita

l-le

ve

l M

ort

alit

y I

ndic

ato

r (S

HM

I), w

hic

h inclu

de

s p

atie

nts

th

at

die

with

in 3

0 d

ays o

f d

isch

arg

e fro

m h

osp

ita

l, t

he T

rus

t is

re

po

rtin

g a

n i

ncre

as

ed

to

1.1

2 (

Ap

r-1

5 t

o M

ar-

16

), p

lacin

g it

in th

e h

igh

er

than

exp

ec

ted

ban

din

g f

or

the f

irst tim

e.

o

F

or

neve

r e

ve

nts

th

e T

rust

has a

ze

ro t

ole

ran

ce.

For

the y

ear

to d

ate

th

e T

rus

t h

as

re

po

rte

d 6

ne

ve

r e

ve

nts

. E

ve

ry n

eve

r e

ve

nt

und

erg

oes a

ro

ot ca

use

ana

lysis

(R

CA

), w

ith

th

e o

utc

om

e r

epo

rte

d t

o T

rust

Bo

ard

th

rou

gh g

ove

rna

nce s

tru

ctu

res. T

hre

e o

f th

e n

eve

r e

ve

nts

occu

rre

d a

t R

OH

(a

ll Ju

ly),

tw

o o

ccu

rre

d a

t N

MG

H (

Ap

ril a

nd

Ju

ne),

and

on

e o

ccurr

ed a

t F

GH

(M

ay).

Th

e W

HO

Ch

ecklis

t is

bein

g r

evie

we

d a

cro

ss a

ll sp

ecia

ltie

s.

o

For

the F

rie

nd

s a

nd

Fam

ily T

est

(FF

T) – th

e r

esp

on

se fro

m o

ur

ow

n s

taff

- th

e T

rust

has s

et

itse

lf a

targ

et to

achie

ve

a s

co

re f

or

rec

om

me

nd

ati

on

as a

pla

ce

fo

r c

are

th

at is

, a

t o

r b

ett

er

than

th

e n

ati

on

al

ave

rag

e. T

he F

FT

sco

re f

or

the la

test p

eriod

(Q

uart

er

2 2

01

6-1

7)

is

belo

w t

arg

et

bein

g in

the

lo

we

r q

uin

tile

(lo

we

st

20%

). A

puls

e c

heck m

on

ito

ring

syste

m is b

ein

g im

ple

me

nte

d w

hic

h a

llow

s a

mo

re d

eta

iled

ana

lysis

. o

F

or

sin

gle

sex

ac

co

mm

od

ati

on

bre

ac

he

s th

e T

rust h

as a

ze

ro t

ole

ran

ce

. F

or

the y

ear

to d

ate

83 p

ati

en

ts h

ave

ex

peri

en

ce

d b

reac

he

s o

f th

is s

tand

ard

, w

ith

19 p

ati

en

ts r

ep

ort

ed

in

Octo

ber

(all

at

NM

GH

). T

he y

ear

to d

ate

bre

ach

es o

ccu

rre

d a

t N

MG

H (

70),

FG

H (

10),

and R

OH

(3).

Y

ear

to d

ate

mo

st of th

e b

rea

ch

es h

ave

be

en d

ela

ys in

tra

nsfe

r fr

om

hig

he

r d

ep

en

de

ncy u

nits t

o a

cu

te w

ard

s fo

llow

ing

ste

p d

ow

n.

o

For

pre

ss

ure

ulc

ers

of

gra

de

3 o

r a

bo

ve

, th

e T

rust re

port

ed 2

in

Octo

be

r w

ith

6 y

ear

to d

ate

thro

ug

h incid

en

t re

port

ing

syste

ms. A

t site le

ve

l ye

ar

to d

ate

th

ere

have

be

en

2 incid

en

ts in

Com

mu

nity s

ett

ing

s, 3 a

t N

MG

H,

and 1

at

FG

H.

o

For

Wa

rd S

afe

Sta

ffin

g le

ve

ls, th

e T

rust is

me

etin

g t

he in

tern

al sta

nd

ard

fo

r 9

0%

or

mo

re o

f p

lan

ned

ward

nu

rsin

g a

nd

mid

wif

e h

ou

rs t

o b

e

fill

ed

, w

ith

an

ag

gre

ga

te O

cto

ber

fill r

ate

of

98.0

% a

nd

a y

ear

to d

ate

rate

of

97.2

%. T

he w

ard

sta

ffin

g le

ve

l fill

rate

s v

ary

by s

hift

and s

taff

g

roup

. T

he a

ve

rag

e fill

rate

an

d a

ction b

ein

g t

aken

is d

eta

iled b

y w

ard

with

in s

ite

in

th

e W

ard

Leve

l S

co

reca

rd s

ectio

n (

pag

e 1

6).

Item

6

of 134

6 2.

De

live

r fi

nan

cia

l p

lan

to

as

su

re s

usta

inab

ilit

y

T

he h

igh

ligh

ted m

etr

ics a

ga

inst th

e c

orp

ora

te o

bje

ctive

s a

re a

s f

ollo

ws:-

o

A r

evis

ed

fin

an

cia

l p

lan

for

the T

rust to

sp

en

d w

ith

in a

deficit c

on

tro

l to

tal fo

r th

e y

ear

of

£15.2

m w

as s

ub

mitte

d to

NH

SI in

Octo

be

r 2

01

6 in

lin

e w

ith

th

e T

rusts

exp

ecte

d d

eficit p

ositio

n f

or

the

ye

ar.

Th

e r

evis

ed p

lan a

ssum

es a

ccess t

o £

20.5

m o

f s

usta

ina

bilit

y a

nd

tra

nsfo

rma

tio

n

fun

din

g,

wh

ich

is c

on

ting

ent

on d

eliv

ery

of

the fin

an

cia

l p

lan a

nd

als

o d

eliv

ery

of

ag

ree

d a

ccess targ

et tr

aje

cto

ries a

long

sid

e a

dd

itio

na

l su

pp

ort

fr

om

com

mis

sio

ne

rs.

At

mo

nth

7 th

e T

rust is

wit

hin

th

e f

inan

cia

l c

on

tro

l to

tal

of

a £

11

.0m

defi

cit

, th

oug

h e

xp

erie

ncin

g p

ressure

on d

eliv

ery

of

its a

ctivity a

nd

inco

me

pla

n,

and a

sh

ort

fall

ag

ain

st

its C

IP t

arg

et.

o

F

or

Ag

en

cy t

he T

rust

has s

et a

ta

rget to

sp

en

d n

o m

ore

th

an

£29

.9m

fo

r th

e y

ear,

and

a lim

it t

o m

on

th 7

of

£17.3

m. T

he y

ear

to d

ate

sp

en

d

is £

23.1

m w

hic

h is £

5.8

m h

igh

er

than t

he p

lann

ed

sp

en

d. T

o m

eet th

is c

orp

ora

te o

bje

ctive

th

e T

rust

will

nee

d t

o s

pe

nd n

o m

ore

th

an

£6.8

m fo

r th

e r

em

ain

de

r of th

e y

ear.

Sig

nific

ant

am

oun

t of w

ork

co

ntin

ue

s to

co

ntr

ol a

nd

re

du

ce th

e r

elia

nce

on a

ge

ncy s

pen

d, w

ith

ad

ditio

na

l m

easu

res

bein

g a

gre

ed

an

d b

ein

g p

ut

in p

lace t

o e

limin

ate

, o

r re

du

ce to

a m

inim

um

, th

e n

on

-clin

ica

l (a

nd

inclu

din

g s

upp

ort

wo

rker)

ag

en

cy s

pen

d.

3.

Su

pp

ort

ou

r sta

ff t

o d

elive

r h

igh

perf

orm

an

ce a

nd

im

pro

ve

me

nt

T

he h

igh

ligh

ted m

etr

ics a

ga

inst th

e c

orp

ora

te o

bje

ctive

s a

re a

s f

ollo

ws:-

o

For

PD

Rs th

e T

rust h

as s

et

itse

lf a

n im

pro

ve

me

nt tr

aje

cto

ry to

re

ac

h 9

0%

by M

arc

h. T

he T

rust is

be

low

its

ye

ar

to d

ate

tra

jecto

ry o

f 8

4%

with

re

po

rte

d p

erf

orm

an

ce

of

65%

. D

ire

cto

r fo

r W

ork

forc

e a

nd O

rga

nis

ation

al D

eve

lopm

ent

is le

ad

ing w

ork

to

im

pro

ve

th

e q

ualit

y o

f a

ppra

isa

ls, a

s

we

ll a

s e

nsu

ring

th

at th

e c

om

ple

tion

incre

ases th

roug

h t

he d

eve

lopm

ent

an

d im

ple

me

nta

tion

of d

eta

iled D

ivis

iona

l le

ve

l p

lan

s.

An a

ssura

nce

re

vie

w o

f th

e P

DR

info

rma

tion

ha

s a

lso b

ee

n c

om

mis

sio

ne

d,

wh

ich

will

be s

ubm

itte

d to

th

e E

xe

cutive

Work

forc

e a

nd

OD

Go

ve

rna

nce C

om

mitte

e.

o

F

or

the s

taff

Fri

en

ds a

nd

Fa

mil

y T

est

(FF

T),

th

e T

rust

has s

et

itse

lf a

targ

et to

ach

ieve

a s

co

re f

or

rec

om

me

nd

ati

on

as a

pla

ce t

o w

ork

th

at is

, a

t o

r b

ett

er

than

th

e n

ati

on

al

ave

rag

e. T

he F

FT

sco

re fo

r th

e la

test p

erio

d (

Qu

art

er

2 2

01

6/1

7)

is b

elo

w t

arg

et

bein

g in th

e l

ow

er

qu

inti

le

(lo

we

st

20%

). T

he D

ire

cto

r fo

r W

ork

forc

e a

nd O

rga

nis

ation D

eve

lopm

ent is

le

ad

ing

th

e im

ple

me

nta

tion

of

the H

ealth

y H

app

y H

ere

Pla

n t

o

imp

rove

wo

rkfo

rce s

atisfa

ction

an

d h

as c

om

mis

sio

ne

d a

sta

ff p

uls

e c

heck r

epo

rtin

g s

yste

m t

o tra

ck p

rog

ress a

t d

ivis

iona

l a

nd

site

leve

l.

4.

Imp

rove

ca

re a

nd

serv

ice t

hro

ug

h i

nte

gra

tio

n a

nd

co

lla

bo

rati

on

T

he h

igh

ligh

ted m

etr

ics a

ga

inst th

e c

orp

ora

te o

bje

ctive

s a

re a

s f

ollo

ws:-

NM

GH

perf

orm

ed

wo

rse

th

an

th

e 9

0.3

7%

in

tern

al (2

01

6-1

7 p

rio

rity

) tr

aje

cto

ry f

or

Oc

tob

er.

As id

en

tifie

d in

th

e B

AF

me

dic

al sta

ffin

g

pre

ssu

res a

t N

MG

H a

re a

pa

rtic

ula

r d

ifficu

lty a

nd

are

bein

g c

losely

ma

nag

ed

. W

ork

is a

lso

und

erw

ay o

n U

rge

nt C

are

pa

thw

ay f

low

im

pro

ve

me

nt

that is

focu

sed

on th

e p

rim

ary

drive

rs a

nd is s

uppo

rte

d b

y t

he P

MO

, N

HS

I a

nd

CC

Gs.

of 134

7 5

. D

em

on

str

ate

co

mp

lia

nc

e w

ith

ma

nd

ato

ry s

tan

da

rds

Th

e h

igh

ligh

ted m

etr

ics a

ga

inst th

e c

orp

ora

te o

bje

ctive

s a

re a

s f

ollo

ws:-

o

For

infe

cti

on

pre

ve

nti

on

an

d c

on

tro

l, th

e T

rust

has

a lim

it f

or

the y

ear

of

no

mo

re t

han

55 C

-dif

fcile

ca

ses,

and y

ear

to d

ate

a lim

it o

f 33

cases

, th

e T

rust h

as r

ep

ort

ed

35 c

ases y

ear

to d

ate

,. A

t site le

ve

l ye

ar

to d

ate

12 c

ases o

ccurr

ed a

t F

GH

, 1

0 a

t N

MG

H,

13 a

t R

OH

and z

ero

at

RI.

FG

H h

as th

e h

igh

est ra

te o

f C

-Difficile

ca

ses p

er

bed d

ay.

Pro

active

man

ag

em

ent of

cle

an

ing is b

ein

g u

nd

ert

ake

n a

nd a

dd

itio

na

l a

ction

s h

ave

b

ee

n a

gre

ed f

ollo

win

g r

ece

ipt

of

an in

tern

al a

ud

it r

epo

rt o

n c

lean

ing.

o

For

MR

SA

, th

e T

rust h

as h

ad

on

e c

as

e y

ear

to d

ate

(fo

llow

ing

a p

erio

d o

f 7

mo

nth

s w

ith

ou

t a c

ase).

Th

e c

ase o

ccurr

ed a

t N

MG

H a

nd

is b

ein

g

revie

we

d b

y t

he n

urs

ing

te

am

.

o

For

the 6

we

ek d

iag

no

sti

c s

tan

da

rd,

the t

raje

cto

ry i

s t

o a

ch

ieve

th

e n

ati

on

al

sta

nd

ard

of n

o m

ore

th

an

1%

of

patie

nts

wa

itin

g m

ore

th

an 6

w

eeks f

or

their te

sts

by t

he e

nd

of

Oc

tob

er.

Th

e T

rust a

ch

ieve

d t

he t

raje

cto

ry w

ith

a r

ep

ort

ed

pe

rfo

rma

nce

of

0.8

%.

Add

itio

na

l e

nd

osco

py

ca

pa

city h

as b

ee

n p

rocure

d to

me

et th

e tra

jecto

ry.

o

F

or

A&

E,

the tra

jecto

ry is f

or

95%

to

be a

ch

ieve

d a

cro

ss a

ll s

ite

s b

y y

ea

r e

nd

. T

he e

xte

rnall

y a

gre

ed

tra

jecto

ry o

f 89.3

% w

as m

isse

d f

or

Oc

tob

er

with r

ep

ort

ed

pe

rfo

rma

nce

of

81.6

%. T

he

Tru

st

als

o p

erf

orm

ed w

ors

e t

han

th

e 9

2.3

% in

tern

al (2

01

6-1

7 p

rio

rity

) s

tre

tch

tra

jecto

ry

for

Octo

be

r. A

t a

site

leve

l a

ll 4

sit

es p

erf

orm

ed

wo

rse

th

an

th

eir

in

tern

al

str

etc

h t

raje

cto

rie

s a

nd

th

eir

exte

rnal tr

aje

cto

rie

s f

or

the m

on

th.

o

For

the C

an

cer

62 d

ay p

erf

orm

ance s

tand

ard

– tim

e fro

m r

efe

rra

l to

tre

atm

ent

- th

e t

arg

et is

fo

r 85

% o

f p

ati

en

ts t

o b

e t

rea

ted

wit

hin

th

e 6

2

da

ys

, w

ith

th

e la

test

repo

rte

d (

Au

gu

st)

perio

d b

ein

g r

epo

rte

d a

s b

elo

w t

he

re

qu

ire

d G

M s

tan

dard

at

83.6

%. R

epo

rte

d p

erf

orm

ance a

ga

inst th

e

nati

on

al

sh

are

d a

cc

ou

nta

bilit

y s

tan

da

rd w

as a

lso

narr

ow

ly b

elo

w t

he

re

qu

ire

d s

tan

dard

of

85%

fo

r Q

uart

er

2 b

ein

g a

t 8

4.9

2%

. O

ther

hig

hlig

hts

fo

r su

ppo

rtin

g m

etr

ics a

re a

s fo

llow

s:-

o

For

12 h

ou

r tr

oll

ey w

ait

bre

ac

he

s th

e T

rust

has a

ze

ro t

ole

ran

ce.

For

the

ye

ar

to d

ate

(A

pri

l to

Se

pte

mb

er)

th

e T

rus

t h

as r

ep

ort

ed

176

bre

ac

he

s,

with

36 r

eport

ed in

Se

pte

mb

er.

For

the y

ear

to d

ate

th

e b

reach

es h

ave

occu

rre

d a

t N

MG

H (

126

), F

GH

(3

2),

and R

OH

(1

8).

o

For

the 2

we

ek b

reast

sym

pto

ma

tic

sta

nd

ard

– t

ime fro

m u

rge

nt re

ferr

al to

bein

g s

een in

ou

tpatie

nts

– t

he t

arg

et

is f

or

93

% o

f p

atie

nts

to b

e

se

en

with

in 2

we

eks, w

ith

th

e l

ate

st

peri

od

(S

ep

tem

ber)

bein

g r

eport

ed a

s b

elo

w t

he r

eq

uire

d s

tand

ard

at

92.9

%.

Me

dic

al sta

ffin

g is b

ein

g

incre

ase

d to

ad

dre

ss a

sh

ort

fall

in c

ore

ca

pa

city.

o

For

the C

an

cer

62 d

ay S

cre

en

ing p

erf

orm

ance s

tand

ard

– tim

e fro

m s

cre

en

ing

serv

ice

refe

rra

l to

tre

atm

ent

- th

e t

arg

et is

fo

r 9

0%

of

pati

en

ts t

o

be t

reate

d w

ith

in t

he 6

2 d

ays

, w

ith

th

e la

test

(Sep

tem

be

r) p

erio

d b

ein

g r

epo

rte

d a

s b

elo

w t

he r

eq

uire

d s

tand

ard

at

23.1

%. T

he T

rust

has fa

iled

this

targ

et fo

r six

co

nse

cu

tive

mo

nth

s.

o

For

the C

an

cer

31 d

ay s

ubse

qu

ent

su

rge

ry s

tanda

rd –

tim

e fro

m d

ecis

ion to

tre

at to

tre

atm

ent

- th

e t

arg

et is

fo

r 9

4%

of

pati

en

ts t

o b

e t

reate

d

wit

hin

th

e 3

1 d

ays

, w

ith

th

e la

test

(Se

pte

mb

er)

perio

d b

ein

g r

eport

ed a

s b

elo

w t

he r

eq

uire

d s

tanda

rd a

t 8

0.0

%.

Th

e T

rust h

as f

aile

d th

is ta

rget

for

two

co

nse

cutive

mon

ths.

Item

6

of 134

8

Cu

rre

nt

Le

ve

lK

ey

Pe

rfo

rman

ce

In

dic

ato

rL

ead

15-1

616-1

7 T

arg

et

Targ

et

Typ

eC

urr

en

tP

eri

od

16-1

7

YT

D

RA

G T

ren

d

2014-1

5

RA

G T

ren

d

2015-1

6

RA

G T

ren

d

2016-1

72 Y

ear

Tre

nd

HS

MR

vers

us D

r F

oste

r bandin

g (

rolli

ng y

ear

- T

he

56 d

iagnostic

gro

ups)

MM

101.1

4LC

L <

=100

R102.7

3Ju

l-16

0H

SM

R -

Ranke

d in

lop 1

0%

of non-s

pecia

list tr

usts

(Rolli

ng y

ear

- T

he 5

6 d

iagnostic

gro

ups)

MM

101.1

4<

=87

I102.7

3Ju

l-16

SH

MI v

ers

us n

atio

nal H

SC

IC b

andin

g (

rolli

ng y

ear)

MM

1.1

2>

1.1

08

R1.1

2M

ar-

16

Cu

rre

nt

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ve

lK

ey

Pe

rfo

rman

ce

In

dic

ato

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ead

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616-1

7 T

arg

et

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et

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urr

en

tP

eri

od

16-1

7

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D

RA

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2014-1

5

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ren

d

2015-1

6

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ren

d

2016-1

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ear

Tre

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FT

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edback

recom

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ets

met

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68

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Sin

gle

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n b

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EI-B

58

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19

Oct-

16

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FT

Recom

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ep

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Cu

rre

nt

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ey

Pe

rfo

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In

dic

ato

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15-1

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arg

et

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et

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vents

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munic

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n (

IP <

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%

Hand o

ver

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munic

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n (

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ays

)JA

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Pre

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2. In

tegr

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Sco

reca

rd1. Pursue quality improvement to assure safe, reliable & compassionate care

RA

G T

ren

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et m

isse

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et

pas

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igh

t o

fR

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tre

nd

ind

icat

es

dir

ect

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of

pas

s

Cari

ng

15-1

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ll ye

ar

per

form

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R

AG

rat

ed

agai

nst

th

e

15-1

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rget

s

Targ

et

Typ

e

R -

Re

gula

tory

I -

Inte

rnal

C -

Con

trac

tual

Tru

st

Pri

ori

ty

Eff

ec

tiv

e

Safe

Cu

rre

nt

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l me

asu

res

pe

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rman

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he

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st P

rio

riti

es

Ab

ove

Tar

get

On

Tar

get

Bel

ow

tar

get

***

den

ote

s a

ta

rget

th

at

sho

ws

a

traj

ecto

ry w

hic

h

is p

has

ed a

cro

ss

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of 134

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5

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=55 b

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<=

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7O

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16

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iff m

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YT

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RA

G T

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2014-1

5

RA

G T

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d

2015-1

6

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G T

ren

d

2016-1

72 Y

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Tre

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6 W

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Dia

gnostic

wait

vs n

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arg

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Dia

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vs tra

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ve

12 H

our

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0R

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Sep-1

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04 h

our

urg

ent care

sta

ndard

vs n

atio

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arg

et

JA85.3

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16

84.6

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RT

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pen P

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=92%

R92.7

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62 d

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GP

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62 d

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JA85.3

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62 d

ay

Upgra

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31 d

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=96%

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ubsequent

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Bre

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arg

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Inte

grat

ed S

core

card

5. Demonstrate compliance with mandatory standards

1

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fe

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sp

on

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e

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of 134

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spend o

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2014-1

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d

2016-1

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FT

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ple

tion (

90%

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>=

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Oct-

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ess &

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% b

y M

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ry T

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>=

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16

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Rate

(6%

by

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2016-1

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ear

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Contr

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pro

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are

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t T

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tra

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84.5

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pro

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are

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t N

MG

H v

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1Im

pro

ve U

rgent C

are

serv

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t F

GH

vs tra

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New

>=

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16

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pro

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are

serv

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t R

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vs tra

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1Im

pro

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are

serv

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t R

I vs tra

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I97.0

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16

97.2

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2. Deliver financial plan to assure

sustainability

Inte

grat

ed S

core

card

3. Support our staff to

deliver high performance &

improvement

4. Improve care & services

through integration &

collaboration

Well

Led

Fin

an

ce

of 134

11

3. S

ite

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w P

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ce

Th

e y

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sh

ad

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me

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at

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Pri

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Wo

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lo

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taff

to

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au

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R is n

ot

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sis

Oct-

15

No

v-1

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Fe

b-1

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ar-

16

Ap

r-16

May-

16

Ju

n-1

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Oct-

16

Sit

e

Av

era

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Tru

st

Av

era

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Qu

ality

HS

MR

(12 m

on

th r

ollin

g)

92.5

292.4

895.3

496.9

799.4

7101.6

7103.5

8103.8

5106.8

6106.1

6

103.6

0102.0

1

Sin

gle

Sex

Accom

modatio

n b

reaches

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011

511

46

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10

16

19

11.0

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FF

T In

pati

en

t L

ike

ly t

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eco

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en

d92.4

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FF

T A

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78.6

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%

Safe

ty T

he

rmo

me

ter

Co

mp

lian

ce

(n

ew

harm

s)

95.3

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%99.3

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98.3

%98.4

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Neve

r E

vents

00

00

00

10

10

00

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0.9

Safe

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eve

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Pre

ssure

Ulc

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Gra

de 3

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bove

00

01

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20.5

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Pre

ssure

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de 2

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79

52

86.2

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ssure

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nsta

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30

02

24

42.0

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Serious U

nto

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5

412

18

25

40

39

35

19

47

24

15

30

28

44

C.D

if

00

52

11

13

30

11

11.5

4.3

33

MR

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01

01

00

00

00

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Readm

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28 d

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r F

oste

r R

olli

ng y

ear

106.0

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3103.3

2103.2

0101.9

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3

A&

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ait

s w

ith

in 4

ho

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79.7

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%73.2

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%77.3

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%

12 h

our

trolle

y w

aits

00

315

33

81

810

18

53

334

21.0

29.3

A&

E A

ttendances

8,2

80

8,3

69

8,3

02

8,1

02

7,8

75

8,9

71

7,7

99

8,6

68

8,0

64

8,3

87

7,4

80

8,0

08

8,5

29

8,1

89

26,7

36

Ave

rage d

aily

medic

al a

nd s

urg

ical o

utli

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18

34

32

37

28

31

33

24

21

15

18

20

18

19

26

Dela

yed T

ransfe

rs o

f care

(bed d

ays

)244

492

336

182

294

420

340

85

79

117

166

201

575

Cancelle

d o

pera

tions r

ate

1.8

2%

2.7

4%

2.1

6%

1.9

7%

3.0

9%

3.8

7%

2.2

9%

2.5

1%

2.4

2%

3.3

0%

1.5

1%

1.9

5%

2.3

%1.1

%

28 D

ay

cancelle

d o

pera

tion b

reaches

00

00

00

52

42

51

32.8

3.8

De

liv

ery

Theatr

e U

tilis

atio

n r

ate

81.4

%80.4

%77.5

%79.4

%78.3

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%77.9

%82.9

%79.5

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Ris

k A

dju

ste

d L

ength

of S

tay

(Dr

Foste

r -

Rolli

ng y

ear)

84.1

985.1

086.0

986.7

087.4

187.8

888.9

89.6

790.8

790.8

7

88.5

790.0

6

Pe

op

le

Turn

ove

r ra

te (

month

ly)

0.7

3%

1.1

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1.1

4%

0.9

9%

1.1

0%

1.2

3%

0.8

8%

1.1

1%

1.1

4%

1.0

8%

3.0

0%

1.0

9%

1.2

4%

1.4

4%

1.2

2%

Vacancie

s r

ate

9.0

3%

8.9

6%

9.1

6%

8.5

1%

6.6

7%

5.7

6%

6.2

2%

6.6

4%

6.9

5%

7.3

2%

7.3

7%

7.3

9%

7.2

0%

7.1

5%

7.5

4%

Sic

kn

ess r

ate

s5.6

9%

5.6

3%

5.8

1%

6.1

7%

6.2

0%

6.1

3%

5.2

7%

4.6

2%

4.2

8%

5.2

6%

4.9

6%

4.7

8%

5.2

0%

4.8

5%

4.9

7%

Pe

rce

nta

ge

of

sta

ff A

pp

rais

als

carr

ied

ou

t

62%

61%

60%

59%

64%

62%

58%

58%

59%

60%

60%

61%

59%

64%

No

rth

Ma

nc

he

ste

r G

en

era

l H

os

pit

al

Tre

nd

Last

6 m

on

ths

Acti

vit

y b

y M

on

th

Item

6

of 134

12

Oct-

15

No

v-1

5D

ec-1

5Jan

-16

Fe

b-1

6M

ar-

16

Ap

r-16

May-

16

Ju

n-1

6Ju

l-16

Au

g-1

6S

ep

-16

Oct-

16

Sit

e

Av

era

ge

Tru

st

Av

era

ge

HS

MR

(12 m

on

th r

ollin

g)

96.2

595.8

997.3

699.8

4101.4

9100.7

100.0

298.6

597.8

997.8

4

99.4

3102.0

1

Sin

gle

Sex

Accom

modatio

n b

reaches

00

00

00

00

03

00

00.5

12.5

FF

T In

pati

en

t L

ike

ly t

o R

eco

mm

en

d91.0

%94.4

%93.9

%93.3

%92.4

%91.5

%93.3

%95.8

%94.6

%91.9

%91.8

%91.4

%

93.1

%93.2

%

FF

T A

&E

L

ike

ly t

o R

eco

mm

en

d80.3

%82.2

%79.8

%81.9

%80.3

%79.3

%83.8

%83.0

%83.9

%81.4

%84.4

%81.2

%

82.9

%81.9

%

Safe

ty T

he

rmo

me

ter

Co

mp

lian

ce

(n

ew

harm

s)

97.7

%97.1

%97.3

%97.6

%97.3

%97.0

%97.2

%98.7

%96.6

%96.2

%96.9

%98.4

%

97.3

%98.4

%

Neve

r E

vents

00

00

00

00

03

00

00.5

0.9

Safe

Sta

ffin

g L

eve

ls96.8

%96.4

%97.3

%98.4

%94.8

%93.8

%97.2

%96.9

%96.6

%97.4

%95.2

%95.8

%97.6

%96.6

%97.0

%

Pre

ssure

Ulc

ers

Gra

de 3

and a

bove

00

00

00

00.0

0.9

Pre

ssure

Ulc

ers

Gra

de 2

45

61

34

94.7

13.4

Pre

ssure

Ulc

ers

- U

nsta

geable

13

24

32

53.2

5.9

Serious U

nto

ward

Incid

ents

3

55

49

13

32

611

17

22

57

44

C.D

if1

01

32

22

02

05

13

1.8

4.3

33

MR

SA

00

00

00

00

00

00

00.0

0.2

0

Readm

issio

ns (

28 d

ays

) D

r F

oste

r R

olli

ng y

ear

108.0

9106.7

9105.1

0104.3

9103.6

4103.6

8103.1

3

104.4

699.9

3

A&

E 4

Ho

ur

Wait

s80.3

%79.4

%72.9

%78.4

%73.4

%71.9

%86.9

%90.4

%86.4

%83.7

%88.6

%84.3

%77.6

%85.2

%84.4

%

12 h

our

trolle

y w

aits

01

21

535

20

12

30

1

3.0

29.3

A&

E A

ttendances

8,4

95

8,6

05

8,4

96

8,6

78

8,0

84

9,1

08

8,1

37

9,2

17

8,5

86

9,1

53

8,2

78

8,6

89

8,8

39

8,7

94

26,7

36

Ave

rage d

aily

medic

al a

nd s

urg

ical o

utli

ers

53

26

55

30

14

01

32

26

Dela

yed T

ransfe

rs o

f care

(bed d

ays

)67

20

30

88

100

109

73

77

104

15

58

73

575

Cancelle

d o

pera

tions r

ate

0.7

3%

1.4

0%

0.9

1%

1.3

4%

2.4

0%

1.5

5%

0.5

8%

0.5

4%

0.7

9%

0.9

8%

0.4

9%

1.2

1%

0.8

%1.1

%

28 D

ay

cancelle

d o

pera

tion b

reaches

00

00

00

21

01

01

10.7

3.8

Theatr

e U

tilis

atio

n r

ate

79.9

%80.1

%78.7

%76.1

%82.2

%80.0

%77.0

%81.0

%81.2

%79.3

%82.0

%80.7

%77.1

%80.2

%78.2

%

Ris

k A

dju

ste

d L

ength

of S

tay

(Dr

Foste

r -

Rolli

ng y

ear)

96.2

096.7

096.6

997.3

299.1

4100.5

7107.7

9101.8

102.4

1

101.5

190.0

6

Turn

ove

r ra

te (

month

ly)

1.1

5%

1.0

0%

0.8

4%

0.6

4%

0.6

5%

1.7

1%

0.8

7%

0.7

5%

0.7

8%

0.8

7%

1.8

1%

1.9

3%

0.9

5%

1.1

8%

1.2

2%

Vacancie

s r

ate

6.8

8%

7.5

6%

7.6

5%

7.9

7%

8.2

5%

7.6

8%

8.6

7%

7.3

5%

7.7

4%

7.5

4%

6.2

8%

6.2

5%

5.0

3%

6.7

0%

7.5

4%

Sic

kn

ess r

ate

s6.2

7%

6.1

4%

6.2

7%

6.1

8%

5.8

6%

5.7

8%

5.4

6%

5.1

0%

5.4

3%

5.2

1%

4.9

7%

4.7

9%

5.3

4%

5.1

4%

4.9

7%

Pe

rce

nta

ge

of

sta

ff A

pp

rais

als

carr

ied

ou

t

68%

66%

65%

67%

74%

70%

66%

66%

69%

70%

69%

71%

69%

64%

Qu

ality

De

liv

ery

Pe

op

le

Ro

ya

l O

ldh

am

Ho

pit

al

Tre

nd

Last

6 m

on

ths

Acti

vit

y b

y M

on

th

of 134

13

Oct-

15

No

v-1

5D

ec-1

5Jan

-16

Fe

b-1

6M

ar-

16

Ap

r-16

May-

16

Ju

n-1

6Ju

l-16

Au

g-1

6S

ep

-16

Oct-

16

Sit

e

Av

era

ge

Tru

st

Av

era

ge

HS

MR

(12 m

on

th r

ollin

g)

