shared agenda group committees in common (cic) papers/2019/group cic - … · recorded of that...

The Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)

Shared Agenda Group Committees in Common (CiC)

Monday, 25th March 2019 at 10:00amHumphrey Booth Lecture Theatre, Mayo Building,

Salford Royal, Stott Lane, SALFORD M6 8HD

AGENDA: Part 11. Presentation:

Improvements across NES Obstetrics and Gynaecology Services

2. Apologies for Absence Chairman

3. Declarations of Interest All

4. Chairman’s Opening Remarks Chairman

5. Minutes of Previous Meeting (Part 1) Chairmanfrom meeting on 28 January 2019

6. CEO Report, including review of: Chief ExecutiveGroup CiC Performance Dashboard

7. Reports from Chief Officers Care Organisation Chief Officers

8. Risk Management Strategy Chief Medical Officer

9. Complaints Policies Chief Medical Officer

10. People Report: Chief Strategy & OD Officerincluding 2018 National Staff Survey Outcome

11. NCA EU EXIT Preparations Report Chief Delivery Officer

12. NAAS / SCAPE Award(s) Chief Nursing Officer

13. Annual Review: FT Code of Governance Group Secretary

14. Sealed Documents Group Secretary

15. Chairman’s Report from the Council of Governors Chairman

16. Reports from Standing Committees:

16.1. Audit Committee Vice-Chairman- meeting held on 1 February 2019

16.2. Executive Group Risk and Assurance Committee Chief Executive

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- meetings held on: 18 February and 18 March 2019

16.3. Charitable Funds Committee Vice-Chairman - meeting held on 20 February 2019

17. Any other business (Part 1)

18. Date and Time of the Next Meeting: Monday 29th April 2019 from 10amVenue: Humphrey Booth Lecture Theatre, Level 1, Mayo Building, Salford Royal NHS Foundation Trust.

Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust and The Pennine Acute Hospitals NHS Trust

Meeting of Group Committees in CommonMonday, 28th January 2019

Part 1- Held in Public - from 10amHumphrey Booth Lecture Theatre, Mayo Building, Salford Royal

DRAFT Shared Minutes

Present:Mr Jim Potter, ChairmanSir David Dalton, Chief Executive OfficerMrs Judith Adams, Chief Delivery OfficerMr Chris Brookes, Chief Medical Officer Mrs Diane Brown, Senior Independent Director Mr Kieran Charleson, Non-Executive DirectorMr Damien Finn, Chief Officer North Manchester Care OrganisationMrs Nicola Firth, Interim Chief Officer, Oldham Care OrganisationMrs Elaine Inglesby-Burke CBE, Chief Nursing Officer Mr Raj Jain, Chief Strategy and Organisational Development Officer Mrs Christine Mayer CBE, Non-Executive DirectorMr Ian Moston, Chief Finance OfficerProfessor Chris Reilly, Non-Executive DirectorMr James Sumner, Chief Officer, Salford Care OrganisationMr Steve Taylor, Chief Officer, Bury & Rochdale Care OrganisationMr John Willis CBE, Vice-ChairmanMrs Jane Burns, Director of Corporate Services and Group Secretary

In Attendance:Rebecca McCarthy, Deputy Trust Secretary

Observing:Kieran Bamber, Popul ConsultingGill Collins, Public GovernorAndrew Lynn, NCA Director of CommunicationsEzmi Mulhearn, PAHT Staff MemberChris Mullen, Public GovernorJackie Schofield, PAHT Staff SideDeborah Seddon, Staff Governor

Apologies for Absence:Dr Hamish Stedman, Non-Executive Director

No. Item Action1. Welcome

The Chairman welcomed everyone present to the meeting of the Group Committees in Common and confirmed this was a shared meeting of committees established by the Boards of Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT). The Chairman confirmed that the meeting would be held in two parts: a first part open to members of the public; and a second part in private session for confidential matters.

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No. Item Action2. Patient Story

The Group Committees in Common listened to a patient story from the North Manchester Care Organisation read by the Chief Officer for North Manchester Care Organisation.

Opening Matters3. Apologies for Absence

Apologies for absence were noted as above.

4. Declarations of Interest The Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as a member of the Group Committees in Common and in particular to any matter being discussed at the meeting. There were no interests declared.

5. Appointment of Chief ExecutiveMr Raj Jain excused himself from the meeting.

The Chairman provided a comprehensive update regarding the search and selection process for the position of Chief Executive further to Sir David Dalton’s decision to retire from his role as Chief Executive on the 31st March 2019. The Chairman confirmed that the Nominations, Remuneration and Terms of Service (NRTS) Committee had developed and implemented a robust recruitment process for the role of Chief Executive of the Salford Royal NHS Foundation Trust, including the establishment of an Appointment Panel to undertake the selection process. The Chairman highlighted that the NRTS Committee had acknowledged that through this role, the Chief Executive would also be the Chief Executive of the Northern Care Alliance NHS Group (NCA) and under the Management Agreement (between NHSI and Salford Royal and other key partners) would have the responsibility of Chief Executive of the Pennine Acute Hospitals NHS Trust.

The Chairman confirmed that, following rigorous candidate assessment and formal interview on 4th January 2019, the Appointments Panel had unanimously agreed that Mr Raj Jain was to be recommended for appointment by the Chairman and all Non-Executive Directors. The Chairman highlighted that himself and all Non-Executive Directors had confirmed, by correspondence, their approval of the recommendation of the Appointments Panel to appoint Mr Raj Jain as the Chief Executive.

The Chairman reported that the Group and Salford Royal NHS Foundation Trust Council of Governors had met on 24th January 2019 and approved the appointment, by the Chairman and Non-Executive Directors, of Mr Raj Jain as Chief Executive.

The Group Committees in Common received the above information and the Chairman and all Non-Executive Directors ratified their approval of the appointment of Mr Raj Jain as Chief Executive, commencing on 1st April 2019.

Mr Raj Jain re-joined the meeting. The Group Committees in Common formally congratulated Mr Raj Jain on his appointment as Chief Executive.

6. Opening Remarks

Mr Tony Whitfield

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No. Item ActionThe Chairman highlighted the sad death of Salford Royal NHS Foundation Trust’s former Director of Finance and Deputy Chief Executive Tony Whitfield. He confirmed that he and a number of other members of the Group Committees in Common had attended the celebration of Tony’s life with family, friends and colleagues.

7. Minutes of the Previous Meeting The Chairman confirmed that Part 1 of the previous meeting held on 20th December 2018 had been open to members of the public. The draft minutes, recorded of that session, were reviewed by the Group Committees in Common and approved as a true record.

8. Matters ArisingNo matters arising.

9. Verbal CEO Report, including review of Group CiC Performance Dashboard

9.1 Financial PositionThe Chief Executive Officer provided headlines with regard to the financial position as at the end of month 9. He confirmed that the Northern Care Alliance NHS Group (NCA) had an operating deficit of £19.3m, with PAHT marginally better than plan, and SRFT £2.7m adverse from the plan including the release of £0.9m of centrally held budgets. With respect to SRFT, the Chief Executive Officer confirmed that clinical income was better than plan due to better than planned performance in non-elective medicine, critical care and dermatology, however the position included the loss of £2.9m Provider Sustainability Fund (PSF) funding, as unable to deliver against the minimum target of 90% for the Urgent Care 4 hour standard (actual performance to date 86.3%). The Chief Executive Officer reported positive discussions were taking place with partner organisations regarding financial support.

The Chief Executive Officer confirmed that the month 9 position for PAHT was £0.2m better than the plan. He added that over performance was £5.6m, however due to the block contract and cap arrangements in place; it was assumed that £0.7m would not to be accessed.

The Chief Executive Officer reported that the combined productivity performance for the NCA was £42.5m, including PAHT £27.4m and SRFT £15.1m, risk adjusted to £38m. He highlighted that there remained a significant risk to the SRFT programme.

The Chief Executive Officer confirmed that the NCA cash position was better than plan, in part due to due to lower than forecast capital expenditure.

9.2 NCA Single Oversight FrameworkThe Chief Executive Officer reaffirmed that the NCA Group Single Oversight Framework had been established to assess and segment Care Organisations. He confirmed that the Care Organisations were assessed against the 5 core themes and that in Quarter 4 the framework would be updated with a 6th cross cutting theme of ‘Leadership, Behaviours and Culture’. The Chief Executive Officer reported that all Care Organisations were rated as Segment 2 – Targeted Support – and confirmed the specific area of targeted support for each. The Chief Executive Officer confirmed that discussions with NHSI and GM Health & Social Care Partnership (GM H&SCP) were ongoing specifically

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No. Item Actionregarding Oldham system’s urgent care performance, recovery trajectories for cancer and financial performance.

In response to the Senior Independent Director seeking clarification regarding the ‘targeted support’ provided to Care Organisations, the Chief Executive Officer stated that this differed dependent on the area of focus, diagnosis and intervention deemed necessary. The Chief Delivery Officer provided examples of this, including ‘reality rounding’ undertaken by Executive Team with the Salford Care Organisation and additional managerial support to the Oldham Care Organisation regarding cancer systems. She emphasised the importance of the addition of the ‘Leadership, Behaviours & Culture’ theme as part of the NCA Single Oversight Framework to provide assurance that these multifactorial issues were being addressed.

9.3 Royal College of Physicians’ Joint Advisory Group on GI Endoscopy (JAG) AccreditationThe Chief Executive Officer reported that the endoscopy units at Fairfield General Hospital, North Manchester General Hospital, Rochdale Infirmary and The Royal Oldham Hospital had now met all of the required JAG accreditation standards, and therefore been awarded JAG accreditation for one year. The Chief Executive Officer thanked the team who had worked tirelessly to deliver the service at this standard.

9.4 Strategic Matters

9.4.1 Estate and Digital Risks – North East Sector Care OrganisationsThe Chief Executive Officer informed the Group Committees in Common that Ian Dalton, Chief Executive of NHS Improvement, had visited both the Royal Oldham and North Manchester sites on 11th January, to better understand the need to address the inadequacies of the estate and digital infrastructure. The Chief Executive Officer confirmed that a briefing report was subsequently being produced to describe the assessed key risk areas, and a plan, including costs, for urgent remedial work in years 1 & 2 and full requirement over 5 years. The Chief Executive Officer confirmed further discussion would take place regarding this matter later in the meeting.

9.4.2 Greater Manchester (GM) Theme 3The Chief Executive Officer highlighted that the Theme 3 programme had reached the stage of site-specific proposals, and that these were now subject to endorsement by the GM Joint Commissioning Board. The Chief Executive Officer stated that the proposals were largely in line with the strategic direction outlined in the NCA Service Development Strategy (SDS). 9.4.3 North East Sector (NES)The Chief Executive Officer informed the Group Committees in Common that the NES Acute Clinical Service Strategy work had been paused pending the submission of Strategic Outline Cases by SRFT and Manchester NHS Foundation Trust (MFT), and subsequent analysis by NHSI. He concluded that it had been agreed to reconvene the NES Programme Board in April to review progress and consider next steps.

8.4.4 North West Sector (NWS)The Chief Executive Officer stated that discussion continued with NHSI regarding financing requirements of the requested capital for the Acute Receiving Centre/Major Trauma business cases.

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No. Item ActionThe Chief Executive Officer confirmed that work continued on the Benign Urology, Orthopaedic, Breast Surgery and Dermatology workstreams within the NWS.

9.4.5 Pennine Care NHS Foundation Trust (PCFT) Community Services TransferThe Chief Executive Officer confirmed that a NES Community Services Board had been established to oversee the proposed transfer of services from PCFT to the NCA, with representation from commissioners, NHSI and GM H&SCP. He confirmed that due diligence had commenced and the NCA’s external advisors identified. He highlighted that recruitment to a dedicated Programme Director was underway and that internal programme arrangements, including formal reporting through the (SRFT) Acquisition Committee had been established. The Chief Executive Officer highlighted the anticipated slippage in timescales and confirmed that a proposed transfer date would be confirmed in due course.

9.4.6 Local Care Organisations (LCOs)The Chief Executive Officer reaffirmed that the LCOs within the NES footprint were currently developing plans for a significant increase in scope and responsibility for 2019/20, and that the NCA was providing leadership within each LCO to support the delivery of these objectives. The Chief Executive Officer provided a brief summary of progress within the following LCO’s: Oldham Cares, Together for Bury, One Rochdale and Salford Together. The Chief Executive Officer concluded that the Executive Team had been considering the measurement of benefits and outcomes enabled by investment in the NES LCOs and confirmed the intention to meet with commissioners to develop a suite of metrics that could be used to determine success.

The Senior Independent Director referred to previous discussion regarding the development of measures for the Salford Integrated Care Organisation, which were not currently considered as part of the Group Performance Dashboard, and sought further information regarding this. The Chief Officer for Salford Care Organisation confirmed that Salford Together had identified 10 measures and trajectories, which were routinely reviewed by the Care Organisation. The Chief Executive Officer echoed this comment and highlighted the importance of developing a common dashboard with clarity on such measures, via the funding agreement with each LCO, which could then be considered by the Group Committees in Common.

9.4.7 Business Development The Chief Executive Officer confirmed that work continued in preparation for the expected national procurement process for Intestinal Failure (IF), one of SRFT’s key specialist centres. He highlighted opportunities being explored via the Group Diagnostic & Pharmacy and Corporate functions.

9.4.8 Strategic Case UpdateThe Chief Executive Officer confirmed that the Strategic Case was nearing completion with a final version of the case to be developed and approved by the end of February 2019.

9.5 Key Performance MetricsA Non-Executive Director referred to the positive data with respect to mortality and harms and queried if this success was publicised, highlighting the number

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No. Item Actionof lives saved and reduction in harms. The Chief Executive Officer confirmed that the Quality Accounts provided opportunity to present and publish this information. The Chief Medical Officer and Chief Nursing Officer acknowledged the improvement journey, as described within the Quality Improvement Dashboards, cautioning that harms were still taking place and that further work was required to reduce variation and improve reliability across the NES Care Organisations. They expressed the balance that must be paid in this regard.

The Vice-Chairman referred to the cancelled operations metric and queried if national data was available for comparison. The Chief Medical Officer highlighted the importance of comparing with similar organisations. The Chief Delivery Officer echoed these comments and confirmed that she would consider national data available and potential for use as a point of reference/benchmarking.

A Non-Executive Director referred to staff vacancy rates, specifically the 27% medical vacancy rate at North Manchester Care Organisation in comparison to a 3% medical vacancy rate at Salford Care Organisation; acknowledging the complexity of the situation, she queried if the benefit of being a single group was being realised in this regard. The Chief Officer for North Manchester Care Organisation highlighted the significant amount of work that had taken place to ensure medical establishments were set correctly and that in increasing medical establishments vacancy rates had increased, albeit more staff were now in post than the same time last year. The Chief Strategy & Organisational Development Officer highlighted that the association with SRFT had been beneficial for both nursing and medical recruitment across the NES Care Organisations, acknowledging the unique challenges facing the North Manchester Care Organisation at this time. In response to the Senior Independent Director seeking further assurance that transfer between Care Organisations was not adversely affecting the North Manchester vacancy position, the Chief Officer for North Manchester confirmed that analysis continued to be undertaken in this regard, and that North Manchester had a net gain from the other Care Organisations.

The Senior Independent Director sought further information regarding plans to improve retention and robustness of key HR controls, in light of Salford Care Organisation currently being £15m above predicted pay spend. The Chief Strategy & Organisational Development Officer acknowledged that improvements in retention would be the swiftest way by which to reduce workforce pressures and highlighted a number of initiatives in place. He confirmed that key HR controls had been put in place to reduce agency spend, specifically in the NES Care Organisations, and recognising that continued focus on this matter was needed, highlighted that the largest part of workforce overspend was due to vacancies and higher workload requiring more staff. The Chief Officer for Salford Care Organisation highlighted that weekly workforce review meetings were in place, and confirmed that additional pay spend was due to vacancies or increased volume of work. He added that the NHS Improvement Use of Resources review had focussed on the key controls in place and found these to be robust.

Chief Delivery Officer

10. Urgent Care Update, including Care Organisation Winter Assurance Reports The Chief Delivery Officer provided a comprehensive Urgent Care update including an overview of the winter planning urgent care system, 2018-19

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No. Item Actionplanning environment, performance versus plan, Care Organisation winter plan assessments, emergency tactical planning analysis, additional 2018-19 Care Organisation winter actions and further NCA /Greater Manchester actions.

The Vice-Chairman recognised that performance trajectories were not being achieved across the Care Organisations and sought assurance that patients were not coming to harm as a result of this. The Chief Delivery Officer confirmed that an Emergency Department Safety Checklist was in place, with good compliance, to ensure safety and dignity of patients. She acknowledged the importance of ensuring patients were able to get into the system in a timely way, as highlighted by ambulance turnover, and acknowledged yearly improvements in this measure.

In response to a Non-Executive Director seeking further information regarding the closure of 53 community beds in the Bury locality, the Chief Officer for Bury & Rochdale Care Organisation confirmed that this decision had been taken by external partners.

In response to a Non-Executive Director seeking further information regarding assertive repatriation support for out of area patients from the Salford Care Organisation, the Chief Officer for Salford Care Organisation confirmed that the number of stranded and super stranded patients from out of area had not increased in December, with support from Greater Manchester in this regard. He highlighted the continued challenge, acknowledging that although numbers had not increased, 40% of stranded and super stranded patients were from out of area, with further support was needed. The Chief Delivery Officer described the challenges being experienced across all urgent care systems in Greater Manchester.

A Non-Executive Director referred to the significant operational challenges in the Care Organisation, and sought view regarding expectations in 2019/20. The Chief Delivery Officer confirmed that improvements from the Integrated Care system in place at Salford were evident, and expressed her view that the development of Local Care Organisations across the NCA’s localities presented an opportunity to work differently, albeit highlighting the imperative of sufficient resources in the community to support this.

The Vice-Chairman queried both the national and regional picture for A&E. The Chief Delivery Officer confirmed that Greater Manchester was under particular scrutiny and was not in a position to meet the 85% baseline agreed as part of the devolution agreement. She added that Care Organisation performance was around average, with significant challenges being experienced across many systems in Greater Manchester. The Chief Medical Officer expressed his view regarding resilience for the future, and referenced the Tameside system which had fundamentally changed, now operating a system akin to an Urgent Care and a Medical Assessment function. He further expressed his view that resilience required a different approach with separation of those patients requiring the full Emergency Department function.

The Group Committees in Common reviewed and confirmed the Urgent Care Update including the additional 2018-19 Care Organisation winter actions and further NCA/Greater Manchester actions to support performance.

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No. Item Action11.

11.1

11.2

Care Quality Commission (CQC) Action Plan Updates

Pennine Acute Hospitals NHS Trust (PAHT)The Chief Nursing Officer presented progress against the PAHT CQC action plan, must and should do actions. She confirmed good progress had been made and highlighted that a revised date had been included in a number of the ‘Should do’ actions to ensure that new systems were embedded across the Care Organisations. The Chief Nursing Officer summarised areas that remained challenging including IM&T solutions, workforce and application of MCA/DOLs and Safeguarding. With respect to the latter, the Chief Nursing Officer provided contextual information regarding the challenges and confirmed that job roles requiring the highest level of safeguarding training had now been identified within ESR, enabling this to be monitored.

Salford Royal NHS Foundation Trust (SRFT)The Chief Nursing Officer presented progress against the SRFT CQC action plan, should do actions, and confirmed good progress was being made. She highlighted that there had been an improvement in response times to complaints, with continued focus on this action, specifically regarding escalation and senior presence at relevant meetings. The Senior Independent Director acknowledged the improvement in response times, and reflected that, as Chair of the Complaints Review Panel, there had been good attendance from staff, although a lack of senior manager presence from the Complaints Department. The Chief Nursing Officer expressed her disappointment regarding this, confirming that Complaints was a group-wide function and would address this matter.

The Chief Nursing Officer referred to estates and facilities actions rated as red, which would unlikely change due to capital requirements and confirmed that future reports would highlight the reason why the action could not be implemented from a capital perspective and alternative solution.

The Group Committees in Common reviewed and confirmed progress against the PAHT and SRFT action plans.

Chief Nursing Officer

12.

12.1

Quality Improvement Strategy Implementation:

Progress ReportThe Chief Nursing Officer presented the Quality Improvement Strategy Progress Report providing work stream highlights for Pressure Ulcer, Sepsis, Deteriorating Patient and VTE Improvement Collaboratives (NES), Diabetes and End PJ Paralysis/Last 1000 Days Collaboratives (NCA) and Productive Community Collaborative (Salford). In addition, the Chief Nursing Officer highlighted progress regarding Urgent Care Improvement Work, Clinical Reliability Groups and Reality Rounding. The Chief Nursing Officer stated that good progress was being made regarding the above, and specifically highlighted the reduction in cardiac arrests rates (part of the Deteriorating Patient Collaborative) and the stretch target now in place.

A Non-Executive Director sought further information regarding the development of Clinical Reliability Groups (CRGs) across the NCA. The Chief Nursing Officer provided contextual information regarding the improvement approach implemented by a number of healthcare organisations with a group structure. She highlighted that the approach could be resource intensive, and therefore the need to pilot Clinical Reliability Groups before deploying more

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No. Item Action

12.2

widely across patient pathways.

Care Organisation QI DashboardsThe Chief Nursing Officer presented the Care Organisation Quality Improvement Dashboards highlighting key headlines regarding mortality, harms, readmission and length of stay and patient experience and NAAS ward ratings.

A Non-Executive Director referred to the relatively stable NAAS ward ratings for the Salford Care Organisation and sought view on achieving this level of stability across the NES Care Organisations. The Chief Nursing Officer highlighted that the current pattern in the NES Care Organisations reflected the pattern seen in Salford as NAAS was initially established. The Vice-Chairman sought confirmation that the same NAAS standards were being implemented across the NCA. The Chief Nursing Officer confirmed the same standards were being implemented, commenting that dips in ratings were, in general, related to leadership and that accountability across the NES Care Organisations would now be applied consistently across the NCA. The Senior Independent Director echoed these comments, confirming consistent application of standards across the NCA.

The Group Committees in Common reviewed and confirmed the Quality Improvement Progress Report and Care Organisation Quality Improvement Dashboards.

13. Learning from Deaths Quarterly ReportThe Chief Medical Officer presented a summary of Learning from Deaths in line with national guidance and the required national reporting criteria. The Chief Medical Officer reported mortality review data from Quarter 1 2018/19, an overview of Mortality & Morbidity Meetings, engagement with the learning culture, key themes identified for improvements to support shared learning.

The Vice-Chairman welcomed the detailed report, and expressed his view that learning with respect to the implications of transferring patients with chronic cognitive impairment/dementia out-of-hours, would have already been widely understood. The Chief Medical Officer fully acknowledged this comment, and highlighted the importance of ensuring learning points were reliably embedded and therefore taken into account on every occasion.

A Non-Executive Director sought further information regarding the effectiveness of each of the Care Organisation Mortality & Morbidity Meetings, and strongly emphasised the importance of these meetings operating effectively. The Chief Medical Officer confirmed that the Salford Care Organisation meeting was well established and functioned extremely effectively. He added that progress had been made across all NES Care Organisations, highlighting the fragility in the system as the Mortality & Morbidity Meetings were person dependent. The Chief Medical Officer commented that the Oldham Care Organisation was maturing, with further focus to continue improvement in this regard.

The Group Committees in Common reviewed and approved the Group Learning from Deaths Report.

14. Reports from Standing Committees

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No. Item Action14.1 Group Executive Risk and Assurance Committee (GRAC) - Meeting held

on 21st January 2019 Group Committees in Common reviewed key matters and decisions made at the meeting held on 21st January 2019 including audit and risk management of PAHT digital instances, Care Organisation and Corporate Functions Statements of Assurance and Board Assurance Framework Q3 position, NCA Board Assurance Framework Q3 position, Q3 Executive Led Care Organisations Annual Plan reviews including segmentation, patient safety updates, Learning from Deaths, Brexit preparations and PAHT estates risks.

15. Any Other Business (Part 1)No other business.

16. Date and Time of the Next MeetingThe Chairman confirmed that the next meeting would take place on Monday, Monday, 25th March 2019 from 10am at Humphrey Booth Lecture Theatre, Mayo Building.

Closure of Part 1 of the Group Committees in Common Meeting17. Exclusion of the Public

The Group Committees in Common resolved to exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be inappropriate, by reason of the sensitive and confidential nature of business.

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Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18

88 88 87 85 85 84 84 84 84 84 84 83 82 81 82

96 94 94 95 93 94 95 95 96 96 95 96 95 95 96Pennine Acute Hospitals Trust

HSMR - Rolling 12 months

Rochdale

Salford

North Manchester Oldham

Salford Royal Foundation Trust

Committee in Common ScorecardSaving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering

Highly Reliable & Trusted

Mortality: Hospital Standardised Mortality Ratio

Fairfield

HSMR is a ratio of the observed number of in-hospital deaths to the expected number of in-

hospital deaths for 56 specific Clinical Classification System (CCS) groups. HSMR is risk

adjusted to take into account key risk factors associated with mortality.

Pennine as a Trust has reduced mortality and

HSMR for Pennine is now statistically better than expected. Salford also remains statistically better

than expected.

Chart Legend: Green/Yellow/Red Dot = Relative Risk

Salford CO's HSMR is statistically better than expected position and Salford remain the highest performing organisation in their peer group. The current position is 82.27 with weekend HSMR at 86.8

Fairfield: HSMR is statistically as expected. The current position is 94.72

with weekend HSMR at 101.0

Rochdale: HSMR is statistically as expected and Rochdale is now the

highest performing site in their peer group. The current position is 79.89 and

weekend HSMR is 86.2.

HSMR for North Manchester has improved over the last few months and is statistically better than expected for the latest position. The current position is 89.62. Weekend HSMR stands at 88.4.

HSMR for Oldham CO is statistically as expected but has

seen an increase. The current position is 105.03. Crude

mortality rates have remained consistent.

Weekend HSMR is 107.9.

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Rochdale

North Manchester Oldham



Mortality: Summary Hospital-level Mortality Indicator

Fairfield

Salford

SHMI is the ratio between the actual number of patients who die following hospitalisation and the

number that would be expected to die on the basis of average England figures, given the characteristics

of the patients treated. SHMI is calculated on a quarterly basis for a rolling 12 month period

Pennine as a Trust has reduced mortality and SHMI is 99.67. Salford also remains statistically better than

expected. SHMI is updated quarterly and these indicators have not changed since the previous

month.

Chart Legend: Green/Blue/Red Dot = Relative Risk

Dashed line = Crude Rate

SHMI is statistically better than the national position. Salford CO's SHMI has remained consistent over the last quarter . The current position is 91.36.

Fairfield: SHMI at Fairfield is just above what is expected although has been

consistently improving over the last year. The current position is 103.29.

Rochdale: SHMI is statistically better

than expected. The current position

remains consistent and is 64.46.

SHMI for North Manchester has reduced over the last few quarters and is now below what is expected for the latest position. The current position is 96.24.

SHMI for Oldham CO has remained consistent for

the last few quarters. The current position is 98.91.

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Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 2018/19

Teaching Non-Teaching 0.16 0.04 0.04 0.08 0.16 0.16 0.11 0.08 0.04 0.04 0.08 0.09

0.18 0.12 0.00 0.00 0.00 0.13 0.13 0.00 0.00 0.00 0.24 0.00 0.00 0.05

0.11 0.09 0.00 0.00 0.11 0.28 0.10 0.19 0.27 0.18 0.00 0.00 0.00 0.11

0.2 0.15 0.09 0.17 0.36 0.25 0.26 0.09 0.26 0.00 0.08 0.00 0.00 0.14



Harms: Clostridium Difficile

C Dif Rates per 1,000 Bed-Days

Mean

Upper Quartile

Lower Quartile

(2017/18)

C Dif Rates per 1,000 Bed-Days

Salford

Bury & Rochdale

North Manchester

Oldham

The Salford Care Organisation had two occurrences of C Diff in February '19. Occurrences per 1,000 bed day remain low.

This metric measures instances of Clostridium Difficile counted cumulatively as a YTD figure. This metric forms part of the

Single Oversight Framework.

When comparing cumulative position to January 17/18 to January 18/19 YTD, the

North East Sector COs have seen a reduction in the number of C Diff infections whereas Salford is higher. However at Salford, rates per 1,000 bed-days are better than mean

national performance for 2017/18.

The Bury & Rochdale Care Organisation had no

occurrences of C.Dif in February '19 and remains below

trajectory.

The North Manchester Care Organisation didn't have any instances of C.Dif in February '19 and is below trajectory.

The Oldham Care Organisation had no occurrences of C.Dif in

February '19. The Care Organisation is now level with trajectory but with only a two infection tolerance if the out-

turn of 20 occurrences is to be achieved.

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15

20

25

30

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8

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Sep-1

8

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8

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C D

iff

Salford C.Diff (YTD Cumulative)

Cumulative Actual Cumulative Trajectory

0

5

10

15

20

25

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

Nu

mb

er

of

C D

iff

Bury & Rochdale C.Diff (YTD Cumulative)


0

5

10

15

20

25

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

Nu

mb

er

of

C D

iff

Oldham C.Diff (YTD Cumulative)


0

5

10

15

20

25

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

Nu

mb

er

of

C D

iff

North Manchester C.Diff (YTD Cumulative)


3/30

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& PAT

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03/2

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0.16 0.16 0.00 0.20 0.24 0.16 0.15 0.12 0.04 0.19 0.17 0.15

0.13 0.13 0.53 0.00 0.00 0.25 0.25 0.00 0.12 0.23 0.38 0.17

0.10 0.00 0.11 0.00 0.00 0.28 0.00 0.00 0.09 0.18 0.10 0.08

0.09 0.00 0.00 0.25 0.17 0.00 0.09 0.16 0.15 0.22 0.08 0.12

Salford

Bury & Rochdale

North Manchester

Oldham



Harms: Falls

Falls per 1,000 Bed-Days

The Salford Care Organisation had four reportable falls in month, which remains within normal variation.

This metric measures falls resulting in moderate harm and above.

All care organisations have normal

variation in falls with moderate and above harm. Numbers remain low across all Care

Organisations.

North Manchester has the lowest level of falls per 1,000 bed-day across the Northern

Care Alliance.

Falls at the Bury & Rochdale Care Organisation continue

to follow a consistent trend. There were three reportable

falls in month.

Falls at the North Manchester Care Organisation have maintained a consistent trend. There was one reportable fall in month.

The Oldham Care Organisation has maintained a consistent trend and there

was one reportable fall in month.

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

Falls

Salford Falls

Falls Average

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

Falls

Bury & Rochdale Falls

Falls Average

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

Falls

North Manchester Falls

Falls Average

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

Falls

Oldham Falls

Falls Average

4/30

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& PAT

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0.28 0.24 0.25 0.04 0.20 0.04 0.04 0.24 0.27 0.11 0.13 0.17

0.51 0.13 0.27 0.25 0.76 0.75 0.25 0.50 0.36 0.46 0.51 0.43

0.84 0.42 0.34 0.28 0.29 0.47 0.45 0.18 0.37 0.62 1.20 0.49

0.62 0.17 0.36 0.42 0.26 0.36 0.35 0.32 0.31 0.29 0.16 0.33

Salford

Bury & Rochdale

North Manchester

Oldham



Harms: Hospital Acquired Pressure Ulcers

Pressure Ulcers per 1,000 Bed-Days

There were 3 reported pressure ulcers in month in the Salford Care Organisation. Current occurrences are consistent with previous months and in line with normal variation.

This metric monitors pressure ulcers at Grade 2 and above.

Data for all Care Organisation is provided by

Tissue Viability Teams.

There were 4 reported pressure ulcers in month in the Bury & Rochdale Care Organisation. Current occurrences are consistent with previous months and in line with normal variation.

There were 2 reported pressure ulcers in month in the Oldham Care Organisation. Current occurrences are consistent with previous months and in line with normal variation.

There were 12 reported pressure ulcers in month in the North Manchester Care Organisation. This is above the average figure for the year and is the highest level since January 18. These are across a number of ward areas.

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

PU

s

Salford Pressure Ulcers

Pressure Ulcers Average

0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

PU

s

Bury & Rochdale Pressure Ulcers


0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

PU

s

Oldham Pressure Ulcers


0

5

10

15

20

25

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

PU

s

North Manchester Pressure Ulcers


5/30

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& PAT

# 274

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0

17/240



Stranded Patients

58.52% of occupied bed days in the Salford Care Organisation were used by stranded patients in February '19 and 32.97% of bed-days were used by super-stranded patients. Both of these measure are worse than the GM standard.

Stranded patients are defined as those with a length of stay

of more than 7 days. Super-stranded are those patients with a length of stay in excess of 21 days. This metric is a

measure of flow across our beds.

GM have now issues thresholds to all organisations for stranded and super stranded patients and these are

reflected in the charts.

All Care Organisations are performing worse than the current GM 35% standard for Stranded patients. Only Oldham is achieving the standard for Super Stranded patients. Salford has a target of 23% and NES 12.6%

From October '18, patients under 18yrs have been removed from this metric as per revised national guidance.

41.22% of occupied bed days in the Bury & Rochdale Care Organisation

were used by stranded patients in February'19 and 17.27% were used

by super-stranded patients. Both stranded & super stranded bed-days remain worse than the GM

standard.

41.16% of occupied bed days in the North Manchester Care Organisation were used by stranded patients in February'19 and 15.98% were used by super-stranded patients. This performance was worse than the expected GM thresholds.

36.16% of occupied bed days in the Oldham Care Organisation

were used by stranded patients in February'19 , which is worse

that the GM threshold. 10.83% were used by super-stranded

patients. Super-stranded performance is better than the

GM threshold.

0%

10%

20%

30%

40%

50%

60%

70%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford Stranded & Super Stranded %

Stranded (7+) Super Stranded (21+)

Stranded Target Super Stranded Target

0%

10%

20%

30%

40%

50%

60%

70%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale Stranded & Super Stranded %



0%

10%

20%

30%

40%

50%

60%

70%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester Stranded & Super Stranded %



0%

10%

20%

30%

40%

50%

60%

70%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham Stranded & Super Stranded %



6/30

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& PAT

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Delayed Transfers of Care: Percent Delayed Bed Days and Delayed Discharge Days

Performance for the Salford Care Organisation is better than the national target for February at 0.76%.

This metric measures the proportion of bed-days occupied by patients classified as

delayed.

The national target delay rate is 3.5% of occupied bed-days.

Recently published NHS Improvement

clarification guidance for DTOCs is currently being reviewed and any amendments to data collection will be applied once approved by Care Organisation governance committees.

Performance for the Bury & Rochdale Care Organisation is

better than the national target for February at 1.62%. The Care Organisation has been focusing on reducing delays, the impact

of which can be seen in the

improvement in performance.

Performance for the North Manchester Care Organisation is worse than the national target for February at 5.79%.

Performance for the Oldham Care Organisation is better than the national target for February at 1.69%.

0

100

200

300

400

500

600

0%

2%

4%

6%

8%

10%

12%

14%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford Delayed Transfers % Bed Day s and Delayed Discharge Days

DTOC % Target Delayed Days

0

100

200

300

400

500

600

0%

2%

4%

6%

8%

10%

12%

14%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale Delayed Transfers % Bed Days and Delayed Discharge Days


0

100

200

300

400

500

600

700

0%

2%

4%

6%

8%

10%

12%

14%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester Delayed Transfers % Bed Days and Delayed Discharge Days


0

100

200

300

400

500

600

0%

2%

4%

6%

8%

10%

12%

14%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Oldham Delayed Transfers % Bed Days and Delayed Discharge Days


7/30

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& PAT

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Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

90.21% 81.70% 82.30% 75.60% 82.00% 82.48% 90.49% 90.90% 89.17% 90.78% 86.51% 83.23% 85.57% 76.97% 71.25% 72.00%

87.12% 80.49% 83.78% 81.70% 81.70% 87.70% 89.84% 91.18% 87.33% 89.54% 87.56% 87.49% 85.37% 80.89% 80.24% 82.10%

90.2% 88.6% 85.5% 86.5% 84.8% 89.2% 93.7% 94.8% 93.5% 95.0% 92.7% 93.6% 92.1% 87.0% 83.8%

73.1% 71.5% 71.6% 73.8% 63.7% 73.6% 73.0% 84.7% 78.8% 80.1% 71.2% 70.8% 70.2% 68.8% 60.1%

88.8% 85.0% 85.3% 85.0% 84.6% 88.6% 90.4% 90.8% 89.3% 89.7% 88.9% 89.0% 87.6% 86.40% 84.40%NHS England Performance


Pennine Acute Hospitals Trust

Best Performer (Other GM)

Worst Performer (Other GM)


Highly Reliable & Connected Care

Urgent Care

A&E 4 Hour Performance

Salford Care Organisation is below it's revised improvement trajectory of 87% with performance of 72.00% in February, which is also a reduction on February 18's performance of 75.60%.

The 7 day reattendance rate was 7.45%, better than national average.

The national target for A&E remains at 95% however STF funding is delivered based on a year-on-year quarterly improvement in performance.

All Care Organisations are missing their

performance trajectories.

The national standard for reattendances is no more than 5%. The latest NHS England average

was 8.2% with all NCA Care Organisations performing better than this .

Bury & Rochdale Care 4hr performance was 89.67% for February, below the

improvement trajectory..

The 7 day reattendance rate was 6.30%, better than the national

average.

The North Manchester Care Organisation was below its revised improvement trajectory for February with a performance of 71.81% against a trajectory of 82%.

The 7 day reattendance rate was 7.97% and was better than the national average.

Oldham Care Organisation performance was 81.02% in

February. The Care Organisation has not achieved its revised

trajectory of 87% but has seen an in-month improvement.

The 7 day reattendance rate was

7.01% and was better than the national average.

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

A&

E R

eat

ten

dan

ce R

ate

(G

ree

n)

A&

E P

erf

orm

ance

(Blu

e)

Salford A&E Performance

Actual Trajectory A&E Reattendance Rate

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

A&

E R

eat

ten

dan

ce R

ate

(G

ree

n)

A&

E P

erf

orm

ance

(Blu

e)

North Manchester A&E Performance


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

A&

E R

eat

ten

dan

ce R

ate

(G

ree

n)

A&

E P

erf

orm

ance

(Blu

e)

Bury & Rochdale A&E Performance


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

A&

E R

eat

ten

dan

ce R

ate

(G

ree

n)

A&

E P

erf

orm

ance

(Blu

e)

Oldham A&E Performance


8/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

20/240

Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

92.29% 92.01% 92.03% 92.02% 92.03% 92.08% 92.43% 92.06% 92.02% 92.02% 91.00% 91.19% 90.09% 89.01% 89.83% 89.64%

90.26% 88.03% 87.27% 86.63% 86.53% 86.53% 86.97% 85.87% 85.91% 85.80% 85.85% 85.91% 85.06% 85.06% 84.69% 84.43%

89.5% 88.2% 88.2% 87.9% 87.2% 87.5% 88.1% 87.8% 87.8% 87.2% 86.7% 87.1% 86.8% 86.6% 86.7%



Elective Access

NHS England


RTT Open Performance


The RTT performance for Salford Care Organisation was 89.64% for February. The size of the list is 2.9% below the baseline agreed by CiC.

Referral to Treatment waiting times for open pathways should not exceed 18 weeks for 92% of patients and a further target has been applied where the size of the

waiting list should not exceed the list size in March '18 by the end of March '19. RTT List sizes for all Care

Organisations have continued to increase month on month.

A further quality measure has been added to monitor the proportion of patients waiting less than 36 weeks

across our Care Organisations.

Paediatrics pathways were reattributed to North Manchester from Oldham in October '18 which has

impacted on the size of this list in both Care Organisations. In totality, the list size for these two

Performance for the Bury & Rochdale Care Organisation is undergoing final validation. Indicative performance for

the Care Organisation is 88.34%.

The total list size is in line with the previous month and is 2% less than

the March '18 baseline.

.

Performance for the North Manchester Care Organisation is awaiting final validation. Indicative performance for the Care Organisation is 86.2%. The total combined list size for both the Oldham & North Manchester Care Organisations is 5% higher the March '18 baseline.

Performance for the Oldham Care Organisation is awaiting final

validation. Indicative performance for the Care Organisation is

78.95%.

The total combined list size for both the Oldham & North

Manchester Care Organisations is 5% higher the March '18 baseline.

700010000130001600019000220002500028000310003400037000400004300046000

74%76%78%80%82%84%86%88%90%92%94%96%98%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

Dec

-18

Jan

-19

Feb

-19

Mar

-19

RTT

Lis

t Si

ze (

Pu

rple

)

RTT

Op

en

Pe

rfo

rman

ce (B

lue

& O

ran

ge)

Salford RTT Open Performance

Actual Target % <36 Week+ RTT List Size

700010000130001600019000220002500028000310003400037000400004300046000

74%76%78%80%82%84%86%88%90%92%94%96%98%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

RTT

Lis

t Si

ze (

Pu

rple

)

RTT

Op

en

Pe

rfo

rman

ce (B

lue

)

Bury & Rochdale RTT Open Performance

Actual Target Stretch Target

% <36 Week+ RTT List Size

700010000130001600019000220002500028000310003400037000400004300046000

74%76%78%80%82%84%86%88%90%92%94%96%98%

100%

Ap

r-17

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

Dec

-18

Jan

-19

Feb

-19

Mar

-19

RTT

Lis

t Si

ze (

Pu

rple

)

RTT

Op

en

Pe

rfo

rman

ce (B

lue

)

Oldham RTT Open Performance


700010000130001600019000220002500028000310003400037000400004300046000

74%76%78%80%82%84%86%88%90%92%94%96%98%

100%

Ap

r-17

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-18

Dec

-18

Jan

-19

Feb

-19

Mar

-19

RTT

Lis

t Si

ze (

Pu

rple

)

RTT

Op

en

Pe

rfo

rman

ce (B

lue

)

North Manchester RTT Open Performance


9/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

21/240

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

96.4% 96.1% 93.4% 94.9% 97.9% 96.1% 95.8% 98.1% 96.2% 96.4% 95.7% 98.96% 99.54% 99.25% 99.20% 98.25% 99.27%

99.2% 99.0% 98.5% 99.1% 99.3% 99.6% 99.6% 98.6% 99.8% 99.3% 99.2% 98.45% 98.46% 99.02% 98.41% 93.26% 97.08%

6 Wk Diagnostic Performance





Diagnostic Access

Performance for the Salford Care Organisation is 99.27%

Key diagnostic tests should to be carried out within 6 weeks of the request for the test

being made for 99% of patients.

A recovery plan has been agreed at the Bury & Rochdale Care Organisation to deliver the

standard by March 2019.

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford Diagnostic 6 Week Performance

Actual Target

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale Diagnostic 6 Week Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester Diagnostic 6 Week Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham Diagnostic 6 Week Performance

Actual Target

Performance for the Bury & Rochdale Care Organisation has hit 100% in the February following successful delivery of the agreed recovery plan.

Performance for the North Manchester Care Organisation has improved significantly in February and has achieved the target with performance of 99.0%.

Performance for the Oldham Care Organisation has improved in February with a performance of 96.67%

10/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

22/240

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19

96.7% 96.1% 95.5% 98.4% 98.8% 96.0% 96.2% 94.3% 96.4% 96.6% 95.3% 93.6% 94.1% 95.8% 97.0% 94.8%

84.1% 97.8% 93.6% 91.1% 91.2% 88.1% 70.3% 68.4% 70.2% 64.1% 70.4% 75.4% 68.6% 73.1% 91.3% 83.2%

94.7% 95.1% 94.8% 93.8% 95.2% 93.2% 90.8% 92.1% 91.1% 91.9% 91.7% 91.2% 92.3% 92.5% 93.7%NHS England Average





Cancer TWW Pathways

TWW

The Salford Care Organisation continues to deliver the standard with a performance of 94.8% in month.

All patients should receive an initial appointment within 14 days of urgent referral for suspected cancer. The standard is 93%

compliance.

Performance against this standard has improved in all Care Organisations with the exception of North Manchester where

capacity issues continue.

The 7 day standard measure the proportion of 2ww appointments booked within 7 days. The aim is to achieve 80% for this standard. All COs are struggling to improve in this area.

Cancer performance is reported at Care Organisation and Trust

level and is two months retrospective.

The Bury & Rochdale care organisation was above the

national standard with 93.16% compliance for January but is

below its trajectory of 97.5% .

Performance for the North Manchester Care Organisation has reduced to 79.9% for January with breaches in breast driving underperformance. The 2 week standard for Breast Symptomatic referrals is at 21% against a 93% standard.

