the northern care alliance nhs group salford royal ... - pat

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

Shared Agenda Group Committees in Common (CiC)

Monday, 4th June 2018 at 10:00amHumphrey Booth Lecture Theatre, Mayo Building,

Salford Royal, Stott Lane, SALFORD M6 8HD

AGENDA: Part 1

1. Patient Story

2. Chairman’s Opening Remarks Chairman

3. Apologies for Absence Chairman

4. Declarations of Interest All

5. Minutes of Previous Meeting (Part 1) Chairman- held on 30th April 2018

6. Verbal CEO Report, including review of: Chief Executive- Group CiC Performance Dashboard - Care Organisation Chief Officers’ Focussed Reports

7. Urgent Care Plans: GP Streaming Chief Delivery Officer/CO Chief Officers

8. Group Board Assurance Framework/ Chief ExecutiveCorporate Risk Register - Opening for 2018/19

9. Compliance: General Data Protection Regulation Chief Strategy & OD Officer(GDPR)

10. Developing the People Strategy Chief Strategy & OD Officer

11.Board Composition: ChairmanNon-Executive Director Skills and Expertise

12. Reports from Standing Committees:

12.1.Group Executive Risk and Assurance Committee Chief Executive- meeting held on 21st May 2018

12.2 Audit Committee Vice-Chairman- meeting held on 24th May 2018

12.3 Charitable Funds Committee Vice-Chairman- meeting held on 30th April 2018

13. Any other business (Part 1)1/318

14. Date and Time of the Next Meeting: Monday, 25th June 2018 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 Pennine Acute Hospitals NHS Trust

Meeting of Group Committees in CommonDraft Shared Minutes

Monday, 30th April 2018Part 1- Held in Public

Present:Mr Jim Potter, ChairmanSir David Dalton, Chief Executive Officer

Mrs Jude 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 Chris Mayer CBE, Non-Executive DirectorMr Ian Moston, Chief Finance OfficerProfessor Chris Reilly, Non-Executive DirectorDr Hamish Stedman, Non-Executive DirectorMr James Sumner, Chief Officer Salford Care OrganisationMr Steve Taylor, Chief Officer Bury & Rochdale Care OrganisationMr John Willis CBE, Vice-Chairman

Mrs Jane Burns, Director of Corporate Services and Group SecretaryMrs Rebecca McCarthy, Deputy Group Secretary

Observing:Gill Collins, Salford Public GovernorJim Collins, Salford Public GovernorJennifer Dennington, Johnson and JohnsonMarie Eccles, Manchester Evening NewsSylvia Edney, Bury & Rochdale Public GovernorTerri Evans, Bury & Rochdale Public GovernorAndrew Lynn, Group Director of CommunicationsSiobhan Moran, Director of Quality ImprovementJ O’Donnell, Staff Side (PAHT)Jackie Schofield, Staff Side (PAHT)Stephen Sutcliffe, Johnson and Johnson

Apologies for Absence: None

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No. Item Action

1. WelcomeThe 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.

2. Patient StoryThe Group Committees in Common listened to patient story (No.123) read by the Chief Officer of Salford Care Organisation.

Opening Matters

3. Apologies for AbsenceNo apologies for absence.

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. Chairman’s Opening Remarks

Meeting with NHS ImprovementThe Chairman informed the Group Committees in Common that discussion continued with NHS Improvement regarding a solution for the continuing deficit at Pennine Acute Hospitals NHS Trust (PAHT).

Talking HeadsThe Chairman confirmed that he had participated in a ‘Chairman’s Talking Head’ highlighting the patient safety improvement journey for PAHT.

6. Minutes of the Previous Meeting The Chairman confirmed that Part 1 of the previous meeting held on 26th March 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 and correct record.

7. Matters ArisingNo matters arising

8. CEO Report including:− Interim High-Level Performance Metrics − Presentations from the Chief Officers of the North Manchester,

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No. Item ActionOldham, Bury & Rochdale and Salford Care Organisations with focus on: Financial Plan 62 Day Cancer Standard Workforce A&E Standard

8.1 SRFT CQC Inspection The Chief Executive confirmed that the SRFT CQC Inspection was underway, with a particular focus on Urgent Care, Medical Services and Surgical Services.

8.2 Financial PositionThe Chief Executive Officer provided headlines with regards to the financial position as at the year-end 2017/18, confirming that the Northern Care Alliance NHS Group (NCA) had an operating surplus of £35.9m and a net deficit of £14.9m. The Chief Executive Officer confirmed that the 2017/18 year-end position for SRFT was a surplus of £17.9m, £19.4m better than plan, and a Use of Resources score of 1. He added that the 2017/18 year-end position for PAHT was a deficit of £32.8m, £21.5m worse than the plan, and a Use of Resources score of 4, with further detail to be provided later in the meeting.

8.3 Care Organisation Chief Officer PresentationsGroup CiC reviewed a Care Organisation Performance Summary with respect to the following measures:

− Financial control− Workforce− 62 day cancer standard− Emergency Department 4 hour standard

The Care Organisation Chief Officers for Salford, North Manchester, Oldham and Bury & Rochdale, each provided focus on a specific measure, highlighting key issues and recovery actions.

8.3.1 SalfordThe Chief Officer for Salford Care Organisation (SCO) provided further detail regarding the SCO financial position, specifically highlighting a number of non-recurrent funds secured in late March, and confirmation from NHS Improvement (NHSI) regarding further STF incentive funding of £13.5m.

8.3.2 North ManchesterThe Chief Officer for North Manchester Care Organisation (NMCO) provided an overview of key statistics relevant to Greater Manchester (GM) and local demand for urgent care services. He confirmed that, notwithstanding fragility in staffing, the implementation of a new model of care from mid-April including additional Acute Medical Unit (AMU) beds and support from commissioners, A&E performance against the 4 hour standard over the previous 10 days had averaged over 90%.

In response to the Vice-Chairman seeking further information regarding stranded patient data, the Chief Executive Officer commented that the number of stranded patients, triangulated with additional data sets, provided context with respect to delays in transfers of care. The Chief Executive Officer

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No. Item Actionconfirmed that the Salford Care Organisation had patients with the highest length of stay, reflective of its specialist services. The Chief Delivery Officer confirmed further work was being undertaken to disaggregate medical and surgical acute patients from the ‘stranded patient’ data, thus providing a more valuable determinant of movement within hospitals.

In response to the Vice-Chairman querying next steps and future assurances with respect to urgent care, the Chief Executive Officer stated that the Group Executive would support NMCO to develop an improvement plan and confirmed the introduction of an adapted version of the Bristol Checklist within each Care Organisation Emergency Department to ensure the safety and personal comfort of patients. Acknowledging the challenge in achieving the standard across all Care Organisations, the Chief Medical Officer specifically emphasised the significant improvements in patient safety and increased consultant staffing within the NMCO Emergency Department since 2016. A Non-Executive Director fully acknowledged the importance of mandatory standards, and reflecting on the aforementioned comments of the Chief Medical Officer, expressed his view that patient safety metrics with respect to urgent care were highlighted within the Group Performance Scorecard. The Group Director of Quality Improvement confirmed a suite of metrics were captured in this regard and would be considered based on the Group Committees in Common requirements.

Comprehensive discussion took place regarding actions required to improve performance against the A&E 4 hour standard, specifically considering workforce and models of care. In conclusion, the Chief Executive Officer requested that improvement plans for each Care Organisation, highlighting trajectory for the year ahead would be presented to the Group Committees in Common in May 2018, alongside a comparison of the GP streaming models being implemented.

8.3.3 Bury and RochdaleThe Chief Officer for Bury & Rochdale Care Organisation (BRCO) provided further detail regarding work underway to address workforce challenges within the BRCO, specifically within Urgent Care at Rochdale Infirmary and Critical Care Unit at Fairfield General Hospital. The Senior Independent Director referred to the results of the National Staff Survey 2017 for PAHT; acknowledging the improvement in scores, she noted that scores remained below the national average in a number of areas, and queried plans in place to address this. The Chief Officer for BRCO confirmed that the BRCO Workforce Committee was currently reviewing and comparing results against both national and Group-wide indicators. The Interim Oldham Care Organisation Chief Officer echoed these comments and highlighted a key challenge for the Oldham Care Organisation was to improve response rate to the survey. The Chief Strategy & Organisational Development Officer highlighted the development of the People Strategy, encompassing learning and development, talent management, recruitment and engagement, to be presented to the Group Committees in Common in May 2018, and confirmed that the strategy would reflect the outcome of the National Staff Survey. The Chief Executive Officer suggested that the Care Organisation presentation with a focus on ‘workforce’ in May 2018 highlighted how the Staff Survey outcome had been used to develop improvement plans.

A Non-Executive Director expressed his view that additional data within the

Chief Delivery Officer

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No. Item Action‘Safe Staffing’ dashboard, for example % of rotas filled with temporary staff, would enable triangulation with patient safety indicators, and view with respect to effective use of resources. The Chief Nursing Officer confirmed that the Directors of Nursing reviewed, on a weekly basis, safe staffing data alongside a suite of measures such as pressure ulcers, falls, sickness absence and vacancy rates, and would include this data in future dashboards.

8.3.4 OldhamThe Interim Chief Officer for Oldham Care Organisation (OCO) provided a detailed update regarding OCO performance against the 2 week wait and 62 day cancer standard, confirming that the improvement trajectory had been bettered in February 2018 for both cancer standards. She confirmed the main risk to delivery of the standard by Quarter 1 2018/19 was the workforce requirement, predominantly in general surgery. In addition, the Interim Chief Officer for OCO confirmed work with the national Cancer Intensive Support Team to improve performance and identify those things that would make a difference. A Non-Executive Director queried key factors in Oldham impacting the 7 day target (percentage of patients receiving an appointment within 7 days of referral for suspected cancer). Furthermore, the Senior Independent Director acknowledged consistent achievement of cancer standards within the SCO and sought further information regarding both internal and external factors impacting performance. The Chief Delivery Officer described key factors impacting performance, specifically highlighting workforce availability, broader engagement with the General Surgery workforce, and importance of GP’s engaging in meaningful conversations with patients prior to their first appointment. The Interim Chief Officer for OCO echoed these comments and highlighted the importance of engagement with commissioning colleagues to drive progress in this regard.

8.4 HarmsThe Chief Executive Officer confirmed positive performance against many patient safety indictors including clostridium difficile, falls and pressure ulcers. He specifically highlighted that HSMR was statistically better than expected for both SRFT and PAHT.

The Group Committees in Common reviewed and confirmed the high level key performance indicators and progress made against priorities.

8.5 Strategic Matters

8.5.1 North East Sector (NES) The Chief Executive Officer confirmed that the NES commissioners had formally set out their commissioning intentions relating to those acute services currently located on the North Manchester General Hospital site but primarily serving the populations of Oldham, Bury and Rochdale, and that a formal letter was anticipated. He added that commissioners would be undertaking further work to develop specific proposals, and that the NCA Clinical Services Strategy would be developed in response to this.

8.5.2 North West Sector (NWS) The Chief Executive Officer reported that work continued to develop plans for the implementation of Healthier Together, working closely with the Greater Manchester Health and Social Care Partnership (GMH&SCP) to secure the

Chief Nursing Officer

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No. Item Actionrelease of capital for the new build, albeit at a slower pace than initially anticipated.

The Chief Executive Officer confirmed work was underway with partners to explore proposals for more resilient dermatology services, and more recently, that work had commenced to secure options for the delivery of a compliant Transient Ischemic Attack (TIA) service(s) across the sector.

8.5.3 OG Surgery, Vascular Services, Neuro Rehabilitation and Theme 3The Chief Executive Officer provided a summary of work underway with respect to specialist services including OG Surgery, Vascular Services, Neuro Rehabilitation and Theme 3. In response to a Non-Executive Director seeking further information regarding the pace of progress for Theme 3 workstreams, the Chief Executive Officer highlighted the complexity of the work underway across GM to consider single service developments and ensure resilient services for the future, in parallel with review of all acute services across GM. The Chief Medical Officer provided further detail regarding the development of a ‘blueprint’ for hospital services across the conurbation, highlighting the far reaching nature of this work and confirmed senior colleagues from across the NCA were involved in all aspects of this work.

8.5.4 Local Care Organisations (LCOs)The Chief Executive Officer stated that work continued with partners to establish LCOs in each of the NCAs localities and highlighted work underway to develop a ‘blueprint’.

9. Learning Report

The Chief Medical Officer presented the Learning from Deaths report summarising mortality data for the NCA for Quarter 2 2017/18. In response to the Senior Independent Director seeking further information regarding the 2.5% increase in falls resulting in moderate/severe harm/death, the Chief Medical Officer confirmed that much work had been undertaken to explore this increase and highlighted the roll out of the revised Fall Safe Bundle in April 2018.

In response to a Non-Executive Director seeking further information regarding work underway to address improvement to documentation, noting that this had been a concern in the North East sector Care Organisations, the Chief Medical Officer acknowledged the importance of accurate documentation and highlighted the challenges associated with the lack of an Electronic Patient Record in the North East sector. The Chief Medical Officer confirmed that this matter was considered in detail via Care Organisation Clinical Effectiveness Committees.

The Chief Nursing Officer presented the Learning from Experience report providing insight and learning themes from complaints and Patient Advice Liaison Service (PALs) and incident management for the NCA during Quarter 3 2017/18.

In response to a Non-Executive Director seeking further information regarding best practice tools and methods for shared learning, the Chief Nursing Officer highlighted the adaption of the Take 5 learning methodology

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No. Item Action(shared from The Royal Perth Bentley Group and the Government of Western Australia East Metropolitan Health Services), a learning solution providing 5 minute education for busy people and highlighted the pilot of different communication methods across the Care Organisations to identify solutions pertinent for each Care Organisation. A Non-Executive Director acknowledged the data presented was for Q3 2017/18, and queried how the NCA was made aware of emergent issues. The Chief Nursing and Medical Officer highlighted a suite of measures providing assurance in this regard, including weekly review of the Serious Untoward Incident Register.

The Senior Independent Director acknowledged the increase in complaints from Q2 to Q3 and the work underway to encourage concerns and issues to be addressed quickly and efficiently at ward/service level, and queried how this work would be measured. The Chief Nursing Officer commented that at this time wards/services were being encouraged to share examples of informal resolution of concerns, with formal complaint numbers continuing to be measured.

The Group Committees in Common reviewed and confirmed the Learning Report and supported the development of the Learning Environment, Patient Care Alert System and Take 5 Learning Methodology to promote organisational shared learning.

10. Patient and Service User Report The Chief Nursing Officer presented the Patient and Service User Experience Report and provided the Group Committees in Common with an update on progress and effectiveness of systems and processes for the collection, analysis and learning from patient and service user feedback including:

− National Patient Survey Report− Family and Friends Test (FFT)− Near Real Time and Real Time feedback

A Non-Executive Director highlighted the diverse populations served across the Care Organisations and queried how ‘the voice’ of service users from minority populations were encouraged and heard. The Chief Nursing Officer acknowledged that the Patient and Service User Team was cognisant of this matter and would address this throughout 2018/19.

The Senior Independent Director referred to the ‘talkback’ process undertaken with Consultants, and expressed her view that this was a valuable source of feedback, alongside review of anecdotal feedback gathered from the Council of Governors. The Chief Nursing Officer acknowledged these comments and how they may be incorporated into future report.

The Group Committees in Common reviewed and confirmed the report and further actions to be taken.

11. Quality Improvement Strategy Implementation: NCA Quality Improvement DashboardThe Chief Nursing Officer presented headlines, including special cause, from Quality Improvement projects taking place across the Northern Care Alliance (NCA). She highlighted special cause reduction in both the HSMR and Risk

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No. Item ActionAdjusted Mortality Index measures and described the introduction of the ‘Toyota Spec’ for HSMR enabling comparison with other NHS organisations both nationally and regionally. The Chairman welcomed the introduction of the Toyota Spec, noting consideration would be given as to how this could be appropriately applied to additional measures.

In response to a Non-Executive Director seeking further information regarding the notable difference in the ‘percentage of cardiac arrests occurring outside of critical care units (per 1000 admissions)’ across the Care Organisations, the Chief Nursing Officer confirmed that the deteriorating patient collaborative had been ongoing within the Salford Care Organisation since 2010, and that work continued across the North East sector Care Organisations to reliably embed changes packages and demonstrate further improvement.

In response to the Vice-Chairman seeking clarification regarding the SHMI measure for PAHT, noting that PAHT was statistically worse than expected for this measure within the Quality Improvement Dashboard and statistically higher than expected within the Group Performance Scorecard, the Group Quality Improvement Director confirmed that the NCA commissioned a more frequent calculation of SHMI, and that the funnel plot reflected the difference in calculation between the local and national provider, alongside a time lag in the national calculation. The Chief Medical Officer reiterated these comments and confirmed that future Quality Improvement Dashboards would demonstrate this improvement.

The Group Committees in Common reviewed and confirmed progress against delivery of the Quality Improvement Strategies and Nursing Assessment and Accreditation System for all Care Organisations.

12. North East Sector IT Infrastructure Stabilisation: Business CaseThe Chief Strategy and Organisational Development Officer provided contextual information relating to the risks to clinical and non-clinical operations of the North East sector Care Organisations caused by poor IT infrastructure and skills, and presented the scope of the business case to address priority technology infrastructure issues. The Chief Financial Officer provided further information regarding the financial case, confirming the proposed cost of the chosen option and impact on PAHT finances and affordability. The Chief Financial Officer confirmed that financial risks had been identified and steps taken to mitigate them, highlighting that as the preferred option required both revenue and capital investment, PAHT would enter into discussions with potential funding sources.