104.4

7105.9

5107.7

7106.7

3108.3

4108.3

6111.5

6111.0

7108.5

4110.8

2

109.7

8102.0

1

Sin

gle

Sex

Accom

modatio

n b

reaches

04

00

30

40

30

03

01.0

12.5

FF

T In

pati

en

t L

ike

ly t

o R

eco

mm

en

d95.8

%94.9

%94.1

%95.6

%92.9

%92.0

%95.3

%95.2

%93.8

%93.3

%95.5

%94.7

%

94.6

%93.2

%

FF

T A

&E

L

ike

ly t

o R

eco

mm

en

d83.8

%81.0

%86.0

%80.6

%82.8

%80.4

%83.7

%86.0

%85.5

%82.7

%80.9

%84.6

%

83.9

%81.9

%

Safe

ty T

he

rmo

me

ter

Co

mp

lian

ce

(n

ew

harm

s)

99.1

%96.3

%95.2

%97.4

%100.0

%98.7

%98.7

%99.6

%98.6

%98.6

%100.0

%99.5

%

99.2

%98.4

%

Neve

r E

vents

00

00

00

01

00

00

00.2

0.9

Safe

Sta

ffin

g L

eve

ls98.3

%99.6

%94.4

%96.0

%95.2

%94.3

%97.0

%95.8

%95.8

%93.2

%93.5

%95.8

%95.6

%94.9

%97.0

%

Pre

ssure

Ulc

ers

Gra

de 3

and a

bove

00

00

01

00.2

0.9

Pre

ssure

Ulc

ers

Gra

de 2

32

33

21

42.5

13.4

Pre

ssure

Ulc

ers

- U

nsta

geable

00

11

10

00.5

5.9

Serious U

nto

ward

Incid

ents

3

14

56

16

15

16

12

64

62

844

C.D

if1

23

42

16

20

10

03

1.0

4.3

33

MR

SA

00

00

00

00

00

00

00.0

0.2

0

Readm

issio

ns (

28 d

ays

) D

r F

oste

r R

olli

ng y

ear

94.5

994.8

594.7

793.1

991.1

190.6

390.9

4

92.5

899.9

3

A&

E 4

Ho

ur

Wait

s78.2

%74.4

%81.2

%75.0

%82.0

%76.9

%82.7

%84.7

%86.4

%82.9

%82.6

%87.6

%83.1

%84.6

%84.4

%

12 h

our

trolle

y w

aits

00

05

121

10

10

17

31

5.3

29.3

A&

E A

ttendances

5,4

68

5,2

35

5,2

63

5,4

36

5,1

68

5,6

78

5,1

32

5,8

25

5,4

64

5,8

14

5,3

59

5,4

01

5,5

87

5,5

75

26,7

36

Ave

rage d

aily

medic

al a

nd s

urg

ical o

utli

ers

79

57

69

66

67

35

35

26

Dela

yed T

ransfe

rs o

f care

(bed d

ays

)505

390

271

275

201

279

258

310

189

292

327

276

575

Num

ber

of cancelle

d o

pera

tions

10

17

57

27

14

89

16

12

13

4

10

0

Cancelle

d o

pera

tions r

ate

0.6

2%

1.0

4%

0.3

9%

0.5

0%

1.7

4%

1.0

6%

0.6

4%

0.6

6%

1.2

0%

0.9

2%

1.0

0%

0.2

8%

0.8

%1.1

%

28 D

ay

cancelle

d o

pera

tion b

reaches

00

10

01

20

00

01

00.2

3.8

Theatr

e U

tilis

atio

n r

ate

71.9

%76.5

%74.7

%70.3

%76.5

%74.7

%76.4

%80.7

%76.8

%79.9

%78.9

%75.0

%78.3

%78.3

%78.2

%

Ris

k A

dju

ste

d L

ength

of S

tay

(Dr

Foste

r -

Rolli

ng y

ear)

73.8

274.9

375.4

776.1

875.8

475.7

576.1

976.4

76.3

176.3

1

76.1

190.0

6

Turn

ove

r ra

te (

month

ly)

0.8

6%

0.6

9%

1.0

2%

1.0

7%

1.0

2%

0.9

7%

1.1

2%

1.4

9%

0.5

6%

0.8

5%

1.9

8%

1.3

6%

0.8

8%

1.1

9%

1.2

2%

Vacancie

s r

ate

6.6

5%

10.2

9%

9.8

1%

9.3

5%

9.7

5%

10.1

3%

9.9

1%

10.1

8%

9.5

9%

9.6

1%

8.9

6%

8.2

1%

7.8

4%

9.0

7%

7.5

4%

Sic

kn

ess r

ate

s6.3

1%

5.9

5%

6.9

2%

6.3

2%

5.4

3%

5.3

9%

5.9

5%

5.9

0%

5.3

9%

5.7

5%

5.1

3%

5.1

2%

5.4

2%

5.4

5%

4.9

7%

Pe

rce

nta

ge

of

sta

ff A

pp

rais

als

carr

ied

ou

t

66%

68%

68%

71%

77%

76%

70%

71%

76%

78%

80%

78%

76%

64%

Acti

vit

y b

y M

on

th

Fa

irfi

eld

Ge

ne

ral H

os

pit

al

Qu

ality

De

liv

ery

Pe

op

le

Tre

nd

Last

6 m

on

ths

Item

6

of 134

14

Oct-

15

No

v-1

5D

ec-1

5Jan

-16

Fe

b-1

6M

ar-

16

Ap

r-16

May-

16

Ju

n-1

6Ju

l-16

Au

g-1

6S

ep

-16

Sit

e

Av

era

ge

Tru

st

Av

era

ge

HS

MR

(12 m

on

th r

ollin

g)

38.6

941.7

140.1

035.4

030.5

233.2

744.7

148.6

148.3

350.0

2

42.5

8102.0

1

Sin

gle

Sex

Accom

modatio

n b

reaches

00

00

00

00

00

00

00.0

12.5

FF

T In

pati

en

t L

ike

ly t

o R

eco

mm

en

d94.4

%93.2

%90.4

%94.3

%94.0

%92.1

%94.7

%95.7

%93.3

%95.3

%94.4

%93.4

%

94.5

%93.2

%

FF

T A

&E

L

ike

ly t

o R

eco

mm

en

d83.8

%78.7

%83.6

%81.4

%81.4

%75.9

%81.7

%83.1

%81.2

%80.3

%84.7

%82.8

%

82.3

%81.9

%

Safe

ty T

he

rmo

me

ter

Co

mp

lian

ce

(n

ew

harm

s)

100.0

%100.0

%100.0

%100.0

%100.0

%100.0

%94.7

%100.0

%100.0

%97.4

%96.0

%100.0

%

98.0

%98.4

%

Neve

r E

vents

00

00

00

00

00

00

00.0

0.9

Safe

Sta

ffin

g L

eve

ls100.1

%99.1

%100.8

%99.4

%96.7

%98.5

%99.2

%99.7

%97.6

%98.9

%98.4

%98.5

%98.9

%98.7

%97.0

%

Pre

ssure

Ulc

ers

Gra

de 3

and a

bove

00

00

00

00.0

0.9

Pre

ssure

Ulc

ers

Gra

de 2

00

00

00

00.0

13.4

Pre

ssure

Ulc

ers

- U

nsta

geable

00

00

10

00.2

5.9

Serious U

nto

ward

Incid

ents

0

00

10

10

00

00

10

044

C.D

if1

00

10

00

00

00

00

0.0

4.3

33

MR

SA

00

00

00

00

00

00

00.0

0.2

0

Readm

issio

ns (

28 d

ays

) D

r F

oste

r R

olli

ng y

ear

84.7

684.7

582.7

081.8

681.0

079.8

979.8

7

81.6

899.9

3

A&

E 4

Ho

ur

Wait

s98.4

%97.5

%98.3

%96.7

%97.0

%94.2

%97.9

%97.2

%98.5

%95.8

%97.5

%96.7

%97.0

%97.1

%84.4

%

12 h

our

trolle

y w

aits

00

00

00

00

00

00

00.0

29.3

A&

E A

ttendances

4,2

00

4,3

41

4,3

11

4,3

78

3,8

94

4,5

76

4,1

84

4,5

35

4,0

82

4,2

30

3,9

79

4,0

81

4,1

58

4,1

78

26,7

36

Ave

rage d

aily

medic

al a

nd s

urg

ical o

utli

ers

00

00

00

00

00

00

00

26

Dela

yed T

ransfe

rs o

f care

(bed d

ays

)0

01

18

75

426

017

48

58

26

575

Cancelle

d o

pera

tions r

ate

0.2

0%

1.7

1%

0.4

3%

0.6

6%

0.2

1%

0.7

5%

0.5

0%

0.3

2%

0.5

0%

0.3

7%

1.0

1%

0.6

5%

0.6

%1.1

%

28 D

ay

cancelle

d o

pera

tion b

reaches

00

00

00

10

00

01

00.2

3.8

Theatr

e U

tilis

atio

n r

ate

75.9

%75.7

%76.1

%73.2

%77.0

%75.2

%77.0

%81.0

%75.4

%76.4

%76.1

%78.4

%75.8

%77.2

%78.2

%

Ris

k A

dju

ste

d L

ength

of S

tay

(Dr

Foste

r -

Rolli

ng y

ear)

56.2

757.2

058.3

258.3

855.5

953.4

052.7

451.8

349.8

349.8

3

53.6

390.0

6

Turn

ove

r ra

te (

month

ly)

0.9

9%

1.3

8%

1.8

4%

1.2

1%

1.6

6%

0.8

4%

0.4

0%

1.0

8%

0.1

5%

0.3

8%

1.3

9%

0.8

4%

0.5

3%

0.7

3%

1.2

2%

Vacancie

s r

ate

13.4

7%

13.5

7%

12.6

8%

14.3

4%

10.1

0%

9.9

7%

10.6

1%

10.2

5%

9.3

3%

8.5

0%

9.0

4%

9.5

5%

7.6

5%

9.0

5%

7.5

4%

Sic

kn

ess r

ate

s5.0

4%

5.6

4%

5.3

6%

5.8

0%

5.6

9%

5.4

0%

4.9

9%

4.5

2%

3.9

9%

3.7

7%

4.1

8%

3.9

0%

4.5

8%

4.1

6%

4.9

7%

Pe

rce

nta

ge

of

sta

ff A

pp

rais

als

carr

ied

ou

t

66%

64%

65%

65%

75%

73%

73%

74%

74%

73%

72%

72%

73%

64%

Qu

ality

De

liv

ery

Pe

op

le

Ro

ch

da

le In

firm

ary

T

ren

d

Last

6 m

on

ths

Acti

vit

y b

y M

on

th

of 134

15

Oct-

15

No

v-1

5D

ec-1

5Jan

-16

Fe

b-1

6M

ar-

16

Ap

r-16

May-

16

Ju

n-1

6Ju

l-16

Au

g-1

6S

ep

-16

Oct-

16

Sit

e

Av

era

ge

Tru

st

Av

era

ge

% o

f N

ort

h M

ancheste

r com

munity

palli

ativ

e p

atie

nts

dyi

ng in

their p

refe

rred p

lace

00

86.0

%0

086.0

%0

072.4

%79.2

%n/a

FF

T C

om

mu

nit

y L

ike

ly t

o R

eco

mm

en

d88.7

%88.4

%92.7

%91.7

%90.4

%92.9

%92.3

%92.4

%94.3

%98.5

%97.5

%97.8

%

94.6

5%

94.6

5%

Pre

ssure

Ulc

ers

Gra

de 3

and a

bove

00

02

00

00.3

0.9

Pre

ssure

Ulc

ers

Gra

de 2

01

11

00

1

Pre

ssure

Ulc

ers

- U

nsta

geable

00

00

00

2

Serious U

nto

ward

Incid

ents

0

01

24

21

11

11

00

144

Norh

Mancheste

r C

om

munity

y acquired M

RS

A c

ases

00

00

00

00

00

0n/a

Norh

Mancheste

r C

om

munity

y acquired C

-Diff

cases

00

00

00

00

00

0n/a

% o

f N

ort

h M

anchste

r citi

zens that C

AS

S a

void

ed

A&

E a

ttendance (

targ

et >

=50%

)58.1

%60.0

%69.4

%87.4

%71.6

%n/a

% o

f N

ort

h M

anchste

r citi

zens that C

AS

S a

void

ed N

-

EL a

dm

issio

n (

Targ

et >

=50%

)41.9

%66.0

%68.0

%66.3

%61.3

%n/a

% o

f citi

zens that C

AS

S a

void

ed h

ospita

l readm

issio

n

(targ

et >

=90%

)93.4

%91.0

%95.0

%94.4

%93.6

%n/a

% o

f elig

ible

Nort

h M

ancheste

r C

om

munity

Str

oke

patie

nts

dis

charg

ed thro

ugh the E

arly

Support

ed

Dis

charg

e p

ath

way

(targ

et >

=40%

)

50.0

%60.0

%44.0

%50.0

%72.0

%75.0

%89.5

%56.0

%58.3

%76.9

%70.1

%n/a

% o

f patie

nts

seen b

y th

e N

ort

h M

ancheste

r N

avi

gato

r

Team

in A

&E

and not adm

itted (

Targ

et >

=60%

)0

00

00

00

065.7

%0.0

%65.7

%n/a

Turn

ove

r ra

te (

month

ly)

0.5

7%

1.8

4%

0.5

7%

0.4

3%

0.2

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1.0

1%

0.9

8%

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3%

1.1

9%

1.4

2%

0.8

6%

1.2

2%

Vacancie

s r

ate

13.1

3%

12.5

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11.7

7%

10.5

1%

10.7

2%

10.5

1%

10.8

3%

6.6

5%

5.0

6%

5.8

4%

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8.4

1%

7.2

0%

6.4

0%

7.5

4%

Sic

kn

ess r

ate

s5.5

0%

5.5

7%

4.9

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6.8

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6.2

3%

6.7

3%

6.1

4%

5.1

0%

5.4

7%

4.2

3%

3.5

7%

3.5

5%

4.6

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4.9

7%

Pe

rce

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ge

of

sta

ff A

pp

rais

als

carr

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t

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72%

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78%

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88%

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36%

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52.5

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64.0

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Pe

op

le

Co

mm

un

ity

Tre

nd

Last

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ality

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for

16-1

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for

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vit

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Agg

rega

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fill

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%)

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Item

6

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18

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32

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1.0

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18

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94

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32

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27

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27

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82

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Du

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Fill

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13

80

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92

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7.5

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Sta

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Du

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ter

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n i

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Cri

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are

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2.5

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19

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56

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92

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On

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N o

n l

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d

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yed

to

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35

92

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09

09

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20

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Sta

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Du

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16

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Sta

ff a

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etr

ics

Inte

gra

ted P

erf

orm

ance r

eport

A c

om

pre

hensiv

e s

et of

Metr

ics D

evelo

p m

etr

ics a

ligned to

SR

FT

12

Tru

st B

oa

rd1

2

1.1

.4IF

eff

ectiv

e, support

ive,

challe

ngin

g c

linic

al l

eaders

hip

is n

ot in

pla

ce a

cro

ss the

Tru

st T

HEN

Clin

ical v

ariatio

n

will c

ontin

ue u

nchecke

d thus

pote

ntia

lly le

adin

g to p

atie

nt

harm

44

CD

Str

uctu

re s

upport

ed b

y D

ND

s a

nd

OM

D

CD

foru

m p

rovid

es le

aders

hip

support

Clin

ical l

eaders

hip

model s

till

to b

e e

mbedded

Appro

ve s

ite M

edic

al

Directo

rs

Leaders

hip

pro

gra

mm

e w

ith

key m

edic

al a

nd n

urs

ing

leaders

4N

o r

elia

ble

assura

nce

No r

elia

ble

assura

nce

Imple

ment site

based m

edic

al

team

s. M

D in

terv

iew

s

tak

ing

pla

ce

18 N

ove

mb

er

2016

Imple

ment clin

ically

driven

SLR

model

Wo

rk b

ein

g u

nd

ert

ak

en

to

de

ve

lop

a L

ead

ers

hip

mo

de

l fo

r C

Ds

to

in

clu

de

the

de

ve

lop

me

nt

of

as

su

ran

ce

me

ch

an

ism

s

12

Tru

st B

oa

rd1

2

Item

6

of 134

26

Directo

r of

Opera

tions

1.2

.3IF

th

e T

rust fa

ils to e

nsure

Work

forc

e c

apacity

,

resilience a

nd f

undin

g to

deliv

er

the im

pro

vem

ent pla

n

whils

t ensuring the o

ther

key

prioritie

s o

f m

ain

tain

ing

busin

ess a

s u

sual,

develo

pin

g a

nd d

eliv

ering o

n

the c

linic

al s

erv

ice s

trate

gy

and s

ignific

ant org

anis

atio

nal

re-s

tructu

re a

re take

n

forw

ard

TH

EN

the p

lan m

ay

not be f

ully

and a

ppro

priate

ly

imple

mente

d

44

Executiv

e le

aders

hip

for

all

key c

hange

pro

gra

mm

es. N

ew

executiv

e r

isk

and

govern

ance a

ssura

nce s

yste

m in

clu

din

g

new

tra

nsfo

rmatio

n b

oard

. D

eliv

ery

mechanis

m f

or

impro

vem

ent pla

n w

ith

weekl

y tra

cki

ng o

f actio

ns. A

ppoin

tment

to s

ite le

aders

hip

team

s. In

year

fundin

g

agre

ed

Tim

elin

e f

or

appoin

tment to

executiv

e s

ite le

aders

hip

team

s. Futu

re y

ears

fundin

g

4M

onito

ring a

rrangem

ents

for

deliv

ery

of

impro

vem

ent pla

n.

Tra

nsfo

rmatio

n B

oard

to

develo

p a

nd s

ign o

ff C

SS

with

com

mis

sio

ners

.

Pro

ject m

anagem

ent

arr

angem

ents

for

imple

menta

tion a

nd d

eliv

ery

of

new

Gro

up a

nd C

O

str

uctu

res. Fully

develo

ped

esta

tes p

lan to d

eliv

er

CS

S.

Mappin

g o

f critic

al p

ath

for

all

str

ate

gic

changes

Map a

ll ke

y a

ctiv

ities a

nd

critic

al p

ath

for

years

1&

2

identif

yin

g f

urt

her

risks

and

actio

ns to b

e take

n (

end N

ov).

Revie

w c

urr

ent re

sourc

e to

support

develo

pm

ent and

deliv

ery

of

changes a

nd

finalis

e b

usin

ess c

ase f

or

investm

ent in

change

resourc

es (

com

ple

te S

OC

end N

ov, FB

C e

nd M

arc

h 1

7).

Agre

e k

ey o

bje

ctiv

e a

nd

prioritie

s w

ith s

ite le

aders

hip

team

s o

nce in

post (J

an

2017).

Build

capacity

and

capability

for

change a

t C

O

when r

esourc

es id

entif

ied

and a

gre

ed (

com

mence N

ov

2016).

Ensure

cle

ar

com

munic

atio

ns a

nd

engagem

ent pla

n a

cro

ss the

Tru

st (o

n-g

oin

g)

12

Tru

st B

oard

12

Chie

f N

urs

e

1.2

.4IF

the T

rust fa

ils to p

rovid

e

safe

sta

ffin

g le

vels

in a

ll

clin

ical a

reas 2

4/7

TH

EN

this

could

lead to r

eductio

n in

patie

nt safe

ty a

nd q

ualit

y o

f

care

alo

ng w

ith p

oor

sta

ff

and p

atie

nt experience.

Specific

focus to b

e m

ade to

the f

ragile

serv

ices: 1.

Fra

gile

Serv

ices 2

. H

ard

to

recru

it are

as 3

Clin

ical a

reas

with

sig

nific

ant sta

ff

short

ages

45

Com

pre

hensiv

e W

ard

sta

ffin

g

esta

blis

hm

ent re

vie

w c

om

ple

ted

Imm

edia

te r

ecru

itment to

100 B

and 6

Posts

Regula

r re

vie

w o

f vacancy, bank

and a

gency u

sage

Sig

nific

ant Tru

st R

N

vacancie

s. N

atio

nal s

upply

of

Regis

tere

d N

urs

es L

ack

of

capacity

and c

apability

. N

o

recru

itment and r

ete

ntio

n

str

ate

gy

3W

ork

forc

e r

eport

s S

yste

ms in

pla

ce to id

entif

y s

taff

ing g

aps

shift by s

hift Q

ualit

y a

nd

Safe

ty d

ashboard

s

Ward

Accre

dita

tion

Fra

mew

ork

(N

AA

S)

stil

l at

pilo

t sta

ge

Revie

w N

AA

S p

ilot re

sults

and im

ple

ment Tru

st w

ide

Ward

Accre

dita

tion

pro

gra

mm

e

12

EA

RC

12

Imp

rove

Pati

en

t

Exp

eri

en

ce

Chie

f N

urs

e1.3

.1IF

the tru

st fa

ils to m

easure

the Q

ualit

y s

tandard

s w

ithin

Clin

ical a

reas T

HEN

it m

ay f

ail

to im

pro

ve the Q

ualit

y a

nd

Safe

ty o

f patie

nt C

are

44

The a

dapta

tion o

f S

RFT W

ard

Accre

dita

tion F

ram

ew

ork

for

intr

oductio

n

in P

ennin

e. C

urr

ently

in p

ilot phase

Exis

ting w

ard

accre

dita

tion

fram

ew

ork

not fit fo

r

purp

ose. Full

imple

menta

tion

of

SR

FT N

AA

S F

ram

ew

ork

to

be d

eliv

ere

d

4O

n-g

oin

g m

onito

ring o

f pilo

t

NA

AS

with

fin

al a

naly

sis

Novem

ber

2016

The T

rust curr

ently

does n

ot

have a

cle

ar

unders

tandin

g o

f

the Q

ualit

y o

f care

Analy

sis

of

pilo

t and

imple

menta

tion o

f a N

urs

e

Accre

dita

tion s

yste

m f

or

Pennin

e

12

Tru

st B

oard

12

of 134

27

Ch

ief

Nu

rse

1.3

.3IF

In

form

ati

on

can

no

t b

e

retr

ieve

d w

ith

as

su

ran

ce

TH

EN

th

ere

will b

e

co

mp

rom

ise

d p

ati

en

t

care

du

e t

o in

ab

ilit

y f

or

clin

icia

ns

to

fin

d u

p t

o

date

/ p

as

t h

isto

ry,

ine

ffic

ien

t clin

ical co

din

g

wh

ich

has

fin

an

cia

l an

d

HS

MR

im

plicati

on

s a

nd

po

ten

tial is

su

es

in

co

ron

ers

/ in

qu

es

ts /

cla

ims

/ c

om

pla

ints

du

e t

o

inab

ilit

y t

o p

rod

uce

a

co

he

ren

t m

ed

ical re

co

rd

54

Fo

r co

ron

ers

cas

es

on

ly m

an

ual

traw

l an

d r

e-s

can

nin

g lo

cally t

o

mak

e a

co

mp

reh

en

siv

e r

eco

rd

availab

le f

or

the

co

ron

er.

Vari

ab

le p

roce

ss

es

in

pla

ce

to

man

ag

e p

ati

en

t

reco

rds

Lack

of

de

fin

ed

ro

les

an

d

res

po

ns

ibilit

ies

Cap

acit

y a

nd

cap

ab

ilit

y t

o

man

ag

e r

eco

rds

ap

pro

pri

ate

ly

5Q

A p

roce

ss

in

pla

ce

in

He

alt

h r

eco

rds

. R

eco

rds

ch

eck

ed

file

d

ap

pro

pri

ate

ly if

no

t s

en

t

back

to

are

a t

he

y c

am

e

fro

m p

rio

r to

se

nd

in

fo

r

scan

nin

g

Au

dit

of

reco

rds

pra

cti

ce

Un

cle

ar

rep

ort

ing

me

ch

an

ism

fo

r Evo

lve

imp

lem

en

tati

on

Bo

ard

Au

dit

of

me

dic

al re

co

rds

to b

e u

nd

ert

ak

en

by

He

alt

h r

eco

rds

to

id

en

tify

are

as

of

po

or

pra

cti

ce

Intr

od

ucti

on

of

co

mp

reh

en

siv

e t

rain

ing

pro

gra

mm

e o

n r

eco

rd

man

ag

em

en

t an

d

acco

un

tab

ilit

y

Cle

arl

y d

efi

ne

ro

les

an

d

res

po

ns

ibilit

ies

aro

un

d

reco

rd m

an

ag

em

en

t

Sta

nd

ard

ise

re

co

rd

man

ag

em

en

t p

roce

ss

Ro

llin

g a

ud

it p

rog

ram

me

14

Tru

st

Bo

ard

14

Item

6

of 134

28

2

. D

eliv

er

fin

an

cia

l p

lans to

assure

su

sta

inab

ility

An

nu

al

Pla

n

Ob

jecti

ve

2016/1

7

Ex

ec L

ea

dR

isk

nu

mb

er

Pri

ncip

al

Ris

ks

Likelihood

Impact

Ke

y C

on

tro

l e

sta

bli

she

dK

ey G

ap

s in

Co

ntr

ols

Control

Ass

ura

nce

Ga

ps

in A

ssu

ran

ce

Acti

on

Pla

n S

um

ma

ryO

pe

nin

g

Po

siti

on

Ass

ura

nce

leve

l

End of Q1

End of Q2

End of Q3

End of Q4

Bo

ard

Assu

ran

ce F

ram

ew

ork

/ C

orp

ora

te R

isk R

eg

iste

r

Dri

ve

eff

icie

ncy

an

d p

rod

ucti

vit

y

to d

elive

r

fin

an

cia

l co

ntr

ol

of

£39.7

m d

efi

cit

(re

vis

ed

to

£12.1

m)

Directo

r of

Fin

ance

2.1

.1If the T

rust fa

ils to m

eet its

financia

l dutie

s in

2016/1

7

due to in

com

e a

nd

expenditu

re is

sues a

nd

failu

re to im

ple

ment C

IP p

lans

then the T

rust w

ill f

ail

its

financia

l dutie

s r

esulti

ng in

regula

tory

actio

n. (t

his

rela

tes

to R

isk

6. S

RR

)

44

The e

sta

blis

hm

ent of

an E

xecutiv

e

Fin

ance, In

form

atio

n a

nd C

apita

l

Govern

ance C

om

mitt

ee; overs

eein

g the

work

of

the C

IP, in

form

atio

n, busin

ess

develo

pm

ent and r

evie

w, pro

cure

ment

and s

erv

ice li

ne r

eport

ing g

roups.

Govern

ance a

rrangem

ents

in p

lace, and

well

esta

blis

hed a

cro

ss the T

rust, f

or

each o

f th

e k

ey w

ork

ing g

roups; and

inclu

din

g d

ele

gate

d b

udgets

and

esta

blis

hed s

yste

ms o

f contr

ol.

Audit

Com

mitt

ee.

Adequate

resourc

es a

nd

ski

lls to m

eet th

e d

em

ands o

f

the C

IP f

ollo

win

g the

depart

ure

of

Ern

st &

Young;

recru

itment and r

ete

ntio

n

difficulti

es w

ith n

ew

ly

esta

blis

hed team

.

Pro

cure

ment str

ate

gy a

nd

pro

cure

ment tr

ansfo

rmatio

n

pla

n (

Cart

er

recom

mendatio

n)

in d

raft

- r

equires s

ign o

ff.

4R

isks

, actio

ns r

eport

ed to

Exec F

inance C

om

mitt

ee.

Fin

ancia

l report

s to T

rust

Board

incorp

ora

ting a

ll

aspects

of

financia

l ris

k to

deliv

ery

of

pla

n. M

onth

ly a

nd

quart

erly r

eport

ing to

regula

tor

- N

HS

I.

Board

overs

ight of

pro

gre

ss

again

st C

art

er

recom

mendatio

ns

Ski

lls tra

nsfe

r under

revie

w

with

appro

priate

people

invite

d to n

ecessary

tra

inin

g

e.g

. D

r Foste

r

12

Tru

st B

oard

12

The e

sta

blis

hm

ent of

an E

xecutiv

e

Opera

tions &

Perf

orm

ance G

overn

ance

Com

mitt

ee to m

anage r

isks

associa

ted

with

deliv

ering c

ontr

actu

al r

equirem

ents

of

activ

ity a

nd p

erf

orm

ance.

Contr

actu

al i

ncom

e "

fixed"

with

Com

mis

sio

ners

for

2016/1

7.

Short

fall

again

st ta

rgets

and

agre

ed tra

jecto

ries f

or

A&

E

and R

TT -

susta

inability

and

transfo

rmatio

n f

undin

g a

t risk.

Div

isio

nal r

ecovery

pla

ns -

for

finance, activ

ity a

nd R

TT.

Inte

rnal C

are

Board

, and

exte

rnal I

mpro

vem

ent B

oard

overs

eein

g A

&E im

pro

vem

ent.

Tru

st to

appeal a

gain

st

financia

l penalti

es. D

em

and

and c

apacity

pla

ns f

or

futu

re

years

Month

ly m

eetin

gs w

ith r

egula

tor

- N

HS

I,

dis

cuss a

nd a

gre

e a

ctio

ns r

ela

ting to

identif

ied a

nd e

merg

ing f

inancia

l ris

ks,

with

in T

rust and a

cro

ss h

ealth

econom

y.

Month

ly d

eta

iled f

inancia

l report

ing to

NH

SI o

f financia

l positi

on, fo

recasts

and

risks

,

Regula

tor

sig

hte

d e

arly o

n

financia

l ris

ks, w

ith

opport

unity

to a

gre

e

corr

ectiv

e a

ctio

ns, re

medie

s

etc

.; T

rust unders

tandin

g o

f

natio

nal p

ositi

on, has a

ccess

to s

enio

r syste

m s

upport

, and

access / u

nders

tandin

g o

f

natio

nal f

inancia

l support

, fo

r

exam

ple

access to lo

ans, and

work

ing c

apita

l

arr

angem

ents

.

Fin

ance D

irecto

r m

eetin

gs w

ith N

E S

ecto

r

com

mis

sio

ners

, to

dis

cuss b

oth

clin

ical

transfo

rmatio

nal,

and o

pera

tional i

ssues/

risks

. M

eet every

tw

o w

eeks

. S

yste

m

wid

e r

isks

share

d a

nd u

nders

tood.

Actio

ns p

lans a

gre

ed, and w

hic

h in

clu

de

exte

rnal c

om

mis

sio

ned s

upport

of 134

29

An

nu

al

Pla

n

Ob

jecti

ve

2016/1

7

Ex

ec L

ea

dR

isk

nu

mb

er

Pri

ncip

al

Ris

ks

Likelihood

Impact

Ke

y C

on

tro

l e

sta

bli

she

dK

ey G

ap

s in

Co

ntr

ols

Control

Ass

ura

nce

Ga

ps

in A

ssu

ran

ce

Acti

on

Pla

n S

um

ma

ryO

pe

nin

g

Po

siti

on

Ass

ura

nce

leve

l

End of Q1

End of Q2

End of Q3

End of Q4

Bo

ard

Assu

ran

ce F

ram

ew

ork

/ C

orp

ora

te R

isk R

eg

iste

r

Reduce s

pend o

n

Agency s

taff

fro

m

£38m

to £

29.9

m

Directo

r of

Work

forc

e

and O

D

2.2

.1IF

recru

itment does n

ot re

ach

sta

ffin

g e

sta

blis

hm

ent le

vels

TH

EN

the q

ualit

y o

f care

will

be c

om

pro

mis

ed a

nd m

ora

le /

sic

kness is

sues w

ill c

ontin

ue

44

Weekl

y P

erf

orm

ance m

onito

ring m

eetin

g

chaired b

y D

irecto

r of

Work

forc

e&

OD

with

senio

r executiv

e a

nd d

ivis

ional

mem

bers

hip

.