The Oldham Care Organisation performance has seed a

reduction in performance to 84.7% for January. Breaches

are high in both upper and lower GI as well as

Gynaecology.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford 2 Week Wait Performance

2ww Target 7day

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale 2 Week Wait Performance

2ww Target 7day Bury & Rochdale Trajectory

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham 2 Week Wait Performance

2ww Target Oldham Trajectory 7day

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

North Manchester 2 Week Wait Performance

2ww Target North Manchester Trajectory 7day

11/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

23/240

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19

88.5% 91.0% 92.1% 87.5% 92.2% 92.2% 88.0% 85.6% 91.9% 84.5% 92.7% 92.4% 87.1% 88.0% 85.7% 83.9%

85.3% 85.3% 80.5% 80.6% 83.5% 83.8% 79.9% 68.4% 74.1% 68.5% 71.6% 77.2% 71.5% 73.7% 78.8% 73.5%

82.3% 82.5% 84.2% 81.1% 81.0% 84.7% 82.3% 81.1% 79.2% 78.2% 79.4% 78.2% 78.4% 79.2% 81.0%NHS England Average




Cancer 62 Day Pathways

62 Day National


Salford failed to meet the 85% national standard for the first time in 6 months, with a performance of 83.9% for January .

Those referred urgently and diagnosed with cancer should begin their first definitive treatment within 62

days of referral. The standard is 85% compliance.

Improvement work across tumour groups continues across the North East Sector. Although performance is

expected to be low for both Oldham & North Manchester, the number of long-waiting patients is

expected to reduce as back-logs are cleared, which is a key leading indicator.

The Bury & Rochdale Care Organisation is below the standard for January with a

performance of 71.43%. The Care Organisation covers Head & Neck and

Sarcoma tumour groups with low numbers resulting in low breach

tolerance. There was one breach in the month.

The North Manchester Care Organisation has seen reduced performance in January at 83.93%. This was mainly due to breaches in lung.

The Oldham Care Organisation continues to experience

expected deterioration in performance to 52.4% in

January as long waiters continue to be treated.

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford 62 Day Performance

62 Day Treatment National 62 Day Target

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale 62 Day Performance

National Target Bury & Rochdale Trajectory

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham 62 Day Performance

National Target Oldham Trajectory

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester 62 Day Performance

National Target North Manchester Trajectory

12/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

24/240


Connected & At Scale

Workforce - Sickness Absence

The Salford Care Organisation sickness absence rates are above the 4.2% target in month at 4.43%, following an upward trend in line with seasonal variation. Latest vaccination rates for flu stand at 64%.

Sickness absence is the percentage of sickness in terms of WTEs. This includes both short-term and long-term sickness over a rolling 12 month

period.

Progress over the last two years in the COs has not been at the desired rate. Policies and

management guidance has been reviewed and updated, and a case management approach

with closer working with Occupational Health has been developed.

Sickness Absence rates are reported two months in retrospect.

The Bury and Rochdale Care Organisation sickness rate is above the 5% target in month at 6.33%, a similar level to the same period last year.

The North Manchester Care Organisation sickness rate is above the 5% target in month at 5.99%. This is lower than the same period last year.

The Oldham Care Organisation sickness levels continue to increase following patterns of seasonal variation. Latest sickness levels are at 5.95%.

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford - Sickness Absence

Salford Stretch Target Target

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale - Sickness Absence

Bury & Rochdale Target

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester - Sickness Absence

North Manchester Target

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham- Sickness Absence

Oldham Target

13/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

25/240



Workforce - Staff Stability Index

The Salford Care Organisation stability index for Medical and Dental staff February19 was 97.53%. The Nursing and Midwifery stability index was 87.78%.

A stability index is now utilised as a workforce indicator to provide consistency across all Care Organisations. The data within the North East sector has been rebased to provide a

consistent measure and adjusted for hosted services.

The stability index is calculated over 12 months and split into Nursing and Midwifery, and Medical and Dental. The

metric measures the number of staff with service of 12 months or more as a proportion of total staff in post 12

months ago. This is not the same as turnover, which measures leavers compared to the number of staff in post.

The sharp reduction in the index for North Manchester Nursing & Midwifery is due to the TUPE of staff to

Manchester FT as part of the community services transfer.

The Bury and Rochdale Care Organisation stability index or February is 95.04% for Medical & Dental staff groups and 85.97% for Nursing & Midwifery

The North Manchester Care Organisation stability index for February is 84.56% for Medical & Dental staff groups and 74.69% for Nursing & Midwifery.

The Oldham Care Organisation stability index for February is 89.09% for Medical & Dental staff groups and 88.92% for Nursing & Midwifery

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford Staff Stability Index

Stability Index N&M Stability Index M&D

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale Staff Stability Index


70%

75%

80%

85%

90%

95%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester Staff Stability Index


70%

75%

80%

85%

90%

95%

100%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham Staff Stability Index


14/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

26/240



Workforce - Staff Vacancy Rate

The Salford Care Organisation vacancy rate for Nursing and Midwifery staff was 4.87%. The Medical & Dental vacancy rate was 5.49%

This metric displays staff vacancy rates. Data is split into Nursing and Midwifery,

and Medical and Dental.

Vacancy rates are primarily a function of staff turnover. We have insignificant

planned workforce change/growth. The new recruitment strategy is starting to

bear fruit. We have seen improvements in recruitment in hard to fill areas, e.g.

critical care, paediatrics.

The Bury & Rochdale Care Organisation vacancy rate for Nursing and Midwifery staff was 10.96%. The Medical & Dental vacancy rate for February was 17.74%.

The North Manchester Care Organisation vacancy rate for Nursing and Midwifery staff was 15.70%. The Medical & Dental vacancy rate for February was 25.60%.

The Oldham Care Organisation vacancy rate for Nursing and Midwifery staff was 6.99%. The Medical & Dental vacancy rate for February was 9.59%.

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Salford Staff Vacancy Rates

Vacancy Rate N&M Vacancy Rate M&D

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Bury & Rochdale Staff Vacancy Rates


0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

North Manchester Staff Vacancy Rates


0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Oldham Staff Vacancy Rates


15/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

27/240



Workforce - Nursing & Midwifery Agency Utilisation

Salford continues its downward trend in agency use for Nursing staff groups and was below average usage during February.

This metric reflects the number of nursing and midwifery shifts filled with agency staff

on a weekly basis.

Considerable work has been implemented to put in effective controls for nursing & midwifery agency. The underlying rate is

showing improvement. Recruitment successes will enhance this performance. The Group bank share arrangement for

nursing staff went live in May.

Bury & Rochdale Care Organisation continues its

downward trend in agency use for Nursing & Midwifery staff groups and was below

average usage during February.

The North Manchester Care Organisation has maintained its reduced level of nursing and midwifery agency usage during February and was below average usage.

The Oldham Care Organisation continues to experienced variation in its level of nursing and midwifery agency usage during February.

0

10

20

30

40

50

01

/04/20

18

15

/04/20

18

29

/04/20

18

13

/05/20

18

27

/05/20

18

10

/06/20

18

24

/06/20

18

08/07

/2018

22

/07/20

18

05

/08/20

18

19

/08/20

18

02

/09/20

18

16

/09/20

18

30

/09/20

18

14

/10/20

18

28

/10/20

18

11

/11/20

18

25

/11/20

18

09/12

/2018

23

/12/20

18

06

/01/20

19

20

/01/20

19

03

/02/20

19

17

/02/20

19

03

/03/20

19

Salford N&M Weekly Agency Utilisation

Actual Av UCL LCL

+1 Sigma -1 Sigma +2 Sigma -2 Sigma

0

50

100

150

200

250

300

350

01

/04

/20

18

15

/04

/20

18

29

/04

/20

18

13

/05

/20

18

27

/05

/20

18

10

/06

/20

18

24

/06

/20

18

08

/07

/20

18

22

/07

/20

18

05

/08

/20

18

19

/08

/20

18

02/09

/2018

16

/09

/20

18

30

/09

/20

18

14

/10

/20

18

28

/10

/20

18

11

/11

/20

18

25

/11

/20

18

09

/12

/20

18

23

/12

/20

18

06

/01

/20

19

20

/01

/20

19

03

/02

/20

19

17

/02

/20

19

03

/03

/20

19

Bury & Rochdale N&M Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

01

/04/20

18

15

/04/20

18

29

/04/20

18

13

/05/20

18

27

/05/20

18

10/06

/2018

24

/06/20

18

08

/07/20

18

22

/07/20

18

05

/08/20

18

19

/08/20

18

02

/09/20

18

16

/09/20

18

30

/09/20

18

14

/10/20

18

28

/10/20

18

11/11

/2018

25

/11/20

18

09

/12/20

18

23

/12/20

18

06

/01/20

19

20

/01/20

19

03

/02/20

19

17

/02/20

19

03

/03/20

19

North Manchester N&M Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

01/04

/2018

15/04

/2018

29/04

/2018

13/05

/2018

27/05

/2018

10/06

/2018

24/06

/2018

08/07

/2018

22/07

/2018

05/08

/2018

19/08

/2018

02/09

/2018

16/09

/2018

30/09

/2018

14/10

/2018

28/10

/2018

11/11

/2018

25/11

/2018

09/12

/2018

23/12

/2018

06/01

/2019

20/01

/2019

03/02

/2019

17/02

/2019

03/03

/2019

Oldham N&M Weekly Agency Utilisation

Actual Av UCL LCL


16/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

28/240



Workforce - Medical & Dental Agency Utilisation

The Salford Care Organisation reduced its level of medical and dental agency staff usage within normal variation during February.

This metric reflects the number of medical and dental shifts filled with agency staff on a weekly

basis.

Care Organisations continue to work on establishments. This work has shown the scope for

improvement and the need for business cases for long standing issues in the workforce. Controls are

still not as reliably implemented as nursing. The key issue is confidence in establishments / rotas and

compliance.

The change in the immigration rules to exclude doctors from the Tier 2 controls from July should

impact positively on agency use.

The North Manchester Care Organisation maintained it's usage medical and dental agency staff in February.

The Oldham Care Organisation significantly increased its level of medical and dental agency staff usage within February but is within normal variation.

0

50

100

150

200

250

300

350

400

01/04

/2018

15/04

/2018

29/04

/2018

13/05

/2018

27/05

/2018

10/06

/2018

24/06

/2018

08/07

/2018

22/07

/2018

05/08

/2018

19/08

/2018

02/09

/2018

16/09

/2018

30/09

/2018

14/10

/2018

28/10

/2018

11/11

/2018

25/11

/2018

09/12

/2018

23/12

/2018

06/01

/2019

20/01

/2019

03/02

/2019

Salford M&D Weekly Agency Utilisation

Actual Av UCL LCL


The Bury & Rochdale Care Organisation maintained its level of medical and dental agency usage with average usage in February

0

50

100

150

200

250

300

350

400

01/04

/2018

15/04

/2018

29/04

/2018

13/05

/2018

27/05

/2018

10/06

/2018

24/06

/2018

08/07

/2018

22/07

/2018

05/08

/2018

19/08

/2018

02/09

/2018

16/09

/2018

30/09

/2018

14/10

/2018

28/10

/2018

11/11

/2018

25/11

/2018

09/12

/2018

23/12

/2018

06/01

/2019

20/01

/2019

03/02

/2019

17/02

/2019

03/03

/2019

Bury & Rochdale M&D Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

01

/04/20

18

15

/04/20

18

29

/04/20

18

13

/05/20

18

27

/05/20

18

10

/06/20

18

24

/06/20

18

08

/07/20

18

22/07

/2018

05

/08/20

18

19

/08/20

18

02

/09/20

18

16

/09/20

18

30

/09/20

18

14

/10/20

18

28

/10/20

18

11

/11/20

18

25

/11/20

18

09

/12/20

18

23/12

/2018

06

/01/20

19

20

/01/20

19

03

/02/20

19

17

/02/20

19

03

/03/20

19

North Manchester M&D Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

01/04

/2018

15/04

/2018

29/04

/2018

13/05

/2018

27/05

/2018

10/06

/2018

24/06

/2018

08/07

/2018

22/07

/2018

05/08

/2018

19/08

/2018

02/09

/2018

16/09

/2018

30/09

/2018

14/10

/2018

28/10

/2018

11/11

/2018

25/11

/2018

09/12

/2018

23/12

/2018

06/01

/2019

20/01

/2019

03/02

/2019

17/02

/2019

03/03

/2019

Oldham M&D Weekly Agency Utilisation

Actual Av UCL LCL


17/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

29/240



Safe Staffing

Salford Care Organisation has met the standard for Care

Staff shift types but is below the standard for Nursing staff

shift types. Nursing staffing did show improvements but

has dipped in February.

The Safe Staffing metric compared the actual number of

ward shifts filled compared to the number of expected to be filled. This is split be nursing and care staff and day and night shifts.

All wards should achieve 95%

compliance.

The Bury & Rochdale Care Organisation has met the

standard for Care Staff shift types but is below the standard

for Nursing shifts.

North Manchester Care Organisation has met the

standard for Care Night and Day Staff shift types and also for Nursing Night shifts but is

below the standard for Nursing day shift types.

The Oldham Care Organisation has met the

standard for Care Staff shift types but is below the

standard for Nursing shift types .

60%

70%

80%

90%

100%

110%

120%

130%

140%

150%

Salford Safe Staffing Performance

Nurses % - Day Nurses % - Night Care Staff % - Day

Care Staff % - Night Target

60%

70%

80%

90%

100%

110%

120%

130%

140%

150%

Bury & Rochdale Safe Staffing Performance



60%

70%

80%

90%

100%

110%

120%

130%

140%

150%

North Manchester Safe Staffing Performance



60%

70%

80%

90%

100%

110%

120%

130%

140%

150%

Oldham Safe Staffing Performance



18/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

30/240

Hospital WardMain Specialty

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffWard Main Specialty

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffFairfield Ward 10 (ITU/HDU) Critical Care Medicine 102.82% 76.79% 104.71% 42.86% 1 12.49% 8.09% Y A&E Observation Ward General Medicine 98.21% 289.47% 100.00% 311.11% 18.06% 3.91% Y

Fairfield Ward 11a Rehabilitation 69.65% 100.78% 84.06% 101.55% 20.61% 6.44% Y Antenatal Ward Obstetrics 91.05% 92.86% 97.94% 92.86% -0.46% 6.15% N

Fairfield Ward 11b Rehabilitation 76.41% 97.84% 75.00% 129.89% 23.89% 3.12% Y Children's Unit Paediatric 104.93% 91.23% 105.70% 36.11% -2.31% 3.55% Y

Fairfield Ward 14 General Surgery 75.40% 96.88% 100.00% 102.38% 33.30% 6.48% Y Critical Care Critical Care Medicine 92.41% 85.71% 94.29% 133.93% -3.14% 1.63% Y

Fairfield Ward 2 CCU Cardiology 96.44% 72.30% 91.07% 85.71% 11.87% 3.65% Y Labour Ward Obstetrics 93.25% 79.46% 92.06% 96.43% -0.47% 6.23% N

Fairfield Ward 20 Geriatric Medicine 79.02% 120.98% 82.14% 94.64% 1 30.13% 8.16% Y Neonatal Unit Obstetrics 76.17% 30.36% 81.87% NA -12.15% 6.16% N

Fairfield Ward 21 General Medicine 80.80% 122.94% 89.29% 142.27% 15.63% 12.22% Y Postnatal Ward Obstetrics 97.77% 91.67% 111.11% 78.57% 3.86% 7.77% N

Fairfield Ward 5 General Medicine 91.07% 110.71% 71.43% 123.81% 18.59% 7.14% Y Ward AMU General Medicine 79.86% 99.41% 84.52% 114.41% 1 18.54% 5.02% Y

Fairfield Ward 7 General Medicine 68.57% 89.68% 70.09% 102.96% 1 13.35% 12.16% Y Ward CCU Cardiology 100.00% NA 85.71% 250.00% -5.43% 11.15% Y

Fairfield Ward 8 General Medicine 84.64% 99.42% 84.82% 107.59% 1 17.99% 4.18% Y Ward F1 Gynaecology 76.68% 90.68% 96.83% 101.79% 11.67% 10.41% Y

Fairfield Ward 9 Trauma & Orthopaedics 75.00% 76.79% 78.57% 91.07% 13.94% 4.10% Y Ward F10 General Medicine 103.57% 125.89% 76.19% 192.86% 18.79% 14.74% Y

Rochdale Floyd Unit Rehabilitation 100.00% 103.80% 100.00% 119.57% -1.27% 12.53% Y Ward F11 Haematology 90.73% 158.52% 83.33% 150.75% 13.28% 5.66% Y

Rochdale Clinical Admissions Unit General Medicine 96.39% 100.00% 90.16% 93.94% 1 -5.33% 7.49% Y Ward F7 General Medicine 97.26% 90.70% 91.51% 111.59% 1 -19.58% 2.96% Y

Rochdale Oasis Unit - RI General Medicine 81.08% 102.50% 91.07% 118.75% 18.40% 14.54% Y Ward F8 General Medicine 101.79% 94.64% 100.00% 116.39% -5.84% 11.15% Y

Rochdale Wolstenholme Unit - RI Intermediate Care 88.69% 98.21% 101.72% 113.95% 1 3.65% 8.26% Y Ward F9 General Medicine 92.86% 94.58% 73.81% 133.96% 17.67% 3.46% Y

Ward G1 General Medicine 80.36% 116.07% 66.67% 146.43% 13.75% 5.04% Y

Ward G2 General Surgery 82.11% 96.43% 82.35% 73.39% 31.22% 9.38% Y

N Ward T3 General Surgery 83.48% 108.93% 72.62% 201.67% 24.53% 14.67% Y

Y Ward T4 STU General Surgery 89.64% 139.50% 98.81% 166.67% 48.60% 7.58% Y

Y Ward T5 General Surgery 82.14% 102.98% 77.38% 175.00% 4.34% 22.16% Y

Y Ward T7 General Surgery 78.90% 137.11% 90.18% 142.86% 1 11.04% 9.69% Y

Y Ward T8 General Surgery 81.36% 117.21% 105.36% 154.35% 18.68% 10.95% Y

Ward to be reassessed after 8 months

SCAPE Ward (3 consecutive green assessments)

NAAS

Naas Accreditation Key

Ward not assessed

Failed Assessment - Reassessed after 2 months


Bury & RochdaleDay

OldhamDay Night

Pressure

UlcersFalls

Nursing

Vacancy

Rate

Sickness

Rate

NightPressure

UlcersFalls

Nursing

Vacancy RateSickness Rate NAAS



Safe Staffing

19/30

SRFT

& PAT

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31/240

Ward Main SpecialtyAverage fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffWard Main Specialty

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staff

ANU Neurology 85.36% 104.79% 94.20% 115.78% -9.71% Y AnteNatal Ward Obstetrics 99.29% 89.29% 87.69% 89.29% 15.29% 0.66% N

ASU Acute Stroke Unit 87.16% 91.29% 93.92% 134.45% 13.60% 0.00% Y Children's Unit Paediatric 75.14% 59.21% 91.88% 180.00% 32.59% 7.92% Y

HASU Stroke 76.29% 140.54% 65.63% 133.94% 0.87% 2.13% Y Critical Care Critical Care Medicine 99.29% 135.71% 99.61% 107.14% 0.00% Y

L1 Trauma Rehab 88.93% 82.08% 80.04% 85.00% 27.91% 0.00% Y Labour Ward Obstetrics 97.20% 82.73% 97.33% 62.50% 27.43% 1.91% N

B5 Acute Trauma 66.12% 167.93% 88.37% 116.38% 0.44% 4.02% Y Neonatal Unit Neonatology 78.66% 96.43% 76.05% NA 6.80% N

B6 Trauma Orthopaedics 71.75% 148.43% 83.20% 162.60% 1 9.87% 4.84% Y PostNatal Ward Obstetrics 93.63% 93.52% 101.14% 96.30% 4.47% 4.35% N

B7 Neurosurgery 74.86% 124.05% 70.56% 123.54% 16.13% 12.83% Y Ward C3 General Surgery 86.43% 117.86% 94.64% 135.48% 23.34% 9.38% Y

B8 Neurosurgery 86.41% 114.12% 63.04% 117.06% 3.74% 6.71% Y Ward C4 General Surgery 66.43% 86.61% 55.36% 75.00% 12.55% 3.91% Y

C2 Neuro Rehab 73.00% 83.64% 93.45% 87.90% 22.31% 6.19% Y Ward C5 General Medicine 98.47% 98.39% 91.07% 147.31% 18.42% 14.10% Y

CCU Critical Care Unit 86.67% 95.98% 77.57% 102.68% -14.27% 4.73% Y Ward C6 General Medicine 100.71% 96.60% 107.55% 103.20% 1 30.64% 3.86% Y

EAU Emergency Assessment Unit 86.79% 84.74% 84.14% 88.32% 12.88% 4.65% Y Ward CCU G4 Cardiology 91.49% 94.64% 101.79% 113.79% 1 Y

HAEM Haematology 86.95% 89.07% 82.87% 96.11% -5.46% 13.35% Y Ward D5 Gastroenterology 98.21% 102.68% 100.00% 106.45% 8.81% 6.00% Y

HB1 General Surgery 77.82% 123.21% 86.39% 91.03% 8.00% 2.69% Y Ward D6 Gastroenterology 92.26% 95.50% 100.00% 103.23% 16.60% 22.18% Y

HB2 General Surgery 62.61% 171.94% 90.52% 147.92% 16.63% 6.82% Y Ward E1 General Medicine 86.44% 114.71% 90.48% 159.78% 25.21% 2.70% Y

HCU Heart Care Unit 68.19% 140.87% 85.00% 175.95% 12.94% 4.72% Y Ward F3 General Surgery 86.73% 113.27% 100.00% 100.00% 11.51% 4.22% Y

HH1M Medical HDU 71.75% 83.04% 71.32% 91.45% 7.82% 14.82% Y Ward F4 General Medicine 96.21% 102.74% 100.00% 106.31% 1 16.21% 6.46% Y

HH2 Respiratory 76.10% 79.69% 73.19% 100.89% 14.75% 3.53% Y Ward F5 General Surgery 87.76% 131.25% 121.82% 140.32% 2 35.04% 5.91% Y

HH3 Renal 73.22% 121.23% 71.82% 189.52% 17.86% 10.10% Y Ward F6 General Surgery 92.86% 100.89% 117.86% 116.07% 31.31% 6.05% Y

HH4 Urology 74.30% 92.15% 82.56% 153.21% 1 18.03% 5.29% Y Ward AMU General Medicine 98.47% 114.44% 92.35% 149.04% 2 2.74% Y

HH5 Surgery 66.59% 136.54% 85.08% 300.55% 21.03% 17.34% Y Ward I5 Trauma & Orthopaedics 77.33% 97.53% 90.48% 113.39% 1 19.77% 8.87% Y

HH6 Surgical HDU 84.24% 95.72% 90.02% 126.03% -13.21% 9.04% Y Ward I6 General Medicine 95.24% 116.22% 77.92% 131.75% 1 36.47% 17.14% Y

HH7 Neuro surgery & ENT 76.61% 143.95% 99.37% 111.95% 8.94% 7.00% Y Ward J3J4 Infectious Diseases 84.09% 141.96% 100.71% 166.67% 2 1 20.66% 16.80% Y

HH8 Intestinal Failure Unit 68.65% 99.07% 62.35% 102.45% 22.08% 4.32% Y Ward J6 General Medicine 97.62% 137.50% 100.00% 137.50% 3.15% 3.77% Y

L2 Gastroenterology 80.40% 68.50% 90.02% 101.45% 19.54% 5.59% Y Ward STU Urology 66.83% 103.42% 96.43% 100.00% 2.47% Y

L3 Cardiology 82.83% 72.63% 119.05% 105.55% 1 -18.67% 6.32% Y

L4 Care of the elderly 62.21% 74.75% 86.69% 85.08% -38.14% 9.81% Y

L5 Care of the elderly 62.20% 69.02% 84.88% 86.41% 1 -19.23% 6.98% Y

L6 Medical / diabetes 74.25% 73.05% 85.08% 80.45% 1 17.83% 9.22% Y N

M2 Neurosurgery 82.87% 80.56% 91.26% 103.52% 28.16% 6.68% Y Y

M2SS Spinal Surgery 92.10% 95.04% 62.03% 100.89% 0.00% 0.00% Y Y

M3 Dermatology 92.86% 90.15% 79.79% 90.95% 19.45% 4.91% Y Y

MAPL Neurology 101.89% 97.99% 90.93% 96.43% 8.96% 3.54% Y Y

SRU Stroke Rehab Unit 77.20% 99.96% 95.36% 137.17% 26.74% 3.69% Y

STU Surgical Triage Unit 81.53% 98.34% 90.52% 127.79% 9.47% 1.93% Y

Theatres 2


SCAPE Ward (3 consecutive green assessments)

NAAS

Naas Accreditation Key

Ward not assessed

Failed Assessment - Reassessed after 2 months


Pressure

UlcersFalls

Nursing

Vacancy

Rate

Sickness

Rate - Jan

2018



Safe Staffing

Day

North ManchesterDay Night

Salford

Pressure

UlcersFalls

Nursing

Vacancy Rate

(Hard to

recruit areas)

Sickness

Rate - Jan

2018

NightNAAS

20/30

SRFT

& PAT

# 274

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Finance

The Salford Care Organisation financial

position for February is £7m worse than the

control total.

SRFT: The year to date position is a deficit of £4.4m which is £8.9m worse than plan where BCLC is profiled in equal 1/12ths. Compared to our control total, where BCLC is

weighted to the second part of the year, the position is £7m worse than plan.

PAHT: The Month 11 position is a deficit of £64.36m which is

£0.7m worse than the planned deficit of £63.6m for the period where BCLC and reserves are profiled in equal 1/12ths.

Compared to our agreed plan where BCLC is weighted into the second part of the year our position is on plan.

Unlike SRFT, PAHT does not have an agreed financial control

total (with NHSI). PAHT is working to a deficit plan for the year of £68.9m.

.

The Bury & Rochdale Care Organisation financial

position for February is £3.2m worse than the

control total.

North Manchester Care Organisation financial

position for February is £0.7m better than the

control total.

The Oldham Care Organisation financial

position for February is £2.8m worse than the

control total.

-£10.00

-£8.00

-£6.00

-£4.00

-£2.00

£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

£m

Salford Finance Performance

Performance vs. Control Total

-£10.00

-£8.00

-£6.00

-£4.00

-£2.00

£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

£m

Bury & Rochdale Finance Performance


-£10.00

-£8.00

-£6.00

-£4.00

-£2.00

£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

£m

North Manchester Finance Performance


-£10.00

-£8.00

-£6.00

-£4.00

-£2.00

£0.00

£2.00

£4.00

£6.00

£8.00

£10.00

Ap

r-18

May-18

Jun

-18

Jul-1

8

Au

g-18

Sep-1

8

Oct-1

8

No

v-18

Dec-1

8

Jan-19

Feb-1

9

Mar-19

£m

Oldham Finance Performance


21/30

SRFT

& PAT

# 274

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03/2

2/20

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40:2

0

33/240

Principal Objective Principal Risks Responsible Officer Principal and Operational Risks

from 2018/19 Care Organisation

BAFs, Scored 12+

Like

liho

od

Imp

act

Key Control Established Key Gaps in Controls

Co

ntr

ol

Assurance Gaps in assurance Action Plan Summary

Op

enin

g P

osi

tio

n 2

01

8/1

9

Q1

20

18

/19

Po

siti

on

Q2

20

18

/19

Po

siti

on

Q3

20

18

/19

Po

siti

on

Q4

20

18

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

01

8/1

9

3.1 We will demonstrate continuous

improvement in operational and

workforce productivity and efficiency

3.1.1 IF we do not develop an

effective productivity

improvement and cost

reduction strategy that

identifies key cost drivers and

solutions for improvement

THEN we may not deliver

financial sustainability

Ian Moston, Chief

Financial Officer

4 5 > Delivery Management

Office

> QPID

> BCLC Committee

> Care Organisation

Statements of Assurance

> CO Finance +

Information Committee

4 > Group CiC Finance Report

> Benchmarking data sets

e.g.Model Hospital

Ongoing oversight and drive via DMO 12 13 13 13

12 12 13 13

Committee in Common ScorecardSaving Lives, Improving Lives

Group Principal Risks Scored 12

Workforce productivity - Salford RS

12

Risk No - 3750

Delivery of BCLC – Salford RS 13

Risk No – 3011

Financial Control Systems – Salford

RS 12

Risk No – 3010

Agency Spend – Salford RS 12

Risk Nos – 2903 and 2901

Delivery of CIP - B&R RS 12

Agency Spend – NM RS 12

Delivery of BCLC – Oldham RS 12

Demand exceeds capacity - D&P RS

13

BCLC -D&P RS12

Medical Workforce - B&R - RS 12

3.2 We work with partners to ensure

financial plans are sustainable and

deliver on our annual income and

expenditure budgets

3.2.2 IF the planned activity

and income levels and/or

expenditure controls are

exceeded leading to NHSI Use

of Resources rating lower

than planned THEN this will

increase regulatory

investigation & intervention

and put at risk Provider

Sustainability FundingIan Moston, Chief

Financial Officer

4 5 > Care Organisation

Finance & Information

Committees

> Divisional Finance

Meetings

> Executive review of

Group CiC Finance KPIs -

monthly

> Care Organisation


> Single Oversight

Framework

Draft 19/20 budget

does not yet deliver

national control total

for SRFT.

4 > Group CiC Finance Report

> Audit Committee oversight of

Going Concern Report/s

Monthly monitoring via escalation

meetings.

Salford & GMHSCP discussions being

undertaken to secure system support

for 19/20.

22/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

34/240



BAFs, Scored 12+

Like

liho

od

Imp

act


Co

ntr

ol


Op

enin

g P

osi

tio

n 2

01

8/1

9

Q1

20

18

/19

Po

siti

on

Q2

20

18

/19

Po

siti

on

Q3

20

18

/19

Po

siti

on

Q4

20

18

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

01

8/1

9



4.1 We will support staff to have

rewarding, productive and fulfilling

careers, enabling us to recruit and

retain talented people

4.1..4 IF we fail to remodel

the workforce THEN we will

fail to deliver the clinical

services strategy. -

Raj Jain, Exec Chief

Strategy and OD

Officer

&

Elaine, Burke, Chief

Nursing Officer

&

Chris Brookes, Chief

Medical Officer

Medical Staffing – Salford RS 12

Risk Nos – 3539 and 2373 (for ICD)

Nurse Staffing – Salford RS 12

Risk Nos – 3540 and 2358 (for

Neurosciences)

Workforce recruitment and

retention – NM RS 12

Medical Workforce – B&R RS 12

Agency spend

Recruitment & Retention -

neurophysiology - Cellular

Pathology - D&P RS12 / Salford 12

Risk No. 2393

Recruitment and Retention in

IM&T. RS 12

4 4 Draft Clinical Services

Strategy to based

workforce transformation

plan on.

Workforce acuity and

workload tools successfully

deployed for in acute and

community nursing and

AHPs.

Director appointed to

focus on system wide

workforce redesign.

Assurance framework in

place to monitor

development and delivery

of strategy.

Lead Director appointed

Transaction programme

providing further capacity

Strategy requires

further development

and communication

plan

Workforce planning

tool to be selected.

System wide workforce

planning capability

absent.

Capacity and capability

of leadership teams to

workforce plan

4 Effective delivery of the plan

Effective delivery of the Clinical

services strategy.

Safer staffing indicator

Harm free care indicators.

Non contractual pay spend

analysis

Workforce Transformation group

reporting to NCA W+OD

programme board

Detail of whole scope

of the programme not

completely defined and

risk stratified.

Detailed strategy and programme

reporting in development

12

23/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

35/240



BAFs, Scored 12+

Like

liho

od

Imp

act


Co

ntr

ol


Op

enin

g P

osi

tio

n 2

01

8/1

9

Q1

20

18

/19

Po

siti

on

Q2

20

18

/19

Po

siti

on

Q3

20

18

/19

Po

siti

on

Q4

20

18

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

01

8/1

9



Develop standard performance

management and delivery system Q3

Develop version 2 of Single Oversight

Framework (End Q1) (2019/20)

GooRoo - Full implementation (Q3)

Delivery of follow up action plan (Q3)

Describe and embed new leadership

and management arrangements for

NCA cancer performance management

incl additional resources (case to GM)

Q2. (2019/20)

12 12 12 125 Single Oversight

Framework incl.


Care Organisation and

Corporate Function Annual

Plan Reviews

Group Planning Approach

Capacity Demand Tool

procured

Standardised

performance

management and

monitoring system

Composite BI

dashboards that align

with delivery of

objectives

SoF to reflect all LCO

elements; contractual

performance; and

capacity & demand

Roll-out of capacity and

demand tool to identify

and effectively plan for

gaps

Effective management,

systems and leadership

of patient follow ups to

ensure safe and

effective clinical care

Effective managment,

leadership and service

improvement capacity

for cancer performance

Reliable workforce to

manage surge and

seasonal variation

4 Quarterly Group Objectives

Delivery Report to Group CiC

GRAC and Exec Development

Committee CO delivery and

governanace systems

5.1 We will ensure good operational

planning and execution to Deliver on

Urgent Care, Cancer, Elective plans

and trajectories and Deploy relevant

Standard Operating Models

5.1.1 IF we fail to have

effective mechanisms in place

for planning, oversight and

execution of our objectives

THEN operational excellence

will not be delivered

Chief Delivery

Officer

Access Targets - Salford RS 13

Risk No - 3734

− Delivery of the A&E 4 Hour

Standard – Salford RS 13

Risk No – 2292

− RTT – Salford RS 13

Risk No – 2726

− 6 week Diagnostic Standard –

Salford RS 13

Risk No – 3238

− 62 day Cancer Standard – Salford

RS 13

Risk No – 3675

− Trauma Capacity – Salford 12

Risk No – 2544

− Elective Capacity – Salford RS 12

Risk No – 3087

− Access to Neuro-Rehabilitation –

Salford RS 12

Risk No – 2500

− Radiology Turnaround Time –

Salford RS 12

Risk No – 1850

- Mortuary Capapcity - Salford - RS

12 Risk No - 2921

- JAG accreditation - Salford - RS 12

Risk No -3073

− Urgent Care demand – NM RS 12

− 62 day Cancer Standard: Capacity

and demand – NM RS 12

− Cancer Follow Up – NM RS 12

− Patient Tracking & Booking – NM

RS 12

CA Access Target - Oldham - RS 12

Delayed diagnostic reporting - D&P -

RS 12

Cellular Pathology reorting - D&P &

Salford- RS 12

Management of FU patients - EA -

RS 12

4

24/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

36/240



BAFs, Scored 12+

Like

liho

od

Imp

act


Co

ntr

ol


Op

enin

g P

osi

tio

n 2

01

8/1

9

Q1

20

18

/19

Po

siti

on

Q2

20

18

/19

Po

siti

on

Q3

20

18

/19

Po

siti

on

Q4

20

18

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

01

8/1

9



5.1.2 IF unsupported and out

of date clinical and technical

support systems are not

modernised THEN technical

brownouts and blackouts will

continue to occur putting

operational performance and

patients at risk. Furthermore

the aim of an interoperable,

single digital instance

unconstrained by geography

will not occur.

Chief Strategy and

OD Officer

IM&T Strategy – NM RS 12

IM&T Systems – B&R RS 12

IM&T Systems – Oldham RS 13

Fragility of IT Network / linitations

of PAS - EA - RS 12

4 4 Development of a single

Digital team across both

organisations.

Recognition at Group

Capital of the need to

update the systems

Limited purchase of

replacement systems

for those past effective

dates.

Transaction timetable

4 Capital investment paper under

consideration

Severe system

downtimes occurring.

Confirmed capital

funding

1. Develop and maintain a costed

imminent replacement programme.

2. Technical staff from both

organisations to provide mutual

support.

3. Ensure replacement programme

reflects the Group aims of a single

instance EPR, Cloud, interoperability,

citizen facing tech and wearable

technology.

12 12

Develop standard performance

management and delivery system Q3

Develop version 2 of Single Oversight

Framework (End Q1) (2019/20)

GooRoo - Full implementation (Q3)

Delivery of follow up action plan (Q3)

Describe and embed new leadership

and management arrangements for

NCA cancer performance management

incl additional resources (case to GM)

Q2. (2019/20)

12 12 12 125 Single Oversight

Framework incl.


Care Organisation and

Corporate Function Annual

Plan Reviews

Group Planning Approach

Capacity Demand Tool

procured

Standardised

performance

management and

monitoring system

Composite BI

dashboards that align

with delivery of

objectives

SoF to reflect all LCO

elements; contractual

performance; and

capacity & demand

Roll-out of capacity and

demand tool to identify

and effectively plan for

gaps

Effective management,

systems and leadership

of patient follow ups to

ensure safe and

effective clinical care

Effective managment,

leadership and service

improvement capacity

for cancer performance

Reliable workforce to

manage surge and

seasonal variation

4 Quarterly Group Objectives

Delivery Report to Group CiC

GRAC and Exec Development

Committee CO delivery and

governanace systems

5.1 We will ensure good operational

planning and execution to Deliver on

Urgent Care, Cancer, Elective plans

and trajectories and Deploy relevant

Standard Operating Models

5.1.1 IF we fail to have

effective mechanisms in place

for planning, oversight and

execution of our objectives

THEN operational excellence

will not be delivered

Chief Delivery

Officer

Access Targets - Salford RS 13

Risk No - 3734

− Delivery of the A&E 4 Hour

Standard – Salford RS 13

Risk No – 2292

− RTT – Salford RS 13

Risk No – 2726

− 6 week Diagnostic Standard –

Salford RS 13

Risk No – 3238

− 62 day Cancer Standard – Salford

RS 13

Risk No – 3675

− Trauma Capacity – Salford 12

Risk No – 2544

− Elective Capacity – Salford RS 12

Risk No – 3087

− Access to Neuro-Rehabilitation –

Salford RS 12

Risk No – 2500

− Radiology Turnaround Time –

Salford RS 12

Risk No – 1850

- Mortuary Capapcity - Salford - RS

12 Risk No - 2921

- JAG accreditation - Salford - RS 12

Risk No -3073

− Urgent Care demand – NM RS 12

− 62 day Cancer Standard: Capacity

and demand – NM RS 12

− Cancer Follow Up – NM RS 12

− Patient Tracking & Booking – NM

RS 12

CA Access Target - Oldham - RS 12

Delayed diagnostic reporting - D&P -

RS 12

Cellular Pathology reorting - D&P &

Salford- RS 12

Management of FU patients - EA -

RS 12

4

25/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

37/240



BAFs, Scored 12+

Like

liho

od

Imp

act


Co

ntr

ol


Op

enin

g P

osi

tio

n 2

01

8/1

9

Q1

20

18

/19

Po

siti

on

Q2

20

18

/19

Po

siti

on

Q3

20

18

/19

Po

siti

on

Q4

20

18

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

01

8/1

9



6.1 We will invest and reconfigure our

Estate and Facilities to enable the

delivery of an efficient and productive

environment which improves patient

and care experience

6.1.2 IF we fail to secure the

necessary funding to remedy

safety risks identified in NES

COs THEN significant and

severe disruption will occur,

the NCA may fail to provide

safe care and treatment, and

legal responsibilities may be

breached

Raj Jain, Exec Chief

Strategy and

Organisational

Development

Officer

NM Theatres 1-6 – NM RS 8 / E&F

RS 12

Onsite Estates – Salford RS 13

Risk No – 3542

Locality Estates – Salford RS 13

Risk No – 3677

Estates Strategy – NM RS 12

Unable to retain current specialist

diagnostics facitlities (3T Scanner)

following transformation process -

D&P. RS 12

Haematology Unit Environment -

Salford. RS 12

Capital requirements for Major

Trauma and Healthier Together -

Salford. RS 12

4 4 Action plan in place to

mitigate risks in the short

term

Detailed option appraisal

submitted to

NHSI/GMHSCP 31st Dec 18

(overall cost of £57m/5

years for PAT sites).

Response requested BC for

up to £10m emergency

capital funding.

Detailed review of Capita

risks undertaken using NCA

risk methodology to

highlight areas of greatest

concern.

External review

commissioned by GMHSCP

to ascertain if NCA is

managing risks identified in

Capital reports. Report due

March.

Certainty around

available internal

funding and external

funding.

Some risks cannot be

ascertained without

carrying out surveys.

Have just had internal

approval to fund these

so these will commence

asap but it will be a few

months before the

results of the surveys

are known.

4 NHSI/GMHSCP have signalled

£10m emergency capital funding

could be made available

following submission of relevant

BC

(Feb 19)

No further assurance

available at this time

Emergency capital funding business

case to be developed and submitted to

NHSI/GMHSCP w/c 25th Feb 19.

Specific internal surveys to be

undertaken to ascertain extent of

existing risk – to commence end of Feb

19.

Discussion to take place with NHSR re

identified risks, concerns and

mitigating actions relating to the

estate and infrastructure across PAT –

scheduled for early Mar 19.

12 12

26/30

SRFT

& PAT

# 274

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03/2

2/20

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Winter Safety: Salford Care Organisation

Cancelled operations at the last minute peaked in October before following a downwards trend. Levels have actually reduced throughout February.

These four metrics aim to provide monitoring for winter safety across our Care

Organisations.

Ward moves and discharges exclude assessment areas, maternity and transfers to

and from theatre suites.

An increase in cancellations in the final week of the month suggest capacity issues but this is not impacting on ambulance delays, which

have seen a reduction.

Ambulance delays of more than an hour increased significantly at the beginning of February before falling to normal levels since.

Late discharges have remained consistent since the beginning of October although an upward trend can be seen since mid-December.

Out of hours ward moves have remained consistent over the month.

0

5

10

15

20

25

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Am

bu

lan

ce h

and

ove

r d

ela

ys

Ambulance handover delays (60+ mins)

Ambulance Handover delays (60+ mins) Average

0

10

20

30

40

50

60

70

80

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

war

d m

ove

s

Ward moves between 10pm and 6am

Ward moves Mean

0

20

40

60

80

100

120

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Late

dis

char

ges

Discharges between 10pm and 8am

Late Discharges Mean

0

5

10

15

20

25

30

35

40

45

50

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

urg

en

t o

pe

rati

on

s ca

nce

lled

Cancelled Operations on the day due to Non-clinical reasons

Cancelled on the day Average

27/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

39/240



Winter Safety: Bury & Rochdale Care Organisation

Number of operations cancelled at the last minute have been relatively consistent since the beginning of October.


Organisations.



Increases in both cancelled operations and ambulance handovers towards the end of

November indicate pressure in the system.

Ambulance handover delays have been consistent throughout February although did rise sharply in the last week of the month.

Late Discharges remains appear to have increased since the end of December. The average has increased to 12 per week following the last week of February which saw 24, the highest in the period.

Ward moves between 10pm and 6am remain relatively consistent, although there was an increase at the end of December/beginning of January.

0

5

10

15

20

25

30

35

40

45

50

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

urg

en

t o

pe

rati

on

s ca

nce

lled



0

5

10

15

20

25

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Am

bu

lan

ce h

and

ove

r d

ela

ys



0

5

10

15

20

25

30

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

war

d m

ove

s


Ward moves Mean

0

5

10

15

20

25

30

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Late

dis

char

ges



28/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

40/240



Winter Safety: North Manchester Care Organisation

There was a peak in cancelled operations in the second week of January with a higher than usual number of cancellations due to bed capacity issues. Levels reduced back to normal levels for the remainder and January and February


Organisations.



Increases in both cancelled operations and ambulance handovers towards the end of

November indicate pressure in the system.

Ambulance handover delays rose sharply over a three week period in November but have since reduced to below the average of 13 in January and February.

Paediatric transfers for bed capacity issue have seen an increase over the winter months but have now begun to reduce.

Ward moves between 10pm and 6am have remained consistent. Late Discharges remain relatively consistent since the beginning of October.

0

5

10

15

20

25

30

35

40

45

50

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

urg

en

t o

pe

rati

on

s ca

nce

lled



0

5

10

15

20

25

30

35

40

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Am

bu

lan

ce h

and

ove

r d

ela

ys



0

10

20

30

40

01

/10

/20

18

08/1

0/2

018

15

/10

/20

18

22

/10

/20

18

29/1

0/2

018

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26/1

1/2

018

03

/12

/20

18

10

/12

/20

18

17/1

2/2

018

24/1

2/2

018

31

/12

/20

18

07

/01

/20

19

14/0

1/2

019

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11/0

2/2

019

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

wa

rd m

ove

s


Ward moves Mean

0

5

10

15

20

25

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22/1

0/2

018

29

/10

/20

18

05

/11

/20

18

12/1

1/2

018

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10/1

2/2

018

17

/12

/20

18

24

/12

/20

18

31/1

2/2

018

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28/0

1/2

019

04

/02

/20

19

11

/02

/20

19

18/0

2/2

019

25

/02

/20

19

Nu

mb

er

of

Late

dis

cha

rge

s



0

5

10

15

20

25

30

35

40

45

50

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er

of

Tran

sfe

rs

Paediatric Transfers Out

Clinical Transfers Bed Capacity Transfers

29/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

41/240



Winter Safety: Oldham Care Organisation

Numbers of cancelled operations on the day remain consistent over the period.


Organisations.



Ambulance delays have remained at an increased level in the latter part of the month

but cancellation of elective activity has remained low.

The number of ambulance handover delays increased sharply from the middle of December to mid-January. The figures have also been rising sharply in certain weeks in February, although the last week was below the average of

Paediatric transfers for bed capacity have reduced in February and this is expected to continue as we come out of the winter months.