A Non-Executive Director acknowledged that the preferred option was the ‘minimum viable service’ and, in light of cyber security issues becoming more prevalent, sought confirmation that this option was satisfactory in this regard. The Chief Strategy and Organisational Development Officer confirmed that the business case had been developed in line with NHS cyber security standards and that this was a matter kept under regular review.

The Group Committees in Common reviewed the PAHT Stabilising Technology Infrastructure Business Case and approved the preferred option recommending that the Trust invested £17m to address priority technology infrastructure issues.

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No. Item Action

13. Implementation of Cyber Security StandardsThe Chief Strategy and Organisational Development Officer confirmed that the Department of Health and Social Care, NHS England and NHS Improvement (NHSI) had published a set of 10 data and cyber security standards called “the 2017/18 data security protection requirements (DSPR)”. He added that NHSI required that each NHS Provider confirmed they are meeting the new cyber security requirements by 11 May 2018, and as part of the assurance process, each NHS Provider’s Board must approve the response to NHSI.

The Chief Strategy and Organisational Development Officer presented information regarding the position of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust individually, with respect to the implementation of the 10 standards, highlighting compliance and/or action required.

In response to the Vice-Chairman querying how the submissions would be used by NHSI, the Chief Strategy and Organisational Development Officer confirmed that the information provided would be used to create a baseline of cyber readiness across the sector and to help target improvement support and resources.

The Group Committees in Common reviewed the position of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust, with respect to the implementation of the 10 data and cyber security standards, and confirmed that the positions could be submitted as reported to NHS Improvement.

14. Standards of Business Conduct: Board Level DirectorsThe Chairman presented a paper detailing the:

declared interests of all members of Board of Directors of Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAHT), Group Committees in Common and Care Organisation Leadership Teams;

compliance with the Fit and Proper Person Requirements (FPPR); and the independence of SRFT Non-Executive Directors in line with the NHS

FT Code of Governance (Provision B.1.2).

The Group Committees in Common confirmed current interests for Directors as follows:

Name and Position Declared Interests

Jim PotterChairman (SRFT, PAHT, Group CiC)

Chairman, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust

Diane BrownSenior Independent Director (SRFT and Group CIC) Non-Executive Director (PAHT)

Non-Executive Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust

Shareholder, AstraZeneca Board of Trustees Cheshire Community

Foundation

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No. Item ActionChris Mayer CBENon-Executive Director(SRFT, PAHT and Group CIC)

The Slynn Foundation, Member of Management Group

Associate of Fiona MacNeill Associates, Leadership facilitation & Coaching

Trustee of the Royal Armouries & member of the Finance & Audit Committee

Non-Executive Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust

With respect to the long term solution for PAHT: o Designated Independent Non-Executive

Director on PAHT Board of Directors, ando Member of the GM Transaction Board.

Professor Chris ReillyNon-Executive Director(SRFT and Group CiC)

Scientific Advisor: Welcome Trust, Stevenage Bioscience Catalyst, Alderley BioHub, REF/HEFCE, Innovate UK, HBMS, Karus Therapeutics

Professor (Honorary) KCL Board of Directors of Medicines Discovery

CatapultDr Hamish StedmanNon-Executive Director(SRFT and Group CiC)

Wife is Diabetes Specialist Nurse Manager at SRFT

Sister in law Paediatric Specialist Nurse at SRFT Primary Care Neighbourhood Lead for Salford

Primary Care TogetherJohn Willis CBEVice-Chairman (SRFT and Group CiC)Non-Executive Director (PAHT)

Trustee and distributor of The Booth Charities, Salford

Life Patron of The Lowry, Salford Non-Executive Director, Pennine Acute Hospitals

NHS Trust/Salford Royal NHS Foundation TrustKieran CharlesonNon-Executive Director (SRFT and Group CiC)

Regional Director of BT Group Member of CBI NW Council Member of Liverpool John Moores University

Employers Board Member of Institute of Directors

Sir David DaltonChief Executive (SRFT, PAHT and Group CiC)

Vice Chair, GM AHSN Governor, Health Foundation Board Member, Health Innovation Manchester Chief Executive, Pennine Acute Hospitals NHS

Trust/Salford Royal NHS Foundation Trust Elaine Inglesby- Burke CBEExecutive Nurse Director (SRFT and PAHT) Chief Nursing Officer (Group CiC)

Trustee of the Willowbrook Hospice: a Specialist Palliative Care Unit set up as an Independent Charity, governed by a Board of Trustees and run on a day to day basis by a CEO and management team

Executive Nurse - Governing Body of St Helens Clinical Commissioning Group

Non-Executive Director,Advancing Quality Alliance (AQUA)

Non-Executive Director, National Institute for Health and Care Excellence (NICE)

Executive Nurse Director, Pennine Acute Hospitals NHS Trust/Salford Royal NHS Foundation Trust

Mr Chris BrookesExecutive Medical Director (SRFT) and Chief Medical Officer (Group CiC)

Chief Medical Officer, England and Rugby Football League

Chief Medical Officer, Wigan Warriors Rugby League

Director, Chris Brookes Sports Medicine Ltd Principal Medical Advisor to the GM MSCP

Ian MostonExecutive Director of Finance (SRFT) and Chief Financial Officer

Director, RS-Chime Ltd Council Member, University of Salford Partner is Interim Director of Workforce, Christie

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No. Item Action(Group CiC) NHS Foundation TrustJudith AdamsExecutive Director of Group Delivery (SRFT) & Chief Delivery Officer (Group CiC)

None

Raj JainExecutive Director of Corporate Strategy and Business Development and Deputy Chief Executive (SRFT),Chief Delivery Officer and Deputy Chief Executive (Group CiC)

Director North West eHealth Board Member, MIMIT

Nicola FirthInterim Chief Officer – Oldham Care Organisation(Group CiC member, non-voting)

None

Damien FinnChief Officer – North Manchester Care Organisation(Executive Director of Finance on the PAHT Board, and Group CiC member, non-voting)

None

Steven TaylorChief Officer - Bury & Rochdale Care Organisation (Group CiC member non-voting)

Governor - Hopwood Hall College

James Sumner Chief Officer - Salford Care Organisation(Group CiC member, non-voting; and SRFT Board member- non-voting)

Member of Healthcare Advisory Board for OCS UK

Professor Matt MakinNorth Manchester Medical Director(Executive Medical Director - PAT Board)

Honorary Professor Bangor University

Jack SharpGroup Director of Service Strategy and Planning (SRFT Board member, non-voting)

None

Dr Peter TurkingtonMedical Director, Salford Care Organisation(SRFT Board member, non-voting)

Private and Medico-Legal Practice at Spire Hospital Manchester

Peter MurphyDirector of Nursing, Salford Care Organisation

Clinical Private Practice Board RN for Knowsley CCG Nursing report for Contillons Solicitors

Diane MorrisonDirector of Finance, Salford Care Organisation

Matt PowlsInterim Managing Director, Oldham Care Organisation

Jawad HussainMedical Director, Oldham Care Organisation

Provides consultation and treatment for NHS Choose and Book patients at Beaumont Private Hospital

Carolyn WoodDirector of Finance, Oldham Care Organisation

None

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No. Item ActionSteph GibsonManaging Director, North Manchester Care Organisation

Simon FeatherstoneDirector of Nursing, North Manchester Care Organisation

None

Shona McCallumMedical Director, Bury and Rochdale Care Organisation

Craig CarterDirector of Finance Bury and Rochdale Care Organisation

None

Tyrone RobertsDirector of Nursing , Bury and Rochdale Care Organisation

The Group Committees in Common reviewed and confirmed the Register of Board of Directors Interests.

Chairman’s Annual Assessment of the Fit and Proper Person Requirement for all directors The Chairman informed the Group Committees in Common that he had conducted an annual assessment of continued compliance with the Fit and Proper Person Requirement and had concluded that all directors, including all Board-level directors, should be considered to be deemed fit and that there is nothing to suggest that any director meets any of the unfit criteria. He stated on receipt of the enhanced DBS check for the Director’s highlighted within the paper, he would report to the Group Committees in Common if this position was to be amended.

The Group Committees in Common endorsed the Chairman’s annual assessment of the Fit and Proper Person Requirement for all directors.

Independence of Non-Executive DirectorsThe Group Committees in Common considered criteria relevant to the determination of the independence of Non-Executive Directors. The Group Committees in Common acknowledged that some Non-Executive Directors had served terms of more than six years at Salford Royal and that one Non-Executive Director had, within the last three years, a material business relationship with Salford Royal as the Chairman of Salford Clinical Commissioning Group. The Group Committees in Common acknowledged that uniquely, Non-Executive Directors at SRFT and PAHT were members only of the Board, and therefore Group Committees in Common, and statutory committees. Non-Executive Directors were not members of either Trust’s management or assurance committees and would continue to operate in this custom within the Group structure, and therefore retained significant independence from the operational management of Group.

In light of this and no other circumstance existing the Group Committees in Common confirmed its determination that all Non-Executive Directors, including the Chairman of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust were independent.

15. Code of Governance ReviewThe Chairman presented the annual review of SRFT’s compliance with the

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No. Item ActionNHS FT Code of Governance, highlighting that although the ‘Code’ was relevant to NHS Foundation Trusts; the review has been widened to encompass compliance for the Northern Care Alliance NHS Group (NCA).

The Chairman confirmed a review of compliance with each provision had been undertaken by the Group Secretary and Chairman. This had determined that the Trust complied 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 The Chairman was re-appointed by the Council of Governors in December 2014. His term of office was set to expire at the end of the Annual Members Meeting 2017, at which point he would have served 11 years as Non-Executive Director/Chairman. The Council of Governors’ decision in this regard was based on the Chairman’s outstanding contribution and performance and, with some relatively recent appointments of Executive and Non-Executive Directors, the reappointment of the Chairman beyond one year would provide stability during what was likely to be a period of significant change and challenge for the organisation.

o In March 2017, the tenure of the Chairman was extended until 30th June 2018 (extending current term of office to three years) by the Council of Governors. The Council of Governors recognised the exceptional circumstances and importance of stability during Group transitional arrangements, and acknowledged the significant experience and expertise of the Chairman. Further to this, in March 2018, with the Council of Governors approved the reappointment of the Chairman for a term of 1 year only, from 30.06.18 until 30.06.19, this decision was aligned to ensuring the successful delivery of plans for what would be a significant transaction for the organisations within the NCA.

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 1 year (1.1.17 until 31.12.17). This was extended to a term of office to 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. Their tenure was extended to two years and three months. At 31st March 2019, one of these Non-Executive Directors will have served eleven years and three months and the other, ten years and three months.

The Group Committees in Common received a detailed report that described the NCA’s level of compliance across every provision within the Code.

The Group Committees in Common reviewed the information provided and confirmed compliance with the provisions of the Code as described, including explanation of why the Trust had departed from B.1.2 and B.7.1.

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No. Item Action

16. Annual Self-CertificationsThe Group Secretary reported that NHS foundation trusts were required to self-certify whether or not they had complied with the conditions of the NHS provider licence; whether or not they had complied with governance requirements; and that they had the required resources available if providing commissioner requested services. She added that although NHS trusts were not issued with a provider licence, they were also required to self-certify whether or not they had complied with conditions equivalent to the licence that NHS Improvement has deemed appropriate.

The Group Secretary confirmed the declarations required and presented the detailed management review with respect to Condition G6, Condition FT4 and Condition CoS7 (Foundation Trusts only).

The Group Committees in Common reviewed and approved the current year’s annual self-certifications as described within the paper, subject to review by the Audit Committee on the 24th May 2018.

17. Reports from Standing Committees:

Group Executive Committees:

Group Risk and Assurance Committee (GRAC) – Meeting held on 23rd April 2018The Chief Executive Officer provided overview of the key matters and decisions made at the meeting on 23rd April 2018.

Group Audit Committee – Meeting held on 26th April 2018The Vice-Chairman provided overview of the key matters and decisions made at the meeting on 26th April 2018.

Further to review at Group Audit Committee, the Group Committees in Common reviewed and approved the refreshed Group Audit Committee Terms of Reference.

18. Chairman’s Report from Council of Governors – Meeting held on 28th March 2018

The Chairman provided the Group Committees in Common with a summary of the key issues discussed and decisions made at the meeting of the Group, and SRFT, Council of Governors on 28th March 2018.

The Group Committees in Common reviewed and confirmed the information provided

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

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No. Item Action

14. Date and Time of the Next MeetingThe Chairman confirmed that the next meeting would take place on Monday, 4th June 2018 from 10am at Humphrey Booth Lecture Theatre, Mayo Building.

Closure of Part 1 of the Group Committees in Common Meeting

15. 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.

Members of the public were requested to leave the meeting room at this point.

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

88.35 90.40 89.41 89.54 89.49 89.39 89.06 88.95 88.38 86.91 84.21 83.42

103.4 103.2 100.9 99.7 98.7 98.8 96.9 97.3 95.8 94.2 94.6 92.1

Salford Royal Foundation Trust

Pennine Acute Hospitals Trust

HSMR - Rolling 12 months

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

Highly Reliable & Trusted

Harms

Fairfield

Rochdale

Salford

North Manchester Oldham

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.

HSMR for Pennine as a Trust has reduced

mortality and is now statistically better than expected. Salford also remains statistically better

than expected.

HSMR is statistically better than national position. Salford CO's HSMR has decreased over the last quarter . The current position is 83.42.

Fairfield: HSMR is statistically as expected and continues to reduce.

the current position is 89. Rochdale: HSMR is statistically

below expected. The current position is 72.62.

HSMR for North Manchester has reduced over the last few months and is within expected statistical ranges. The current position is 100.14.

HSMR for Oldham CO remains statistically

better than expected. The current position is

91.73.

18/318

14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 17/18 Q1 17/18 Q2

96.95 102.94 91.66 83.31 80.77 88.91 86.83 89.55 100.06 96.84 84.09 83.26

103.75 106.21 108.15 103.85 116.26 118.10 113.36 104.49 110.32 111.18 93.89 89.57

SHMI - QuarterlySalford Royal Foundation Trust




Harms

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 rates and then risk adjusted to take

into account key risk factors associated with mortality.

Salford's SHMI remains statistically lower than expected, although there has been an increase in

quarter. Pennine as a Trust also has a SHMI which is statistically better than expected (against 95%

Confidence Intervals).

70

80

90

100

110

120

130

140

Salford SHMI Quarterly

Actual Av UCL LCL

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

SHMI for the Salford Care Organisation is statistically better than the expected level. The current position is 83.26.

80

90

100

110

120

130

140

14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 17/18 Q1 17/18 Q2

Fairfield SHMI Quarterly

0

20

40

60

80

100

120

140

14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 17/18 Q1 17/18 Q2

Rochdale SHMI Quarterly

SHMI for Fairfield is below the expected range at 92.0.

SHMI at Rochdale remains below expected levels at

42.27.

70

80

90

100

110

120

130

140

North Manchester SHMI Quarterly

Actual Av UCL LCL


SHMI for the North Manchester Care Organisation is below expected levels standing at 96.62.

70

80

90

100

110

120

130

140

Oldham SHMI Quarterly

Actual Av UCL LCL


SHMI for the Oldham Care Organisation has

continued to reduce and is 86.65 for the

current quarter.

19/318



Clostridium Difficile

0

5

10

15

20

25

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

Salford C.Dif (YTD Cumulative)

Cumulative Trajectory Cumulative Actual

There Salford Care Organisation is above it's expected trajectory of 2 occurences for 2018/19 with a cumulative position of 4.

0

5

10

15

20

25

Bury & Rochdale C.Dif (YTD Cumulative)

Cumulative Actual Cumulative Trajectory

0

5

10

15

20

25


North Manchester C.Dif (YTD Cumulative)


0

5

10

15

20

25


Oldham C.Dif (YTD Cumulative)


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

This metric forms part of the Single

Oversight Framework.

There has been a 26% reduction in the number of cases of CDif in the North

East Sector in 2017/18.

The Bury & Rochdale Care Organisation had no

instances of C.Dif in April '18.

The North Manchester Care Organisation had no instances of C.Dif in April '18.

The Oldham Care had one instance of C.Dif in April'18

but is below trajectory.

20/318



Falls

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

Salford Falls

Actual Falls

Four moderate+ falls have been reported in month at the Salford Care Organisation which is in line with current trends and variation.

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

Bury & Rochdale Falls

Actual Falls

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

North Manchester Falls

Actual Falls

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

Oldham Falls

Actual Falls

This metric measures falls resulting in moderate harm and above.

All care organisations have normal

variation in falls with moderate and above harm. In the coming months the NCA will

be scaling the standardised falls work from the NES across all areas of all are

organisations.

Falls at the Bury & Rochdale Care

Organisation have followed a consistent

trend. There has been 1 reportable fall 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.

21/318



Harms

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

Salford Pressure Ulcers

Actual Pressure Ulcers G2+

There were 7 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.

The North East Sector has seen a 34% reduction in pressure ulcers (acute and

community) since the start of the improvement work. There are 2 further

learning sessions planned before the spread and sustain phase commences.

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.

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

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

Oldham Pressure Ulcers


The Oldham Care Organisation is maintaining lower levels of pressure ulcers in line with reductions since April '17. There were 7 reported pressure ulcers 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

North Manchester Pressure Ulcers


The North Manchester Care Organisation has seen 8 reported pressure ulcer in month which is in line with normal variation.

22/318

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

84.8% 89.9% 82.1% 83.6% 91.6% 93.0% 89.5% 87.1% 90.2% 81.7% 82.3% 75.6% 82.0% 82.5%

81.3% 80.9% 86.4% 83.5% 84.5% 85.0% 85.1% 89.5% 87.1% 80.5% 83.8% 81.7% 81.7% 87.7%

92.1% 94.6% 93.6% 93.4% 94.7% 94.0% 92.8% 92.4% 90.2% 88.6% 85.5% 86.5% 84.8% 89.2%

79.8% 81.7% 84.5% 84.7% 78.3% 78.3% 79.7% 84.6% 73.1% 71.5% 71.6% 73.8% 63.7% 73.6%

Best Performer (Other GM)

Worst Performer (Other GM)



Highly Reliable & Connected Care

Urgent Care

A&E 4 Hour Performance


The Salford Care Organisation is above it's improvement trajectory with performance of 82.48% in April, below April 17's performance of 89.9%. The 7 day reattendance rate was 6.39%, below the 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 have seen improvements

in April year-on-year with the exception of Salford.