Weekl

y m

onito

ring o

f re

cru

itment activ

ity

and a

gency u

sage v

ia E

xec m

eetin

g,

Inte

rnal c

ontr

ol r

egro

up a

nd Perf

orm

ance

and O

ps Exec c

om

mitt

ee

HH

H p

lan

New

recru

itment sta

ndard

s e

sta

blis

hed

Exit

inte

rvie

ws s

oft

ware

in p

lace

Monito

ring a

rrangem

ents

for

the n

ew

recru

itment

sta

ndard

s n

ot yet in

pla

ce

Lack

of

robust use o

f Exit

inte

rvie

w p

rocess

Deta

iled p

roje

ctio

n o

f ski

ll m

ix

arisin

g f

rom

loss o

f

experience s

taff

/ r

etir

em

ent

bulg

e

4H

R d

ashboard

monito

red

weekl

y a

t Exec W

F

Govern

ance C

om

mitt

ee

Key in

dic

ato

rs a

nd e

xceptio

n

report

ed to the B

oard

None

Focus r

ecru

itment in

novativ

e

join

t w

ork

ing a

nd a

dvert

isin

g

posts

with

neig

hbouring

Tru

sts

Imple

ment m

onito

ring

arr

angem

ents

for

New

Recru

itment S

tandard

s

Imple

ment ro

bust exit

inte

rvie

w p

rocess

De

live

ry o

f p

lan

re

gu

larl

y

revie

we

d t

hro

ug

h E

xe

cs

Pe

rfo

rman

ce

an

d

Op

era

tio

ns

an

d w

ee

kly

thro

ug

h t

he

Im

pro

ve

me

nt

pla

n p

rog

ram

me

de

live

ry

me

eti

ng

12

Tru

st B

oard

12

Reduce v

acancy

gap to 6

%

2.2

.2IF

sta

ff v

acancie

s d

o n

ot

reduce in

line w

ith p

lan T

HEN

the q

ualit

y o

f care

will n

ot

impro

ve a

nd f

inancia

l

susta

inability

will n

ot be

deliv

ere

d.

44

Weekl

y m

onito

ring o

f re

cru

itment activ

ity.

HH

H p

lan

New

recru

itment sta

ndard

s e

sta

blis

hed

Exit

inte

rvie

ws s

oft

ware

in p

lace a

nd f

irst

quart

er

results

analy

sed.

Com

mis

sio

ned T

rack

as n

ew

recru

itment

managem

ent syste

m

Monito

ring a

rrangem

ents

for

the n

ew

recru

itment

sta

ndard

s n

ot yet in

pla

ce

Deta

iled p

roje

ctio

n o

f ski

ll m

ix

arisin

g f

rom

loss o

f

experience s

taff

/ r

etir

em

ent

bulg

e

Esta

blis

hm

ent not at re

quired

level i

n a

ll are

as.

4H

R d

ashboard

monito

red

weekl

y a

t Exec W

F

Govern

ance C

om

mitt

ee

Key in

dic

ato

rs a

nd e

xceptio

n

report

ed to the B

oard

Focus r

ecru

itment in

novativ

e

join

t w

ork

ing a

nd a

dvert

isin

g

posts

with

neig

hbouring

Tru

sts

Imple

ment m

onito

ring

arr

angem

ents

for

New

Recru

itment S

tandard

s

Imple

ment ro

bust exit

inte

rvie

w p

rocess.

De

taile

d r

ecru

itm

en

t

imp

rove

me

nt

pla

n

de

ve

lop

ed

wit

h

imm

ed

iate

fo

cu

s o

n

recru

itm

en

t to

me

dic

al

po

sit

ion

s w

ith

in t

he

frag

ile

se

rvic

es

an

d

clo

sin

g v

acan

cy g

ap

fo

r

qu

alifi

ed

nu

rse

s

12

Tru

st B

oard

12

Item

6

of 134

30

3

: S

upp

ort

Hig

h P

erf

orm

ance

an

d Im

pro

ve

me

nt

4:

Impro

ve

Care

an

d S

erv

ice

s t

hro

ug

h In

teg

ratio

n a

nd

Colla

bo

ratio

n

An

nu

al

Pla

n

Ob

jecti

ve

2016/1

7

Ex

ec L

ea

dR

isk

nu

mb

er

Pri

ncip

al

Ris

ks

Likelihood

Impact

Ke

y C

on

tro

l e

sta

bli

she

dK

ey G

ap

s in

Co

ntr

ols

Control

Ass

ura

nce

Ga

ps

in A

ssu

ran

ce

Acti

on

Pla

n S

um

ma

ryO

pe

nin

g

Po

siti

on

Ass

ura

nce

leve

l

End of Q1

End of Q2

End of Q3

End of Q4

Bo

ard

Assu

ran

ce F

ram

ew

ork

/ C

orp

ora

te R

isk R

eg

iste

r

Imp

rove

Sta

ff

Co

ntr

ibu

tio

n t

o

Go

als

an

d V

alu

es

Directo

r of

Work

forc

e

and O

D

3.2

IF s

taff

do n

ot part

icip

ate

in a

good q

ualit

y P

DR

TH

EN

sta

ff

rete

ntio

n m

ay r

educe a

nd the

work

forc

e c

apabilitie

s o

f

Tru

st to

deliv

er

hig

h

perf

orm

ance a

nd

impro

vem

ent m

ay b

e

com

pro

mis

ed.

53

HH

H p

lan

New

PD

R p

rocess la

unched

Report

s o

n c

om

plia

nce r

ate

Managers

not held

to a

ccount

for

not undert

aki

ng P

DR

s

No m

eth

od o

f m

onito

ring

qualit

y o

f PD

R (

as d

istin

ct

from

num

ber

of

PD

Rs

undert

ake

n)

4M

onito

ring b

y W

ork

forc

e a

nd

Leaders

hip

Board

with

Div

isio

nal/d

epart

menta

l level

report

ing.

Managers

not held

to a

ccount

for

not undert

aki

ng P

DR

s

No m

eth

od o

f m

onito

ring

qualit

y o

f PD

R (

as d

istin

ct

from

num

ber

of

PD

Rs

undert

ake

n)

Develo

p a

nd im

ple

ment a P

DR

qualit

y m

onito

ring s

yste

m w

ith

whic

h to im

pro

ve the

eff

ectiv

eness o

f th

e

convers

atio

n. S

ite b

ased

report

ing b

ein

g d

evelo

ped.

Intr

oductio

n o

f 360 d

egre

e

feedback

for

managers

Div

isio

nal D

ire

cto

rs a

nd

Div

isio

nal H

R B

P h

ave

be

en

re

qu

es

ted

to

su

bm

it

as

su

ran

ce

pla

ns

to

co

nfi

rm r

eq

uir

ed

targ

et

will b

e m

et

12

Tru

st B

oard

12

An

nu

al

Pla

n

Ob

jecti

ve

2016/1

7

Ex

ec L

ea

dR

isk

nu

mb

er

Pri

ncip

al

Ris

ks

Likelihood

Impact

Ke

y C

on

tro

l e

sta

bli

she

dK

ey G

ap

s in

Co

ntr

ols

Control

Ass

ura

nce

Ga

ps

in A

ssu

ran

ce

Acti

on

Pla

n S

um

ma

ryO

pe

nin

g

Po

siti

on

Ass

ura

nce

leve

l

End of Q1

End of Q2

End of Q3

End of Q4

Bo

ard

Assu

ran

ce F

ram

ew

ork

/ C

orp

ora

te R

isk R

eg

iste

r

Directo

r of

Esta

tes a

nd

Facilitie

s

4.4

.2IF

lack

if in

vestm

ent in

NM

GH

esta

te c

ontin

ues d

ue to

natio

nal s

hort

age o

f public

div

idend c

apita

l or

busin

ess

case n

ot appro

ved a

t G

reate

r

Mancheste

r or

treasury

levels

TH

EN

tem

pora

ry w

ork

to

allo

w p

atie

nt care

in c

urr

ent

facilitie

s w

ill n

eed to c

ontin

ue

44

Esta

te c

ontr

ol p

lan

Back

log M

ain

tenance p

lan

Agre

ed C

apita

l Develo

pm

ent

Pla

n f

or

Nort

h M

ancheste

r

4?

Assura

nce p

rocess f

or

esta

te d

evelo

pm

ent

Agre

e C

linic

al S

trate

gy f

or

the

Tru

st and N

ort

h M

ancheste

r's

pla

ce w

ithin

that

Identif

y c

apita

l solu

tions w

ith

SH

S G

M D

evo

Agre

e a

nd f

und in

terim

ward

upgra

de p

rogra

mm

e

12

Tru

st B

oard

12

Imp

rove

th

e

Urg

en

t C

are

se

rvic

e a

t N

ort

h

Man

ch

es

ter

in

lin

e w

ith

CQ

C

an

d N

HS

i

req

uir

em

en

ts

Directo

r of

Opera

tions

4.3

.1IF

the T

rust is

unable

to

sta

bilise a

nd s

usta

in the

medic

al w

ork

forc

e to s

upport

ED

and A

MU

TH

EN

there

is a

risk

that th

e T

rust on the

NM

GH

site

could

not pro

vid

e

24/7

em

erg

ency c

are

45

Recru

itment pla

n w

ith C

MFT / S

RFT

Use o

f in

terim

locum

s

Overs

eas r

ecru

itment

PA

T w

ork

forc

e p

lan to m

obilise a

nd

str

ength

en

Pennin

e s

taff

response to E

D

GM

off

er

of

Consulta

nt sta

ff

Imple

menta

tion o

f N

WA

S p

ath

finder

QI p

lan

Longer

term

fundin

g o

f

Impro

vem

ent Pla

n.

Susta

inability

of

inte

rim

solu

tion f

rom

GM

pro

vid

er

beyond M

arc

h

3D

aily

rota

scru

tiny

Impro

vem

ent Pro

ject

Care

Board

GM

Impro

vem

ent B

oard

Monito

ring o

f Im

pro

vem

ent

Pla

n a

t C

are

Board

and G

M

Impro

vem

ent B

oard

Se

nio

r m

an

ag

er

an

d

clin

ical le

ad

ers

hip

gap

s

on

NM

GH

sit

e

Contin

ue to im

ple

ment

Impro

vem

ent Pla

n (

timelin

es

outli

ned w

ithin

pla

n)

Contin

ue to s

eek

long term

financia

l fundin

g (

agre

em

ent

by D

ec 2

016).

Ensure

transpare

ncy o

f ro

ta a

nd

ease o

f use b

y d

evelo

pin

g

ele

ctr

onic

ally

(end O

ct 2016 -

com

ple

ted).

Develo

p P

lan B

post M

arc

h (

Dec2016).

Appoin

t to

and s

trength

en

clin

ical a

nd m

anagerial

leaders

hip

into

Dept (D

ec

2016)

12

Tru

st B

oard

12

of 134

31

5:

Dem

onstr

ate

Co

mp

lian

ce w

ith

Ma

nd

ato

ry S

tand

ard

s

Directo

r of

Opera

tions

4.3

.2IF

the T

rust is

unable

to

impro

ve p

atie

nt flow

and

reduce U

C d

em

and thro

ugh a

ll

site

s w

ith e

merg

ency

depart

ments

TH

EN

the

natio

nal s

tandard

s f

or

access

will n

ot be m

et and p

atie

nt

care

will b

e c

om

pro

mis

ed

55

Esta

blis

hm

ent of

impro

vem

ent pro

jects

focussin

g o

n h

ospita

l flo

w a

nd u

rgent

care

(adults

and p

aeds).

Work

ing w

ith

EC

IP to d

evelo

p a

nd d

eliv

er

pla

n a

ligned to

UC

natio

nal i

mpro

vem

ent prioritie

s. Jo

ined

natio

nal a

mbula

tory

em

erg

ency c

are

netw

ork

.

Syste

m w

ide p

lans to b

e

develo

ped v

ia U

C d

eliv

ery

board

. Fundin

g a

nd p

lans f

or

dela

yed tra

nsfe

rs o

f care

.

Medic

al w

ork

forc

e c

apacity

to e

nsure

tim

ely

revie

ws

again

st sta

ndard

s a

gre

ed.

Senio

r nurs

ing c

apacity

to

support

flo

w a

nd d

ischarg

e

pla

nnin

g a

t w

ard

level.

Robust lo

cal a

nd s

yste

m w

ide

escala

tion p

olic

ies

3U

C Q

ualit

y a

nd p

erf

orm

ance

meetin

gs a

cro

ss a

ll Eds.

Monito

ring o

f Im

pro

vem

ent

Pla

ns a

t care

Board

, tr

ust

Board

and G

M. O

ps a

nd

perf

orm

ance a

ssura

nce

Com

mitt

ee

Syste

m le

vel p

erf

orm

ance

vie

w a

nd a

ssura

nce

Deliv

ery

of

PA

HT

impro

vem

ent pla

n p

roje

cts

(tim

elin

es o

utli

ned w

ithin

pla

n).

Fin

alis

e p

lan f

or

SR

G

fundin

g a

nd r

esilience p

lan

(Oct 2016, changed N

ov

2016))

and U

C s

yste

m w

ide

impro

vem

ents

with

EC

IP

(Marc

h 2

017).

Fin

alis

e lo

cal

and s

yste

m w

ide e

scala

tion

polic

y a

nd p

lans (

Nov 2

016)

.

Revie

w U

C D

eliv

ery

Board

arr

angem

ents

(D

ec 2

016)

13

Tru

st B

oard

13

An

nu

al

Pla

n

Ob

jecti

ve

2016/1

7

Ex

ec L

ea

dR

isk

nu

mb

er

Pri

ncip

al

Ris

ks

Likelihood

Impact

Ke

y C

on

tro

l e

sta

bli

she

dK

ey G

ap

s in

Co

ntr

ols

Control

Ass

ura

nce

Ga

ps

in A

ssu

ran

ce

Acti

on

Pla

n S

um

ma

ryO

pe

nin

g

Po

siti

on

Ass

ura

nce

leve

l

End of Q1

End of Q2

End of Q3

End of Q4

Bo

ard

Assu

ran

ce F

ram

ew

ork

/ C

orp

ora

te R

isk R

eg

iste

r

Achie

ve the

follo

win

g k

ey

Access targ

ets

:

A&

E t

arg

et

Op

en

RT

T

path

way t

arg

et

Can

ce

r 62 d

ay

targ

et

Dia

gn

os

tic t

arg

et

Directo

r of

Opera

tions

5.1

IF e

ffectiv

e d

ata

qualit

y

pro

cess a

re n

ot in

pla

ce

TH

EN

data

subm

issio

ns, data

used f

or

assura

nce a

nd

govern

ance p

rocesses a

nd

data

used to p

rogre

ss p

atie

nt

treatm

ent m

ay b

e

com

pro

mis

ed

54

Weekl

y c

ancer

and R

TT P

TL m

eetin

gs in

pla

ce. C

entr

alis

ed a

ccess a

nd b

ooki

ng

functio

n a

nd team

s. C

ancer

tracke

rs a

nd

MD

Ts. N

ew

PTL c

reate

d f

or

follo

w u

p

patie

nts

. Part

ial b

ooki

ng in

pla

ce f

or

som

e

specia

litie

s. S

yste

matic

audit

pla

n a

gre

ed

to v

alid

ate

open p

ath

ways.

No d

aily

ED

bre

ach a

naly

sis

by s

ite le

d b

y D

M a

nd

attended b

y le

ad c

linic

ian. N

ot

all

clin

icia

ns r

ecord

in

Sym

phony N

o R

TT tra

inin

g

pro

gra

mm

e in

pla

ce. W

eekl

y

PTL m

eetin

g n

eeds to f

ocus

on n

on b

reach p

ath

ways.

RTT f

unctio

nalit

y in

PA

S n

ot

util

ised. W

ork

forc

e c

apacity

to u

ndert

ake

valid

atio

n w

ork

Part

ial b

ooki

ng n

ot in

pla

ce in

all

specia

litie

s.

4C

urr

ent bre

ach r

eport

s a

nd

data

subm

issio

ns s

igned o

ff

by D

ivis

ional D

irecto

rs.

Actio

n p

lan a

ssure

d v

ia

Opera

tions a

nd P

erf

orm

ance

Com

mitt

ee

Subm

issio

ns s

ign o

ff n

ot

support

ed b

y D

ata

Qualit

y

relia

bility

GM

cancer

clo

ck

sta

rt / s

top

pro

cess n

ot in

pla

ce a

t PA

T

(Natio

nal s

yste

m u

sed)

Tra

inin

g p

rogra

mm

e f

or

RTT

to b

e p

rocure

d a

nd

imple

mente

d (

com

mence O

ct -

Marc

h 2

016)

Revie

w o

f

booki

ng a

nd s

chedulin

g team

syste

ms a

nd p

rocesses

(com

menced O

ct -

Marc

h

2016).

Data

Qualit

y

impro

vem

ent pro

gra

mm

e

required (

baselin

e

assessm

ent D

ec 2

016).

Imple

ment R

TT f

unctio

nalit

y in

PA

S (

upgra

de 2

017).

Dete

rmin

e u

se o

f G

M S

tart

/

Sto

p c

lock

pro

cess fo

r

cancers

(com

ple

ted p

olic

y

adopte

d O

ct 2016).

Com

mence P

AS

cle

anse a

nd

imple

ment new

contr

ols

(com

menced O

ct 2016,

conclu

de A

pril 2

017).

Deliv

er

ED

data

qualit

y p

lan (

Sept

2016 -

Mar

2017).

Develo

p

robust B

I tools

and s

yste

ms

to e

nsure

data

is v

iable

, tim

ely

and a

ccura

te f

or

opera

tional

team

s (

Sept 2016-

April 2

017)

13

Tru

st B

oard

13

Item

6

of 134

32

Infe

cti

on

s:

C,D

iff

MR

SA

Medic

al

Directo

r

5.2

IF the T

rust fa

ils to m

eet

mandato

ry s

tandard

s f

or

infe

ctio

n c

ontr

ol T

HEN

this

could

lead to p

atie

nt harm

and

/ or

the q

ualit

y o

f patie

nt care

could

be a

ffecte

d w

hic

h

could

lead to r

egula

tory

involv

em

ent and r

eputa

tional

dam

age

44

Infe

ctio

n C

ontr

ol P

olic

y

Hand w

ashin

g m

andato

ry tra

inin

g

Infe

ctio

n C

ontr

ol t

eam

in p

lace

Cle

anin

g c

ontr

act and s

chedule

in p

lace

Nurs

e e

quip

ment cle

anin

g s

chedule

pro

cess in

pla

ce

Infe

ctio

n c

ontr

ol g

ap a

naly

sis

identif

ied c

leanin

g n

ot m

eetin

g

required s

tandard

s in

som

e

are

as

5In

fectio

n c

ontr

ol r

eport

to

Infe

ctio

n c

ontr

ol c

om

mitt

ee

Cle

anin

g r

eport

to c

leanin

g

com

mitt

ee

Key in

fectio

n c

ontr

ol i

ssues in

IPR

to Q

ualit

y a

nd P

atie

nt

experience a

nd T

rust B

oard

Infe

ctio

n C

ontr

ol a

nd c

leanin

g

audits

carr

ied o

ut

?R

ein

sta

te s

tandard

s to

cle

anin

g c

ontr

acto

rs w

ith

sig

nific

ant im

pact

Ward

accre

dita

tion p

rocess

focusses o

n 'd

ays s

ince la

st

infe

ctio

n'

Dir

of

Es

tate

s a

nd

Facilit

ies

un

de

rtak

en

walk

rou

nd

at

NM

GH

wit

h D

N.

Mo

nth

ly m

ee

tin

g w

ith

Dir

Es

tate

s a

nd

Facilit

ies

wit

h

se

nio

r m

an

ag

er

fro

m G

4S

,

acti

on

pla

n a

gre

ed

.

Su

gg

es

t s

ep

ara

tin

g o

ut

cle

an

ing

as

a s

ep

ara

te

ris

k t

o a

llo

w v

isib

ilit

y o

f

ris

k a

nd

imp

rove

me

nt/

de

teri

ora

tio

n.

13

Tru

st B

oard

13

of 134

C:\Users\244991-admin\AppData\Local\Temp\31492e16-662b-4361-b8e3-7dcd9f4674be.doc

Title of Report Financial Position to 31st October 2016

Submitted to Trust Board of Directors

Date November 2016

Executive Summary

The report summarises the financial performance to 31st October 2016

Actions requested The Board is asked to review the issues raised and consider if there are any issues that need to be identified and addressed.

Corporate Priorities supported by this paper: 1. Pursue Quality Improvement to assure Safe, Reliable and Compassionate Care 2. Deliver Financial Plans to assure sustainability 3. Support High Performance and Improvement 4. Improve Care and Services through Integration and Collaboration 5. Demonstrate Compliance with Mandatory Standards

Risks: This paper addresses the risk to;

Delivery of the 2016/17 cost improvement programme (CIP) of £25.8m, £17.8m of which is recurrent and £8.0m non recurrent.

Cash balances and liquidity to be managed to deliver EFL, CRL and Public Sector Payment Policy.

Delivery of planned activity levels for 2016/17.

Contractual Risks.

Development and Assurance This paper has been prepared by the senior finance team and reviewed by the Executive Director of Finance

Public and/or patient involvement: None relevant for this paper.

Resource implications: None relevant for this paper.

Communication: Updates on the Trust’s financial performance are included in regular briefings to staff.

Have all implications been considered? YES NO N/A

Alignment to Trust Vision, Values and Priorities

Assurance through the Committee structure

Consultation (internal or external)

Contract Implications

Equality and Diversity

Financial / Efficiency Implications

Information Governance Assurance

IM&T Requirements

National policy / legislation

Patient Experience

Partnerships

Sustainability and Carbon Reduction

Workforce Implications

Item

7

of 134

C:\Users\244991-admin\AppData\Local\Temp\31492e16-662b-4361-b8e3-7dcd9f4674be.doc

Name Damien Finn

Job Title Director of Finance

Email [email protected]

Date November 2016

of 134

Fin

ancia

l P

ositio

n t

o 3

1st

Octo

be

r 2

01

6

Mo

nth

7

Fin

an

ce

Pe

rfo

rma

nc

e R

ep

ort

2016-1

7

Item

7

of 134

1.

Fin

ance o

verv

iew

2.

Fin

ance d

ashboard

3.

CIP

perf

orm

ance

4.

Div

isio

nal I&

E s

um

mary

5.

Fin

ancia

l risks s

um

mary

6.

KP

I penaltie

s &

CQ

UIN

schem

es

7.

Key f

inancia

l ta

rgets

8.

Bala

nce s

heet (s

tate

me

nt

of

financia

l

positio

n)

9.

Capital expenditure

10.

Cash

Appe

ndix

A Incom

e a

nd e

xpenditure

Appendix

BR

olli

ng c

ash flo

w

Appe

ndix

C A

gen

cy e

xpenditure

tre

nd

Appe

ndix

D A

gen

cy r

un r

ate

Appe

ndix

E A

cute

contr

act

activity p

erf

orm

ance

Glo

ssary

Con

tents

of 134

Th

eT

rust’s

cu

rre

nt

deficit

pla

nre

fle

cts

NH

SI’s

late

st

form

ally

issu

ed

contr

olto

talo

f£

15

.2m

for

the

year.

Th

e£

15

.2m

deficit

pla

nre

flects

an

additio

nal

allo

cation

of

£3

.1m

of

transfo

rmation

fundin

gfr

om

GM

toin

cre

ase

the

£6

.1m

alr

eady

com

mitte

db

ylo

cal

CC

Gs

toth

e£

9.2

mn

ee

de

das

part

of

the

Tru

st’s

sta

bili

sation/im

pro

vem

entpla

n.

Ina

dd

itio

nto

the

£3.1

min

ve

stm

en

tfr

om

GM

,N

HS

Ia

pp

rove

da

“lik

efo

r

like”

adju

stm

ent

toth

eT

rust

contr

ol

tota

lin

cre

asin

gth

isto

a£

15

.2m

deficit

inlin

ew

ith

the

Tru

st’s

expecte

doutturn

positio

n.

As a

t m

onth

7 the Y

TD

fin

ancia

l positio

n is a

n £

11.0

m d

eficit a

gain

st a

pla

nne

d d

eficit o

f £11.0

m. A

bre

akeven p

ositio

n a

gain

st pla

n -

see

Appen

dix

A. In

sum

mary

the v

aria

nce p

ositio

n a

t m

onth

7 c

om

pare

d to

month

6 is:-

1.

Fin

ance O

verv

iew

(1)

Va

rian

ce

M7

Va

rian

ce

M6

Move

me

nt

£'m

£'m

£'m

Inco

me

(0.9

)(1

.1)

0.2

Exp

en

ditu

re(3

.8)

(3.3

)(0

.5)

CIP

Slip

pa

ge

(2.1

)(1

.6)

(0.5

)

Re

se

rve

Mitig

atio

n6.8

6.0

0.8

To

tal

0.0

0.0

0.0

Ap

rM

ayJu

nJu

lA

ug

Sep

Oct

No

vD

ecJa

nFe

bM

ar

Pla

n(4

,21

5)(7

,93

0)(5

,29

7)

(6,2

65)

(7,2

29)

(8,1

94)

(11,

04

9)(1

2,0

49)

(13,

22

3)(1

4,1

09)

(14

,659

)(1

5,2

47)

Act

ual

(5,2

46)

(9,7

97)

(5,2

73

)(6

,24

2)(7

,20

4)(8

,17

4)(1

1,0

24)

Var

ian

ce a

gain

st P

lan

(1,0

31)

(1,8

67)

2423

2520

2512

,04

913

,22

314

,10

914

,65

915

,24

7

(20

,00

0)

(18

,00

0)

(16

,00

0)

(14

,00

0)

(12

,00

0)

(10

,00

0)

(8,0

00

)

(6,0

00

)

(4,0

00

)

(2,0

00

)0

Surplus/Deficit £'000

Item

7

of 134

Key

poin

tsto

note

are

:

T

he

Tru

stpositio

nassum

es

paym

ento

f;

•T

he

ST

Fallo

cation

with

no

pena

ltie

s,£12

.0m

YT

D(£

20.5

mfu

llye

ar)

•C

CG

suppo

rto

f£

4.1

mY

TD

from

a1

%nationalcontingen

cy

held

atC

CG

levela

nd

•T

ransfo

rmation

fundin

go

f£

1.8

mY

TD

(£3

.1m

full

year)

from

GM

T

he

incom

efigure

report

ed

above

recogn

ises

the

agre

em

ent

of

afixed

outturn

positio

nw

ith

the

4m

ain

CC

Gs,

the

year

todate

be

ne

fit

of

wh

ich

is£

3.6

m(T

his

isover

an

dabove

the

contr

ibution

from

the

CC

Gs

1%

nationalcontingen

cy

above)

T

he

unde

rlyin

gin

com

epositio

nis

un

ch

an

ge

dw

ith

an

un

de

rpe

rfo

rman

ce

of

£5

.0m

YT

D,

with

contr

act

incom

eachie

vin

gpla

novera

llin

Octo

ber

20

16

.

Y

ear

todate

Agency

spend

is£

23

.1m

com

pare

dto

pla

nne

dspend

of

£1

7.3

mre

sultin

gin

aY

TD

overs

pen

do

f£

5.8

m.

(See

Appen

dix

D).

Th

ea

ge

ncy

month

lyru

nra

teh

as

dro

pped

from

a£

3.5

mave

rag

eu

pto

Ju

ly,

befo

reth

ee

nh

an

ce

da

ge

ncy

contr

ols

be

ga

nto

take

eff

ectto

an

avera

ge

of

£3

.0m

for

the

pe

rio

dA

ug

us

tth

rou

gh

toO

cto

be

r.

F

urt

her

reductio

ns

inth

ea

ge

ncy

run

rate

are

anticip

ate

da

sn

on

clin

ical

agency

continues

tob

ere

duce

d,

new

lyqualif

ied

nurs

ing

sta

ff

are

recru

ited

an

dth

eim

pacto

fa

nin

cre

ase

ba

nk

rate

begin

sto

take

eff

ect.

C

IPslip

pag

eo

f£

2.1

mY

TD

with

CIP

deliv

ery

of£

11

.5m

inm

onth

7again

sta

targ

eto

f£

13

.6m

R

eserv

em

itig

ation

isth

eapplic

ation

of

agency

reserv

e,

no

n-p

ay

expen

diture

reserv

es

linked

todeliv

erin

gth

ein

com

epla

nw

hic

hhave

notbeen

utilis

ed

due

tou

nd

erp

erf

orm

an

ce

.

1.

Fin

ance O

verv

iew

(2)

of 134

1.

Fin

ance O

verv

iew

(3)

Ob

jecti

ve

%

allo

cati

on

YT

D P

erf

orm

an

ce (

Mo

nth

7)

Ta

rge

tA

ch

ieve

dV

arian

ce

Fin

an

cia

l C

on

tro

l T

ota

l 70%

Ach

ieve

d£8.4

m£8.4

m0

Ac

ce

ss

Sta

nd

ard

s:

A&

E 4

Ho

ur

Ta

rge

t12.5

0%

Fa

iled

£1.5

m£0.9

m(£

0.6

m)

RT

T 9

2%

*12.5

0%

Ach

ieve

d£1.5

m£1.5

m0

62 D

ay

Ca

nce

r*5%

Ach

ieve

d£0.6

m£0.6

m0

Dia

gn

ostic

0%

Ach

ieve

d£0.0

m£0.0

m0

To

tal

100%

£12.0

m£11.4

m(£

0.6

m)

Susta

inabili

ty a

nd T

ransfo

rmation F

und 2

016/1

7 –

Crite

ria a

nd M

easure

ment

Th

e T

rust w

ill b

e a

ble

to

acce

ss th

e £

20

.5m

ST

F o

n d

eliv

ery

of th

e y

ear

to d

ate

co

ntr

ol to

tal p

lus m

ilesto

ne

s fo

r C

art

er

imp

lem

en

tatio

n a

nd

age

ncy

sp

en

d r

edu

ctio

n. T

he T

rust is

als

o r

eq

uire

d t

o d

eliv

er

aga

inst

an

im

pro

ve

me

nt p

lan o

n c

ore

sta

nd

ard

s in

clu

din

g a

ccid

en

t a

nd

em

erg

en

cy f

our

hou

rs,

RT

T 9

2%

an

d 6

2 d

ay c

ance

r to

acce

ss th

e f

und

. M

on

th 7

perf

orm

ance

is d

eta

iled in

th

e ta

ble

be

low

. U

nle

ss p

erf

orm

ance

aga

inst

the

A&

E f

our

hou

r

targ

et is

back o

n tra

jecto

ry b

y th

e e

nd

of th

e y

ear

the y

ear

to d

ate

va

lue a

t risk is £

0.6

m.T

he A

&E

pen

alty

is a

ssu

me

d to

be r

eco

ve

red

with

in t

he

repo

rte

d fin

an

cia

l p

ositio

n a

nticip

atin

g a

su

cce

ssfu

l a

pp

ea

l, w

hic

h is a

ris

k.

* D

ue

to

th

e tim

ing o

f th

e p

erf

orm

ance

data

, a

ch

ieve

me

nt is

base

d o

n th

e f

irst

six

mo

nth

s o

f th

e y

ear.

Item

7

of 134

1.

Fin

ance O

verv

iew

(4)

Th

e T

rust

is fo

reca

stin

g to

hit th

e d

eficit c

on

tro

l to

tal o

f £

15

.2m

se

t b

y N

HS

I,

alth

ou

gh

th

ere

are

a n

um

be

r o

f ke

y v

ari

ab

les (

risks)

tha

t co

uld

im

pa

ct o

n the

Tru

sts

ab

ility

to

de

live

r a

£1

5.2

m d

eficit.