Late ward moves reduced in February. Late Discharges have remained consistent and in line with the average throughout February.

0

5

10

15

20

25

30

35

40

45

50

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

urg

en

t o

pe

rati

on

s ca

nce

lled

Cancelled operations on the day due to Non-clinical reason

Cancelled on the day Mean

0

10

20

30

40

50

01

/10

/20

18

08

/10

/20

18

15

/10

/20

18

22

/10

/20

18

29

/10

/20

18

05

/11

/20

18

12

/11

/20

18

19

/11

/20

18

26

/11

/20

18

03

/12

/20

18

10

/12

/20

18

17

/12

/20

18

24

/12

/20

18

31

/12

/20

18

07

/01

/20

19

14

/01

/20

19

21

/01

/20

19

28

/01

/20

19

04

/02

/20

19

11

/02

/20

19

18

/02

/20

19

25

/02

/20

19

Nu

mb

er

of

Am

bu

lan

ce h

and

ove

r d

ela

ys


Ambulance Handover delays (60+ mins) Mean

0

10

20

30

40

50

01/1

0/2

018

08/1

0/2

018

15/1

0/2

018

22/1

0/2

018

29/1

0/2

018

05/1

1/2

018

12/1

1/2

018

19/1

1/2

018

26/1

1/2

018

03/1

2/2

018

10/1

2/2

018

17/1

2/2

018

24/1

2/2

018

31/1

2/2

018

07/0

1/2

019

14/0

1/2

019

21/0

1/2

019

28/0

1/2

019

04/0

2/2

019

11/0

2/2

019

18/0

2/2

019

25/0

2/2

019

Nu

mb

er o

f w

ard

mo

ves


Ward moves Mean

01020304050

01/1

0/2

…

08/1

0/2

…

15/1

0/2

…

22/1

0/2

…

29/1

0/2

…

05/1

1/2

…

12/1

1/2

…

19/1

1/2

…

26/1

1/2

…

03/1

2/2

…

10/1

2/2

…

17/1

2/2

…

24/1

2/2

…

31/1

2/2

…

07/0

1/2

…

14/0

1/2

…

21/0

1/2

…

28/0

1/2

…

04/0

2/2

…

11/0

2/2

…

18/0

2/2

…

25/0

2/2

…

Nu

mb

er o

f La

te d

isch

arge

s



0

10

20

30

40

50

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Nu

mb

er o

f Tr

ansf

ers

Paediatric Transfers Out

Clinical Transfers Bed Capacity Transfers

30/30

SRFT

& PAT

# 274

090

03/2

2/20

19 11:

40:2

0

42/240

GROUP COMMITTEES IN COMMON - FEBRUARY 2019

PERFORMANCE SUMMARY

Actions taken to reduce agency spend, including migration of locum doctors to NHSP, is making good progress, with reductions in both agency spend and locum use above trajectory. Agency spend has reduced from £1.2m (exl VAT) a month in July 2018 , to £0.6m (Incl vat) in Feb 2019. VAT is a casue for concern as it has become applicable. Costs will increase, like for like in remainder of year.

Sickness absence has continued to be a cuase of concern. While we have made good progress with reducing long term sickness, short term absence has been increasing in recent months. We have review processes in place to ensure management action, best practice and Trust policy is being actively followed. We expect improvement in the remainder of the year.

We have recruitment plans for Medical , Nursing and Midwifery workforce. This is overseen by a workforce progamme board. The Stability Index reported includes staff within the LCO transfer, this index will improve over the next few months. We have responded to the staff survey results with increased staff engagement activities. These will inform our future plans.

URGENT CARE

WORKFORCE

CANCER CARE

FINANCE

The Salford system has faced signifcant challenges during the winter period, with all escalation areas open throughout January and February despite the Urgent Care Team helping nearly 250 people per month avoid hospital admission and significant additional GP appointment capacity in neighbourhoods. Performance has improved week on week during February and in March the organisation has seen significant improvement to circa 85% which is the highest performance in GM for A&E activity.

QUALITY & PATIENT SAFETY

Cancer 2WW - All specialties saw a decline in performance in January due to an increase in breaches attributed to patients choosing to delay appointments till after the Christmas/ New yYar period. 60% of all January breaches attributed to patient choice and 31% due to capacity. Unvalidated 2WW February 2019 position shows an improving position to 91.3% and is on track to achieve 93% for March. Cancer 62 day - Performance against the 62 day standard remains below target and trajectory. This position reflects the work being undertaken by the specialties to reduce the overall size of their PTLs and clearing the backlog of long waiting patients. It is predicted that February and March will see a similar under trajectory position to allow recovery from April. Total backlog size in colorectal has reduced from a high of 92 in October 2018 to 26 with many of these long waiting patients dated for treatment in March.

BR is delivering a contribution of £31.0 against plan of £34.2m, giving a YTD adverse variance of £3.2m. Key drivers to the £3.2m variance are; Undelivered BCLC (£2.2m) - BRCO have delivered c£3.4m of BCLC, the main variance is caused by not achieving the stretch target. Planned mitigations against risk of delivery in 2019/20 have been early engagement to identify BCLC schemes, particularly within Theatres and Out patients, with the support of Four Eyes Insight. The DMO approach will be concentrated on: Medical Agency Spend Theatre productivity Ophthalmology Outpatients Under-delivery of Contract Income (c£1m) - Elective Orthopaedics, ENT and Sub acute rehab are the main drivers. Capacity planning work will help address ENT and Orthopaedics issues for 2019/20 Legacy sub-acute rehab issue h as now been dealt with through contract negotiations for 2019-20

C Diff: The NES Care Organisations are all on trajectory or better. Salford Care Organisation is over trajectory. However at Salford, rates per 1,000 bed-days are better than mean national performance for 2017/18. Recent data are showing normal variation for all Care Organisations Falls with harm: All care organisations have normal variation in falls with moderate and above harm. Pressure ulcers: The NES Care Organisations have achieved a 35% reduction in pressure ulcers throughout the life of the QI collaborative to date (includes both acute and community). NES change packages have been developed for both acute and community and are in the process of being launched

Salford North Manchester Oldham Bury & Rochdale

2 Week Wait 94.8% 79.9% 84.7% 93.2%

7 Day Appointment 43.5% 22.2% 13.2% 13.2%

62 Day 83.9% 83.9% 52.4% 71.4%


Control Total -£7.00 £0.70 -£2.80 -£3.20

(£m)


Sickness Absence 4.43% 5.99% 5.95% 6.33%

N&M Agency Shifts 68 1120 675 503

M&D Agency Shifts 548 1496 1232 1070

N&M Stability Index 87.78% 74.79% 88.92% 85.97%

M&D Stability Index 97.53% 84.56% 89.09% 95.04%

N&M Vacancy Rates 4.87% 15.70% 6.99% 10.96%

M&D Vacancy Rates 5.49% 25.60% 9.59% 17.74%


4hr Performance 72.00% 71.80% 81.02% 89.67%

Delayed Transfers 0.76% 5.79% 1.69% 1.62%

Stranded Patients 58.52% 41.16% 36.16% 41.22%


C Dif 2 0 0 0

Falls 4 1 1 3

Pressure Ulcers 3 16 2 4

1/1

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& PAT

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & The Pennine Acute Hospitals NHS Trust (PAT)

Meeting Group Committees in Common

Author (s) Josh Hennighan, Risk ManagerPaul Downes, Head of Patient Safety

Presented by Chris Brookes, Chief Medical Officer

Date 25th March 2019

Executive Summary The Northern Care Alliance NHS Group is continually developing risk management towards a holistic NCA approach; versions of a Risk Management Strategy are available describing Pennine Acute and Salford Royal as separate Trusts. This version supersedes both the PAT and SRFT risk management strategies and aligns all Care Organisations and Group Business Units under one Risk Management Strategy.

There are on-going Mersey Internal Audit Agency (MIAA) audits being undertaken on Committee Effectiveness and Risk Maturity. The recommendations from these reports (expected April – May 2019) will form the basis of NCA wide improvement work to refine and further develop the Risk Management Strategy, Risk Register Management and the Assurance Framework as a whole. This version of the Risk Management Strategy was approved at the March 2019 Group Risk and Assurance Committee (GRAC) as an interim document. This improvement work and new documents as described will be presented to GRAC by September 2019.

Annual Plan Objective

1 Pursue Quality Improvement to assure safe, reliable and compassionate care 2 Improve care and services through integration, collaboration and growth 3 Deliver the financial plan to assure sustainability 4 Support our staff to deliver high performance and continuous improvement 5 Deliver Operational Excellence 6 Develop our clinical services strategies and the Northern Care Alliance enabling strategies

Associated Risks Risks of not having a proper strategy and framework to identify and having systematic processes to mitigate, eliminate, manage risks include:

Financial implications in terms of fines from CCGs, NHS England Reputation impact, including CQC, MIAA Patient Safety Patient Experience Ongoing business success Product/ project failure Loss of income/ financial loss Staff dissatisfaction if the organisation is non-proactive in terms of risk

Title of Report NCA Risk Management Strategy

1/2

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& PAT

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management

Recommendations Ratify this Strategy and support the development of the new Strategy, Risk Register and Assurance Framework documents by September 2019 following MIAA recommendation reports.

Equality Does this paper relate to a matter where equality issues may arise? NIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.

This document contains some confidential information that would need to be redacted before the document was made available to the public.

Freedom of Information Please ‘cross’ one of the boxes

This document is entirely confidential, as the redaction of confidential information would render the document meaningless.

Under the Data Sharing Agreement, the NCA may be required to share this paper with MFT. This is distinct from information disclosed under the FOIA. As MFT will acquire part of PAT they will need to understand a range of matters which may otherwise be exempt under FOI e.g. contracts to be split and specific workforce-related issues.

Please consider the statements below and indicate which applies in relation to this paper:

a) This paper relates solely to PAT and can be released

b) This paper relates solely to SRFT and is therefore not eligible for release

c) This paper contains information relating to both PAHT and SRFT. All information other than that relating to PAHT will be fully redacted.

Data Sharing Agreement with Manchester University NHS FT (MFT) in relation to the Transaction

d) This paper contains reference to both PAHT and SRFT but contains no quality, finance or operational performance data relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.

X

X

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Risk Management StrategyReference Number: TBC Version Number: 1.0 Issue

Date:Leave blank as will be completed upon publication

Page 1 of 35

It is your responsibility to check on the intranet that this printed copy is the latest version

NCAPSTBC (19) Risk Management Strategy

Lead Author: Josh Hennighan – Risk ManagerAdditional author(s)Division/ Department:: Clinical GovernanceApplies to: Northern Care Alliance NHS GroupDate approved:Expiry date: September 2019Contents Contents

Section PageClick here for the document summary sheet: 31 What is the policy about? 42 Where will this document be used? 43 Why is this document important? 54 What is new in this version? 55 Risk Management Strategy 6

5.1 Risk Appetite 65.2 Strategic Context 65.3 Strategic Aim 65.4 Risk Management Objectives 75.5 Supporting Framework for Achievement of Risk Management Objectives 75.6 Risk Management Approach 85.7 Risk Identification 85.8 Risk Scoring 95.9 Board Assurance Framework structure 115.10 Alignment of risks to committees 115.11 Assurance on Controls 115.12 Risk Financing 125.13 Cost of Claims including Clinical Negligence 135.14 Funding for High Cost Implications of Serious Incidents 135.15 Risk Acceptance (Risk Tolerance) 135.16 Incident Reporting 135.17 Investigation of Adverse Incidents and Near Misses with a Fair Blame

Culture13

5.18 Authority to Investigate Adverse Events and Near Misses 145.19 Learning lessons from Incidents claims and complaints 145.20 Serious Incidents and Concise Investigations Reports 145.21 Analysis of incidents, complaints and claims 145.22 Encouraging learning and promoting improvements in practice 15

Group arrangements:Salford Royal NHS Foundation Trust (SRFT)Pennine Acute Hospitals NHS Trust (PAT)

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5.23 Risk Management Committee Structure – NCA/ Group level 165.24 Risk Management Committee Structure – Diagnostics and Pharmacy (D&P) 165.25 Risk Management Committee Structure – Care Organisation level 175.26 Risk Management Committee Structure – Divisional level (not including

Diagnostics and Pharmacy or Corporate)19

5.27 Local Arrangements – risk management strategies for all areas 205.28 Risk Management Training 20

6.1 Roles and responsibilities – Group 226.2 Roles and responsibilities – Care Organisations and Diagnostics &

Pharmacy24

7 Monitoring document effectiveness 278 Abbreviations and definitions 289 References and Supporting Documents 2810 Document Control Information 2911 Equality Impact Assessment (EqIA) screening tool 3012 Appendices 32

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Document Summary Sheet

Policy Incident Reporting and Investigation, Serious Incidents, Concise

Investigations, Never Events and Duty of Candour

Key points to note:

Risk Management is a key component of all aspects of successful business delivery Risk management is an integral component of NCA Governance Framework The aims of risk management within the NCA are to minimise harm to patients, staff

or visitors Datix must be the primary repository for all risks logged on any risk register All risks must be reviewed on regular schedules, and all risks must work towards

being managed, mitigated or eliminated where possible Risks must be escalated throughout the governance structure at both Care

Organisation and NCA levels where required All risks must be scored on the NCA scoring scale (5 + 5 + 5). Significant risks (12+) must be escalated to the Group Risk and Assurance

Committee. Report and manage all incidents on Datix


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1. What is this policy about?

The Northern Care Alliance (NCA) NHS Group recognises that the principles of governance must be underpinned by an effective risk management system designed to deliver improvements in patient safety and care as well as the safety of its staff, patients and services users and visitors.Risk management is the key system through which clinical, non-clinical, organisational and financial risks are managed for the benefit of patients, staff, visitors and other stakeholders through comprehensive systems of control. Those key systems must be fully embedded at every level of the organisation to ensure compliance with current and future risk management related standards and legislation and fulfil the organisations commitment to the provision of high quality treatment, care and services.Risk management is the responsibility of all staff and requires commitment and collaboration from all staff both clinical and non-clinical. Managers at all levels are expected to take an active lead to ensure that risk management is a fundamental part of their operational working and service delivery. Specific roles, accountability and responsibilities are defined later in this document. This document therefore applies to all employees of the Northern Care Alliance, include all Care Organisations including contractors and other third parties working within the organisation.

2. Where will this document be used?

The focus of this strategy is to ensure that the Northern Care Alliance NHS Group has robust systems and processes in place to proactively assess risks to patients, service users, staff and visitors and prevent and mitigate these materialising in practice. These risks will be managed as part of normal trust business and monitored via the BAF (Board Assurance Framework), DAFs (Divisional Assurance Framework) reports and standing agenda risk reports at the care organisation committees.For those situations where risk does materialise, it is paramount that learning is identified and implemented. This strategy is designed to ensure that departments and services review their working practices following every significant accident, incident, complaint, claim, inspection, inquest, Structured Judgement Reviews (SJR), learning from Morbidity and Mortality meetings or audit to provide, maintain high standards of care and management and continuity of service delivery. This learning must be shared with other relevant areas of practice, internally and externally to the organisation, and reported to relevant external authorities.

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3. Why is this document important?

3.1 This policy sets the processes and procedures for risk management.

3.2 Relevant external policies and regulations to this policy:

Policy/Regulation Link to documentNCAPS001 (18) Incident Reporting and Investigation, Serious Incidents, Never Event, Duty of Candour and Learning from Deaths

http://nm-ashanti.pat.nhs.uk:86/DMS/DesktopModules/WroxDocs/ViewDocument.aspx?ItemID=2930&mid=9000&key=2930

NCAG006(18) Inquest Policy http://nm-ashanti.pat.nhs.uk:86/DMS/DesktopModules/WroxDocs/ViewDocument.aspx?ItemID=652&mid=9000&key=652

NCAG002(17) Group Governance Framework Manual


NCAG012(18) Policy and Procedure for Clinical Negligence, Liabilities to Third Parties (LTPS), Property Expenses Scheme (PES) Claims and clinical Ex-Gratia Payments


If the links posted above do not work please contact the author or advise the Document Control Administrator.

4. What is new in this version?

4.1 This is a new joint document which supersedes previous Pennine Acute Hospitals NHS Trust, and Salford Royal NHS Foundation Trust individual policies as below:

Trust Policy SupersededPennine Acute Hospitals NHS Trust policy EDQ012 v8.2 Risk Management

Strategy & Policy Salford Royal NHS Foundation Trust Salford COARC_TG10(03) – Issue

No 10 – Risk Management Strategy

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5. Risk Management Strategy

The definition of risk is the forecasting and evaluation of [ADD SUB TYPES] sd risks together with the identification of procedures to avoid or minimise their impact.

5.1 Risk Appetite

The long term sustainability of the organisation depends on the delivery of the strategic objectives and relationships with patients and service users, staff, public and strategic partners. We do not accept risks that materially impact on patients or staff safety or compliance and regulatory objectives. The NCA has a higher risk appetite relating to our pursuance of innovation and transformation objectives.

5.2 Strategic Context

The key stakeholders of the Trust requiring information and collaboration on risks include:• Northern Care Alliance’s patients and service users, visitors and staff• Our partner organisations in the NHS• Clinical Commissioning Group (CCG)• NHS North West Electronic Information System (StEIS)• National Reporting and Learning System (NRLS)• Director of Public Health• NHS England• NHS Improvement• Health and Safety Executive• NHS Resolution (NHSR), formerly NHS Litigation Authority• Care Quality Commission (CQC)• Confidential Enquiries• Medicines Control/Medical Devices Agency• Serous Hazards of Transfusion (SHOT)• Environmental Health• Food Standards Agency• NHS Estates• Police• Coroner• Professional Regulatory Bodies• Other NHS Trusts and Organisations(this is not an exhaustive list)

5.3 Strategic Aim

The purpose of this strategy is to ensure a consistent and integrated approach to the management of all risks across the whole organisation. It is intended to be complimentary to the Quality Improvement Strategy, Incident, inquest, claim and complaint policies.The key objectives of this strategy are to provide a framework to ensure:

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• Safety and integrated governance• Control and management of risk at every level of the organisation to achieve annual plan

objectives• Learning occurs from retrospective events such as: accidents, incident, complaint, claim,

inspection, inquest, Structured Judgement Reviews (SJR), outcomes from Morbidity and Mortality meetings or audits.

• Assurance of continued compliance with current and future standards and legislation

5.4 Risk Management Objectives

This strategy has five elements, based on the Health Foundation’s 2014 Policy for monitoring and measuring safety. Each element has key milestones in place in order to;

a. Ascertain whether it has been safe for patients, service users, staff and others in the past

b. Identify whether our systems and processes are reliable

c. Ensure sensitivity to operations so that we are safe in the present

d. Anticipate and prepare to ensure that we are safe in the present

e. Integration and learning to ensure we are responding and learning as appropriate

5.5 Supporting Framework for Achievement of Risk Management Objectives

NCA recognises that by its very nature, health care is an activity which involves risk, not least because some risks have to be taken in order to improve the quality of treatment and care for patients. The NCA also recognises that mistakes and errors can happen; therefore a strategy and a framework are required to deal with the hazards and risks associated with its main function of providing high quality health care to people. The level of risk tolerance is determined by the Directors and specified by the level at which particular risk profile scores are delegated to.

5.6 Risk Management Approach

Good governance in the NHS is dependent on the level of integration of clinical governance, corporate governance and financial governance. Risk management is the system that underpins and integrates these three aspects of governance and Board assurance. The primary purpose of the Risk Management System is to provide assurance regarding the achievement of the annual plan. This includes: • Protect patients and staff from harm. • Improve the quality of care and treatment. • Eliminate or reduce unnecessary costs.It also provides the mechanism through which the Board can assure all stakeholders that the NCA’s internal controls are effective.Risk Management is a proactive approach that addresses every element of the organisation’s activities and comprises a four-phase cycle:

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• Risk Identification• Risk Analysis• Risk Control• Risk Funding Fig 1 shows how these phases interact with each other:

Fig 1Integral to an effective risk management system is the proactive identification of risks which are then analysed in order to determine their relative importance. Risk control measures are taken to reduce the consequence likelihood of a risk occuring. Those measures which do not require extra funding should be implemented, but where extra funding is needed then consideration of how to identify these funds, including a business case as appropriate, must be undertaken.It may be appropriate to ‘transfer’ the risk by eg sub-contracting an element of service as appropriate.

5.7 Risk Identification

Risks will be identified, analysed, prioritized and documented at all levels in the organisation. These risks can arise from any aspect of the organisation including:• Clinical practice• The environment. • Buildings and equipment • Chemical or hazardous substances• People employed by the Trust or by visitors, patients or contractors• Procedures, systems or practices• Financial activities• Communication and information.• Legislation• Business plans

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Risk identification involves examining all sources of risk from the perspective of all stakeholders at all levels in the organisation. The following are a list of methods among many others which may be used to identify risks:• Healthcare Communication• Adverse Incidents, complaints and PALS contacts and claims• HM Coroner inquests• Parliamentary and Health Service Commissioner (Ombudsman) reports• Global Trigger tool analysis, complimented by benchmarking National Reporting and Learning System (NRLS) reports against other Trusts. • Audits and inspections both internal and external• Risk identification workshops• Self-assessments against CQC KLOES and other standards • Patient and staff satisfaction surveys• Strength, Weakness, Opportunity and Threat (SWOT) analysis

All identified risks must be risk assessed and recorded as assurance statements within the Datix Risk Register module.

A risk register is:

“A log of all risks of all kinds that threaten an organisation’s success in achieving its declared aims and objectives. It is a dynamic document, which is populated through the organisation’s risk assessment process.

This enables risk to be quantified and ranked, and information about risks to be collated and analysed. It therefore provides a structured approach to decision-making about whether or how risks should be treated.”

5.8 Risk Scoring

A key part of the risk assessment process is the assignment of a risk score to each risk. This enable risks to be ranked in terms of priority for action and review. Highest scoring risks being the biggest threat to the organisation achieving its objectives and therefore requiring Board level review.

Risk scores are the product of the likelihood of the risk and the impact of the risk

Likelihood.A risk’s likelihood must be given a score between 1 and 5 using the following criteria:

1 = rare - do not expect this to happen2 = unlikely - most probably will not happen3 = occasionally - 50:50 chance of occurring4 = likely - most probably will happen5 = almost certain - confident that this will happen.

Impact

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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 tales 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 service disability to a person or persons and / or significant loss of reputation for the 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.

Controls

Risk control is the means by which the risk's impact, or frequency, or both are reduced, transferred or retained. Controls include:• Systems• Training• Contingency Plans and strategies• Policies, Procedures, Guidelines, Protocols• Design of equipment, buildings and materials• Insurance

A control score is a self-assessment on the strengths of the controls on the risk. This helps add context to a risk where it may be difficult to minimise impact and/or likelihood but the risk is controlled. This helps prioritise the risk and the allocation of resources to improve the position of the risk.

1 - Fully under control2 - Adequately controlled3 - Partial control4 - Requires further controls5 - No controls identifiedA score is allocated based on the potential impact, likelihood of occurrence of the risk and the controls measures currently in place.The risk control objective is to reduce risks to their lowest reasonably practicable level, consistent with its mission to provide highest quality patient care and treatment, the training of future healthcare staff and increasing knowledge via research. Each risk is then given a Risk Profile score which is the sum of the scores"Likelihood" + "Impact" + "Risk Control".The risk profile score determines at what level the risk needs to be managed.

Score

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3 - 5 Minor risks Adequately managed and may be retained if further control limits the capacity to control higher ranking risks. Managed at Directorate level.

6 -10 Moderate Managed by the Division’s governance structures.

10 and over

Serious Must be reported through the Care Organisation Assurance and Risk Committee (COARC) and/or its sub-Committees

12 and over

Significant Reported to Group Risk and Assurance Committee for the attention of the Board.

Action plans used to manage risks must be documented within the appropriate section of the Datix Risk register module and actioned by the review / deadline date for completion. Risks with a profile score of 10 or more will be reported to COARC or its sub-committees via the risk report and presented by the Divisional Managing Directors or Deputy/Associate Directors of corporate services. COARC (or delegated sub-committee) will review these risks and underpinning control systems to assure whether the risk is controlled to an acceptable level.

5.9 Board Assurance Framework structure

Within the Northern Care Alliance there is Board Assurance Framework (BAF) developed and maintained by each Care Organisation (managed by the Care Organisation Associate Director of Governance) and a NCA Group level BAF (managed by the Group Associate Director of Corporate Affairs who acts in the formal role Trust Secretary for both the Pennine Acute and Salford Royal Boards where delegated to GCiC).

The Group BAF is managed via the Group Risk and Assurance Committee, chaired by the NCA Chief Executive or nominated deputy.

Each Care Organisation also manages their CO level BAFs via their Care Organisation Assurance and Risk Committee (COARC).

Each division has a Divisional Assurance Framework (DAF) which mirrors the form and function of the BAF.

5.10 Alignment of risks to committees

Each risk scored as described as Serious (10 and over) or Significant (12 and over) will be aligned to one or more Group wide and/or CO appropriate committee(s). This ensures specialist oversight at a high level providing assurance of progression and monitoring. For example a risk regarding staffing levels at 11 may be received at a CO workforce committee and CO clinical effectiveness committee as appropriate.

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5.11 Assurance on Controls

Assurances are the means by which evidence is provided to ascertain that the controls thought to be in place are being implemented and are effective, for example monitoring reports presented to a committee or a confirmation of works completed e-mail to the responsible manager/clinician. The Group Committees in Commong (GCiC) for NCA and COARCs for Care Organisations requires assurance that control measures are effective. The Board Assurance Framework (BAF) records those risks associated with the delivery of the strategic objectives, the controls in place to mitigate those risks, the gaps in control, the assurance (evidence) of controls in place and gaps in assurance. It :-• covers all of the organisation’s annual objectives agreed within the business plan;• identifies the risks to the achievement of objectives and targets;• identifies the objectives and targets the organisation is striving to achieve;• identifies and examines the system of internal control in place to manage the risks;• identifies and examines the review and assurance mechanisms which relate to the

effectiveness of the system of internal control;• records the actions taken by to address control and assurance gaps The BAF allows the CO and/or NCA to determine where to make efficient use of resources to improve quality and safety of the care and management of patients. It provides a structure for the evidence to support the production of the annual governance statement.The assurance framework is the primary mechanism by which the NCA determines the priorities for audit of controls in place and includes both internal management audits and external independent audits. Through a process of audit and monitoring the Trust will undertake a review of the effectiveness of the risk control measures regularly and at least on an annual basis. Risk Control and Monitoring Measures will also include some or all of the following:• Statistical and Trend reporting of Incidents, Complaints and Claims to the Board and

relevant Committees.• Correlation between adverse incidents / near miss reporting and dates of occurrence• Cross-tabulated reporting over a range of variances.• Audit of the effectiveness of Adverse Incident Reporting Procedures to enable

benchmarking to take place.• Audit of Patient Records against Adverse Events / Near Miss Reporting• Audit of the effectiveness of Care Organisation/ Group Business Unit systems and processes such as Fire Training, Fire Drills and Health and Safety Training.• Root Cause Analysis (RCA) of Adverse Incidents via Incident Management and

investigation Policies.• Approval processes for bank and agency usage

5.12 Risk Financing

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The funding of risk control measures is primarily through the budgets agreed annually with managers across the Care Organisation/ Group Business Unit. Financial planning and business planning should therefore include the management of identified risks. As the financial year progresses decisions may need to be taken as to the most appropriate use of funds to manage unexpected risk control requirements and this is determined at the level of the organisation identified by the risk score. Every activity in operating a business will bring with it risks that can only be completely eliminated by ceasing that activity. Even when the NCA has taken reasonable measures to eliminate or reduce risks, some risks will always remain. Therefore it is imperative to actively work on controlling or managing risks which are impossible to eliminate. There are three forms of financial function involved in the transfer or reduction of risk, all are carefully controlled so to minimise the amount of funds that are diverted away from direct patient care.All Capital expenditure including medical and non-medical equipment replacement and upgrading will also need to be included and budget planning. With most risks the consequence cannot be decreased due to the nature of the risk, only the likelihood and controls remain in the gift of control of managers. Financial risk consequence however can be lessened dependant on risk management e.g. a lower fine for failure to deliver on target. Therefore it is important for consequence of risk actualisation to be considered when managing financial risk.

5.13 Cost of Claims including Clinical Negligence

The NCA is currently covered for the cost of clinical negligence through the NHS Litigation Authority. This covers claims arising from clinical incidents on or after 1 April 1995. A separate scheme, Existing Liabilities Scheme (ELS), also administered by the NHSLA, funds clinical negligence claims arising from incidents occurring before 1 April 1995.

5.14 Funding for High Cost Implications of Serious Incidents

The funding of Serious Adverse Incident Management may be met, or supported, centrally where significant cost issues are identified (e.g. excessive laboratory costs following an unexpected serious outbreak of a particular disease). Additional monies will be sought from the Department of Health or other relevant source The NCAG012(18) Policy and Procedure for Clinical Negligence, Liabilities to Third Parties (LTPS), Property Expenses Scheme (PES) Claims and clinical Ex-Gratia Payments policy is the key reference material for this aspect.

5.15 Risk Acceptance (Risk Tolerance)

At times risks will be identified which cannot be eliminated or the cost of eliminating it is unreasonable and the controls outweighs the benefit of that expenditure. These residual risks should be recorded on the Risk Register. The risk profile score determines the frequency and scope required for monitoring.

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5.16 Incident Reporting

The Group Incident Reporting and Investigation, Serious Incidents, Never Event, Duty of Candour and Learning from Deaths requires that all clinical and non-clinical incidents, accidents or near miss occurrences are reported and investigated, and that lessons are appropriately shared across the organisation, within the local health economy and within the wider NHS.The NCA maintains an electronic reporting system (Datix) for recording all incidents. The incident reporting database provides the Care Organisation/ Group Business Unit with the ability to follow the course of an incident investigation, to monitor completion of investigations, identify remedial actions and to ensure lessons are learned to avoid future occurrence. It may provide early details of an incident that has the potential to lead to a complaint or claim and may identify multiple incidents involving the same people together with a grading of the incident’s seriousness. The reporting system assists with the identification of departmental and corporate trends, drawing the attention of managers to areas that may require further analysis and exploration. The NCA believes that all incidents should be openly, consistently and fairly investigated so that lessons are learned and improvements are made in the quality and standard of care we deliver. This is essential for the delivery of the clinical governance agenda. Incidents will be managed within the Divisional groups with advice and support provided by the Divisional Governance Managers and NCA Risk Team.

5.17 Investigation of Adverse Incidents and Near Misses with a Fair Blame Culture

The NCA operates a ‘fair blame’ and open and transparent culture to facilitate the reporting of incidents.

Disciplinary action does not form part of the response to a report of an incident or event. In exceptional cases where there is cause for concern and there has been a lack of insight or transparency the following may result in disciplinary action; however these are reviewed on a case by case basis:• The incident/event results in a police action• In the view of the NCA or CO and/or any professional registration body, the action causing the incident is far removed from acceptable practice;• There is failure to report an incident in which a member of staff was either involved or about which they were aware.

5.18 Authority to Investigate Adverse Events and Near Misses

The manager and their nominated staff responsible for the area in which the incident/near miss occurs produce a ‘Managers Report’ on the incident which specifies:• The nature of the incident.• Root causes of the incident (for moderate and above incidents or trends of minor and near miss incidents). A detailed root cause analysis investigation is required for all Serious Incidents• Immediate action taken to protect patients, staff and the NCA from further harm.• Action taken as a result of learning from the incident.

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5.19 Learning lessons from Incidents claims and complaints

The NCA is a learning organisation, and is committed to learning from Incidents, claims and complaints.

A SMART action plan must be developed for each investigation of a moderate and above incidents or trends of minor and near miss incidents. SMART Action plans are designed to improve controls and/or assurances on controls on risks which have been identified and/or existing risks that have realised and identified as incident(s) and/or near miss(es).

5.20 Serious Incidents and Concise Investigations Reports

An investigation report will be prepared following thorough investigation of Serious Incidents (SI) and those identified as requiring a Concise (sometimes referred to as SIARC) Investigation (CI).Timeframes for investigation, criteria for identification, governance processed and further details regarding incidents are set out in the NCAPS001 (18) Incident Reporting and Investigation, Serious Incidents, Never Event, Duty of Candour and Learning from Deaths policy. 5.21 Analysis of incidents, complaints and claims

The NCA ensures a systematic approach to the analysis of incidents, complaints and claims. This information will be included in the aggregated Learning from Experience and Learning from Deaths reports.

Divisional Directors of Nursing/Medicine and the Chairs of Divisions/ Divisional Managing Directors are responsible for ensuring that there is robust review of information pertinent to the outcomes of investigations into incidents, complaints and claims at Divisional level and communicated to relevant individuals or groups. The Governance Manager for each Division is responsible for co-ordinating analysis and learning from incidents, complaints and claims relevant to their areas.

5.22 Encouraging learning and promoting improvements in practice

The NCA’s systematic approach to encourage learning and promote improvements in practice based on analysis of incidents, complaints and claims, is a key aspect of the Risk Management Strategy.The NCA will ensure the risks derived from individual and aggregated information are assessed using the NCA’s approved risk assessment and risk register processes. GRAC (for Group level risks) and COARCs (Care Organisation) and its sub-committees will consider individual and aggregated information and ensure the development and management of risk registers, including key controls, gaps in controls, key assurances, gaps in assurances, risk scores, action plan and review dates, where risks are considered significant. Managers responsible for the investigation of incidents, complaints and claims, supported by the relevant CO Associate Director of Governance, will ensure risks from individual incidents, complaints and claims are assessed and managed using the NCA’s approved risk assessment and risk register processes.

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All risk assessments will have a SMART action plan, describing how the risk will be treated e.g. staff training, awareness raising, change in practice, improved methods of communication, new initiatives, environmental improvements, guidance for staff, patients or others, clarification of roles and responsibilities.The NCA ensures both local and organisational learning from incidents, complaints and claims by the following methods:• Local ownership of incidents, complaints and claims• Development of risk registers and action plans as appropriate, at local level• Monitoring of action plans at agreed forums• Service Review process• Complaints Review Panel review of randomly selected complaints• SI and CI Summary reports, action plans and risk registers• Learning from Experience• Learning from Deaths• Incidents, complaints and claims review at Specialty and Division level• Working Groups e.g. Falls Working Group, Pressure Ulcer Review Group, Transfusion Committee• Review of Serious Incidents, including approval of associated action plans and

monitoring to completion.Within Care Organisations; the Governance Managers will ensure, through the local governance structures and accountability arrangements to the Associate Director of Governance, that any opportunity for cross-organisational learning from incidents, complaints and claims is identified and implemented. The Group Assurance and Risk Committee is responsible for monitoring the effectiveness of how the Group ensures both local and organisational learning from incidents, complaints and claims and will ensure Group level risk management objectives, which include this requirement, are reviewed and reported upon. Action plans will be developed to address any deficiencies. GRAC also maintains an oversight on Care Organisation Assurance and Risk Committees. The Care Organisation Assurance and Risk Committees, in addition for Care Organisation oversight as above, are also responsible for ensuring lessons learnt from detailed investigation of adverse events are embedded into organisational culture and practice. The Care Organisations will review agreed actions, following the detailed investigation of adverse events, and ensure lessons learnt are embedded into organisational culture and practice.

5.23 Risk Management Committee Structure – NCA/ Group level

Group Committees in Common (GCiC)

The NCA Group Committees in Common (GCiC) is the senior body with delegated ultimately accountability for the oversight of all risks in the Northern Care Alliance. This responsibility is delegated by the SRFT and PAT Boards. The Chief Executive Officer, supported by the GCiC Members, has responsibility for this Risk Management Strategy and adequate systems of internal control which supports the achievement of the NCA’s strategic objectives.Audit Committee

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The Audit Committee function is delivered at the level of the Northern Care Alliance. Its primary role is to conclude upon the adequacy and effective operation of the organisation’s overall internal control system. In performing that role, the Committee’s work will predominantly focus upon the framework of risks, controls and related assurances that underpin the delivery of the organisation’s objectives (the Assurance Framework). As a result, the Committee has a pivotal role to play in reviewing the disclosure statements that flow from the organisation’s assurance processes. In particular these cover the Annual Governance Statement and Quality Accounts included in their Annual Report. Both of these documents should come to the Audit Committee before being submitted for approval to the Board.Audit Committee provides a key forum through which the Group’s Non-Executive Directors bring independent judgement to bear on issues of risk management and performance. The constructive interface between Audit Committee and GRAC supports the effectiveness of the Group’s systems of internal control.Group Assurance and Risk Committee (GRAC)This Committee meets monthly and is chaired by the Chief Executive Officer. Membership includes all the Group Directors and CO leadership. The committee provides a holistic approach to the management of all risks and provides the GCiC with assurances that a comprehensive risk register is maintained and all risks are effectively managed. The committee oversees the operational implementation of the Risk Management Strategy. The GRAC reviews the Board Assurance Framework, receives Assurance Statements from COs & Group Business Units and reviews the Corporate Risk Register four times a year and, receives relevant assurance reports on the adequacy of risk management controls prior to review by the GCiC. The GRAC receives the quarterly aggregated report detailing key incident, complaints and claims reporting data, and is responsible for ensuring and monitoring a systematic approach to learning and improvement. GRAC formally receives the NCA Learning from Experience (LFE) and Learning from Death (LFD) papers. Group level Sub-Committees to GRACThere are multiple sub-committees which receive and manage risk at NCA level which are then in turn reported to GRAC as required. These committees are focused on a specialist work stream as indicated by title of sub-committee and are detailed in the below diagram.

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5.24 Risk Management Committee Structure – Diagnostics and Pharmacy

The Diagnostics and Pharmacy Group Business Unit (DPGBU) is group wide division with its own governance arrangements and independent leadership which, in the same manner as Care Organisations, are accountable to NCA Group as a whole.

Diagnostic and Pharmacy - Management Board The Management Board is the senior body ultimately accountable for the oversight of all risks in the DPGBU. The Managing Director, supported by the Management Board Members, has responsibility for this Risk Management Strategy and adequate systems of internal control which supports the achievement of the Division’s strategic objectives.

Care Organisation committeesRepresentatives from the DPGBU form part of the attendees list at Care Organisation committees as detailed below where mutually agreed by the CO and DPGBU.Diagnostic and Pharmacy committeesDiagnostics and Pharmacy host their own committees, attendees represent Care Organisation where mutually agreed by the CO and DPGBU as required.

Diagnostic and Pharmacy - Assurance and Risk

Diagnostic and Pharmacy - Directorate Ops and Performance

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Diagnostic and Pharmacy - Directorate Quality Governance

Diagnostic and Pharmacy - Finance and Workforce Committee

Diagnostic and Pharmacy - Ops and Performance

Diagnostic and Pharmacy - Quality Governance5.25 Risk Management Committee Structure – Care Organisation level

Whilst there are some variations between naming and exact Terms of Reference between Care Organisations; each CO runs committees which fulfil the requirements in regards to risk management as outlined below.

Management Board The Management Board is the senior body ultimately accountable for the oversight of all risks in the Care Organisation. This may be delegated to the COARC. The Chief Officer, supported by the Management Board Members, has responsibility for this Risk Management Strategy and adequate systems of internal control which supports the achievement of the Care Organisation’s strategic objectives.Care Organisation Assurance and Risk Committee (COARC)This Committee meets monthly and is chaired by the Chief Officer. Membership includes all the CO Directors. The committee provides a holistic approach to the management of all risks and provides the Management Board with assurances that a comprehensive risk register is maintained and all risks are effectively managed. The committee oversees the operational implementation of the Risk Management Strategy for the CO. The COARC (or delegated sub-committee) reviews the CO Board Assurance Framework and Corporate Risk Register four times a year and, receives relevant assurance reports on the adequacy of risk management controls prior to review by the Management Board (or delegated committee). The COARC receives the quarterly aggregated report detailing key incident, complaints and claims reporting data, and is responsible for ensuring and monitoring a systematic approach to learning and improvement. Clinical Effectiveness Committee. (CEC)This Committee meets at least bi-monthly and is chaired by the Medical Director. The committee provides assurance to COARC, about the quality of clinical practice throughout the CO.Quality and Patient Experience Committee (QPE)This Committee meets monthly and is chaired by the Director of Nursing. The committee provides assurance to COARC, the NCA/CO's strategies relating patient, service user and staff experience are achieved. Finance, Information & Capital Committee (F&I)This Committee meets monthly and is chaired by the Director of Finance. Membership includes all of the Executive Directors of the Board of Directors. The committee provides assurance to the COARC relating to the Trust’s financial position.Health and Safety Committee

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The Health & Safety Committee is chaired by the Associate Director of Governance, supported by the Northern Care Alliance Assistant Director of Health and Safety. Its membership consists of senior managers, clinicians, Health & Safety Advisors and staff representatives and is a key part of the risk management system, reporting to the QPE Committee. Its aim is to reduce the number of accidents to people whether patients, staff or members of the public and to monitor and assure compliance with the Health and Safety statutory framework.

5.26 Risk Management Committee Structure – Divisional level (not including Diagnostics and Pharmacy or Corporate)

Each Division has a Governance Committee and/or Divisional Assurance & Risk Committee (DARC). This Committee will meet monthly, chaired by the Divisional Managing Director, Chair of Division or Divisional Director of Nursing. At this meeting all serious risks, incidents, issues from complaints and claims that are assessed as significant within the Division are reviewed and actions to control these risks are determined and issued to the Manager or lead Clinician responsible for the management of that risk. The committee oversees the operational implementation of the Risk Management Strategy in that Division and, if appropriate, escalates concerns to the CO Assurance Committees.The Divisional Governance Committees also review

Serious Incident Reports to ensure thorough and comprehensive root cause analysis investigation has taken place, comprehensive recommendations are made against the findings, action plans are in place to rectify deficiencies and that appropriate risk registers exist.

The Divisional Risk Register and receive reports on the adequacy of the assurance arrangements within the Divisions prior to review by the COARC and its sub-committees.

Clinical and Non Clinical service lines systematically assess their performance within Divisional Governance Committees and at biannual service reviews. The service review briefing includes governance, assurance and performance reports detailing the position against all annual plan objectives. The reviews encompass information routinely presented to Divisional and Corporate Governance Committees but present an overview of all aspects relating to each service in the one place.The reviews include Divisional (Clinical services) and Departmental (Support departments) risk registers. Risks are reviewed and risk profiled through the Divisional Assurance Committees and those scored 10 and above presented to COARCInternal AuditInternal Audit is an independent and objective appraisal service within an organisation. As such, its role embraces two key areas:1. An independent and objective opinion to the Accountable Officer, the Board and the Audit

Committee on the degree to which risk management, control and governance support the achievement agreed objectives of the organisation.

2. An independent and objective consultancy service, specifically to help line management improve the organisation’s risk management, control and governance arrangements.

An Internal Audit Annual Plan will be completed detailing the purpose and scope of the

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assignments to be carried out including their prioritisation. The plan will clearly define its relationship with the Assurance Framework. Internal Audit will also review, appraise and report on matters as set out in the organisation’s Standing Financial Instructions

5.27 Local Arrangements – risk management strategies for all areas

The Operational Management Groups will have systems in place to ensure risks are identified, analysed, prioritised and documented at all levels and across all areas. This will include:

Comprehensive departmental risk assessments Specific risk assessments of service developments or changes to usual practice

Specific risk assessment of any areas of concern possibly identified from other risk management activity e.g. incident reporting trend review, complaints, claims, PALS contacts, clinical audits

Review of key risk management data including incident reporting, complaints, claims, inquests, PALS contacts, clinical audit reports

Provision and careful monitoring of effective risk management action plans including those developed following complaints, incidents, claims

Review and implementation of national guidance and warnings e.g. NPSA initiatives and Safety Alerts, MHRA Safety Notices and Hazard Alerts, NCEPOD and national enquiry reports, National Service Frameworks and NICE guidance

Continuous review of compliance against key national standards

Establishment and maintenance of comprehensive Risk Registers in all areas and at Division level. Risk Registers will be maintained and appropriately reviewed.

5.28 Risk Management Training

Training needs analysisAn annual training needs analysis will be conducted and coordinated through the Learning and Development Department. The Associate Director of Governance will advise on the risk management needs for all staff groups and volunteers within the CO. COs are supported by the NCA Patient Safety team who also strive to deliver standardisation between all COs and Group Business Units. Ensuring the effective delivery of all risk management training for all staff groups and volunteersThe outcome of the risk management training needs analysis is recorded within the NCA’s Learning Management System.The Care Organisation will maintain contemporary records of all staff in employment and

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volunteers. Staff records directly populate the Learning Management System and ensure the training needs of all staff are considered. Volunteer records are maintained on share point.The Learning Management System receives a nightly update of starters and leavers from the Human Resources Database (IPS) and records the specific training needs of all staff groups:-

The system for ensuring all staff are booked onto the relevant training programme in accordance with training needs analysis is as follows:-The training needs analysis will identify risk management training to all NCA posts (the list of NCA posts is generated from the Human Resources database). Staff will be assigned to their post on the Learning Management System, thus ensuring all staff are booked onto the relevant training programme. The Learning Management System Administrator allows audits to be conducted monthly to ensure all jobs have mandatory training requirements assigned.