Unplanned rettendances at A&E within 7 days have been added as a balancing quality measure.

The national standard for reattendances is no more than 5%. The NHS England average for March '18 was 7.9%. North Manchester CO is

above the national average and a review is underway to understand this.

The Bury & Rochdale Care Organisation met the March

trajectory with a performance of 96.6% against an improvement

trajectory of 93.6% and improved on April '17.

The 7 day reattendance rate was 7.38,

below the national average.

The North Manchester Care Organisation did not achieve its improvement trajectory for April with a performance of 78.4%, an improvement on April '17. The 7 day reattendance rate was 8.73%, above the national average.

Oldham Care Organisation performance was 87.4% in April.

The Care Organisation has not delivered the April trajectory but

is impoved on April '17.

The 7 day reattendance rate was 6.53%, below th e 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

nac

e (B

lue

)

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

nac

e (B

lue

)

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

nac

e (B

lue

)

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

nac

e (B

lue

)

Oldham A&E Performance


23/318



Stranded Patients

55.68% of occupied bed days in the Salford Care

Organisation were used by stranded patients in April '18

of which 41.65% were Gen Med/Elderly. 30.58% of bed-

days were used by super-stranded patients.

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. A subset of General Medicine and Care of the Elderly

patients is also shown.

This metric is a measure of flow across our beds. The focus for improvement in our Care Organisations is General Medicine and Care of the Elderly. The QI collaborative "End PJ Paralysis" and work of the

Integrated Discharge Team is expected to reduce super-stranded patients. The improvement work on flow and

reliable ward rounds will target stranded patients.

33.28% of occupied bed days in the Bury & Rochdale Care were used by stranded patients in April '18 of which 25.95% where Gen Med/Elderly. 11.4% were used by super-stranded patients.

38.22% of occupied bed days in the North Manchester Care Organisation were used by stranded patients in April '18 of which 14.54% where Gen Med/Elderly . 14.03% were used by super-stranded patients.

38.44% of occupied bed days in the Oldham Care Organisation

were used by stranded patients in April '18 of which 10.29%

where Gen Med/Elderly. 11.60% were used by super-stranded

patients.

0%

10%

20%

30%

40%

50%

60%

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

Salford Stranded & Super Stranded %

Stranded (7+) Super Stranded (21+)

Gen Med/Elderly Stranded Gen Med/Elderly Super Stranded

0%

10%

20%

30%

40%

50%

60%

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

Bury & Rochdale Stranded & Super Stranded %



0%

10%

20%

30%

40%

50%

60%

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

North Manchester Stranded & Super Stranded %



0%

10%

20%

30%

40%

50%

60%

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

Oldham Stranded & Super Stranded %



24/318



Delayed Transfers of Care % Bed Days

Performance for the Salford Care Organisation

is below the national target for April at 1.63%.

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.

A review is underway in order to

provide assurance that guidance for the classification of delays is applied

consistently across all Care

Performance for the Bury & Rochdale Care Organisation is above the national target for April at 3.21%.

Performance for the North Manchester Care Organisation is 5.38% for April, above the national target. Manchester CCG have invested into the Integrated Discharge Team to reduce levels of delays.

The Oldham Care Organisation has a

performance of 1.85% for April, below the national

target .

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 Days

DTOC Target

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

DTOC Target

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

DTOC Target

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

Oldham Delayed Transfers % Bed Days

DTOC Target

25/318

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

92.71% 92.40% 93.03% 93.00% 92.35% 92.20% 92.04% 92.26% 92.29% 92.01% 92.03% 92.02% 92.03% 92.08%

92.20% 92.04% 92.05% 92.20% 90.90% 89.82% 90.38% 90.37% 90.26% 88.03% 87.27% 86.63% 86.53% 86.53%

90.30% 89.90% 90.40% 90.30% 89.90% 89.40% 89.10% 89.30% 89.50% 88.20% 88.20% 87.90% 87.20%



Elective Access

NHS England


RTT Open Performance


The Salford Care Organisation continues to meet the 92% standard with performance of 92.08% for April. The size of the list has remained at the same level month on month and 99.62% of patient have waited less than 36wks.

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.

A further quality measure has been added

to monitor the proportion of patients waiting less than 36 weeks across our Care

Organisations.

The Bury and Rochdale Care Organisation has met the 92% standard with performance of

92.08% for April. The size of the list has remained at the

same level month on month and 99.58% of patient have

waited less than 36wks.

The North Manchester Care Organisation is below the 92% standard at 84.47% in April. There was 1 open 52 week breach reported for Paediatric Oral Surgery. The size of the list has remained at the same level month on month and 99.58% of patient have waited less than

The Oldham Care Organisation continues to perform below the 92% standard with performance of 82.53% in April. The size of the list has remained at the same level month on month and 98.53% of patient have waited less than 36wks.

7000

12000

17000

22000

27000

32000

37000

42000

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-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-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

7000

12000

17000

22000

27000

32000

37000

42000

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

7000

12000

17000

22000

27000

32000

37000

42000

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

De

c-1

7

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

De

c-1

8

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


7000

12000

17000

22000

27000

32000

37000

42000

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

De

c-1

7

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

De

c-1

8

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


26/318

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

99.1% 99.0% 99.1% 98.1% 95.4% 95.0% 96.4% 96.1% 93.4% 94.9% 97.9% 96.1% 95.8%

99.2% 99.1% 97.5% 97.6% 97.5% 98.3% 99.2% 99.0% 98.5% 99.1% 99.3% 99.6% 99.6%

6 Wk Diagnostic Performance





Diagnostic Access

Performance for the Salford Care Organisation in April '18 was 95.79%, below the target of 99%.

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 Salford Care Organisation to deliver the

standard.

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

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

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

Indicative performance for the Bury & Rochdale Care Organisation in April'18 was 100%, meeting the target of 99%.

Performance for the North Manchester Care Organisation in April'18 was 99.16%, meeting the target of 99%.

Performance for the Oldham Care Organisation in April'18 was 99.56%, above the target of 99%.

27/318

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

92.8% 93.2% 97.0% 95.2% 96.1% 97.0% 96.3% 96.7% 96.1% 95.5% 98.4% 98.8% 96.0%

93.5% 87.4% 95.6% 85.1% 85.7% 82.6% 86.8% 84.1% 97.8% 93.6% 91.1% 91.2% 88.1%





Cancer TWW Pathways

TWW

The Salford Care Organisation continues to deliver the standard with a performance of 96% in March.

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

compliance.

Cancer performance is reported at Care Organisation and Trust level and is two months retrospective.

The 7 day standard measure the proportion of 2ww

appointments booked within 7 days. The aim is to acheive 80% for this standard.

Performance against this standard has improved in all Care

Organisations with the exception of North Manchester. This is due to capacity issues and process issues with the e-Referrals

System within primary care. The Care Organisation has engaged with commissioners to review this.

The Bury & Rochdale care organisation continues to meet

the standard with 100% compliance for March.

The North Manchester care organisation was above the national standard with performance for March of 92.84% but below it's trajectory. This is a result of capacity issues in the breast service and aims to recover by the end of June.

The Oldham Care Organisation is belowit's

recovery trajectory with a performance of 81.9% for March and also below the

national standard. This may have a n impact on 62 day

performance during for

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

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

28/318

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

89.8% 89.0% 90.2% 87.0% 89.1% 85.8% 91.5% 88.5% 91.0% 92.1% 87.5% 92.2% 92.2%

76.1% 77.1% 79.9% 73.9% 82.7% 83.8% 81.7% 85.3% 85.3% 80.5% 80.6% 83.5% 83.8%Pennine Acute Hospitals Trust



Cancer 62 Day Pathways

62 Day NationalSalford Royal Foundation Trust

Salford continues to meet the 85% standard with a performance of 92.2% for March against the national standard.

Those referred urgently and diagnosed with cancer should begin their first definitive treatment within 62 days of referral. The

standard is 85% compliance.

Cancer performance for the North East Sector care was attributed to care organisations from

July '17.

Improvement work across tumour groups continues across the North East Sector with support from the national Intensive Support

Team.

The Bury & Rochdale Care Organisation is below the

standard for March with a performance of 88.89%. This

is due to one breach. The care organisation covers ENT

tumour groups.

The North Manchester Care Organisation is above the national standard and it's trajectory for March with a performance of 87.33%.

The Oldham Care Organisation is above it's recovery trajectory with a performance of 75.4%.

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 28 Day Faster Diagnosis

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

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

29/318


Connected & At Scale

Workforce - Sickness Absence

The Salford Care Organisation sickness absence rates are below the 4.2% target in month at 3.31%.

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 revamped, and a renewed focus on sickness management

is being deployed. Some benefit will accrue from this. Our approaches to wellness and skills of managers are important ingredients that are now subject to development plans.

The Bury and Rochdale Care Organisation sickness rate is below the 5% target in month at 4.82%.

The North Manchester Care Organisation sickness data is above the 5% target for April '18 at 5.05%.

The Oldham Care Organisation sickness data is below the 5% target in month at 4.75%.

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

30/318



Workforce - Staff Retention Rates

The Salford Care Organisation retention rate for Medical and Dental staff April 18 was 84.81%, for Nursing and Midwifery staff the rate was 89.52%.

Staff retention rates are calculated as a stability index over 12 months and split into Nursing and

Midwifery, and Medical and Dental . Data is being updated historically for the North East Sector.

Of all the workforce indicators, retention has the most significant impact. Guided by the national

NHSI retention collaborative, significant action has been planned/implemented. The Pioneers and

BME programmes are home grown initiatives that have been implemented. The ability of line

management to be “great people” managers requires support and is a focus of attention. These initiatives will support improvement.

The Bury and Rochdale Care Organisation 17/18 retention rate for Medical and Dental staff was 85.98%, for Nursing and Midwifery staff the rate was 82.94%

The North Manchester Care Organisation 17/18 retention rate for Medical and Dental staff was 85.71%, for Nursing and Midwifery staff the rate was 82.72%

The OldhamCare Organisation 17/18 retention rate for Medical and Dental staff was 89.73%, for Nursing and Midwifery staff the rate was 80.97%

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 Retention Rates

Retention Rate N&M Retention Rate M&D

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 Retention Rates


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 Retention Rates


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 Retention Rates


31/318



Workforce - Staff Vacancy Rate

The Salford Care Organisation vacancy rate for Nursing and Midwifery staff the rate was 6.2%. Data for Medical and Dental staff is currently unavailable.

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, eg critical

care, paediatrics.

The Bury and Rochdale Care Organisation April '18 vacancy rate for Medical and Dental staff was 18.16%, for Nursing and Midwifery staff the rate was 11.11%

The North Manchester Care Organisation April '18 vacancy rate for Medical and Dental staff was 17.9%, for Nursing and Midwifery staff the rate was 13.55%

The OldhamCare Organisation April '18 vacancy rate for Medical and Dental staff was 7.33%, for Nursing and Midwifery staff the rate was 7.96%

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%

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


32/318



Workforce - Nursing & Midwifery Agency Utilisation

Salford has maintained it's level of nursing and midwifery agency usage during April with normal variation.

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.

Bury & Rochdale Care Organisation has seen a

stabilisation of nursing and midwifery agency usage

during April.

The North Manchester Care Organisation has sustained it's decrease in agency usage for nursing and midwifery staff groups in April.

The Oldham Care Organisation maintains its level of nursing and midwifery agency utilisation during April.

0

100

200

300

400

500

05

/03

/20

17

12

/03

/20

17

19

/03

/20

17

26

/03

/20

17

02

/04

/20

17

09

/04

/20

17

16

/04

/20

17

23

/04

/20

17

30

/04

/20

17

07

/05

/20

17

14

/05

/20

17

21

/05

/20

17

28

/05

/20

17

04

/06

/20

17

11

/06

/20

17

18

/06

/20

17

25

/06

/20

17

02

/07

/20

17

09

/07

/20

17

16

/07

/20

17

23

/07

/20

17

30

/07

/20

17

06

/08

/20

17

13

/08

/20

17

20

/08

/20

17

27

/08

/20

17

03

/09

/20

17

10

/09

/20

17

17

/09

/20

17

24

/09

/20

17

01

/10

/20

17

08

/10

/20

17

15

/10

/20

17

22

/10

/20

17

29

/10

/20

17

05

/11

/20

17

12

/11

/20

17

19

/11

/20

17

26

/11

/20

17

03

/12

/20

17

10

/12

/20

17

17

/12

/20

17

24

/12

/20

17

31

/12

/20

17

07

/01

/20

18

14

/01

/20

18

21

/01

/20

18

28

/01

/20

18

04

/02

/20

18

11

/02

/20

18

18

/02

/20

18

25

/02

/20

18

04

/03

/20

18

11

/03

/20

18

18

/03

/20

18

25

/03

/20

18

01

/04

/20

18

08

/04

/20

18

15

/04

/20

18

22

/04

/20

18

29

/04

/20

18

06

/05

/20

18

13

/05

/20

18

Salford N&M Weekly Agency Utilisation

Actual Av UCL LCL


0

100

200

300

400

500

05/03

/2017

12/03

/2017

19/03

/2017

26/03

/2017

02/04

/2017

09/04

/2017

16/04

/2017

23/04

/2017

30/04

/2017

07/05

/2017

14/05

/2017

21/05

/2017

28/05

/2017

04/06

/2017

11/06

/2017

18/06

/2017

25/06

/2017

02/07

/2017

09/07

/2017

16/07

/2017

23/07

/2017

30/07

/2017

06/08

/2017

13/08

/2017

20/08

/2017

27/08

/2017

03/09

/2017

10/09

/2017

17/09

/2017

24/09

/2017

01/10

/2017

08/10

/2017

15/10

/2017

22/10

/2017

29/10

/2017

05/11

/2017

12/11

/2017

19/11

/2017

26/11

/2017

03/12

/2017

10/12

/2017

17/12

/2017

24/12

/2017

31/12

/2017

07/01

/2018

14/01

/2018

21/01

/2018

28/01

/2018

04/02

/2018

11/02

/2018

18/02

/2018

25/02

/2018

04/03

/2018

11/03

/2018

18/03

/2018

25/03

/2018

01/04

/2018

08/04

/2018

15/04

/2018

22/04

/2018

29/04

/2018

06/05

/2018

13/05

/2018

Bury & Rochdale N&M Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

450

500

05/03

/2017

12/03

/2017

19/03

/2017

26/03

/2017

02/04

/2017

09/04

/2017

16/04

/2017

23/04

/2017

30/04

/2017

07/05

/2017

14/05

/2017

21/05

/2017

28/05

/2017

04/06

/2017

11/06

/2017

18/06

/2017

25/06

/2017

02/07

/2017

09/07

/2017

16/07

/2017

23/07

/2017

30/07

/2017

06/08

/2017

13/08

/2017

20/08

/2017

27/08

/2017

03/09

/2017

10/09

/2017

17/09

/2017

24/09

/2017

01/10

/2017

08/10

/2017

15/10

/2017

22/10

/2017

29/10

/2017

05/11

/2017

12/11

/2017

19/11

/2017

26/11

/2017

03/12

/2017

10/12

/2017

17/12

/2017

24/12

/2017

31/12

/2017

07/01

/2018

14/01

/2018

21/01

/2018

28/01

/2018

04/02

/2018

11/02

/2018

18/02

/2018

25/02

/2018

04/03

/2018

11/03

/2018

18/03

/2018

25/03

/2018

01/04

/2018

08/04

/2018

15/04

/2018

22/04

/2018

29/04

/2018

06/05

/2018

13/05

/2018

North Manchester N&M Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

450

500

05

/03/20

17

12

/03/20

17

19/03

/2017

26/03

/2017

02

/04/20

17

09

/04/20

17

16/04

/2017

23/04

/2017

30

/04/20

17

07

/05/20

17

14/05

/2017

21/05

/2017

28

/05/20

17

04/06

/2017

11/06

/2017

18/06

/2017

25

/06/20

17

02/07

/2017

09/07

/2017

16

/07/20

17

23

/07/20

17

30/07

/2017

06/08

/2017

13

/08/20

17

20

/08/20

17

27/08

/2017

03/09

/2017

10

/09/20

17

17

/09/20

17

24/09

/2017

01/10

/2017

08

/10/20

17

15

/10/20

17

22/10

/2017

29/10

/2017

05

/11/20

17

12/11

/2017

19/11

/2017

26/11

/2017

03

/12/20

17

10/12

/2017

17/12

/2017

24

/12/20

17

31

/12/20

17

07/01

/2018

14/01

/2018

21

/01/20

18

28

/01/20

18

04/02

/2018

11/02

/2018

18

/02/20

18

25

/02/20

18

04/03

/2018

11/03

/2018

18

/03/20

18

25

/03/20

18

01/04

/2018

08/04

/2018

15

/04/20

18

22/04

/2018

29/04

/2018

06

/05/20

18

13

/05/20

18

Oldham N&M Weekly Agency Utilisation

Actual Av UCL LCL


33/318



Workforce - Medical & Dental Agency Utilisation

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

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 North Manchester Care Organisation maintained its level of medical and dental agency staff usage within normal variation during April.

The Oldham Care Organisation maintained its level of medical and dental agency staff usage within normal variation during April.