Th

e k

ey v

ari

ab

les a

re;

Inco

me

–in

co

me

un

de

rpe

rfo

rman

ce o

f £

3.3

m h

as b

ee

n r

eco

gn

ise

d w

ith

in

the

£1

5.2

m d

eficit, h

ow

eve

r, t

he

Tru

st

ha

s u

nd

erp

erf

orm

ed

by a

fu

rth

er

£3

.6m

as a

t th

e e

nd

of

Octo

be

r w

hic

h h

as b

ee

n m

itig

ate

d in

ye

ar

by a

fix

ed

inco

me

de

al w

ith

th

e 4

ma

in C

CG

s.

ST

F P

en

altie

s –

Th

e T

rusts

pla

n a

ssu

me

s fu

ll p

aym

en

t o

f S

TF

fu

nd

ing

.

Assu

min

g th

e T

rust

de

live

rs th

e c

on

tro

l to

tal e

xclu

din

g S

TF

fu

nd

ing

th

ere

is

£3

.2m

of fu

nd

ing

at ri

sk (

still

to b

e e

arn

ed

) re

late

d to

th

e a

cce

ss ta

rge

ts.

CIP

De

live

ry –

At

the

en

d o

f O

cto

be

r th

e T

rust

ha

s s

till

to d

eliv

er

£6

.9m

of

its C

IP t

arg

et.

Wors

t ca

se

sce

na

rio

assu

me

s o

nly

33

% d

eliv

ery

ag

ain

st th

is

targ

et,

mo

st lik

ely

66

% d

eliv

ere

d a

nd

be

st ca

se

10

0%

de

live

red

.

CQ

C/s

tab

ilisa

tion

–T

he

re is £

9.2

m a

va

ilab

le fo

r in

ve

stm

en

t. If a

ll cu

rre

nt

co

mm

itm

ents

ma

teri

alis

ed

in y

ea

r th

en

th

e p

ote

ntia

l ove

rsp

en

d w

ou

ld b

e

£0

.6m

.

Ag

en

cy s

pe

nd

–a

ra

ng

e o

f a

ge

ncy o

ve

rsp

en

ds h

ave

be

en

ca

lcu

late

d w

ith

be

st ca

se

assu

min

g a

ll p

lan

ne

d m

itig

atio

ns ta

ke

eff

ect,

be

st ca

se

assu

me

s

cu

rre

nt sp

en

d tre

nd

co

ntin

ue

s a

nd

wo

rst

ca

se

assu

me

s a

le

ve

l o

f sp

en

d in

the

la

tte

r e

nd

of

the

fin

an

cia

l ye

ar

at

the

20

15

/16

ra

te. A

ge

ncy s

pe

nd

is

mitig

ate

d b

y a

co

mb

ina

tio

n o

f su

bsta

ntive

sta

ffin

g v

aca

ncie

s a

nd

an

ag

en

cy

rese

rve

.

Fo

recast

Perf

orm

an

ce A

gain

st

Pla

n

Be

st

Ca

se

Mo

st

Lik

ely

Wo

rst

Ca

se

£'0

00

£'0

00

£'0

00

Pla

nn

ed

su

rplu

s/(

deficit)

(15

,24

7)

(15

,24

7)

(15

,24

7)

Ke

y v

ari

ab

les

Inco

me

und

erp

erf

orm

ance

aga

inst

pla

n(3

,58

0)

(5,1

37

)(6

,13

7)

ST

F p

en

altie

s0

0(3

,20

3)

CIP

De

live

ry -

Va

rian

ce

to

ta

rge

t0

(2,3

00

)(4

,60

0)

CQ

C/s

tabili

sa

tio

n in

ve

stm

ent

ove

rsp

en

d0

0(6

00

)

Ag

en

cy O

ve

rsp

en

d-

abo

ve

£2

9.9

m(3

,72

0)

(8,2

38

)(1

0,6

97

)

Inco

me

mitig

atio

n -

fixe

d d

ea

l/C

CG

su

pp

ort

3,5

80

5,1

37

6,1

37

Re

se

rve

Mitig

atio

n -

exp

en

ditu

re

budgets

1,4

80

1,4

80

2,4

80

Ag

en

cy m

itig

atio

n -

su

bsta

ntive

va

ca

ncie

s1

,86

04

,05

85

,34

9

Ag

en

cy m

itig

atio

n r

ese

rve

5,0

00

5,0

00

5,0

00

Po

ten

tia

l s

urp

lus

/(d

efi

cit

)(1

0,6

27

)(1

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deficit

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.

Sta

tuto

ry D

uty

Tru

st

Ta

rge

tP

os

itio

n t

o D

ate

1B

reak-e

ve

nta

kin

g o

ne

ye

ar

with

ano

the

r.D

eficit p

lan o

f £

15

.2m

at ye

ar

end

.

Th

e T

rust is

re

po

rtin

g a

deficit o

f £

11

m a

t th

e e

nd

of O

cto

be

r 2

01

6

befo

re im

pairm

ents

and

do

na

ted

asse

ts w

hic

h a

re e

xclu

de

d fro

m

the b

rea

k e

ve

n d

uty

pla

ce

d o

n tru

sts

. N

HS

ih

as a

gre

ed

th

e T

rust’s

revis

ed c

ontr

ol to

tal fo

r th

e y

ear

of £

15

.2m

(fr

om

£12

.1m

).

2N

ot

to e

xce

ed

th

e E

xte

rna

l

Fin

an

ce

Lim

it (

EF

L).

Not to

exceed the E

FL

.

Th

e p

lann

ed

EF

L f

or

the y

ear

is a

positiv

e £

18

.0m

base

d o

n a

ye

ar

end

ca

sh

bala

nce

of £

1.9

m.T

he D

oH

have

ye

t to

fo

rma

lly

co

nfirm

th

e T

rust’s E

FL

fo

r th

e y

ear

follo

win

g t

he r

evis

ed c

ontr

ol

tota

l.

3T

o a

ch

ieve

a 3

.5%

re

turn

on

ca

pita

le

mp

loye

d.

Atr

ust d

eb

t re

mu

ne

ratio

n ta

rge

t

ca

lcu

late

d a

t 3

.5%

of a

ve

rag

e n

et re

leva

nt

asse

ts

3.5

% r

etu

rn w

ill b

e a

ch

ieve

d a

t ye

ar

end b

y p

aym

ent

of th

e

div

iden

d (

paid

Se

pt a

nd

Ma

rch

).

A d

ivid

en

d o

f £7

.9m

fo

r th

e y

ear

is inclu

ded in t

he O

cto

ber

revis

ed p

lan a

nd s

even m

onth

’s s

hare

of

the d

ivid

en

d h

as b

ee

n a

ccru

ed

at th

e e

nd

of O

cto

be

r 2

01

6.

4

No

t to

exce

ed

th

e C

apita

l

Re

so

urc

e L

imit (

CR

L)

for

the

ye

ar.

No

t to

exce

ed

th

e C

RL

fo

r th

e y

ear.

Th

ere

vis

ed p

lann

ed

CR

L f

or

the y

ear

is £

23

.7m

. T

his

has b

een

co

nfirm

ed b

y N

HS

i.

Th

e T

rust h

as u

nd

ers

pen

t a

ga

inst

the p

lan

for

the y

ear

to d

ate

by

£4.1

m.

Do

H D

uty

Tru

st

Ta

rge

tP

erf

orm

an

ce

Pu

blic

Se

cto

rP

aym

ent

Po

licy (

PS

PP

)

95%

of tr

ade

cre

dito

rs to

be p

aid

with

in

30 d

ays o

f re

ce

ipt o

f in

vo

ice

/go

od

s.

Ca

sh

pla

ns a

nticip

ate

re

gu

lar

paym

ent

of

cre

dito

rs t

o a

ch

ieve

th

is t

arg

et.

95%

by

num

ber

&99%

by

va

lue

of

cre

dito

rshad

been

paid

with

in

30

days.

of 134

8. B

ala

nce

sh

ee

t (S

tate

men

t of fin

an

cia

l po

sitio

n)

Th

e p

lan a

nd

co

ntr

ol to

tal h

as b

ee

n r

evis

ed in

Octo

be

r. T

he p

lann

ed

I&E

deficit is

now

£15

.8m

(£

15

.2m

aft

er

techn

ica

l a

dju

stm

ents

) fo

llow

ing

ag

reem

ent b

y N

HS

i.

Ca

pita

l (F

ixe

d A

sse

ts)

is e

xp

ecte

d to

sp

en

d £

2m

le

ss th

an

th

e r

evis

ed

pla

n f

or

the y

ear.

T

his

is m

ain

ly d

ue

to

dela

ys w

ith

th

e In

term

edia

te

Ca

re F

acili

ty (

ICF

) a

t N

MG

H. T

he fo

reca

st u

nd

ers

pen

d w

ill b

e u

sed

to

su

pp

ort

wo

rkin

g c

apita

l (r

edu

cin

g p

aya

ble

s

–a

llow

s f

lexib

ility

to

ma

na

ge

ca

sh a

t ye

ar

end

).

Ma

in y

ear

to d

ate

(Y

TD

) p

oin

ts a

t th

e e

nd

of O

cto

be

r:

Ne

t C

urr

en

t A

sse

ts/L

iab

ilit

ies –

£13

2k d

iffe

rent fr

om

pla

n. T

he le

ve

l o

f

receiv

able

s a

nd

paya

ble

s d

urin

g th

e y

ear

is d

ifficu

lt to

pre

dic

t (m

ain

ly

due

to

pre

pa

ym

ents

and

accru

als

) a

nd

are

ge

ne

rally

co

un

ter

bala

nce

each

oth

er.

P

rovis

ions h

ave

no

t b

ee

n u

sed

as e

xp

ecte

d b

y t

he e

nd

of

Octo

be

r w

hic

h,

tog

eth

er

with

a f

avo

ura

ble

ca

sh p

ositio

n r

esults in

a

sm

all

va

rian

ce in

ne

t cu

rre

nt a

ssets

/lia

bili

tie

s a

t th

e e

nd

of O

cto

be

r.

To

tal a

ss

ets

em

plo

ye

d/t

axp

aye

rs e

qu

ity –

Ove

rall

the n

et p

ositio

n is

bro

ad

ly in

lin

e w

ith

pla

n.

FIN

AN

CIA

L Y

EAR

20

16

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REV

ISED

P

LAN

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ISED

P

LAN

AC

TUA

LV

aria

nce

FOT

Var

ian

ceY

ear

YTD

YTD

YTD

Ye

ar3

1.3

.17

31

.10

.16

31

.10

.16

31

.10

.16

£0

00

£0

00

£0

00

£0

00

£0

00

NO

N C

UR

REN

T A

SSET

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Ass

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& In

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3,4

60

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7,5

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me

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62

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EQU

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25

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25

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85

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54

69

0

Item

7

of 134

9. C

apital exp

end

itu

re

* E

sta

tes a

nd I

M&

T fig

ure

s a

re n

et

of

any e

stim

ate

d c

apital to

revenue t

ransfe

r

Th

e r

evis

ed C

RL

pla

n o

f £

23

.7m

has b

ee

n a

gre

ed

by

NH

Siin

Octo

be

r.

Th

e fo

reca

st o

ut-

turn

(F

OT

) sh

ow

s t

hat th

e In

term

edia

te

Ca

re F

acili

ty (

ICF

) sch

em

e is f

ore

ca

st to

sp

en

d £

2m

le

ss

than

pla

nn

ed

. T

his

is d

ue

to

dela

ys r

elo

catin

g h

igh

vo

lta

ge

and

te

lecom

s c

able

s b

y U

nite

d U

tilit

ies a

nd

BT

respe

ctive

ly. T

he fo

reca

st u

nd

er

sp

en

t re

sou

rce

will

be

ca

rrie

d fo

rwa

rd to

201

7/1

8. T

he O

AS

IS s

ch

em

e w

ill o

ut-

turn

gre

ate

r th

an

pla

n d

ue

to

hig

her

than

exp

ecte

d te

nd

er

co

sts

. E

ve

ry e

ffo

rt h

as b

ee

n m

ade

to

ke

ep

th

e e

xtr

a c

ost

dow

n.

Th

e C

CG

has b

ee

n a

pp

roa

ch

ed

fo

r a

co

ntr

ibutio

n.

At th

e e

nd

of O

cto

be

r, e

xp

en

ditu

re/C

RL

is u

nd

ers

pen

t b

y

£4.1

m. A

part

fro

m th

e IC

F a

nd

OA

SIS

sch

em

es, th

e

und

ers

pen

ds a

re tim

ing

/pro

filin

g is

su

es. F

or

exa

mp

le, th

e

MR

sca

nn

er

itse

lf (

£1m

) is

due

to

be d

eliv

ere

d in

No

ve

mb

er

rath

er

than

Octo

be

r a

s o

rig

inally

pla

nn

ed

.

Esta

tes, IM

&T

and

M&

S a

re b

eh

ind t

heir y

ear

to d

ate

(YT

D)

pla

nn

ed

sp

en

d p

rofile

but a

re w

ork

ing

to

wa

rds

achie

vin

g t

heir y

ear

end

co

ntr

ol to

tals

.

Th

e p

rog

ram

me

is c

urr

ently e

xp

ecte

d to

sp

en

d £

2m

le

ss

than

th

e r

evis

ed p

lan b

y t

he y

ear

end

.

FIN

AN

CIA

L Y

EAR

20

16

/17

Rev

Pla

nR

ev P

lan

AC

TUA

LV

aria

nce

Var

ian

ce

Ye

arY

TD

YT

DY

TD

FOT

Sch

eme

31

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73

1.1

0.1

63

1.1

0.1

63

1.1

0.1

63

1.3

.17

£0

00

£0

00

£0

00

£0

00

£0

00

Inte

rmed

iate

Car

e Fa

cilit

y N

MG

H3

,77

06

98

32

73

71

2,0

28

MR

Sca

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er (

4th

) FG

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51

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93

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27

0

Sim

ula

tio

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81

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74

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0

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T *

5,6

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45

71

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nat

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8)

00

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Cap

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L)2

3,6

81

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48

2,9

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4,1

00

2,0

06

of 134

10

. C

ash

Th

e c

ash b

ala

nce

at th

e e

nd

of O

cto

be

r is

£1.6

m b

ett

er

than

pla

nn

ed

. T

his

is d

ue

to

lo

we

r th

an

exp

ecte

d c

redito

r p

aym

ents

in O

cto

be

r.

Th

e p

lan h

as b

ee

n r

evis

ed f

rom

Octo

be

r fo

llow

ing

th

e r

evis

ed

I&E

co

ntr

ol to

tal a

nd

re

sub

mis

sio

n o

f p

lans to

NH

Sila

st m

onth

.

Th

e p

lann

ed

ye

ar

end

ca

sh b

ala

nce

of £

1.9

m r

em

ain

s

unch

an

ge

d.

Th

e fo

reca

st fo

r th

e r

em

ain

de

r o

f th

e y

ear

is u

pd

ate

d e

ach

month

.

Ap

rM

ayJu

nJu

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ug

Sep

Oct

No

vD

ec

Jan

Feb

Mar

Rev

Pla

n 1

6/1

72

2.2

22.

42

0.1

24.

72

1.9

10.

21

0.7

13.

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Cash Balance £millions

Dif

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5.7

Item

7

of 134

Appendix

A –

Incom

e a

nd E

xpenditure

Sta

tem

ent

Op

en

ing

Pla

nC

han

ges

to

Pla

nR

evi

sed

A

nn

ual

Pla

nY

ear

to

Dat

e

Pla

nY

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to

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e

Act

ual

Ye

ar t

o D

ate

V

aria

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Fore

cast

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

INC

OM

EC

CG

acu

te c

on

trac

ts3

97

,96

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Engl

and

co

ntr

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list

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04

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25

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52

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NH

S En

glan

d c

on

trac

t -

area

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9,3

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Glo

ssary

of 134

1

Title of Report Infection Prevention and Cleanliness Report

Submitted to Board of Directors Date 24 November 2016

Executive Summary

This report sets out the Trust’s infection prevention and control activities and performance for the period April – November 2016 and provides assurance for:

NHS Outcomes Framework – domain 5 : Treating and caring for people in a safe environment and protecting them from avoidable harm;

CQC Regulation 12(2)(h) - assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated.

Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance.

Actions requested The Board is asked to note the report in relation to compliance with corporate objectives; the Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance (commonly known as The Hygiene Code) and the National Cleaning Standards.

Corporate Priorities supported by this paper: 1. Provide quality improvement to assure safe, reliable and compassionate care. 5. Demonstrate compliance with mandatory standards

Risks: This paper addresses the risk of failure to:

To comply with NHS Outcomes Framework – domain 5 : Treating and caring for people in a safe environment and protecting them from avoidable harm;

To comply with CQC Regulation 12(2)(h) - assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated.

Comply with the Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance.

Development and Assurance This paper has been prepared by the Head Nurse Infection Prevention and the Associate Director of Facilities. The Trust Infection Prevention and Control Committee has reviewed the report and obtain assurance that relevant procedures have been followed.

Public and/or patient involvement: PLACE assessments continue throughout the year.

Resource implications: Increased length of inpatient admission; increased usage of antimicrobials as a result of infection.

Communication: Performance and preventative measures are publicised both externally and internally through Trust reporting and communication channels.

Item

8

of 134

2









IM&T Requirements


Patient Experience

Partnerships



Name Professor Matthew Makin

Job Title Medical Director; Director Infection Prevention & Control


Date 15.11.16

of 134

3

Infection Prevention and Cleanliness Report;

Including Clostridium Difficile Exception Report.

Submitted to Trust Board

24 November 2016

1. Introduction

The following report demonstrates progress against the annual infection prevention programme and in achieving compliance with national standards and performance indicators. The report provides assurance by monitoring the activity of infection prevention and control and identified key issues are noted. The Board is asked to note the report as a point of concern in relation to compliance with corporate objectives; the Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance (commonly known as The Hygiene Code) and the National Cleaning Standards.

2. Strategic Context 2.1 To provide assurance on compliance with:

NHS Outcomes Framework –domain 5 : Treating and caring for people in a safe environment and protecting them from avoidable harm;

Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance (commonly known as The Hygiene Code)

NICE guidance

2.2 This report summarises progress against the work plan for 2016/17 and sets out the Trust’s infection control activities and performance during April – November 2016.

2.3 The infection prevention programme of work continues to be delivered. The progress

is monitored through the Infection Prevention and Control Committee (IPCC), which meets 6 times a year and is chaired by the Director Infection Prevention & Control (Medical Director). Reports are submitted at each committee on progress against the annual plan and key performance objectives.

3. Objectives for reduction of HCAIs.

The objectives for reduction for Clostridium difficile infections (CDI) cases for 2016/17, is calculated based on a stretch trajectory from 2014/15 and has been continued from 2015/16 objective as 55 cases for this year. The objective for MRSA bacteraemias remains as zero tolerance.

3.1 Objectives for reduction of MRSA bacteraemia:

The Trust has investigated 6 pre 48hr bacteraemias since April 2016. All cases have been investigated with the relevant CCG; 4 cases have been confirmed as third party (i.e. not assigned to the Trust). The 5th case has been assigned to North Manchester CCG. The 6th case reported in September was assigned to the Trust. The Trust is currently investigating a 7th case admitted on the 31st October with community acquired sepsis and cerebral haemorrhage.

The bacteraemia case assigned to the Trust in September was almost certainly unavoidable. However, lapses in hospital care relating to documentation, screening and patient’s on-going social circumstances contributed to lapses in care, including a missed opportunity for leg ulcer and wound swabs to be done.

Item

8

of 134

4

This may have been due to the patient refusing wound care, however there is nothing documented to suggest patient was refusing wound swabs. When the MRSA nose and groin screen came back provisionally positive, there was a ward level failure in communication and a missed opportunity to consider the significance of the result. The district nursing referral was not communicated to the district nurses. Because the patient had multiple admissions to other Trusts and was refusing wound care, it is safe to assume that acquisition of MRSA may have happened anywhere.

3.2 Objectives for reduction of Clostridium difficile infection (CDI)

The objective for CDI for 2016/17 is a continuance of last year’s objective of 55 cases.

The Trust has reported 35 hospital attributed CDI cases with 19 agreed with the Lead Commissioners as unavoidable cases (i.e. no lapses in care, no inappropriate prescribing).

The graphs below highlight (1) monthly reported cases per site; (2) SPC chart for total hospital attributed cases.

Please see appendix 1 for SPC charts for CDI per hospital site.

of 134

5

3.3 Increase in Clostridium difficile infection cases during October 2016

All hospital attributed CDI cases receive a root cause analysis investigation as per NHSE Assessment tool for CDI Risk Factors (2015). From the individual RCAs, the following key themes have been identified. All RCAs have been discussed with the relevant Clinical Teams and improvement plans requested for escalation and reporting through Divisional Governance and the Trust Infection Prevention and Control Committee.

3.3.1 Actions to Support CDI Reduction Strategy:

The table below identifies the key findings from each RCA completed for the October cases with any significant areas of lapses in protocol highlighted

Ward/

Site

Isolated

Timely

CDI

Risk

Assess

Bristol

Stool

Chart

Hand

Hygiene

Score

PPE

Score

Domestic

Cleaning

Score

Nurse

Cleaning

Score

Antibiotic

policy

followed

18- FGH Yes Yes Yes 100% 100% 97.69% 100% Yes

F7- ROH Yes Yes Yes 100% 100% 91.58% 86.05% n/a

5- FGH Yes Yes Yes 92% 100% 97.99% 87.10% Yes

T5- ROH No No Yes 70% 80% 94.33% 85.51% Yes

E3- NMGH Yes Yes Yes 94% 55% 82.80% 62.50% Yes

11B- FGH Yes No Yes 100% 100% 95.23% 57.58% Yes

AMU- ROH Yes No Yes 100% 100% 95.56% 88.89% Awaiting

4 out of the 7 cases reported during October had an identified key

theme of community associated diarrhoea, however there were delays in sending a stool sample and therefore the cases were automatically assigned to the Trust. This had been reported to both individual wards and Divisional/site Leads as part of the RCA feedback.

All patients are required to have bowel movements recorded on a Bristol stool chart, therefore an action following these cases, is to add a reminder on the chart to (1) risk assess for CDI and (2) send stool sample if patient has type 5-7 stools recorded without any other cause for diarrhoea.

This is also being escalated as a lessons learnt theme to all Divisional/site Leads and site/Divisional harms meetings.

Continued cleaning issues at North Manchester have been escalated to the Cleaning Contract provider.

A challenge has additionally been set for "100 days free of CDI" for each ward. The intention being to identify high risk wards on each site and implement improvement plans with the clinical teams and those wards where no cases are reported, to share their good practice.

Current wards within 100 days of last CDI case are: Fairfield – wards 5, 11b and 18 NMGH – E3, D6

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Oldham – wards ICU, F11, G1, G2, and T3 (should achieve 100 days this month); wards AMU, F7, F8 T5 remain within 100 days.

The Infection Prevention Team have commenced a 2 month pilot scheme of diarrhoea ward rounds, where medical and surgical wards are visited weekly to support ward teams with assessing patients with diarrhoea for risk of CDI. Whilst this pilot is resource intensive, it is hoped that the pilot evaluation will identify weaknesses in knowledge which can be targeted for enhanced training.

3.3.2 Actions to Date and Planned Actions

The IPC team have been working with site services managers responsible for cleanliness and G4S Management to address any issues.

Daily Chlorclean cleaning for all floors within in-patient areas commenced 01/08/16. This is in line with the daily Chlorclean cleans on all wards for general cleaning that has been in place since 08/10/14.

Regular meetings with the Cleaning Contractor Management Team are on-going and an improvement plan is being closely monitored by both the Facilities and IP Heads of Service. Regular spot-checks are jointly taking place with IP, Facilities, and Cleaning Contract teams of standards of cleaning across the 5 sites.

A micro-teaching package is also in development by the Microbiology team to support Medical colleagues in assessing severity of CDI disease and appropriate treatment plans.

4. Carbapenemase Producing Enterobacteriaceae (CPE) 4.1 All NHS Acute Trusts received a published toolkit regarding Carbapenemase-

producing Enterobacteriaceae (CPE). The Toolkit requires that any inpatient admission is screened for CPE based on a risk assessment and isolated until results are available.

4.2 A programme of training and cascading of the screening protocols is in progress. A risk assessment has been completed for insufficient isolation rooms.

4.3 The graphs below indicate new reported CPE cases per month from April 2015 –

present by hospital site:

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4.4 Reactive–based Infection Control Management:

Contact tracing of patients who are in a bay or ward with a confirmed CPE patient, has had significant implications for the affected ward.

The confirmed patient requires transfer to a side room and the patient contacts require cohort nursing and screening,

To prevent further cross transmission, the cohorted patients remain in the same bay/ward which requires closing that area to admissions, transfers to other wards or hospitals. The IPT has adopted this process for any cases of CPE identified to date with no further transmission to other wards and containment of the case has proved successful.

There has been an increase in cases identified at NMGH and Oldham site. These cases have been reviewed and likely cause for acquisition relates to recent foreign travel or foreign hospital admission and recent admission to neighbouring Manchester hospitals. However, as the admission screening programme becomes embedded, the number of cases may increase with the pressure of cohorting patients; closing bays and the risk of cross transmission increases.

5. E. Coli Bacteraemias 5.1 Health Secretary Jeremy Hunt has launched new plans to reduce infections in the

NHS. He announced government plans to halve the number of gram-negative bloodstream infections by 2020; this is primarily in relation to data from E coli bacteraemias which form part of the national mandatory reporting of HCAIs.

5.2 E.coli bacteraemias are primarily associated with urinary tract infections and as the

graph below indicates, the majority of these infections are community associated (i.e. identified within the first 48hrs of admission).

5.3 Public Health England (PHE) commentary on national surveillance of E. coli bacteraemias states that the counts and rates have increased by 29.0% and 25.8% overall, between January-March 2013 and the current quarter (April-June 2016), with seasonal peaks generally reported between July and September each year. Similarly between April-June 2015 and April-June 2016 there was a 7.2% increase.

5.4 The Department of Health’s plan to reduce these infections includes:

more money for hospitals making the most progress in reducing infection rates with a new £45 million quality premium

independent Care Quality Commission (CQC) inspections focusing on infection prevention based on E. coli rates in hospitals and in the community, and taking action against poor performers

the NHS publishing staff hand hygiene indicators for the first time

displaying E. coli rates on wards, making them visible to patients and visitors in the same way that MRSA and C. difficile are currently

improving training and information sharing so NHS staff can learn from the best in cutting infection rates

appointing a new national infection lead, Dr Ruth May

5.5 The graph below highlights (1) the rates of E.coli infection for all cases (both pre and post 48hr) benchmarked with all North of England NHS Trusts and (2) Trust E.coli bacteraemias indicating the hospital and community associated variance.

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6. Facilities Cleaning Report 6.1 Cleaning Performance

Cleaning performance in the Trust has improved in September and October and all sites exceed the required compliance standard. North Manchester achieved an overall green status for both months.

In October there were a total of 148 audits completed by Trust monitoring officers, many in association with the infection prevention team and the overall compliance by the cleaning contractor in all risk categories across the Trust was 93.41%.

The Director of Estates and Facilities met with National and Regional G4s Directors on 21 October 2016, and reiterated with them the requirement for improved sustained performance and agreed a number of actions to ensure the improvements at North Manchester are sustained. Action include weekly meetings to review the improvement plan and G4S action log..

The Associate Director of Facilities has been liaising with the in house cleaning team from Salford Royal to undertake further independent cleaning audits. Two wards at North Manchester were audited in October and exceeded the required cleaning standard. However the team commented on the cluttered environment and advised that communication between the wards and cleaning teams should be improved. This has been addressed at the site cleaning meeting and with the individual ward managers. Further audits are planned for November

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A project to improve floor cleaning has commenced. A floor survey for North Manchester General Hospital highlighted that long term use of chlorinated products on their own without the follow up of a maintainer to restore and protect the surface had led to poor appearance. A number of operational changes were agreed and floors are no longer being “buffed” on the pilot wards, giving the domestics more time for general cleaning, which has helped to improve cleaning performance.

The Trust Monitoring Officers continue to levy penalties in line with the cleaning specification when audits fail to reach their specified cleaning score, within the rectification time frames Appendix 2 details the Trust Monitoring Officers average cleaning scores for very high and high risk functional areas for September and October.

Cleaning spot checks continue to take place on all sites monthly and any cleaning issues noted are immediately escalated to the appropriate department for rectification. The infection prevention team are actively involved with spot checks on all sites.

6.2 Nursing Cleaning Performance

The average cleaning scores for Nursing & AHP very high and high risk functional areas for September and October can be found in appendix 3

For the period 1 September to 31 October 2016 the following was noted: o There were 5 areas rated red for nurse cleaning at Royal Oldham in

September but only 1 in October which is an improvement on the previous quarter.

o There were 17 areas rated red for nurse cleaning in September and 18 in October, which is significantly higher than the previous quarter.

o There were 3 red wards at Fairfield General Hospital in September but none in October.

o All nurse cleaning at Rochdale Infirmary, Tudor Court and the Floyd Unit scored 100%.

Reports regarding nurse, midwife & HCA cleaning continue to be drawn up monthly and sent to the Heads of Nursing for circulation and action. The reports are also discussed at the site cleaning meetings

Commodes were found to be not clean on 4 clinical areas. This was brought to the attention of the nursing staff and rectified at the time. The main failing nursing element is dressing trolleys.

7. Investigation of incident, surrounding the death of three day old pre-term baby:

Incident number 260287.

7.1 An Investigation of is currently in progress in relation to an incident, surrounding the

death of three day old pre-term baby born on 27/09/16 in North Manchester General.

The baby was transferred at birth to the neonatal unit NMGH the same day and

transferred again to ROH level 2 Neonatal unit a few hours later.

The baby had sever co-morbidities due to extreme prematurity.

The baby deteriorated and developed signs of sepsis, on day three 30/09/16.

Severe gram negative sepsis was suspected and the baby died 30/09/16 with

parents present. Blood culture result shows Pseudomonas Aeruginosa.

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7.2 Investigation actions to date:

Water samples for all clinical hand wash basins at ROH and NMGH as well as in a side room on labour ward NMGH were tested and filters placed on the taps until results back and further Microbiologist advice given.

Filters remain in place where positive water samples for pseudomonas identified or the clinical hand wash basin isolated if taps are not compatible with filter.

All incubators in which the baby was nursed at ROH and NMGH were identified and swabbed, and reported negative Pseudomonas results.

Review of tap temperatures and running times were all compliant with national recommendations

Risk assessment has been update regarding the use of sensor taps updated.

IV care management review was initiated.

Review of intravenous lines sited/used (including dates) and what was run through them, including any TPN.

Review of sterile bottled water use on NNU to ensure how used and how often replaced (daily).

Draft incubator cleaning SOP to be completed.

Assurance checks for incubator humidity water supply changes, and ventilator circuits.

Review/monitor for the correct method of cleaning clinical hand wash basins to prevent contamination of taps has been completed.

7.3 All the water samples identified with pseudomonas were phage typed in comparison

with the pseudomonas identified in the baby’s blood and reported as different. No other source was identified.

. 8. Recommendations

The Board is asked to note the above report in relation to compliance with corporate objectives; the Health & Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance (commonly known as The Hygiene Code) and the National Cleaning Standards.