The process for ensuring all staff undertake the relevant training programmes and that non-attendees are followed up is as follows:-Staff will be initially allocated to a training programme waiting list (this is either by themselves or by their manager) with a date by which the training must be completed. Staff will then be offered training on a priority basis e.g. if their training is about to, or has, expire they are allocated the first available course. The Learning Management System will report by exception, thus identifying staff that have not completed training within the specified timeframe. Managers will receive reminders which name the members of staff that have outstanding training. These reminders will be repeated until the training is completed. Reports detailing the percentages of training provided and outstanding will be presented to the Research and Education Committee for monitoring purposes.

Training programmes are developed for each training course by the relevant trainer. All training sessions will be evaluated and changes / improvements implemented accordingly.Within the Learning from Experience and Learning from Deaths twice a year report, the GRAC or COARCS will ensure monitoring arrangements are in place to review the overall effectiveness of the delivery of risk management training for all staff groups and volunteers, in relation to the:

System for ensuring that all staff are booked onto the relevant programmes

Process for ensuring that all staff undertake the relevant training programmes and those non-attendees are followed up.

Where monitoring identifies deficiencies, the COARC (or delegated sub-committees) will make recommendations, action plans will be developed and changes implemented accordingly.Effective delivery of risk management awareness training for NCA Board members and senior managersRisk management awareness and specific topic training will be provided for Board members and senior managers based on individual training needs analysis and any deficiencies highlighted by the board members and senior managers themselves. Such areas for improvement will be incorporated into the next training event.The Group Assurance and Risk Committee will ensure monitoring arrangements are in place to review the overall effectiveness of the delivery of risk management awareness training for Board members and senior managers, in relation to:

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Individual training needs analysis

The system by which attendance / participation records are co-ordinated centrally

The programme of regular updates.And, where monitoring identifies deficiencies, that recommendations will be made, an action plan developed and changes implemented accordingly.

6. Roles and responsibilities – Group

NCA Employees and volunteersAll employees of the NCA and volunteers have a responsibility to:

Work in accordance with all NCA/CO policies and procedures Attend induction and regular mandatory update training on risk management policy and

procedures Identify and report through risk assessment, any risks they feel exist within their department

or during the delivery of their services Provide incident reports and supporting documentation for any unexpected event or incident

they are involved in.Individual Clinicians Employed by the NCAAll clinicians employed by the NCA have a responsibility to:

Practice within the standards of their professional bodies, any other national standards and any locally determined clinical policies and guidelines to ensure their practice is as risk free as possible;

Report through their own department’s self-assessment process and line management arrangements, any risks they feel exist within the service and their practice;

Provide incident reports and supporting documentation for any unexpected event or incident arising from clinical care or treatment provided;

Attend induction and receive mandatory update training on risk management policy and procedures.

Participate in induction and all relevant mandatory training for incident reporting and investigation as defined in the Induction and Mandatory Training Policy (EDH024);

Be risk aware and ensure any risks identified as properly escalated, managed or mitigated.

Report all incidents on the electronic Incident Reporting System, known as Datix, and that details are recorded accurately within 24 hours of the date of the incident identification.

Co-operate fully with incident procedures, including providing written statements as appropriate to their involvement in the incident if requested.

To actively participate with the service to implement any actions; and

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Be aware that failure to adhere to the standards set by the NCA or CO for the management and investigation of incidents and complaints may result in disciplinary investigation and subsequent action.

Chief Executive

Responsible for overseeing risk management across all organisational, financial and clinical activities. Chairman of the Group Executive Risk and Assurance Committee (GRAC), which reports directly to Group CiC (GCiC) and has overarching responsibility for risk management including: the development and implementation of the Group’s Assurance Framework and Risk Management Strategy; monitoring of all Group-level risks; overseeing the Group’s Single Oversight Framework; and reviewing Care Organisation Assurance Framework/Risk Registers.

The Chief Executive Officer will prepare and sign an Annual Governance Statement for inclusion in the NCA’s Annual Report and Accounts, which includes the Quality Accounts.

Director of Governance and Corporate NursingThe Director of Governance at the Northern Care Alliance has responsibility for ensuring compliance with Health and Safety legislation across the alliance, embedding best practice and alerts at a national level into local practice. Director of Patient Safety and Professional StandardsThe Director of Patient Safety at the Northern Care Alliance has delegated responsibility for risk management and responsibility for ensuring compliance with Patient Safety legislation across the alliance. Head of Quality AssuranceThe Head of Quality Assurance is responsible to the Director of Patient Safety and Professional Standards for providing advice and facilitating the effective management of clinical and non-clinical risk. This responsibility includes establishing dynamic risk management systems and processes that form an integral part of routine organisational and departmental activity.The Head of Quality Assurance provides the principal lead role in establishing risk management systems in accordance with criteria described by external assurance organisations.Associate Director of Patient ResponsivenessThe Associate Director of Patient Responsiveness is responsible for ensuring the NCA and all Care Organisation operates the NHS Complaints’ regulations effectively and within specified targets, and to monitor and report on the NCAs performance in respect of the procedure.S/he will inform the clinical governance agenda by ensuring staff and the organisation learn from complaints. S/he will provide detailed reports and trend analysis, and ensure changes in practice as appropriate. This includes thematic review and identification of risks at any level which may become apparent. S/he will provide aggregated data reports to the Care Organisation Assurance and Risk Committee twice a year to support the organisations risk management assurance systems.Head of Legal ServicesThe Head of Legal Services is responsible for ensuring the NCA and Care Organisations

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effectively manage and respond to inquests and claims within specified targets, to monitor and report on the NCA’s performance in respect of the procedure. This includes thematic review and identification of risks at any level which may become apparent.S/he will provide detailed reports and trend analysis, and ensure changes in practice as appropriate.S/he will provide aggregated data reports to the Care Organisation Assurance and Risk Committee twice a year to support the organisations risk management assurance systems.Assistant Director of Health & SafetySupport and contribute to the development of Risk Registers on all H&S non-clinical risks, and advise on appropriate control strategies.

6.2 Roles and responsibilities – Care Organisations and Diagnostics & Pharmacy

The CO Directors are accountable for ensuring a system of internal control which supports the achievement of the organisation’s objectives is in place. The system of internal control ensures that:

The CO Principal Objectives are agreed. Principal risks to those objectives are identified Controls which eliminate or reduce these risks are implemented. The effectiveness of these controls is assured. Reports on unacceptable or serious risks and the effectiveness of control mechanisms are

received by the CO Directors and independent assurors. Action plans are agreed to improve control over serious or unacceptable risks. Policies are in place to determine what level of risks should be retained.

Care Organisation Associate Director of Governance

The Associate Director of Governance is responsible for consistently implementing the organisational arrangements for Governance throughout the CO. S/he manages the implementation of governance and ensures the CO is prepared for external review of all governance systems including the Care Quality Commission. S/he is responsible for ensuring adequate resource is available for the above activities.S/he will contribute to the development of a culture where by clinical and non-clinical risk management is converged and integral to the CO’s performance management processes.With strategic and managerial responsibility for governance and risk management, s/he provides key information and reports to ensure risks identified are reduced / eliminated. In addition, s/he will act for the Director of Nursing in co-ordinating and integrating all of the CO’s risk management arrangements.The CO Associate Director of Governance takes the lead, on behalf of the Directors, for maintaining the Board Assurance Framework that defines the principal risks, and associated controls, assurances and action plans, to achieving the NCA’s annual objectives.They also facilitate the implementation of actions required by the Directors in relation to the

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Board Assurance Framework and corporate governance.CO Directors (including Associate or Assistant Directors)The Directors are accountable for ensuring a system of internal control which supports the achievement of the organisation’s objectives is in place. The system of internal control ensures that:

The NCA’s Principal Objectives are worked towards. Principal risks to those objectives are identified Controls which eliminate or reduce these risks are implemented. The effectiveness of these controls is independently assured. Reports on unacceptable or serious risks and the effectiveness of control mechanisms are

received from the Executive Directors and independent assurors. Action plans are agreed to improve control over serious or unacceptable risks. Policies are in place to determine what level of risks should be retained. This system (of internal control) will be managed through the accountable officer who is the Chief Officer and supported by an effective committee structure.

CO Chief OfficerThe Chief Officer is the Chairperson of the COARC and has overall accountability for the management of all risks across the CO.Through this Committee, the Chief Officer provides leadership and strategic direction to the risk management processes. This responsibility includes consideration of the Care Organisation’s Risk Register and resource allocation relating to the significant risks of the CO or NCA. In addition, the Board Assurance Framework has five other Assurance Committees, which review relevant risks and assurances,

Quality and People Experience Committee,

Clinical Effectiveness Committee,

Finance, Information & Capital Committee,

Operations and Performance Committee

Workforce CommitteeThe above committees are each chaired by a Director. The Care Organisation’s Directors are members of all the Care Organisation Governance Committees. The recommendations of the Care Organisation Governance Committees (or delegated sub-committees) are made to the CO Directors via the Care Organisation Assurance and Risk Committee, where competing priorities are debated and agreed or accepted. The Chief Officer as the Accountable Officer and is accountable for ensuring:

The COs Principal Objectives are agreed

Sound systems of internal control, based on an on-going management process, designed to identify the principal risks to the achievement of the organisation’s objectives; to evaluate the nature and extent of those risks; and to manage them efficiently, effectively and economically, are in place

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Internal Audit Plans are in place which review the effectiveness of the system of internal control

Systems of internal control are underpinned by compliance with the core controls assurance standards of Governance, Financial Management and Risk Management.

The Chief Officer will use the Governance Committees as the principal means by which these responsibilities are made operational and their effectiveness monitored. Terms of reference for these committees are available on the Trust’s intranet.The Chief Officer has delegated responsibility for risk management to the Directors.CO Director of NursingThe Director of Nursing is responsible to the Chief Officer for the CO’s clinical and organisational risk management activities. S/he is responsible for ensuring compliance with all national risk management standards. S/he is responsible for the management of risks within her/his areas of operational responsibility. CO Director of FinanceThe Director of Finance is responsible to the Chief Officer for the CO’s financial risk management activities. The Director of Finance is responsible for ensuring that the CO carries out its business of providing healthcare within sound financial governance arrangements that are controlled and monitored through robust audit and accounting mechanisms that are open to public scrutiny on an annual basis. Her/His accountability for Financial Risk Management and Control is through the Chief Officer and Chairman of the Group. There are close working arrangements with the Director of Nursing with regard to ensuring that Financial Planning and Financial Risk Management integrates with the CO’s Clinical and Organisational Risk Management activities and is closely involved in consideration of the recommendations of the COARC. H/she is responsible for the management of risks within his/her areas of operational responsibility. CO Medical DirectorThe Medical Director is responsible to the Chief Officer for the management of risks within his/her areas of professional and operational responsibility. CO Associate Director of WorkforceThe Associate Director of Workforce is responsible to the Chief Officer for the management of risks within his/her areas of operational responsibility. Divisional Managing Directors/Chairs of Divisions/Divisional Directors of Nursing/Divisional Directors of Medicine/ Heads of departments in Diagnostics and PharmacyThe Chairs of Divisions, the Divisional Managing Directors and the Divisional Directors of Nursing ensure local systems and processes are in place for the identification and management of risks within their areas of responsibility.They work at both a corporate and local level, contributing to the management and identification of risk across the organisation and ensure staff develop and maintain safe systems of practice which is evidence based.CO Head of Assurance and Performance

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There is variation about the delivery of this role across the COs. The role detailed below may also fall under the CO Associate Director of Governance.The Head of Assurance and Performance takes the lead, on behalf of the Directors, for maintaining the Board Assurance Framework that defines the principal risks, and associated controls, assurances and action plans, to achieving the NCA’s annual objectives.They also facilitate the implementation of actions required by the Directors in relation to the Board Assurance Framework and corporate governance.Clinical Directors, Service Managers, Assistant Directors of Nursing, Lead Nurses Clinical Directors ,Service Managers, Assistant Directors of Nursing, Lead Nurses will ensure the CO’s risk management policies and processes are fully implemented within their services, risk registers are maintained, and will therefore be able to ensure principal risks to the CO’s objectives are systematically identified, evaluated, eliminated or reduced and managed. Divisional Governance ManagersThe Divisional Governance Managers support the Divisional senior management structure in ensuring that the NCA becomes imbued with a ‘Culture of Governance’ and will lead on consistent implementation of the organisational arrangements for Governance in line with the Care Quality Commission's Essential Standards for Quality and Safety. They will keep their Divisional groups informed of best practice and assist in the management of Governance locally. The Divisional Governance Managers work closely with the Associate Director of Governance and the Head of Risk Management in supporting the CO’s Governance and Risk structure and its supporting mechanisms, ensuring that all governance and risk issues are appropriately reported and co-ordinated.The Divisional Governance Managers will ensure NCA systems for the identification, management and reduction of risk are implemented throughout their areas of responsibility, monitoring compliance against internal and external standards.Chief Internal Auditor The Chief Internal Auditor’s formal annual report to the Accountable Officer and the Audit Committee will present an opinion on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. This opinion will encompass the Assurance Framework and requirements in relation to national standards as well as the conclusions arising from internal audit assignments.

7. Monitoring document effectiveness

7.1 Key standards:

1) High quality risk management at all levels2) BAFs at CO and NCA levels kept up to date and provide a comprehensive position

on the organisations risk profile3) Continuously develop risk management for individual risks by use of identification

and development of Controls and Assurances and;4) Continuously review risks, develop action plans to manage, mitigate or eliminate

risks

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5) Ensure any risks that require escalation are escalated appropriately via the governance structures

6) Monitor of relevant incidents, complaints, inquests to known risks.

Method(s): Using built in analytical tools within the risk management database, as well as quality audits of reports and data quality. High quality assurance seeking based upon DAFs, CO BAFs and the NCA BAF.

Team responsible for monitoring: Group Risk and Assurance Committee (GRAC) and Care Organisation Risk and Assurance Committee(s)

Frequency of monitoring: Quarterly at least

Process for reviewing results and ensuring improvements in performance: Reporting of CO BAFs to Group and continuous improvement of risk profiles.

.8. Abbreviations and definitions

Explained in document.

9. References and Supporting Documents

9.1 References

9.2 Related SRFT/PAT documents

Northern Care Alliance NHS Group policiesEDG0334 Board Assurance Framework PolicyTT1(06) Group Governance Framework ManualIncorporating Standing Orders of the Board of Directors, Standing Orders of the Council of Governors, Reservation and Delegation of Powers and Standing Financial Instructions.

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10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.

Nominated Lead author:

Name Josh Hennighan

RoleRisk Manager

Lead author contact details:

Full contact telephone number0161 922 3122 (int 43122)

Full trust email [email protected]

Lead Author’s Manager:

Name Alison Talbot

RoleHead of Legal Services

Applies to:Salford CO

Yes

Oldham CO

Yes

North Manchester CO

Yes

Bury & Rochdale CO

Yes

Northern Care Alliance Group (NCA)

YesDocument developed in consultation with :

Group Patient Safety TeamAssociate Directors of GovernanceSerious Incident Progress GroupDivisional Governance ManagersComplaintsLegal Services

Keywords/ phrases:

RiskBAFDAF

Communication plan:

Via the Patient Safety Team, Divisional Governance Managers and Care Organisation Associate Directors of Governance

Document review arrangements:

This document will be reviewed by August 2019, ongoing development work to improve risk management will be reflected in a subsequent version of this document.

Add name of Committee and Chairpersons name and role:

Group Risk and Assurance CommitteeChris Brooks, Group Medical Director

Insert full approval date:

Approval:

How approved: Formal Committee decision

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11. Equality Impact Assessment (EqIA) screening toolLegislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

YesGovernance leadership across COs and NCA

1b) Have any amendments been made as a result? If yes, specify what.

No

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or UnsureThis may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.Protected Group Yes No UnsureAge (e.g. are specific age groups excluded? Would the same process affect age groups in different ways?)

X

Sex (e.g. is gender neutral language used in the way the policy or information leaflet is written?)

X

Race (e.g. any specific needs identified for certain groups such as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions; dietary needs that may conflict with medication offered.)

X

Sexual orientation (e.g. is inclusive language used? Are there different access/prevalence rates?)

X

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or breastfeeding women?)

X

Marital status/civil partnership (e.g. would there be any difference because the individual is/is not married/in a civil partnership?)

X

Gender Reassignment (e.g. are there particular tests related to gender? Is confidentiality of the patient or staff member maintained?)

X

Human Rights (e.g. does it uphold the principles of Fairness, Respect, Equality, Dignity and Autonomy?)

X

Carers (e.g. is sufficient notice built in so can take time off work to attend appointment?)

X

Socio/economic (e.g. would there be any requirement or expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

X

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Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these?(what action has been taken or will be taken, who is responsible for taking a future action, and when it will

be completed by – may include adjustment to wording of policy or leaflet to mitigate)N/A

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?(what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet)N/A

Will this policy require a full impact assessment? Yes / No(a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please contact the Inclusion and Equality team for advice on [email protected])

Author: Josh Hennighan – Risk ManagerDate: 14/03/2019

Sign off from Equality Champion:Date:

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mailto:[email protected]



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12. Appendices

None

For investigation templates please see the risk management intranet page or contact your divisional governance management.

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Compliance checklist for authors

This sheet must be completed by the author prior to approval and will be removed by Document Control prior to publication.

Tick/Comment

1. Have you registered your document with Document Control? If your document affects both SRFT and PAT it will need a specific reference number allocated.

Y

2. Have you fully completed the document's header box at the top of each page?

Y

3. Is the official NCA logo displayed correctly at the top of the title page & the document summary sheet if used?

Y

4. If you have not used the document summary sheet have you removed it?

N/A

5. Have you removed all of the template instructions? (the guidance text in grey)

Y

6. Have you indicated the correct document type on the title page? (i.e. Policy, Guideline)

Y

7. Is your title clear, appropriate and with the subject first? Y8. Have you adhered to the style and format as described in the policy

template: font size, colour and type?Y

9. Is all text left aligned (with the exception of the title page, figures, & tables)?

Y

10. Has ‘Title case’ been used which means that only 1st letter of the title words are in block capitals - Whole words should not be put in block capitals; italics should not be used, & underlining should not be used apart from for hyperlinks.

Y

11. Have you been explicit where this document is to be used being clear which Care Organisation/s it affects?

Y

YYYYYYYYYYY

12. Have all the core sections been included?1) What is the policy/Guideline for?2) Where will this document be used?3) Why is this document important?4) What is new in this version?5) Policy/Procedure/Guideline?6) Roles and responsibilities.7) Monitoring document effectiveness.8) Abbreviation and definitions.9) References and supporting documents.10) Document control information11) EqIA screening tool Y

13. Is Section 5 and its subsections the main area that contains all the relevant policy information and instruction?

Y

14. Have you fully completed Section 10 the Document Control Information?

Y

15. Is it clear where the document has been for consultation/endorsement? Y16. Are you able to evidence that all stakeholders have been consulted

and provided the opportunity to contribute to the document?Y

17. Are all dates within the document written as dd/mm/yyyy? Y18. What dissemination & training arrangements have been made? (If

applicable, please state arrangements other than the policy being Y

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made available on the Document Management System) 19. Have you added relevant key words to support searching for the

document?Y

20. Is the correct Disclaimer in the document footer present? (See policy template for correct wording)

Y

21. Are page numbers in the format of 'page x of y'? Y22. Has a contents page been completed and page numbers match the

actual contents?Y

23. Are the monitoring methods in Section 7 measurable and achievable? (E.g. would you be able to provide evidence to demonstrate what you have said?)

Y

24. Have all abbreviations used, including within the appendices, been listed and explained in Section 8?

Y

25. Have you completed the EqIA form and has it been countersigned by your Equality Champion?

Y

26. Have you used consistent terminology throughout? (i.e. if something is called a policy is it referred to as a policy throughout)

Y

27. Do all hyperlinks contained in the document work? (I.e. take the reader to where they should go)?

Y

28. If used, are images sourced & acknowledged appropriately? (i.e. copyright permissions checked & source acknowledged as per source request)

Y

29. Have you carried out a spelling and grammar check? Y30. Have you ensured there are no ‘embedded’ documents as the reader

will not be able to open them once the document is published? Y

31. Have you carried out a final proof read to ensure that your document makes sense?

Y

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)


Author (s) Jayne Downey, Director of Governance and Corporate NursingLynne Logan, Group Associate Director Patient Responsiveness

Presented by Elaine Inglesby-Burke, Chief Nursing Officer

Date 25 March 2019

Executive Summary

The Complaints Handling Policy will deliver an efficient and effective complaints procedure, not only because it is legally required to do so, but because it is committed to identifying and implementing service improvements and enhancing patient experience as a result.


Pursuing Quality Improvement to assure safe, reliable and compassionate care

Associated Risks

Recommendations The Group Committees in Common is asked to note and approve the content for dissemination throughout the Northern Care Alliance NHS Group

Equality Does this paper relate to a matter where equality issues may arise? No This document does not contain confidential information and can be made available to the public.








Title of Report Complaints Handling Policy

x

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c) This paper contains information relating to both PAT and SRFT. All information other than that relating to PAT will be fully redacted.

d) This paper contains reference to both PAT and SRFT but

contains no quality, finance or operational performance data relating to PAT which could be relevant to the transaction and is therefore not eligible for release.

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Complaints Handling Policy Reference Number: Insert here Version Number: Insert here Issue


Page 1 of 33


Complaints Handling PolicyLead Author: Lynne Logan, Group Associate Director - Patient

ResponsivenessAdditional author(s) Josephine McCreath (Case Manager, NES CO) & Ben

Vickers (Complaints Manager, Salford CO)Division/ Department: ComplaintsApplies to: Northern Care Alliance NHS GroupDate approved: Insert full approval date dd/mm/yyyyExpiry date: Insert full expiry date dd/mm/yyyy* This includes documents relevant to multiple Care Organisations, Corporate and Support

ServicesContents Contents

Section PageClick here for the document summary sheet: 31 What is the policy about? 52 Where will this document be used? 53 Why is this document important? 54 What is new in this version? 55 What is the Policy? 5

5.1 What can a complaint be made about? 65.2 Who may complain? 65.3 Time limits for making a complaint 75.4 How to make a complaint 75.5 How the Group will respond 75.6 Reference to external agencies 95.7 Process for handling joint complaints 95.8 Unresolved complaints 95.9 The 2nd Stage – Responding to the Ombudsman 105.10 Communication with Patient/Carer/Individual raising concerns 105.11 Support for people making a complaint 105.12 Supporting staff 115.13 Providing advice and assistance 115.14 Lessons learned and action arising from complaints 115.15 Claims for compensation 125.16 Unreasonably demanding individuals 12

6 Roles and responsibilities 117 Monitoring document effectiveness 178 Abbreviations and definitions 189 References and Supporting Documents 19


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10 Document Control Information 2011 Equality Impact Assessment (EqIA) screening tool 2212 Appendices 24

Appendix 1 Grading Matrix (Risk Assessment) & Levels of Resolution 25Appendix 2 Template Resolution Summary 27Appendix 3 Complaint Process Flowchart 30

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Document Summary Sheet

Policy for the Handling of Complaints

The Northern Care Alliance NHS Group (NCA) is committed to providing high standards of care centred on patients and service users. As part of this process the Group will deliver an efficient and effective complaints procedure, not only because it is legally required to do so, but because it is committed to identifying and implementing service improvements and enhancing patient experience as a result.

Key Principles

The following key principles must be applied in order to deliver this:

Complaints and concerns will be dealt with in a fair, flexible and conciliatory manner, encouraging open communication between all parties;

All complaints and concerns must be dealt with in line with the Group’s Duty of Candour (DOC) policies (refer to your organisation’s DOC policy: North East Sector CO’s “Incident Reporting & Investigation Serious Incidents, Never Events, Duty of Candour and Learning from Deaths” EDQ008 or Salford CO’s “Duty of Candour: Being Open Policy” TC20 (06)

High standards of conduct are expected from all staff at all times to ensure that service users/representatives will be treated respectfully, courteously and sympathetically;

The requirement to maintain confidentiality during the complaints process will be absolute (where a safeguarding concern is raised, sharing of information may be necessary without the consent of the patient);

All patient or service users and their families will be advised how they can raise a concern or make a formal complaint via information leaflets available on all wards and clinical service units and the internet;

All people who make complaints will be advised of the various independent support agencies that are available to assist them in making their complaint;

As far as possible, people who make complaints will be involved in decisions about how their complaints are handled and considered;

The Group will aim to resolve complaints within the Group as part of local resolution (first stage of the national complaints procedure), wherever possible;

Complainants receive a meaningful apology when appropriate;


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The Group will co-operate with other organisations when a complaint involves other outside organisations or multiple agencies;

No person who makes a complaint will be discriminated against on the grounds of religion, gender, race / ethnicity, disability, age or sexual orientation or because they have made a complaint;

Violence, racial, sexual, verbal or any other forms of harassment are unacceptable and will not be tolerated on the part of staff or people who make complaints.

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1. What is this policy about?

1.1 It describes the requirements and procedures for the investigation and management of formal and informal complaints, received across the Group.

2. Where will this document be used?

2.1 This document is for use by staff members working throughout the Group.

3. Why is this document important?

3.1 As a Group employee you need to follow this policy so that the Group can ensure compliance to best practice and legal obligations to demonstrate that:

Any service users of the Group, their family, or members of the public are given the opportunity to seek advice, raise concerns, and/or make a complaint about any of the services it provides

That a person who raises a complaint, receives a high quality response in a timely manner;

Lessons learned from complaints are acted upon and shared throughout the organisation to improve standards of care and prevent avoidable harm/ poor experience

3.2 Adherence to the policy will ensure that complaints are investigated and managed in line with:

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 www.opsi.gov.uk/si/si2009/uksi_20090309_en_1

The NHS Constitution for England https://www.gov.uk/government/publications/the-nhs-constitution-for-england

The Parliamentary and Health Service Ombudsman’s (PHSO): My expectations for raising complaints and concerns 2014 http://www.ombudsman.org.uk/myexpectations

The Local Government and Social Care Ombudsman (LGO)http://www.lgo.org.uk

The CQC responsiveness requirements The PHSO principles of good complaint handling

4. What is new in this version?

4.1 PAHT and Salford CO policies have been combined to form a Group policy. Procedures have been updated to accurately reflect current practice. There is also reference to the Local government and social care requirement for ASC complaints which are handled by complaints staff within the Adult Social Care Division.

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http://www.opsi.gov.uk/si/si2009/uksi_20090309_en_1

https://www.gov.uk/government/publications/the-nhs-constitution-for-england

http://www.ombudsman.org.uk/myexpectations



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5. Policy

5.1 What can a complaint be made about?

5.1.1 A complaint can be made to the Group about any matter reasonably connected with the exercise of its functions including:

Care or treatment provided; Anything to do with the hospital or healthcare environment; Any member of staff; How services are organised if this has affected treatment or care; Complaints about the Group's staff or facilities relating to the care provided to

any patient or service user, in a private pay bed (but not to the private medical care provided by the Consultant outside of their NHS Contract);

Care, treatment or an establishment that has been commissioned by the Group to provide care on behalf of the NHS

5.2 Who may complain?

5.2.1 The Regulations specify that complaints may be made by: A person who receives or has received services from the Group; or Any person who is affected or likely to be affected by any action, omission or

decision of the Group; A Person who is acting as a representative of:

o a person who has died; o a child; o a person who is unable to make the complaint themselves because of

lack of physical incapacity or lack of mental capacity, o any individual who has otherwise asked the representative to act on

their behalf

Where a complaint is made by a representative, the representative must demonstrate that they have the appropriate authority or consent to act. Consent is not required from MPs when they act directly on behalf of a constituent, as the Group may assume that the MP has obtained sufficient consent to release relevant confidential information (see section 17 S1 2002 (2905)), but is required when acting on behalf of a third party (e.g. complaint by a daughter on behalf of her mother’s care being represented by the MP).

Where a complaint is made on behalf of a person who has died, it is important to check that the person making the complaint is the deceased patient’s next of kin or is acting with their authority. Where this is not the case, the consent of the next of kin should be sought in writing and they will be asked by the Complaints Department to complete a Form of Authority. In doing so, the Group will offer the next of kin the opportunity to review the complaint that has been made.

Where a representative makes a complaint on behalf of a child or a person who lacks capacity, prior to investigating the complaint, Group staff will satisfy themselves that there are reasonable grounds for the complaint to be made by the representative rather than by the child or the person who lacks capacity. Group staff will also satisfy themselves that the representative is conducting the complaint in the best interests of the person on whose behalf the complaint is being made. If not satisfied, the

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representative will be notified in writing of the reasons for refusing to investigate the complaint.

Young people aged between 16 and 19 – unless there is clear medical evidence that they lack mental capacity, their express authority should be obtained before responding to the complaint if it will involve disclosing confidential patient information.

Children under the age of 16 – if a complaint is made by a child who is ‘Gillick competent’ (i.e. of sufficient intelligence and maturity to consent to treatment), their agreement should be obtained before responding to the complaint if doing so will involve disclosing confidential patient information. If, however, a complaint is made on behalf of a child under the age of 16 who is not Gillick competent, no authority from the child will be needed to respond to those with parental responsibility.

5.3 Time limits for making a complaint

5.3.1 The Regulations require that a complaint must be made within twelve months of:

The date on which the matter which is the subject of the complaint occurred; or

The date on which the complainant became aware of the matter which is the subject of the complaint (if later than the date on which the matter occurred).

However, where a complaint is made outside this time limit, the Complaints Department may exercise discretion to waive the time limit where it can be demonstrated, and satisfied that:

The Complainant had good reasons for not making the complaint within the time limit and,

It is still possible to investigate the complaint effectively and fairly

Local experience is that complaints made outside the established time limits can prove difficult to investigate and extremely problematic to resolve, not least because of the inevitable doubts over memories of events some time previously. This is a relevant factor to be considered in determining whether it will be possible to investigate a ‘late’ complaint effectively.

If it is not possible to waive the time limit, and where the complaint is not accepted into the Complaints Procedure, an explanation of this will be provided to the Complainant.

5.4 How to make a complaint

5.4.1 Complaints can be made verbally or in writing either via letter or electronically to the Chief Executive, Chief Officers for each CO, the Complaints Department, or via the Care Organisations’ websites. The Complaint’s Department will review, and a decision will be made whether to register the concerns raised as either a formal or informal complaint.

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5.5 How the Group will respond

5.5.1 All written formal complaints received by the Group will be sent to the Complaints Department. These will be processed for investigation in line with the Complaints Process Flowchart (Appendix 3).

5.5.2 Formal complaints

All patients / service users / representatives have the right to have their complaint treated as a formal complaint. A formal complaint is acknowledged in writing within 3 working days. A written response will be provided following an investigation into the issues raised, or following a local resolution meeting (which can take place following investigation), usually within 25 working days or up to a maximum of 60 where a case is complex or the subject of an incident investigation. Where a complaint response and an incident investigation are deemed appropriate, responses can be combined or sent separately.

In some circumstances, and in line with the Complaints Regulations 2009, we will agree different timescales with the complainant to respond to their concerns, within a maximum period of 6 months (see Levels of Resolution chart, Appendix 1)

5.5.3 Informal complaints

An informal complaint is where an issue is raised as a complaint (or a concern, via PALS or to ward staff) but it is possible to resolve at a local level to the service user/representative’s satisfaction, without going through the formal complaint process, as described above. The issue could be raised at the time the service or care is being provided to the service user or at some point after. It may be possible for the member of staff who received the informal complaint to resolve the issue at the time. If not, the issue should be passed to the appropriate senior colleague. Although the service user/representative may submit an informal complaint, the nature of the complaint may contain serious concerns, and should be triaged in the same manner as a formal complaint.

It is important to let the service user/representative know how you are progressing the complaint and advise them of the formal complaints procedure if they remain dissatisfied.

5.5.4 Duty of Candour

A culture of openness, transparency and candour is essential to improving patient safety and service quality. Patients who have been harmed during their healthcare treatment are owed an explanation of what went wrong, as soon as possible after an incident. Apologising and explaining what has happened helps healing, acceptance and perspective. It helps staff come to terms with the consequences of errors. The Group is committed to supporting its staff in achieving a culture of openness, transparency and candour. The Francis Report 2012 defines these characteristics as:

Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.

Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

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Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it

5.5.5 Complaint Investigation

Verbal complaints received in wards and departments by staff will be addressed promptly and fully by those staff, involving more senior management within the Division as appropriate. This is the most effective method of dealing with complaints; it reduces tension and conflict, demonstrates understanding and empathy and builds confidence in Group staff and services.

Verbal complaints received by PALS will be addressed promptly and fully by those staff, involving more senior management within the Division as appropriate.

Written complaints or verbal complaints where a written response has been requested will be risk assessed by the Group Associate Director of Patient Responsiveness /Complaints & PALS Manager along with the relevant Case Manager. Details of the Complaints Grading Matrix are contained in Appendix 1.

Written complaints will be acknowledged within 3 working days of receipt in the Complaints Department.

The Chief Executive Officer (CEO) has overall responsibility for managing all complaints; however, has delegated authority to the Chief Officers of the respective Care Organisations and their nominated deputies.

All complaints received by the Group will be acknowledged by the Complaints Team (i.e. when a letter comes to the CEO, it is forwarded to the Complaints Team same day and they acknowledge the complaint). This will minimise delays and any confusion regarding appropriate process.

If the individual(s) who has raised a concern contacts the CEO office during the course of an investigation, it will be referred back to the Complaints Team, who will allocate an appropriate person to have a discussion with the individual(s)/ service user.

All formal complaints will receive a signed response letter. .5.6 Reference to external agencies

5.6.1 If a review of a complaint reveals a possible case of criminal activity or other serious matter, the person in receipt of the complaint should ensure the Chief Nurse is notified via the CO, and has access to the appropriate AIR information immediately.

In such cases it will be necessary to refer the matter/s raised to an external agency or agencies e.g. Police, Her Majesty’s Coroner, etc. The Chief Nurse will be responsible for triggering such a referral.

5.7 Process for handling joint complaints

5.7.1 Please refer to the Salford CO Protocol for handling joint Complaints between health and social care

5.7.2 Complaints from a Managed service or Hosted Service.

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Hosted services:

Where a clinical service is provided on a particular site but staff are managed and responsible to different Directors.

Should a complaint be received regarding a Hosted service, relating to one discipline of staff, the complaint will be lodged against the relevant Care Organisation. If there are more than one disciplines involved, the Associate Directors of Governance will identify which Care Organisation will take responsibility for the complaint.

Managed Services:

Managed Services may be provided on each of the hospital sites, but managed by one particular Care Organisation. Should the circumstances within a complaint relate to one site but involve a service managed by another CO, a decision is required regarding where the complaint is lodged.

Once again, in a similar process to the allocation of Incident Investigations, the Associate Directors – Governance will decide based upon the content of the complaint, which Care Organisation will take responsibility for the complaint and who will be the Lead Investigator.

In complaints where there is more than one discipline or involving more than one site, the AD’s- Governance will agree which CO will take responsibility and who will be the Lead Investigator.

Complaints which are from Hosted or Managed Services will be included in the Monthly Patient Responsiveness Report.

5.8 Unresolved complaints

5.8.1 In situations whereby the service user/representative is dissatisfied with the response provided to their complaint and they communicate this to the relevant Organisation, this complaint will be logged as a dissatisfied complaint. The following criteria defines a dissatisfied complaint:

Feedback from the service user / representative expressing dissatisfaction at the complaint response;

Where no new issues are raised as part of this feedback by the person making the complaint;

Where local resolution is not exhausted.

5.9 The 2nd Stage – Responding to the Ombudsman

5.9.1 The remit of the PHSO or LGO is to assess complaint cases where local resolution has been unsuccessful. Once the Complaints Case Handler has forwarded contact details for the PHSO or LGO onto the individual raising concerns, it is up to the individual to pursue their case with the PHSO or LGO.

The Group will comply with all requests and recommendations made by the Parliamentary and Health Service Ombudsman (PHSO) or the Local Government and Social Care Ombudsman ( LGO).

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5.10 Communication with Patient/Carer/Individual raising concerns

5.10.1 Regular contact and appropriate record keeping is essential to record action taken to resolve issues of concern. Answers provided must be full, frank, open and honest with all points addressed.

5.10.2 All staff will make every effort to deal with issues as they arise, informally and promptly. This includes informing senior clinicians and managers where it has not been possible to resolve concerns, and ensuring appropriate advice is given about how to take their issue forward. Voice your appreciation, comment or concern leaflet to be available across the Group and leaflets displayed.

5.10.3 Patients/ service users, their relatives or carers who raise a complaint or concern, must not be discriminated against and it is inappropriate for correspondence relating to a complaint or concern to be filed in the patient’s health records. The Complaints Department will retain comprehensive records of all correspondence and documents relating to the complaint in the files held on behalf of the Group Executives. Similar records will be held regarding concerns raised through PALS.

5.10.4 Services will not be withdrawn from a patient because he/she makes a complaint or raised a concern. On rare occasions, where there may be a mutual loss of confidence and trust to the extent that the relationship between patient/service users and clinician is no longer sustainable, the Group will ensure ongoing treatment and care is provided by alternative means.

5.10.5 Where the Group’s version cannot be reconciled with those of the individual who has raised concerns then this will be made explicit.

5.11 Support for people making a complaint

5.11.1 Making a complaint can be daunting and evidence confirms many people who might wish to complain do not because they do not know how to or they find the process intimidating. The Group therefore loses valuable feedback from its patients.

The Independent Complaints Advocacy Service (ICA) has been established to assist people who wish to complain. It will aim to ensure persons who raise concerns have the support they need to articulate their concerns and navigate the complaints system so that their concerns can be resolved more quickly and effectively. The service can be accessed through a variety of routes including PALS and Complaints staff. It will advertise locally through a variety of means agreed with ICA managers.

5.12 Supporting staff

5.12.1 It is important to recognise that complaints investigations can have a significant impact on the staff involved.

Staff involved in the complaints investigation process must be given support, which may include some or all of the following: Support from their line manager or professional lead, the opportunity to access professional advice from their relevant professional body or union, staff counselling services and occupational

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health services. They should also be provided with information about the stages of the investigation and how they will be expected to contribute to the process.

The Group is clear that the complaints investigation itself is separate to any other legal and/or disciplinary process. The Group will advocate justifiable accountability when required but will operate a policy of zero tolerance for inappropriate blame and those involved must not be unfairly exposed to punitive disciplinary action, increased medico-legal risk or any threat to their registration by virtue of involvement in the investigation process.

5.13 Providing advice and assistance

5.13.1 Clear information on how to make a complaint must be made available to the public through leaflets throughout Group premises and information on the Group/ Care Organisation web-sites.

5.14 Lessons learned and action arising from complaints

5.14.1 The Group will learn from complaints by identifying trends at a local and strategic level, which will assist in the prevention and recurrence or more serious incidents or other similar complaints occurring in the future.

5.14.2 The Lead Investigating Officers are responsible for preparing action plans arising from individual complaints and for ensuring that these are implemented. Action plans should cross reference to actions of other providers (e.g. other NHS Trusts or Social Services departments) where appropriate, with a link to quality improvement practices across the Group.

5.14.3 Lessons learned arising from complaints is a critical part of complaints management. Investigating Officers will be responsible for providing feedback, in respect of complaint outcomes, to appropriate individuals who can take action and ensure lessons are learned. Lessons are also required to be shared across relevant meetings at Ward/Department, Directorate, Divisional and Care Organisation level.

Internally, this will be through the provision of reports to Group Committees in Common on a quarterly basis which specifically highlight reports from the Parliamentary and Health Service Ombudsman.

Any theme or issue recognised which poses an immediate risk to the Group will be escalated to the relevant Executive outside of the normal reporting schedule.

5.14.4 Reports are available to monitor new complaints received, the age of the complaint and complaint trends via the CO’s Complaints Dashboard.

5.14.5 Complaints handling to be reviewed as follows:

Monthly by the complaints Review Panel at Salford CO. Monthly by the Complaints Review Panel at NES CO.

These review functions are chaired by a Non-Executive Director and has a senior medical officer as part of the core group. These review functions will provide external

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scrutiny of the Group’s complaints handling.

5.14.6 A monthly summary of all completed complaint investigations, age of complaints, new complaints received and trends will be submitted to the Care Organisations, Quality & Patient Experience Committees.

5.15 Claims for compensation

5.15.1 Requests for compensation should be processed in accordance the NHS Resolution Service rather than through the Complaints procedure.

5.15.2 There may be circumstances in which the individual raising concerns indicates that an ex-gratia payment would be appropriate under the NHS Complaints Procedure and this should be processed in accordance with the Group’s Scheme of Delegation at the discretion of the Divisional Management Team.

5.15.3 Guidance on financial remedy can be sought by the complaints team from the Parliamentary and Health Service Ombudsman or the Local Government and Social Care Ombudsman..

5.16 Unreasonably demanding individuals

5.16.1 Please refer to the NCA Policy: Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants Policy

5.16.2The Policy for dealing with Unreasonably Demanding, Persistent or Vexatious Complainants aims to address the challenges presented by persistent comebacks from people who are generally deemed to be ‘difficult’ and ‘vexatious’. This document also provides advice as how best to deal with them. The intention is to provide clear yet flexible strategies.

It remains the responsibility of staff to ensure that all issues raised by individuals are thoroughly considered and addressed. Individuals with concerns should be kept informed of what is happening. Staff should always be willing to answer queries that patients or visitors may have or refer them to an appropriate person, ensuring that in the process they have enough information to satisfy their immediate needs. When a complaint is made the complainant needs to be kept informed of progress and the deadlines we aim to achieve.

It is important to try to resolve matters using appropriate and sometimes alternative approaches before invoking this procedure. The implementation of this procedure should only be used as a last resort and after all reasonable measures have been taken to try to resolve the complaint.

6. Roles and responsibilities

6.1 All staff

Frontline staff are usually best placed to address issues and complaints raised by those who use the Group’s services. By taking prompt and effective action many issues can be addressed without the need for recourse to the formal complaints

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procedure. This approach is better for the individual raising concerns and for staff. It reduces tension and conflict, demonstrates understanding and empathy and builds confidence in Group staff and services.

All employees have a responsibility to ensure that:

They observe and comply with this policy and associated procedures. They proactively address issues raised by those who use the Group’s

services in order to minimise the number of complaints.

Where faced with a verbal concern they make every effort to rectify the problem immediately by:

o Investigating the issues and providing a response; o Contacting the most appropriate person to find out the information

required, if necessary seeking advice from their line manager; o Passing the issue on to a named person and informing the

individual raising concerns why they have done so, who this is and when they can expect a response.

They co-operate fully with complaint investigation and resolution; They support the implementation of action plans arising from complaints. They protect the interests of vulnerable adults and children. Reference to

the Group’s Safeguarding Team is advised if staff are unsure about this aspect.

They should not seek to influence vulnerable individuals for the purpose of financial, personal or professional gain.

They are aware that failure to adhere to the standards set by the Group for the management and investigation of incidents and complaints may result in disciplinary investigation and subsequent action.

They are mindful of the Data Protection Act and their NHS responsibilities in terms of patient confidentiality, particularly where a complaint is made by a representative on behalf of another individual.

They are aware that all documents generated in the course of a complaints investigation (including internal memoranda / comments etc.) are generally liable to be disclosed under the Data Protection Act or in any subsequent legal claim.

They are aware that the PHSO may request to see any information that is gathered as part of the complaint investigation. Equally, it may be necessary to disclose such correspondence to a complainant or their representative in any subsequent legal proceedings.

They are aware that all Group staff dealing with complaints must consider the needs of vulnerable people such as adults with learning difficulties, children, some older people or people with particular disabilities, (such as visual impairment or hearing impairment), and will offer support from relevant agencies to such individuals.

They are aware that all Group staff dealing with complaints must consider the need for language or sensory support, in line with Group policy on Interpretation & Translation (EDH023), in order to make sure that the complaints procedure is accessible to all.

They are aware that Correspondence about concerns/complaints being handled by PALS or the Complaints Department should be kept separate from health records, subject to the need to record in the health records

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any information which is relevant to the patient’s clinical management. When concerns are handled by clinical or nursing staff documentation may be filed in the patient’s health records (documentation placed in a sealed envelope in the records when a concern has been raised by a patient’s relative/carer/friend). Patients will be advised at the outset that investigation of their complaint may require examination of medical records and associated documents.

6.2 Group Committees in Common (CiC)

The CiC will ensure that:

Complaints are taken seriously within the organisation; Complaint handling, particularly lessons learned, is integrated within

governance & risk management processes and systems for improving the patient experience;

Complaints handling is supported by adequate resources; It approves arrangements for dealing with complaints It is receipt of the LFE report following approval from each Care

Organisation’s Quality and People’s Experience Committee (QPE) and Care Organisation Assurance and Risk Committee (COARC)

6.3 Chief Executive

As accountable officer, the Chief Executive must ensure that responsibility to manage complaints, including informal complaints / PALS within the Group is delegated to an appropriate executive lead, as outlined in the executive portfolios;

The Chief Executive (or nominated deputy) will review, approve and provide signatory to all complaint responses. This may also include the Medical Directors, Directors of Nursing, Directors of Social Care and Chief Officers for each CO.