0

50

100

150

200

250

300

350

400

05/03

/2017

12/03

/2017

19/03

/2017

26/03

/2017

02/04

/2017

09/04

/2017

16/04

/2017

23/04

/2017

30/04

/2017

07/05

/2017

14/05

/2017

21/05

/2017

28/05

/2017

04/06

/2017

11/06

/2017

18/06

/2017

25/06

/2017

02/07

/2017

09/07

/2017

16/07

/2017

23/07

/2017

30/07

/2017

06/08

/2017

13/08

/2017

20/08

/2017

27/08

/2017

03/09

/2017

10/09

/2017

17/09

/2017

24/09

/2017

01/10

/2017

08/10

/2017

15/10

/2017

22/10

/2017

29/10

/2017

05/11

/2017

12/11

/2017

19/11

/2017

26/11

/2017

03/12

/2017

10/12

/2017

17/12

/2017

24/12

/2017

31/12

/2017

07/01

/2018

14/01

/2018

21/01

/2018

28/01

/2018

04/02

/2018

11/02

/2018

18/02

/2018

25/02

/2018

04/03

/2018

11/03

/2018

18/03

/2018

25/03

/2018

01/04

/2018

08/04

/2018

15/04

/2018

22/04

/2018

29/04

/2018

06/05

/2018

13/05

/2018

Salford M&D Weekly Agency Utilisation

Actual Av UCL LCL


The Bury & Rochdale Care Organisation saw a decreased usage of medical and dental agency staff in April.

0

50

100

150

200

250

300

350

400

05/03

/2017

12/03

/2017

19/03

/2017

26/03

/2017

02/04

/2017

09/04

/2017

16/04

/2017

23/04

/2017

30/04

/2017

07/05

/2017

14/05

/2017

21/05

/2017

28/05

/2017

04/06

/2017

11/06

/2017

18/06

/2017

25/06

/2017

02/07

/2017

09/07

/2017

16/07

/2017

23/07

/2017

30/07

/2017

06/08

/2017

13/08

/2017

20/08

/2017

27/08

/2017

03/09

/2017

10/09

/2017

17/09

/2017

24/09

/2017

01/10

/2017

08/10

/2017

15/10

/2017

22/10

/2017

29/10

/2017

05/11

/2017

12/11

/2017

19/11

/2017

26/11

/2017

03/12

/2017

10/12

/2017

17/12

/2017

24/12

/2017

31/12

/2017

07/01

/2018

14/01

/2018

21/01

/2018

28/01

/2018

04/02

/2018

11/02

/2018

18/02

/2018

25/02

/2018

04/03

/2018

11/03

/2018

18/03

/2018

25/03

/2018

01/04

/2018

08/04

/2018

15/04

/2018

22/04

/2018

29/04

/2018

06/05

/2018

13/05

/2018

Bury & Rochdale M&D Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

05/03

/2017

12/03

/2017

19/03

/2017

26/03

/2017

02/04

/2017

09/04

/2017

16/04

/2017

23/04

/2017

30/04

/2017

07/05

/2017

14/05

/2017

21/05

/2017

28/05

/2017

04/06

/2017

11/06

/2017

18/06

/2017

25/06

/2017

02/07

/2017

09/07

/2017

16/07

/2017

23/07

/2017

30/07

/2017

06/08

/2017

13/08

/2017

20/08

/2017

27/08

/2017

03/09

/2017

10/09

/2017

17/09

/2017

24/09

/2017

01/10

/2017

08/10

/2017

15/10

/2017

22/10

/2017

29/10

/2017

05/11

/2017

12/11

/2017

19/11

/2017

26/11

/2017

03/12

/2017

10/12

/2017

17/12

/2017

24/12

/2017

31/12

/2017

07/01

/2018

14/01

/2018

21/01

/2018

28/01

/2018

04/02

/2018

11/02

/2018

18/02

/2018

25/02

/2018

04/03

/2018

11/03

/2018

18/03

/2018

25/03

/2018

01/04

/2018

08/04

/2018

15/04

/2018

22/04

/2018

29/04

/2018

06/05

/2018

13/05

/2018

North Manchester M&D Weekly Agency Utilisation

Actual Av UCL LCL


0

50

100

150

200

250

300

350

400

05/03

/20

1712

/03/20

1719

/03/2

017

26/03

/2017

02/04

/20

1709

/04/20

1716

/04/2

017

23/04

/2017

30/04

/20

1707

/05/20

1714

/05/2

017

21/05

/2017

28/05

/20

1704

/06/20

1711

/06/2

017

18/06

/2017

25/06

/20

1702

/07/20

1709

/07/2

017

16/07

/2017

23/07

/20

1730

/07/20

1706

/08/2

017

13/08

/2017

20/08

/20

1727

/08/20

1703

/09/20

1710

/09/20

1717

/09/20

1724

/09/20

1701

/10/20

1708

/10/20

1715

/10/20

1722

/10/2

017

29/10

/2017

05/11

/20

1712

/11/20

1719

/11/2

017

26/11

/2017

03/12

/20

1710

/12/20

1717

/12/2

017

24/12

/2017

31/12

/20

1707

/01/20

1814

/01/2

018

21/01

/2018

28/01

/20

1804

/02/20

1811

/02/2

018

18/02

/2018

25/02

/20

1804

/03/20

1811

/03/2

018

18/03

/2018

25/03

/20

1801

/04/20

1808

/04/2

018

15/04

/2018

22/04

/20

1829

/04/20

1806

/05/2

018

13/05

/2018

Oldham M&D Weekly Agency Utilisation

Actual Av UCL LCL


34/318



Safe Staffing

Salford Care Organisation has met the standard for

Care Staff shift types but is below the standard for

Nursing staff shift types.

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 staff shift types.

North Manchester Care Organisation has met the

standard for Care Staff shift types but is below

the standard for Nursing staff shift types.

The Oldham Care Organisation has met the

standard for Care Staff night shift types but is

below the standard for all other 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



35/318

Ward Main SpecialtyAverage fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffNAAS Ward Main Specialty

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staff

ANU Neurology 66.67% 97.89% 68.47% 96.15% 0 1 42.04% 7.31% Y AnteNatal Ward Obstetrics 98.09% 91.67% 87.32% 93.33% 0 0 77.30% 4.10% N

ASU Acute Stroke Unit 63.56% 91.54% 66.67% 100.00% 0 0 29.77% 4.81% Y Childrens Paediatric Surgery 78.92% 49.69% 94.19% 300.00% 0 0 8.60% 6.40% N

B3 Stroke 53.54% 85.86% 69.57% 114.12% 0 0 18.79% 9.03% Y Critical Care Critical Care 94.33% 108.33% 90.91% 96.67% 1 0 26.70% 5.40% Y

B3 Annexe General Surgery 100.00% 100.00% 100.00% 103.45% 0 0 45.37% 21.23% Y Labour Ward Obstetrics 96.84% 76.67% 93.63% 89.66% 0 0 87.10% 0.00% N

B4 Trauma Rehab 65.33% 95.53% 66.67% 105.66% 0 0 33.09% 2.81% Y Neonatal Unit Obstetrics 78.29% 76.67% 75.28% - 0 0 18.20% 4.40% N

B5 Acute Trauma 82.75% 263.89% 101.67% 203.33% 0 0 15.95% 6.10% Y PostNatal Ward Obstetrics 96.93% 93.89% 95.83% 92.86% 0 0 -182.90% 4.00% N

B6 Trauma Orthopaedics 91.28% 155.83% 100.00% 300.00% 0 1 21.60% 2.45% Y Ward C3 General Surgery 89.33% 100.00% 101.67% 131.25% 0 0 25.80% 8.10% Y

B7 Neurosurgery 71.45% 333.33% 92.22% 255.00% 0 0 18.93% 3.55% Y Ward C4 General Surgery 64.00% 73.95% 76.67% 76.67% 0 0 28.30% 5.50% Y

B8 Neurosurgery 99.30% 193.98% 76.67% 238.33% 0 0 25.86% 7.67% Y Ward C5 General Medicine 99.26% 96.40% 98.33% 132.29% 0 0 -33.10% 2.90% Y

C2 Neuro Rehab 69.26% 83.94% 80.00% 97.50% 0 0 28.08% 6.95% Y Ward C6 General Medicine 105.76% 97.24% 103.45% 103.06% 0 0 -33.10% 2.90% Y

CCU Critical Care Unit 102.56% 107.47% 107.08% 118.18% 2 0 -1.11% 3.68% Y Ward CCU G4 Cardiology 87.33% 90.00% 96.67% 96.67% 0 0 13.80% 18.40% Y

CPIU Programmed Investigation Unit 101.08% 78.28% 84.38% 123.53% 0 0 -22.73% 4.36% Y Ward D5 Gastroenterology 94.44% 100.00% 101.67% 93.33% 0 0 36.80% 6.20% Y

EAU Emergency Assessment Unit 81.10% 134.96% 84.53% 135.85% 0 0 13.97% 5.28% Y Ward D6 Gastroenterology 93.85% 101.65% 100.00% 103.13% 0 0 76.20% 12.80% Y

HAEM Haematology 99.19% 70.00% 66.04% 96.67% 0 0 4.18% 0.70% Y Ward E1 General Medicine 96.77% 107.14% 98.89% 202.86% 0 0 19.40% 17.70% y

HB1 General Surgery 76.11% 211.39% 66.67% 1390.00% 0 0 32.94% 6.72% Y Ward F3 General Surgery 86.19% 108.33% 105.00% 145.00% 0 0 6.90% 6.70% Y

HB2 General Surgery 93.51% 166.67% 68.60% 236.67% 0 0 2.45% 4.27% Y Ward F4 General Medicine 94.00% 135.45% 108.62% 127.78% 0 0 13.60% 6.00% Y

HCU Heart Care Unit 84.36% 102.50% 77.69% 106.67% 0 0 6.00% 1.45% Y Ward F5 General Surgery 89.42% 100.00% 115.38% 98.36% 0 0 13.80% 2.60% Y

HH1M Medical HDU 147.88% 87.65% 174.17% 102.17% 0 0 9.34% 5.43% Y Ward F6 General Surgery 90.95% 97.50% 100.00% 113.33% 0 1 8.30% 11.90% Y

HH2 Respiratory 91.70% 150.17% 78.64% 368.97% 0 0 2.45% 6.05% Y Ward H3 General Medicine 93.13% 114.78% 92.92% 137.74% 0 0 45.20% 6.90% Y

HH3 Renal 91.19% 122.78% 75.83% 171.67% 0 0 4.51% 8.37% Y Ward I5 Trauma & Orthopaedics 70.27% 93.33% 83.96% 100.00% 6 0 28.40% 9.10% Y

HH4 Urology 85.24% 102.97% 101.67% 138.10% 0 0 12.12% 3.00% Y Ward I6 General Medicine 88.89% 130.41% 86.67% 136.67% 0 0 34.70% 11.30% Y

HH5 Surgery 77.58% 112.44% 66.67% 127.37% 0 0 39.54% 7.38% Y Ward J3J4 Infectious Diseases 87.58% 118.45% 100.67% 147.37% 0 0 22.90% 4.80% Y

HH6 Surgical HDU 104.85% 98.06% 136.67% 113.51% 0 0 9.26% 0.59% Y Ward J6 General Medicine 96.11% 123.14% 100.00% 135.00% 0 0 5.20% 4.50% Y

HH7 Neuro surgery & ENT 57.42% 102.46% 66.67% 116.96% 0 0 28.79% 9.66% Y Ward STU Urology 65.24% 91.67% 96.67% 100.00% 0 0 12.60% 1.10% Y

HH8 Intestinal Failure Unit 91.34% 128.89% 82.22% 163.16% 0 0 6.15% 5.01% Y

L2 Gastroenterology 103.26% 136.34% 100.00% 143.33% 2 0 -10.63% 2.11% Y

L3 Cardiology 80.89% 81.28% 67.78% 292.31% 2 0 23.83% 3.98% Y

L4 Care of the elderly 86.70% 119.44% 103.33% 158.33% 0 0 28.11% 0.69% Y N

L5 Care of the elderly 84.11% 126.06% 100.00% 198.33% 1 0 59.78% 11.85% Y Y

L6 Medical / diabetes 84.03% 108.96% 80.73% 128.10% 0 0 28.77% 7.29% Y Y

M2 Neurology 106.67% 100.00% 104.44% 114.71% 0 1 47.95% 8.51% Y Y

M3 Dermatology 82.67% 101.72% 96.67% 113.33% 0 0 6.92% 4.52% Y Y

MAPL Neurology 92.12% 79.57% 100.00% 100.00% 0 0 3.37% 6.87% Y

PNDS Sub-Acute Care (Pendleton Suite) - - - - 0 0 34.27% 10.46% Y

SRU Stroke Rehab Unit 73.33% 99.17% 100.00% 98.82% 0 0 30.83% 11.61% Y

STU Surgical Triage Unit 92.90% 177.46% 100.00% 106.67% 0 0 0.75% 2.93% Y

Ward to be reassessed after 8 months

SCAPE Ward (3 consecutive green assessments)

NAAS

Naas Accrediation Key

Ward not assessed

Failed Assessment - Reassessed after 2 months


Pressure

UlcersFalls

Nursing

Vacancy

Rate

Sickness

Rate



Safe Staffing

Day

North ManchesterDay Night

Salford

Pressure

UlcersFalls

Nursing

Vacancy

Rate

Sickness

Rate

Night

36/318

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 98.37% 65.00% 101.67% 73.33% 0 0 2.90% 1.00% Y A&E Observation Ward General Medicine 111.67% 188.89% 100.00% 500.00% 0 0 17.40% 2.40% Y

Fairfield Ward 11a Rehabilitation 64.17% 103.81% 90.00% 107.92% 0 0 16.20% 8.70% Y Antenatal Ward Obstetrics 99.45% 121.31% 102.22% 100.00% 0 0 -4.20% 5.40% N

Fairfield Ward 11b (Stroke) Rehabilitation 82.33% 100.69% 91.11% 145.83% 0 0 12.00% 11.70% Y Childrens Unit Paediatric Surgery 93.70% 98.43% 96.17% 72.41% 0 0 17.60% 5.00% N

Fairfield Ward 14 General Surgery 87.78% 93.22% 101.67% 113.33% 0 0 13.00% 13.90% Y Critical Care Critical Care 95.85% 88.33% 99.45% 103.33% 1 0 13.40% 7.60% N

Fairfield Ward 2 CCU Cardiology 98.33% 78.48% 91.67% 100.00% 0 0 13.20% 4.20% Y Labour Ward Obstetrics 107.39% 100.83% 105.93% 85.00% 0 0 21.20% 4.00% N

Fairfield Ward 20 Geriatric Medicine 78.33% 106.67% 94.44% 110.83% 0 1 13.30% 8.00% Y Neonatal Unit Obstetrics 74.55% 38.33% 80.85% - 0 0 18.50% 5.20% N

Fairfield Ward 21 General Medicine 87.87% 98.58% 95.56% 123.01% 1 0 3.90% 3.60% Y Postnatal Ward Obstetrics 105.84% 95.41% 105.83% 85.00% 0 0 -4.30% 2.60% N

Fairfield Ward 5 General Medicine 88.33% 113.75% 84.00% 158.89% 0 0 19.90% 3.60% Y Ward AMU General Medicine 85.28% 94.58% 92.57% 110.16% 0 0 22.50% 7.00% Y

Fairfield Ward 7 General Medicine 81.20% 92.79% 83.95% 96.32% 1 0 17.90% 3.80% Y Ward CCU Cardiology 97.50% 150.00% 98.33% 700.00% 0 0 1.20% 4.20% Y

Fairfield Ward 8 General Medicine 89.30% 90.00% 90.83% 96.33% 0 0 9.40% 3.60% Y Ward F1 Gynaecology 82.25% 90.07% 103.03% 98.33% 0 0 21.70% 8.60% Y

Fairfield Ward 9 Trauma & Orthopaedics 77.90% 68.33% 75.56% 98.33% 1 0 8.90% 8.00% Y Ward F10 General Medicine 98.89% 122.92% 96.67% 136.56% 0 0 9.70% 8.80% Y

Rochdale Floyd Unit Rehabilitation 103.39% 118.28% 98.33% 131.18% 0 0 4.00% 4.40% Y Ward F11 Haematology 82.46% 134.48% 91.11% 187.30% 0 0 11.60% 8.10% Y

Rochdale Clinical Admissions Unit General Medicine 100.47% 93.85% 103.13% 126.32% 0 0 5.60% 4.50% Y Ward F7 General Medicine 80.69% 104.00% 92.79% 105.71% 4 0 12.60% 2.80% Y

Rochdale Oasis Unit - RI General Medicine 100.83% 121.01% 100.00% 132.84% 1 0 21.60% 14.50% Y Ward F8 General Medicine 104.17% 96.67% 100.00% 109.52% 0 0 1.20% 4.20% Y

Rochdale Wolstenholme Unit - RI Intermediate Care 100.00% 101.25% 100.00% 89.13% 0 0 6.70% 3.00% N Ward F9 General Medicine 106.08% 92.26% 95.56% 128.57% 0 0 17.70% 10.30% Y

Ward G1 General Medicine 93.85% 101.25% 66.67% 128.26% 0 0 15.30% 4.90% Y

Ward G2 General Surgery 93.56% 86.11% 87.78% 90.00% 0 0 18.70% 5.60% Y

N Ward T3 General Surgery 87.50% 99.44% 84.44% 143.33% 1 0 18.80% 8.80% Y

Y Ward T4 STU General Surgery 88.73% 94.52% 100.00% 138.64% 0 0 7.30% 4.30% Y

Y Ward T5 General Surgery 89.58% 110.00% 88.89% 130.00% 0 0 11.60% 8.50% Y




SCAPE Ward (3 consecutive green assessments)

NAAS

Naas Accrediation 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

37/318



Finance

The Salford Care Organisation financial

position for April is £28k better than the control

total.