Professor Matthew Makin Medical Director / Director of Prevention and Control of Infection

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Appendix 1: SPC charts for hospital attributed CDI by hospital site:

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Appendix 2 - Average Trust Monitoring Cleaning Scores for Very High Risk & High Risk Areas

September – October 2016

Fairfield Score

% Rochdale Score

% Oldham Score

% Manchester Score

%

2 94.05 CAU 97.54 ICU 93.29 I5 79.46

11a 88.61 Oasis Ward 97.97 G1 88.60 F4 chemo 94.7

A&E 94.11 UCC 98.40 F7 86.96 A&E 86.65

1 90.57 Floyd Unit 94.75 T5 84.87 Koala Ward 89.17

5 96.96 Wolstenholme 96.15 Public Toilets 87.16 Post Natal Ward 84.4

6 96.09 Tudor Court 98.40 F8 CCU 92.46 C3 85.23

7 93.51 Public Toilets 97.25 Obs Theatre 90.18 C4 87.19

9 98.91 Eye Day Care 99.34 F11 Ward 97.6 E1 84.30

11b 97.29 Day Surgery ext 98.38 Ph3 Endoscopy 98.33 E3 88.03

12 95.93 Day Surgery 98.98 ACU 94 SCBU 94.51

14 94.97 Eye Theatre 97.35 A&E 92.37 D6 89.48

18 98.05 Theatres 98.44 A&E Ward 92.82 F5 84.32

20 96.56 Renal 98.91 G2 95.58 F6 85.58

21 96.16 Endoscopy 97.62 F1 95.21 H3 86.16

Public Toilets 93.63 F5 92.72 H4 84.61

Endoscopy 99.18 F5/F6 93.16 G6 Renal 93.58

Silver Heart Th 99.39 F6 96 I6 86.78

Theatre 1234 99.06 AMU 93.9 J4 Renal 93.82

Theatre 567 98.49 F9 92.27 F4A 93.31

Outer Theatre 96.64 F10 94.61 DSU 93.69

ICU 97.08 T3 97.91 HSDU 88.38

T4 94.32 J3 94.87

Post Nat Ward 91.74 Endoscopy 93.56

T6 94.94 ANC Ward 91.31

T7 95.93 J6 90.32

T7 annex 90.79 D5 90.59

Children Ward 95.65 CCU 97.41

Delivery 98.20 DSU Theatres 95.71

F11 Day Unit 99.25 Public Toilets 90.7

G3 Endoscopy 97.66 Children Ward 94.23

HDU 95.80 Birthing Centre 95.69

HSDU 97.12 Pharmacy 92.5

NICU 95.40 F3 90.77

Pharmacy 94.17 F2 92.91

F4 Birthing 98.93 F1 94.63

Ph1 Outer Th 97.08 J4 95.61

Ph1 Theatres 96.69 G2 STU 91.58

Theatre 8 97.52 J5 90.64

CCW 95.52

Paeds Theatre 98.19

Theatre 1-6 95.72

Theatre 7-10 96.99

Standards achieved Delivery 95.17

Minor failures, within 10% of the required standard, small number of elements failing

Several elements failing in a number of areas

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Appendix 3 - Average Nursing & AHP Cleaning Scores for Very High Risk & High Risk Areas

September – October 2016 Fairfield Score % Rochdale Score % Oldham Score % Manchester Score %

A&E 89.13 CAU 100 Post Natal Ward 79.19 A&E 57.61

1 100 Oasis Ward 100 Theatre 8 80 G6 Renal 61.43

2 100 UCC 100 T6 65 E3 46.64

5 98.75 Floyd Unit 100 Ph1 Outer Th 92.86 F5 64.28

6 100 Wolstenholme 100 A&E 80.98 F6 57.47

7 100 Tudor Court 100 HDU 85.71 H3 50.6

9 100 Eye Day Care 100 ICU 91.67 H4 63.09

11a 91.17 Day Surgery ext 100 NICU 93.48 Koala Ward 79.41

11b 78.79 Day Surgery 100 A&E Ward 86.67 F4 chemo 72.73

12 87.5 Eye Theatre 100 ACU 86.33 Delivery Suite 76.28

14 93.17 Theatres 100 F5/F6 85.19 D6 70.95

18 100 Renal 100 F7 86.92 E1 75.09

20 100 Endoscopy 100 G3 Endoscopy 93.33 C4 75

21 93.55 T5 84.25 I5 52.08

Endoscopy 100 T7 89.73 J6 78.44

Silver Heart Th 100 Children Ward 100 Paeds Theatre 73.9

Theatre 1234 100 F11 Day Unit 100 F3 83.33

Theatre 567 100 F11 Ward 100 G2 STU 89.65

Outer Theatre 100 Obs Theatre 86.67 J5 82.35

ICU 100 Ph1 Theatres 94.74 Endoscopy 85.51

F4 Birthing 100 DSU 85.7

G1 100 Children Ward 81.77

G2 96.6 D5 89.8

AMU 90.28 Theatre 1-6 91.79

F5 91.66 DSU Theatres 94.

Delivery 95 Theatre 7-10 90.16

F6 100 CCW 91.89

F9 100 J4 93.75

F10 100 C3 86.84

T3 97.13 J4 Renal 94.44

T7 annex 100 Birthing Suite 93.75

T4 91.66 SCBU 95

F1 100 ANC Ward 100

Ph3 Endoscopy 100 J3 96.43

I6 91.42

CCU 100

Post Natal Ward 90

F1 100

F4A 100

F2 91.66

Standards achieved Minor failures, within 10% of the required standard, small number of elements failing Several elements failing in a number of areas

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Title of Report Board Assurance Framework and Corporate Risk Register


Date 24 November 2016

Executive Summary

The Board Assurance Framework (BAF) takes as its basis the Annual Plan objectives and priorities for 2016/17. The BAF outlines the risks against achieving the Trust Corporate Priorities. There may be other risks escalated from Executive Director or Divisional Risk Registers that are added as strategic risks. The BAF was submitted to Trust Board on 27 October 2016 since then the following has taken place:

J Lenney, J Adams, K Calvin-Thomas, L McCluskie and M Makin have reviewed and updated where required, Controls, Assurances, Actions and Risk scores. Updates are noted in bold

A risk relating to retrieval of information / medical records from the Evolve system (1.3.3) has been added for the Executive Risk and Assurance Committee to consider and approve. This has been highlighted in grey / bold. The risk has still to be considered at the Executive Quality and Patient Experience Governance Committee.

Director of Estates and Facilities intends to but has not yet separated out ‘Cleaning’ as a risk to allow visibility of risk and improvement/deterioration. A timescale for this is required

Escalated risks from Divisions are not included in this iteration of the BAF / Corporate Risk Register. The work to redefine the Trust’s Risk Policy, implement training on the new arrangements and to ensure full alignment of all Risk Registers is being undertaken by the Director of Patient Safety and the Director of Governance. This was noted at the Executive Quality and Patient Experience Governance Committee. This work is still to be completed and a timescale for completion is required.

A Board Assurance Framework policy has been prepared to mirror the Salford Royal Foundation Trust policy and was submitted to the Executive Assurance and Risk Committee for review and approval. The Board Assurance Framework policy has been developed based on principles which will allow the Board to be able to make accurate judgements as to the degree to which serious risks to its objectives are being managed effectively and efficiently. The updated BAF was reviewed by EARC on 22 November 2016. A verbal update on any significant issues will be provided to the Board.

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Actions requested The Board is asked to:

Review the BAF

Determine whether it adequately represents the risks related to achievement of the Trust’s objectives and provides a framework to provide assurance of mitigation of those risks;

Assess the risk relating to the Evolve system (1.3.3) but note that the Executive Quality and Patient Experience Governance Committee still need to consider the risk

Corporate Priorities supported by this paper: 1.Pursue Quality Improvement to assure safe, reliable and compassionate care 2.Deliver financier plans to assure sustainability 3.Support High Performance and Improvement 4.Improve care and services through integration and collaboration 5.Demonstarte compliance with mandatory standards

Risks: All strategic risks are relevant

Development and Assurance This paper has been prepared by the Head of Corporate Governance and Assistant Chief Executive / Board Secretary. The BAF was reviewed by EARC on 22 November 2016.

Public and/or patient involvement: None

Resource implications: There are potential resources implications within all of the actions needed to mitigate the strategic risks.

Communication: The BAF will become a public document through the publication of the Board papers.


Alignment to Trust Vision, Values and Priorities X

Assurance through the Committee structure X

Consultation (internal or external) X

Contract Implications X

Equality and Diversity X

Financial / Efficiency Implications X

Information Governance Assurance X

IM&T Requirements X

National policy / legislation X

Patient Experience X

Partnerships X

Sustainability and Carbon Reduction X

Workforce Implications X

Name Gavin Barclay

Job Title Assistant Chief Executive / Board Secretary



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Strategic Risk Register and Board Assurance Framework

Appendix – Risk Scoring Matrix Risk scoring (Salford Royal Foundation Trust Model) Risk scores are the product of the likelihood of the risk and the impact of the

risk on the Trust. A risk’s likelihood must be given a score between 1 and 5 using the following

criteria: 1 = rare - do not expect this to happen 2 = unlikely - most probably will not happen 3 = occasionally - 50:50 chance of occurring 4 = likely - most probably will happen 5 = almost certain - confident that this will happen.

A risk’s impact on the Trust must be given a score between 1 and 5 using the

following criteria: 1 = almost non - no obvious harm* 2 = minor - no permanent harm (recovery within month)* 3 = moderate - semi-permanent harm (recovery takes longer than 1

month but no more than 1 year) and/or adverse publicity for the Trust. *

4 = major - permanent harm not resulting in death or severe disability to a person or persons and/or start of a national investigation into the Trust and/or disruption of key Trust services which significantly hinder the Trust in meeting its responsibilities.*

5 = catastrophic - death or permanent severe disability to a person or persons and/or significant loss of reputation for the Trust and/or loss of key Trust services which prevent the Trust meeting its responsibilities.*

* Note that harm in all the above includes damage to the organisation, its finances, its reputation, its business, its patients, staff or visitors.

Key controls are the means by which the principal risk’s impact or likelihood

may be reduced together with references to documentary evidence of the existence and effectiveness of that control mechanism. Risk control is achieved by reducing the likelihood of the risk, reducing the impact of the risk and / or transferring the risk. The risk controls are also identified through a risk profiling process and summarised on the Board Assurance Framework as are any gaps in risk control.

Risk profiling gives a "Risk Control" score of:

1 = risk is fully under control 2 = risk is adequately controlled 3 = action to control risk adequately has started and appears effective 4 = action to control risk is agreed but no action started 5 = no actions to control risk identified

Each risk is then given a Risk Profile score which is the sum of the scores

"Likelihood", "Impact" and "Risk Control". (Note – the new methodology adds the scores rather than multiples so new maximum risk score is 15).

The Risk Profile score is summarised on the Risk Register:

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3 - 5 Minor risks which are adequately managed and may

be retained if further control limits the capacity to control higher ranking risks.

Managed at Directorate level. 6 and over Moderate risks which must be managed by the

Division’s governance structures. 10 and over Serious risks which must be managed and reported through the Executive Assurance and Risk Committee. 12 and over Significant risks to the Trust which must be managed and reported through the Board of Directors via the Executive Assurance and Risk Committee

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ing t

o p

atient

harm

44

CD

Str

uctu

re s

upp

ort

ed

by D

ND

s a

nd O

MD

CD

foru

m p

rovid

es lead

ers

hip

supp

ort

Clin

ical le

ad

ers

hip

mode

l still

to

be e

mbed

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Appro

ve s

ite M

edic

al D

irecto

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Lea

ders

hip

pro

gra

mm

e w

ith k

ey

medic

al an

d n

urs

ing lead

ers

4N

o r

elia

ble

assura

nce

No r

elia

ble

assura

nce

Imple

ment

site b

ased m

edic

al

tea

ms.

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in

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iew

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g

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ce 1

8 N

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16

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ically

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LR

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rk b

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nd

ert

ake

n t

o

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hip

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o in

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de t

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pm

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t o

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ism

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35

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Item

10

Page 88 of 134

An

nu

al P

lan

Ob

jecti

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2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

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Likelihood

Impact

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sit

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End of Q2

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End of Q4

1.1

.5IF

th

e T

rust is

un

able

to

recru

it

and

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in s

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taff

to

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linic

al sta

ffin

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TH

EN

the

Tru

st w

ill r

em

ain

hea

vily

relia

nt

on

ag

ency s

taff

whic

h m

ay in tu

rn c

om

pro

mis

e

patient

care

44

Job P

lann

ing f

ram

ew

ork

Agre

e w

ard

esta

blis

hm

ent

Repo

rtin

g m

edic

al esta

blis

hm

ent

No M

edic

al sta

ffin

g f

un

ction

Baselin

e r

evie

w o

f M

edic

al

sta

ffin

g

Nationa

l A

gen

cy c

ap m

ay

restr

ict overa

ll availa

bili

ty w

hic

h

may a

lso c

om

pro

mis

e p

atient

care

3 J

ob p

lann

ing c

om

ple

ted r

epo

rts

Ward

sta

ffin

g r

epo

rt 're

d f

lagg

ed'

to s

cru

tiny

Mechan

ism

of

repo

rtin

g J

ob

pla

ns a

gain

st vacancie

s

Ro

bu

st

po

licy in

pla

ce

cu

rren

tly v

ari

ab

le c

om

plian

ce.

To

co

nsid

er

'a p

au

se a

nd

re-

sta

rt' in

Ap

ril w

ith

in

ten

se

train

ing

an

d d

evelo

pm

en

t

pri

or

to n

ew

jo

b p

lan

nin

g

rou

nd

fo

r 20

17 /

18

Baselin

e r

evie

w o

f m

edic

al

sta

ffin

g t

o b

e u

nde

rtaken.

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gre

ss w

ork

on

capa

city /

activity o

f exis

ting m

edic

al sta

ff.

Med

ica

l R

ec

ruit

men

t str

ate

gy

to E

xec

s 9

No

vem

ber

20

16

11

EAR

C1

1

Medic

al

Directo

r

1.1

.6IF

lessons learn

t are

not

acte

d

up

on

T

HE

N s

yste

m failu

res

could

affect th

e q

ualit

y o

f patient

care

deliv

ere

d a

nd

regu

lato

ry

involv

em

ent

an

d r

epu

tationa

l

dam

age

could

occur

35

Sta

ndard

Opera

ting Instr

uctions in p

lace

within

th

e T

rust

Dia

gn

ostic r

evie

w p

aper

Lea

rnin

g f

rom

Experi

ence r

epo

rt to

Tru

st

Board

qu

art

erl

y

Feed

back o

f S

eri

ous incid

en

t re

vie

ws

dis

sem

inate

d b

y local le

arn

ing t

hro

ug

h

div

isio

na

l te

am

s

Lea

rnin

g f

rom

Experi

ence N

ew

sle

tte

r

Dia

gn

ostic r

evie

w

recom

mend

ations

Furt

he

r

work

to b

e u

nd

ert

aken in r

ela

tion

to N

PS

A16 -

Earl

y iden

tification

of fa

ilure

to

act on

radio

logic

al

imagin

g r

epo

rts S

tan

dard

ope

rating instr

uction v

ari

ed

acro

ss s

ites a

nd D

ivis

ions

Local le

arn

ing p

rocesses n

ot

em

bed

ded

acro

ss the

Tru

st

Feed

back s

essio

n s

pora

dic

at

tim

es.

Due

to c

apa

city issues L

earn

ing f

rom

experi

ence N

ew

sle

tte

rs n

ot

alw

ays d

istr

ibute

d

3Q

ualit

y a

ssura

nce a

udit

und

ert

aken

Inte

rnal pro

fessio

na

l sta

ndard

s

laun

ched

'Y

our

requ

est Y

our

respon

sib

ility

'

Lea

rnin

g f

rom

experi

ence r

epo

rt

Polic

ing Inte

rnal pro

fessio

na

l

sta

ndard

s

Feed

back fro

m Q

ualit

y

assura

nce a

udit

Dia

gn

ostic R

evie

w G

roup

impro

vem

ent

pla

n

Imple

menta

tion o

f Im

pro

vem

ent

pla

n

Audit o

f sta

ndard

ised a

pp

roach

6 m

onth

'lo

ok b

ack' exerc

ise to

be

un

de

rta

ke

n

MIA

A in

tern

al a

ud

it

reco

mm

en

dati

on

s c

urr

en

tly

bein

g w

ork

ed

th

rou

gh

,

imp

lem

en

ted

an

d m

on

ito

red

via

th

e r

e-i

nste

ad

Dia

gn

osti

c

revie

w g

rou

p

11

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Meet

CQ

C

req

uir

em

en

ts -

deliv

er

impro

vem

ents

within

tim

escale

s

Chie

f N

urs

e1

.2.1

IF t

he

Tru

st fa

ils to d

eliv

er

the

CQ

C Im

pro

vem

ent

pla

n T

HE

N

the

Tru

st m

ay fail

to s

ave a

nd

impro

ve liv

es thro

ugh

relia

ble

care

and b

e t

he

subje

ct of

CQ

C

rein

forc

em

ent

action

35

Impro

vem

ent

pla

n m

onitore

d b

y G

M

Impro

vem

ent

Board

and

inte

rnally

via

th

e IM

O

thro

ug

h th

e C

are

Board

. O

vers

ee p

rogre

ss

aga

inst Q

ualit

y e

lem

ents

thro

ugh

the

Qualit

y

and

Patient

Experi

ence C

om

mitte

e .

Enga

gem

ent

with a

nd s

upp

ort

fro

m C

CG

s

and

LA

to d

eliv

er

on

im

pro

vem

ent

pla

n.

Capa

city a

nd c

apa

bili

ty o

f

lead

ers

. A

deq

uate

and

app

ropri

ate

ly s

kill

ed s

taff

. La

ck

of sta

ndard

isation.

Intr

odu

ction

of

the

Site

ba

se

d m

an

ag

em

en

t

fram

ew

ork

N

o a

gre

em

ent

of

mana

gem

ent

contr

act w

ith

SR

FT

3M

onitori

ng o

f im

pro

vem

ent

pla

n

by G

M Im

pro

vem

ent

Board

and

inte

rnally

via

th

e r

ele

vant

corp

ora

te a

ssura

nce c

om

mitte

es

Assura

nce d

ashbo

ard

Im

pro

vem

ent

pla

n

Urg

en

t an

d e

merg

en

cy c

are

impro

vem

ent

pla

n

Mate

rnity im

pro

vem

ent

pla

n

Paed

iatr

ic im

pro

vem

ent

pla

n

Addre

ss m

ana

gem

ent

capa

city

issues in p

lan im

ple

menta

tion

11

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11

Chie

f N

urs

e1

.2.2

IF t

he

Tru

st fa

ils to d

eliv

er

the

Qualit

y Im

pro

vem

ent

pla

n T

HE

N

the

Tru

st m

ay fail

to s

ave a

nd

impro

ve liv

es thro

ugh

relia

ble

care

35

Qualit

y Im

pro

vem

ent

pla

n m

onitore

d b

y G

M

Impro

vem

ent

Board

and

inte

rnally

via

th

e IM

O

thro

ug

h th

e C

are

Board

. O

vers

ee p

rogre

ss

aga

inst Q

ualit

y e

lem

ents

thro

ugh

the

Qualit

y

and

Patient

Experi

ence C

om

mitte

e .

Enga

gem

ent

with a

nd s

upp

ort

fro

m C

CG

s

and

LA

to d

eliv

er

on

im

pro

vem

ent

pla

n.

An

intr

odu

ction o

f vari

ous e

lem

ents

of

the

QI

str

ate

gy intr

odu

ction o

f p

ilot N

AA

S

Capa

city a

nd c

apa

bili

ty o

f

lead

ers

. A

deq

uate

and

app

ropri

ate

ly s

kill

ed s

taff

. La

ck

of sta

ndard

isation.

Intr

odu

ction

of

the

Site

ba

se

d m

an

ag

em

en

t

fram

ew

ork

. N

o a

gre

em

ent

of

mana

gem

ent

contr

act w

ith

SR

FT

Qualit

y Im

pro

vem

ent

Str

ate

gy/p

lan s

till

be

ing

develo

pe

d

3M

onitori

ng o

f im

pro

vem

ent

pla

n

inte

rnally

via

th

e r

ele

vant

corp

ora

te a

ssura

nce c

om

mitte

es

Assura

nce d

ashbo

ard

Qualit

y Im

pro

vem

ent

str

ate

gy

and

action p

lan s

till

in

develo

pm

ent.

Dete

riora

ting

patient

in p

lace c

olla

bo

rative to

com

mence 1

0th

Novem

ber

2016

11

EA

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35

da7

95

Page 89 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

blish

ed

Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

Gap

s in

Assu

ran

ce

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on

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n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

End of Q4

Directo

r of

Opera

tions

1.2

.3IF

th

e T

rust fa

ils to e

nsure

Work

forc

e c

apa

city, re

sili

ence

an

d f

un

din

g t

o d

eliv

er

the

impro

vem

ent

pla

n w

hils

t

ensuri

ng t

he

oth

er

key p

riori

ties

of m

ain

tain

ing b

usin

ess a

s

usual, d

evelo

pin

g a

nd

de

liveri

ng

on

th

e c

linic

al se

rvic

e s

tra

teg

y

and

sig

nific

ant

org

an

isationa

l re

-

str

uctu

re a

re ta

ken f

orw

ard

TH

EN

the

pla

n m

ay n

ot be

fully

an

d a

pp

rop

ria

tely

im

ple

me

nte

d

44

Executive lead

ers

hip

fo

r all

key c

han

ge

pro

gra

mm

es. N

ew

executive r

isk a

nd

govern

an

ce a

ssura

nce s

yste

m inclu

din

g n

ew

transfo

rmation b

oa

rd. D

eliv

ery

mechan

ism

for

impro

vem

ent

pla

n w

ith w

eekly

tra

ckin

g o

f

actions. A

ppo

intm

ent

to s

ite lead

ers

hip

tea

ms. In

year

fund

ing a

gre

ed

Tim

elin

e f

or

ap

poin

tment

to

executive s

ite lead

ers

hip

te

am

s.

Futu

re y

ears

fun

din

g

4M

onitori

ng a

rrang

em

ents

for

deliv

ery

of

impro

vem

ent

pla

n.

Tra

nsfo

rmation B

oard

to d

evelo

p

and

sig

n o

ff C

SS

with

com

mis

sio

ne

rs.

Pro

ject m

ana

gem

ent

arr

ang

em

ents

for

imple

menta

tion a

nd

de

livery

of

new

Gro

up

an

d C

O s

tructu

res.

Fully

de

velo

pe

d e

sta

tes p

lan t

o

deliv

er

CS

S. M

app

ing o

f cri

tical

pa

th f

or

all

str

ate

gic

ch

an

ge

s

Map a

ll key a

ctivitie

s a

nd c

ritical

pa

th f

or

ye

ars

1&

2 id

en

tify

ing

furt

he

r ri

sks a

nd a

ctions to b

e

taken (

end

Nov).

Revie

w c

urr

ent

resourc

e to

supp

ort

develo

pm

ent

an

d d

eliv

ery

of

chan

ges a

nd fin

alis

e b

usin

ess

case fo

r in

vestm

ent

in c

han

ge

resourc

es (

com

ple

te S

OC

end

Nov, F

BC

end

Marc

h 1

7).

Agre

e

key o

bje

ctive a

nd p

riori

ties w

ith

site lead

ers

hip

te

am

s o

nce in

post (J

an 2

01

7).

Build

capa

city

and

capa

bili

ty for

chan

ge a

t C

O

when

resourc

es iden

tified a

nd

agre

ed (

com

mence N

ov 2

016).

Ensure

cle

ar

com

munic

ations

an

d e

ng

ag

em

en

t p

lan

acro

ss t

he

Tru

st (o

n-g

oin

g)

12

Tru

st B

oard

12

Chie

f N

urs

e

1.2

.4IF

the

Tru

st fa

ils to p

rovid

e s

afe

sta

ffin

g levels

in a

ll clin

ical are

as

24

/7 T

HE

N this

could

lead

to

redu

ction in p

atient

safe

ty a

nd

qua

lity o

f care

alo

ng

with p

oor

sta

ff a

nd p

atient

experi

ence.

Specific

focus to b

e m

ade

to t

he

fragile

serv

ices: 1

. F

ragile

Serv

ices 2

. H

ard

to

recru

it a

reas

3 C

linic

al are

as w

ith s

ignific

ant

sta

ff s

hort

ages

45

Com

pre

he

nsiv

e W

ard

sta

ffin

g e

sta

blis

hm

ent

revie

w c

om

ple

ted Im

media

te r

ecru

itm

ent

to

100

Band

6 P

osts

Regu

lar

revie

w o

f vacancy,

ban

k a

nd a

gen

cy u

sage

Sig

nific

ant

Tru

st R

N v

acancie

s.

Nationa

l supp

ly o

f R

egis

tere

d

Nurs

es L

ack o

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city a

nd

capa

bili

ty. N

o r

ecru

itm

ent

an

d

rete

ntion s

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gy

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e r

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ap

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ualit

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AS

) still

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35

da7

95

Item

10

Page 90 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

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y G

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s in

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Control

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End of Q2

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Directo

r of

Esta

tes a

nd

Facili

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1.2

.5IF

robu

st syste

ms a

nd

pro

cesses a

re n

ot in

pla

ce to

monitor

the

main

tenan

ce o

f

equ

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ent

/ m

edic

al de

vic

es

TH

EN

patient

ha

rm a

nd d

ela

y in

treatm

ent

could

occur

as w

ell

as

pote

ntial re

gu

lato

ry a

ction d

ue

to

non

com

plia

nce to

the

Pro

vis

ion

and

use o

f W

ork

Equip

ment

Regu

lations 1

998 (

PU

WE

R

Regu

lations)

(this

rela

tes to R

isk

5 S

RR

)

25

Tru

st ap

pro

ved p

lan t

o e

nsure

devic

es a

re

100

% c

om

plia

nt

with m

anu

factu

res s

erv

ice

recom

mend

ations. M

edic

al de

vic

e types

assessed a

nd

cate

gori

sed a

ccord

ing t

o

severi

ty o

f harm

lik

ely

in th

e e

vent

of

failu

re

Pre

-pla

nn

ed m

ain

tenan

ce s

ched

ule

(P

PM

)

develo

pe

d fo

r all

eq

uip

ment

Appo

intm

ent

of

serv

ice c

ontr

acts

to

supp

ort

PP

Ms w

here

app

ropri

ate

Recru

itm

ent

an

d tra

inin

g

of

app

ropri

ate

train

ed

technic

al sta

ff in p

lace to

supp

ort

th

e

pre

-pla

nn

ed m

ain

tenan

ce s

ched

ule

Capital re

pla

cem

ent

pro

gra

mm

e b

ased o

n

expecte

d life c

ycle

of eq

uip

ment.

Equip

ment

libra

ry p

rocesses d

evelo

pe

d fo

r

mana

gem

ent

of

cro

ss T

rust “h

igh u

se”

devic

es

Monitori

ng o

f in

cid

en

ts to iden

tify

tre

nd

s a

nd

patt

ern

s indic

ating incorr

ect use o

f ele

ctr

o-

bio

medic

al eq

uip

ment.

Main

tenan

ce o

f hig

h r

isk e

quip

ment

monitore

d m

onth

ly v

ia K

PIs

Equip

ment

main

tenan

ce s

ched

ule

s m

onitore

d

month

ly b

y E

BM

E M

ana

gers

for

com

plia

nce

Tra

inin

g o

f u

sers

in c

hecks for

serv

ice d

ue

da

te a

nd

pro

ce

sse

s f

or

ma

inte

na

nce

.

Weekly

repo

rtin

g t

o d

ivis

iona

l m

ana

gem

ent

tea

m a

nd H

ea

d o

f Q

ualit

y.

Full

site a

udit o

f in

-use

equ

ipm

ent

no

t com

ple

te.

Data

base s

till

be

ing c

lean

sed

the

refo

re inaccura

te r

epo

rtin

g

likely

. R

ecru

itm

ent

of

add

itio

na

l

sta

ff n

ot yet com

ple

te.

3 M

onth

ly r

epo

rtin

g t

o D

ivis

iona

l

ST

ET

, T

rust Q

&P

Medic

al

Devic

e M

ana

gem

ent

Revie

w

Gro

up

an

d q

uart

erl

y r

epo

rtin

g t

o

Medic

al an

d S

cie

ntific

Com

mitte

e.

Repo

rtin

g t

o b

e r

ealig

ne

d to

the

new

Com

mitte

e s

tructu

re

Imple

ment

finalis

ed

Impro

vem

ent

pla

n

Site a

udits

Data

bases

Recru

it s

taff

Repo

int a

lignm

ent

10

EA

RC

10

Imp

rove P

ati

en

t

Exp

eri

en

ce

Chie

f N

urs

e1

.3.1

IF the

tru

st fa

ils to m

easure

th

e

Qualit

y s

tan

dard

s w

ithin

Clin

ical

are

as T

HE

N it m

ay fail

to

impro

ve th

e Q

ualit

y a

nd S

afe

ty

of p

atient

Care

44

The a

da

pta

tion o

f S

RF

T W

ard

Accre

ditation

Fra

mew

ork

for

intr

odu

ction in P

enn

ine.

Curr

ently in p

ilot p

hase

Exis

ting w

ard

accre

ditation

fram

ew

ork

no

t fit fo

r pu

rpose.

Full

imple

menta

tion o

f S

RF

T

NA

AS

Fra

mew

ork

to b

e

deliv

ere

d

4O

n-g

oin

g m

onitori

ng o

f p

ilot

NA

AS

with f

inal an

aly

sis

Novem

ber

2016

The T

rust curr

ently d

oes n

ot

have a

cle

ar

unde

rsta

ndin

g o

f

the

Qualit

y o

f care

Analy

sis

of

pilo

t a

nd

imple

menta

tion o

f a

Nurs

e

Accre

ditation s

yste

m for

Penn

ine

12

Tru

st B

oard

12

Chie

f N

urs

e1

.3.2

IF the

Tru

st fa

ils to e

ng

age

with

the

Clin

ical sta

ff b

y inspir

ing a

nd

supp

ort

ing s

taff

TH

EN

th

e

qua

lity o

f and

the

com

passio

n in

giv

ing c

are

may d

eclin

e

34

Enha

ncin

g e

ng

age

ment

with s

taff

via

: T

eam

bri

efs

an

d E

xec L

ead S

pecia

l bri

efings S

taff

FF

T s

urv

eys A

nnu

al N

ationa

l S

taff

Surv

ey 6

Weekly

Ward

Mana

gers

Meetings S

enio

r

Nurs

ing t

ea

m w

alk

roun

ds a

nd s

had

ow

ing

Revis

ed T

erm

s o

f R

efe

rence fo

r N

urs

ing a

nd

Mid

wifery

Board

s E

xte

rnal m

otivationa

l

spea

ker

pro

gra

mm

e

Execs w

ard

walk

roun

ds a

nd

work

with n

ot yet e

sta

blis

hed

Senio

r N

urs

e C

linic

al W

alk

roun

ds to c

om

mence N

ovem

ber

20

16

4Q

uart

erl

y s

taff

en

gag

em

ent

repo

rt to

t T

rust B

oard

Annu

al N

ationa

l S

taff

Surv

ey

repo

rt

All

mana

gers

at

all

levels

fully

en

ga

ge

d in

all

asp

ects

of

inspir

ing a

nd

supp

ort

ing

Exec / T

rust B

oard

walk

abo

ut

pro

gra

mm

e

agre

e S

trate

gy A

dvis

ory

Gro

up

arr

ang

em

ents

D

evelo

p

and

em

bed

Le

ade

rship

pro

gra

mm

e fo

cused o

n inspir

ing

and

supp

ort

ing s

taff

11

EA

RC

11

Ch

ief

Nu

rse

1.3

.3IF

In

form

ati

on

ca

nn

ot

be

retr

ieved

wit

h a

ssu

ran

ce

TH

EN

th

ere

will b

e

co

mp

rom

ise

d p

ati

en

t ca

re d

ue

to in

ab

ilit

y f

or

cli

nic

ian

s t

o

fin

d u

p t

o d

ate

/ p

ast

his

tory

,

ineff

icie

nt

cli

nic

al co

din

g

wh

ich

has f

inan

cia

l an

d H

SM

R

imp

lica

tio

ns a

nd

po

ten

tial

iss

ues i

n c

oro

ners

/ i

nq

uests

/

cla

ims / c

om

pla

ints

du

e t

o

inab

ilit

y t

o p

rod

uce a

co

here

nt

med

ica

l re

co

rd

54

Fo

r co

ron

ers

case

s o

nly

man

ual tr

aw

l an

d

re-s

ca

nn

ing

lo

call

y t

o m

ake

a

co

mp

reh

en

siv

e r

eco

rd a

vaila

ble

fo

r th

e

co

ron

er.