6.4 The Group Associate Director - Patient Responsiveness (GAD)

The GAD is the senior manager with responsibility for complaints policy development, implementation and for managing the procedures for handling complaints in accordance with the regulations.

The GAD will ensure that:

The Group’s complaints handling policy reflects national regulations and guidance;

Systems and processes in place are sufficient to provide the Chief Executive with assurance that robust arrangements are in place;

The Group meets all performance standards in respect of complaints management;

Systems are in place to ensure that the Group CiC , Chief Executive and managers throughout the Group receive regular reports on key performance indicators and are made aware of trends in complaints so that they can take action through the relevant clinical governance and risk management processes;

An annual report on complaints is provided to the Group CiC and published, to provide an assurance to the Group CiC of compliance with

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Care Quality Commission outcome 17. A programme of staff training in complaints handling is developed and implemented across the Group

The GAD or nominated deputy will review and approve complaints responses prior to review by the relevant Site Executive. The GAD will refer any complex clinical complaints to an appropriate senior professional clinician internally e.g. Care Organisation Director of Nursing/Medical Director, or externally, if required.

6.5 Complaints Team (Group Associate Director of Patient Responsiveness, Complaints Managers, Case Managers and Administrative staff)

The Complaints Team will ensure that:

All complaints received are processed in line with this policy; Complaints/ PALS staff balance the needs of complainants and staff; Complainants are supported through their complaints in a sympathetic

and understanding manner, and are advised on the most appropriate route to resolve their complaint, involving other staff or agencies as required;

Staff are supported through the complaints process; Appropriate responses to the required standard are prepared in

conjunction with Divisional and Directorate staff, within the relevant timescales;

Trends in complaints are identified and drawn to the attention of senior managers and regular key performance indicator and trend analysis reports are provided;

They provide support to front line staff in dealing with immediate situations and provide advice to all staff with regard to formal and informal resolution of complaints

Queries or concerns about draft responses are raised with relevant clinical staff, Divisional or Directorate managers so that an appropriate response is provided to the complainant

The need for independent review of any complaint is identified and arrangements for such reviews (to be undertaken by someone not employed by the Trust) are put into place

Case Managers assist those who use the Group’s services by providing advice, information and acting as liaison with Care Organisation staff.

6.6 Divisional Directors

Divisional Directors are responsible for ensuring that complaints concerning their Division are investigated in line with this Policy.

Divisional Directors will ensure that:

They assign a senior person/an Investigating Officer for any received complaints. This person must not be directly involved in the complaint being made;

The Investigating Officer for all complaints must be independent and not be someone who:

o is directly involved in the complaint;

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o had direct involvement in managing the care and treatment of the patient;

or

an independent clinical view will be sought.

Any RED graded complaints, deemed to be an SI, must be investigated in line with Incident Reporting & Investigation Policy EDQ008) V6.3 that states that ‘For all SI investigations within the Trust, including red rated complaints deemed to be SI, at least one member of the investigation team must be trained in RCA methodologies.’

All new RED triaged complaints and Serious Incidents will be reported at the relevant weekly Divisional Management Team Meeting.

Staff throughout the Division proactively address issues raised by those who use the Group’s services in order to minimise the number of complaints;

Staff throughout the Division are empowered to resolve complaints informally and to provide explanations to those who use the Group’s services so that issues raised are addressed as locally as possible without the need to enter into a formal process;

An objective and comprehensive investigation is carried out into complaints received so that full, complete and readily understandable information is provided for the complaint response;

Staff throughout the Division co-operate fully with complaint investigation and resolution;

They have agreed the draft version of complaint responses prior to submission for signature in line with relevant timescales;

Action plans are prepared and implemented when lessons learned are identified during complaint investigations;

They identify and act on risks and ensure that these are discussed and managed through the relevant Division, clinical governance and risk management processes;

Root Cause Analysis (RCA) is undertaken where major / catastrophic or recurring issues or themes are identified.

6.7 Investigating Officer and process of investigation

Investigating Officers will ensure that an appropriate investigation is carried out in respect of complaints received, by:

Obtaining relevant statements, evidence etc. and liaison with other service teams within the Group to ensure a robust investigation is undertaken to the concerns raised

Completing the Resolution Summary template to summarise the investigation into all concerns raised and ensure that the response covers all issues

Provide a written overview to the investigation that evokes the tone and sentiment to be conveyed in the response

Monitoring any action plans that arise from complaint investigations, in liaising with Governance Managers and ensure corrective actions are fully completed

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Ensuring timescales within the investigation request are met; this involves liaising with colleagues within the Group as necessary

Meeting with Complainants as necessary Ensuring risk registers are maintained if any risks are identified and that

any serious issues are escalated within the Division as necessary Ensuring that staff involved in complaints receive feedback on the

investigation and action plan

6.8 Complaints Case Manager

Jointly, with the GAD/ Complaints & PALS Manager, triage any complaints received;

Ensure timely communication is maintained with anyone raising a complaint or concern;

The Complaints Case Managers will provide reports to any group, sub-committee, committee as required;

The Complaints Case Managers will review and approve all complaints responses prior to the GAD/ Complaints & PALS Manager

Complaints Case Managers will consider the possibility of mediation, conciliation or other forms of dispute resolution where this may be an appropriate method of resolving a complaint.

6.9 Divisional Governance Managers

To triangulate the actions and learning or themes from complaints within the wider governance agenda, to ensure continuous improvements in patient safety and experience are maintained within the clinical divisions.

To provide assurance to the monthly complaints review panel, chaired by Non Exec Director, that the content and issues raised in complaints and PALS are regularly discussed at Divisional Governance Board Meetings.

6.10 Patient Advice & Liaison Service (PALS) Officer

Responsibility for co-ordinating responses to any query that is received via PALS processes, including working with appropriate individuals to help resolve informal concerns;

Ensure communication is maintained with anyone raising a complaint or concern

7. Monitoring document effectiveness

7.1 Team responsible for monitoring: Complaints Department Frequency of monitoring: Monthly Process for reviewing results and ensuring improvements in performance:

o Quarterly Review of ‘Learning from Experience Report’ to the Quality & Performance (Q&P) Committee. This will contain qualitative and

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quantitative analysis of number and nature of complaints claims and incidents to enable targeted improvements where required

o Weekly summary of completed complaint investigations, age of complaints, new complaints received and trends submitted to the Senior Management Team (SMT) meeting.

o Monthly summary of all completed complaint investigations, age of complaints, new complaints received and trends submitted to the Patient’s Experience Committee.

o Independent review of complaints handling processes by trust auditors will take place at least once every 3 years and prior to the date of the next review of this policy.

o A quarterly Quality Assurance Group (QAG), chaired by a Non-Executive Director will review a cross-section of complaint responses to ensure policy has been adhered to.

.8. Abbreviations and definitions8.1 Abbreviations

CEO Chief Executive Officer CNST Clinical Negligence Scheme for Trust CQC Care Quality Commission HMC Her Majesty’s Coroner LFE Learning From Experience Report LTPS Liabilities to Third Parties MP Member of Parliament NHSLA NHS Litigation Authority NICE National Institute of Clinical Excellence NPSA National Patient Safety Agency PAT Pennine Acute Hospitals NHS Trust PALS Patient Advocacy & Liaison Service PHSO Parliamentary & Health Service Ombudsman Q&P Quality & Performance RCA Root Cause AnalysisSRFT Salford Royal Foundation Trust SMT Senior Management Team SI Serious Incident

8.2 Definitions of Terms used

The Group adopts the principles of the 4 C’s as laid down by the Department of Health:

Complaint - A complaint is an expression of dissatisfaction requiring a response.

Comment - A comment can be a remark or observation that does not require a formal response;

Concern - A concern is a minor criticism or informal complaint which is dealt with in the first instance by the Patient Advice and Liaison Service (PALS) if it cannot be resolved at Ward / Clinical Service Unit (CSU) level;

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Compliment - An expression of gratitude as a result of services provided to service users, relatives, carers or members of the public to Group staff.

Unreasonably Demanding Persistent and VexatiousComplaintants - On occasions when there is nothing further which can be done to assist a complainant to rectify a real or perceived problem. These complaints take up a disproportionate amount of staff time and resources and dealing with the complainants can cause undue stress to staff. Such complaints are considered to be unreasonably demanding, by virtue of being habitual or persistent. Where a complaint meets two or more of the following criteria it may be defined as being unreasonably demanding.

Persistence by the individual in pursing an issue or complaint after the NHS complaints procedure has been fully and properly implemented and exhausted;

Changing the substance of the issue or complaint, continually raising new issues or continually raising further concerns / questions whilst the complaint is being addressed or upon receipt of a response in order to prolong contact (new issues which are significantly different from the original complaint will not be included within this category and may need to be addressed as separate complaints);

Unwillingness to accept documented factual evidence or to accept that facts can be difficult to verify if a long period of time has elapsed;

Will not identify the precise subject matter of the complaint; Harassing any member of staff or being personally abusive or verbally aggressive

or racially abusive (see Trust’s ‘Policy for Managing Violence, Aggression & Unacceptable Behaviour’ EDE005, available via the Document Management System) Meeting this criterion alone will be sufficient to determine the complaint to be unreasonably demanding without the need for a second criterion to be met and to suspend all contact with the complainant;

Threatening or using actual physical violence (Trust’s ‘Policy for Managing Violence, Aggression & Unacceptable Behaviour’ EDE005); Meeting this criterion alone will be sufficient to determine the complaint to be unreasonably demanding without the need for a second criterion to be met and to suspend all contact with the complainant;

Meetings or face-to-face / telephone conversations tape recorded by the complainant without the prior knowledge or consent of other parties involved;

Unreasonable demands / expectations made and failure to accept these may be unreasonable;

Repeated refusal to follow alternative avenues open to the complainant (e.g. refusal to refer the complaint to Ombudsman).

9. References and Supporting Documents

9.1 References

Local Authority Social Services and National Health Service Complaints (England) Regulations 2009

Data Protection Act Freedom of Information Act NHS Constitution (DH, 2009) The Principles of Good Complaint Handling (Parliamentary and Health Service

Ombudsman, 2008) The Local Government and Social Care Ombudsman-Principles of complaints

handling

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Department of Health (2009) Listening, improving, responding: a guide to better customer care

NHSLA Litigation Authority guidance about complaints My Expectations for Raising Complaints and Concerns (Parliamentary & Health

Service Ombudsman, 2014) Care Quality Commission Core Standards

9.2 Related SRFT/PAT documents

Incident Reporting & Investigation Policy including Serious Incident Framework and Duty of Candour (EDQ008)

Handling clinical negligence claims, liabilities to third parties claims (LTPS), property expenses scheme claims (PES), HM Coroner Inquests and making clinically related Ex - Gratia payments (EDG010)

Being Open Policy (EDQ025) Induction and Mandatory Training Policy (EDH024) Risk Management Policy (EDQ012) Protection of Adults at Risk (NCWC011) Safeguarding Strategy (EDN010) Dealing with Habitual or Vexatious Complainants Policy (EPSE3(06)) Security Policy and Guidelines (EDE010)

10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.

Nominated Lead author:

Name Lynne Logan Group Associate Director - Patient Responsiveness

Lead author contact details:

Full contact telephone number0161 918 4297 [email protected]

[email protected]

Lead Author’s Manager:

Jayne Downey Director of Governance and Corporate Nursing

Applies to: Northern Care Alliance Group (NCA)

Document developed in consultation with :

Josephine McCreath (Case Manager, NES CO) Ben Vickers (Complaints Manager, Salford CO)Complaints DepartmentGovernance

Keywords/ phrases:

Complaints, Concerns, PALS, Unreasonably Demanding Complainants, accident, incident, near miss, reporting, candour

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Communication plan:

To be published on the Trust Document Management System available via the Trust intranet (‘Policies & Documents’) Notification via email to Executive Directors, Divisional Medical Directors, their management teams and key advisors. Training will be provided for staff in relation to this policy as follows:

Induction – All new staff (incorporated as part of the Trust’s Clinical Governance Module)

Customer Service training What makes a good complaint investigation and response – targeted at

Investigating Officers and Senior Managers RCA Training – targeted at Investigating Officers of Serious Incident Investigations (cohort of staff trained in the organisation – see Incident Reporting & Investigation Policy)

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Add name of Committee and Chairpersons name and role:

Insert full approval date: dd/mm/yyyy

Approval:

How approved: Chair’s actions Formal Committee decision

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11. Equality Impact Assessment (EqIA) screening toolLegislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes/noOutline activity/method

1b) Have any amendments been made as a result? If yes, specify what.

Yes/noOutline changes made

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or UnsureThis may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.Protected Group Yes No UnsureAge (e.g. are specific age groups excluded? Would the same process affect age groups in different ways?)

x

Sex (e.g. is gender neutral language used in the way the policy or information leaflet is written?)

x

Race (e.g. any specific needs identified for certain groups such as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

x

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions; dietary needs that may conflict with medication offered.)

x

Sexual orientation (e.g. is inclusive language used? Are there different access/prevalence rates?)

x

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or breastfeeding women?)

x

Marital status/civil partnership (e.g. would there be any difference because the individual is/is not married/in a civil partnership?)

x

Gender Reassignment (e.g. are there particular tests related to gender? Is confidentiality of the patient or staff member maintained?)

x

Human Rights (e.g. does it uphold the principles of Fairness, Respect, Equality, Dignity and Autonomy?)

x

Carers (e.g. is sufficient notice built in so can take time off work to attend appointment?)

x

Socio/economic (e.g. would there be any requirement or expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

x

Disability (e.g. are information/questionnaires/consent forms available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

x

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Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these?(what action has been taken or will be taken, who is responsible for taking a future action, and when it will

be completed by – may include adjustment to wording of policy or leaflet to mitigate)

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?(what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet)

Will this policy require a full impact assessment? No(a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please contact the Inclusion and Equality team for advice on [email protected])

Author: Type/sign: Date:

Sign off from Equality Champion: Date:

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mailto:[email protected]



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12. Appendices

Appendix 1

Grading Matrix (Risk Assessment) & Levels of Resolution

When a formal complaint is received, it is graded to assess the type of response required, and the time length within an investigation needs to be completed. Using the Risk Assessment Tool, the grading process involves considering three questions before a decision is reached:

1. How serious is the complaint (i.e. what the effect has been/could have been on the people involved and how complex the issues are)?

2. What are the potential risks to the organisation?

3. How likely is the issue to reoccur?

The risk assessment Tool:

How serious is the issue? Seriousness DescriptionNegligible

Minor

Unsatisfactory service or experience – not directly related to care. No impact or risk to the provision of care.

OR

A single resolvable issue relating to care. Minimal impact and relatively minimal risk to the provision of care or service. No real risk of litigation.

Moderate Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation.

Major

Catastrophic

Significant issues regarding standards, quality of care, safeguarding or denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation. Possibility of litigation or adverse local publicity.

OR

Serious issues that may cause long-term damage, such as grossly sub-standard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. High probability of litigation and strong possibility of adverse national publicity.

How likely is the issue to reoccur?

Likelihood DescriptionRare Isolated or a “one off” incident. A slight or vague connection to service provision.Unlikely Do not expect this to happen again, but it is possiblePossible May re-occur occasionally or happens from time to time. Likely Will probably re-occur several times a year, but not a persistent issue. Almost Certain Re-occurring and predictable. A persistent issue.

Based upon the questions considered, and choices picked from the tables above, the below table is then used to work out the most appropriate grading for the case:

LikelihoodAlmost Certain Likely Possible Unlikely Rare

Catastrophic

Serio

usne

ss

Major

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ModerateMinorNegligible

Under normal process, cases graded “High” will be responded to within 60 working days and all cases graded “Medium” or “Low” within 25 working days. However, there may be circumstances in which the response time will need to be either shortened or lengthened, depending on the specifics of the case. In such circumstances, the timescale will need to be agreed with the complainant, and must be within 6 months of receiving the complaint, in line with the Complaints Regulations 2009. The below “Levels of Resolution” table provides guidance on the decision making process for response times.

Level 1 – Service managed resolution (response timescale: by end of next working day) HELP Phone can support this processIssues/concerns that can be responded to without a formal investigation where there is no barrier to the service resolving the matter. E.g. appointments, questions around medication, staff attitude, patient property, waiting times, facilities and estates issues, food.Criteria:Reported to be arising from circumstances resulting in minor injury, damage or lossNo likelihood of litigation / No reputational riskNo barrier to local resolution. E.g. no conflict of interest, no resource issues limiting ability to respond, no breakdown in relationshipsLevel 2 – Resolution with PALS involvement – Standard (response timescale: within 5 working days)Issues/concerns that can be responded to without a formal investigation where there is a barrier to the service resolving the matter.Criteria:Reported to be arising from circumstances resulting in minor injury, damage or loss.Little or no likelihood of litigation / reputational risk.Barrier to local resolution. E.g. conflict of interest, resource issues limiting ability to respond, breakdown of relationship between service and enquirer, inhibited communication between enquirer and service.Level 3 – Resolution with PALS involvement – complex (response timescale: within 10 working days)Issues/concerns that can be responded to without a formal investigation where there is a barrier to the service resolving the matter, where multiple services and/or issues, agencies or parties involved. Meetings, phone calls, emails correspondence.Criteria:Reported to be arising from circumstances resulting in moderately serious injury, damage or lossMultiple services or issues, agencies or parties involvedLittle likelihood of litigation / reputational riskBarrier to local resolution. E.g. conflict of interest, resource issues limiting ability to respond, breakdown of relationship between service and enquirer, inhibited communication between enquirer and serviceLevel 4 – Complaint (response timescale: within 25 working days)Issues/concerns that require formal investigation into low number of issues relating to a low number of services. Single organisation.Criteria:Reported to be arising from circumstances resulting in harm / potential harm. Potentially life threatening to a person or substantial damage or loss to self or property.Possible likelihood of litigation / reputational riskMultiple issues (10 or more) or Divisions (3 or more) or multiple organisationsLevel 5 – Complex Complaint (response timescale: Upto 60 working days or to be determined by escalation to Director of Governance, DDNS, to be discussed with the complainant)Issues/concerns requiring formal investigation, where other processes are ongoing or will be required (SIARC, SUI, Safeguarding or legal proceedings)CriteriaReported to be arising from circumstances resulting in life threatening events, extremely serious harm or death, substantial damage or lossHigh probability of litigation / high risk to reputation of TrustComplexity requiring Board-level awareness and oversight

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Appendix 2

Template Resolution Summary

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Complaints Process Flowchart

.

Appendix 3

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Tick/Comment



3. Is the official Group logo displayed correctly at the top of the title page & the document summary sheet if used?

Yes


N/A


Yes


Yes

7. Is your title clear, appropriate and with the subject first? Yes8. Have you adhered to the style and format as described in the policy

template: font size, colour and type?Yes


Yes


Yes


Yes

YesYesYesYesYesYesYesYesYesYesYes

12. Have all the core sections been included?1) What is the policy/Guideline for?2) Where will this document be used?3) Why is this document important?4) What is new in this version?5) Policy/Procedure/Guideline?6) Roles and responsibilities.7) Monitoring document effectiveness.8) Abbreviation and definitions.9) References and supporting documents.10) Document control information11) EqIA screening tool

Yes


Yes


Yes

15. Is it clear where the document has been for consultation/endorsement? Yes16. Are you able to evidence that all stakeholders have been consulted

and provided the opportunity to contribute to the document?Yes

17. Are all dates within the document written as dd/mm/yyyy? Yes18. What dissemination & training arrangements have been made? (If

applicable, please state arrangements other than the policy being Notification via email to Executive Directors,

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made available on the Document Management System) Divisional Medical Directors, their management teams and key advisors. Training will be provided for staff in relation to this policy as follows:


Customer Service training

What makes a good complaint investigation and response – targeted at Investigating Officers and Senior Managers

RCA Training – targeted at Investigating Officers of Serious Incident Investigations (cohort of staff trained in the organisation – see Incident Reporting & Investigation Policy)

19. Have you added relevant key words to support searching for the document?

Yes


Yes

21. Are page numbers in the format of 'page x of y'? Yes22. Has a contents page been completed and page numbers match the

actual contents?Yes


Yes


Yes



Yes


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N/A

29. Have you carried out a spelling and grammar check? Yes30. Have you ensured there are no ‘embedded’ documents as the reader

will not be able to open them once the document is published? Yes


Yes

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Author (s) Jayne Downey, Director of Governance and Corporate NursingLynne Logan, Group Associate Director- Patient Responsiveness

Presented by Elaine Inglesby-Burke, Chief Nurse Northern Care Alliance


Executive Summary

The aim of this policy is to detail the action to be taken if an individual’s behaviour in trying to resolve a concern or complaint is unreasonably demanding, persistent or vexatious.


Pursuing Quality Improvement to assure safe, reliable and compassionate care

Associated Risks

Recommendations The Group Committees in Common is asked to note and approve the content for dissemination throughout the Northern Care Alliance NHS Group

Equality Does this paper relate to a matter where equality issues may arise? No

This document does not contain confidential information and can be made available to the public.








Title of Report Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants

x

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Dealing with Unreasonably demanding, persistent or Vexatious ComplainantsReference Number: Insert here Version Number: Insert here Issue


Page 1 of 15


Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants

Lead Author: Lynne Logan, Group Associate Director - Patient Responsiveness

Additional author(s) Sonia Chouhan (Case Manager, NES CO) Division/ Department: ComplaintsApplies to: Northern Care Alliance NHS GroupDate approved: Insert full approval date dd/mm/yyyyExpiry date: Insert full expiry date dd/mm/yyyy

* This includes documents relevant to multiple Care Organisations, Corporate and Support ServicesContents Contents

Who Should read this document 3 Key points 3 Background & Scope 3 What’s new in this version 4 Policy Introduction 4 Definition 5

Deciding that someone is an unreasonably persistent complainant 6

handling unreasonably persistent complainants 6 Withdrawing habitual or Vexatious status 7 formal disqualification from NCA 8 Explanation of terms / definitions 8 Roles and Responsibilities 8 Compliance checklist for authors 11 Document control information 14 Policy Implementation Plan 14 Monitoring and Review 14 Endorsement 15 Screening equality analysis outcomes 16


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Who should read this document?

This policy is relevant to all staff involved in the management of complaints.

For example: Members of the Complaints Department Senior Clinicians/ Nursing and Service Staff Care Organisation Directors Executive Team

Key Points

This policy defines a structure for the Northern Care Alliance NHS Group (NCA) to deal with complainants who are habitual and/or vexatious. The policy should be used as a last resort and after all reasonable measures have been taken to resolve issues of concern following the Trust’s Complaints Policy.

The aim of this policy is to detail the action to be taken if an individual’s behaviour in trying to resolve a concern or complaint is unacceptable and provides details of unacceptable behaviour.

The policy should be read in conjunction with the Violence and Aggression Policy.

Background and Scope

This policy aims to address the challenges presented by persistent comebacks from people who are generally deemed to be ‘difficult’ and ‘vexatious’. This document also provides advice as how best to deal with them. The intention is to provide clear yet flexible strategies.

It remains the responsibility of staff to ensure that all issues raised by individuals are thoroughly considered and addressed. Individuals with concerns should be kept informed of what is happening. Staff should always be willing to answer queries that patients or visitors may have or refer them to an appropriate person, ensuring that in the process they have enough information to satisfy their immediate needs. When a complaint is made the complainant needs to be kept informed of progress and the deadlines we aim to achieve.

It is important to try to resolve matters using appropriate and sometimes alternative approaches before invoking this procedure. The implementation of this procedure should only be used as a last resort and after all reasonable measures have been taken to try to resolve the complaint.

What is new in this version?


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This Policy has been adapted from Salford Royal NHS Foundation Trust (SRFT) Policy to be used by all staff within the Norther Care Alliance NHS Group (NCA)

1. Introduction

1.1 NCA is committed to treating all complaints equitably and recognises that it is the right of every individual to pursue a complaint.

1.2 Generally, dealing with a complaint is a straightforward process, but in a minority of cases, people pursue their complaints in a way which can either impede the investigation of their complaint or can have significant resource issues for authorities. These actions can occur either while their complaint is being investigated, or once an authority has concluded the complaint investigation.

1.3 We do not expect staff to tolerate unacceptable behaviour by complainants or their representative. Unacceptable behaviour includes behaviour which is abusive, offensive or threatening and may include:

Using abusive or foul language on the telephone Using abusive or foul language face to face Sending multiple emails Leaving multiple voicemails

1.4 Prior to implementing this policy, it is important that everything possible has been done to satisfy the individual, such as referring issues to more senior managers as appropriate. The relevant Complaints Policy must have been appropriately followed and the issue handled appropriately. It should be appreciated that some habitual or vexatious complainants may have issues which contain substance and great care should be taken to listen to any new issue raised.

2. Definition?

2.1 Unreasonably persistent complainants are those complainants who, because of the frequency or nature of their contacts with NCA, hinder the consideration of their or other people’s, complaints.

2.2 Some of the actions and behaviors of unreasonable and unreasonably persistent complainants include:

Refusing to specify the grounds of a complaint, despite offers of assistance from the Complaints Department.

Refusing to co-operate with the complaints investigation process while still wishing their complaint to be resolved.

Refusing to accept that issues are not within the remit of a complaints procedure, despite having been provided with information about the procedure’s scope.

Insisting on the complaint being dealt with in ways which are incompatible with the adopted complaints procedure or with good practice.

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Making what appear to be groundless complaints about the staff dealing with the complaints, and seeking to have them replaced.

Changing the basis of the complaint as the investigation proceeds and / or denying statements he or she made at an earlier stage in the investigation.

Introducing trivial or irrelevant new information which the complainant expects to be taken into account and commented on, or raising large numbers of detailed but unimportant questions and insisting they are all fully answered.

Electronically recording meetings and conversations without the prior knowledge and consent of the other persons involved.

Adopting a 'scattergun' approach: pursuing a complaint or complaints with NCA, at the same time, with a Member of Parliament/a councilor/CCG

/ /solicitors/the Ombudsman. Making unnecessarily excessive demands on the time and resources of staff whilst a

complaint is being looked into, by for example excessive telephoning or sending emails to numerous members of staff, writing lengthy complex letters every few days and expecting immediate responses.

Submitting repeat complaints, after the complaints processes has been completed, essentially about the same issues, with additions/variations which the complainant insists make these 'new' complaints which should be put through the full complaints procedure.

Refusing to accept the decision or repeatedly arguing the point and complaining about the decision.

Combinations of some or all of the above.

3. Deciding that someone is an unreasonably persistent complainant?

3.1 Before deciding that someone is an unreasonably persistent complainant, the Complaints Lead must be satisfied that:

The complaint is being or has been investigated properly Any decision reached on the complaint is the right one:

- Communications with the complainant have been adequate;- The complainant is not providing any significant new information that might affect

the authority’s view on the complaint

3.2 Where the Complaints Lead is satisfied that someone is an unreasonably persistent complainant, the Complaints Lead will then notify the complainant, identify the behavior that is considered to be unreasonable and ask the complainant to behave reasonably in future.

3.3.1 If the complainant is unable or unwilling to comply with this request then the Complaints Lead will develop a plan for all future contacts with the complainant.

4. Handling Unreasonably Persistent Complainants

4.1 The plan for dealing with unreasonably persistent complainants could include some or all of the following:

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Placing time limits on telephone conversations and personal contacts. Restricting the number of telephone calls that will be taken (for example, one call on one

specified morning/afternoon of any week). Limiting the complainant to one type of contact (telephone, letter, email etc.) and/or

requiring the complainant to communicate only with one named member of staff. Requiring any personal contacts to take place in the presence of a witness. Refusing to register and process further complaints about the same matter. Where a decision on the complaint has been made, providing the complainant with

acknowledgements only of letters, or emails, or ultimately informing the complainant that future correspondence will be read and placed on the file but not acknowledged. A designated officer should be identified who will read future correspondence.

4.2 A copy of the plan and the policy on unreasonably persistent complainants will be sent to the complainant along with details about how to appeal the decision and/or the details of the plan.

4.3 The plan will specify how long it will apply to the complainant and when it is to be reviewed.

4.4 When unreasonably persistent complainants make complaints about new issues these should be treated on their merits, and decisions will need to be taken on whether any restrictions which have been applied before are still appropriate and necessary.

5. Recording

All contacts with persons considered to be unreasonably persistent will be recorded on the complaints log.

6. Withdrawing Habitual or Vexatious Status

This status can be withdrawn at any time, if for example the complainant subsequently demonstrates a more reasonable approach. If they submit a further complaint relating to new matters via the normal complaints procedure this will apply. The trust membership department will be notified accordingly.

7. Formal Disqualification from Group Membership

Any person may not become or remain a member if they have been designated a vexatious complainant may not remain a member of the Organisation .

A letter advising a person that they are formally designated as a vexatious complainant, must inform them of the above and confirm that the Trust’s Membership Department has been provided with a copy of the letter and will now remove their name and details from the Trust’s Membership Database.

8. Explanation of Terms & Definition

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Terms explained in document

9. Roles & Responsibilities

1. Roles and Responsibilities:

1.1 Group Executive Nurse Director

1.1.1 Accountable to the Committees in Common (CiC) for ensuring compliance with this policy in all parts of the Group.

1.2 Director of Governance and Corporate Nursing

1.2.1 Responsible to the Group Executive Nurse Director for ensuring that this policy is implemented in all parts of the Group and for ensuring that the policy is reviewed and updated by the specific review dates.

1.2.2 Responsible for reviewing individual cases and for deciding on the appropriate course of action with the Complaints Manager.

1.2.3 Responsible for ensuring the Membership Department is informed of any additions/changes to the central register of Vexatious Complainants.

1.3 Care Organisation Directors of Nursing

1.3.1 Support the Group Executive Nurse Director and Director of Governance and Corporate Nursing in implementing all aspects of this policy

1.4 Associate Director-Patient Responsiveness

1.4.1 Discuss with Patient Advisors action to be taken in respect of complainants whose behaviour is challenging.

1.4.2 Discuss individual cases with Associate Director of Governance and Corporate Nursing as necessary.

1.4.3 Responsible for ensuring the policy is reviewed 1.4.4 Maintaining Central Register of Vexatious Complainants’ and ensuring that the

status of ‘Vexatious ‘ is reviewed every 12 months for each Complainant.

1.4.5 Liaise with the Trust’s Security Management Specialist (SMS) whether the complainant has had action taken against them in accordance with the Violence and Aggression Policy and present information on individual cases to Director of Governance and Corporate Nursing so that a decision can be taken as to the most appropriate course of action regarding complainants who are habitual or vexatious.

1.4.6 Responsible for informing the Membership Department of any additions/changes to the central register of Vexatious Complainants.

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1.5

1.6 Executive Directors, Care Organisation Directors, Divisional Managing Directors, Chair of Divisions, Deputy Divisional Directors of Nursing,,Clinical Directors, Department Heads and Divisional Nurses.

1.6.1 Responsible for ensuring all their staff comply with this policy?

1.7 All Staff

1.7.1 Responsible for following the practice detailed in this policy

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Tick/Comment



3. Is the official Group logo displayed correctly at the top of the title page & the document summary sheet if used?

Yes


N/A


Yes


Yes

7. Is your title clear, appropriate and with the subject first? Yes8. Have you adhered to the style and format as described in the policy

template: font size, colour and type?Yes


Yes


Yes


Yes

YesYesYesYesYesYesYesYesYesYesYes

12. Have all the core sections been included?1) What is the policy/Guideline for?2) Where will this document be used?3) Why is this document important?4) What is new in this version?5) Policy/Procedure/Guideline?6) Roles and responsibilities.7) Monitoring document effectiveness.8) Abbreviation and definitions.9) References and supporting documents.10) Document control information11) EqIA screening tool

Yes


Yes


Yes

15. Is it clear where the document has been for consultation/endorsement? Yes16. Are you able to evidence that all stakeholders have been consulted

and provided the opportunity to contribute to the document?Yes

17. Are all dates within the document written as dd/mm/yyyy? Yes18. What dissemination & training arrangements have been made? (If

applicable, please state arrangements other than the policy being Notification via email to Executive Directors,

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made available on the Document Management System) Divisional Medical Directors, their management teams and key advisors. Training will be provided for staff in relation to this policy as follows:


Customer Service training

What makes a good complaint investigation and response – targeted at Investigating Officers and Senior Managers

RCA Training – targeted at Investigating Officers of Serious Incident Investigations (cohort of staff trained in the organisation – see Incident Reporting & Investigation Policy)

19. Have you added relevant key words to support searching for the document?

Yes


Yes

21. Are page numbers in the format of 'page x of y'? Yes22. Has a contents page been completed and page numbers match the

actual contents?Yes


Yes


Yes



Yes


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N/A

29. Have you carried out a spelling and grammar check? Yes30. Have you ensured there are no ‘embedded’ documents as the reader

will not be able to open them once the document is published? Yes


Yes

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Document Control Information

Procedure for Dealing with Habitual or Vexatious Complainants

Lead Author: Lynne Logan, Group Associate Director-Patient ResponsivenessAdditional authors: N/A

Document owner: Lynne LoganContact details: 0161 918 4297

Classification: PolicyScope: Group wideApplies to: All staffDocument for public display: Yes

Keywords: Complainants, Complaints, Difficulty,

Associated Documents: Violence and Aggression RM21 06

Unique Identifier: EPSE3(06)Issue number: Replaces: Authorised by: Group Risk and Assurance CommitteeAuthorisation date: March 2019 Next review: March 2021

Policy Implementation Plan

The policy will be followed by the Complaints Team in discussion with lead managers as necessary..

Monitoring and Review

. The Associate Director Patient Responsiveness will ensure a Central Register of those Complainants who have been categorised in this way is maintained.

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Endorsement

Endorsed by:

Name of Lead Clinician/Manager or Committee Chair

Position of Endorser or Name of Endorsing Committee

Date

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Screening Equality Analysis Outcomes

The Trust is required to ensure that all our policies/procedures meet the requirements of its service users, that it is accessible to all relevant groups and furthers the aims of the Equality Duty for all protected groups by age, religion/ belief, race, disability, sex, sexual orientation, marital status/ civil partnership, pregnancy/ maternity, gender re-assignment. Due consideration may also be given to carers & socioeconomic factors.

Have you been trained to carry out this assessment? If 'no' contact Equality Team 62598 for details.

Name of policy or document : Procedure for Dealing with Unreasonably demanding, persistent or Vexatious Complainants

Key aims/objectives of policy/document: To ensure Staff treat all complainants in the same way and provide guidance on how to deal with complainants who are unable to accept information provided

1) a) Who is this document or policy aimed at?

Complaints Team and senior Investigators

2) a) Is there any evidence to suggest that your ‘end users’ have different needs in relation to this policy or document; (e.g. health/ employment inequality outcomes) (NB If you do not have any evidence you should put in section 8 how you will start to review this data)

No

3) a) Does the document require any decision to be made which could result in some individuals receiving different treatment, care, outcomes to other groups/individuals?

No

b) If yes, on what basis would this decision be made? (It must be justified objectively)

N/A

4) a) Have you included where you may need to make reasonable adjustments for disabled users or staff to ensure they receive the same outcomes to other groups ?

People with additional needs will receive all additional support before this procedure is implemented.

5) a) Have you undertaken any consultation/ involvement with service users or other groups in relation to this document?

Not significantly different than previous policy.

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b) If yes, what format did this take? Face/face or questionnaire? (please

provide details of this)

N/A

c) Have any amendments been made as a result?

N/A

6) a) Are you aware of any complaints from service users in relation to this policy?

None not had to use.

b) If yes, how was the issue resolved? Has this policy been amended as a result?

N/A

8) a) To summarise; is there any evidence to indicate that any groups listed below receive different outcomes in relation to this document?

Yes No unsurePositive Negative*

Age XDisability XSex XRace XReligion & Belief XSexual orientation XPregnancy & Maternity XMarital status/civil partnership XGender Reassignment XCarers *1 XSocio/economic**2 x

1: That these two categories are not classed as protected groups under the Equality Act.2: Care must be taken when giving due consideration to socio/economic group that we do not inadvertently discriminate against groups with protected characteristics

Negative Impacts*If any negative impacts have been identified you must either a) state below how you have eliminated these within the policy or b) conduct a full impact assessment: 9) How will the future outcomes of this policy be monitored?

Patient and Staff Experience Committee

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10) If any negative impact has been highlighted by this assessment, you will need to undertake a full equality impact assessment:

Will this policy require a full impact assessment? Yes/No (if yes please contact Equality Team, 62598/67204, for further guidance)

High/Medium/Low Type/sign Lynne Logan date: Feb 2019

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Meeting Group Committees in CommonAuthor (s) Lynda Spaven Director of Learning & Organisational Development

Presented by Raj Jain, Chief of Strategy & OD


Executive Summary

This report provides an overview of work against the KPI’s agreed for Workforce & OD by the CiC at its meeting on 29th October 2018. This is the first People Report and as such metrics are not available for every theme. Focus has been on briefing the Board on progress to date in preparation for reporting by metrics in the June report. This report also provides a detailed section on the 2018 National Staff Survey results.


Theme 4: Support our staff to deliver high performance and continuous improvements

Associated Risks All associated principle risks described within the Group BAF

Recommendations To take forward discussion on the content of the quarterly report and identify additional metrics for future reporting.

Equality Does this paper relate to a matter where equality issues may arise? No, it is a report on Workforce and OD work against KPI’s.If so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.








Title of Report People Report – March 2019

X

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X

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1. Introduction

1.1 Production of a quarterly People Report to the Committee in Common was formally agreed by the CiC on 29th October 2019.

1.2 This is the first People Report to be produced and it is acknowledged that further development will be required as maturity of key performance indicators, data availability and data reliability increases.

1.3 This integrated report will bring together data that enables the board to deeply understand the progress, issues and risks of key workforce change projects.

1.4 The report will provide assurance or identify issues/risks on our statutory & regulatory compliance.1.5 Data on business as usual will enable focus on significant issues relevant to the success or failure of objectives

and targets.1.6 The People Report will provide a lens on the mood of our staff through intelligence from the National Staff

Survey and Quarterly Survey results. This will provide an opportunity to gauge the effectiveness of leadership, culture change and embedding of NCA Values

1.7 The report format will cover 11 strategic Themes linked to the Pillars of the People Strategy:

Safe Staffing EDI Productive Staffing Staff Engagement & Welfare Operational Gap Talent Development Performance Leadership Development Statutory & Regulatory Compliance Skills & Competencies - current

Skills & Competencies – future workforce

2. Integrated Report by Themes

2.1 Safe StaffingNo Data available for this report

2.2 EDIThe EDI Road Map has been developed and staff side representatives are currently being engaged with the suggested KPI’s. Once agreed future reports will contain EDI data related to the agreed KPI’s

2.3 Productive Staffing - Agency

North Manchester COMedical and Dental agency spend has significantly reduced over the course of this year. From a peak of £1.2m per month in July, we have reduced spend to 572k per month, based on Jan’s data. This has been achieved predominantly by migrating doctors to NHSP and recruitment. Work continues to reduce agency spend and the care organisation was below trajectory at Month 10.

Nursing and Midwifery agency spend has reduced slightly from a peak of £504k per month in April, to around £400k per month. It has remained pretty static throughout this year and new bank rates are being piloted to determine their impact of fill rates and agency requirements.

Agency spend to month 10 was £10.1M for M&D staff and £4.2M for nursing and midwifery staff.

Bury & Rochdale CON&M – agency spend continues to be below trajectory however January 2019 saw an increased usage of registered agency staff to around £20k however increased spend was also noted in bank. There is no non registered agency spend currently.

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M&D – agency spend saw a reduction in both November and December but a significantly increased position in January 2019 attributed to Consultant spend (£100K), specifically around stroke, some increased non consultant spend (£50k). The care organisation was slightly above trajectory at month 10. Newly configured Medical Workforce Productivity meetings have commenced.

Agency spend to month 10 was £6.45M for M&D staff and £1.18M for nursing staff.

OldhamAgency spend remains high due to site pressures and activity to support cancer surgery with no success on migration from agency. There are significant numbers of doctors in the recruitment pipeline and the care organisation was successful in recruiting to a number of surgical vacancies this month.

Agency spend to month 10 was £6.7M for M&D staff and £2.8M for nursing and midwifery staff.

SalfordLevels of agency spend remain low for nursing staff and were under ceiling for Month 10.Medical agency spend continues to reduce with a positive impact from the rotational clinical fellow programme and agency migration.

2.4 Staff Engagement & Welfare2.4.1 National Staff Survey 2018 was coordinated by the Picker Institute and was distributed to a consensus

population at Salford & NES CO from October until early December. Both Salford and Pennine are benchmarked against other Combined Acute & Community Trusts.

2.4.2 The following charts depict the key results from the 2018 survey. Where possible the results have been presented by Care Organisation however when viewing the charts the following should be taken into account:

SRFT & PAT completed and reported on separately as two legal entities NES CO have been extracted at locality 1 level – for the purpose of reporting by NHS England the CO

have been described as directorates. This means that a like for like CO comparison will not be 100% accurate - the NES CO results do not

include corporate services, estates & facilities or Pharmacy & Diagnostic Group whereas SRFT’s do Whole organisation comparison charts are comparable

2.4.2 The demographics by organisation (PAT & SRFT) at shown in the at a glance table below; response rates have increased by 1% for both organisations compared to 2017 results. Further work needs to be undertaken this year to increase staff engagement in completing the survey especially at NES CO where the 34% response rate was significantly lower than the national average.

2.4.4 SRFT results are within the parameters of best and worse national results for the 10 Themes (described in Page 6).

For 2019 the themes of Quality of Care and Safe Environment – Violence should be focused on to ensure an upward trend towards the best organisation ratings.

There is an small upward trend on staff engagement (↑0.1) There is a small downward trend on Health & Wellbeing (↓0.1) The remaining themes are comparable to previous years results There are no areas of significant improvement against themes although there has been significant

improvement (≥3%) against questions 5g, 5a, 21d, 17a, 5h (see page 14)

2.4.5 PAT results are within the parameters of best and worse national results for the 10 Themes

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Whilst there has been an upward trend for immediate managers theme (increased from 6.4 to 6.6) it is only 0.1 above the reported worst score – this theme should be focused on for 2019

Safe environment – Violence is another theme which should be paid particular attention to for 2019 – the score has remained the same but is only 0.2 above the worst organisation nationally

Safety Culture (↑0.1) & Quality of Appraisals (↑0.1) are showing a small upward trend There has been a small downward trend for Equality, Diversity and Inclusion (↓0.1) and Health &

Wellbeing (↓0.2) All other theme scores are comparable to last year’s results There are no areas of significant improvement against themes although there has been significant

improvement against questions 28b, 5g, 17d, 5a, 19g (see page 14)

2.4.6 Analysis from each CO is presented on pages 16 – 18.

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Pennine Acute Demographics at a Glance

9401Invited to complete the

survey

9200Eligible at the end of

survey

34%Completed the survey

(3167)

40%Average response rate

for similar trusts

33%Your previous response

rate

54% Q21c. Would recommend organisation as place to work

60%Q21d. If friend/relative needed treatment would be happy with standard of care provided by organisation

71% Q21a. Care of patients/service users is organisation's top priority

19

756

Significantly better

Significantly worse

No significant difference

Historical comparison*2

17

71

Significantly betterSignificantly worseNo significant difference

Comparison with average*

Salford Demographics at a Glance

7905Invited to complete the

survey

7796Eligible at the end of

survey

43%Completed the survey

(3332)

40%Average response rate

for similar trusts

42%Your previous response

rate

62% Q21c. Would recommend organisation as place to work

80%Q21d. If friend/relative needed treatment would be happy with standard of care provided by organisation

76% Q21a. Care of patients/service users is organisation's top priority

91

72


Significantly worse


Historical comparison*

76

77


Significantly worse


Comparison with average*

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2.4.7 Themes

The NSS questionnaire consists of 90 questions which this year have been grouped into newly formed Themes. Themes are the summary indicators which provide an overview of staff experience:

Equality, Diversity & Inclusion – includes levels of fair treatment, discrimination and reasonable adjustments

Health & Wellbeing - includes flexible working, positive action on health & wellbeing (H&WB), work related stress, musculoskeletal issues and pressure to come to work when unwell

Immediate Managers – includes support from immediate managers, feedback on work, interest in H&WB, being valued, supported with learning, training and development

Morale – includes engagement, respect at work, work relationships, choice on how to do work, encouragement & pressure; it also includes the questions on intention to leave the organisation

Quality of Appraisals – includes setting clear objectives, helping to improve job, discusses the organisations values and leaving individuals feeling valued

Quality of Care – includes levels of satisfaction with care they give, the difference their role makes and opportunity to deliver care they aspire to

Safe Environment – bullying & harassment (B&H) – includes personal experience in the last 12 months of B&H from service users, relatives, public, managers and colleagues

Safe Environment – violence - includes personal experience in the last 12 months of violence from service users, relatives, public, managers and colleagues

Safety Culture – includes whistleblowing/raising concerns, lessons learnt and feedback shared, incident reporting & response and fair treatment – no blame culture

Staff Engagement – includes looking forward to coming to work, being able to use initiative and make suggestions to improve services, recommending the organisation as a place to work and receive treatment

Further detail on the questions within each theme can be found at Appendix A

The following Charts illustrate scores against Themes by Organisations (SRFT & PAT) and Care Organisations; the final charts illustrate the staff engagement data and trends against national ratings.