Financial performance is monitored against Care Organisation budgetary control totals

(note 1: Corporate and Support Services for Pennine care organisations are managed centrally and excluded. These are YTD £892k better than plan) (note 2: Salford’s

figures exclude Hosted Services which are YTD £2k worse than plan) (note 3: both plans are weighted for

higher levels of expected efficiency in the second half of the year. For Pennine COs this is included in the

Corporate position).

System resilience income is not yet secured in the NE sector and productivity delivery in all CO are key drivers of the YTD position. Agency spend is £300k above plan

in the Pennine CO and better than plan in Salford.

The Bury & Rochdale Care Organisation financial

position for April is £592k worse than the control

total.

North Manchester Care Organisation financial


total.

The Oldham Care Organisation financial


total.

-£16.00-£14.00-£12.00-£10.00

-£8.00-£6.00-£4.00-£2.00£0.00£2.00£4.00£6.00£8.00

£10.00£12.00£14.00£16.00£18.00£20.00£22.00

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

Ap

r-18

£m

Salford Finance Performance

Performance vs. Control Total

-£16.00-£14.00-£12.00-£10.00

-£8.00-£6.00-£4.00-£2.00£0.00£2.00£4.00£6.00£8.00

£10.00£12.00£14.00£16.00£18.00£20.00£22.00

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

Ap

r-18

£m

Bury & Rochdale Finance Performance


-£16.00-£14.00-£12.00-£10.00

-£8.00-£6.00-£4.00-£2.00£0.00£2.00£4.00£6.00£8.00

£10.00£12.00£14.00£16.00£18.00£20.00£22.00

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

Ap

r-18

£m

North Manchester Finance Performance


-£16.00-£14.00-£12.00-£10.00

-£8.00-£6.00-£4.00-£2.00£0.00£2.00£4.00£6.00£8.00

£10.00£12.00£14.00£16.00£18.00£20.00£22.00

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

Ap

r-18

£m

Oldham Finance Performance


38/318

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

018/

19

Q1

2018

/19

Po

siti

on

Q2

2018

/19

Po

siti

on

Q3

2018

/19

Po

siti

on

Q4

2018

/19

Po

siti

on

Clo

sin

g P

osi

tio

n 2

018/

19

2.3 We will ensure a safe and sustainable

future for the Care Organisations of

Salford, Bury, Rochdale and Oldham and

collaborate with the City of Manchester

and NHSi to secure the transition of

North Manchester

2.3.1 IF we fail to secure the transition of North

Manchester and acquire Bury, Rochdale and

Oldham THEN we will be unable to ensure a

safe and sustainable future for the Northern

Care Alliance.

Focussed Executive development via: SRFT

Acquisition Committee

Raj Jain, Chief

Strategy and OD

Officer

&

Ian Moston,

Chief Financial

Officer

Vascular intervention – Salford RS 12

Risk No – 3547

Non-vascular intervention – Salford RS 12

Risk No – 2275

3 5 SRFT Acquisition Committee established.

Counterfactual being developed

GM Programme management arrangements

in place

Funding for the transaction yet to be

identified/secured

People/band-with for the completion

and implementation of the transaction

yet to be identified

4 Monthly Acquisition

Committee

Draft Strategic Plan to be

presented to SRFT Board in

June 2018

12

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 4 > Delivery Management Office

> QPID

> BCLC Committee

> Care Organisation Statements of

Assurance

4 > Group CiC Finance

Report

> Benchmarking data

sets e.g.Model

Hospital

12

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 Funding

Ian Moston,

Chief Financial

Officer

3 5 > Care Organisation Finance & Information

Committees

> Divisional Finance Meetings

> Executive review of Group CiC Finance

KPIs - monthly

> Care Organisation Statements of

Assurance

4 > Group CiC Finance

Report

> Audit Committee

oversight of Going

Concern Report/s

12

Develop standard

performance management

system

Develop version 2 of Single

Oversight Framework

GooRoo - full

implementation

12

Annual Plan Theme 3: Deliver the Financial Plan to assure sustainabilityDelivery of BCLC – Salford RS 13

Risk No – 3011

Financial Control Systems – Salford RS 12

Risk No – 3010

Agency Spend – Salford RS 12

Risk No – 2903

Capital for equipment – Salford 12

Risk No – 3122

Financial performance – NM RS 12

Delivery of CIP – NM RS 12

Agency Spend – NM RS 12

Delivery of BCLC – Oldham RS 12

3.2 We work with partners to ensure

financial plans are sustainable and deliver

on our annual income and expenditure

budgets

Annual Plan Theme 5: Deliver Operational Excellence5. 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 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

− Urgent Care demand – Salford RS 13

Risk No – 2292

− RTT – Salford RS 13

Risk No – 2294

− Diagnostic Standard – Salford RS 13

Risk No – 2299

− 62 day Cancer Standard – Salford RS 12

Risk No – 3675

− Access to Mental health Services – Salford RS 12

Risk No – 3452

− 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

− OG Cancer – Salford RS 12

Risk No – 3236

− 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

− Sustaining Ophthalmology Service – B&R RS 12

− Patient flow – Oldham RS 12

− Access Standards – Oldham RS 12

4 4 Single Oversight Framework incl.

Statements of Assurance

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

Effective management of follow ups

Reliable workforce to manage surge and

seasonal variation

4 Quarterly Group

Objectives Delivery

Report to Group CiC

GRAC and Exec

Development

Committee



Group principle risks scored 12

Annual Plan Theme 2: Improve care and services through integration, collaboration and growth

39/318

of 12

Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAHT)

Meeting Group Committees in Common

Author (s) Chief Delivery Officer and Care Organisation Chief Officers

Presented by Chief Delivery Officer and Care Organisation Chief Officers

Date 4th June 2018

Executive Summary

This paper presents information about the Urgent Care Improvement Plans within each

of the Northern Care Alliance’s Care Organisations, specifically with respect to GP

Streaming.

Recommendations Group Committees in Common is asked to receive and review the information

provided.

Public and/or Patient Involvement (including equality related impact) N/A

Communication N/A

Freedom 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 Urgent Care Improvement Plan: GP Streaming

X

40/318

of 12

Urgent Care Improvement Report

Report of: Bury Care Organisation

GP Streaming Update

Current Model Descriptor

Hours of Operation

Primary Care Streaming has been in place in pilot form at FGH since December 2016 using BARDOC GPs and a BARDOC nurse undertaking initial triage at the point of arrival by patients at A&E. This has operated 7 days a week, 4 hours week day evenings and 6 hours at the weekend. In addition to above an alternative approach locating local GPs in A&E during the day was also piloted by the GP Federation throughout February and March 2018. A series of tests of change have occurred as outlined below:

2 Different Providers

Changes to hours of operation

Triage by BARDOC ANP

Triage to streamlining from triage nurse

Lead Nurse / Consultant undertaking hourly review of patients presenting and streaming to GP

GP based in the ED

GP based in Out-Patients.

18:00-22:00 Monday to Friday 16:00-22:00 Saturday and Sunday

Numbers Seen

On average 1.8 patients per hour have been seen by Primary Care, these numbers have been consistent irrespective of the varying operating models outlined above.

Financial Model

At present the GP streaming model for FGH hasn’t proved to be successful in terms of numbers deflected away from A&E and as such the pilot scheme has been left as a pilot until all tests of change have been concluded. No financial model on a permanent GP streaming has been agreed, and the recommendation is that this is not a stand alone scheme but forms part of the co located Urgent Treatment Centre development in 2018.

Intended and Actual Impact of GP Streaming

The intended impact of the GP streaming model for FGH was to ensure a certain quota of patients were streamed as appropriate to deflect away from an overcrowded A&E department and ensure the waiting time in the department is kept to a minimum for patients to be seen by a clinician. The actual impact has been limited in its success with little or no impact towards the A&E department due to very

41/318

of 12

little numbers being streamed to the GP particularly around acuity of the patients that attend FGH A&E department. This is directly evidenced by examination of HRG codes as FGH has a lower proportion of minors patients when compared to peers.

Next Steps for Streaming

With the development of an Urgent Treatment Centre planned for FGH in 2018 the ability to stream additional patients away from A&E will be significantly improved by the provision of lower level diagnostics – GP streaming will be encompassed within the Urgent Treatment Centre and this will have a far greater impact on the A&E department than what has been evidenced to date.

Additional CO Improvement activities to deliver safe and reliable UC performance

Development of an Urgent Treatment Centre

Integrated IDT approach being ward based

Criteria lead discharge on the back end wards

Extension of ACU to 24 hours run through AMU

Review and restructure of both medical and A&E doctor rotas

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Report of: Oldham Care Organisation

GP Streaming Update


Hours of Operation

Provider is GTD.

One GP per 12 hour shift.

Band 7 streaming nurses in place and stream to GPs and other alternatives to ED e.g. ambulatory care, mental health, gynae assessment.

Currently GPs are based in consulting rooms within the ED however we are undertaking a test of change utilising adjoining outpatient capacity to separate the minors’ stream. This runs from 18.00 – 00.00 Monday –Friday and Saturday/ Sunday 09.00 – 00.00.

GP fill rate average >90% .Evenings and weekends have a lower GP fill rate than weekday shifts. Governance Structure: Governance clinical group meets monthly and oversees safety, effectiveness and clinical pathways.

Steering group meets monthly to review operational issues and performance.

11.00 – 23.00 7 days per week.

Numbers Seen

Number of Attendances to ED and PC

0 1 2 3 4 5 6 7 8 9 10 11 12

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

Total

Attendances

8384

8965 8646 927

2 845

9 876

9 945

5 923

6 915

4 906

4 784

6 8968 8531

114749

ED 802

3 8580 8293

8715

8023

8311

8935

8593

8634

8495

7280

8329 8053 1082

64

PC 361 385 353 557 436 458 520 643 520 569 566 639 478 6485

% PC 4.31%

4.29%

4.08%

6.01%

5.15%

5.22%

5.50%

6.96%

5.68%

6.28%

7.21%

7.13% 5.60

% 5.65

%

0.00%

2.00%

4.00%

6.00%

8.00%

0

2000

4000

6000

8000

10000

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

A&E Attendances - % Primary Care Streamed

ED PC % PC

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Percentage seen by GP stream is between 4-7% of total attendances over the last 12 months. Activity data does not include patients streamed to ENP for minor injuries or fast-tracked to GAU (gynae), STU (surgical) and AEC (ambulatory). From March 2018 plans were put in place to increase the average streaming to GP to an average of 2 per hour by 12 weeks (i.e. from current 6% of attendances to consistent 8%) via additional training of streaming nurses and introduction of the MTS enhanced matrix. Paper streaming audit data and feedback from the streaming nurses suggests streaming percentage may be higher (up to 17%) but has not been evidenced via electronic systems. This has been investigated and both streaming and activity data will be collated via Symphony from June onwards to gain a more accurate picture of activity. This will include patients passed back to ED and there is a live audit of streaming against the MTS matrix planned in July. Triage category of patients seen within the primary care stream is mainly within the ‘Yellow/Green ‘categories with very few ‘Blue’ ( lowest acuity) category patients due to the nearby location of the Oldham WiC. There are also significant numbers of Orange category patients seen in the primary care stream including some arriving by ambulance.

Triage Category of PC

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

Total

Red 0 0 0 0 0 1 0 0 0 0 0 0 0 1

Orange 11 16 18 13 10 5 20 14 32 21 20 18 11 209

Yellow 123 131 119 168 142 137 187 207 179 233 216 278 173 2293

Green 210 225 202 293 275 312 312 414 302 310 326 332 291 3804

Blue 2 4 0 4 4 2 0 3 3 4 1 8 2 37

NULL 15 9 14 79 5 1 1 5 4 1 3 3 1 141

A streaming matrix and SOP has been developed by the clinical reference group (brief excerpt below). This is intended to support consistency of streaming and prevent ‘pass back’ of patients to ED.

Red Amber Yellow Green Blue Comments

Abdominal pain in adults

ED ED ED

unless PC PC moderate pain and under 60

Abdominal pain in children

ED ED ED

unless PC PC Signs of moderate pain (hot);

Abscesses & local infections

ED ED PC PC PC

Allergy ED ED PC unless PC PC low sats;

An overnight trial of streaming was undertaken in March/ April with mixed results. Subsequent heat mapping of PC amenable arrivals by hour and by day has led to a proposal to trial a second GP at peak arrival times ( twilight )

0.0%

1.0%

2.0%

0204060

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

Ambulance Arrivals Streamed to Primary Care

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dependant on availability of GPs to fill these shifts and compare outcomes. This is planned during July/August.

Financial Model

Current funding via CCG as a pilot scheme with GTD as the provider. There is a current business case in final draft requesting Transformation Funding to develop the primary care streaming pilot in ED into a robust Urgent Treatment Service providing an interface between primary care, community and social care and secondary care. Funding is requested for double running for PC streaming while the WiC remains open (2018-19) and whilst the integration into an UTS is established (2019-20).


Performance within the Primary Care stream has been over 95% for the majority of the year. Difficulty in physical separation of the streams due to estate issues does adversely impact on primary care performance.

Average time spent in the department is well within the expected target of 240 minutes and as such the PC stream supports 4 hour performance.

On average the conversion to admission for PC streamed patients is 10% compared to 25% conversion for all patients. However, this is higher than expected for a primary care service reflecting the relative higher acuity of patients seen at Oldham.

60.00%

70.00%

80.00%

90.00%

100.00%

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

% Within 4 Hours Comparison

PC % Within 4 Hours Standard ED % Within 4 Hours

0.00

50.00

100.00

150.00

200.00

250.00

300.00

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

Time In Department (Comparison)

ED - Ave Minutes PC - Ave Minutes Target

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The Cluster Business Partners are attending the Steering Group and Cluster Clinical lead attending some Clinical Governance meetings but pathways not in place to support further deflection. Care coordinators have been introduced during May to support redirection of patients to alternative pathways via the clusters. This is in the early stages of implementation and reliant on Cluster development to fully realise performance benefits. Dedicated space for Primary Care is identified on TROH estates plans but the timescale is 3-4 years. There is a current test of change utilising OPA during OOH periods to measure the impact of separating the minors’ stream including Primary Care. Scoping of alternative suitable accommodation for orthopaedic outpatients including, modular buildings, is currently being explored.


Shareforyou data sharing now agreed and funding for EMIS Enterprise agreed across the borough. IMT working with CCG and EMIS in relation to implementation requirements;

Workforce: There are ongoing challenges in terms of sufficient workforce to meet demand. The business case for additional ED workforce was approved in principle in mid-March. This would right-size the nursing budget against current rota numbers and increase medical staffing establishment. The Directorate is awaiting confirmation of funding to proceed with recruitment;

A joint action plan between Oldham Care Organisation and NWAS has been agreed to support improved ambulance handover times. Average notification to handover time in April was 14:22 with 66% patients being handed over in 15 minutes and Oldham ranked 3rd in Greater Manchester. This is due to improved processes at handover, resourcing a handover nurse to release paramedic crews and improvements to flow across the site reducing overcrowding in the ED;

’10 by 10’ has improved the timeliness of discharging impacting positively on flow with the Division demonstrating high engagement levels with this initiative. In addition, there have been daily breach analysis meetings to ascertain root causes of breaches with themes and actions identified as a result;

Pilot of twilight bed management shifts to overlap with night practitioner start times;

Daily breach meeting analysis with identified consultant 4 hour champion;

Additional dedicated x-ray porter for the ED during twilight periods.

0.00%

5.00%

10.00%

15.00%

20.00%

0

200

400

600

800A

pr-

17

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

Outcome of Primary Care Streamed Patients

Non-Admitted Admitted % Convert to Adm

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Report of: North Manchester Care Organisation

GP Primary Care Streaming Update


Hours of Operation

GP primary care streaming was initially implemented at NMCO in August 2016 the aim of which was to provide primary care expertise and additional medical workforce capacity to the Emergency Department (ED). Over the last 12 months, this streaming has been incorporated into the “Same Day Care” (SDC) Model which also includes a minor injury stream. This model is delivered through a mixed staffing workforce of GP’s, ENP’s and on occasions ED junior medical staff with oversight provided by the ED Consultant workforce. Prior to this new model (which commenced fully from mid- April 2018, patients attended ED in the traditional way (i.e. triage and wait to be seen). The new model involves early decision-making at triage by a senior nurse clinician who directs patients to SDC, ED or ambulatory care. A capital build to create a separate entrance to SDC (within the adjacent outpatient department) will commence in June 2018 and when complete all adult ambulatory presenters will attend SDC and be streamed accordingly to the most appropriate area.

10.00hrs to 22.00hrs 7 days a week

Numbers Seen

The graph above indicates the number of patients seen by month within primary care streaming during the last 12 months which averages 26 on a daily basis.

0

5

10

15

20

25

30

35

0

200

400

600

800

1000

GP Streamed Patients

Streamed

Daily Ave

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Since the commencement of SDC we are seeing a median of 65 patients a day streamed out of the ED department which is supporting improved flow and performance against the 4 hour standard.

Financial Model

The cost of the GP workforce is currently a pass through cost to Manchester Health and Care Commissioning (MHCC) although there are ongoing discussions regarding the potential redesign of the service offer to achieve better value for money. Additional recurrent funding from MHCC has also been secured to provide more reliable senior nurse decision making at triage.


The intention of GP streaming was to identify a cohort of patients through an agreed criteria managed by primary care physicians. An evaluation of pure primary care presentations identified that the cohort of patients was neither large enough nor consistent enough to warrant a singular stream. NMCO therefore developed a collaborative model that allows for better separation of this stream from traditional ED activity. This is the Same Day Care model (SDC) which opened fully from 16th April 2018 operating within the Outpatient department footprint (adjacent to ED) which allows protection of the work stream from an overcrowded department.