Vari

ab

le p

roces

ses

in

pla

ce t

o

man

ag

e p

ati

en

t re

co

rds

Lack

of

defi

ned

ro

les

an

d

resp

on

sib

ilit

ies

Cap

acit

y a

nd

ca

pab

ilit

y t

o

man

ag

e r

eco

rds a

pp

rop

riate

ly

5Q

A p

roces

s in

pla

ce in

Healt

h

reco

rds. R

ec

ord

s c

heck

ed

file

d a

pp

rop

riate

ly if

no

t se

nt

back

to

are

a t

hey c

am

e f

rom

pri

or

to s

en

d in

fo

r sc

an

nin

g

Au

dit

of

reco

rds p

racti

ce

Un

cle

ar

rep

ort

ing

mech

an

ism

for

Evo

lve im

ple

men

tati

on

Bo

ard

Au

dit

of

med

ica

l re

co

rds t

o b

e

un

dert

ake

n b

y H

ealt

h r

eco

rds

to id

en

tify

are

as

of

po

or

pra

cti

ce

Intr

od

ucti

on

of

co

mp

reh

en

siv

e

train

ing

pro

gra

mm

e o

n r

eco

rd

man

ag

em

en

t an

d

acc

ou

nta

bilit

y

Cle

arl

y d

efi

ne r

ole

s a

nd

resp

on

sib

ilit

ies

aro

un

d r

eco

rd

man

ag

em

en

t

Sta

nd

ard

ise

reco

rd

man

ag

em

en

t p

roces

s

Ro

llin

g a

ud

it p

rog

ram

me

14

Tru

st

Bo

ard

14

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43

35

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95

Page 91 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

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Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

Gap

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Assu

ran

ce

Acti

on

Pla

n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

End of Q4

Dri

ve e

ffic

ien

cy a

nd

pro

du

cti

vit

y t

o

deliver

fin

an

cia

l

co

ntr

ol o

f £3

9.7

m

defi

cit

(re

vis

ed

to

£12

.1m

)

Directo

r of

Fin

an

ce

2.1

.1a

IF the

Tru

st fa

ils to m

eet

its

finan

cia

l du

ties in 2

016

/17

du

e

to incom

e a

nd e

xpen

diture

issues a

nd fa

ilure

to

im

ple

ment

CIP

pla

ns T

HE

N the

Tru

st w

ill

fail

its fin

an

cia

l du

ties r

esultin

g

in r

egu

lato

ry a

ction.

(this

rela

tes

to R

isk 6

. S

RR

)

The e

sta

blis

hm

ent

of

an E

xecutive F

inan

ce,

Info

rmation a

nd

Capital G

overn

an

ce

Com

mitte

e; overs

eein

g t

he

work

of

the

CIP

,

info

rmation,

bu

sin

ess d

evelo

pm

ent

an

d

revie

w, pro

cure

ment

an

d s

erv

ice lin

e

repo

rtin

g g

roup

s. G

overn

an

ce a

rrang

em

ents

in p

lace, a

nd w

ell

esta

blis

hed

acro

ss the

Tru

st, fo

r ea

ch o

f th

e k

ey w

ork

ing g

roup

s; an

d

inclu

din

g d

ele

ga

ted

bu

dge

ts a

nd e

sta

blis

hed

syste

ms o

f contr

ol.

Audit C

om

mitte

e.

Adeq

uate

resourc

es a

nd s

kill

s to

meet

the

de

mand

s o

f th

e C

IP

follo

win

g t

he

de

part

ure

of E

rnst

& Y

oun

g; re

cru

itm

ent

an

d

rete

ntion d

ifficultie

s w

ith n

ew

ly

esta

blis

hed

tea

m. P

rocure

ment

str

ate

gy a

nd p

rocure

ment

transfo

rmation p

lan (

Cart

er

recom

mend

ation)

in d

raft -

requ

ires s

ign o

ff.

Ris

ks, actions r

epo

rted

to E

xec

Fin

an

ce C

om

mitte

e. F

inan

cia

l

repo

rts to T

rust B

oard

incorp

ora

ting a

ll aspects

of

finan

cia

l ri

sk to d

eliv

ery

of

pla

n.

Month

ly a

nd q

uart

erl

y r

epo

rtin

g

to r

egula

tor

- N

HS

I.

Board

overs

ight

of

pro

gre

ss

aga

inst C

art

er

recom

mend

ations

Skill

s tra

nsfe

r un

der

revie

w w

ith

app

ropri

ate

pe

ople

invited

to

necessary

tra

inin

g e

.g. D

r F

oste

r

Tru

st B

oard

12

2.1

.1b

The e

sta

blis

hm

ent

of

an E

xecutive

Opera

tions &

Perf

orm

ance G

overn

an

ce

Com

mitte

e to m

ana

ge r

isks a

ssocia

ted w

ith

deliv

eri

ng c

ontr

actu

al re

qu

irem

ents

of

activity

and

pe

rform

ance.

Contr

actu

al in

com

e "

fixed"

with

Com

mis

sio

ne

rs for

2016

/17

.

Short

fall

ag

ain

st ta

rgets

an

d

agre

ed t

raje

cto

ries for

A&

E a

nd

RT

T -

susta

inab

ility

an

d

transfo

rmation f

un

din

g a

t ri

sk.

Div

isio

na

l re

covery

pla

ns -

for

finan

ce, a

ctivity a

nd R

TT

.

Inte

rnal C

are

Board

, an

d

exte

rnal Im

pro

vem

ent

Board

overs

eein

g A

&E

im

pro

vem

ent.

Tru

st to

ap

pea

l ag

ain

st finan

cia

l

pen

altie

s. D

em

and

an

d c

apa

city

pla

ns for

futu

re y

ears

2.1

.1c

Month

ly m

eetings w

ith r

egula

tor

- N

HS

I,

dis

cuss a

nd a

gre

e a

ctions r

ela

ting t

o

iden

tified a

nd

em

erg

ing f

inan

cia

l ri

sks, w

ithin

Tru

st an

d a

cro

ss h

ealth e

cono

my. M

onth

ly

deta

iled f

inan

cia

l re

po

rtin

g t

o N

HS

I of

finan

cia

l po

sitio

n,

fore

casts

an

d r

isks,

Regu

lato

r sig

hte

d e

arl

y o

n

finan

cia

l ri

sks, w

ith o

ppo

rtun

ity

to a

gre

e c

orr

ective a

ctions,

rem

edie

s e

tc.; T

rust

und

ers

tan

din

g o

f n

ationa

l

positio

n,

ha

s a

ccess to s

enio

r

syste

m s

upp

ort

, a

nd a

ccess /

und

ers

tan

din

g o

f n

ationa

l

finan

cia

l supp

ort

, fo

r exam

ple

access to loan

s, an

d w

ork

ing

capital arr

ang

em

ents

.

2.1

.1d

Fin

an

ce D

irecto

r m

eetings w

ith N

E S

ecto

r

com

mis

sio

ne

rs, to

dis

cuss b

oth

clin

ical

transfo

rmationa

l, a

nd o

pera

tiona

l is

sues/

risks. M

eet

every

tw

o w

eeks. S

yste

m w

ide

risks s

hare

d a

nd u

nde

rsto

od. A

ctions p

lans

agre

ed,

and

whic

h inclu

de

exte

rnal

com

mis

sio

ne

d s

upp

ort

Directo

r of

Fin

an

ce

2.1

.2a

SR

FT

lead

ers

hip

supp

ort

New

ly

esta

blis

hed

Clin

ical T

ransfo

rmation G

roup

work

ing w

ith C

CG

's a

cro

ss the

NE

S -

to

agre

e, constr

uct an

d a

lign s

ecto

r pla

ns for

clin

ical an

d fin

an

cia

l susta

inab

ility

. F

inan

ce

gro

up

esta

blis

hed

to f

ocus o

n S

HS

, H

ea

lthie

r

Toge

the

r an

d C

ST

.

20

16

/17

fin

an

cia

l p

lan

se

cu

red

£2

0.5

m S

TP

fun

din

g a

nd

£9

m q

ualit

y Im

pro

vem

ent

fun

din

g.

Clin

ical S

trate

gy n

ot yet finalis

ed

Lon

ger

term

fin

an

cia

l supp

ort

not

yet a

gre

ed

CE

O lead

ers

hip

and r

epo

rtin

g t

o

Tru

st bo

ard

on c

lose w

ork

ing

with C

CG

s, G

M a

nd N

HS

I.

CS

T p

rogra

mm

e n

ot yet

esta

blis

hed

. In

tegra

ted b

usin

ess

pla

n a

nd

LT

FM

Develo

p T

rust C

linic

al S

trate

gy

Agre

e long

er

term

fin

an

cia

l

supp

ort

with G

M

Agre

e S

HS

an

d G

roup

arr

ang

em

ents

Imple

ment

HT

EA

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11

IF the

Tru

st fa

ils to b

ecom

e

finan

cia

lly a

nd c

linic

ally

via

ble

TH

EN

the

Tru

st m

ay n

ot be

ab

le

to p

rovid

e s

erv

ices to t

he

local

peo

ple

Pri

ority

2: D

eliv

er

financia

l pla

ns to a

ssure

susta

inabili

ty

34

41

1

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35

da7

95

Item

10

Page 92 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

blish

ed

Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

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s in

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ran

ce

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on

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n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

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2.1

.2b

A r

unn

ing t

ota

l of

com

mitm

ents

is m

ain

tain

ed

and

pre

sente

d t

o t

he C

are

Board

and

Fin

an

ce

Com

mitte

e. Id

en

tified p

ressure

s a

re

pri

ori

tised t

o e

nsure

to

tal com

mitm

ents

rem

ain

within

th

e a

vaila

ble

envelo

pe

. P

lans

reflecte

d in a

long

er

term

fin

an

cia

l pla

n,

an

d

fun

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g r

equ

irem

ent

/ g

ap a

na

lysis

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Pla

nn

ing

pro

cess

iden

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ne

ed

for

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sk

an

dcontinge

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fun

ds

tom

ana

ge

inyear

iden

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pre

ssure

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finan

cia

lpla

n

incorp

ora

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bo

thre

curr

ent

an

d

non

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risks.

Continue

d fo

cus o

n p

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t

the

Busin

ess a

nd D

evelo

pm

ent

Revie

w G

roup

2.1

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ly m

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ith r

egula

tor

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dis

cuss a

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gre

e a

ctions r

ela

ting t

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tified a

nd

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erg

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inan

cia

l ri

sks, w

ithin

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st an

d a

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ss h

ealth e

cono

my. M

onth

ly

deta

iled f

inan

cia

l re

po

rtin

g t

o N

HS

I of

finan

cia

l po

sitio

n,

fore

casts

an

d r

isks,

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lato

r sig

hte

d e

arl

y o

n

finan

cia

l ri

sks, w

ith o

ppo

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ity

to a

gre

e c

orr

ective a

ctions,

rem

edie

s e

tc.; T

rust

und

ers

tan

din

g o

f n

ationa

l

positio

n,

ha

s a

ccess to s

enio

r

syste

m s

upp

ort

, a

nd a

ccess /

und

ers

tan

din

g o

f n

ationa

l

finan

cia

l supp

ort

, fo

r exam

ple

access to loan

s, an

d w

ork

ing

capital arr

ang

em

ents

.

2.1

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Fin

an

ce D

irecto

r m

eetings w

ith N

E S

ecto

r

com

mis

sio

ne

rs, to

dis

cuss b

oth

clin

ical

transfo

rmationa

l, a

nd o

pera

tiona

l is

sues/

risks. M

eet

every

tw

o w

eeks. S

yste

m w

ide

risks s

hare

d a

nd u

nde

rsto

od. A

ctions p

lans

agre

ed,

and

whic

h inclu

de

exte

rnal

com

mis

sio

ne

d s

upp

ort

A c

om

pre

he

nsiv

e r

em

edia

tion p

rogra

mm

e is

und

erw

ay to a

dd

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ny p

revio

us p

oor

pra

ctice (

pro

cess),

lack o

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rity

in r

ole

s (

re-

defined

) o

r w

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astr

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he

r ne

w r

ole

s h

ave b

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iden

tified w

hic

h n

eed

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dre

ssin

g

to r

ein

forc

e th

e n

ew

pro

cess a

nd

techno

logy r

igou

r be

ing p

ut

in

pla

ce.

IM&

T &

Qualit

y A

ssura

nce

Com

mitte

e (

IIQ

AC

)

.A C

han

ge A

dvis

ory

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up

(CA

G)

monitors

chan

ges to t

he

massiv

ely

com

ple

x infr

astr

uctu

re

on

a d

aily

ba

sis

to

en

su

re a

ll

part

ies im

pact assess, fo

llow

go

od

go

ve

rna

nce

, fu

lly t

est

chan

ges a

nd h

ave b

ack-o

ut

pla

ns

Wid

er

Clin

ical-

IM

&T

inte

gra

tion

ne

ed

ed

. T

his

ha

s b

ee

n

pro

po

sed a

s b

ein

g m

et b

y a

Join

t E

PR

(JE

RP

)

Imple

menta

tion B

oard

Cla

rify

an

d e

sta

blis

h th

e J

EP

R

Board

or

sim

ilar

Main

tain

curr

ent

dir

ection o

f

travel an

d a

ll contr

ols

as w

e

work

clo

sely

with S

alford

and t

he

rest of

GM

Regu

lar

monitori

ng o

f a

ll syste

ms &

infr

astr

uctu

re is in p

lace a

nd a

lert

ing is

actively

ad

dre

ssed t

o m

inim

ise p

ote

ntial

syste

ms o

uta

ges a

nd e

nsure

rapid

recovery

when

ou

tag

es d

o o

ccur.

The C

linic

al S

trate

gy G

roup

(CS

G)

allo

ws s

enio

r clin

icia

ns to

define n

ew

syste

m r

equ

irem

ents

& p

riori

ties for

IM&

T to w

ork

to.

2.1

.3b

The IM

&T

Str

ate

gy is in p

lace -

with k

ey

com

pon

ent

ag

reem

ent

to a

move to

ward

s a

n

EP

R.

The c

urr

ent

IM&

T s

trate

gy w

ill

not

levera

ge

the

op

tim

um

alig

nm

ent

with S

RF

T s

yste

ms

A P

enn

ine T

echnic

al D

esig

n

Auth

ori

ty (

TD

A)

gro

up

ha

s b

een

esta

blis

hed

to e

nsure

th

at fu

ture

techno

logy d

ecis

ions a

nd

chan

ges to a

ny s

yste

ms a

re

alig

ne

d to

the

IM

&T

Str

ate

gy this

has n

ow

be

en e

xte

nded

acro

ss

the

wid

er

Salford

Cha

in o

f

Hospitals

as a

Gro

up

TD

A

34

11

EA

RC

Directo

r of

Fin

an

ce

2.1

.3a

IF the

Tru

st fa

ils to b

ecom

e

finan

cia

lly a

nd c

linic

ally

via

ble

TH

EN

the

Tru

st m

ay n

ot be

ab

le

to p

rovid

e s

erv

ices to t

he

local

peo

ple

IF the

Tru

st fa

ils to a

chie

ve a

cohe

rent

rang

e o

f IM

&T

clin

ical

syste

ms T

HE

N t

he

re w

ill b

e a

lack o

f in

tero

pe

rabili

ty a

nd s

ub

optim

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ort

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decis

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akin

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Page 93 of 134

An

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Exec L

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mb

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Pri

ncip

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isks

Likelihood

Impact

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taff

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m

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m to £

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Directo

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forc

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2.2

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recru

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ffin

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TH

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re w

ill b

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com

pro

mis

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nd

mora

le /

sic

kness issues w

ill c

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44

Weekly

Perf

orm

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onitori

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eeting

chair

ed b

y D

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Work

forc

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OD

with

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up a

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Exec c

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evie

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pera

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lan

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oard

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ap

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ff v

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s d

o n

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du

ce

in lin

e w

ith p

lan T

HE

N t

he

qua

lity o

f care

will

no

t im

pro

ve

and

fin

an

cia

l susta

inab

ility

will

no

t b

e d

eliv

ere

d.

44

Weekly

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ng o

f re

cru

itm

ent

activity.

HH

H p

lan

New

recru

itm

ent

sta

ndard

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sta

blis

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E

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inte

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oftw

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art

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results a

naly

sed.

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mis

sio

ne

d T

rack

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ew

recru

itm

ent

mana

gem

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syste

m

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sta

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pla

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of skill

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sin

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experi

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taff

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sta

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all

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Imp

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en

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3.1

IF t

he

Tru

st fa

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ng

age

sta

ff

in th

e o

pera

tiona

l an

d s

trate

gic

pri

ori

ties T

HE

N t

he

qu

alit

y o

f

patient

care

may b

e

com

pro

mis

ed

33

New

qu

art

erl

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uls

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heck s

urv

ey intr

odu

ced

tha

t asks w

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up

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Item

10

Page 94 of 134

An

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al P

lan

Ob

jecti

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7

Exec L

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Ris

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Pri

ncip

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Likelihood

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Div

isio

nal H

R B

P h

ave b

een

req

ueste

d t

o s

ub

mit

ass

ura

nce p

lan

s t

o c

on

firm

req

uir

ed

targ

et

will b

e m

et

12

Tru

st B

oard

12

Red

uce s

ickn

ess

an

d a

bsen

ce t

o

4.6

%

Directo

r of

Work

forc

e a

nd

OD

3.3

IF the

Tru

st fa

ils to r

edu

ce h

igh

sta

ff a

bsence levels

TH

EN

excessiv

e u

se o

f lo

cum

s /

age

ncy s

taff

could

occur

whic

h

could

lead

to s

ub s

tan

dard

care

bein

g d

eliv

ere

d a

nd

in

cre

ased

pre

ssure

on p

erm

ane

nt sta

ff

furt

he

r im

pacting o

n s

ickness

and

ab

sence levels

an

d

expen

diture

levels

43

New

att

end

ance p

olic

y in p

lace w

ith r

evis

ed

trig

ge

r fo

r m

an

age

ment

action.

Capsticks

HR

A c

ontr

act to

supp

ort

mana

gers

in

han

dlin

g a

tte

nda

nce issues in p

lace.

Revis

ed S

LA

with O

ccupa

tiona

l he

alth

agre

ed.

O

H

nurs

e e

mbed

ded

in h

igh s

ickness a

bsence

dep

art

ments

for

3 m

onth

s.

HH

H p

lan.

Hold

ing m

ana

gers

to a

ccoun

t fo

r

no

t u

nd

ert

akin

g t

ime

ly R

TW

Tra

nsitio

n f

rom

Fir

st C

are

repo

rtin

g s

yste

ms to lin

e

mana

gers

de

alin

g w

ith initia

l

absence r

epo

rts fro

m s

taff

will

requ

ire O

D / tra

inin

g inpu

t

3W

ork

forc

e a

nd L

ea

ders

hip

Pro

gra

mm

e B

oard

, R

ep

ort

s to

Q&

P a

nd T

rust B

oard

Cascade

att

end

ance levels

to

dep

art

menta

l.

M

onth

ly

repo

rts d

issem

inate

d t

o

div

isio

na

l te

am

s.

Im

ple

ment

accoun

tab

ility

syste

m for

mana

gers

on

un

dert

akin

g R

TW

.

10

EA

RC

10

Develo

pm

en

t an

d

ag

reem

en

t o

f a

refr

esh

ed

Clin

ica

l

Serv

ice

s S

trate

gy

(CS

S)

Directo

r of

Str

ate

gy

4.1

IF the

Tru

st fa

ils to d

evelo

p a

n

effe

ctive a

nd a

gre

ed C

linic

al

Serv

ice S

trate

gy (

inclu

din

g

Healthie

r T

oge

the

r) T

HE

N w

e

could

continue

to p

rovid

e

serv

ices w

hic

h a

re n

ot clin

ically

or

finan

cia

lly s

usta

inab

le in th

e

mediu

m a

nd long

term

an

d w

ill

be

un

ab

le t

o p

rovid

e t

he

qu

alit

y

of serv

ices n

eede

d b

y o

ur

patients

.

IF c

apital re

qu

ired t

o e

xecute

the

CS

S c

an n

ot

be

accessed a

nd

secure

d T

HE

N the

CS

S w

ill

have to

be

rew

ork

ed

sig

nific

antly.

33

Work

to a

gre

e a

dra

ft h

igh level C

SS

will

be

com

ple

te b

y N

ovem

ber

2016

.

The C

linic

al T

ransfo

rmation B

oard

me

t in

Octo

ber

20

16 a

nd

will

be

a k

ey m

eeting t

o

en

ga

ge

CC

G,

La

s a

nd

He

alth

wa

tch

colle

ctively

.

Regu

lar

meetings in p

lace w

ith k

ey

sta

keho

lders

sta

rtin

g in N

ovem

ber.

CS

S s

hare

d w

ith Im

pro

vem

ent

Board

in

Octo

ber

20

16.

The T

rust w

ill s

ubm

it c

apital assum

ptions a

s

part

of th

e 2

017

/19

pla

nn

ing f

ram

ew

ork

.

Govern

an

ce s

yste

m n

ot yet fu

lly

esta

blis

hed

an

d r

epo

rtin

g

arr

ang

em

ents

to b

e c

onfirm

ed.

3G

overn

an

ce s

tructu

re in p

lace

via

Clin

ical T

ransfo

rmation

Board

and

Im

pro

vem

ent

Board

Esta

te c

ontr

ol pla

n

Back log M

ain

tenan

ce p

lan

The T

rust re

qu

ires a

n O

utlin

e

Busin

ess C

ase to

be

cle

ar

abou

t

the

str

ate

gy a

nd its

revenu

e a

nd

capital im

plic

ations.

Dra

ft S

OC

pro

du

ced

A p

rogra

mm

e a

nd e

ng

age

ment

pla

n is r

equ

ired t

o a

rtic

ula

te h

ow

the

str

ate

gy w

ill b

e p

rogre

ssed

with inte

rnal an

d e

xte

rnal

sta

keho

lders

.

An

im

ple

men

tati

on

pla

n is in

develo

pm

en

t

An initia

l In

vestm

ent

Pla

n w

ill

be d

evelo

pe

d b

y N

ovem

ber

20

16

to

en

ab

le t

he

Tru

st

to

beg

in n

ego

tiation o

f re

venu

e a

nd

capital fo

r th

e C

SS

.

A P

rogra

mm

e a

nd E

nga

gem

ent

Pla

n t

o s

ecure

th

e n

ext le

vel of

deta

il on

serv

ice c

han

ge is

requ

ired in N

ovem

ber

2016

.

A d

raft Im

ple

menta

tion P

lan w

ill

be d

evelo

pe

d b

y J

anu

ary

20

18.

9E

xec S

trate

gy

Govern

an

ce

9

Pri

ority

4: Im

pro

ve C

are

and S

erv

ice

s thro

ugh Inte

gra

tion a

nd C

olla

bora

tion

C:\

Use

rs\2

44

99

1-a

dm

in\A

pp

Dat

a\Lo

cal\

Tem

p\b

9f2

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c-9

4b

7-4

f18

-9f8

3-8

8b

43

35

da7

95

Page 95 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

blish

ed

Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

Gap

s in

Assu

ran

ce

Acti

on

Pla

n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

End of Q4

NE

S p

rop

osal

Directo

r of

Str

ate

gy

4.2

IF t

he

Tru

st is

un

successfu

l in

supp

ort

ing t

he

NE

S

com

mis

sio

ne

rs to s

ubm

it a

colle

ctive b

id fo

r tr

ansfo

rmation

fun

din

g T

HE

N t

he

com

mis

sio

nin

g o

f a

cute

serv

ices

is lik

ely

to c

ontinue

to b

e

fragm

ente

d a

nd

un

able

to

supp

ort

de

velo

pm

ent

in th

e

CS

S.

24

The T

rust is

an

active m

em

ber

of th

e N

ES

Overs

ight

Gro

up

whic

h is p

rogre

ssin

g t

his

work

.

The T

rust ha

s a

gre

ed

to t

ake a

lead

on

pulli

ng t

og

eth

er

a r

esourc

ing p

ropo

sal an

d

vir

tua

l te

am

for

this

work

.

Pro

po

sal conte

nt

an

d

subm

issio

n t

imescale

to

the

GM

tea

m n

ot yet a

gre

ed

.

Sin

gle

com

mis

sio

nin

g f

un

ction

desig

n a

gre

ed in p

rincip

le b

ut

curr

ently d

oes n

ot ha

ve a

n

action p

lan in p

lace.

3T

rust ro

le in th

is b

ein

g m

ana

ged

via

th

e C

TB

.

Supp

ort

fo

r N

ES

a

com

mis

sio

nin

g a

pp

roach is a

cle

ar

cond

itio

n o

f a

ccessin

g

transfo

rmation f

un

din

g a

t G

M

level.

Pro

po

sal conte

nt

an

d tim

escale

for

subm

issio

n r

equ

ired.

Tim

escale

fo

r pu

blic

ation o

f

Inde

pen

den

t R

ep

ort

into

the

NE

S w

ork

requ

ired.

Dra

ft

ind

ep

en

den

t re

po

rt f

or

NE

S

rece

ived

Tru

st to

convene

a G

roup

ea

rly

Novem

ber

2016

to a

gre

e

conte

nt

an

d s

ubm

issio

n late

Novem

ber.

Tru

st to

rais

e issue o

f

Inde

pen

den

t R

evie

w v

ia th

e

Overs

ight

Gro

up

in m

id-

Novem

ber

2016

. D

raft

rep

ort

rece

ived

Bo

ard

Rep

ort

pro

du

ced

9E

xec S

trate

gy

Govern

an

ce

9

Su

pp

ort

Develo

pm

en

t o

f

Lo

cal

Care

Org

an

isa

tio

ns

(LC

Os)

in

Man

ch

este

r B

ury

,

Ro

ch

dale

an

d

Old

ham

Directo

r of

Str

ate

gy

4.3

IF the

Tru

st fa

ils to b

e f

ully

en

ga

ge

d in

th

e d

eve

lop

me

nt

of

LC

Os in e

ach localit

y T

HE

N

opp

ort

un

itie

s for

pro

vis

ion o

f

inte

gra

ted c

are

may n

ot be

realis

ed a

nd

assum

ptions w

ithin

the

CS

S a

bout

pa

tient

activity

flow

s m

ay lead

to f

urt

he

r

insta

bili

ty in s

erv

ice p

rovis

ion.

34

Clin

ical T

ransfo

rmation

Board

esta

blis

hed

.

Pro

gra

mm

e M

ana

ger

to c

o-o

rdin

ate

Tru

st

respon

se to

LC

O w

ork

in p

lace.

Within

CT

B, th

ere

is c

urr

ently n

o

cla

rity

fro

m L

CO

s o

n the

ir

mode

ls, w

hic

h m

ean

s w

e a

re

una

ble

to

qu

antify

the

im

pact of

serv

ice c

han

ge.

3C

TB

in p

lace a

nd a

gre

ed a

s a

foru

m thro

ugh

whic

h to

und

ers

tan

d th

e flo

ws fro

m L

CO

s

into

the

acute

secto

r.

Meetings in p

lace w

ith a

ll LC

O

Chie

f O

ffic

ers

/Chie

Executives

and

Tru

st re

pre

sente

d in a

ll

localit

y m

eetings.

Govern

an

ce s

tructu

re y

et to

fu

lly

bed

in a

nd b

eg

in to

de

liver

vis

ibili

ty o

f LC

O w

ork

.

Incre

ase e

nga

gem

ent

an

d

und

ers

tan

d o

f LC

O m

ode

ls v

ia

localit

y g

roup

s d

uri

ng N

ovem

ber

20

16

.

Cre

ate

an initia

l scope

of

LC

O

impact by D

ecem

ber

2016

to

fee

d into

CS

S.

Lin

k L

CO

de

velo

pm

ent

to n

ew

site m

ana

gem

ent

arr

ang

em

ents

by J

anu

ary

20

17.

9E

xec S

trate

gy

Govern

an

ce

9

Pro

gre

ss

Sin

gle

Ho

sp

ital S

erv

ice

in

Man

ch

este

r

Directo

r of

Str

ate

gy

4.4

.1IF

the

re is n

o a

ppro

pri

ate

lead

ers

hip

of th

e S

ingle

Hospital

Serv

ice p

rogra

mm

e w

ho h

as the

capa

bili

ty, capa

city a

nd fo

cus to

deliv

er

TH

EN

the

re m

ay b

e a

lack o

f alig

ne

d inte

gra

tion w

ith

Healthie

r T

oge

the

r an

d P

AT

s

clin

ical serv

ice c

han

ges

23

Clin

ical T

ransfo

rmation B

oard

(C

TB

) in

pla

ce

Pro

gra

mm

e M

ana

ger

in p

lace to

work

as p

art

of S

HS

.

Directo

rs o

f S

trate

gy a

nd T

ransfo

rmation

atte

ndin

g S

HS

pro

gra

mm

e m

eetings.

Rela

tionship

develo

pe

d w

ith P

rogra

mm

e

Directo

r of

the

SH

S.

Tim

escale

fo

r N

MG

tra

nsfe

r in

to

SH

S c

urr

ently O

cto

ber

20

19 -

a

transitio

n p

lan is y

et to

be

agre

ed.

A s

hare

d v

isio

n f

or

the

futu

re o

f

serv

ices o

n N

M h

as y

et to

be

agre

ed.

3P

rogre

ss o

n S

HS

is b

ein

g r

epo

rt

to t

he

CT

B.

The T

rust is

en

gag

ing in v

isio

n

work

for

NM

G b

ein

g led b

y

Mancheste

r C

CG

.

Tru

st is

a m

em

ber

of th

e

Mancheste

r H

ealth a

nd

Wellb

ein

g E

xecutive G

roup

An a

gre

ed

tra

nsitio

n p

lan is

requ

ired f

or

NM

G, w

hic

h is

sig

ne

d u

p to

by a

ll pa

rtie

s.

Meeti

ng

bein

g a

rran

ged

fo

r

late

No

v / D

ec

Fir

st sessio

n f

or

NM

G v

isio

n

bein

g h

eld

on 2

1st O

cto

ber

20

16

.

Work

on

a T

ransitio

n P

lan h

as

bee

n r

ais

ed a

s p

art

of

SH

S

Pro

gra

mm

e, to

be a

gre

ed

by

Novem

ber

2016

.

8E

xec S

trate

gy

Govern

an

ce

8

Directo

r of

Esta

tes a

nd

Facili

ties

4.4

.2IF

lack if in

vestm

ent

in N

MG

H

esta

te c

ontinue

s d

ue to

na

tiona

l

short

age o

f p

ublic

div

iden

d

capital or

bu

sin

ess c

ase n

ot

app

roved a

t G

reate

r M

ancheste

r

or

treasury

levels

TH

EN

tem

pora

ry w

ork

to a

llow

pa

tient

care

in c

urr

ent

facili

ties w

ill n

eed

to c

ontinue

44

Esta

te c

ontr

ol pla

n

Back log M

ain

tenan

ce p

lan

Agre

ed

Capital D

evelo

pm

ent

Pla

n f

or

Nort

h M

ancheste

r

4?

Assura

nce p

rocess for

esta

te

develo

pm

ent

Agre

e

Clin

ical S

trate

gy for

the T

rust

and

Nort

h M

ancheste

r's p

lace

within

th

at

Iden

tify

capital solu

tions w

ith

SH

S G

M D

evo

Agre

e a

nd

fun

d inte

rim

ward

upg

rade

pro

gra

mm

e

12

Tru

st B

oard

12

Imp

rove t

he U

rgen

t

Care

serv

ice

at

No

rth

Man

ch

este

r

in lin

e w

ith

CQ

C

an

d N

HS

i

req

uir

em

en

ts

Directo

r of

Opera

tions

4.3

.1IF

the

Tru

st is

un

able

to

sta

bili

se

and

susta

in th

e m

edic

al

work

forc

e to

supp

ort

ED

and

AM

U T

HE

N the

re is a

ris

k tha

t

the

Tru

st on

the

NM

GH

site

could

not p

rovid

e 2

4/7

em

erg

en

cy c

are

45

Recru

itm

ent

pla

n w

ith C

MF

T / S

RF

T

Use o

f in

teri

m locum

s

Overs

eas r

ecru

itm

ent

PA

T w

ork

forc

e p

lan t

o m

obili

se a

nd

str

eng

the

n

Penn

ine s

taff

respon

se to

ED

GM

off

er

of

Consultan

t sta

ff

Imple

menta

tion o

f N

WA

S p

ath

finde

r

QI

pla

n

Lon

ger

term

fun

din

g o

f

Impro

vem

ent

Pla

n.