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Overall Results by Themes – Comparison of Salford & North East Sector Care Organisations

Pennine Acute Hospitals

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Comparison Bar Chart by CO

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Staff Engagement Trends

2014 2015 2016 2017 20180

1

2

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4

5

6

7

8

9

10

PAT Salford Best Worst

Staff Engagement Trend Comparing Salford and PAT

2014 2015 2016 2017 2018PAT 6.5 6.7 6.6 6.8 6.8Salford CO 7.5 7.0 7.0 7.0 7.1B&R CO N/A N/A N/A N/A 7.2Oldham CO N/A N/A N/A N/A 6.9NM CO N/A N/A N/A N/A 7.0

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Significant findings for SRFT & PATSRFT Top 5 scores (compared to average) PAT Top 5 scores (compared to average)

80%

Q21d. If friend/relative needed treatment would be happy with standard of care provided by organisation 45% Q10c. Don't work any additional unpaid hours per week for this organisation,

over and above contracted hours

40% Q19e. Appraisal/performance review: organisational values definitely discussed 40% Q5g. Satisfied with level of pay

57% Q4f. Have adequate materials, supplies and equipment to do my work 62% Q11c. Not felt unwell due to work related stress in last 12 months

76% Q13a. Not experienced harassment, bullying or abuse from patients/service users, their relatives or members of the public 47% Q4e. Able to meet conflicting demands on my time at work

83% Q13c. Not experienced harassment, bullying or abuse from other colleagues 73% Q28b. Disability: organisation made adequate adjustment(s) to enable me to

carry out work

SRFT Most Improved from last survey PAT Most Improved from last survey39% Q5g. Satisfied with level of pay 73% Q28b. Disability: organisation made adequate adjustment(s) to enable me to

carry out work55% Q5a. Satisfied with recognition for good work 40% Q5g. Satisfied with level of pay

80% Q21d. If friend/relative needed treatment would be happy with standard of care provided by organisation 60% Q17d. Staff given feedback about changes made in response to reported

errors57% Q17a. Organisation treats staff involved in errors fairly 53% Q5a. Satisfied with recognition for good work

56% Q5h. Satisfied with opportunities for flexible working patterns 55% Q19g. Supported by manager to receive training, learning or development definitely identified in appraisal

SRFT Bottom 5 score (compared to national average) PAT Bottom 5 score (compared to national average)

57% Q19f. Appraisal/performance review: training, learning or development needs identified 60% Q21d. If friend/relative needed treatment would be happy with standard of

care provided by organisation63% Q20. Had training, learning or development in the last 12 months 20% Q11a. Organisation definitely takes positive action on health and well-being

38% Q10c. Don't work any additional unpaid hours per week for this organisation, over and above contracted hours 63% Q20. Had training, learning or development in the last 12 months

85% Q17b. Organisation encourages reporting of errors 54% Q21c. Would recommend organisation as place to work85% Q19a. Had appraisal/KSF review in last 12 months 82% Q19a. Had appraisal/KSF review in last 12 months

SRFT Least improved from last survey PAT Least improved from last survey20% Q11a. Organisation definitely takes positive action on health and well-

being 20% Q11a. Organisation definitely takes positive action on health and well-being

70% Q16b. In last month, have not seen errors/near misses/incidents that could hurt patients 70% Q16b. In last month, have not seen errors/near misses/incidents that could

hurt patients

73% Q11b. In last 12 months, have not experienced musculoskeletal (MSK) problems as a result of work activities 73% Q11b. In last 12 months, have not experienced musculoskeletal (MSK)

problems as a result of work activities

81% Q16a. In last month, have not seen errors/near misses/incidents that could hurt staff 81% Q16a. In last month, have not seen errors/near misses/incidents that could

hurt staff

49% Q8d. Immediate manager asks for my opinion before making decisions that affect my work 49% Q8d. Immediate manager asks for my opinion before making decisions that

affect my work

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2.4.8 Responses from Care Organisations Chief Officers

Bury & Rochdale

Following the results of the 2017 survey, Bury & Rochdale took the view to focus on two key areas, personal development, and health & wellbeing. A number of events shared this approach with staff and asked for their involvement in contributing to improving the experience for our staff at work.

The ten themed approach taken to the survey results this year gives an overview of our performance in respect of the key areas that talk to how our staff are experiencing work but, which will also provide a tool to allow leaders and teams to take forward action in areas where they want to see changes. Reflecting upon our successes from 2017 to 2018, we wanted to provide a better experience for staff and a focus on personal and team development, and our staff engagement score gives an indication that improvements are being made and sustained. The Care Organisation reported a staff engagement score of 7.2 against an organisation average of 6.8, with morale scoring 6.2 against an organisational average of 6.0. Making a commitment to personal development has shown an improvement in the quality of appraisals our staff have and the support they receive from their immediate managers, both of which were above the organisational average, 5.4 to 5.1, and 6.9 to 6.6 respectively.

The health and wellbeing of our staff has been of primary concern to the Care Organisation over the last twelve months, with our Health & Wellbeing Group now fully established to provide focus for our staff. Whilst the Care Organisation has seen improvements in its scores above that of the organisations average, 5.9 to 5.7, there is still significant work to be done to deliver change and see staffs experiences at work change. This is also reflected in other key themes which would indicate that health and wellbeing continues to need to be one of our key focuses for the coming year. The scores for themes relating to providing a safe environment and a safety culture is where Care Organisation performance was lower than organisational average, and although improvements were made across some metrics there is still some way to go to make sustained improvements in this area, although this pattern is not out with the national themes identified across all NHS employers.

Overall, the Care Organisation has continued to perform well in the survey making improvements on previous years scores. The year ahead will see the Care Organisation continue to provide a sustained focus on improving our staff experience and engagement, developing fulfilling roles for staff through both personal and team development, and focusing on improving the health and wellbeing of our staff in line with our annual priorities. Our next steps as a senior leadership team is share findings and key themes in our joint session with staff side colleagues and to jointly set priorities for the year ahead with Division’s to deliver locally owned actions.

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Salford Royal NHS Foundation Trust

The Organisation reported a 43% response rate for 2018, receiving comments from 3330 staff from across the organisation. This was slightly above the average response rate of 41% for Combined Acute and Community Trusts.

The survey has been reported against 10 core themes this year allowing comparison against both national benchmarks and internally across divisions. Care organisation action plans will be drawn up around these ten themes allowing staff to easily identify with work in specific areas. The results show better than average scores in two of the ten core themes (Safe Environment – Bullying and Harassment, and Staff Engagement) and worse than average in three of the themes (Equality, Diversity and Inclusion, Quality of Care and Morale). Across the divisions similar trends were reported.

Against the Care Organisations results the best performing Division was the Division of Surgery and Tertiary Medicine. Their results show better than average results in 9 of the 10 Themes reported at Care Organisation Level.

Overall, the Care Organisation has continued to perform well across a number of areas and continues to see improvements on previous year’s scores. In the coming year the Care Organisation will look to provide a sustained focus on improving performance in those areas highlighted in our results in line with our key objectives within our annual plan. Work will be undertaken through both the organisations strategic workforce committee, Staff Partnership Forum and divisional workforce groups to work up local action plans. We will also be working with communications to ensure those areas of strong performance are celebrated with staff.

North Manchester Care Organisation Staff Survey Results 2018

The National Benchmark Staff Survey report for Pennine is not broken down to a ‘Localities’ as such we are not currently able to easily compare North Manchester’s performance to the national performance. However, by comparing the benchmarks reports with the separate locality reports, we are able to draw some comparisons.

North Manchester exceeded the performance of Pennine in 73% of the questions in this year’s survey. Our performance was lower than that of Pennine in 7% of the questions. Key areas where Pennine and North Manchester have improved performance and have exceeded Pennine’s performance include:

Key areas where North Manchester have improved performance:i. The organisation takes action to ensure errors are not repeated: Pennine (68.5%) North Manchester (74.4%) National Average (70.0%)

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ii. My employer made reasonable adjustments to enable me to carry out my work: Pennine (74.2%) North Manchester (74.4%) National Average (73.3%)

iii. Opportunities for flexible working patterns: Pennine (53.1%) North Manchester (55.9%) National Average (52.8%)iv. Staff have not felt pressure by my manager to come to work when not feeling well: Pennine (70.2%) North Manchester (77%) National Average

(74.8%)v. Staff receive regular updates on patient/ service user experience: Pennine (57.3%) North Manchester (60.7%) National Average (61.2%)

While some of these results are reassuring, there is still more to be done to improve these scores too along with the areas that need greatest attention:

I. Organisation definitely takes positive action on health and well-being: Pennine (19.8%), North Manchester (20.8), National Average (27.8%)II. Would recommend organisation as a place to work: Pennine (53.9%), North Manchester (55.3%), National Average (61.1%)

III. If a friend/ relative needed treatment I would be happy with the standard of care provided by the organisation: Pennine (60.3%), North Manchester (60%), National Average (69.9%)

Like many Care Organisations and other Trusts, we are not satisfied with the number of staff who are reporting experiencing harassment and bullying from patients/ relatives or colleagues and managers. North Manchester performed consistently with the rest of Pennine and slightly worse than the National Average score.

We have established staff forums over the next three weeks, across all staff groups, to discuss these areas of concern and for staff to feed into this year’s response to the staff survey. We will be able to report our actions for 2018 in early April.

Oldham Care Organisation

The National Benchmark Staff Survey report for Pennine is not broken down to ‘Localities’ and as such we are not currently able to easily compare the Care Organisation performance to the national performance, however, themes can be identified, and actions to address be determined.

Oldham Care Organisation (OCO) returned a 30.7% response rate which is significantly lower than we would like, and improving this will be a key priority for 19/20.

The OCO had improved and /or are better than the national average for some areas including feedback to staff regarding changes made following incident reporting staff having had appraisal or personal development plan

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staff access to non-mandatory training

A number of areas require improvement and they include : The organisation takes positive action on health and well being Bullying and violence Resourcing

The findings of the survey will be discussed with staff at engagement forums, team brief and through the divisional meetings. The full report, discussion and action areas will be detailed, addressed and monitored through the OCO Workforce Assurance Committee

2.4.9 Action Planning

Staff Engagement (SE) team have developed an SE delivery plan and for 2019-20 will work with each of the CO ADWs and SLTs to agree key priorities for local SE activities. Local priorities will be determined and agreed based on key SE data including – NSS, FFT, national and local audit outcomes.

Group SE objectives for 2019-20 include –

2 cohorts per quarter (8 per quarter in total) from each CO for the Go Engage programme. COs will be supported to nominate their cohorts using NSS data to identify teams in need of SE support.

3 x Quarterly FFT pulse surveys Operationalizing the NSS Collaborating with Go Engage providers to develop a tool that can be used locally by leaders to measure and assess team culture Agreeing data analysis & reporting for NSS with stakeholders in advance of 2019-20 survey

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2.5 Operational Gap

North Manchester

Sickness Absence: 5.73%

Sickness absence at North is current 5.73%. This is down from 6.5% in Jan 2018. Current absence is split 3% LTS and 2.73 % ST. We have a number of long term sickness absence cases involving cancer.

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Jan-

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May

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Jun-

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p-18

Oct

-18

Nov

-18

Dec

-18

Jan-

19

North Manchester CO- Monthly Sickness Absence % (FTE)

North Manchester

Average

UCL

LCL

Target

Voluntary Turnover: 9.7%

Voluntary Turnover has remained relatively static at 9.7%. This figure masks improvements within General Medicine and Surgery (both of which are consistently under 9%). This is matched by higher levels of turnover in Women’s and Children’s. Work is being undertaken to analyse what factors are affecting Women’s and Children’s turnover.

8.16 8.87 8.54

14.07

9.70

0.002.004.006.008.00

10.0012.0014.0016.00

352 Division ofSurgery (N)

352 NMIntegrated

Medicine (N)

352 NorthManchester

COManagement

(N)

352 Women &Children's

Division (N)

NorthManchester

CO

Voluntary Turnover by Division for North Manchester CO - LTR FTE % February 2018 - January 2019

Bury and Rochdale

Sickness absence levels have increased in January 2019 at 6.33%, a pattern which reflects peaks in December and January for the previous two years. As expected this peak in attributable predominantly to short term sickness absence. We have undertaken a deep dive across nursing led by

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the Nurse Director where each absence case was reviewed for completeness and this has been continued with medical and managerial staff. Meeting are set up in the next two weeks to complete a similar review for AHP’s and estates staff following discussion at SWAC. Regular reviews of long term sickness cases with the ADW and the HRBP’s happens with the HRA’s and there is a sickness absence action plan which was developed by the team. In addition to supporting management the Care Organisation has now established the health and wellbeing group which is taking action to support individuals to stay well and in work.

0.00%

1.00%

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4.00%

5.00%

6.00%

7.00%

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Jan-

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n-18

Feb

-18

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-18

Apr

-18

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-18

Jun-

18Ju

l-18

Aug

-18

Sep

-18

Oct

-18

Nov

-18

Dec

-18

Jan-

19

Bury & Rochdale CO- Monthly Sickness Absence % (FTE)

Bury & Rochdale

Average

UCL

LCL

Target

Turnover

Turnover has improved at BRCO and is currently at just under 11% with the BRCO vacancy factor reducing from 15% to just under 6% since May 17. Hosted services have significantly higher turnover at 24% and work will need to be undertaken to look further in to this. Data relating to turnover is limited currently however work was undertaken by the HRA in the latter part of 2018 to identify any recurring themes or hotspots and actions to be taken and the ADW is reviewing this again in April 2019.

7.07

10.57 10.30

12.75

10.69

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

352 Bury &Rochdale COManagement

(BR)

352 BuryIntegratedCare (BR)

352 HMRIntegratedCare (BR)

352 HostedService (BR)

Bury &Rochdale CO

Voluntary Turnover by Division for Bury & Rochdale CO -LTR FTE % February 2018 to January 2019

Oldham

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Sickness

Sickness fell slightly in January from a peak of around 6.3% in December to 5.9%. Long term sickness reduced in month but this was offset by an increase in short term sickness. The division of surgery had the highest level of sickness in month at 7.27%

0.00%

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4.00%

5.00%

6.00%

7.00%

8.00%

Jan-

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b-17

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-17

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May

-18

Jun-

18Ju

l-18

Aug-

18Se

p-18

Oct

-18

Nov

-18

Dec

-18

Jan-

19

Royal Oldham CO- Monthly Sickness Absence % (FTE)

Royal Oldham

Average

UCL

LCL

Target

Turnover

Vacancy rates are unchanged at around 6.24% across the care organisation. Whilst voluntary turnover is relatively high in Women and Children’s services at 9.65% we have very low rates of vacancies with the rate vacancy being 2.73%. Vacancy rates are higher in Medicine and Surgery with rates in Medicine of 5.38% and in Surgery of 8.45%.

7.338.46

12.59

6.71

9.658.48

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Voluntary Turnover by Division for Royal Oldham CO -LTR FTE % February 2018 -January 2019

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Salford

Sickness Absence: 4.50%

Sickness absence within Salford Care Organisation was reported at 4.50% as at the end of February 2019. This is down from 5.28% in Jan 2018.

The integrated Care Division continues to report the highest absence rates at 4.72% for the same period.

2017

01

2017

02

2017

03

2017

04

2017

05

2017

06

2017

07

2017

08

2017

09

2017

10

2017

11

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01

2018

02

2018

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02

[$-10409]0,00

[$-10409]1,00

[$-10409]2,00

[$-10409]3,00

[$-10409]4,00

[$-10409]5,00

[$-10409]6,00

Absence Rate

Target

Absence Rate - Salford Care Organisation

Turnover

Voluntary Turnover: 10.5%

Voluntary Turnover has remained relatively static over the last twelve months. The Manchester Centre for clinical Neurosciences continues to report low levels of turnover and is currently reporting at 8.3%.

Total

236 Man

cheste

r Centre

for Clin

ical

Neuroscience

s

236 Corporate Se

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Divisio

n

236 Integra

ted Care

Divisio

n

236 Divisio

n of Surge

ry

& Tertiary

Medicin

e

0,0%2,0%4,0%6,0%8,0%

10,0%12,0%

Total

236 Manchester Centre for Clinical Neurosciences

236 Corporate Services Division

236 Integrated Care Division

236 Division of Surgery & Tertiary Medicine

Voluntary Turnover by Division for Salford Care Organisation Feb 2018- Jan 2019

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2.6 Talent Management & DevelopmentBackground & key data Following a report1 outlining the significant challenges facing the NHS (and wider system) in recruiting and retaining senior level talent, the focus of T27 and pilots 1 & 2 was on succession planning for the most senior roles in NCA. Directors were asked to nominate talent/potential in their teams. The T27 process was managed by Carol Rothwell and part outsourced to a consultancy.

T27 Pilot 1 Pilot 2

Focus Group Top 27 (+) CO and Group roles

Senior leaders (director minus 1 & 2) in COs

Senior leaders in Group Functions (director minus 1 & 2)

Numbers nominated

26 93 started83 reported back

35

How managers determined who to nominate

Automatic inclusion

Briefing session with CO senior leaders

Nom Mgrs were briefed in how to identify potentialCOMS-VB model introduced and applied

How nominees were signed up

n/a Pledge (completed by less than 50%)

Asked to submit a brief Biography and undertake psychometrics

Pitch process n/a N/A Talent Panel – Nom Mgrs pitched their talent

Structured Development Review uptake

Assessment = 100%

4 = no 90% dates set

Withdrew from process

n/a 10 4

Changed/Moved jobs within 12 months

5 28 Estimate 30% in first 4 months still waiting for returns on our questionnaire to nominees

Ready now (self) 43 Not yet complete

Actively engaged in development/ Doing a project

3 81 All to date

EDI data 2 non-white British15 male11 female10 x 50+ years

2 non-white British20 male5 x 21-34 years14 x 50+ years4 other (SO)

Not yet complete

1 https://www.kingsfund.org.uk/sites/default/files/2018-07/Leadership_in_todays_NHS.pdf

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https://www.kingsfund.org.uk/sites/default/files/2018-07/Leadership_in_todays_NHS.pdf

Talent Management (TM) objectives for 2019-20 -

1. Continue to consult to deliver a cohesive and agreed approach to TM for NCA supported by a plan for operationalizing TM.

2. Ensure the roll-out of My Contribution (CF2) supports our aspirations and expectations of TM at an organisational and individual level.

3. Determine and ensure buy-in to an NCA Group ethos & principles for TM.4. Consult & engage key stakeholders and agree TM priorities with COs and functions.5. Source and make available tried and tested tools for TM. 6. Continue to collaborate, engage, and learn from the national and regional agenda for TM.7. Research digital solutions that support TM in large and complex organisations.

NCA TM – proposed underpinning principles and ethos to date (work in progress). Our approach to TM will –

• Be inclusive ethos where individuals are encouraged and supported to manage their careers and stay with us

• Identify and track at risk/hard to fill posts• Support managers in identifying & developing future talent • Actively support teams with challenges in SP• Include a pipeline of/for graduate management trainees • Offer group projects identified as development opportunities• Provide career paths for all key pathways including clinical, medical & DM and key group

functions• Development opportunities for all leaders • Ensure the content of development programmes aligns to strategic aims and develops the

mindset, skills & behaviours needed to deliver the NCA services and transformation agendas

• Improve on our NSS results - Identify actions to achieve an improvement in NSS results (see following slides)

• Enable TM data to be gathered as part of the annual ‘My Contribution’ conversations.

TM data/measures to determine priorities for COs & functions – To be determined as part of the TM local delivery plan but may include -

• At risk vacancies (NCA & national)• At risk vacancies filled form within• Time to hire • Turnover• Numbers of leaders directly involved in development activities• Talent pipeline opportunities created and delivered • Graduate management trainees (GTMs) appointed on completion of training• Show a trend for improvement in NSS results (see following slides)

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2.7 Leadership Development

2.7.1 Work has been undertaken to develop a NCA wide leadership model (top of next page) which has defined the key areas of delivery and describes the mindset, skills and behaviours our leaders need. The Leadership wheel aligns to our NCA values (below) and was presented to 150 top managers at the leadership summit held in November. Following feedback the model below was agreed and the Talent and Organisational Development team are embarking on wider staff engagement to ensure buy in to our values and leadership behavioural frameworks through:

Initial research into strategic drivers and vision, SRFT & PAT ‘well-led’ ratings, staff survey results, and culture to inform the model created.

Pilot of a leading edge social media platform (NCAexplore) which provides opportunities for extensive online engagement with 500 staff (including those generally hard to reach staff) about our values. NCAexplore is also hosting a ‘Let’s Talk Leadership’ online forum to engage leaders around our mindset, skills and behaviours

Additional non-digital programme of engagement to ensure wider reach including – values exercise in all new staff induction programmes, traditional comms, roving reporters gathering stories, and focus groups being held with different staff groups.

Aligning and validating outputs of the above to patient experience research work and NCA group strategies, objectives and vision.

Ensuring the models & frameworks are incorporated in our existing processes and policies and

Developing a structured process for stakeholder comms & engagement with COs, functions, staff side and other key staff groups to ensure the models and frameworks developed are socialised and embedded across the organisation.

2.7.2 NCA Values and how they align to the four Key Areas of Delivery for our leaders

Our four NCA values are being brought to life though a programme of engagement and comms that will mean the mindaset, skills, and behaviours described in our behavioural frameworks deliver our vision of saving lives and improving lives for patients and communities as well as resonating with staff throughout the NCA.

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2.7.3 NCA

2.7.4 Medical LeadershipFollowing the Medical Staff Engagement (MSE) Survey and subsequent MSE Task & Finish Group a Medical Engagement & Leadership senior OD Consultant is being appointed for 18 months. This role will be instrumental in working with our medical leaders to develop a suite of medical leadership programmes, identify augmented skills set and critical roles for talent development and improve engagement.

Pioneering

Highly reliable Evidence-based Highest quality

Connected At scale

Trusted

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2.8 Performance – Contribution Framework 2 (CF2)CF2 socialisation continues to be rolled out across the NCA. Progress has been slower than hoped due a variety of reasons (see table below). Since January socialisation training plans with trajectories have been put in place for each CO & Pharmacy & Diagnostics Group. Update reports against trajectories are reported on each month at the Workforce, OD & TM Programme Board.

Table showing numbers requiring training, training places offered and utilisation

Total NCA managers/leaders requiring CF2 socialisation:

5443 Total ½ day socialisation workshops delivered: 157

Total trained to date: 1062 Places offered: 3454

Total remaining: 4381 Total attendees: 1062

% remaining: 80.5% Total places offered not utilised: 2392

Table demonstrating uptake of socialisation by CO and Directorates

Total managers/leaders Total trained to date % remaining

Salford 2259 328 85.5%Oldham 604 92 84.8%North Manchester 661 80 87.9%Bury & Rochdale 670 133 81.1%Group/Corporate 961 332 65.5%Diagnostics & Pharmacy 288 97 66.3%NCA Total 5443 1062 80.5%

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Appraisal Completion Rates and NSS Quality of Appraisal Rates by Care Organisation

Care Organisation Salford Bury & Rochdale Oldham North Manchester% Appraisals Completed 75% 64% 65% 63%

2018 NSS Results(Best Nationally 6.2)

5.4 5.4 5.3 5.2

Actions Future Developments Planned & begun delivery of refresh to senior teams in CO and

Group – 5 slides for SLTs to commit to action for CF2 roll-out Designed and tested a 1.5 hour session for trained, competent and

confident LMs Set up system to ensure right nominees to sessions Paperwork finalised & staff side approved Gathered & delivered first set of weekly data to CO’s Both intranet sites refreshed & more accessible First collaboration on CF2 roll-out support W&LOD CO boards presented with local data

Step by step guide for senior leaders to implement CF2 Holding to account at every level- Linking execs to senior leaders Group CF2 comms plan -’big bang’ link to Annual Planning in April 2019 Reporting on CF2 in the local staff engagement delivery plans Continue to secure SLT support for roll out Continue to comm the culture change intentions/agenda of CF2 Positively use the NSS data to reinforce the need for CF2 (see next slides)

CF2 must be an action for all CO as part of the engagement plan; there is correlation with the poor NSS results for the appraisal theme, appraisal rates and uptake of CF2.

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2.9 Skills & Competence Current Workforce

2.9.1 A learning needs analysis was conducted during 2018 to determine the skills and knowledge requirements of the current workforce to support achievement of organisational and care organisation goals. Each CO LNA was signed off by Directors of Nursing

2.9.2 The LNA data is currently being utilised to compile the Training Delivery Plan. The Training plan will provide an overview of what will be delivered, how it will be delivered and the number of places on offer for 2019/20. The Training Delivery Plan will be submitted for review and sign off to the April CiC meeting.

2.9.3 Reports will be available for future People Reports to provide an update on performance against delivery plan and uptake of training places offered by Care Organisation.

2.10 Skills & Competence Future Workforce

2.10.1The first Nursing Associates (NA) qualified in January/February 2019. They are employed in low acuity areas across group. Evaluation of the impact these roles have on patient care and experience will be reported on in future reports. As part of ‘growing our own workforce’ it is hoped that 50% of the new NA will progress to become 1st level registered nurses, with 50% remaining in the role.

2.10.2Current NA, Training Nursing Associates on programme, future offer:

2.10.3The NCA is currently collaborating with University of Salford to commence a pilot group of 20 Apprentice Nurses in January 2020. The funding for training these nurses will be drawn from the Apprenticeship Levy. These apprentices will be employed by NCA whilst completing their programme. It is anticipated that this will be a progression route for Nursing Associates and HCA’s.

2.10.4The NMC have published their Standards of proficiency for registered nurse and described the future nurse. This includes detail of the skills, knowledge and attributes all nurses must demonstrate. As an organisation we need to provide practice learning opportunities that allow students to develop and meet the Standards of proficiency for registered nurses to deliver safe and effective care to a diverse range of people across the four fields of nursing practice: adult, mental health, learning disabilities and children’s nursing, we need to ensure that students experience the variety of practice expected of registered nurses and meet the holistic needs of people of all ages. We must provide practice learning opportunities that allow students to meet the communication and relationship management skills and nursing procedures, as set out in Standards of proficiency for registered nurses, within their selected fields of nursing practice: adult, mental health, learning disabilities and children’s nursing which will include a range of

TNA and NA across groupNursing associates qualified Feb 19 32Trainee nursing associates Cohort 2 April 18 – April 20 53Trainee nursing associates Cohort 2 Sept 18 – Sept 20 21Trainee nursing associates recruited to start April 19 38Trainee nursing associates places on offer to start Sept 19 42Trainee nursing associates places on offer to start March 20 40

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clinical skills previously not delivered within practice i.e. IV therapy, venepuncture, prescribing. We must also ensure technology enhanced and simulation-based learning opportunities are used effectively and proportionately to support learning and assessment and pre-registration nursing programmes leading to registration in the adult field of practice.

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2.11 Statutory & Regulatory Compliance

2.11.1Over the last 12 months standardisation of mandatory training has been underway across the NCA. Simultaneously alignment to the Core Skills Framework has occurred. The team have progressed to standardising role essential training for different staff groups. Mandatory Training compliance reports are sent to CO & Directorates on a monthly basis.

2.11.2There are limitations to the report format as we are still operating two learning management systems across Group. Competencies have been established differently in each organisation – e.g. Moving & Handling at PAT reports on both theory and practical; at SRFT it is identified as separate competencies. Mandatory Training data at PAT is in the process of being migrated from a long established database into the OLM function of ESR due to quality issues with the previous database. Neither of the current systems fully meets the workforce & OD needs of the NCA. A functionality specification is currently being undertaken with a view to procure a modern learning management system with the capability to track and report on all areas from Mandatory training to Talent tracking.

2.11.3 Compliance targets for all core skills topics is set at 95%

PAT Compliance Table

Care OrganisationsPennine Acute Trust B&R CO NMCO

Oldham COCompetency

% Trained%

Trained%

Trained%

TrainedHandwashing Technique| 76% 81% 86% 84%

Equality, Diversity and Human Rights - 3 Years| 86% 91% 87% 89%Equality and Human Rights Tier 2|Core 79% 79% 79% 80%

Fire Safety - 1 Year| 73% 76% 74% 79%Health, Safety and Welfare - 3 Years| 88% 92% 90% 90%

Infection Prevention and Control - Level 1 - 3 Years (Non-clinical)| 90% 96% 94% 96%

Infection Prevention and Control - Level 2 - 1 Year (clinical)| 71% 77% 74% 79%

Information Governance and Data Security - 1 Year| 75% 80% 75% 80%

Moving and Handling - Level 1 - 3 Years| 92% 96% 94% 95%Preventing Radicalisation - Levels 1 & 2 (Basic

Prevent Awareness) - 3 Years| 88% 94% 93% 94%

Safeguarding Adults - Level 1 - 3 Years| 88% 93% 92% 93%Safeguarding Adults - Level 2 - 3 Years| 88% 93% 92% 93%

Safeguarding Children - Level 1 - 3 Years| 87% 92% 90% 93%Safeguarding Children - Level 2 - 3 Years| 87% 92% 89% 93%

Overall Compliance 80% 83% 82% 83%

NB Corporate Functions & Pharmacy & Diagnostic staff are included in the PAT overall figure

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SRFT Mandatory Training Compliance

% Compliant 87.35%% Compliant 80.77%% Compliant 83.30%% Compliant 79.15%% Compliant 77.69%% Compliant 96.03%% Compliant 87.15%Completed 556% Compliant 92.08%

% Compliant 91.54%

% Compliant 93.01%% Compliant 91.28%

% Compliant 88.38%Completed 1650% Compliant 95.20%

% Compliant 90.23%

% Compliant 83.46%

% Compliant 94.12%% Compliant 84.65%

% Compliant 83.43%

% Compliant 50%

% Compliant 68.75%% Compliant 94.02%% Compliant 90.35%Completed 103% Compliant 91.94%% Compliant 92.98%% Compliant 84.27%% Compliant 66.67%

Total

ANTT CompetenciesANTT Renal - Heamodialysis

course Name

Fire Safety ClinicalFire Safety Medical StaffFire Safety Non ClinicalHealth and SafetyInfection Control Medical StaffInfection Prevention Control Lv 1Infection Prevention Control Lv 2Information GovernanceManual Handling Medical StaffManual Handling Non Patient PracManual Handling Non Patient ThryManual Handling Patient Cont ThryManual Handlng Patient Cont Pract

Resus (Paediatric BLS)

Prevent TrainingResus (Adult BLS)Resus (Immediate Life Support)Resus (Paediatric and Adult BLS)

Safeguarding Children Group 3Safeguarding Children Group 4

Safeguarding Adults level 1Safeguarding Adults Level 2Safeguarding Children Group 1Safeguarding Children Group 2

3.0 RecommendationsMetrics from this report indicate:

The need to listen to our staff and develop thorough action plans with realistic targets ensure interventions to improve all areas of the NSS in particular H&WB, Appraisal and incidences of bullying, harassment and violence

A NCA Leadership Model with the mindset, skills and behaviours clearly defined for all leaders to aspire to, be managed against and for talent to be easily identified

Full commitment, at all levels to the culture change required to fully implement CF2 Improved digital systems which can produce meaningful workforce and OD

performance data

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Appendix A

The questions contributing to each theme as well as an explanation of how the theme scores are calculated.

1. Equality, diversity & inclusion

Q14 - “Does your organisation act fairly with regard to career progression / promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age?”

Q15a - “In the last 12 months have you personally experienced discrimination at work from patients / service users, their relatives or other members of the public?”

Q15b - “In the last 12 months have you personally experienced discrimination at work from manager / team leader or other colleagues?”

Q28b - “Has your employer made adequate adjustment(s) to enable you to carry out your work?"

Calculation: All participants who have replied to at least half of the questions in the theme get allocated an overall score which is the mean value of their rescored questions. The theme value is the mean score of all individuals' overall scores.

2. Health & wellbeing

Q5h - "The opportunities for flexible working patterns."

Q11a - “Does your organisation take positive action on health and well-being?”

Q11b - “In the last 12 months have you experienced musculoskeletal problems (MSK) as a result of work activities?”

Q11c - “During the last 12 months have you felt unwell as a result of work related stress?”

Q11d - “In the last three months have you ever come to work despite not feeling well enough to perform your duties?”

Calculation: All participants who have replied to at least three of the questions in the theme get allocated an overall score which is the mean value of their rescored questions. The theme value is the mean score of all individuals' overall scores.

3. Immediate managers

Q5b - “The support I get from my immediate manager.”

Q8c - “My immediate manager gives me clear feedback on my work.”

Q8d - “My immediate manager asks for my opinion before making decisions that affect my work."

Q8f - “My immediate manager takes a positive interest in my health and well-being.”

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Q8g - “My immediate manager values my work.”

Q19g - “My manager supported me to receive this training, learning or development.”


4. Morale

Q4c - “I am involved in deciding on changes introduced that affect my work area / team / department.”

Q4j - “I receive the respect I deserve from my colleagues at work.”

Q6a - “I have unrealistic time pressures.”

Q6b - “I have a choice in deciding how to do my work.”

Q6c - “Relationships at work are strained.”

Q8a - “My immediate manager encourages me at work.”

Q23a - “I often think about leaving this organisation.”

Q23b - “I will probably look for a job at a new organisation in the next 12 months.”

Q23c - “As soon as I can find another job, I will leave this organisation.”

Calculation: This theme score is calculated based on two separate sub-scales, where participants who get a score for both the sub-scales get an overall morale score, which is the average of the two sub-scores. The theme value is the mean score of all individuals' overall scores.

The sub-scales are: Stress (q4c, q4j, q6a-c, q8a) and Intention to leave (q23a-c). Participants need to reply to at least 3/6 of the questions for Stress, and at least 2/3 of the questions for Intention to leave to get a sub-score for each. The sub-scores are the mean of their contributing rescored questions.

5. Quality of appraisals

Q19b - “It helped me to improve how I do my job.”

Q19c - “It helped me agree clear objectives for my work.”

Q19d - "It left me feeling that my work is valued by my organisation."

Q19e - “The values of my organisation were discussed as part of the appraisal process."


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6. Quality of care

Q7a - “I am satisfied with the quality of care I give to patients / service users.”

Q7b - “I feel that my role makes a difference to patients / service users.”

Q7c - “I am able to deliver the care I aspire to.”

Calculation: All participants who have replied to at least two of the questions in the theme get allocated an overall score which is the mean value of their rescored questions. The theme value is the mean score of all individuals' overall scores.

7. Safe environment - Bullying & harassment

Q13a - “In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from patients / service users, their relatives or other members of the public?”

Q13b - “In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from managers?”

Q13c - “In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from other colleagues?”


8. Safe environment - Violence

Q12a - “In the last 12 months how many times have you personally experienced physical violence at work from patients / service users, their relatives or other members of the public?”

Q12b - “In the last 12 months how many times have you personally experienced physical violence at work from managers?”

Q12c - “In the last 12 months how many times have you personally experienced physical violence at work from other colleagues?”


9. Safety culture

Q17a - “My organisation treats staff who are involved in an error, near miss or incident fairly.”

Q17c - “When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again.”

Q17d - “We are given feedback about changes made in response to reported errors, near misses and incidents.”

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Q18b - “I would feel secure raising concerns about unsafe clinical practice.”

Q18c - “I am confident that my organisation would address my concern.”

Q21b - “My organisation acts on concerns raised by patients / service users.”


10. Staff engagement

Q2a - “I look forward to going to work.”

Q2b - “I am enthusiastic about my job.”

Q2c - “Time passes quickly when I am working.”

Q4a - “There are frequent opportunities for me to show initiative in my role.”

Q4b - “I am able to make suggestions to improve the work of my team / department.”

Q4d - “I am able to make improvements happen in my area of work.”

Q21a - “Care of patients / service users is my organisation's top priority.”

Q21c - “I would recommend my organisation as a place to work.”

Q21d - “If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation.”

Calculation: This theme score is calculated based on 3 separate sub-scales, where all participants who get a score for at least 2/3 of the sub-scales get an overall staff engagement score, which is the mean of the sub-scores. The theme value is the mean score of all individuals' overall scores. The sub-scales are: Motivation (q2a-q2c), Ability to contribute to improvements (q4a, q4b, q4d), and Recommendation of the organisation as a place to work/receive treatment (q21a, q21c, q21d). Participants need to reply to at least 2/3 of the questions in a sub-scale to get a score for it. The sub-scores are the mean of their contributing rescored questions.

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Meeting Group Committes in Common

Author (s) Allan Cordwell, Head of Group Emergency Planning, Resilience & Response Unit & Reserve Forces Champion

Presented by Mrs Judith Adams, Chief Delivery Officer


Executive Summary This report outlines the continuing preparations that are being undertaken by

the NCA EU Exit Task Group to mitigate the impact of the planned United Kingdom exit from the European Union on March 29th 2019. The Exit plans for the NCA Group conform to guidance from the NHS EU Exit Strategic Commander. Daily reporting to NHS England to confirm Group preparedness and report any local difficulties commences on the 19th March. The Group lead for EU Exit is Jude Adams.

The service area work stream leads have prepared the Group for the potential consequences of EU exit if this takes place without a deal on the 29th March. NHS E has directed NHS Trusts not to increase stock levels of medicines and medical supplies but checks with suppliers have been completed to assure the Group that they have overstocked. Where necessary, alternative suppliers have been identified. Residual risk remains however for the delivery of highly specialized items such as the import from Holland of short half-life radio isotopes, and the supply of blood reagents from Europe for some Biochemistry tests. Business Continuity plans are in place in the Group for these and other risks. Strategically, the NHS is securing alternative supply routes to the channel ports and requesting suppliers to increase stock levels by an additional 6 week supply. To adapt to out of hours delivery disruption, two receiving points of the Group - at Salford Royal and the Royal Oldham - will remain open 24 hours a day, 7 days a week should there be a no deal exit on the 29th March.

Annual Plan Objective Deliver Operational Excellence

Associated Risks Medicines and supplies stock depletion below levels to maintain normal patient care services.

Recommendations Group Committees in Common is asked to support the NCA’s direction in continuing to conform to NHS England requirements on preparation for EU exit, particularly in the case of a no deal scenario, and maintain local vigilance to ensure continuity of supply of both medicines and medical supplies to ensure continuation of patient services.

Title of Report EU Exit Preparedness

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Equality Does this paper relate to a matter where equality issues may arise? Y/NIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.











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Northern Care Alliance

NCA EU Exit Preparations

NCA EPRRU March 2019

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1.0 Introduction1.1 This report outlines the continuing preparations that are being undertaken by the NCA EU Exit Task Group to mitigate the impact of the effects of the planned United Kingdom exit from the European Union on March 29th 2019. The Exit plans for the NCA Group conform to the NHSE and the EU Exit Strategic Commander’s (Keith Willett) guidance.

The Group lead for EU Exit is Jude Adams who has led the EU Exit Team which has been coordinated by the Group Emergency preparedness, resilience and response team.

2.0 Group EU Exit Task Group

2.1 Each of the following work streams has a Group Lead and the Head of EPRRU coordinated the meetings and circulation of Action Plans; Communications, Supplies, Workforce, Clinical Trials, Data, Finance, Medicines and Reciprocal Healthcare.

2.2 Each work stream has been charged with assessing the operational risks of an EU Exit on the 29th March 2019. All work stream Leads have reported there are no high or moderate risks to the Group from a ‘no deal’ EU Exit. Finance are estimating the costs to the Group to running 24 hour, 7 day a week, receipt and distribution stores which will be provided at two hospital

locations (SR and TROH) to reduce potential disruption of supply chains.

2.3 In addition, certain specialised medicines and specialist equipment are being early ordered in case of supply disruption, although the general guidance not to over-order is being adhered

to.

2.4 The NCA updated ‘Temperature Check’ has been completed and returned to NHSE. The NCA Group Temperature check is listed below in Appendix ‘A’.

3.0 Waypoints3.1 The NCA EU Exit Task Group continues to meet, Chaired by Jude Adams, to prepare the

Group for an EU exit on the 29th March and particularly for the risk of a no deal Exit.

3.2 A Twenty Four hour, 7 day a week stores Receipt & Distribution service is being prepared from the 29th March 2019, should there be a no deal EU Exit.

3.3 Continuing assessment of specialist items delivery disruption and provision of contingency plans.

3.4 Provide a Group daily sitrep to NHS England from the 19th March.

3.5 Continuing to respond to NHSE / other Agencies, requests for information / assessment of NCA preparedness and response to EU Exit risks.

3.6 Continue Communications updates to brief staff.

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Appendix A – Updated Group “temperature check” provided to NHS England

TopicNorthern Care Alliance (NCA) R / A / G Rating

Comments & Risks Identified Assurance Provided By

Operational Communications

GREEN NCA Communications are setting up web pages on Trust Intranets and using group media to communicate EU Exit preparations to front line staff

Andrew Lynne

Operational Readiness

GREEN NCA meets all requirements in this section of the temperature check EPRRU

Supply GREEN Plans are in place for longer lead times and receiving deliveries out of hours, however, operational readiness requires 2 weeks’ notice

Joe Lever / Claire Parker

Workforce GREEN Assurance from Workforce Lead that the systems required within the Temperature check are in place. No risks have been identified.

David Hargreaves / Amy Goodall

Clinical trials GREEN Assurance received from Clinical Trials lead that there are no risks, no European Grants utilised.

Steve Woby

Data GREEN Assurance from Data Lead that the systems required within the Temperature check are in place. No risks have been identified

Jym Bates

Finance GREEN The Finance Lead has not flagged any risks associated with EU Exit for the NCA Nicky Tamanis

Health Demand GREEN Wider risks of EU Exit on the local health system has been assessed with partners via LHRP /LRF and no further risks have been identified

LHRP

Medicines & Vaccines

GREEN Whole sale / Manufacturer supply assuranceShort half-life (6 hours) radio isotopes used in Nuclear Medicine are used by 200 patients a month across the NCA. Daily supply is from the Christie who in turn have a twice weekly “Generator” supply from Holland. Currently arriving by sea, Christie is considering moving to shipping by air to reduce supply chain risk. Alternative bilirubin supplier identified to ensure continued bloods biochemistry tests.

Lindsay Harper / Philippa Jones

Reciprocal Healthcare

GREEN ready to train staff in any changes in reciprocal healthcare of EU Exit No moderate / high risks

Toni Coyle / Dawn Robinson

Requests from external orgs

GREEN Food suppliers information to NHSE Rob Jepson

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Meeting Group Committees in CommonAuthor Fiona Morris, Corporate Lead Nurse

Presented by Elaine Inglesby-Burke, Chief Nursing OfficerDate 25th March 2019

Executive Summary

This paper is to provide recommendations to the Trust Board regarding the community teams attending SCAPE Panel on the 19th March 2019

Annual Plan Objective Associated Risks

Recommendations The Group Committees in Common is asked to review the recommendations and to approve SCAPE status for the following teams:

Swinton District Nurses and East Central 0-19 Team

Equality Does this paper relate to a matter where equality issues may arise? NIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.








Title of Report SCAPE Panel Recommendations

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d) This paper contains reference to both PAHT and SRFT but

contains no quality, finance or operational performance data relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.

1. Introduction

1.1 The CAAS (Community Assessment and Accreditation System) is used on all community areas to highlight best practices as well as deficiencies in practice, patient safety, education and management. This system has been in operation since 2013.

1.2 The aim is for all community services to achieve SCAPE (safe clean and personal every time) status. Once services are consistently assessed as ‘green’ they may apply for SCAPE and further rigorous assessments continue.

1.3 SCAPE goes beyond care, treatment and therapy delivery; services being considered must demonstrate multidisciplinary working on improvement and safety. SCAPE is a reward for achievement of quality standards as well as being a Trust leader in patient safety.

2. SCAPE Panel

2.1 On the 19th March 2019 the Panel sat to review Swinton District Nurses and East Central 0-19 Team applications for SCAPE. East Central 0-19 had previously been deferred SCAPE status in July 2018.

2.2 The Panel consisted of the Director of Nursing, a Non-Executive Director, the Delivery and Improvement Director, a Divisional Nurse Director, an Assistant Director of Nursing, a Lead Nurse and a patient representative. Unfortunately the Deputy Medical Director could not attend, however the Consultant Nurse for Major Trauma accepted the Panel invite at short notice.

2.3 The Panel process involved reviewing background information supplied by the teams, spending time with community staff in the morning of Panel: attending clinics, treatment rooms and shadowing staff on various home visits. There followed team presentations and engagement in a question and answer session.

3. Recommendations

3.1 The Board is recommended to approve SCAPE status for the following teams:

Swinton District Nurses and East Central 0-19 Team

3.2 The Panel felt that East Central 0-19 team had reflected on their previous SCAPE application and had worked through the 2018 recommendations as a more cohesive team. They demonstrated close working relationships with each other and the community.