Capital work to create a new entrance for SDC All ‘ambulant adults’ will be streamed through this service maximising the potential numbers seen Consideration as to how paediatric ED may adopt similar principles


Leadership A change in matron oversight has improved the nursing leadership in ED. Additional medical

consultant leadership has been identified from SRFT and will start mid-June 2018 Director level attendance at all site/bed meetings on a rota basis continues Setting of thrice daily internal goals/targets for flow at the Bed Meeting (ED Breaches, Discharge

Lounge utilisation, AMU Discharges) Empowering Teams to make the right decisions at the right times

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Safety 2 hourly consultant led quality rounds in ED to provide clinical oversight and direction are now

embedded as part of routine practice. Impact measures are being finalised for audit purposes Reliable “rounding” by ED senior nurses now takes place Medical AMU Consultant presence in ED from 08.00 (when necessary) to review overnight patients

and to ensure each has a clear management plan Individual patients in ED are discussed at Site Meetings and any ‘special requirements’ identified in

a timely manner Coaching on in-patient board rounds by a Clinical Director is in place

Flow

A business case to expand the Integrated Discharge Team has been ratified within the Care Organisation and funded by MHCC; recruitment of the team is underway.

Care Organisation Director led QI Task &Finnish Groups focussing on Urgent care, Earlier Discharge, Systems and Processes meet weekly.

A business case for additional QI facilitators has been approved by MHCC and recruitment is underway

A Test of change is underway for Manchester patients’ where they are “discharged to assess” to their own homes

Stranded Patients Metric

A Point Prevalence audit of stranded patients was carried out in conjunction with ECIP on 6th April 2018. The report is being finalised and will be used to target key areas for focus

All patients over 30 days are reviewed by the Divisional Clinical Directors with a view to considering alternative clinical/social pathways where appropriate

SAFER Bundle

The SAFER bundle is being audited against compliance by the QI Improvement Groups Clinical Directors are participating in observing the effectiveness of ward board rounds

Workforce

ED Consultant establishment is 12 WTE, during the last 9 months substantive appointments have been made increasing from 2.5 WTE to 4.40 WTE (in addition 2 medium term locums have also been appointed and 1WTE continues to support the department from MFT). This has increased the number of “shop floor” DCC’s to improve patient safety & oversight however the department is still heavily reliant on locums as there is a 50% vacancy factor in the junior medical team

Acute Physician establishment is 10.56wte with 2.30WTE in post; a recent successful recruitment campaign has resulted in 2 WTE appointments.

Successful recruitment of 8 middle grade ED clinicians following a campaign delivered jointly with Bury Care Organisation. Start date tbc

Continued nurse recruitment to enable the opening of the remaining AMU beds before September 2018

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Report of: Salford Care Organisation

GP Streaming Update


Hours of Operation

Primary Care Streaming has been in place in pilot form at Salford since October 2017 using Salford Primary Care Together GPs and a streaming nurse undertaking initial triage at the point of arrival by patients at A&E. The GP rota coverage is now at 100% and has a consistent team of 7 GPs working across the various shifts within the service.

Based on activity modelling undertaken the GP Streaming Service was set up to run between the hours of 8.00 a.m. and 8.00 p.m. As the Emergency Department has always had a GP Out of Hours co-located service, patients presenting to the Emergency Department with primary care conditions outside of these hours continue to be deflected via triage to the OOH service.

Numbers Seen

We are currently streaming circa 750 patients per month (c 12-15% of A&E attendances) which is just over 2 patients per hour of operation.

Financial Model

The service has been funded for the first 12 months via Transformation Funding and is currently operating within its budget with a slight underspend. The performance of the model is being evaluated in order to assess how (and whether) it could or should be funded long term (from November 2018).


The intended impact of the GP streaming model was to deflect significant numbers of patients away from A&E and reduce pressure on the department. It was suggested this impact could be up to circa 15-20% of attendances. The actual impact has been limited in terms of the reduction of patients being seen by the A&E department; however, there have been significant reductions in the numbers of patients going to the GP out of hours as a result (c20-25% reduction).


There are a number of possible future developments that would see the evolution of the Streaming Service such as:

Further expansion of the service to become an ‘Urgent Care Treatment Centre’ to support the development of the Emergency Department into the Regional Major Trauma Centre. The Centre would be sited at SRFT and re-located into an area to receive primary care and minor injuries presentations. This model would be considered on site due to the requirement for the x-ray and diagnostics to manage presenting needs

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effectively.

Development of the ‘Urgent Care Primary Care Offer’ – a scoping exercise is being carried out to consider the efficiencies of merging the OOHs / Streaming / SWEAP / Acute Home visiting and the Community Childrens Service into one service model. This will include seeing primary care same day urgent care demand as well as enabling booking off-site (deflection) from the Emergency Department into same day / next day primary care capacity.


Focus on stranded patients at 14 days (not 7) delivering more reliable bed capacity Review of Out of Hours and streaming (as per above)

Salford Urgent Care Team launched in April 18 (working with NWAS to respond to 999 calls where patients could be managed at home)

Further development of neighbourhood model to reduce high risk patient presentation

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1

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


Author (s) Jane Burns, Director of Corporate Services/Group SecretaryAll Executive Directors and Care Organisation Chief Officers

Presented by Sir David Dalton, Chief Executive

Date 4th June 2018

Executive Summary Principal Risks, to the delivery of the Group’s approved principal objectives for 2018/19, have been identified by Group Chief Officers. Those risks are set out in the attached Group Board Assurance Framework.

At its meeting on 21st May 2018, Group Risk and Assurance Committee (GRAC) received and reviewed the Care Organisations’ 2018/19 Opening Board Assurance Frameworks/Risk Registers. The Care Organisations’ principal and operational risks, scored at 12 or above, have since been referenced within the Group Board Assurance Framework/Risk Register, and where necessary the principal risk rows/scores have been adjusted accordingly.

GRAC will receive and review the Annual Plans and Board Assurance Frameworks/Risk Registers for key corporate and Group-wide functions in June 2018, which will in turn inform the continuing development of the Group Board Assurance Framework/ Risk Register.

Each month throughout 2018/19, Group Committees in Common will continue to receive:

all Group Principal Risks, scored at 12 and above, as part of the Group CiC Dashboard (with summary of significant Care Organisation, corporate and Group-wide function risks); and

all Care Organisation principal and operational risks, scored at 12 and above, as part of the Care Organisations’ Statement of Assurance.

Recommendations Group Committees in Common is asked to receive and review the 2018/19 Opening Group Board Assurance Framework/Risk Register.

Public and/or Patient Involvement (including equality related impact) N/ACommunication The 2018/19 Opening Group Board Assurance Framework/Group Risk Register is to be presented to Group Committees in Common (Part 1) on 4th June 2018.

Title of Report Group Board Assurance Framework/Risk Register - Opening 2018/19:Principal Risks

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2

Freedom 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.

X

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3

Principal Risk areas for 2018/19:

Principal Risk Area Responsible Officer/s Risk Score1. Development and implementation of NCA Quality Improvement Strategy Elaine 92. Deployment of framework for Clinical Reliability Groups Elaine & Chris 113. Provision of improvement capacity and capability to deploy The Method Elaine 104. Integrate care pathways across Acute, Community and Social Care Jude 105. Deliver the benefits of scale across Group Shared Services Functions Jude & Ian 116. Transition of North Manchester and Acquisition of Bury, Rochdale and Oldham Raj & Ian 127. Engagement, collaboration and support to other organisations Raj 98. Productivity improvement and cost reduction strategy Ian 129. Sufficient cash over a 3 year period Ian 1010. Not exceeding planned activity and income levels and/or expenditure controls Ian 1211. Reduction of staff turnover to historically low rates Raj, Elaine and Chris 1112. Attract sufficient numbers of newly qualified staff Raj, Elaine and Chris 1113. Remodel the workforce Raj, Elaine and Chris 914. Improve staff satisfaction Raj, Elaine and Chris 1015. Plan, oversee and execute our objectives Jude 1216. Determine the estates requirements and productively utilise the resource Raj 917. Develop a service and governance model for ACO/LCOs that is acceptable to

stakeholdersRaj 9

18. Develop and deploy our Standard Operating Model Jude 1019. Identify, resource and deliver appropriate digital innovations Raj 820. Effective programmes of change and deployment of our improvement

methodologyRaj, Chris and Elaine 10

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4

Key to Assurance Framework and Corporate Risk Register

Risks are stated in the “IF….THEN…” format

Likelihood scores are defined as:

1 = rare - do not expect this to happen2 = unlikely - most probably will not happen3 = occasionally - 50:50 chance of occurring 4 = likely - most probably will happen 5 = almost certain - confident that this will happen.

Impact scores are defined as:

1 = almost non- no obvious harm2 = minor - no permanent harm (recovery within month)3 = moderate - semi-permanent harm (recovery takes longer than 1 month but no more than 1 year) and/or

adverse publicity for the Care Organisation. 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 Care Organisation and/or disruption of key Care Organisation services which significantly hinder the Care Organisation in meeting its responsibilities.

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

Control scores are defined as:

1 = risk is fully under control2 = risk is adequately controlled 3 = action to control risk adequately has started and appears effective4 = action to control risk is agreed but no action started or not yet effective5 = no actions to control risk identified.

Risk tolerance levels:

3 – 5 = minor risk which is adequately managed and may be retained if further control limits the capacity to control higher ranking risks.

6 - 9 = moderate risk which must be reported and managed locally by the departmental, directorate or group manager/lead clinician.

10 - 11 = significant serious risk which must be reported to the Care Organisation Assurance and Risk Committee (COARC).

12 - 15 = Significant serious risk to the Care Organisation/Group which must be reported to and managed through the Care Organisation Management Board and Group Committee in Common, via COARC and GRAC respectively.

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Northern Care Alliance NHS Group: Board Assurance Framework 2018/19


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

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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

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on

Q4

20

18

/19

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01

8/1

9

1.1.1 IF we fail to develop and

deliver an NCA Quality

Improvement Strategy THEN we

may fail to provide safe, reliable

and compassionate care

Elaine Burke,

Chief Nursing

Officer

3 3 Established SRFT and

PAHT Strategies in

place

QI Dashboards

Quarterly Project

Update Report to

Group CiC

Strategies not aligned

across NCA

3 QI Dashboards -

Ward to Board

Quarterly Project

Update Report to

Group CiC

Produce NCA Quality

Improvement

Strategy and present

to Goup CiC for

approval by October

2018

9


deploy a framework for Clinical

Reliability Groups (as per QI

Strategy) THEN unwanted

variation in service and standards

will continue.

Chris Brookes,

Chief Medical

Officer

&

Elaine Burke,

Chief Nursing

Officer

3 4 Standard operating

clinical policies in

place across the NCA

Clinical Effectiveness

Committee (CEC)

established in each

Care Organisation

Group-wide Learning

from Deaths

Programme

established

Variation in compliance

with clinical policies

Ensuring actions arising

from CO CECs are

monitored and reliably

implemented

Reliable

implementation of

actions from analyses

of deaths

4 Key risks in CO

BAFs overseen via

CO CECs. Issues

escalated

appropriately via

COARCs and

Statements of

Assurance to

Group.

Clinical Audit

Internal Audit

Consistent delivery

and implementation

of actions from CO

CECs assured via SoA

11

1.1 We will

demonstrate

continuous

improvement

towards our goal of

being the safest

health and social

care organisation in

England

Maintaining high quality services –

NM RS 12

Recognition of deteriorating

patient – NM RS 12

Sepsis – NM RS 12

Sepsis – B&R RS 12

Infection Control – Oldham RS 12

Annual Plan Theme 1: Pursue Quality Improvement to assure safe, reliable and compassionate care

1

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Northern Care Alliance NHS Group: Board Assurance Framework 2018/19


Officer



BAFs, Scored 12+

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Imp

act

Key Control

Established

Key Gaps in Controls

Co

ntr

ol


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9

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18

/19

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18

/19

Po

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/19

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/19

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9

Annual Plan Theme 1: Pursue Quality Improvement to assure safe, reliable and compassionate care


deliver appropriate improvement

capacity and capability to deploy

The Method THEN we will not

deliver the Quality Improvement

Strategy

Elaine Burke,

Chief Nursing

Officer

3 3 QI Strategy

QI Capacity and

Capability

Programmes

Codifying all aspects of

The Method

4 Develop a framework

with AQUA for

operational

excellence using The

Method with Middle

Managers

10

1.1 We will

demonstrate

continuous

improvement

towards our goal of

being the safest

health and social

care organisation in

England

Maintaining high quality services –

NM RS 12

Recognition of deteriorating

patient – NM RS 12

Sepsis – NM RS 12

Sepsis – B&R RS 12

Infection Control – Oldham RS 12

2

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BAFs, Scored 12+

Like

liho

od

Imp


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19

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20

18

/19

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18

/19

Po

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/19

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/19

2.1 We will provide

leadership and utilise

scale and technology to

Improve care and deliver

the goals of our Care

Organisations and their

locality plans

2.1.1 Through our leadership, scale

and technology, IF we fail to integrate

care pathways across Acute,

Community and Social Care THEN we

will not deliver intended care benefits

across the system

Judith Adams,

Chief Delivery

Officer

3 4 Work underway to

develop a cross-cutting

clinical service strategy

for the NCA.

PMO and DMO in place

for LCO developments and

change programmes

GDE Strategy and Fast

Follower funding in place

Draft LCO Blueprint

developed

Talent pipeline to

ensure effective

leadership across LCOs

Rapid development of

QI/Digital expertise to

scale

3 Executive

Development

Committee

Delivery

Management

Office (DMO)

Care Organisation Leadership

Teams to integrate with

localities

Programme Management Team

to be fully formed and effective

The NCA’s LCO Blueprint to be

fully developed and adopted

Finalise business cases for

investment re QI / Digital

capacity

Talent management for leaders

system

10

2.2 We will develop

Group Shared Services

functions to deliver

scale, resilience,

operational excellence

and transformation for

our Care Organisations

and partners

2.2.1 IF we fail to deliver the benefits

of scale across Group Shared Services

Functions THEN services will not be

resilient, have opportunity to

transform and thus deliver Operation

Excellence.

Jude Adams,

Chief Delivery

Officer

&

Ian Moston, Chief

Financial Officer

3 4 Plans in place to

implement first wave

shared services

(Radiology, Pathology and

Pharmacy)

4 Implementation of first wave

shared services.

Plans to be developed for the

implementation of second

wave shared services – urgent

& emergency care, and

paediatric services

11


Vascular intervention – Salford

RS 12

Risk No – 3547

Non-vascular intervention –

Salford RS 12

Risk No – 2275

3

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2.3 We will ensure a safe

and sustainable future

for the Care

Organisations of Salford,

Bury, Rochdale and

Oldham and collaborate

with the City of

Manchester and NHSi to

secure the transition of

North Manchester

2.3.1 IF we fail to secure the

transition of North Manchester and

acquire Bury, Rochdale and Oldham

THEN we will be unable to ensure a

safe and sustainable future for the

Northern Care Alliance.

Focussed Executive development via:

SRFT Acquisition Committee

Raj Jain, Chief

Strategy and OD

Officer

&

Ian Moston, Chief

Financial Officer

3 5 SRFT Acquisition

Committee established.

Counterfactual being

developed

GM Programme

management

arrangements in place

Funding for the

transaction yet to be

identified/secured

People/band-with for

the completion and

implementation of the

transaction yet to be

identified

4 Monthly

Acquisition

Committee

Draft Strategic Plan to be

presented to SRFT Board in

June 2018

12

2.4 We will grow and

strengthen the Northern

Care Alliance to ensure a

sustainable future for

our populations served

2.4.1 IF we fail to effectively engage,

collaborate and support other

organisations THEN we will be unable

to grow and strengthen the Northern

Care Alliance.

Raj Jain, Chief

Strategy and OD

Officer

2 4 Well-developed

collaborative strategic

approach.