Susta

inab

ility

of in

teri

m s

olu

tion f

rom

GM

pro

vid

er

beyond

Marc

h

3D

aily

rota

scru

tiny

Impro

vem

ent

Pro

ject

Care

Board

GM

Im

pro

vem

ent

Board

Monitori

ng o

f Im

pro

vem

ent

Pla

n

at C

are

Board

and

GM

Impro

vem

ent

Board

Sen

ior

man

ag

er

an

d c

lin

ica

l

lea

ders

hip

gap

s o

n N

MG

H s

ite

Continue

to im

ple

ment

Impro

vem

ent

Pla

n (

tim

elin

es

outlin

ed

within

pla

n)

Continue

to s

eek long

term

finan

cia

l fu

ndin

g (

agre

em

ent

by

Dec 2

016).

Ensure

tra

nspare

ncy

of ro

ta a

nd e

ase o

f use b

y

develo

pin

g e

lectr

onic

ally

(end

Oct 20

16 -

com

ple

ted).

Develo

p

Pla

n B

po

st M

arc

h (

Dec201

6).

Appo

int to

and s

treng

the

n

clin

ical an

d m

ana

geri

al

lead

ers

hip

into

Dept

(Dec 2

016)

12

Tru

st B

oard

12

C:\

Use

rs\2

44

99

1-a

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in\A

pp

Dat

a\Lo

cal\

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10

Page 96 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

blish

ed

Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

Gap

s in

Assu

ran

ce

Acti

on

Pla

n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

End of Q4

Directo

r of

Opera

tions

4.3

.2IF

the

Tru

st is u

nable

to

impro

ve p

atient

flow

an

d r

edu

ce

UC

dem

and

thro

ugh

all

sites

with e

merg

en

cy d

epart

men

ts

TH

EN

th

e n

atio

na

l sta

nd

ard

s f

or

access w

ill n

ot be

met a

nd

patient

care

will

be

com

pro

mis

ed

55

Esta

blis

hm

ent

of

impro

vem

ent

pro

jects

focussin

g o

n h

ospital flow

an

d u

rgen

t care

(adu

lts a

nd p

aed

s).

Work

ing w

ith E

CIP

to

develo

p a

nd

de

liver

pla

n a

ligne

d to

UC

nationa

l im

pro

vem

ent

pri

ori

ties. Join

ed

nationa

l am

bula

tory

em

erg

en

cy c

are

netw

ork

.

Syste

m w

ide p

lans to b

e

develo

pe

d v

ia U

C d

eliv

ery

boa

rd. F

undin

g a

nd

pla

ns for

dela

yed t

ransfe

rs o

f care

.

Medic

al w

ork

forc

e c

apa

city to

ensure

tim

ely

revie

ws a

gain

st

sta

ndard

s a

gre

ed

. S

enio

r

nurs

ing c

apa

city to s

upp

ort

flo

w

and

dis

charg

e p

lann

ing a

t w

ard

level. R

ob

ust lo

cal an

d s

yste

m

wid

e e

scala

tion p

olic

ies

3U

C Q

ualit

y a

nd p

erf

orm

ance

meetings a

cro

ss a

ll E

ds.

Monitori

ng o

f Im

pro

vem

ent

Pla

ns a

t care

Board

, tr

ust B

oard

and

GM

. O

ps a

nd p

erf

orm

ance

assura

nce C

om

mitte

e

Syste

m level pe

rform

ance v

iew

and

assura

nce

Deliv

ery

of

PA

HT

im

pro

vem

ent

pla

n p

roje

cts

(tim

elin

es o

utlin

ed

within

pla

n).

Fin

alis

e p

lan f

or

SR

G fun

din

g a

nd

resili

ence p

lan

(Oct 20

16,

chan

ged

Nov 2

016))

and

UC

syste

m w

ide

impro

vem

ents

with E

CIP

(M

arc

h

201

7).

Fin

alis

e local an

d s

yste

m

wid

e e

scala

tion p

olic

y a

nd p

lans

(Nov 2

016)

. R

evie

w U

C

Deliv

ery

Board

arr

ang

em

ents

(Dec 2

016)

13

Tru

st B

oard

13

Assu

re

develo

pm

en

ts o

f

hig

h a

cu

ity s

erv

ice

s

at

Ro

yal O

ldh

am

as

part

of

Healt

hie

r

To

geth

er

imp

lem

en

tati

on

Medic

al

Directo

r

4.4

IF the

Tim

escale

s for

imple

menta

tion o

f H

igh A

cuity

serv

ices a

re n

ot a

chie

vable

TH

EN

the

re is a

ris

k tha

t pa

tient

care

fo

r th

at coho

rt o

f pa

tients

may b

e c

om

pro

mis

ed

34

CS

T B

oard

to b

e in

pla

ce c

hair

ed b

y the

CE

O

Pro

ject te

am

in p

lace

Directo

r of

Str

ate

gy a

nd D

irecto

r of

Tra

nsfo

rmation involv

ed in d

iscussio

ns

CS

T B

oard

not

yet e

sta

blis

hed

4G

overn

an

ce S

tructu

re d

rafte

d

Min

ute

s / a

ctions w

ill b

e taken

and

monitore

d

Govern

an

ce S

tructu

re n

ot yet in

pla

ce

Cle

ar

imple

menta

tion p

lan

Cle

ar

Lead

an

d tim

escale

s to

achie

ve A

pri

l 20

17 d

ea

dlin

e

Task a

nd fin

ish g

roup

.

Clin

ical le

ad

an

d p

roje

ct

mana

ger

iden

tified

Appo

inting a

HT

CD

Octo

ber

20

16

11

EA

RC

11

Achie

ve th

e fo

llow

ing

key A

ccess targ

ets

:

A&

E t

arg

et

Op

en

RT

T p

ath

way

targ

et

Can

cer

62

day

targ

et

Dia

gn

osti

c t

arg

et

Directo

r of

Opera

tions

5.1

IF e

ffective d

ata

qu

alit

y p

rocess

are

not in

pla

ce T

HE

N d

ata

subm

issio

ns, da

ta u

sed f

or

assura

nce a

nd g

overn

an

ce

pro

cesses a

nd d

ata

used t

o

pro

gre

ss p

atient

treatm

ent

may

be c

om

pro

mis

ed

54

Weekly

cancer

an

d R

TT

PT

L m

eetings in

pla

ce. C

entr

alis

ed a

ccess a

nd b

ookin

g

fun

ction a

nd

tea

ms. C

an

cer

trackers

an

d

MD

Ts. N

ew

PT

L c

reate

d f

or

follo

w u

p

patients

. P

art

ial bo

okin

g in p

lace fo

r som

e

specia

litie

s. S

yste

matic a

udit p

lan a

gre

ed t

o

valid

ate

open

pa

thw

ays.

No d

aily

ED

bre

ach a

naly

sis

by

site led b

y D

M a

nd a

tten

ded

by

lead

clin

icia

n.

Not a

ll clin

icia

ns

record

in S

ym

pho

ny N

o R

TT

train

ing p

rogra

mm

e in p

lace.

Weekly

PT

L m

eeting n

ee

ds to

focus o

n n

on b

reach p

ath

ways.

RT

T fun

ctiona

lity in P

AS

no

t

utilis

ed.

Work

forc

e c

apa

city to

und

ert

ake v

alid

ation w

ork

Part

ial bo

okin

g n

ot

in p

lace in a

ll

specia

litie

s.

4C

urr

ent

bre

ach r

epo

rts a

nd d

ata

subm

issio

ns s

igne

d o

ff b

y

Div

isio

na

l D

irecto

rs. A

ction p

lan

assure

d v

ia O

pera

tions a

nd

Perf

orm

ance C

om

mitte

e

Subm

issio

ns s

ign o

ff n

ot

supp

ort

ed

by D

ata

Qualit

y

relia

bili

ty

GM

cancer

clo

ck s

tart

/ s

top

pro

cess n

ot in

pla

ce a

t P

AT

(Nationa

l syste

m u

sed)

Tra

inin

g p

rogra

mm

e fo

r R

TT

to

be p

rocure

d a

nd

im

ple

mente

d

(com

mence O

ct -

Marc

h 2

016

)

Revie

w o

f boo

kin

g a

nd

sched

ulin

g t

ea

m s

yste

ms a

nd

pro

cesses (

com

menced O

ct -

Marc

h 2

016

). D

ata

Qualit

y

impro

vem

ent

pro

gra

mm

e

requ

ired (

baselin

e a

ssessm

ent

Dec 2

016).

Im

ple

ment

RT

T

fun

ctiona

lity in P

AS

(upg

rade

201

7).

D

ete

rmin

e u

se o

f G

M

Sta

rt / S

top

clo

ck p

rocess fo

r

cancers

(com

ple

ted p

olic

y

ad

op

ted

Oct

20

16

). C

om

me

nce

PA

S c

lean

se a

nd im

ple

ment

new

contr

ols

(com

menced O

ct

201

6, conclu

de

Apri

l 20

17).

Deliv

er

ED

data

qualit

y p

lan

(Sept

20

16 -

Mar

20

17).

Develo

p

robu

st B

I to

ols

an

d s

yste

ms to

ensure

data

is v

iable

, tim

ely

an

d

accura

te for

opera

tiona

l te

am

s

(Sept

20

16-

Apri

l 20

17)

13

Tru

st B

oard

13

Pri

ority

5: D

em

onstr

ate

Com

plia

nce w

ith M

andato

ry S

tandard

s

C:\

Use

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35

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95

Page 97 of 134

An

nu

al P

lan

Ob

jecti

ve

2016/1

7

Exec L

ead

Ris

k

nu

mb

er

Pri

ncip

al R

isks

Likelihood

Impact

Ke

y C

on

tro

l esta

blish

ed

Ke

y G

ap

s in

Co

ntr

ols

Control

Assu

ran

ce

Gap

s in

Assu

ran

ce

Acti

on

Pla

n S

um

mary

Op

en

ing

Po

sit

ion

Assu

ran

ce

level

End of Q1

End of Q2

End of Q3

End of Q4

Directo

r of

Opera

tions

5.1

.2IF

Capa

city a

nd D

em

and

is n

ot

matc

hed

for

challe

ng

ed

specia

litie

s T

HE

N p

atients

may

no

t b

e t

rea

ted

with

in r

eq

uire

d

tim

escale

s r

esultin

g in p

ote

ntial

harm

to

pa

tients

, po

or

experi

ence a

nd f

ailu

re o

f

nationa

l dia

gn

ostic s

tan

dard

,

RT

T s

tan

dard

and

sta

ndard

s for

pla

nn

ed p

atients

44

Pro

cess in p

lace to

com

mence R

TT

clo

ck o

n

all

pla

nn

ed p

atients

on

ce th

eir

da

te is

reached

.

P

atients

tracked v

ia P

TL.

D

iagn

ostic

Impro

vem

ent

pla

n a

nd

tra

jecto

ry a

gre

ed

Recovery

pla

n in p

lace fo

r en

doscopy u

sin

g

inde

pen

den

t secto

r capa

city

Work

forc

e r

ecru

itm

ent

to c

reate

susta

inab

le e

ndo

scopy c

apa

city

requ

ired.

Requ

ires r

obu

st T

&O

,

pa

ed

de

ntistr

y r

eco

ve

ry p

lan

an

d

traje

cto

ry. C

ap

acity a

nd d

em

and

pla

nn

ing t

o b

e in p

lace fo

r all

specia

litie

s. P

lans to b

e

develo

pe

d to

en

sure

capa

city

(the

atr

es, O

P a

nd b

eds)

accessib

le a

nd f

ully

utilis

ed

4W

eekly

repo

rtin

g a

ga

inst

traje

cto

ry. W

eekly

PT

L m

eeting.

Month

ly a

ssura

nce a

t

Opera

tions a

nd p

erf

orm

ance

com

mitte

e. C

on

tract

perf

orm

ance m

eetings

Div

isio

na

l an

d S

erv

ice L

ine O

ps

and

Perf

orm

ance m

eetings to b

e

em

bed

ed a

nd

DA

RC

to b

e

com

menced

Imple

ment

Gastr

o D

iagn

ostic

action p

lan a

nd

tra

jecto

ry

(com

ple

te O

ct 20

16 -

com

ple

ted

and

de

livere

d).

Develo

p f

urt

he

r

traje

cto

ry a

nd p

lan f

or

ga

str

o to

redu

ce w

aits for

firs

t

app

oin

tment

an

d s

usta

in

dia

gn

ostics (

deliv

ery

Oct -

Marc

h

201

7).

Agre

ed

tra

jecto

ries for

T&

O a

nd p

aed

de

ntistr

y (

Oct

201

6-

traje

cto

ries a

gre

ed

an

d

monitore

d )

. D

evelo

p G

astr

o

busin

ess c

ase (

Nov 2

017).

Capa

city a

nd d

em

and

an

aly

sis

to b

e c

om

ple

ted fo

r all

specia

litie

s (

Dec 2

016).

Utilis

ation im

pro

vem

ent

pla

ns to

be o

utlin

ed

(D

ec 2

016).

B&

S

revie

w (

Oct -

Marc

h 2

017

)

12

Tru

st B

oard

12

Infe

cti

on

s:

C,D

iff

MR

SA

Medic

al

Directo

r

5.2

IF the

Tru

st fa

ils to m

eet

mand

ato

ry s

tan

dard

s for

infe

ction c

ontr

ol T

HE

N this

could

lead

to p

atient

ha

rm a

nd / o

r th

e

qua

lity o

f patient

care

could

be

affe

cte

d w

hic

h c

ould

lead

to

regu

lato

ry involv

em

ent

an

d

repu

tationa

l da

mage

44

Infe

ction C

ontr

ol P

olic

y

Hand

washin

g m

and

ato

ry tra

inin

g

Infe

ction C

ontr

ol te

am

in p

lace

Cle

an

ing c

ontr

act an

d s

ched

ule

in p

lace

Nurs

e e

quip

ment

cle

an

ing s

ched

ule

pro

cess

in p

lace

Infe

ction c

ontr

ol ga

p a

naly

sis

iden

tified c

lean

ing n

ot

meeting

requ

ired s

tan

dard

s in s

om

e

are

as

5In

fection c

ontr

ol re

po

rt to

Infe

ction c

ontr

ol com

mitte

e

Cle

an

ing r

epo

rt to

cle

an

ing

com

mitte

e

Key infe

ction c

ontr

ol is

sues in

IPR

to Q

ualit

y a

nd P

atient

experi

ence a

nd T

rust B

oard

Infe

ction C

ontr

ol an

d c

lean

ing

aud

its c

arr

ied o

ut

?R

ein

sta

te s

tan

dard

s to c

lean

ing

contr

acto

rs w

ith s

ignific

ant

impact

W

ard

accre

ditation p

rocess focusses

on 'days s

ince last in

fection'

Dir

of

Esta

tes a

nd

Facil

itie

s

un

dert

ake

n w

alk

ro

un

d a

t

NM

GH

wit

h D

N. M

on

thly

meeti

ng

wit

h D

ir E

sta

tes a

nd

Facil

itie

s w

ith

se

nio

r m

an

ag

er

fro

m G

4S

, ac

tio

n p

lan

ag

reed

.

Su

gg

est

sep

ara

tin

g o

ut

cle

an

ing

as

a s

ep

ara

te r

isk

to

allo

w v

isib

ilit

y o

f ri

sk

an

d

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rovem

en

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ete

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rati

on

.

13

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st B

oard

13

C:\

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10

Page 98 of 134

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Title of Report Charitable Funds Committee – 19 October 2016



Executive Summary

The minutes of the Charitable Funds Committee held on 19

October 2016 are attached. The following Exception, Escalation and Assurance Report is noted for Board consideration. Exception Report

No items. Escalation Report

An allocation of £40,000 from the Cancer Research Fund and £40,000 from the RL Gardner Fund for the creation of office accommodation for the Cancer Research Delivery Team and the Research Management and Governance Team in the Clinical Research Unit at Fairfield General Hospital was approved for recommendation to the Trust Board.

Assurance Report

Annual Report and Accounts for the year were approved.

An unqualified External Audit Opinion had been received.

The Charitable Fundraising Report was received and the ongoing fundraising work was commended.

The Charity’s objectives were reviewed and no amendments made.

The Terms of Reference of the Committee were reviewed and no amendments made.

The portfolio management client service review was received.

It was agreed to market test the portfolio management service.

The Committee noted that there would be no further applications for funding for the Arts Project, commented that they were disappointed at this approach and agreed not to make any allocation to a ward level comforts fund until such time as a full proposal was provided.

A legacy of £210,000 has been received and is available to spend upon receipt of proposals from the Trust.

Actions requested The Board is asked to note the minutes.

Corporate Priorities supported by this paper: The issues in this paper are relevant to the following Trust objectives. 1. Pursue Quality Improvement to assure safe, reliable and compassionate care 3. Support our Staff to Deliver High Performance & Improvement

Item

11a

Page 99 of 134

C:\Users\244991-admin\AppData\Local\Temp\93ce0ce8-4f23-46d2-92fd-d8c4f43b105f.docx

Risks: The Committee has considered and maintains a risk register for the Charity.

Development and Assurance Minutes record discussion at the Charitable Funds Committee and are submitted to the subsequent meeting for approval.

Public and/or patient involvement: Significant patient and public involvement in various fundraising schemes.

Resource implications: Not relevant for this paper

Communication: The Charitable Funds Committee communicates its work to the Trust Board as corporate Trustee.









IM&T Requirements X



Partnerships X



Name Shauna Dixon

Job Title Non-Executive Director

Date November 2016

Page 100 of 134

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Minute

Charitable Funds Committee Room 249, Second Floor, Trust HQ

19 October 2016 8.30am – 10.00am

Owner Timescale

Present Mrs S Dixon, Non-Executive Director (Chair) Mr G Barclay, Assistant Chief Executive / Board Secretary Mr D Finn, Director of Finance Mr P Haigh, Head of Financial Control Mr J Willis, Non-Executive Director

Apologies Professor M Makin, Medical Director Ms S Owen, Charitable Fundraising Co-ordinator

In Attendance Dr S Woby, Director of Research and Development (Item 26/16) Mr R Jones, KPMG (Item 28/16 onwards)

25/16 Introduction, Apologies & Declarations of Interest Mrs Dixon led the introductions and asked for any declarations of interest; none were received.

26/16 Request for Funding: FGH Clinical Research Unit Dr Woby spoke to his paper which was a funding request for allocations from the Cancer Research Fund and the RL Gardner Fund for expansion of the Clinical Research Unit at Fairfield General Hospital. Dr Woby said that high quality research activity across the Fairfield site had seen a four-fold increase over the past 3 years and industry sponsored activity had seen a 30% increase over the past financial year. He expected a further 40% increase in industry activity during 2016/17. Despite this rise in research activity the Fairfield site had no dedicated office space for either the Cancer Research Delivery Team or the Research Management and Governance Team. The general consensus across R&D services was that the overall performance of an R&D service improved when the delivery staff and the management and governance function were co-located within the same unit. Significant work had already been completed on converting 75% of ward 19 at FGH into a clinical research unit. The remaining space on ward 19 would be an ideal location for the management and governance team as well as additional member of the research delivery team (eg Cancer Research nurses). Dr Woby therefore sought an allocation of £80,000 for the costs of converting the accommodation. Mr Haigh said that £80,000 was available in the Cancer Research fund and £300,000 was available in the RL Gardner Fund.

Item

11a

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Mr Barclay said that a previous proposal, which had been withdrawn for amendment, had requested funding for clinical ward accommodation for research activity and he had supported that approach. However, he had concerns about using Charitable Funds to create office accommodation. Dr Woby said that the staff who would use the offices were supporting clinical activity and the accommodation was required. Mr Finn asked whether ward 19 was in an area of FGH that may become redundant in the future. Dr Woby said that it was not. Mr Finn asked about the level of income which the Trust received from research and development activity and Dr Woby said this was approx £500,000 per annum. Mrs Dixon asked whether allocation of funding to such a scheme fell within the remit of the Trust’s charity. Mr Barclay said that such an allocation would be competent within the remit of the Trust’s Charitable funds. While noting Mr Barclay’s objections, the Committee approved the funding submission and agreed that £40,000 be allocated from the Cancer Research fund and £40,000 the RL Gardner fund. It was noted that this level of expenditure would need to be approved by the Trust Board. An allocation of £40,000 from the Cancer Research Fund and £40,000 from the RL Gardner Fund was approved for recommendation to the Trust Board.

PH

27/16 Minutes of the Previous The minute of the meeting held on 14 June 2016 was submitted and approved.

28/16 Audited Annual Report / Accounts 2015/16 and Trustee Representation Letter The draft Annual Report and accounts for 2015/16 which had been presented to the Committee at the June meeting had since been audited by KPMG. There had been no significant changes to the accounts or report since the draft. The audited Annual Report and Accounts and the Trustee Representation letter were approved.

29/16 KPMG Audit Highlight Memorandum Mr Jones spoke to the Audit Highlights Memorandum and Management letter for the year ended 31 March 2016. Mr Jones said that there were no significant accounting issues to draw to the attention of the Committee and no significant audit issues or adjustments. An unqualified audit opinion had been issued and Mr A Smith, Audit Partner, would sign the audit letter to that effect. The Audit Highlight memorandum was noted.

30/16 Charitable Fund Raising Report Mr Barclay spoke to the report and highlighted the on-going fund raising activity including work with the Joshua Wilson Brain Tumour Charity which would benefit the paediatric A&E

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department at North Manchester General Hospital, the Link for Pink charity fashion show, work carried by a group of colleagues from Dr Fosters on maintenance of the Baby Memorial Garden at NMGH, acceptance of an application to MedEquip4Kids for £6,900 for art and environment work on the paediatric ultrasound unit at the Royal Oldham Hospital and the development of a proposal for a new large scale charitable appeal for a garden project for dementia services at Rochdale Infirmary. There had also been a large number of smaller scale fundraising activities carried out by both staff and local people across the Trust’s footprint. The Committee commended the ongoing fundraising and the report was noted.

31/16 Art Project Mr Barclay spoke to his report and said that since 2005 the Trust had supported an annual programme of arts activity across its hospitals. The Charitable Funds Committee had supported the Arts Project by allocating £34,000 per annum from the general fund to the Arts Project. The Arts Project had been very successful in obtaining matching funding for the contribution made by the Charitable Funds Committee. Mr Barclay said that following discussion with the Chief Executive it had been decided that the 2016/17 should be the last year of the separately funded Arts Project. Existing projects would be brought to a close during the year and no further projects would be commissioned. It was anticipated that expenditure in 2016/17 would be £28,000 rather than £34,000. In place of the Arts Project it was planned to empower ward sister and equivalents to make incremental patient comfort improvements in their ward areas by being able to bid against a central fund for small amounts of money which they could use locally. Details of the scheme were being worked up. In the meantime Mr Barclay asked the Charitable Funds Committee to allocate £6,000 which was the projected underspend on the Arts Project in 2016/17 to this new fund – a ward level comforts fund - and to allocate £34,000 to this fund in 2017/18. Mrs Dixon said that the Arts Project had been highly successful in improving the environment throughout the hospitals and involving staff and local communities in those projects and she was disappointed that the project would cease. She was concerned about the loss of community involvement. Mrs Dixon said she was also concerned about setting up a fund for minor ward improvements as her previous experience of such funds was that very little impact could be made from these small sums of money. Mrs Dixon said that she would not wish to allocate any funding until the detail of the proposal was available. The Committee noted that there would be no further applications for funding for the Arts Project, commented that they were disappointed at this approach and agreed not to make any allocation to a ward level comforts fund until such time as a full proposal was provided.

32/16 Finance Report for the Year to August 2016

Item

11a

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Mr Haigh spoke to the report and said that the Charity had received income of £365,000 for the year to August (donations £69,000, legacies £243,000 and interest / dividends £53,000). In the same period the Charity spent £104,000 (patients amenities £69,000, staff amenities £5,000, admin expenses £16,000 and fund raising costs £15,000). The Charity had investments at the end of August of £2,662,000. The risk profile balance of the funds was 56% low, 44% medium compared to a target of 50 / 50. Since the last report there had been four significant legacies and nine significant donations/fund raising income. A legacy of £210,000 had been received in August 2016. Mr Haigh spoke to the future forecast for the General Fund. It was noted that there would be a projected shortfall in 2017/18 although this did not take account of any income being allocated. The Committee were content to monitor this position as in previous years this had self-corrected. In terms of the £210,000 legacy it was agreed that Mr Finn would ensure that Trust Management was aware that this sum was available and to invite appropriate bids against this sum to be submitted to the Charity. The report was noted.

DF

33/16 Review of Objectives Mr Haigh spoke to his paper which submitted the objectives for review. The Committee approved the objectives with no change.

34/16 Terms of Reference Mr Haigh spoke to the paper which submitted the Terms of Reference for review. The Terms of Reference were approved with no amendments.

35/16 Portfolio Management Mr Haigh spoke to his report and stated that over the last 3 years the dividends / interest percentage yield net of management fee had been 4.1% in 2013/14, 4.1% in 2014/15 and 4% in 2015/16. Mr Haigh said this compared favourably with benchmarks. The Committee agreed that the charity should continue with an overall investment strategy of 50/50 between low and medium risk. The Committee considered the appointment of Brewin Dolphin as investment providers. It was noted that Brewin Dolphin had been originally appointed as investments advisors in April 2004 and the contract had been extended on a number of occasions since that time. It was agreed that after 12 year a further extension could not be agreed and the investment providers

Page 104 of 134


should be market tested. It was agreed that the Portfolio Management should be put to tender and a new five year term established from 1 April 2017. It was agreed that the Committee would formally discount using the same advisor as SRFT Charity in order to maintain the integrity of the two charities. The report was noted and it was agreed to put the portfolio management out to tender.

PH

36/16 Brewin Dolphin Client Service Review Mr Haigh spoke to the paper which set out Brewin Dolphin’s client service review. Mr Jones said that there was a misalignment between the ethical intent stated in the Charity’s annual report and accounts and the statement by Brewin Dolphin. The Charity stated that it did no invest in tobacco or armament production whereas the client service review stated that some portfolio funds may include up to 15% invested in companies that had links to tobacco or armament sales or production. It was agreed that Mr Haigh would raise with Brewin Dolphin the practical implications of not investing in any portfolio funds which may include investment in tobacco or armament sales or production. The report was noted.

PH

37/16 Charity’s Official Investment Fund Signatories Mr Haigh spoke to his paper which updated proposed authorised signatories for the COIF. The updated signatories list was approved.

38/16 Date of Next Meeting It was agreed that the next meeting of the Committee be held on Thursday 15 December 2016 in Room 249, Trust HQ, NMGH at 8.30am

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C:\Users\244991-admin\AppData\Local\Temp\935be203-da76-4e33-bcdc-7c31b480c7aa.docx

Title of Report Audit Committee – 21 October 2016



Executive Summary

This report summarises the Exception, Escalation and Assurance items from the Audit Committee meeting held on 24 November 2016. The minute is attached. Exception Report Internal Audit limited assurance reports – Divisional Governance Report – noted that this related to the former committee structure, however a number of the matters commented upon for action would be carried forward into the new committee arrangements. High priority recommendations – noted the increased emphasis on closing down actions but a number remained overdue. Escalation Report Review of Standing Orders and SFIs – recommended a number of amendments to the Trust Board for approval. Assurance Report Revised agenda format with inclusion of two items where the Committee could seek assurance from Directors on specific topics. Quality Improvement Plan reviewed. Key issue identified was importance of engagement with staff in order to ensure actions were embedded. Committee agreed that key issue lay with Executive management identifying the key messages and line managers across the Trust working with their own staff to ensure these were understood. New Finance Director’s Report which covered losses, special payments, debtors, creditors and actions from the Annual Audit letter. Cleaning arrangements – in depth discussion with the Director of Estates and Facilities. Revised Audit Plan for the remainder of 2016/17 which had been refocused on Improvement Plan matters. Audit Contract Renewal – progress noted – on time and on target. Counter Fraud Progress Report - noted.

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C:\Users\244991-admin\AppData\Local\Temp\935be203-da76-4e33-bcdc-7c31b480c7aa.docx

Future meetings will feature scrutiny of sub 12 BAF risks where Executive Directors will be invited to present risks for scrutiny (2 per meeting).

Actions requested The Board is asked to note the highlight report.

Corporate Priorities supported by this paper: 1. Pursue Quality Improvement to assure Safe, Reliable and Compassionate Care 2. Deliver Financial Plans to assure sustainability 3. Support High Performance and Improvement 4. Improve Care and Services through Integration and Collaboration 5. Demonstrate Compliance with Mandatory Standards

Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.

Development and Assurance Minutes record discussion at the Audit Committee and are submitted to the subsequent meeting for approval.

Public and/or patient involvement: Not relevant for this paper.

Resource implications: Not relevant for this paper

Communication: The Audit Committee communicates its work to the Trust Board.









IM&T Requirements X



Partnerships X



Name John Willis

Job Title Non-Executive Director

Date November 2016

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C:\Users\244991-admin\AppData\Local\Temp\23612619-a848-42e5-8d10-5fab4b0c994c.docx

Minute

Audit Committee Executive Directors’ Meeting Room, Second Floor, Trust Headquarters, North Manchester General Hospital

21 October 2016 2.00pm – 5.00pm

Owner Timescale

Present Mr J Willis, Non-Executive Director (Chair) Mrs D Brown, Non-Executive Director (To item 104/16) Mrs C Guereca, Non-Executive Director Mrs C Mayer, Non-Executive Director (Item 101/16 onwards) Mrs S Dixon, Non-Executive Director Mrs M Ollerenshaw, Non-Executive Director (To item 104/16)

In Attendance Mr G Barclay, Assistant Chief Executive / Board Secretary Mr T Crowley, MIAA Mrs J Downey, Director of Governance Mr D Finn, Director of Finance & IM&T Mr A Gordon, Lead Local Counter Fraud Specialist Mr P Haigh, Head of Financial Control Mrs E Squires, MIAA Mr A Smith, KPMG Mrs N Tamanis, Deputy Director of Finance Mrs L McCluskie, Director of Estates & Facilities (Item 102/16)

95/16 Introductions Mr Willis welcomed everyone to the meeting.

96/16 Declarations of Interest There were no declarations of interest.

97/16 Chairman’s Remarks Mr Willis commented on the revised agenda format with the inclusion of two items where the Committee could seek assurance from Directors on specific topics. He said this would be a regular feature of the all Audit Committee meetings.

98/16 Minute of the Previous Meeting The minute of the meeting dated 19 July 2016 was submitted and approved.

99/16 Plan Business Cycle and Action Log 83/16 – Declarations of Interest. Mr Barclay to conclude the actions on expanding arrangements on Declarations of Interest.

GB

100/16 Quality Improvement Plan Mrs Downey spoke to the summary of the CQC and SRFT Diagnostic Improvement Plan. She said that all of the actions

Item

11b

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required arising from the CQC report and the SRFT Diagnostic had been identified and included in a reporting structure which ultimately led to the Trust Board. Progress against actions was monitored through a weekly operational update meeting. All of the “must do” and “should do” actions had been linked to one of the Executive Governance Committees. A gap analysis was being undertaken to identify whether the assurance was in place and reliable or whether further additional reports would need to be commissioned. Mrs Downey highlighted a number of specific actions:

The SRFT 2008 Nursing Accreditation and Assurance System model was being piloted on six wards and would be evaluated in November 2016.

The Quality Improvement Strategy would be submitted to the Trust Board in November 2016. Work on the learning collaboratives had started in advance of formal approval of the strategy.

Progress was being made on the appointment of additional consultants for Critical Care.

Significant work was underway in midwifery and on a review of nurse staffing numbers on general inpatient wards.