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3.3 Swinton District Nurses demonstrated integrated care very well and the Panel felt the team were confident and competent in delivering safe, clean and personal care.

3.4 All data presented was thoroughly interrogated by the Panel. It was evident that both teams work closely with community partners to create supportive and compassionate services. Both teams will have a series of recommendations following Panel.

3.5 If Swinton District Nurses and East Central 0-19 Team are approved, the total number of SCAPE community teams in the Trust will stand at 13. There will be further SCAPE Panels in 2019.

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Author (s) Rebecca McCarthy, Deputy Trust SecretaryJane Burns, Group Secretary

Presented by Jim Potter, Chairman


Executive Summary

An annual review of the SRFT’s compliance with the NHS FT Code of Governance has been undertaken. Although the Code is relevant to NHS Foundation Trusts, as in 2018, the review has been widened to encompass compliance for the Northern Care Alliance NHS Group (NCA);

The annual review confirms that: - the development actions reported in the previous review have

been completed;- SRFT complies with the Code’s provisions, with the exception of:

Provision B.7.1 In exceptional circumstances, NEDs may serve longer than six years (two three-year terms following authorisation of the FT) but subject to annual reappointment;

- relevant information will be publicised by SRFT in its Annual Report and Accounts 2018/19.


N/A

Associated Risks N/A

Recommendations The Group Committees in Common is asked to: review the information provided; confirm the statements of comply and explain; request any required action.

Equality Does this paper relate to a matter where equality issues may arise? NIf so, has due regard been given to equality analysis of any adverse impacts

Freedom of Information

This document does not contain confidential information and can be made available to the public.

Title of Report Annual Review: NHS FT Code of Governance

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Please ‘cross’ one of the boxes

This document is entirely confidential, as the redaction of confidential information would render the document meaningless.Under the Data Sharing Agreement, the NCA may be required to share this paper with MFT. This is distinct from information disclosed under the FOIA. As MFT will acquire part of PAT they will need to understand a range of matters which may otherwise be exempt under FOI e.g. contracts to be split and specific workforce-related issues.







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3

1. Introduction and Context

1.1. The NHS Foundation Trust Code of Governance (the Code) was first published in 2006, revised in 2010 and, following significant regulatory change as a result of the 2012 Act, was updated in January and July 2014.

1.2. The provisions of the Code, as best practice advice, do not represent mandatory guidance however, statutory requirements are highlighted within the Code, disclosure requirements are imposed and FTs are strongly encouraged to take full account of the provisions.

1.3. Compliance against the Code has previously been reviewed by SRFT on an annual basis. Although the Code is relevant to NHS Foundation Trusts, in 2018, the review was widened to encompass compliance for the Northern Care Alliance NHS Group.

1.4. The review undertaken in March 2018 identified the following developmental actions, which were completed during 2018/19:

− NCA values approved; central to the Contribution Framework 2.0− Collective Council of Governors Performance Evaluation conducted in October 2018

and reported to Group Council of Governors in December 2018.− Full disclosure in Annual Report 2017/18 regarding two NED’s reappointment beyond 6

years and tenure beyond annual reappointment.− Chairman of Audit Committee continued to actively pursue training and development

opportunities to ensure current financial input. − Group Membership and Public Engagement Strategy approved by Group Council of

Governors in June 2018

2. Code of Governance Review 2018/19

2.1 This year’s review has determined that SRFT complies with the Code’s provisions, with the exception of:

− Provision B.7.1 In exceptional circumstances, NEDs may serve longer than six years (two three-year terms following authorisation of the FT) but subject to annual reappointment.

o In March 2017, the Council of Governors extended the tenure of two Non-Executive Directors, the Vice Chairman and Senior Independent Director, both of whom had served more than three years. The original term of office for both Non-Executive Directors was one year (1.1.17 until 31.12.17). This was extended to a term of office of two years and three months, until 31.03.19. Governors acknowledged the importance of stability during Group transitional arrangements, and the outstanding performance and significant expertise of these Non-Executive Directors, also appointed as PAHT Non-Executive Directors.

o At 31st March 2019, the Vice-Chairman will have served eleven years and three months. In December 2018, the Council of Governors reappointed the Vice-Chairman for a two

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4

month period, with a term of office ending on 31st May 2019, to ensure appropriate scrutiny of the 2018/19 Annual Report and Accounts via Audit Committee, prior to submission to NHS Improvement at the end of May 2019.

o At 31st March 2019, the Senior Independent Director will have served ten years and three months, and will stand down as a Non-Executive Director.

2.2 SRFT’s 2018/19 Annual Report and Accounts will confirm compliance with the provisions of the Code and an explanation of the reasons for departure from B.7.1 as described above.

3. A detailed report has been compiled that describes compliance across every provision within the Code. This is available as a paper for information within the meeting papers.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAHT)


Author (s) Rebecca McCarthy, Deputy Group Secretary

Presented by Jane Burns, Director of Corporate Services/Group Secretary

Date 28th January 2019

Executive Summary

This paper reports all documents sealed between 1st October and 28th February 2019 by the Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust respectively.

Recommendations The Group Committees in Common is asked to review and confirm seals made during the above period.

Public and/or Patient Involvement (including equality related impact) N/A

Communication N/AFreedom of Information Please ‘cross’ one of the boxes below:

a) This document does not contain confidential information and can be made available to the public.

b) This document contains some confidential information that would need to be redacted before the document was made available to the public.

c) This document is entirely confidential, as the redaction of confidential information would render the document meaningless.

Title of Report Sealings Report

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1. Introduction

1.1 The Common Seal of the Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT) is affixed to documents under the authority of the Group Committees in Common in accordance with Standing Orders.

1.2 A Register of Seals is maintained by the Group Secretary.

1.3 Standing Orders require that a report of all seals is made to the Group Committees in Common. This report provides information about the seals made for SRFT and PAHT between 1st October and 28th February 2019.

2. Seals

2.1 Salford Royal NHS Foundation Trust

The following documents were sealed between 1st October and 28th February 2019.

Seal Number Description Date of

Seal

FT411 Seal applied to:

Counterpart Lease of Summerfield House, 544 Eccles New Road, Salford, M5 5AP between:LSREF4 Churchill Properties LimitedandSalford Royal NHS Foundation Trust

14.11.18

2.2 Pennine Acute Hospitals NHS Trust

The following documents were sealed between 1st October and 28th February 2019.

Seal Number Description Date of

Seal

289 Seal applied to:

Lease between Pennine Acute Hospitals NHS Trust and Network Nurseries Limited.Relating to land at Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2BA.

21.12.18

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Meeting Group Committees in CommonAuthor (s) Rebecca McCarthy, Deputy Trust SecretaryPresented by Jim Potter, Chairman


Executive Summary

This paper provides the Group Committees in Common with a summary of the key issues discussed and the decisions made at the meeting of the Group Council of Governors and Salford Royal NHS Foundation Trust Council of Governors meetings held on 21st March 2019


N/A


Recommendations The Group Committees in Common is asked to review and confirm the information provided.

Equality Does this paper relate to a matter where equality issues may arise? NOIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.




Title of Report Chairman’s Report from the Group and Salford Royal NHS Council of Governors Meeting on 21st March 2019

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Group Council of Governors – 21st March 2019

The Trust’s Chairman presided over the meeting and 18 governors were present. The Chief Executive Officer and Group Secretary supported the meeting.

The Chief Strategy & Organisational Development Officer, Chief Delivery Officer, Chief Nursing Officer, Chief Officers of Bury & Rochdale, Oldham and Salford Care Organisations, Deputy Group Secretary, Membership and Public Engagement Manager, Group Director of Communications, 4 Non-Executive Directors were in attendance.

1. Introductory Matters

a. Chairman’s Opening Remarks included update about: − Governor changes− Formally thanked Mrs Diane Brown, Senior Independent Director and Sir David

Dalton for their commitment and extensive contribution to the organisation.

b. Declarations of Interest – No interests were declared.

c. Minutes of the Previous Meeting – Approved as a correct record.

d. Matters Arising – No matters arising.

2. Documents for Approval

2.1. Council of Governors Subgroup Structure & Term of References Subject to single revision to the ‘Engagement’ section, reviewed and approved recommendation to the SRFT Council of Governors to approve the Council of Governors Subgroup structure and Terms of References.

2.2. Standing Orders of the Council of Governors including Group Council of Governors Terms of ReferenceReviewed and approved recommendation to the SRFT Council of Governors to approve the Standing Orders of the Council of Governors, and the Terms of Reference for the Shadow Group Council of Governor Committee, including the suggested amendment to reduce quoracy from 21 governors (approximately two thirds) to 17 governors (approximately half), which must include 8 members of the SRFT Council of Governors.

2.3. Code of Conduct for Governors Reviewed and approved the recommendation to the SRFT Council of Governors to approve the Code of Conduct for Governors.

2.4. Policy for Raising Serious ConcernsReviewed and approved the recommendation to the SRFT Council of Governors to approve the Council of Governors’ Policy for Raising Serious Concerns that are Critical to the Overall Performance and Welfare of the Foundation Trust and Resolving Disagreements between the Council of Governors and Board of Directors.

3. Reports from Committees

3.1. Nominations, Remunerations and Terms of Office Committee: Remuneration of Non-Executive Directors including the Chairman

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Reviewed and confirmed to the SRFT Council of Governors their support for the proposed remuneration levels for Non-Executive Directors, including the Chairman, for 2019/20.

3.2. Update from Audit Committee including consultation on the Terms of ReferenceReviewed the update from the Audit Committee, and the proposed Terms of Reference.

4. Key Appointments

4.1. Consultation with Governors: Appointment of the Senior Independent Director Reviewed and approved the recommendation to the SRFT Council of Governors to support the appointment by the Group Committees in Common of Professor Chris Reilly as Senior Independent Director with effect from 1st April 2019.

4.2. Appointment Process: Deputy Lead GovernorReviewed and approved the recommendation to the SRFT Council of Governors to approve the proposed process for the appointment of the Deputy Lead Governor, noting the proposed timetable which would enable completion of the nomination process for a Deputy Lead Governor by 27th June 2019. Nominations were requested by Friday 5th April 2019.

5. Digital update – Transformation of Community Services PresentationComprehensive update received regarding digital solutions to support transformation of community services and improved patient care. Included update regarding digital infrastructure concerns across the NES Care Organisations.

6. Summary Performance Report from Chief ExecutiveReceived comprehensive update regarding the high level performance metrics; specifically unscheduled care, elective care, quality & safety, workforce and finance.

7. Strategic Programmes ReportUpdate provided regarding key strategic developments, including:

− Group Transaction− Group Service Development Strategy− Integrated/Local Care Organisations− North East Sector/Healthier Together− North West Sector/Healthier Together− Major Trauma

8. Closing Mattersa. Council of Governors Action Sheet – Reviewed and approvedb. Any Other Business c. Date and Time of the Next Meeting:

27th June 2019 at 5pm, North Manchester General Hospital

Papers for Information:A. Group Performance DashboardB. Group Council of Governors Minutes – 5th December 2018C. Strategic Direction Subgroup Summary – 24th January 2019D. Draft minutes: Nominations, Remuneration and Terms of Office Committee – 7th March

2019 E. Joint Group Committees in Common to Group Council of Governors – Summary of

Meeting held on 25th February 2019F. Group Council of Governors’ Meeting Dates for 2019

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Salford Royal NHS Foundation Trust Council of Governors – 21st March 2019

The meeting did not process as the meeting would not have been quorate. The Chairman confirmed that he would contact all governors via email to ratify decisions and matters discussed at the Group Council of Governors, as detailed above.

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Author (s) Rebecca McCarthy, Deputy Trust Secretary

Presented by John Willis, Vice-Chairman


Executive Summary

A summary is provided of the key matters and decisions from the Group Audit Committee meeting held on 1st February 2019.

Recommendations The Group Committees in Common is asked to review and confirm the outcomes of the Group Audit Committee meeting held on 1st February 2019.

Equality Does this paper relate to a matter where equality issues may arise? NoThis document does not contain confidential information and can be made available to the public.




1. IM&T Internal Audit Recommendations Progress Report Audit Committee received a comprehensive update regarding outstanding IM&T internal audit recommendations and reviewed and confirmed the management plan to mitigate the IM&T risks.

2. Data Quality Assurance ProgrammeAudit Committee reviewed details of the clinical coding audits that had taken place during 2018/19, including key findings and progress against recommendations, for Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospital NHS Trust (PAHT).

3. Corporate CQC Assurance Reviews Audit Committee reviewed the findings from the targeted CQC ‘mock’ inspections in the following areas:− Radiology: Fairfield General Hospital − Radiology: Salford Royal

Title of Report Report from Group Audit Committee – 1st February 2019

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In addition, Audit Committee reviewed the recommendations and action plan for the North East Sector and Salford Care Organisation.

4. Chief Finance Officer Report Reviewed and approved the report which provided Group Audit Committee with information on the following finance-related matters: 2018/19 Q2 Provider Sector Performance, Debtors and Creditors over 6 months old and > £10k, Waiver of tender procedures, Update on external audit action plan from the Audit Findings Report (ISA 260), Approved Business Cases, Losses and Special payments.

5. Internal Audit Progress Report including escalated Care Organisation high risks – Reviewed and confirmed the progress of internal audit findings and reports issued to the Northern Care Alliance NHS Group (NCA) since November 2018 as per the below table.

CoverageYear Work Completed Assurance Level

B&R NM O S

2018/19 Hosted Services Moderate X X X

2018/19 Assurance Framework Support

N/A

6. NCA Internal Audit Plan 2019/20 DiscussionThe following areas were suggested for consideration:− Use of Vanguard funding − Health and safety processes− Data Analytics − Fundamental HR practices/processes, including compliance e.g. Annual Leave,

Overtime− Staff engagement − Review of Electro Biomedical Engineering (EBME) systems

7. NCA Anti-Fraud Progress ReportReviewed and confirmed the NCA Anti-Fraud Progress Report highlighting key messages, delivery against plan, quarterly assessment against the standards for providers and investigation summary.

8. External Audit Progress Report – Reviewed and confirmed.

9. External Audit Plan PAHT/SRFT – Reviewed and confirmed the respective PAHT and SRFT External Audit Plans 2019.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & The Pennine Acute Hospitals NHS Trust (PAT)


Author (s) Su Statom, Head of Corporate Governance

Presented by Sir David Dalton, Chief Executive Officer

Date 25 March 2019

Executive Summary

A summary is provided of the key matters and decisions from theGroup Risk and Assurance Meetings held on 18 February 2019 and 18 March 2019


N/A


Recommendations The Group Committees in Common is asked to: Review and confirm the outcomes of the Group Risk and

Assurance Committee meeting held on 18 February 2019 and 18 March 2019

Equality Does this paper relate to a matter where equality issues may arise? Y/NIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.









Title of Report Summary: Group Risk and Assurance Committee (GRAC)

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d) This paper contains reference to both PAHT and SRFT but

contains no quality, finance or operational performance data relating to PAHT which could be relevant to the transaction and is therefore not eligible for release.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

Group Risk and Assurance Committee (GRAC)Summary of meeting on Monday 18 February 2019, at 1pm,

Frank Rifkin Lecture Theatre, 1st Floor, Mayo Building, Salford Royal

PresentSir David Dalton, Chief Executive Officer (Chair)Judith Adams, Chief Delivery OfficerJane Burns, Director of Corporate Services and Group SecretaryChris Brookes, Chief Medical OfficerRaj Jain, Chief Strategy and OD OfficerJames Sumner, Chief Officer, Salford Care OrganisationJym Bates, Associate Director of Digital & AssuranceJayne Downey, Director of Governance and Corporate NursingNicola Firth, Chief Officer, Oldham Care OrganisationNicky Tamanis, Deputy Group Finance DirectorDamien Finn, Chief Officer, North Manchester Care Organisation, Simon Featherstone, Nurse Director, North Manchester Care OrganisationElaine Inglesby-Burke CBE, Chief Nursing OfficerLindsay Harper, Head of Pharmacy, Diagnostics and Pharmacy, for Chris SleightSteve Taylor, Chief Officer, Bury and Rochdale Care OrganisationEmma Wright, Director of Information & Business IntelligenceSu Statom, Head of Corporate Governance

Apologies for AbsenceIan Moston, Chief Financial Officer Paul Downes, Director of Patient Safety and Professional StandardsChris Slight, Director of Diagnostics and Pharmacy

1. Apologies for AbsenceAs above

2. Declarations of interestThe Chair asked Directors to declare any interest relevant to the business of the meeting. No interests were declared.

3. Minutes from Previous Meeting Held on 21 January 2019The minutes from the meeting held on 21 January 2019 were confirmed as an accurate record.

Matters arising:3.1 Group Board Assurance Framework Q3 PositionThe Group Board Assurance Framework (BAF) was presented to GRAC for consideration by the Group Secretary. GRAC confirmed the Q3 position The Chair noted that there was a disparity between the risks, scores, assurance, controls action plans across the Care Organisation and requested that a standardised approach across Group should be considered.

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Action: The Director of Corporate Services /Group Secretary and Director of Governance and Corporate Nursing to work with the Associate Directors of Governance to agree and achieve a consistent approach across Group.

3.2 Patient safety update - Biliary Stent Removal GRAC received the updated paper regarding Biliary Stent removal, which provided detail about improvement actions. The Associate Director of Digital & Assurance provided an update on the development of a Stent registry and explained that several options were currently under review.

Action: Options appraisal paper to be submitted to the April 2019 meeting of GRAC.

3.3 Maintenance of Medical Equipment GRAC received an updated status report on the Maintenance of Medical Equipment.

Action: GRAC requested a further update to provide assurance that there was a single effective Planned Preventative Maintenance (PPM) programme of Medical Equipment in place across Group to18 March 2019 meeting

4. Statements of Assurance

4.1 Salford Care Organisation (SCO)GRAC received and noted the Statement of Assurance from Salford Care Organisation.Key issues discussed: Finance: Reported not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. Challenge sessions and weekly internal meetings continue. Discussions ongoing with stakeholders to determine how they can provide support Operational Performance: Reported not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter and following quarter. Urgent care – Recovery plan developed in collaboration with Salford CCG. Recent analysis noted a repeated pattern happening at late evening / night in Minors – plans formulated to extend opening hours until 1am, initial results have shown an improvement.Quality: Confirmed is satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards and targets for the following quarter. Infection control – Cdiff coming back closer to trajectory but have already exceeded target figure. 5 MRSA reported over last month currently being investigated. The Executive Chief Nursing Officer suggested that there was an opportunity to test the reliability of practice at ward level and wards looking into each other practiceDiagnostics Performance – noted a 36% increase in MRI referrals over the last quarter with an overall increase of 50%, when including GM referrals.

Action re increase in MRI referrals: The Chief Delivery Officer requested a detailed review of referrals to determine whether there was scope for improved practice.

4.2 Oldham Care Organisation (OCO) GRAC received and noted the Statement of Assurance from Oldham Care OrganisationKey issues discussed:Quality: Confirmed satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards. CDifficile was discussed. The Chief Officer stated that performance had been reviewed by OCO Medical Director and the Group Associate Director Infection Control and reported that OCO was back on trajectory and had been 67 days C-

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difficile infection free. Analysis of Oldham community acquired c-difficile cases showed that they were nearly 50% greater than hospital cases which highlighted the importance of the health-economy improvement approach currently being undertaken.Finance: Reported is not satisfied that plans in place are sufficient to deliver the agreed financial control total or the planned year-end forecast outturn. Better Care Lower Cost (BCLC) schemes continue to be developed. Any recurrent opportunities will be considered as part of the 2019/20 budget setting process. Director led fortnightly meetings continue, assured through the DMO framework.

Action: GRAC requested for next GRAC, 18 March 2019, all Care Organisation’s to provide an overview of their plans on how and to what extent they will deliver the Financial plan.

Operational Performance: Reported not satisfied that plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the Quarter. Urgent Care; 4 hour access target remains behind trajectory. Comprehensive recovery plans submitted through NCA to NHSi and via Urgent Care Delivery Board to NHSE with a commitment to achieve 80% in February improving to 85% in March. Cancer: Performance remains behind trajectory but improving picture. All specialities have produced revised recovery trajectories in line with agreed year end trajectories. RTT: Showing a more optimistic picture. GRAC noted the good effort made to recover the position. Total waiting list continues to shrink due to enhance validation processes and delivery of additional clinical activity. Detailed recovery plans have been submitted to NCA Exec team with focus on close management of pathways and conversion of surgical outpatient capacity to operative capacity Mandatory Training: Reported due to technical issues with ESR, the Care Organisation does not have up to date information in relation to the mandatory training position. Local records are being kept as a contingency; the Learning and Development team is working to correct the issue centrally.

4.3 North Manchester Care Organisation (NMCO)GRAC received and noted the Statement of Assurance from North Manchester Care Organisation.Key issued discussed:Quality: Reported is satisfied that the plans in place are sufficient to ensure ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. No CDifficile declared and on trajectory. A number of mixed sex breaches reported in December due to increasing site pressures. HSMR continues to reduce. Mortality Oversight Group continues to oversee the efforts to increase the number of mortality reviews and have noted a significant improvementFinance: The CO reports a favourable variance against YTD financial targets and continues to manage the key financial risks which will be closely managed into the new financial plan. Key focus areas are Agency spend, Income and activity and BCLCOperational Performance: The management team informed GRAC that operational performance and workforce is the Care Organisation’s highest risks and is not satisfied that plans are sufficiently robust to deliver the capacity requirement to meet demand and achieve core NHS access and performance targets for the current quarter. Failed to meet access trajectories for Q3 and being unable to recruit to posts has impacted on winter plan delivery. Recovery plans in place and monitored and challenged weekly. Mandatory Training: Reported due to technical issues with ESR, the Care Organisation does not have up to date information in relation to the mandatory training position. Local records are being kept as a contingency; the Learning and Development team is working to correct the issue centrally.

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4.4 Bury and Rochdale Care Organisation (B&RCO)GRAC received and noted the Statement of Assurance from Bury and Rochdale Care Organisation.Key issues discussedQuality: Reported satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards. Improvement noted in NASS across Fairfield General Hospital. The CQC improvement plan is progressing well. Decline in Friends and Family Test (FFT) reported. The CO is working in partnership with the NCA strategy to improve. Mortality; an increase in trajectory notedFinance: Reported is not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. Reported a deterioration in month largely due to under delivery in BCLC, a seasonal reduction in elective activity and an increase in in-tariff drugsOperational Performance: Reported not satisfied that plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the following quarter. The CO reported that it did not meet the 4 hour access target and remains behind trajectory. Improvement actions have been agreed as a locality in line with Greater Manchester (GM) requirements. RTT: reports an improvement in line with plans to adjust activity. The Diagnostic position remains on track

4.5 Diagnostics and Pharmacy Group (G&PG) GRAC received and noted the Statement of Assurance from Diagnostics and Pharmacy Group. Key issues discussed:Quality: Reported is satisfied that the plans in place are sufficient to ensure: ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. All pathology areas are now UKAS accredited or have action plans in place to receive accreditation. Pharmacy, Salford, continue to deliver against medicine reconciliation rates but performance across NES remains fragile.Finance: Reported is not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. Financial pressures are largely due to BCLC delivery shortfall - work continues on the delivery of Medicines Management and continued reliance on outsourcing to meet the demand on Radiology services at SRFT. Operational Performance: Reported is not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter due to slippage against turnaround times in Cellular Pathology across the NCA, however, plans are now in place to deliver recovery within the NES in Q4 and improvement at Salford within this area.Leadership and Capability: Reported the Senior leadership team is not as yet fully in place. GRAC requested decisions regarding the leadership team should be resolved and establishment of the Senior team be delivered at pace. Action: Executive Chief Delivery Officer and Director of Diagnostics and Pharmacy

6. Items to be referred to Audit Committee GRAC considered all items discussed and agreed that on this occasion there were no items for referral to Audit Committee

7. GRAC Action TrackerGRAC reviewed the action tracker and updates provided.

8. Any Other Business – No further business raised or discussed.

9. Date and Time of Next Meeting18 March 2019 1pm – 3pm, Seminar room 9 & 10, 2nd floor Mayo Building.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

Group Risk and Assurance Committee (GRAC)Summary of meeting on Monday 18 March 2019, at 1pm,Seminar Rooms 9 & 10, 2nd Floor,

Mayo Building, Salford Royal

PresentRaj Jain, Chief Strategy and OD Officer (Chair)Ian Moston, Chief Financial Officer Paul Downes, Director of Patient Safety and Professional StandardsChris Slight, Director of Diagnostics and PharmacyJane Burns, Director of Corporate Services and Group SecretaryChris Brookes, Chief Medical OfficerLindsay McCluskie, Group Director, Capital, Estates and FacilitiesJames Sumner, Chief Officer, Salford Care OrganisationPete Turkington, Medical Director, Salford Care OrganisationJym Bates, Associate Director of Digital & AssuranceJayne Downey, Director of Governance and Corporate NursingNicola Firth, Chief Officer, Oldham Care OrganisationSteph Gibson, for Damien Finn, Managing Director, North Manchester Care OrganisationSimon Featherstone, Nurse Director, North Manchester Care OrganisationElaine Inglesby-Burke CBE, Chief Nursing OfficerSteve Taylor, Chief Officer, Bury and Rochdale Care OrganisationShona McCallum, Medical Director, Bury and Rochdale Care OrganisationDenise Turner, for Jude Adams, Director of Planning & PerformanceEmma Wright, Director of Information & Business IntelligenceSu Statom, Head of Corporate Governance

Apologies for AbsenceSir David Dalton, Chief Executive Officer Judith Adams, Chief Delivery OfficerDamien Finn, Chief Officer, North Manchester Care OrganisationJawed Husain, Medical Director, Oldham Care Organisation

1. Apologies for AbsenceAs above

2. Declarations of interestThe Chair asked Directors to declare any interest relevant to the business of the meeting. No interests were declared.

3. Minutes from Previous Meeting Held on 18 February 2019The minutes from the meeting held on 18 February 2019 were confirmed as an accurate record.

3.1 Patient safety update - Biliary Stent Removal GRAC received the updated paper regarding Biliary Stent removal, which provided detail about improvement actions. The Director of Patient Safety and Professional Standards informed GRAC that Mersey Internal Audit Agency (MIAA) had been asked to review all data processes. TORs to be agreed 19 March 2019.

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The Chief Officer, Oldham Care Organisation explained to GRAC that the ERCP coordinator post had been reviewed and determined that a nurse specialist role, undertaking nurse–led clinics would be more appropriate. New job descriptions are currently being developed.

The Associate Director of Digital & Assurance provided an update on the development of a Stent registry and explained that a company had been identified and are currently working through required criteria. The Chair requested that the final specification is agreed with the Chief Medical Officer, in liaison with the Care Organisations Medical Directors, prior to final approval

Action: The Associate Director of Digital & Assurance to provide update to the April 2019 meeting of GRAC.

3.2 Maintenance of Medical Equipment The Group Director, Capital, Estates and Facilities provided GRAC with an updated status report on the Maintenance of Medical Equipment and explained that currently two different systems are in use across the NCA. GRAC agreed that a single NCA operating model for the Electro Biomechanical service should be developed

Action: The Group Director, Capital, Estates and Facilities to bring recommendations for establishing a single model to GRAC in June 2019

4. Statements of Assurance

4.1 Oldham Care Organisation (OCO) GRAC received and noted the Statement of Assurance from Oldham Care OrganisationKey issues discussed:Quality: Confirmed satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards. 0 MRSA bacteraemia and 0 C-difficile infections have been reported in month. 5 serious incidents declared in January 2019; investigations are underway with initial duty of candour complete. The Medical Director, Oldham Care Organisation currently undertaking work to support the Care Organisation Mortality Oversight Group (COMOG).Action: Themes and action plans to support improvement to be appended to April’s SOA Finance: Reported is not satisfied that plans in place are sufficient to deliver the agreed financial control total or the planned year-end forecast outturn. Better Care Lower Cost (BCLC) schemes continue to be developed. Any recurrent opportunities will be considered as part of the 2019/20 budget setting process. Director led fortnightly meetings continue, assured through the DMO framework.Operational Performance: Reported not satisfied that plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the Quarter. Urgent Care; 4 hour access target remains behind trajectory. Comprehensive recovery plans submitted through NCA to NHSi and via Urgent Care Delivery Board to NHSE GRAC noted that OCO had been identified as an outlier regarding Diagnostic waiting times and requested further information be provided via April’s SOA- Action – Chief Officer OCOGRAC discussed current Access standards and the confusion around which standards the Care Organisations were measured against, i.e. agreed local plans, national standards or Greater Manchester standards. The Chief Officers requested confirmation on which performance targets the Care Organisations .should be working towards

Action: The Chief Delivery Officer and Director of Planning & Performance to provide clarity (and front page of template of Statements of Assurance to be revised to reflect) on what will operational performance be measured against, for the next quarter?

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Cancer: Performance remains behind trajectory but improving picture. All specialities have produced revised recovery trajectories in line with agreed year end trajectories. RTT: Showing a more optimistic picture due to enhance validation processes and delivery of additional clinical activity.

Action: All Care Organisation to provide a narrative on the aggregate position within their next month’s Statement of Assurance.

4.2 North Manchester Care Organisation (NMCO)GRAC received and noted the Statement of Assurance from North Manchester Care Organisation.Key issued discussed:Quality: Reported is satisfied that the plans in place are sufficient to ensure ongoing compliance with all existing quality standards and targets for the current quarter and following quarter. No CDifficile or MRSA declared in month and remains on trajectory. HSMR continues to reduce. Mortality Oversight Group continues to oversee the efforts to increase the number of mortality reviews and have noted a significant improvementGRAC discussed the Non-Elective Caesarean Sections outlying position. The Director of Nursing, NMCO, stated that the CO was assured that the underlying causes were understood and any further steps required would be taken to ensure that the outlying position is resolved. It was highlighted that if the Categorisation of C-Sections followed National Guidance then the Care Organisation would cease to be an outlier. The Chief Nursing Officer raised concern with regards changes being made to the categorisation and requested prior to any changes being made a quality and safety impact assessment is undertaken - ActionFinance: NMCO reported a favourable variance of £0.75m against its YTD contribution target of £18.25m. The CO Management Team is satisfied that there are sufficient plans in place to meet its annual financial plan. Key areas of focus are Agency expenditure, Income and activity and BCLC – NMCO delivered £7.9m against its annual target of £7.2m; £0.7m over-achieved. NMCO Management Team continues reviewing every scheme in detail and accelerating implementation wherever possible. The main risk to the CO is the high level of non-recurrent savings which will need to be addressed in-year and managed in setting next year targets for its clinical divisions. Operational Performance: The NMCO Management team is not satisfied that plans are sufficiently robust to deliver the capacity requirement to meet demand and achieve core NHS access and performance targets for the current quarter. 4hr access performance remains a challenge with the significant factor being lack of flow from the Emergency Department. A revised trajectory has been agreed for the remainder of the year.Mandatory Training: Issues regarding the migration of data and quality of data on the training database were discussed. This has affected the entire North East Sector Care Organisations.

Action: Request the Director People & Organisational Development to provide an update / progress report for April GRAC meeting

. Unopened Mail: GRAC discussed the previously identified issue surrounding ‘Unopened mail’. It was agreed that the Director of Patient Safety and Professional Standards should undertake a review of current practises to assess the potential clinical impact and provide an update / progress report to the April GRAC meeting. To support this work all CO are requested to review their current practice and inform the Director of Patient Safety and Professional Standards. - Action

4.3 Bury and Rochdale Care Organisation (B&RCO)

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GRAC received and noted the Statement of Assurance from Bury and Rochdale Care Organisation.Key issues discussedQuality: Reported satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards. Quality KPIs progressing well and in line with trajectoriesCQC improvement plan progressing well, evidenced by quantitative as well as qualitative data. Mortality reporting an increased trajectory

Finance: Reported is not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. Reported a deterioration in month largely due to under delivery in BCLC, a seasonal reduction in elective activity and an increase in in-tariff drugsOperational Performance: Reported not satisfied that plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the following quarter. There continues to be a significant increase in demand for urgent care services. During January and February the Fairfield ED acuity profile increased. Despite these challenges the Care Organisation remained the best performing in ED performance in Greater Manchester year to date. The Care Organisation continues to have no patients waiting over 52 weeks for treatment and has achieved the required standard of reducing the total waiting list size to the March 2018 position.Surgical Transfer Protocol: GRAC requested, as a matter of urgency, that the Surgical Transfer SOP is finalised and the risk noted on B&RCO Board Assurance Framework is updated accordingly. – Action – Chief Medical Officer, B&RCO Medical Director

4.4 Salford Care OrganisationGRAC received and noted the Statement of Assurance from Salford Care OrganisationKey issues discussedQuality: Reported satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards. The Care organisation reported a statistically significant increase in falls. Analysis currently being undertaken with an early indication showing themes within Intermediate Care. One MRSA reported in January. RCA undertaken and learning urgently disseminated throughout the Divisional teams with an increased focus on good infection control practice.Finance: Reported is satisfied that plans in place are sufficient to deliver the agreed financial control total (excluding PSF) for the current quarter and planned year end forecast outturn. Discussions have concluded with system stakeholder organisations who all confirm agreement to provide support in 2018/19. Medical agency spend is below the NHSI agency cap spend for the second month running and early indications signal that this trend continues in to March with further improvements.Operational Performance: Reported is not satisfied that plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the following quarter. A&E performance showed an improvement over the last month, the two main drivers being reduction in bed occupancy and over 21 day length of stay. RTT – waiting lists being held at September position has impacted on 92% standard. GRAC discussed reliability of validation processes and agreed that this should be included in the Internal Audit programme and to ask IST to undertake a review of RTT processes and systems similar to review recently completed across the North East Sector Care Organisations – Action – The Director of Planning & PerformanceConcerns were raised regarding the potential impact of the new tax and pension regimes specifically to consultant earnings. This will be discussed further at the Executive meetings once further information has been obtained

4.5 Diagnostics and Pharmacy Group (G&PG) GRAC received and noted the Statement of Assurance from Diagnostics and Pharmacy Group.

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Key issues discussed:Quality: Management Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing quality standards and targets for the following quarter. All areas across NCA are fully accredited save Salford Cellular Pathology; however UKAS have inspected Cellular Pathology at Salford and have recommended accreditation. Pharmacy at Salford continues to deliver against medicine reconciliation rates but performance across NES remains fragile.Finance: Reported is not satisfied that the plans in place are sufficient to deliver the agreed financial control total for the current quarter and planned year end forecast outturn. Financial pressures are largely due to BCLC delivery shortfall. Recovery plans are in place.Operational Performance: Reported is not satisfied that the plans in place are sufficient to deliver the capacity requirement to meet demand and achieve core NHS access targets for the current quarter. The key risk to delivery relates to the failure within Radiology across the NES to deliver against the 6 Week Diagnostic target in all modalities. A positional paper and recovery plan has been submitted to DPG SMT forecasting full recovery by the end of April 2019. SCO radiology continues to work to the agreed recovery plan in the context of a significant increase in demand. A positional paper and recovery plan for 2019/20 has been submitted but further work is required to provide necessary assurance. Leadership and Capability: Reported the Senior leadership team is not as yet fully in place. Work is progressing with models to be agreed by the end of April 2019IM&T: GRAC noted the increase risk score from 12 to 14 for the risk pertaining to the expiry of the warrantee of the Pathology Lab Centre server on 31 March 2019. The Director for Diagnostics and Pharmacy explained this was because if the server fails pathology would be unable to issue results. He went on to say that accelerated work is being undertaken and the expectation would be for the risk score to be reduced as soon as work completed and tested. GRAC requested business continuity plans are reviewed to support and the risk reworded to reflect any updates. – Action - The Director for Diagnostics and Pharmacy and Director of Corporate Services and Group Secretary

5. HSIB Maternity InvestigationGRAC received the paper regarding the Healthcare Safety Investigation Branch (HSIB) Maternity Investigation. The Director of Patient Safety and Professional Standards provided a brief overview of the HSIB Maternity Investigations programme and the involvement of North Manchester and Oldham Care Organisation and further explained the investigation element was part of a national strategy to improve maternity safety by investigating cases which meet the ‘Each Baby Counts’ criteria and a defined criteria for maternal deaths.

Updates will be provided through OCO Statement of Assurance.

6. Annual Planning UpdateThe Director of Planning & Performance provided GRAC with a brief update stating that the majority of plans were in place. Those not yet completed were due to contracting and finance final arrangements but expected all draft plans to be in place by 21 February 2019 and on track for the final submission date of 4 April 2019. Final plans will be submitted to Group Committees in Common scheduled 25 March 2019.

7. Joint Highlight Report from Subcommittees The Chair confirmed that this first joint report from the subcommittees formalised the dual reporting line of the Executive Subcommittees to both Executive Development Committee and GRAC. GRAC acknowledged the benefit of the single report providing visibility of both strategic decision making and assurance.GRAC discussed quoracy of the Executive Subcommittees, noting that a number of the subcommittees were not quorate during February 2019 meetings.

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GRAC requested Committees to review the Terms of Reference, specifically deputisation, to ensure appropriate membership and quoracy, in order for effective decision making to take place. – Action

8. For Approval8.1 Complaints Handling Policy

GRAC reviewed and approved the Complaints Handling policy prior to presentation to Group CiC.

8.2 Policy Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants GRAC reviewed and approved the Policy Dealing with Unreasonably Demanding, Persistent or Vexatious Complainants prior to presentation to Group CiC.

8.3 Risk Management Strategy GRAC reviewed the Risk Management Strategy. The Director of Patient Safety and Professional Standards explained to GRAC that this was an initial draft prior to receiving report from a MIAA due in April 2019. The Chair requested comments to be forwarded to The Director of Patient Safety and Professional Standards by 22 March 2019 for Chairman approval following which the strategy will be updated and circulated.- Action

9. Items to be referred to Audit CommitteeGRAC considered all items discussed and agreed that on this occasion there were no items for referral to Audit Committee.

10. GRAC Action TrackerGRAC reviewed the action tracker and were satisfied that all actions were completed or working towards early completion.

11. Any Other Business No further business raised or discussed.

12. Date and Time of Next Meeting24 April 2019 1:30pm – 5pm, Seminar room 11 & 12, 2nd floor Mayo Building.

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Author (s) Rebecca McCarthy, Deputy Trust Secretary

Presented by John Willis, Vice-Chairman


Executive Summary

A summary is provided of the key matters and decisions from the Group Charitable Funds Committee meeting held on 20th February 2019.

Recommendations The Group Committees in Common is asked to review and confirm the summary of the Group Charitable Funds Committee meeting on 20th February 2019.

Equality Does this paper relate to a matter where equality issues may arise? NoThis document does not contain confidential information and can be made available to the public.




1. Finance Reports: − PAHT− SRFT

Reviewed draft income and expenditure position and the balance sheet position as at quarter three 2018/19 (to 31st December 2018) with respect to Charitable Funds.

2. Strategic Direction - Charitable Funds FunctionDetailed discussion took place regarding the strategic direction of the Charitable Funds function across the NCA. The Charitable Funds Committee discussed potential opportunity to take a more proactive approach, acknowledging the resource and capacity requirements to develop and maintain this approach, in a competitive environment. The Charitable Funds Committee supported further initial work to scope potential for a more proactive approach, prior to pursuing this matter further.

Title of Report Report from Group Charitable Funds Committee – 20th February 2019

X

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FOR INFORMATION - NHS FT Code of Governance Compliance Review

1

A. Leadership

A.1 The role of the board of directors

Main PrincipleEvery NHS foundation trust should be headed by an effective board of directors. The board is collectively responsible for the performance of the NHS foundation trust.

The general duty of the board of directors, and of each director individually, is to act with a view to promoting the success of the organisation so as to maximise the benefits for the members of the trust as a whole and for the public

Section Code Provision 2018/19 Position Developmental Action

Comply or Explain

A.1.1 Sufficiently regular meetings of the BoD

Formal schedule of matters reserved for decision by the BoD

Clear statement detailing role and responsibilities of CoG

Statement explaining how disagreements between the CoG and BoD will be resolved

Annual Report to describe how BoD and CoG operate

Group CiC met 10 times during 2018/19, sufficiently regularly to fulfil their responsibilities.

Group Governance Framework Manual (GGFM) in place, reviewed annually via Audit Committee and Group CiC, which includes Standing Orders (SO)s and Schemes of Board and Council of Governors Reservation and Delegation of Powers (SORD)

Schemes for Reservation and Delegation of Powers - Decisions reserved for the Council of Governors (CoG) includes role and responsibilities of CoG and statement regarding how disagreements between the CoG /Group Group CoG and Board of Directors/Group CiC will be resolved

GGFM explains that the SID supports CoG/Group CoG and BoD/Group CiC relationships and an approved policy is in place to describe how serious concerns raised by the CoG/Group CoG will be effectively managed including a process detailing how disagreements will be resolved.

Annual Report describes how BoD/Group CiC and CoG/Group CoG operate.

Comply

A.1.2 Annual Report:o Identify Chairman, Deputy

Chairman, CEO and SIDo Chair and members of Audit and

NRTS Committeeso Number of meetings of BoD,

Annual Reports identify key members of the BoD, Group CiC, Audit and Nominations Committees

Number of meetings and attendance reported within Annual Reports.

Comply

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Audit, NRTS and individual attendance of members.

A.1.3 BoD to issue objectives of Trust regarding balance of interests of patients, community and other stakeholders – as basis for decision making/forward planning

The NCA Operational Plan 2018/19 describes how the NCA will achieve its vision. Priorities, Governing Objectives and Outcomes are developed collectively by Group CiC and provide a common framework for all Care Organisations and Corporate functions to work within, enabling appropriate reflection of the needs of the local Care Organisation populations.

2017/18 Annual Report reports on the Trusts’ balanced forward view and how it takes the interests of patients and local community into account, including report regarding membership engagement. This will be reflected in 2018/19 Annual Reports.

NCA values established and central to Contribution Framework 2.0.

Comply

A.1.4 Adequate systems in place to measure and monitor effectiveness, efficiency, economy and quality.

Board to regularly review against regulatory requirements and approved plans

Annual Plan, Corporate, Care Organisation and Divisional Objectives and Key Performance Indicators in place and assigned, overseen via Assurance Framework including regular and appropriate review of the Board Assurance Framework.

Productivity Improvement Programme (BCLC) and management arrangements in place.

Regular review by Group CiC of: Integrated Performance Dashboard, Monthly Finance and Activity Report, QI Dashboard and Quality Accounts, NHSI submissions. Appropriate delegation to standing committees of Board.

Comply

A.1.5 Relevant metrics, measures, milestones and accountabilities to be in place to assess delivery of performance

Where appropriate, independent advice should be commissioned by the Board (in high risk/complex areas) to provide adequate and reliable level of assurance

Annual Plans in place for corporate departments and care organisation with objectives and key KPIs – accountability assigned to Group Directors and Care Organisation Leadership Teams as appropriate.

Quality Improvement (QI) Strategy, QI Dashboard, Comprehensive Quality Accounts and Annual Report

Group Integrated Performance Dashboard. NCA Single Oversight Framework in place, based on 5

themes: Quality of care, Finance and use of resources, Operational performance, Strategic change, Leadership and Improvement capability (well-led). Introduction of

Comply

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cross-cutting themes - Leadership, Behaviours and Culture

Appropriate independent advice commissioned by Group CiC, as appropriate, to key strategic developments.

A.1.6 Board to report on its approach to clinical governance and its plans to improve clinical quality

Board to record where, within the structure of the organisation, consideration of clinical governance occurs

Clinical governance and quality improvement established within the NCA and Care Organisation governance arrangements

NCA assurance framework defines all elements of governance

Group Governance Framework Manual in place Reported to Group CiC: Quality Improvement (QI)

Strategy, QI Dashboard, Comprehensive Quality Accounts, Learning from Experience, Learning from Deaths, Annual Governance Statement and Annual Report.

Comply

A.1.7 CEO to follow procedure set by Monitor for advising BoD and CoG, and recording and submitting objections to decisions of BoD in matters of regularity and wider responsibilities of the Accounting Officer procedure.

CEO fully aware of responsibilities within Accounting Officer Memorandum – statement within Annual Report

Responsibilities set out in Group CiC approved GGFM including Standing Orders for Group CiC and CoG

Annual Governance Statement and Annual Report Group Scheme of Delegation of Powers sets out

Delegations derived from Accounting Officer Memorandum

Comply

A.1.8 BoD to establish constitution and standards of conduct for the Trust and its staff in accordance with The Nolan Principles

SRFT Constitution in place NCA values established. CF2.0

performance/behaviours framework established with NCA values at the core.

Standards of Business Conduct Policy established, and included in GGFM, for all NHS Staff

Comply

A.1.9 BoD to operate a code of conduct that builds on values and reflects high standards of probity and responsibility

BoD should follow policy of openness and transparency and make clear how potential conflicts of interest are dealt with.

Code of Conduct for Board level Directors in place The Group CiC’s Standing Orders and GGFM confirm

adoption of the Standards of Business Conduct for Staff.