Working across

organisational boundaries

to improve effectiveness

and deliver sustainability

Vanguard –

Groups/Chains

Association of Groups

3 On-going implementation of

collaborative strategic

approach

9

Vascular intervention – Salford

RS 12

Risk No – 3547

Non-vascular intervention –

Salford RS 12

Risk No – 2275

4

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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 4 > Delivery Management

Office

> QPID

> BCLC Committee

> Care Organisation


4 > Group CiC

Finance Report

> Benchmarking

data sets

e.g.Model Hospital

12

3.2.1 IF we do not generate sufficient

cash over a 3 year period THEN we

may not be able to support the

planned investment and meet

operational costs

Ian Moston, Chief

Financial Officer

3 4 > Strategy & Investment

Committee

> Capital Committee

> BCLC Programme

Boards

> Transaction/

Acquisition Committee

> Care Organisation


> 5 Year Capital

Programme

3 > Group CiC

Finance Report

Five Year Capital Programme to

be developed and approved in

2018/19

10

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

Funding

Ian Moston, Chief

Financial Officer

3 5 > Care Organisation

Finance & Information

Committees

> Divisional Finance

Meetings

> Executive review of

Group CiC Finance KPIs -

monthly

> Care Organisation


4 > Group CiC

Finance Report

> Audit

Committee

oversight of Going

Concern Report/s

12

3.2 We work with

partners to ensure

financial plans are

sustainable and deliver

on our annual income

and expenditure

budgets

Delivery of BCLC – Salford RS 13

Risk No – 3011

Financial Control Systems –

Salford RS 12

Risk No – 3010

Agency Spend – Salford RS 12

Risk No – 2903

Capital for equipment – Salford 12

Risk No – 3122

Financial performance – NM RS 12

Delivery of CIP – NM RS 12

Agency Spend – NM RS 12

Delivery of BCLC – Oldham RS 12

Annual Plan Theme 3: Deliver the Financial Plan to assure sustainability

5

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4.1 IF we fail to reduce staff turnover

to historically low rates THEN we will

not have sufficient staff

4 4 • OD and HR strategies

and policies are being re-

launched

• The new Care

Organisation structure

coupled with the new HR

and Learning and

Development Business

Partners model has been

implemented

• Revised workforce

committee established

• Revised staff side

engagement and

consultation structures

established

• Number and

capability of

professional managers

• Staff side

organisation

• EVP not yet launched

3 • Trajectories for

improvement

agreed for each

Care Organisation

(including agency

spend)

• Tracking at Exec

/ CiC level

• Process measure

EVP and new accreditation

system to be brought to May

CiC

11

4.2 IF national qualified staff shortages

persists and we are unsuccessful in

attracting newly registered staff in

sufficient numbers THEN we will not

have sufficient staff

4 4 • New recruitment

strategy launched

Employer Value

Proposition (EVP)

3 Vacancy reduction

trajectories agreed

for each Care

Organisation

(along with agency

cost reduction)

EVP and new accreditation


CiC

11

4.3 IF we fail to remodel the

workforce THEN we will have

insufficient staff with the right

competencies

3 3 Clinical work force

transformation strategy

and plan

Workforce planning

methodology

Professional capacity

3 Process and

outcomes

KPIs

Lead Director appointed

Transaction programme

providing further capacity

9

4.4 IF we fail to improve staff

satisfaction and well-being THEN

sickness and absence will not fall to

planned levels

4 3 • Revised sickness

absence management

guidelines produced

• Well strategy being

implemented

• Employer Value

Proposition (EVP) not

yet launched

3 • KPI and process

monitoring

• Trajectories

agreed for each

Care Organisations

EVP plus new accreditation


CiC

10

Raj Jain, Exec

Chief Strategy

and OD Officer

&

Elaine, Burke,

Chief Nursing

Officer

&

Chris Brookes,

Chief Medical

Officer

Medical Staffing – Salford RS 12

Risk No – 3539

Nurse Staffing – Salford RS 12

Risk No – 3540

Workforce recruitment and

retention – NM RS 12

Medical Workforce – B&R RS 12

Medical staffing in Urgent Care –

B&R RS 12

Recruitment and retention –

Oldham RS 12

4.We will support staff

to have rewarding,

productive and fulfilling

careers, enabling us to

recruit and retain

talented people

Annual Plan Theme 4: Support our staff to deliver high performance and continuous improvement

6

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Principal and Operational Risks from

2018/19 Care Organisation BAFs, Scored

12+

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act

Key Control Established Key Gaps in Controls

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18

/19

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9

Annual Plan Theme 5: Deliver Operational Excellence

5. 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 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

− Urgent Care demand – Salford RS 13

Risk No – 2292

− RTT – Salford RS 13

Risk No – 2294

− Diagnostic Standard – Salford RS 13

Risk No – 2299

− 62 day Cancer Standard – Salford RS 12

Risk No – 3675

− Access to Mental health Services –

Salford RS 12

Risk No – 3452

− 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

− OG Cancer – Salford RS 12

Risk No – 3236

− 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

− Sustaining Ophthalmology Service –

B&R RS 12

− Patient flow – Oldham RS 12

− Access Standards – Oldham RS 12

4 4 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

Effective management

of follow ups

Reliable workforce to

manage surge and

seasonal variation

Quarterly Group

Objectives Delivery

Report to Group

CiC

GRAC and Exec

Development

Committee

4 Develop standard performance

management system

Develop version 2 of Single

Oversight Framework

GooRoo - full implementation

12

7

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Annual Plan Theme 6: Develop and implement our Service Development Strategy and the Northern Care Alliance enabling strategiesPrincipal Objective Principal Risks Responsible

Officer



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9

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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

6.1.1 IF we do not effectively

determine the estates requirements

and productively utilise the resource

THEN we will not be able to deliver

Group objectives

Raj Jain, Exec

Chief Strategy

and

Organisational

Development

Officer

2 4 Capital Committee Strategic Programme

alignment

3 DMO Reporting Establish mechanisms for the

strategic programme alignment

in conjunction with DMO

9

6.2 With our

partners we will

determine future

models of care and

a sustainable service

configuration to

ensure clinical and

financial

sustainability

6.2.1 IF we fail to develop a service

and governance model for ACO / LCOs

that is acceptable to stakeholders

THEN we will not secure lead provider

status in Oldham, Rochdale and Bury

Raj Jain, Exec

Chief Strategy

and

Organisational

Development

Officer

2 4 NES Strategy Board

Acquisition Board

Exec Development and

Delivery Committee

Strategic Programme

alignment

Planning capacity

required to do

strategic work

3 DMO Reporting Establish mechanisms for the


in conjunction with DMO

Staocktake of demand and

capacity

9

Onsite Estates – Salford RS 13

Risk No – 3542

Locality Estates – Salford RS 13

Risk No – 3677

Digital – Salford RS 13

Risk no – 3676

Estates Strategy – NM RS 12

IM&T Strategy – NM RS 12

IM&T Systems – B&R RS 12

IM&T Systems – Oldham RS 12

NM Theatres 1-6 – NM / E&F RS

12

8

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9

6.3. We will reduce

variation in care &

improve experience

and outcomes

through the

development of our

Standard Operating

model, our clinical

reliability groups,

and deployment of

our Quality and

Productivity

Improvement

(QPID)

methodology

6.3.1 IF we fail to develop and deploy

our Standard Operating Model THEN

we will not reduce variation in care

and improve patient outcomes and

experience

Judith Adams,

Exec Chief

Delivery Officer

3 4 Establish Standard

Operating Model (SOM)

Design Authority

Build SOM responsibilities

into change programme

for Group

Mechanism to capture

current SOM depoyed -

PAHT

No electronic solution

to capture and codify

current elements

Effective audit

mechanism to ensure

adherance

3 Executive

Development and

Delivery

Committee

Develop digital solution to

capture and codify elements of

SOM

Complete SOM from

standardisation and scale

change managemnt

programme

Capture and codify NAAS, Risk

& Governance, and QI

Programmes

10

6.4 We will reduce

variation in care &

improve experience

and outcomes

through the

development of our

Standard Operating

model, our clinical

reliability groups,

and deployment of

our Quality and

Productivity

Improvement

(QPID)

methodology

6.4.1 IF we fail to identify, resource

and deliver appropriate digital

innovations THEN we will not

transform care models and

productivity of Group

Raj Jain, Exec

Chief Strategy

and

Organisational

Development

Officer

2 4 EDHEC

GDE Programme Plan

Strategic programme

alignment

2 DMO Reporting Establish mechanisms for


8


Risk No – 3542


Risk No – 3677


Risk no – 3676






12

9

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9

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9

6.5 Through

excellence in

change

management and

delivery of new

ways of working we

embed the changes

resulting from our

NCA strategies

6.5.1 IF we fail to have in place

effective programmes of change and

deployment of our improvement

methodology THEN we will not embed

the intended transformational

changes

Raj Jain, Exec

Chief Strategy

and OD Officer

&

Chris Brookes,

Chief Medical

Officer

&

Elaine Burke,

Chief Nursing

Officer

3 3 QI Strategy

QI Capacity and Capability

Programmes

CQA Programme

4 Develop a framework with

AQUA for operational

excellence

10


Risk No – 3542


Risk No – 3677


Risk no – 3676






12

10

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1


Meeting Group Committees in CommonAuthor Jym Bates, Associate Director of Digital, Group Data Protection Officer

Presented by Raj Jain, Chief Strategy and OD Officer and Senior Information Risk Officer (SIRO)

Date 4th June 2018

Executive Summary

This paper reports that the Group has made good progress in preparing a strong, legal footing in regards to the expectations of GDPR.

Recommendations Group Committees in Common is asked to receive and review this update with respect to compliance with GDPR, and confirm any further actions if required.

Public and/or Patient Involvement: N/A(Including equality related impacts)Communication: As reportedFreedom of InformationPlease indicate appropriate box below

A – This document is for full publication

B – This document contains FoIA exempt information

C – This whole document is exempt under the FoIA

If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal.

Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections.

Title of Report The General Data Protection Regulation / The Data Protection Bill 2018:Progress Highlight Report

X

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2

Progress

GDPR and the accompanying Data Protection Act 2018 became law on Friday 25 May 2018.This represents the most far reaching changes to data law for nearly two decades and brings the UK onto the same level as the rest of Europe. However it is important to realize that we are already doing a considerable part of GDPR, so that many of our actions are about slight improvements to our existing standards. The regulations play particular emphasis on the rights of the individual namely: -

You will be informed which data we hold has been collected from you and that which has been collected from others

You have a right of access to the data we hold on you. You have the right to have mistakes or errors in your data corrected You have the right of erasure also known as the right to be forgotten. You have the right to stop us from using your records You have the right of data portability. This is to have your data provided to you in a format easily

read by a commonly used computer program. You have the right to object You have the right to prevent automatic decision making. This is when a computer makes a

decision about you. You have the right to prevent profiling however health profiling is sometimes essential to help us

support wellness. This is when aspects of your health are used to identify you as someone who could be helped.

You have a right to complain

Privacy notices informing patients, children and staff have been released initially on the internet and intranet with leaflets in the process of being prepared. A further privacy notice to support research is at the initial draft stage. All these notices will be organic and will need to change on a regular basis as case law is developed and the Regulation applied.

Most agencies including the Information Commissioners Office consider that the first few months following the release of the Act and Regulations are not to be considered as your are totally ready but rather that the organisation is defendable and we are working to be totally compliant.

The NCA has assessed its current progress against the Information Commissioners standards and the results of this are detailed in the table below.

Metric Not Yet Implemented

Partially Implemented

Successful Implementation

Not Applicable Status

Data Controller 0 5 26 0 GreenData Sharing 0 3 7 0 GreenInformation Security

0 3 19 0 Green

Records Management

0 3 13 0 Green

CCTV 1 6 2 0 Amber

The Committee is asked to accept the achievements so far in being able to operate under the regulation. There are further actions to perform and a high level plan is represented overleaf. All actions are managed from within the Information Governance Steering Group and exception reporting is through the Executive Digital Health Enterprise Committee, which reports directly to Executive Development Committee and onwards to Group Committees in Common..

67/318

3

GDPR Action Plan Lead – Jym Bates

Managed – Monthly by IGSG Review – Monthly by EDHEC Exception Reporting

Objective Action Lead Resource Implications

(S)tart(C)omplete(N)ot started

Progress Issues

Research Prepare a Privacy Note to be used in research

Jym BatesSteve Woby

Low at present (s) Rough draft prepared ready for review

Difficulty assigning a legal purpose to reviewing ‘cold’ records to isolate potential research candidates

Health Records To state, follow and audit against disposal and retention policy

Hayley Barton Low at present (s) Awareness of what is required. SRFT and PAT combining policies

Larger paper base in PAT. Need to co-ordinate the digitisation process in line with clinical and legal requirement

Human Resources To state, follow and audit against disposal and retention policy.

Jym BatesDavid Hargreaves

Medium to high

(s) Identification of process Need to stop local managers stockpiling files

Information Asset Management

To develop a single NCA register

Jym BatesHayley BartonRichard WakefieldJiten Patel

Medium to High

(s) Develop a single managed register across both legal entities.

Information in different systems in the different organisations

Data Processing Contracts

Move from ISAs to DPCs

Jym BatesHayley Barton

Medium (s) Identify unrepresented data flows.Move existing ISAs onto DPCs at reviewMove onto electronic system eventually

Electronic system needs re-write and also change in base operations

IAO Roles Review, increase clinical post holders and fill vacant slots

COOsJohn LlewellynPhill James

Medium (s) Increasing clinical and managerial involvement

Lack of buy in

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4





Progress Issues

CSO Role Increase the number of Clinical Safety Officers supporting new products and upgrades

Gareth ThomasD NursingRachel DunscombeJym Bates

Medium (s) Identify and train additional CSO Lack of buy in (historically)

Contacting the ICO

Ensure systems are in place for prompt incident reporting and alerting the DPO or IG

Jym Bates Low (s) At present to continue to use the HSCIC site. IG has access to all Datix. Information gone out to on call managers to alert DPO via email.

Decision Logs Maintain a decision log in relation to IG and IS

Jym Bates Low (s) Database being developed. To use MS Teams across Care Organisations

Technical RBAC / Access controlsCyber

Digital System Owners

Medium (s) Appraise Access Controls as systems are reassessed

Requests by the Police for data

Ensure that the release of data to the Police and Coroner follow legal precepts

Paul DownsJym Bates

Low to Medium

(s) Policy in development

Fax machines To remove the fax machine requirement across Group

Jym Bates Medium to High

(n) To commence a report to identify utilisation of fax machines

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5





Progress Issues

CCTV To ensure prompt access of high quality images to support SAR.Purchase of software to de-identify

Rob Jepson Jym Bates

Medium to High

(n) Review currently underway

Information Security

To ensure the safety and integrity of data and data holding systems

Jym BatesJohn LlewellynPhill James

Medium to High

(s) Teams supported by NCC at SRFT looking at mirroring the structure at PAT.

70/318

Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAHT)


Author (s) Raj Jain, Chief of Strategy & OD Lynda Spaven, Director of People & OD David Hargreaves, Director of Workforce

Presented by Lynda Spaven, Director of People & OD David Hargreaves, Director of Workforce

Date 4th June 2018

Executive Summary

This paper recommends the adoption of a People Strategy which aims to change the Target Cultural Operating Model through strategies for: Leadership, Contribution Framework 2.0, Talent Management, L&OD, HR Policies & Sourcing. It sets out a mobilisation plan and identifies risks and controls for implementation

Recommendations Group Committees in Common is asked to:

formally confirm the values to be adopted by the NCA;

agree in principle to the adoption of the proposed People Strategy and support its delivery and investment.


Communication N/A

Freedom 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 Developing the Northern Care Alliance’s People Strategy

X

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1.0 Background

1.1 The formulation of the Northern Care Alliance, bringing SRFT & PAHT together

working in a group structure of health and care providers, enables significant

opportunities to improve clinical and financial viability. Both organisations are on a

journey of transformation – albeit at different stages; nonetheless we can optimise the

benefits of pooling existing knowledge, expertise and best practice to support the

Groups mission of bringing long term health benefits to the populations of Salford and

the North East Sector of Manchester (Bury, Rochdale, Oldham & North Manchester)

through highly reliable, safe and compassionate care.

1.2 The Group structure will ensure consistent practices, policies, process, standards and

procedures. It will also provide greater opportunities for innovation and excellence in

the services we provide. Transformation, achieved whilst maintaining excellent patient

and people care, will only be possible by developing our people – they are our core

strength. We plan to build a culture in which people know they are valued and

supported, are an integral part of a team and are empowered to improve and innovate.

1.3 To achieve this cultural shift we need to re-craft the psychological contract with our

staff by developing and delivering our employee value proposition (EVP). This EVP will

define the essence of the organisation; what we stand for and how we are unique –

„The Place to Be‟. The NCA EVP will be supported by a robustly researched and

comprehensive People Strategy that is driven by and contributes to delivering on the

NCA Operating Model (diagram 1). The People Strategy is driven by and contributes

to the achievement of strategic objectives at NCA Group and Care Organisation levels

by applying a Target Operating Model approach to translating strategic ambition into

people and organisational design, management and development. Our aim – to

develop the culture and capability to ensure we meet our over-arching aim of „Saving

Lives; Improving Lives‟.

Diagram 1 – Influences & Drivers - NCA Operating Model and the People Strategy

People Strategy delivering

Leadership & Culture Target

Models

Processes - Standard Operating

Models

High Reliability Organisation

Culture

Digital Transformation

Structure & Governance

QI -

Continuous & Transformational Improvement

LEAN principles

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1.4 If culture is „how we think, act and interact‟, then it is clear that the key enablers of

culture change are our leaders and the teams they work with. Hiring, developing and

retaining leaders who have the capability and potential to collectively deliver is

fundamental to our success. We will be developing our leaders to –

shape teams & culture

ensure highly reliable performance

engage individuals & partners, and

deliver services to an exceptional professional standard across many systems.

1.5 This will involve us supporting our values-based leaders to reflect on and assess

their existing knowledge, skills, behaviours, and mind-set and identify areas for

development. Our aim is to provide a robustly designed benchmark that ensures

leaders at every level can measure themselves against a collaborative and caring

leadership model based on the characteristics of creating a high reliability culture.

2.0 Creating Consistent Performance

2.1 The establishment of the 4 Care Organisations, which now define the NCA Group,

has been a major factor in strengthening and increasing leadership visibility. Each

CO has been tasked with meeting the overarching strategic priorities of the NCA;

each are at different maturity levels and each have their own cultures and

subcultures. This has created variance in the ability to transform, recruit & retain

staff. There are frustrations in the CO‟s as energy is focused on managing

underperformance, poor quality data, agency costs and staff shortages to the

detriment of high performance, succession planning, innovation and service

transformation.

2.2 One of our key aims is to reduce this variance and create consistency through the

delivery of our people strategy whilst also acknowledging the need and importance of

each CO maintaining their cultural characteristics. The approach will be to apply a

Target Operating Model approach to developing a culture which reduces variance

and supports high reliability. Some of the drivers of this are:

Variable Standards

Poor/inadequate data

DRIVERS CURRENT IMPACTS PEOPLE PILLAR TARGET

The

Place

to B

e

Gaps & Hotspots

Command & Control V

Empowered & Inspired

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2.3 To deliver cultural shift and fulfil our mission of Improving Lives, Saving Lives we will

build on the strengths and expertise within the NCA, challenged and informed by best

practice in health, care and other sectors, to deeply embed an inclusive culture based

on:

Core Values & Behaviours

Patient & People Focused, Quality, Accountability & Respect

Characteristics of a high reliability organisation

Deference to expertise, reluctance to over simplify, relentless pursuit

of quality, commitment to resilience and sensitivity to operations

High performance operating model

Clarity of purpose, standards and outcomes

Coaching approach to performance management

Regular performance review & forward planning supported by data

Developing our people supported by quality feedback

2.4 We will embed through our standard people processes the espoused culture using

our 3 year People Strategy which focuses on 6 foundation pillars (diagram 2).