Mr Finn said that Trust had been able to secure £9.2 million additional funding to support improvements in the current financial year. While considerable staffing had been introduced to the Trust over the last few years there remained a gap as the Trust had been unable to appoint into its current establishment and had since agreed to further increase the establishment. A significant piece of work was underway on recruitment. Mrs Brown said that while recruitment was important it was also important that the Trust made best use of existing staff. Mrs Guereca asked about leadership and Mrs Downey said the new and strengthened site leadership arrangements would bring clearer accountability and behaviours. Mr Willis asked about the underlying data systems and Mrs Downey said that much more work was required to improve data systems data quality. It was agreed to consider further scrutiny of data quality at a future meeting of the committee. There was general comment recognising the importance of engaging with staff in order to ensure that actions were embedded. Mr Barclay commented that while corporate communications had a role to play the key issues lay in Executive Management identifying the key messages and line managers across the Trust working with their own staff to ensure these were understood. The report was noted.

GB/JW

101/16 Finance Director’s Report Mr Finn introduced the first report to the Committee which covered a number of finance related matters.

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Mr Haigh reported on losses and special payments and commented that for the financial year to date £243K related to bad debts and claims abandoned for overseas visitors. £12k had been paid in ex-gratia payments due to loss of personal effects. Audit Committee members commented that in addition to the financial loss this represented a very poor patient experience. Mr Haigh spoke to the report on debtors and the progress being made on these. He also summarised the position in terms of creditors. It was agreed that future reports should provide an overview on whether the overall debtors and creditors balance was improving or deteriorating. Mr Finn summarised the tender waivers for quarter two. While acknowledging that a number of these related to assessments linked to further reviews within the Trust, the Committee expressed concern that the reason for waiver was that the time scale precluded completive tendering. Mr Finn said that the matters raised in the Annual Audit letter from KPMG had been included in the report and were highlighted for the Committee’s attention. The most significant issues related to the Trust’s underlying operational deficit. Mr Finn reported that NHS Improvement had earlier in the day agreed that the Trust’s control total for 2016/17 should be amended to £15.2 million deficit. Mr Finn said that the draft financial plan for the next two years would be submitted to NHS Improvement by 24 November 2016. Mrs Mayer asked about the extent to which the Trust’s action plans were singular and encompassed everything the Trust had to achieve or whether there remained multiple action plans which staff had to contend with. Mr Finn said he was confident that all of the actions required of the Trust had been included in action plans and they were complimentary to each other. Mr Finn commented on the new single oversight framework which had been issued by NHS Improvement. The Trust had been rated at level 3 which required mandated support. This support was being provided by Salford Royal FT. The report was noted.

102/16 Cleaning Arrangements Mr Willis welcomed Mrs McCluskie to the meeting and said that concern about cleaning had been expressed at the previous meeting. Mrs McCluskie said that the issues about cleaning were well known and the internal audit report provided a fair reflection of the current position. Mrs McCluskie said that while there were areas of poor performance this was by no means universal. There were other areas in the Trust where the cleaning standards were excellent. She said that she intended to put in place a number of actions:

A more robust mechanism with set standards for the weekly meeting.

Item

11b

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Improved governance and management of cleaning standards at a local level but with escalation where appropriate.

Initial and immediate improvements to ward environments to address areas where cleaning was problematic.

Engaging with senior nursing teams on issues raised by the cleaning contractor.

Mrs McCluskie said that she would meet with G4S on a monthly basis until there was an improvement in the cleaning standards. She would engage a joint peer review with SRFT on cleaning monitoring in order to benchmark PAHT cleaning monitoring. Mrs McCluskie commented that the current cleaning contract was very input based and therefore left a significant amount of risk with the Trust. She also commented that the contract was lean in terms of the hours allocated for cleaning. The cleaning contract was due for re-tender in May 2018 and Mrs McCluskie said that the new contract should be output based. Management would need to consider the future of the cleaning contract and whether to seek to bring the service back in-house. Mrs Dixon said that Mrs McCluskie had confirmed the views of Non-Executive Directors that the Trust was managing a contract rather than managing cleaning. She said there were significant issues and differences of cleaning standards between sites which related to staff availability, ability and also language and communication issues. Mrs Mayer said that any changes made should be sustainable and followed through. Mrs Dixon asked for some assurance on the data which she said did not match with perceptions of cleaning during walk rounds. Mr Willis thanked Mrs McCluskie for attending the meeting and said that the Committee would look forward to the next report.

LMcC

103/16 Internal Audit Progress Report Mrs Squires spoke to the report. The Divisional Governance Report had limited assurance and had raised a number of issues. Internal Audit had not made any formal recommendations but noted that the issues raised would be part of the restructuring of assurance arrangements across the Trust. Mrs Downey confirmed that this would be picked up as part of the work on accountability and assurance. In response to a question from Mr Willis on progress and impact, Mrs Downey said this would be evidenced through the new governance structures. Mrs Mayer and Mrs Brown asked about progress with implementation of site management and Mr Barclay described the current progress and status. Mr Willis commented that the internal audit on complaints provided significant assurance yet complaints had been raised as a major issue in the CQC report, particularly in relation to

Page 111 of 134


lessons learned. Mrs Downey said that governance including responding to complaints had not been seen as a priority by Divisional Management to date. Their focus had been on day to day operational management of the service. There was limited staff and capability in the Divisions to undertake anything other than the operation management role. There was a need to provide much greater support to Divisions. Mrs Brown asked whether the audit had measured process or quality of response and outcome and Mrs Downey said the audit had not addressed quality. However, the re-introduction of the front of house PALs service had seen a reduction in complaints and improvements in the Complaints Department had seen a reduction in the number of complainants who came back to the Trust following the Trust’s response. It was agreed that the Committee could usefully have a discussion at the next meeting on what might be included in a ward review – e.g. complaints, incidents, lessons learned. Mrs Squires spoke to the high priority outstanding recommendations. She said that the importance of addressing these had been raised by the Chief Executive with the Executive Directors and since the paper had been drafted a further four actions had been closed. Mrs Squires said that for the remaining recommendations some progress had been made on each, even though they had not yet been formally closed. It was agreed that Mrs Squires and Mr Willis would discuss how this information was presented to the Committee. The report was noted.

JD JW/LS

Dec 16 Dec 16

104/16 Revised Internal Audit Plan 2016/17 Mrs Squires spoke to the revised Internal Audit Plan for 2016/17 which aligned the remaining Internal Audit resource for the year to support the implementation of the Trust’s Improvement Plan and provide appropriate assurance in key areas. The key changes included audits on:

IM&T Asset Management:

IM&T Service Desk Performance Indicators:

Sites reporting:

Clinical Audit:

CQC Standard of Communications and handover:

Medicines Management:

Use of Pathologists:

CQC Medical Job Planning:

Mandatory Training:

Duty of Candour. The audit on waiting lists had been undertaken separately and the audit of quality account indicators had been removed as this was undertaken by External Audit. The audit on bank and agency staff had also been removed. It was agreed that future audit reports should include reference to the reason for the audit and the links to the Trust Priorities and Board Assurance Framework (BAF).

Item

11b

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The changes were approved. It was agreed to consider the outline areas for inclusion in the 2017/18 Audit Plan at the next meeting of the Committee.

JW

Dec 16

105/16 MIAA Insight – Update The update on events, briefing note and bench marking was noted.

106/16 External Audit Technical Update Mr Smith spoke to his paper and highlighted the new accounting manual which merged the former Foundation Trust and NHS Trust manuals. There were no major changes arising from the new manual. The capitalisation threshold was now £5k. There were more prescriptive requirements on disclosure of remuneration. The report was noted.

107/16 Audit Contract Renewal Mr Willis reported that the joint auditor appointment panel with SRFT had met earlier in the day to interview shortlisted firms. A recommendation on appointment would be submitted to the Trust Board in November 2016 and also to the SRFT Council of Governors.

108/16 Corporate Risk Register and Board Assurance Framework Mr Barclay spoke to his report which took account of actions agreed at the Trust Board on 6 October 2016. Mr Barclay said that a further iteration would be submitted to the Trust Board on 27 October 2016. Mr Willis said that the Audit Committee should consider a number of sub 12 risks and ask the relevant Executive Director to attend the Committee to present their risks. The report was noted.

GB

Dec 16

109/16 Review of Standing Orders and Standing Financial Instructions Mr Barclay spoke to his paper which proposed revisions to the Standing Orders and Standing Financial Instructions and included a review of financial authority limits compared to SRFT. The Committee approved the revisions and recommended them to the Trust Board for approval.

110/16 Counter Fraud Progress Report – Quarter 2 Mr Gordon spoke to his report and highlighted a number of issues including:

Liaison protocols agreed with Payroll, External Audit, Internal Audit and the Communications Department

Promotion of the need to complete a Declaration of Interest had resulted in an increased submission of forms

An outstanding action in terms of overseas visitors posters – Mr Gordon to discuss with Mr Barclay

AG

Page 113 of 134


Introduction of a new probity form for consultant radiologists claiming ad hoc sessions

Two issues from the investigation register regarding typing of private correspondence

Allegation regarding fraudulent claims The report was noted.

111/16 Date and Time of Next Meeting It was agreed that the next meeting of the Committee be held on Thursday 15 December 2016, in the Executive Directors Meeting Room, 2nd Floor, Trust HQ, NMGH at 2pm.

Item

11b

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Page 115 of 134

Title of Report Clinical Audit Annual Report 2015/16



Executive Summary

The annual report of clinical audit activity undertaken throughout the Pennine Acute Hospitals NHS Trust, during the period 1st April 2015 to 31st March 2016 in provided in the supplementary papers pack. The annual report illustrates the range and breadth of clinical audit activity undertaken across the organisation, and summarises findings and progress during this time period. Many healthcare professionals working across the Trust have shown high levels of enthusiasm in relation to auditing the quality of local practice. The number of clinical audit projects undertaken throughout the Trust remains high: 267 new clinical audit registration forms were received and registered onto the clinical audit database between the 1st April 2015 and 31st March 2016. These include external requirements, Trust priorities, national and regional audits. During the period a total of 246 projects reached completion (this includes 119 projects registered in previous years). 153 (62.1%) of these have led to change in practice or demonstrated good practice with no change needed and 21 projects have action plans that are currently being implemented and are under review. The main report gives details of some of the changes that have resulted from successfully completed clinical audit projects. 99 audits registered during this period are in progress with a further 5 not being started during this period due to changes in policies, no identified lead and changes to divisional and directorate structures. During 2015/16, the Department of Health (DH) provided trusts with a list of national audit projects and national confidential enquiries which they were required to report on in their Quality Accounts. This list identified 35 national clinical audits and 3 national confidential enquiries covering NHS services that are provided by PAHNT. The Trust participated in all of the national clinical audits and national confidential enquiries relevant to its services. Over this period the clinical audit department allocated a member of the team to work with the Cancer Leads and the Cancer team providing a process for timely data completeness, data validation and data submission. This has ensured that data submitted by the Trust in the national cancer audits is complete and accurate and there has been a marked improvement in the quality of data.

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Going forward for 2016/17 the clinical audit department will work closely with senior clinical leads to ensure that results are reviewed with key recommendations linked to the services the Trust provides and have a clear and robust action plan developed and the directorate and divisions take responsibility for monitoring implementations and were appropriate have areas of concern added to their risk registers.

Actions requested To note.

Corporate Priorities supported by this paper: 1.Pursue Quality Improvement to assure safe, reliable and compassionate care 3.Support High Performance and Improvement 4.Improve care and services through integration and collaboration 5.Demonstrate compliance with mandatory standards

Risks: Risks related to ensuring that actions are followed through – lessons learned and embedded – relates to risk 1.1.6 on the Board Assurance Framework.

Development and Assurance The Clinical Audit Department has prepared the report which has been reviewed by the Deputy Medical Director.


Resource implications: None specific to this report although there are considerable resources required to fully implement clinical audit and the follow up actions.

Communication: Promulgated via the intranet once approved.









IM&T Requirements X



Partnerships X



Name Matt Makin

Job Title Medical Director



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Title of Report Emergency Preparedness, Resilience and Response (EPRR) - Core Standards compliance 2016/17


Date November 2016

Executive Summary

NHS England requires that all acute NHS Trusts meet the 47 core standards for Emergency Preparedness Resilience and Response and the Trust Board receives a compliance document from the Trust’s self-assessment which is signed off by the Trust’s Accountable Emergency Officer, Jon Lenney. (as attached.) The 47 standards are all met within the Trust which provides full compliance. This self-assessment will be audited by the NE sector CCGs resilience staff.

Actions requested The Trust Board is asked to receive the statement of compliance as required by NHS England, that the Trust meets the EPRR core standards in their entirety.

Corporate Priorities supported by this paper:

Support our staff to deliver high performance and improvement

Demonstrate compliance with mandatory standards

Risks: That the Trust suffers economic and reputational loss in a poor recovery from a major incident and that the Trust is in breach of NHS England requirements for EPRR.

Development and Assurance This paper has been prepared by the EPRR unit and approved by the Trust Accountable Emergency Officer.


Resource implications: None.

Communication: The self-assessment and compliance document will be audited by the resilience staff of the CCGs of the NE Sector and will be communicated to NHS England.









IM&T Requirements X

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Partnerships X



Name Jon Lenney

Job Title Director of HR and OD and Accountable Emergency Officer


Date 31st October 2016

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Emergency Preparedness, Resilience and Response (EPRR) Assurance 2016-17

STATEMENT OF COMPLIANCE Pennine Acute Hospitals NHS Trust has undertaken a self-assessment against the NHS England Core Standards for EPRR (v4.0). After self-assessment, and in line with the definitions of compliance stated below, the organisation declares itself as demonstrating the following level of compliance against the 2016-17 standards: Full

Compliance Level Evaluation and Testing Conclusion

Full Arrangements are in place that appropriately address all the Core Standards that the organisation is expected to achieve. The Board has agreed with this position statement.

Substantial Arrangements are in place, however, they do not appropriately address one to five of the Core Standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed.

Partial Arrangements are in place, however, they do not appropriately address six to ten of the Core Standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed.

Non-compliant*

Arrangements are in place, however, they do not appropriately address eleven or more of the Core Standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance.

*Should an organisation be non-compliant the LHRP will regularly monitor progress throughout the year until it has attained an agreed level of compliance

The results of the self-assessment were as follows: Number of applicable

standards Standards rated as

Red1 Standards rated as

Amber2 Standards rated as

Green3

47 0 0 47

Acute providers: 47** Specialist providers: 38** Community providers: 38** Mental health providers: 38** CCGs: 30

1 Not compliant with Core Standard and not in the EPRR Work Plan within the next 12 months

2Not compliant but evidence of progress and in the EPRR Work Plan for the next 12 months

3Fully compliant with Core Standard

**Includes HAZMAT/CBRN standards applicable to providers: Standards: Acutes 14 / Specialist, Community, Mental health 7

Where areas require further action, this is detailed in the attached EPRR Work Plan and will be reviewed in line with the organisation’s governance arrangements. I confirm that the above level of compliance with the EPRR Core Standards has been confirmed to the organisation’s board / governing body.

________________________________________________________________ Signed by the organisation’s Accountable Emergency Officer

24/11/2016 26/10/2016

Date of board / governing body meeting Date signed

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Title of Report Annual Review of Standing Orders and Standing Financial Instructions



Executive Summary

Standing Orders and Standing Financial Instructions are reviewed annually. Minor amendments are proposed.

Actions requested To approve the amendments. (Amendments to Standing Orders and SFIs is a matter reserved for the Board).

Corporate Priorities supported by this paper: 1.Pursue Quality Improvement to assure safe, reliable and compassionate care 2.Deliver financial plans to assure sustainability 3.Support High Performance and Improvement 4.Improve care and services through integration and collaboration 5.Demonstrate compliance with mandatory standards

Risks: None

Development and Assurance The Assistant Chief Executive / Board Secretary has reviewed the Standing Orders / SFIs and has involved the Director of Finance, Deputy Director of Finance, Head of Financial Control and the Head of Procurement. The Audit Committee has considered the amendments and recommends them to the Board for approval.



Communication: Promulgated via the intranet once approved.









IM&T Requirements X



Partnerships X



Name Gavin Barclay

Job Title Assistant Chief Executive / Board Secretary


Date 26 September 2016

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Annual Review of Standing Orders and Standing Financial Instructions

Submitted to Trust Board of Directors 24 November 2016

Introduction Standing Orders and Standing Financial Instructions are reviewed annually. Minor amendments are proposed. Amendments Proposed 1.2.26 and throughout the document – renaming of NHS TDA as NHS Improvement. 1.2.27 – additional paragraph allowing “Division / Divisional Director” to be applied and interpreted equally to the emerging Site / Provider Unit structure and their triumvirate management teams. 3.2.1- Notice of Meetings and the Business to be transacted – additional of the ability to serve notice of meetings to Board members by electronic means in addition to by post. 4.8.4 - Removal of the paragraph which specified the Quality and Performance Committee and the Finance, Infrastructure and Business Development Committees as sub-committees of the Board. Similarly removed from the scheme of delegation 35.1 (1c) – Scheme of Delegation – amendment to section on tender waivers to bring into line with 15.5.3(j) – no waivers over OJEU limit (15.5.3(j) was amended last year but 35.1 (1c) was omitted). Appendix A, B and C - changes to titles as required. Appendix A - £100k financial authority limit – addition of Site Triumvirates, Associate Chief Nurse and Director of Safety (new posts) Appendix B - £25k financial authority limit – addition of Senior Directorate Managers (previously grouped with Directorate Managers) Appendix C – Amendments to titles and addition of selected other senior posts who may open tenders.

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Financial Authority Limits The financial authority limits were last amended in 2012 when there were marginal uplifts to the lower bandings. The financial authority limits have been reviewed and have been compared to the Salford Royal FT financial authority limits. PAT and SRFT Financial Authority Limits

PAT SRFT

Up to £5k Authorised signatories No category below £10k

Up to £10k Directorate managers Authorised signatories

Up to £25k Heads of Services Assistant / Deputy Directors Senior Directorate Managers

Service managers Departmental Heads Selected deputy departmental heads

Up to c£100k (PAT uses £100k, SRFT uses OJEU limit which is £111k)

Divisional Directors “Corporate “ Directors who are not Execs

Managing Directors Deputy and Assistant DoF Exec Directors

Up to £250K Exec Directors Chief Exec or DoF

Up to £500k Chief Exec

Up to £1m Chief Exec and DoF Trust Board

Over £1m Trust Board

PAT has a differentiation of authority at £5k and £10k – the £5k was introduced several years ago to strengthen financial control at ward level.

£10k and £25k authorised signatory levels are broadly comparable.

PAT and SRFT both have Divisional / Managing Directors with this authority level. PAT has a slightly wider range of signatories in the £100k bracket – this is reasonable given the size of the Trust.

Over £100k – PAT Executives can sign up to £250k - SRFT Executives can sign up to £100k.

Chief Exec can sign off £500k in both Trusts (additionally DoF at SRFT).

Board authorisation is required at SRFT for £500k, at PAT this level requires dual Chief Exec and DoF sign off. Requiring Board authorisation at £500k would be too low for PAT.

There is sufficient commonality between the two Trusts to retain the PAT authority levels at present, pending a further review as the Group structure emerges.

Recommendation To approve the amendments. (Amendments to Standing Orders and SFIs is a matter reserved for the Board). Gavin R Barclay Assistant Chief Executive / Board Secretary 17 November 2016

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Title of Report Appointment of External Auditors



Executive Summary

This paper sets out the steps taken to evaluate and select a firm of External Auditors for the Trust; and brings recommendation for appointment from the Joint Audit Working Group established with Salford Royal FT.

Actions requested To approve the appointment of Grant Thornton for a period of three years with an option for this to be extended by a further 1 year subject to mutual agreement.


Risks: None

Development and Assurance The Audit Committee has overseen the work of the Joint Auditor Panel in line with the national guidance issued.



Communication: To the Audit Committee and Board.









IM&T Requirements X



Partnerships X



Name John Willis

Job Title Non-Executive Director, Chairman - Joint Auditor Working Group, Chairman - Audit Committee


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Appointment of External Auditors

Submitted to Trust Board of Directors 24 November 2016

Introduction Following the closure of the Audit Commission, NHS Improvement issued guidance earlier in the year outlining how NHS Trusts should go about appointing their own External Auditors. While this has been common practice for Foundation Trusts for many years, this is a new procedure for NHS Trusts. Due to the close working relationship between Pennine Acute and Salford FT, the Trust took advantage of an element of the guidance which encouraged NHS Trusts to work with other health bodies such as a neighbouring FT. This has been the first joint procurement carried out between Pennine Acute and Salford Royal FT. The Trust Audit Committee and the Salford FT Council of Governors approved the process for the appointment of an External Auditor in June 2016. The Audit Committee and the Salford Royal FT Council of Governors acknowledged that as both organisations would continue to work closely for the foreseeable future that the two organisations should align their selection processes for an External Auditor, with the objective of awarding the two organisational contracts to a single External Auditor Firm. It was agreed that a Joint (Salford Royal and Pennine) Audit Working Group would be established, with appropriate representation from the Pennine Audit Committee and the Salford Royal Council of Governors. Membership of the Joint Audit Working Group was:

Mr John Willis CBE, Chairman of Audit Committee Pennine (Chair)

Mrs Camilla Guereca, Pennine, Non-Executive Director

Mrs Chris Mayer, Pennine, Non-Executive Director

Mrs Angela Railton, Salford Royal, Public Governor

Dr Albert Rooms, Salford Royal, Public Governor

Mr David Trenbath, Salford Royal, Public Governor Supported by:

Mr Ian Moston, Salford Royal, Executive Director of Finance

Mrs Diane Morrison, Salford Royal, Salford Director of Finance

Mrs Jane Burns, Salford Royal, Trust Secretary

Mr Mark Storey, Salford Royal, Senior Procurement Manager

Mr Damien Finn, Pennine, Executive Director of Finance

Mrs Nicky Tamanis, Pennine, Deputy Director of Finance

Mr Gavin Barclay, Pennine Board Secretary Process A joint specification, defining the role, capabilities and contract length required for appointment of an External Auditor was completed in August 2016 and reviewed by the Joint Audit Working Group. In line with the specification, a mini-competition under the NHS Shared Business Services (SBS) framework agreement ‘Internal / External Audit, Counter Fraud & Well Led Governance Review’ was undertaken. Four bids were received from firms with established and demonstrable standing within the healthcare sector. Bids received from the suppliers were initially evaluated

Page 125 of 134

by Mrs Diane Morrison and Mrs Jane Burns for Salford Royal and Mrs Nicky Tamanis for Pennine, following which scores were collated and moderated during a consensus meeting, providing a joint evaluation score. The initial evaluations were subsequently reviewed by Mr John Willis, Chairman of Pennine Audit Committee), Mr Ian Moston and Mr Damien Finn. All supplier responses to specification were of a high standard (as expected), however supplier costs differed. The Joint Audit Working Group met on 30 September 2016 to review the initial evaluation of the bids received, and agreed unanimously that the top two scoring firms should be invited to present to the Joint Audit Working Group. The Joint Audit Working Group specified that the representatives providing the presentation from each firm were the proposed audit team(s). On 21 October, the two shortlisted firms presented to the Joint Audit Working Group, and supporting Trust Officers. Each supplier provided a 10 minute presentation on the topic: “Draw out the key reasons why your organisation is particularly well placed to provide the external audit service to the Trusts”. A number of questions, agreed in advance by the Joint Audit Working Group, were asked of each supplier: Decision Following the detailed review and assessment of the suppliers’ bids and individual supplier presentation and question and answer session, the Joint Audit Working Group confirmed that each supplier shortlisted were capable of providing a high quality External Audit service to the Trusts. On balance, as Grant Thornton was ranked as the preferred supplier following the initial evaluation of the suppliers tender documents; were able to offer the lowest cost solution and were felt to offer a more ‘personalised’ service. The Joint Audit Working Group’s unanimous decision was that Grant Thornton was the preferred supplier to be appointed as the External Auditor for Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The final decision to appoint rests with the Trust Board and the Salford Royal Council of Governors, to which papers will be presented on 24 November and 1 December respectively. Recommendation To approve the appointment of Grant Thornton for a period of three years with an option for this to be extended by a further 1 year subject to mutual agreement. John Willis Non-Executive Director Chairman, Joint Auditor Working Group Chairman, Audit Committee 17 November 2016

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Title of Report Whistleblowing Policy



Executive Summary

The Whistleblowing Policy has been updated to take account of the role of the Freedom to Speak Up Guardian and the Trust’s Speak in Confidence communication system. The full policy is include in the supplementary papers pack.

Actions requested To approve the policy.


Risks: None

Development and Assurance The Deputy Director of Workforce has updated the policy which has been considered and recommended to the Board for approval by the Executive Workforce Governance Committee.



Communication: Promulgated via the intranet and routine Trust communication channels once approved.









IM&T Requirements X



Partnerships X



Name Jon Lenney

Job Title Director of Workforce and OD



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Title of Report Single Hospital Service Joint Board Sub Committee Terms of Reference

Submitted to Board of Directors


Executive Summary

The attached paper outlines the approach taken to the development of a Joint Board Sub Committee to support decision making as part of the SHS programme on behalf of the Boards of Pennine Acute Hospitals Trust, Central Manchester Foundation Trust and University Hospitals South Manchester. The paper outlines the governance structure, membership and responsibilities which the Joint Board Sub-Committee will have delegated to it by the Boards of the three organisations, once the Terms of Reference have been approved by all three Boards. Key areas that the Joint Committee will focus on are agreements of the clinical benefits case for Part 1 and Part 2 of the SHS, oversight of the programme, ensuring effective joint working and where required Memorandum of Understanding and ensuring effective engagements with each Board and other relevant stakeholders. In terms of membership, the Chair and Chief Executive are members of the Joint Committee supported by the Directors of Finance and Strategy.

Actions requested The Board is asked to approve the Terms of Reference of the Joint Board Sub Committee for the SHS.

Corporate Priorities supported by this paper: 1- Pursue Quality Improvement to assure safe, reliable and compassionate care 2- Deliver financial plan to assure sustainability 3- Support our staff to deliver high performance and improvement 4- Improve care and services through integration and collaboration 5- Demonstrate compliance with mandatory standards

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Risks: A clear and agreed Clinical Strategy is fundamental to the Trust achieving clinical and financial sustainability. The Clinical Strategy cannot be developed in isolation otherwise there is a risk of lack of support from the Commissioners and the wider local health economy. Therefore the Strategy must be consistent with the CCG’s commissioning intentions, Healthier Together, Local Care Organisations, Single Hospital Service, the Salford Group, and work being undertaken at a Greater Manchester level on acute service (theme 3).

Development and Assurance This paper has been prepared by the Director of Strategy.

Public and/or patient involvement: Public and patient involvement is not required at this stage

Resource implications: This work is being fed into the development of a Business Case for NHS Improvement and GM to begin a discussion on revenue and, crucially, capital required to enable this plan.

Communication: For the attention of the Board of Directors









IM&T Requirements


Patient Experience

Partnerships



Name Katy Calvin-Thomas

Job Title Director of Strategy



Page 129 of 134

1

SINGLE HOSPITAL SERVICE JOINT BOARD SUB-COMMITTEE

TERMS OF REFERENCE

1. PURPOSE 1.1 To agree the Terms of Reference for the Joint Board Sub-Committee. 2. BACKGROUND 2.1 On 31 August 2016, the Single Hospital Service (SHS) Management Group agreed

to a proposal to establish a Joint Board Sub-Committee to oversee implementation of

the approvals and changes needed to create a new, single hospital Trust for the City

of Manchester. The Joint Board Sub-Committee would replace the previous Joint

Board.

2.2 The Joint Board Sub-Committee forms part of a wider set of governance

arrangements details of which are shown in annex one.

3. TERMS OF REFERENCE 3.1 Following consultation with the Central Manchester Hospitals Foundation Trust,

South Manchester University Hospital NHS Foundation Trust and Pennine Acute

Hospitals NHS Trust about the role and scope of the Joint Board Sub-Committee,

draft Terms of Reference have been developed and are included in annex two.

3.2 The Sub-Committee is asked to agree the draft Terms of Reference with a view to

seeking the appropriate delegated authority from the three Trust Boards to enable

the Joint Board Sub-Committee to become fully operational from November 2016.

4. RECOMMENDATION 4.1 The Joint Board Sub-Committee is asked to:

I. agree the proposed Terms of Reference; and II. seek the appropriate delegated authority from the Boards of Central

Manchester Hospitals Foundation Trust, South Manchester University Hospital NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

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2

Annex one

UHSM Board CMFT Board PAHT Board

Single Hospital Service Joint Board Sub

Committee

Single Hospital ServiceProgramme Board

Clinical Advisory Group

Programme Team and Workstream Meetings inc.

SHS Operational Group

HWBExec

HWBBoard

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3

Annex two

City of Manchester Single Hospital Services

Single Hospital Service Joint Board Sub-Committee

Terms of Reference

Background

This document outlines the Terms of Reference for the Single Hospital Service (SHS) Joint

Board Sub Committee which has delegated responsibility from the University Hospitals of

Central Manchester Foundation Trust (CMFT) and University Hospital of South Manchester

Foundation (UHSM) Trust and Pennine Acute Hospitals NHS Trust (PAHT) Boards to

oversee the delivery of the Single Hospital Service for Manchester.

Responsibilities

The SHS Joint Board Sub-Committee has delegated authority from the Boards of CMFT,

UHSM and PAHT to deliver the following:

Agree the clinical benefits, strategic and business cases for Project 1 (the merger of

CMFT and UHSM) and Project 2 (the subsequent acquisition of North Manchester

General Hospital by the newly created Foundation Trust) and any submissions to the

GM Transformation Fund in respect of the Single Hospital Service programme, and

recommend these to the relevant full Boards for formal approval.

Provide oversight of the programme, working closely with partners to assess value

for money, clinical benefits, costs and risks of the business case.

Ensure effective joint working to achieve agreement of any relevant documentation,

including signed Memorandum of Understanding/Heads of Agreement and

Transaction Agreements

To monitor and support the work of the Programme Team to ensure the programme:

is adequately resourced and operates within agreed resources

progresses in a timely manner, in line with the agreed project plan

To ensure effective engagement and dialogue with the Boards of the three Trusts

and, through those Boards, with the Councils of Governors, staff and other key

stakeholders within the three Trusts

Administration

Administration of the Joint Board Sub Committee will be the responsibility of the Programme

Team. Agendas for meetings will be agreed by the relevant Chair (see below). The

Programme Manager - Governance will be responsible for ensuring the timely preparation

and distribution of agendas and papers for meetings and for ensuring production of accurate

minutes.

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4

Chair

The Joint Board Sub Committee will be chaired on a rotational basis by the Chairs of CMFT,

UHSM and PAHT.

Membership and quorum

Membership of the Joint Board Sub Committee shall be as follows:

Organisation Name Position

SHS Programme Team

Peter Blythin Stephen Gardner

Programme Director Deputy Programme Director

CMFT Steve Mycio Ivan Bennett Mike Deegan Robert Pearson Adrian Roberts Darren Banks

Chair Non-Executive Director Chief Executive Medical Director Executive Director of Finance Executive Director of Strategy

UHSM Barry Clare Trevor Rees Diane Whittingham Mandy Bailey Tim Barlow Matt Graham

Chair Non-Executive Director Chief Executive Nurse Director Chief Financial Officer Director of Strategy

PAHT Jim Potter To be nominated Sir David Dalton Prof. Matt Makin Damien Finn Katy Calvin-Thomas

Chair Non-Executive Director Chief Executive Medical Director Director of Finance Director of Strategy

Attended by Lynne Burgess Anne Marie-Miller

PMO Governance Manager Communications Lead – Programme Team

.

The meeting will be quorate if there is executive and non-executive representation from each

of the provider trusts.

Voting rights

The Chairs, Non-Executives Directors, Chief Executives, Directors of Finance and Medical

or Nurse Directors from each trust shall have voting rights.

Reporting

The Joint Board Sub Committee will agree a joint report on its business for submission to the

three Trust Boards.

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5

The Chairs of UHSM and CMFT are responsible for ensuring that their respective Councils

of Governors are briefed on Joint Board Sub Committee business.

The Programme Director and the Executive Regional Managing Director (North) are

responsible for reporting Joint Board Sub Committee business to NHS Improvement.

Frequency of Meetings

The Joint Board Sub Committee shall meet on a monthly basis.

Review

These terms of reference shall be reviewed in three months to ensure that they remain fit for

purpose.

November 2016

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