Standing Orders of Group CiC and CoG including Group CoG terms of reference make clear how potential conflicts of interest are dealt with.

Agenda and Meeting Minutes for all meetings including Directors and Governors make clear how proceedings

Comply

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and decision making that conflict with the need to protect the interest of the public or commercial matters will be managed i.e. in private session.

A.1.10 Appropriate insurance cover to cover the risk of legal action against directors

Directors currently covered by NHSLA/Constitution provisions

Annual commercial contract, works and travel insurance, and a policy for professional indemnity and public liability for non-NHS income generation activities in place.

SRFT: Comprehensive review of level of cover for SRFT directors and officers, and as applicable to Hosted Services, conducted via Corporate Finance, Information & Capital Governance Committee.

Comply

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A.2 Division of responsibilities

Main PrincipleThere should be a clear division of responsibilities at the head of the NHS foundation trust between the chairing of the boards of directors and the council of governors, and the executive responsibility for the running of the NHS foundation trust’s affairs. No one individual should have unfettered powers of decision.

Section Code Provision Current Position Action Required Comply or Explain

A.2.1 Division of responsibilities between the chairperson and chief executive should be clearly established, set out in writing by the board of directors.

Division of responsibility between Chair and CEO set out in writing in GGFM, approved by Group CiC.

Comply

A.2.2 Statutory Requirement: Role of Chair and CEO must not be

undertaken by same individual

Position of Chair and CEO held by different individuals

Comply

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A.3 The chairperson

Main PrincipleThe chairperson is responsible for leadership of the board of directors and the council of governors, ensuring their effectiveness on all aspects of their role and leading on setting the agenda for meetings.


A.3.1 Chairman should, on appointment, meet the independence criteria set out in B.1.1

CEO should not go on to be chairperson of the same NHS foundation trust

Chairman’s JD and person specification details the requirement for the Chairman to meet current independence criteria on appointment.

Annual review takes place of the independence of all NEDs, including Chairman.

Comply

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A.4 Non-executive Directors

Main PrincipleAs part of their role as members of a unitary board, non-executive directors should constructively challenge and help develop proposals on strategy. Non-executive directors should also promote the functioning of a board as a unitary board.


A.4.1 BoD to appoint Senior Independent Director (SID), in consultation with the CoG

SID appointed by the BoD in consultation with the CoG. New SID to be appointed by the BoD on 25th March 2019, to commence 1st April 2019.

SID letter to all Governors on appointment and SID supports governor induction and ongoing training.

SID role description includes description of relationship with the Chairperson and other Directors

Comply

A.4.2 Chairperson to hold meetings with the non-executive directors without the executives present

Led by SID, non-executive directors should meet without the chairperson, at least annually, to appraise chairpersons performance and if deemed appropriate.

Chair meets with NEDs without Chief Officers (Executives) present prior to and following each Group CiC/BoD meeting.

Led by the SID, NED’s meet annually, without the Chairman present, to appraise Chair performance.

Comply

A.4.3 Where directors have concerns, which cannot be resolved, they are recorded in the board minutes

On resignation, director to provide written statement if have any concerns

Group CiC/BoD minutes fully record all matters raised, discussions, concerns, and agreements

Draft Group CiC/BoD meeting minutes are reviewed at the subsequent Board meeting to ensure they provide a true account of the proceedings.

Comply

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A.5 Governors

Main Principle

The council of governors has a statutory duty to hold the non-executive directors individually and collectively to account for the performance of the board of directors. This includes ensuring the board of director’s acts so that the foundation trust does not breach the conditions of its license. It remains the responsibility of the board of directors to design and then implement agreed priorities, objectives and the overall strategy of the NHS foundation trust.

The council of governors is responsible for representing the interests of NHS foundation trust members and the public and staff in the governance of the NHS foundation trust. Governors must act in the best interests of the NHS foundation trust and should adhere to its values and code of conduct.

Governors are responsible for regularly feeding back information about the trust, its vision and performance to members and the public, and the stakeholder organisations that either elected them or appointed them. The trust should ensure governors have appropriate support to help them discharge this duty.

Section Code Provision Current Position Developmental Action

Comply or Explain

A.5.1 CoG to meet sufficiently regularly – at least four times a year

Governors should make every effort to attend CoG

Trust should facilitate attendance

Group CoG/SRFT CoG meetings take place on a quarterly basis, rotating via the Care Organisations. Robust arrangements in accordance with the wishes of governors.

Attendance monitored and action taken when necessary.

Comply

A.5.2 CoG not too large to be unwieldy. CoG should be of sufficient size for

requirements of duties Role, structure, composition and procedures

of the CoG to be reviewed regularly (see B.6.5)

Composition of the CoG Policy in place and reviewed every two years by the CoG.

Composition of CoG reviewed and revised during 2008 (all classes), 2011 (staff classes) and 2013 post-Health Act amendments. Review of CoG composition also conducted during 2014/15 – no change.Composition of CoG reviewed in September 2016, specifically relating to the staff constituency classes; further reviewed in line with Group transitional arrangements in March 2017.

SRFT CoG comprises of 13 Governors. The Group CoG includes an additional 21 Shadow

Comply

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Governors. Formal CoG Performance Evaluation

mechanism developed, agreed and regularly implemented. Collective performance of CoG conducted in December 2018. Training and development plan in place.

Standing Orders of the CoG and all key procedures in place and annually reviewed.

A.5.3 Annual Report - to identify governors and constituency,

whether elected or appointed and term of office

- identifies nominated Lead Gov. Record of meetings and attendance at CoG

to be kept and made available to members on request

Annual Report identifies governors, constituencies, class, term of office etc.

Record of governor attendance at CoG kept and available on request – also included on nominations at re-election.

Comply

A.5.4 Roles and responsibilities of CoG set out in written document – with explanation of responsibilities of CoG towards members and other stakeholders, and how governors will seek views and inform them.

Roles & responsibilities of the CoG are set out clearly in the Constitution, GGFM and Standing Orders and clearly described within the Annual Report.

Dedicated area on Trust website providing clear explanation as per this provision.

Membership and Public Engagement Strategy approved by Council of Governors and Membership and Public Engagement Annual Plan in place.

Comply

A.5.5 Governors have a responsibility to make CoG arrangements work and should take the lead in inviting the CEO, Execs and NEDs to meetings

Any Governors may raise questions about the affairs of the NHS foundation trust

Lead and Deputy Lead Governor fully involved in CoG agenda setting process.

CEO/Deputy CEO attends and participates at each CoG meeting.

Group CiC members attend to observe CoG meetings, and participate as required

Governors made aware of this requirement during Governor Induction and core skills training – Holding to Account, Effective Questioning and Challenge

All Governors proactively invited to raise questions on any issue

Chairman meets with Governors during the

Comply

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year to discuss pertinent issues following Group CiC meeting and answer any queries.

Governors reminded of their responsibility to make arrangements work via statement on all relevant agendas.

A.5.6 CoG to establish policy for engagement with BoD – for concerns regarding performance of BoD, compliance with new provider licence or other matters

CoG to input into board’s appointment of a SID (See A.4.1)

Policy for Raising Serious Concerns established by the CoG. Includes how disagreements between CoG/Group CoG and BoD/Group CiC will be resolved

SID appointed by BoD in collaboration with the CoG. Governors aware of role of SID.

Comply

A.5.7 CoG to ensure its interaction and relationship with the BoD is appropriate and effective.

Timely communication of relevant information and unambiguous language.

In addition to Group CiC attendance at Group CoG/CoG meetings and NED involvement in Group CoG Subgroups, the Group CoG and Group CiC meet on two occasions per year to discuss the forward plans of the organisation

Lead and Deputy Lead Governor, Chairman, CEO and Group Secretary conduct quarterly CoG agenda-setting meeting

Timely information flows agreed, including relevant communication notifications

Group CoG receive Group Performance Dashboard.

Governor Portal includes Group CiC/BoD Agenda and Minutes section.

Comply

A.5.8 CoG should only use power to remove chair or NED after exhausting all other means of engagement with BoD

CoG should raise any issue with Chairman with the SID in first instance.

This provision covered within Constitution and would be considered if the circumstance ever arose

Policy for Raising Serious Issues or Concerns in place.

Comply

A.5.9 CoG to receive and consider other appropriate information to discharge its duties, including clinical and operational data

All relevant information made available appropriately to Group CoG/CoG regarding clinical developments, key business challenges and risks and any required assurance briefings

Comply

A.5.10 Statutory Requirement: CoG to hold NEDs individually and

collectively to account for the performance of the BoD

Governor attendance at Group CiC meetings and post Group CiC Governor briefing sessions with Chairman.

NED attendance and interaction at Group

Comply

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CoG/CoG meetings. NED attendance and interaction at Group

CoG Subgroups. Joint Group CiC and Group CoG sessions

take place on 2 occasions during the year. SID attendance at Governor development

and training. CoG [Group CoG] approved NED appraisal

and performance review process Group CoG established Nominations sub-

committee for detailed review of NED appraisal and performance review, and final CoG review and approval

CoG appoint all NEDs and ensures this responsibility is highlighted during selection and appointment process.

A.5.11 Statutory Requirement: CoG to receive the annual accounts; any

report of the auditor on them; and the annual report.

Received annually at CoG [Group CoG] meeting in September.

Comply

A.5.12 Statutory Requirement: Governors provided with agenda prior to any

meeting of the board, and a copy of approved minutes as soon as practicable afterwards

Governors are able to access the agenda (Part 1 and Part 2) prior to each Group CiC meeting and minutes (Part 1 and Part 2) as soon as practicable afterwards – retained on the Governor Portal.

Comply

A.5.13 Statutory Requirement: CoG may require one or more directors to

attend a meeting to obtain information about trust performance or directors performance of duties to help CoG decide on proposing a vote on trust or directors performance

SRFT Constitution sets out that the CoG has this ability

Governors aware of this ability via Induction, training and evaluation of performance

Directors attend Group CoG/CoG meetings and Subgroup meetings as required.

Comply

A.5.14 Statutory Requirement: Governors can refer question to independent

panel for advising governors. More than 50% of governors must approve

this referral CoG should have dialogue with BoD before

Independent Panel for Advising Governors disbanded – Provision no longer applicable.

Comply

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considering a referral.

A.5.15 Statutory Requirement: Governors to use their rights and voting

powers to represent interests of members/public on major decisions taken by BoD:- More than half BoD and CoG to approve

a change to constitution of the NHS foundation Trust

- More than half BoD and CoG to approve significant transaction

- More than half BoD and CoG to approve merger, acquisition, separation or dissolution

- More than half BoD and CoG to approve increase to non-NHS income ≥ 5% a year

- Governors to determine whether non-NHS work will significantly interfere with trust’s principal purpose.

Appropriately set out in SRFT’s Constitution and Standing Orders of the CoG.

Comply

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B. Effectiveness

B.1 The composition of the board

Main PrincipleThe board of directors and its committees should have the appropriate balance of skills, experience, independence, and knowledge of the NHS foundation trust to enable them to discharge their respective duties and responsibilities effectively.


Comply or Explain

B.1.1 BoD to identify in annual report each NED it considers to be independent

BoD should determine whether NEDs are independent in character, judgement and whether there circumstances or relationships could exist that affect such independence

BoD to state its reasons if it determines that a director is independent despite relevant circumstance/criteria

Annual Report identifies each NED considered by the Group CiC to be independent.

Robust mechanism to identify independence – reviewed and approved by Group CiC

Group CiC states its reasons if it determines that a director is independent despite relevant circumstance/criteria

Comply

B.1.2 At least half the BoD, excluding chairperson, should comprise independent NEDs

There are 12 members of the Board, excluding the chairperson, this includes 6 Executive Directors.

All current NEDs considered to be independent Annual review of NED independence (April each

year)

Comply

B.1.3 No individual should hold at the same time position of director and governors of any NHS foundation trust

Trust constitution prevents an individual holding office as both director and governor at the same time

Provisions included in Code of Conduct for Directors and Governors

Comply

B.1.4 Annual Report to detail each director’s area of expertise and clear statement about BoD’s balance, completeness and appropriateness to the FT

Both statements to be available on FT’s internet site

Annual Reports detail each director’s area of expertise and clear statement about Group CiC/BoD balance, completeness and appropriateness to the Trust

Annual Reports available on internet sites

Comply

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B.2 Appointments to the board

Main PrincipleThere should be a formal, rigorous and transparent procedure for the appointment of new directors to the board. Directors of NHS foundation trusts must be “fit and proper” to meet the requirements of the general conditions of the provider licence.


B.2.1 Nominations committee(s) to be responsible for the identification and nomination of executive and non-executive directors

Nominations committee(s) should give full consideration to succession planning taking into account future challenges, risks and opportunities facing the FT and skills and expertise required within the BoD to meet them.

Group CiC established Nominations, Remuneration and Terms of Service (NRTS) Committee for Executive Directors:o reviews the structure, size and composition of

the Group CiC and, where appropriate, make recommendations to the Group CiC for change

odetermines succession plans for the CEO and other EDs and assist in determining the responsibilities of and procedures for appointment of EDs, including the CEO

Group CoG established Nominations, Remuneration and Terms of Office (NRTO) Committee for Non-Executive Directors.

Comply

B.2.2 Directors and governors to meet “fit and proper” persons test described in provider licence i.e. without recent criminal conviction or director disqualification and not bankrupt.

Trusts to abide by CQC guidance regarding appointments to senior positions

Robust compliance regime in place for Fit and Proper Persons CQC requirement – reviewed annually by Group CiC

Directors sign Annual Fit and Proper Person Requirement Self-Assessment.

Directors sign acceptance of Code of Conduct for Board level Directors which highlights importance of meeting fit and proper person requirements that would lead to termination if deemed ‘unfit’

Trust Management of Employment Checks Policy in place and covers all Director level appointments.

Governors sign acceptance of Code of Conduct for Governors which highlights importance of meeting fit and proper person requirements for Governors as detailed in Licence.

Governors complete annual declaration of compliance with fit and proper person as detailed

Comply

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in SRFT’s Licence.

B.2.3 There may be one or two nominations committees, if two one for Exec Directors and one for Non-Exec Directors

Nominations committee(s) should evaluate, at least annually, the balance of skills/experience on the board and prepare a description of the role and capabilities for a particular appointment, including Chair

Two Nominations Committees: Group CiC NRTS Committee responsible for nominations of EDs and CoG’s NRTO for nominations of NEDs.

Group CiC NRTS is responsible for evaluating the balance of skills on the Group CiC, advising Group CoG re NED positions and the Group CiC re ED positions and preparing role and capabilities of a particular appointment (Exec or NED), including the Chairman

Robust template for Director JDs and Person Specs – specific expertise, background, skills and qualities (as agreed via NRTS) included at each vacancy

CoG established Policy for the Composition of NEDs.

Comply

B.2.4 Chairman or an independent NED to chair the nominations committees

A Governor can chair the committee for the appointment of NEDs or Chairman.

Chairman chairs NRTS and NRTO Committees When the Chairman’s performance or

remuneration being considered by the CoG’s NRTO, the Lead Governor chairs the Committee.

NRTO current ToR state: When the Chairman’s nomination is being considered by NRTO, Vice-Chairman chairs the committee

Comply

B.2.5 Governors should agree with the nominations committee a clear process for the nomination of a new chair and non-exec directors

Nominations committee should make recommendations to the CoG

Group CoG/CoG agreed recruitment process in place.

CoG’S NRTO Committee has completed several NED (including Chairman) appointments and reappointments and made recommendations to CoG

Comply

B.2.6 Nominations committee responsible for appointment of NEDs, and any interview panel, should consist a majority of governors

NRTO and Selection Panels consist majority of governors.

Comply

B.2.7 CoG to take into account the views of the board of directors on the qualifications, skills and experience required for each non-executive director position

Board approved NED JD and PersonSpecifications presented to the Group CoG/CoG prior to each recruitment process.

Comply

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B.2.8 Annual report should describe the appointment process followed by CoG for NEDs and Chair

Process described in Annual Report where required.

Comply

B.2.9 An independent external adviser should not be a member or have a vote on nominations committee(s)

Independent external advisers do not have vote on nominations committees.

Comply

B.2.10 Separate section of the annual report should describe work of nominations committee, including board appointments process

Role of nomination/s committee should be set out in publicly available, written terms of reference

Annual Report includes section about the NRTS Committee and details of any Exec Director appointment processes

Work of NRTO committee also included in Annual Report, including details of any NED appointment processes

Terms of Reference for Nominations Committees are available on Trusts website.

Comply

B.2.11 Statutory Requirement: Chairperson, NED’s and, except in case

of appointment of CEO, the CEO appoint executive directors

Chairperson, NEDs and CEO approval of all Executive Director appointments (CEO does not approve a CEO appointment)

NRTS Committee approves Exec Directors JD and sets appointment process

Comply

B.2.12 Statutory Requirement: CoG to approve CEO appointment

following appointment by committee of chair and NEDs

Constitution requires CEO appointment to be CoG approved.

CoG approved appointment of CEO by Chairman and NEDs – January 2019.

Comply

B.2.13 Statutory Requirement: CoG responsible for appointment,

reappointment and removal of chairperson and other NED’s

Group CoG’s NRTO Committee oversees the processes leading to CoG fulfilling its responsibility to appoint, reappoint or remove chairperson and other Non-Executive Directors.

Comply

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B.3 Commitment

Main PrincipleAll directors should be able to allocate sufficient time to the NHS foundation trust to discharge their responsibilities effectively


B.3.1 Chair’s appointment: nominations committee should prepare JD, including time commitment and availability in times of emergency

Chair’s significant commitments to be disclosed to the CoG before appointment and disclosed in annual report

Changes in commitments to be reported to CoG as they arise and disclosed in next annual report

Chair of FT cannot, at the same time, be the substantive chair of another FT

Group CiC/NRTS Committee prepares role description covering time commitment and availability in times of emergency

Commitments reviewed by Group CoG’s Nominations Committee and Group CoG during appointment process to ensure no significant commitments that would interfere with the demands of the role.

Changes in commitments would be reported to Group CoG if they arised.

Chairman appointed as Chairman of Pennine Acute Hospitals NHS Trust.

Comply

B.3.2 NED terms and conditions should be made available to the CoG

Letter of appointment should set out expected time commitment

NEDs to undertake to have sufficient time to fulfil role

NED significant commitments should be disclosed to CoG before appointment and as changes arise

NED terms and conditions outlined in role description presented to Group CoG, available online during appointment process and via Trust Secretary’s office at other times

Letter to NED on appointment – sets out expected time commitment

NEDs undertake to have sufficient time to fulfil role

Significant commitments disclosed to CoG prior to appointment and reappointment.

Comply

B.3.3 BoD should not agree to full-time exec taking on more than one non-exec directorship of an FT or other organisation of comparable size/complexity, nor chairmanship

This provision would be reviewed if the circumstance arose.

Comply

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B.4 Development

Main PrincipleAll directors and governors should receive appropriate induction on joining the board of directors or the council of governors and should regularly update and refresh their skills and knowledge. Both directors and governors should make every effort to participate in training that is offered.


B.4.1 Chair should ensure new directors and governors receive full, formal and appropriate induction

Directors should seek to engage with key stakeholders (patients, clinicians, staff)

Directors to have access to training courses

Induction programmes in place for directors and governors

Directors take part in series of work-withs as part of a rolling programme.

Directors have access to individual and collective training/development as necessary or as requested

Comply

B.4.2 Chair to regularly review and agree with each director training and development needs

PDPs for all Directors are agreed via Chairman (for NEDs) and CEO (for Directors) and are reviewed annually. Chairman aware of all training and development needs for individual Group CiC members.

Comply

B. 4.3 Statutory Requirement: Board to ensure CoG have skills and

knowledge to discharge duties appropriately

Comprehensive training and development programme established by/for Group Governors, including joint FT events.

Comply

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B.5 Information and Support

Main PrincipleThe board of directors and the council of governors should be supplied in a timely manner with relevant information in a form and of a quality appropriate to enable them to discharge their respective duties. Statutory requirements on the provision of information from the board of directors to the council of governors are provided in ‘Your Statutory Duties: A reference guide for NHS foundation trust governors’.


B.5.1 BoD and CoG should be provided with high quality, appropriate information.

BoD and CoG should agree their information needs with EDs through the Chair

Information for boards should be concise, objective, accurate and timely, accompanied by clear explanations of complex issues

BoD should have complete access to any information necessary, including access to senior managers and other employees

High quality reports and background information provided to Group CiC and Group CoG

Standardised front sheet for all Group CiC and Group CoG papers to ensure clarity and appropriate review of paper.

Group CiC has full access to all sources of information.

Comply

B.5.2 In challenging assurances received from Executive, BoD need not seek to appoint adviser for every issue, but should ensure sufficient information and understanding to make informed decision.

When complex or high risk issues arise, first course of action should be to encourage deeper analysis in timely manner within the FT. On occasion, NEDs may reasonably decide that external assurance is appropriate.

Effective challenge and request for further information and analysis demonstrated at Group CiC and Audit Committee – evidenced within relevant minutes, action sheet and follow-up actions.

Comply

B.5.3 BoD to ensure NEDs have access to independent professional advice and training courses/material where judged necessary

Decisions to appoint an external adviser should be collective decision of the majority of NEDs

Availability of independent external sources of advice should be made clear at appointment

Independent advice, information and training made available as necessary/requested

Comply

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B.5.4 Committees and CoG to have sufficient resources to undertake duties

Committees and Group CoG provided with sufficient resources.

Comply

B.5.5 NED’s should consider whether they are receiving necessary information in a timely manner and feel able to raise appropriate challenge of recommendations of the Board

High quality reports and background information provided to NEDs

Standardised front sheet for all Group CiC papers to ensure clarity and appropriate review of paper.

Group CiC has full access to all sources of information

Chair meets with NEDs prior to and following every Group CiC meeting to review information and required challenge.

NED able to raise any concerns about the information they receive and their ability to raise appropriate challenge via either Chairman or Group Secretary.

Comply

B.5.6 Governors should canvass the opinion of their members, and for appointed governors the bodies they represent, on the FTs forward plan

Annual Report to state how this requirement has been undertaken

Group CoG Sub-groups to oversee governor and member input into the development of the forward plan.

Twice-yearly Group CiC and Group CoG workshop to discuss opinions and views about forward plan, including objectives, priorities and strategy

Description within Annual Report about how this requirement has been undertaken

Comply

B.5.7 BoD should take account of the views of the CoG on the forward plans and communicate where views have been incorporated, and if not, reasons for this.

Group CoG Sub-groups each to review ‘Strategic Direction’ from a locality perspective. Group CoG reviews Strategic Programmes Report on a quarterly basis.

Full report to and review by CoG at twice yearly Group CiC and Group CoG workshop.

Comply

B.5.8 Statutory Requirement: BoD must have regard for the views of the

CoG on the trusts forward plan

As described at B.5.6 and B.5.7 above.

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B.6 Evaluation

Main PrincipleThe board of directors should undertake a formal and rigorous annual evaluation of its own performance and that of its committees and individual directors.

The outcomes of the evaluation of the executive directors should be reported to the board of directors. The chair should take the lead on the evaluation of the executive directors.

The council of governors, which is responsible for the appointment and re-appointment of non-executive directors, should take the lead on agreeing a process for the evaluation of the chairman and the non-executives, with the chairman and the non-executives. The outcomes of the evaluation of the chairman should be agreed by him/her with the SID. The outcomes of the evaluation of the non-executive directors and the chairman should be reported to the governors. The governors should bear in mind that it may be desirable to use the senior independent director to lead the evaluation of the chairman.

The council of governors should assess its own collective performance and its impact in the NHS foundation trust.


B.6.1 BoD should state in the annual report how evaluation of board, committees and directors has been undertaken, bearing in mind the desirability for independent assessment, and the reason why the trust adopted a particular method of performance evaluation

Statement included in Annual Report. Comply

B.6.2 Evaluation of FT boards should be externally facilitated at least every three years.

Monitor’s board leadership and governance framework to be used as basis for this evaluation

External facilitator to be identified in annual report and statement made to any connection to Trust

SRFT rated ‘Outstanding’ in CQC inspection conducted in May 2018 ; including ‘outstanding in ‘well led’ domain on consecutive occasion

PAHT rated ‘Requires Improvement’ in CQC Inspection in March 2018; including ‘good’ in ‘well led’ domain.

SRFT BoD participated in externally facilitated Well Led Framework for Governance Review in 2016/17 delivered by MIAA, in partnership with AQuA. Self-assessment completed prior to review and focus areas for discussions identified.

Self-Assessment against Well Led Governance

Comply

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Framework undertaken at NCA in 2018/19. Independently reviewed by MIAA to provide assurance on compliance with KLOEs (outcome to be reported May 2019).

Annual evaluation of Group CiC standing committees undertaken.

Board performance evaluation and that of its committees reported within Annual Report

NRTS Committee reviews performance evaluation of each Executive Director.

The Chairman undertakes an annual performance assessment of each NED and reports to Group CoG via NRTO.

B.6.3 SID to lead performance evaluation of Chairperson, within framework agreed by CoG

Appraisal process for Chairman, led by SID, within framework agreed by Group CoG

Comply

B.6.4 Chairperson, with assistance from Trust Secretary, should use performance evaluations to determine individual and collective professional development programme for NED’s

PDPs for NEDs are agreed via Chairman. Comply

B.6.5 CoG should periodically assess its collective performance and communicate to members how they have discharged duties including impact and effectiveness on:

− holding the non-executive directors individually and collectively to account for the performance of the board of directors

− communicating with their member constituencies and the public and transmitting their views to the board of directors

− contributing to the development of forward plans of the trust

CoG have established and conducted regular collective performance evaluations, the most recent taking place in December 2018.

Comprehensive presentation to AMM (APM) about Group CoG performance including how they have performed statutory duties and responsibilities.

Regular communications to members via The Loop, Members Events, E-communications and via partner organisations.

Comply

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B.6.6 Clear policy and a fair process for the removal of any governor that consistently and unjustifiably fails to attend CoG meetings, has a conflict of interest, or fails to discharge their responsibilities

Removal may be appropriate where behaviours or actions by a governor or group of governors is incompatible with values/behaviours of Trust

Independent assessor can be used

Approved Code of Conduct for Governors in place that outlines circumstances that would result in removal of governor - agreed and signed by all governors.

Code of Conduct for Governors reviewed during 2016/17 and 2017/18 and 2018/19 (March) and includes details of values and the requirement of adherence.

Consideration of independent assessor if situation arose.

Comply

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B.7 Re-appointment of directors and re-election of governors

Main PrincipleAll non-executive directors and elected governors should be submitted for re-appointment or re-election at regular intervals. The performance of executive directors of the board should be subject to regular appraisal and review. The council of governors should ensure planned and progressive refreshing of the non-executive directors.


B.7.1 Chair to confirm to governors that performance of NED proposed for re-appointment continues to be effective

Any term beyond six years (two three year terms) for NED – rigorous review and take account of the need for progressive refreshing of the BoD

In exceptional circumstances, NEDs may serve longer than six years (two three-year terms following authorisation of the FT) but subject to annual reappointment. May affect independence.

Chair confirms to governors that performance of NED proposed for re-appointment continues to be effective or otherwise

Term of office for NEDs and Chair considered and agreed by NRTO Committee, in full consideration of Monitor’s guidance of terms of no more than three years and any term beyond six years requiring rigorous review.

In December 2018 CoG reappointed the Chairman from 30.06.19 until 30.06.20 (1 year term only), based on recommendation from NRTO Committee. Acknowledged that the Chairman served 11 years and confirmed reappointment in the best interests of the organisations.

In March 2017, CoG extended the tenure of two NED’s that had served beyond 6yrs. This extended their current term of office to two years and three months, 1.1.17 until 31.03.19 (original term of office prior to extension 1 year 1.1.17 until 31.12.17). Governors acknowledged the importance of stability during Group transitional arrangements, and the significant experience and expertise of the Non-Executive Directors, also NEDs at PAHT. One NED, included in the above, will stand down on 31.03.19. One NED, has been re-appointed for a period of two months (until 31.05.19).

Full disclosure in Annual Report regarding two NED’s reappointment beyond 6 years and tenure beyond annual reappointment.

Group SecretaryCompletion: May 2019

Explain

B.7.2 Elected governors must be re-elected at regular intervals – no more than three years

Elected governors’ term of office set at no more than three years

Biography details and past attendance published

Comply

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Biography details, and any other relevant information, to be made available at election

Prior performance information, such as attendance records to also be made available at election

during election.

B.7.3 Statutory Requirement: CoG to approve CEO appointment at first

general meeting following appointment by committee of chair and NEDs

Appointment of all other execs by committee of CEO, Chair and NEDs

Constitution requires CEO appointment to be CoG approved. CoG approved appointment of CEO by Chairman and NEDs – January 2019.

Executive Director/Chief Officer appointments to-date approved by CEO, Chair and all other NEDs.

Comply

B.7.4 Statutory Requirement: NED’s, including chairperson, appointed

by CoG for specified terms subject to re-appointment thereafter at intervals of no more than three years

Term of office for NEDs and Chair considered and agreed by NRTO Committee, in full consideration of Monitor’s guidance of terms of no more than three years.

Comply

B.7.5 Statutory Requirement: Elected governors subject to re-election

by members at regular intervals not exceeding three years

Elected governors’ term of office set at no more than three years.

Comply

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B.8 Resignation of directors

Main PrincipleThe board of directors is responsible for ensuring on going compliance by the NHS foundation trust with its licence, its constitution, mandatory guidance issued by Monitor, relevant statutory requirements and contractual obligations. In so doing, it should ensure it retains the necessary skills within its board and directors and works with the council of governors to ensure there is appropriate succession planning.


B.8.1 The Board of Directors should not agree to an executive member of the Board leaving the employment of an NHS foundation trust, except in accordance with the terms of their contract, including but not limited to service of their full notice period and/or material reductions in their time commitment to their role, without the Board first having completed and approved a full risk assessment.

EDs leaving the employment of the Trust have complied with the terms of their contract of employment.

This provision would be reviewed if the circumstance arose.

Comply

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C. Accountability

C.1 Financial, quality and operational reporting

Main PrincipleThe board of directors should present a fair, balanced and understandable assessment of the NHS foundation trust’s position and prospects


C.1.1 Directors should explain responsibility for preparing annual report and accounts in the annual report

Directors should state that the report and accounts are fair, balanced and understandable, and provide information necessary for patients, regulators and other stakeholders to assess the trusts performance, business model and strategy

Should be a statement by auditors about their reporting responsibilities

Directors should also explain approach to quality governance.

Annual Report includes all required statements.

Comply

C.1.2 Directors should report that the FT is a going concern

Annual Review and detailed mid-year review of Going Concern at Audit Committee and relevant inclusion within Annual Report.

Comply

C.1.3 At least annually, BoD should set out financial, quality and operating objectives and sufficient information to allow members/governors to evaluate FT’s performance

Annual Plan, Annual Report and Accounts, Quarterly Integrated Performance Dashboard to Governors

Monthly Group Performance Dashboard made available to public via Group CiC papers on Trusts website. Group CoG papers made on Trusts website.

Annual Report and Annual Accounts made available on Trusts website. Presented to Group CoC/CoG annually.

Comply

C.1.4 BoD must notify Monitor, CoG and the public if appropriate, about any major new developments which may lead to a substantial financial, performance or reputation change

Group CiC update to NHSI as required and continually considers public communication. Routine discussions with appropriate manager at NHSI.

Chairman provides regular report to Group

Comply

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BoD must notify Monitor and CoG and consider whether to bring to public attention all information concerning a financial or performance change which would have a significant impact on the FT if made public

CoG members about all matters discussed and decisions made at Group CiC.

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C.2 Risk management and internal control

Main PrincipleThe board of directors is responsible for determining the nature and extent of the significant risks it is willing to take in achieving its strategic objectives. The board should maintain sound risk management systems.

The board of directors should maintain a sound system of internal control to safeguard patient safety, public and private investment, the NHS foundation trust’s assets, and service quality. The board should report on internal control through the Annual Governance Statement (formerly the Statement on Internal Control) in the annual report.


C.2.1 Directors to maintain oversight of risk management and internal control and report to members and governors in the annual report

Review should cover financial, clinical, operational controls, compliance controls and risk management systems

Group CiC led Assurance and Risk Framework in place.

Annual Internal Audit Plans constructed in full collaboration with Audit Committee to ensure that there is an effective internal audit function established by management that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive, Group CiC, Care Organisations and the SRFT and PAT Boards.

Annual Governance Statements compiled by the CEO, reviewed by Auditors, Audit Committee and approved/signed by CEO

Annual Report (including AGS) presented to Governors and Members at Group CoG and AMM/APM

Comply

C.2.2 Disclose in Annual Report if trust has internal audit function, structure and role it performs. If it does not have an internal audit function, processes it employs for evaluating and continually improving internal control processes

Confirmation and relevant information included in Annual Report.

Comply

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C.3 Audit committee and auditors

Main PrincipleThe board of directors should establish formal and transparent arrangements for considering how it should apply the corporate reporting and risk management and internal control principles and for maintaining an appropriate relationship with the NHS foundation trust’s auditors.


C.3.1 BoD must establish an audit committee composed of at least three independent NEDs

BoD should satisfy itself that at least one member of audit committee has recent/relevant financial experience

Chairman of the trust should not chair or be a member of the audit committee, he can attend by invitation as appropriate.

Group Audit Committee established by Group CiC, fully established with independent NEDs

BoD has appointed Chair of Audit Committee with relevant financial experience.

Chair of Audit Committee actively pursues update and development to ensure current financial input.

Development Action:New Chairman of Audit Committee to be appointed in June 2019; to be made aware of requirement to actively pursue training and development to ensure current financial input.

Group Secretary/Chairman of Audit Committee

Comply

C.3.2 Main roles and responsibilities of audit committee should be set out in publicly available, written ToR

The Council of Governors should be consulted on the terms of reference that should be refreshed regularly

ToR should include how Audit Committee will: monitor integrity of financial

statements and any formal financial announcements;

review internal financial controls and review the internal control and risk management systems;

monitor and review effectiveness of internal audit function;

Appropriate terms of reference established for Audit Committee and publicly available – annual review and refresh

Auditors meet with the CoG annually and regularly attend CoG meetings.

Chairman of Audit Committee provides regular update about matters reviewed at Audit Committee to the Group CoG Strategic Direction Sub-group and Group CoG from March 2019 onwards.

Group CoG consulted on Audit Committee Terms of Reference in March 2019

Comply

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review and monitor external auditor’s independence/objectivity and effectiveness of audit process

develop and implement policy on engagement of external auditor to supply non-audit services

report to CoG - matters for action or improvement

C.3.3 CoG should take lead in agreeing with audit committee the criteria for appointing, reappointing and removing auditors

CoG approved the process for the appointment of an External Auditor at its meeting in June 2016. CoG established a Joint (Salford Royal and Pennine) Audit Working Group, with appropriate representation from Salford Royal’s CoG and the Audit Committees of both organisations. The Joint Audit Working Group selected Auditors for recommendation to CoG for appointment – appointment made by CoG December 2016 (Grant Thornton).

Comply

C.3.4 Audit Committee should make a report to CoG about the performance of the external auditor to enable the CoG to consider re-appointment.

Audit Committee should make recommendations about appointment, re-appointment and removal of external auditor, and approve remuneration and terms of engagement of the external auditor

Audit Committee made report to CoG in June 16 about the process for appointment of the External Auditor – agreed by CoG.

Report presented to CoG from Chairman of Audit Committee in December 2016 providing recommendation from Joint Audit Working Group re appointment of External Auditor.

Comply

C.3.5 If the CoG does not accept the audit committee’s recommendation, the BoD should include explanatory statement in annual report – setting out reasons why CoG has taken different position.

Information to be included in Annual Report if situation arose.

Comply

C.3.6 FT should appoint external auditor for a period of three to five years.

Comprehensive market-testing exercise undertaken during June-December 2016 to select External Auditor, joint process established with PAHT. CoG appointed Grant Thornton as External Auditor from 1st April 2017 for a period of three years with an

Comply

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option for this to be extended by a further 1 year subject to mutual agreement.

C.3.7 When CoG ends an auditor’s appointment in disputed circumstances, chair should inform Monitor of reasons behind decision

Chair provides an update to NHSI about significant CoG changes/issues – an issue of this nature has not arisen to date but would be included.

Comply

C.3.8 Audit committee should review arrangements by which staff can raise issues in confidence about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.

Audit committee should ensure proportionate and independent investigation and follow-up action

Audit Committee annually reviews Whistle-blowing and Concerns Reporting Policy and systems in place to ensure staff can raise issues in confidence about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters

Regular counter-fraud update reports received by Audit Committee

Comply

C.3.9 Annual Report should describe how Audit Committee has discharged its responsibilities, including:- Significant issues in relation to

financial statements, operations and compliance and how addressed;

- How it assessed effectiveness of external audit process and approach to appointment of external auditor, value of service, length of tender and when tender last conducted

- If auditor provided non-audit services, value of non-audit services provided and how auditor objectivity and independence is safeguarded

Section within the Annual Report that comprehensively reports on how Audit Committee has discharged its responsibilities.

Comply

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D. Remuneration

D.1 The level and components of remuneration

Main PrincipleLevels of remuneration should be sufficient to attract, retain and motivate directors of quality, and with the skills and experience required to lead the NHS foundation trust successfully, but an NHS foundation trust should avoid paying more than is necessary for this purpose and should consider all relevant and current directions relating to contractual benefits such as pay and redundancy entitlements


D.1.1 In designing schemes of performance-related remuneration of executive directors, the remuneration committee should: Consider whether directors should be

eligible for annual bonuses. If so, conditions should be relevant, stretching and designed to match long term interests of public.

Payouts should be subject to challenging performance criteria reflecting FT objectives

Performance criteria and any upper limits for annual bonuses and incentive schemes should be set and disclosed

Remunerations Committee to consider pension consequences and associated costs of basic salary increases, especially directors close to retirement - only basic pay should be pensionable

The terms of reference for the Group CiC NRTS Committee cover the requirements of this provision

Criteria and bonus payment ceilings established and written

Only basic pay is pensionable Formal review of basic remuneration packages of

Executive Directors previously undertaken by Ernst and Young and more recently using external benchmarking data.

Executive level salary bands were changed in light of the above to ensure SRFT, and from April 2017, the NCA, continued to attract and retain effective people.

Comply

D.1.2 Levels of remuneration for chair and other NEDs should reflect time commitment and responsibilities

Level of remuneration for Chairman and NEDs reviewed by CoG’s NRTO Committee, reported to and approved by CoG – time commitment and responsibilities taken into account. Remuneration benchmarked utilising NHS Providers Remuneration Survey and Deloitte Benchmarking Review,

Comply

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undertaken in March 2018. Further review and revised remuneration considered at CoG in March 2019.

D.1.3 When Exec Director is released to work as non-executive elsewhere, the remuneration disclosure of the annual report should include whether or not director will retain such earnings

Remuneration disclosure of Annual Report will include information where required.

Comply

D.1.4 Remuneration committee should carefully consider compensation commitments of directors’ in the event of early termination – the aim to avoid rewarding poor performance

Provision covered within terms of reference Group CiC’s NRTS Committee

Comply

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D.2 Procedure

Main PrincipleThere should be a formal and transparent procedure for developing policy on executive remuneration and for fixing the remuneration packages of individual directors. No director should be involved in deciding his or her own remuneration


D.2.1 BoD must establish remuneration committee of NEDs, including at least 3 independent NEDs

Remuneration Committee terms of reference to be made available

Where remuneration consultants are appointed, statement made available about whether connection with FT

Group CiC’s NRTS Committee established – all NEDs independent

Group CiC’s NRTS Committee terms of reference available for review via Group Secretary’s Office and on website

Statement re Remuneration consultants would be included in relevant Annual Report

Comply

D.2.2 Remuneration committee to have responsibility for setting remuneration for all exec directors, including pension rights and any compensation payments

Remuneration committee should recommend and monitor the level and structure of remuneration for senior management

Group CiC’s NRTS Committee terms of reference set out all aspects of this provision.

Comply

D.2.3 CoG should consult with external professional advisers to market-test remuneration levels of the chair and other non-execs at least once every three years

Group CoG’S NRTO Committee’s terms of reference enable invitation of an external adviser as required

Remuneration for NEDs reviewed using NHS Providers Remuneration Survey and Deloitte benchmarking data.

Plans in place to consider the benefits of using professional advisers in future years

Comply

D.2.4 StatutoryRequirement: The council of governors is responsible

for setting remuneration of NED’s and Chairperson

Group CoG’s NRTO Committee reviews annually the remuneration of NED’s and chairperson and makes recommendation to Group CoG/CoG, who is responsible for setting remuneration for Chair and NEDs – review conducted by NRTO Committee most recently in March 19, presented to Group CoG/CoG for approval in March 2019.

Comply

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E. Relations with stakeholders

E.1 Dialogue with members, patients and the local community

Main PrincipleThe board of directors should appropriately consult and involve members, patients and the local community.

The council of governors should represent the interests of trust members and the public.

Notwithstanding the complementary role of the governors in this consultation, the board of directors as a whole has responsibility for ensuring that regular and open dialogue with its stakeholders takes place.


E.1.1 BoD should make available a public document setting out its ‘involvement’ policy

Membership and Public Engagement Strategy in place – initially approved by BoD and CoG, revised and approved by CoG in March 13 and March 16. Group Membership and Public Engagement Strategy reviewed by Engagement Subgroup in April 2018, approved by Group CoG in June 2018.

Group CoG leads on implementation of the Strategy

Engagement Sub-group of Group CoG led on review of implementation of strategy and reviewed progress against KPIs. From April 2019, to be reviewed via Care Organisation CoG Subgroups

Strategy is publicly available

Comply

E.1.2 BoD should clarify in writing how public interests will be represented

Approach to addressing overlap and interface between governors and local consultative forums in place to be included.

Annual Plan describes aims to represent public interests

Group Membership and Public Engagement Strategy and Plan describes approach between governors and local consultative forums

Comply

E.1.3 The Chairman should ensure the views of governors and members are communicated to the BoD

The Chair should discuss the affairs of the FT with governors

NEDs to attend governor meetings SID should attend sufficient meetings of

governors to listen to views and develop

Chairman reports to the Group CiC from each Group CoG/CoG meeting – views of governors/members conveyed

Chairman ensures appropriate discussion of the NCA’s affairs with governors

Chairman meets with governors regularly following Group CiC meetings to discuss pertinent issues and answer queries

Comply

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understanding NEDs attend Group CoG/CoG meetings and supports CoG sub-groups

SID attends training and development events for governors

E.1.4 BoD should ensure effective mechanisms for communication between governors and members from its constituencies

Contact procedures for members that wish to communicate with governors and/or directors should be made clearly available to members on the FTs website and in the annual report

Deputy Group Secretary and Membership and Public Engagement Leads in post to develop and support mechanisms for communication between governors and members across the NCA

Group Membership and Public Engagement Strategy and Plan established

Contact procedures publicly available – The Loop / Internets/ Annual Reports

‘Contact your Governor’ pages and link established on SRFT/PAHT websites

Comply

E.1.5 BoD should state in annual report how members of the Board, in particular NEDs, develop an understanding of the views of governors and members

Information included in Annual Reports, including attendance at Group CoG/CoG meetings. NEDs attend CoG Subgroups, Group CiC to Group CoG meetings, training and development sessions.

Comply

E.1.6 BoD should monitor how representative its membership is, and the level and effectiveness of engagement and include in Annual Report

This should be used to review the Membership Strategy, taking into account emerging best practice

Group Membership and Public Engagement Strategy established

Group CoG Engagement sub-group has established relevant KPIs to monitor representative membership, and level and effectiveness of engagement. This will be reviewed via Care Organisation CoG Subgroups from April 2019

Annual Reports include comprehensive membership section.

Comply

E.1.7 Statutory Requirement: BoD must make board meetings and

annual meeting open to public

Group CiC meetings open to public Annual Members/Public Meeting open to public

Comply

E.1.8 Statutory Requirement: Trust must hold annual members

meetings, director to present annual report and accounts and any report of the auditor on the accounts

Annual Members/Public Meetings held in October 18. Agenda available on website.

Comply

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E.2 Co-operation with third parties with roles in relation to NHS foundation trusts

Main PrincipleThe board of directors is responsible for ensuring that the NHS foundation trust co-operates with other NHS bodies, local authorities and other relevant organisations with an interest in the local health economy.


E.2.1 BoD should maintain a schedule of the third party bodies to which the FT has a duty to co-operate

Directors should be clear of the form and scope of the co-operation

NCA’s key stakeholders and mechanisms for engagement outlined in Operational Plan.

NCA Service Development Strategy in place. NES Clinical Services Strategy in development.

The Group Corporate Governance Framework sets out third party bodies and the scope of the cooperation required.

Comply

E.2.2 BoD should ensure mechanisms are in place to co-operate with relevant third party bodies and that relationships are maintained

Annually the Board should review effectiveness and relationships and take steps to improve them

Annual Plans set to include relevant objectives geared to ensuring the NCA is actively pursuing appropriate and effective relationships with third parties.

Comply

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