Diagram 2 – The Six Foundation People Pillars

3.0 Aims of the People Strategy 2018-2021

3.1 Our People Strategy sets out the inter-related strategic aims, which will support the

delivery of our strategic priorities and will further embed our values and behaviours

over the next 3 years.

3.2 Our ambition is to support the achievement of NCA‟s mission to save and improve

lives and be the safest health & care organisation in England by:

Becoming a sought after employer who attracts and retains the best talent by

providing an inclusive culture of care and well-being.

EMPLOYEE VALUE PROPOSITION

Support & Compassion|Exemplary Professional Practice|Structural Empowerment|Learning & Innovation

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Developing leadership, management, and team capability that is recognised as

„best in class‟ and is founded on context, congruent, that is relevant to a service-

driven, inclusive, multi-generational workforce.

Providing innovative and practical opportunities for all staff to reach their

potential.

Retaining and rewarding our staff through recognising their contribution in the

delivery of the organisations priorities

Shaping policies, procedures and processes that ensure efficiency and

consistency

Enabling efficient, service-driven, and wherever possible flexible approaches to

workforce planning and organisation.

4.0 Delivering the People Strategy

4.1 The principles that provide the „golden thread‟ to how we will deliver our people

services are: -

4.2 The People Strategy will be delivered by creating clarity of purpose and focus and

building a model of partnership working both within the workforce team, CO and our

staff side colleagues to deliver support and services to the business as is shown

below in diagram 3.

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Diagram 3: Core Elements of the People Strategy

5.0 Our Ambitions

5.1 Within the People Strategy we have prioritised 6 key deliverables fundamental to

creating a high values, high performing culture which form the pillars of our People

Strategy:-

5.1.1 Leadership & Culture Strategy -To develop and inspire the highest calibre of

leaders to enable accelerated transformation through our people through:

An explicit and „bought in to‟ / agreed NCA Leadership model across group which

is collaborative and supportive and ensures inclusive leadership is established as

a key value and driver of behaviour and performance

A model which is led from the top with CiC & CO Directors role modelling and

driving the culture through the model

A clear expectation of our culture and what is expected of leaders at all levels in

respect of developing and maintaining their team‟s culture.

Development of contextual leadership competencies which provides an

underpinning framework for how we measure mindset, skills, values and

behaviours associated with a highly reliable organisation

Establish a robust approach to identifying, assessing and appointing leaders and

managers with the requisite mindset, skills, values and behaviours throughout the

group to deliver on the achievement of our strategic aims and the transformation

programme.

A suite of leadership development activities and interventions to strengthen and

support leaders in delivering the transformation agenda and build a high reliability

culture across group

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The accountability and governance framework to embed performance enhancing

change and ensure continuous improvement enabling the gathering, comparing

and reporting of key performance data in respect of leadership, culture and

teamwork.

Recognition for excellence in leadership, culture, and team development.

5.1.2 Contribution Framework 2.0 - Re-designing the NCA Performance Management

approach to provide the system for connecting the Board to the ward by acting as the

enabler for linking all activity to the strategic priorities – the golden thread

Develop a system which drives the NCA mission through a high performance

culture

Focuses and motivates staff empowering them to improve care

Puts the spotlight on the values based behaviours we want people to buy into

Uses a coaching approach to provide clear performance expectations aligned to

the mission and individual

Focuses on the future not the past through regular performance review which is

developmentally based

Facilitates continuous improvement as a consequence of learning from incidents

and errors, building in meaningful and developmental in the moment feedback.

Developing leaders to be outstanding in people performance management and

development.

Providing leadership & management development that equips our people for the

challenges of leading in the ever-changing health & social care context

Links to other HR people process to strengthen talent and address poor

performance

Ensuring good people are motivated to stay, supported by an inclusive Talent

Strategy that identifies potential and provides diverse opportunities for

development.

Developing a culture of resilience & well-being.

Supporting leaders to create teams that balance challenge and support, and feel

safe

5.1.3 Talent Management Strategy which attracts develops and retains the best talent

through:

Establishing and embedding a Talent Management Strategy (TMS) to attract,

develop and retain the best talent.

Our TMS will apply best practice in modern methods of people management to

ensure we can deliver the right development, in the right place at the right time.

Potential/Talent will be captured and monitored through a digital system creating

a central point for „Ready Now, Ready Later‟ identification to support the mapping

of availability, need and skill

The Contribution Framework will be used to support succession planning,

identifying those with high potential who are delivering beyond/in their role,

actively supporting NCA values & culture, and have the drive and motivation to

achieve more.

The TMS will -

o Inform our leadership development plans to ensure resources are directed

effectively to successfully develop future and current leaders.

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o Provide for the need to skill up talent to lead on new frontiers such as

integrated care and digital advancement.

o Help to fill the pipeline needed to ensure leadership posts in the C.O.‟s

are filled by high calibre people that meet the (business and strategic)

needs of the NCA

5.1.4 Learning & Development Strategy to equip people with the professional

competence and expertise needed to be a Highly Reliable Organisation by:

Establishing a NCA Learning Academy which is closely aligned with workforce

transformation, being at the cutting edge of education, learning & development

Developing higher level partnerships with HEI to maximise funding, new role

development; ensuring close alignment with the workforce needs of NCA

Re-defining the relationship with HEE becoming a beacon of best practice for

L&D delivery which will attract income, through our commissioning power, to

support our workforce transformation

Developing new roles that leverage the new models of care, e.g. ICOs – staff that

are not bound by the silos of health or social care who can deliver seamlessly

across traditional boundaries

Nurturing greater corporate social responsibility within each locality by widening

access to employment opportunities and working with schools & FE to attract

talent and support health inequalities

„Reimagining work‟ – supporting the redesign of workflow, the competencies and

roles that then follow to optimise the value of digital and back office services

Becoming the world‟s best at the use of digitally assisted learning from

simulation, digital on the job coaching, to simple apps that support learning

Maximising digital programmes such as V-Care, extending to all aspects of the

NCA; introduction of “i-Staff” programme to develop the most digitally enabled

workforce nationally

Applying consistent approaches to workforce development that deliver reliability

& economies of scale

Developing a Learning Needs Analysis that enables L&D to be delivered at lower

cost and wider portfolio

5.1.5 HR Policy Through our HR policies we will:

Bring our policy framework up to the 21st to challenge out of date practice and

mindsets which disempower our CO managers.

Develop reward and recognition strategies.

Work with staff side to develop an „arm in arm‟ relationship to strengthen the NCA

Employee Value Proposition by moving beyond compliance and working together to

create the best place to work and build a career.

Move away from staff side/management side to true partnership working.

Through coaching, empower managers to operate our policies.

Develop policies which can meet the multi-generational agenda.

Support the development of a blended workforce through workforce planning and

innovative role development and deployment.

Increase the opportunities for flexible working.

Improve the retention of our staff.

Ensure that inclusion is at the heart of what we do.

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Ensure value for money and a productive workforce through agency reduction,

absence reduction and through the development of high quality job planning and

rostering practices and supporting the implementation of trendcare.

Enable the workforce to respond to digital.

Enable to workforce to respond to the need for new organisational forms.

Develop self-service and digital solutions for transactional HR processes.

Further develop workplace wellbeing including financial wellbeing.

Support the transaction/acquisition.

5.1.6 Sourcing Strategy – Through our Sourcing Strategy we will:

Devise systems and processes to attract the best.

Create a strong brand image for the NCA in the recruitment marketplace.

Increase our conversion rates of applicants into employment.

Minimise the time taken to fill posts and as a consequence reduce agency spend.

Through our connection with Talent Management and Learning & Development, and

through proactive recruitment, avoid long term temporal solutions such as acting up

or interim posts.

Improve selection methods to ensure appointees have a cultural fit and ensure a

robust assessment against mindset, values and behaviours.

Maximise the benefits of digital to promote careers at NCA and our EVP.

Enable internal career rotations and redeployments across care organisations to

improve retention rates and minimise cost through organisational change.

Recruit at scale whether through targeted local initiatives or overseas.

6.0 Reliable Implementation

6.1 There have been many good people/workforce strategies presented at Trust Boards

across the NHS, yet there remains significant underperformance on the people

front. The reasons for this are many including; lack of resources to deliver, lack of

commitment to „see the job through‟ especially in times of crisis, lack of continuity in

leadership. Our strategy will be best of breed; our implementation will be even

better. It is on implementation that we aim to differentiate and bring success to the

people agenda across the NCA; to achieve this we require the buy in to our Target

Cultural Operating Model described earlier.

6.2 Implementation will have 5 domains:

6.2.1 HR and L&OD: We have started the journey to transform the function. Through

replicating Ulrich‟s business partnering and centre of excellence model to develop a road

map for development, we have determined what we need to change and what good looks

like. We are planning development sessions to ensure that our business partners are

equipped with the tools they need to have in order to work effectively in the support of our

customers and have moved transactional work to shared services to free up time to focus on

the strategic and value adding.

6.2.2 Care Organisations are the centre of our attention. Care Organisations are the

centre of attention. The approach will be to support CO Directors and their teams to

become excellent at leadership & management and support them with highly

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effective people process. We will contract with the care organisations leadership

teams through formally agreed SLAs and agreed performance metrics.

6.2.3 Staff side organisations. We wish to develop objectives that are just as important to

staff side organisations as they are to leaders of the service. This, coupled with a

value set that will drive deep collaboration will leverage the talents and capacity of

staff side organisations to deliver on agreed objectives.

6.2.4 The NCA Academy: We will create a transformed approach to support the

professional development of staff. Branding this as an Academy will enable our staff

to have a recognisable and tangible “asset" that they value as being a differentiator

for the NCA. The academy will provide a vehicle to which partners, including Salford

University, can be more securely attached in an ambition to deliver greater success

for all. It will increase our opportunities to attract private sector sponsorship to

support the development of our people.

6.2.5 Digital: NCA‟s Academy will have a digital first strategy. Wherever it has been

evidenced that digital can bring better staff outcomes, we will seek to deploy. The

Academy will be the home of the GDE initiated workforce innovations. The Academy

will host our workforce transformation programme, including changes that are driven

by digital as well as the programmes to deliver new roles at scale.

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6.2.6

7.0 Mobilisation, Key Milestones and Metrics

Work stream 100 Days 6mths Year 1 Year 2 Year 3 Metrics

Leadership & Teams

• Engagement on mindset values & behaviours

• Leadership MVB agreed

• Included within CF 2.0

• Gap analysis of leadership culture between CO

• Leadership model finalised

• Review & integration into leadership programmes

• Mobilisation – leadership development plans for each CO

• Team development toolkit in place

• Leaders trained in model & MVB and use of coaching

• Rollout of leadership development plans ongoing

• Early signs of role modelling evident

• Leadership MVB embedded in culture reinforced by CF2.0

• Supply of up & coming talent

• Role modelling widespread

• Reduction in variance

• High performing teams

• Constant supply chain

• Staff Survey by CO

• Pulse check surveys by CO

• WRES

• Sickness & Absence rates reduced

• Improved retention rates

• EVP Accreditation

• Improved CO performance

Performance Management

• Socialise the PM model (CF2.0)

• Build business case for awareness training

• Test of change pilot • Train CiCD & COD as

champions • Engage with staff side &

HRBP • Recommendations for

rating and annual increments

• Link between NCA strategic planning process and CF2 mapped

• Embed agreed MVB • Align HR policy to

NCA PM method • Secure buy in • Alignment with Talent

Management • Develop digital

platform

• Embedded within Talent Management process, succession planning & workforce digital platform

• Full mobilisation achieved with single system and digital platform

• Staff are thriving • Sustainability • Fast tracking of talent • Dealing with poor

performers

Embedded in culture – the way we do things around here

• FFT Results • Evidence of Golden

Thread by CO • Number of leaders

qualified in CF2.0 • Staff Survey Results • Improved retention

rates • Improved CO

performance

Talent Management

• Development centres run

• Talent Pool Created

• COD & CICD equipped with skills

• MVB agreed

• PDP & fast track programme commenced

• Links to DMO & Recruitment in place

• Role modelling

• Further Talent cohorts including BME

• Tracking into leadership posts

• Strategy agreed

• Feed from CF2.0 MVB

• Talent conversations routine

• Talent pool widened • Min 1 person per job

• Extended to external orgs

Embedded in culture • Tracking of talent pool • Demographic data –

inclusion & diversity

• Supply of leadership talent to posts

• WRES

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• Engagement with staff and staff networks ( BAME, DAWN, LGBT)

• Talent Board established

in place • Improved recruitment & retention rates

Learning & Development

• LNA conducted- cyclic

• Training plan 18/19

• Career frameworks development commenced

• Competencies for priority groups

• Closer alignment with workforce transformation/planning

• Standardisation of training delivery

• Review of policies processes to ensure best practice and quality

• Delivery against training plan

• Career frameworks for implemented

• Standardisation of training delivery ongoing

• Increased digital offer V-Care for Community & Maternity

• Build business case for Learning Academy

• Supporting redesign of workflow and new role development

• Digital People system in place

• Developed ROI process

• Data collated from CF2.0 for LNA

• SOM for key delivery areas

• Infrastructure to support SOM in place

• Development of Learning Academy – closer links and partnership with HEI – new roles aligned to business needs

• Development ‘iStaff’ • Simulation training

enhanced; supporting learning from deaths

• Evaluate L&OD against Building Learning & Development Excellence

• Evidence of ROI

• Digital coaching developed

• Learning Academy fully integrated into organisation providing career pathways for employee lifecycle

• Increased offer to LHE through digital learning platforms

• V-Care extended to all aspects of NCA

• Developing staff into new roles

• Increased CSR offer – pipeline of talent from schools & FE into Learning Academy/HEI as recruitment pipeline

• World’s best at use of digitally assisted learning

• Increased commissioning power – reputation & quality

• Cutting edge learning & development renowned as the ‘Place to Be’ for developing careers

• Learning Academy Establish with SOM & funding

• CF2.0 ratings • Staff Survey • Talent Pool & pipeline • Income generation • National recognition for

digital learning • Evidence of ROI • Redesigned roles

provided highly reliable services

EVP • Wide scale engagement with staff on values and behaviours

• Establishment of leadership consultation groups

• Business case - investment for roll out

• Development of EVP Accreditation & rating process through engagement with staff side and staff networks - rigour

• Initiation plan agreed • Socialisation of model

• Teams assessed against accreditation framework

• Board Panels established

• Local development plans for improvement

• Celebration & recognition of successful teams

• Iterative cycle of assessment agreed

• Agreed targets for % teams reaching Silver and Gold levels

• All teams achieving minimum of Bronze level of accreditation

• Targets achieved for Sliver & Gold

• Teams achieving positive rating

• Staff Survey Results • Recruitment &

retention rates improved

• Sickness absence rates decrease

• Performance/NAAS ratings improved

HR Policies • Development of care organisation and NCA wide consultative processes

• Health and wellbeing engagement across

• Development of SLAs for resourcing and for workforce

• Joint policy development with staff side

• HR BP development programmes

• Further development of shared services

• Job planning and rostering

• Transaction concluded

• Self-service and digital offer

• Partnership working embedded

• Blended workforce • SLA refresh

• Agency spend • Absence rates • Retention and

turnover rates • Staff engagement

score

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Group • Pioneer role out to

Salford • Bank share in place for

NCA nursing • Credit Union publicised • Workforce, OD and TM

Committee established • Development of

common OH policies

• Reward and JE • Partnership

workshops • Trendcare in at

Salford and commencing across other COs

• Medical bank share implemented

• Salary Finance implemented

• Benefits alignment

implementations • RCF roll out to

remaining 3 COs • Trendcare roll out • SEQOHS accreditation • Common physio

offering to staff

• Further policy and T&C harmonisation post transaction

• Workplace wellbeing accreditation

• Model Hospital metrics

Sourcing • Shared service • Standardised processes • Links with students –

earn and learn

• Recruitment SLA for each CO

• Brand development • Revised resourcing

structure • Sourcing strategy • Explore earn, learn,

return

• Careers website developed

• Digital onboarding • R&S training reviewed • Assessment process

development • Options for

international recruitment

• Support to transaction in terms of redeployments

• Review sourcing strategy

• SLA refresh • Brand refresh

• Time to recruit • Vacancy rate • Conversion rates • Recruiter and applicant

satisfaction

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8.0 Risks & Challenges

Risk Controls

Capacity & Capability

Failure to bring in high calibre HR/OD talent & accelerate the skill level of existing staff to ensure role modelling of the new culture enable staff to operate at top of their game in advanced HR/OD methods will impact on the effectiveness and speed of implementation of the strategy If there is insufficient capacity and capability to support significant workforce transformation both within the HR/OD function and within the service, we may be unable to deliver the workforce we need to meet changing service need Failure to secure Salford University as a key delivery partner in supplying innovative and cost effective programmes of education could result in the NCA failing to secure sufficient numbers of staff with the right skills that are required to support clinical transformation.

Active acceleration through the new CF2.0 methodology

Team development workshops to socialise and buy in to strategy

OD consultant to shadow and mentor HR/OD talent

Development centres to determine development need and plan for increased internal bench strength

Gap analysis of team culture, leadership & management – EVP Assessment- against aspirant culture model.

Identification of quick wins & medium/long term team development plan

Distribution of OD resources to maximise impact

Development of toolkit to enable self-managed change

Further development of strong links with UoS

Exploration of joint roles which will support delivery and be cost effective

Reciprocal understanding of NCA & UoS pressures in respect of funding – development of a joint model which offers best value

Cost/Funding

Failure to secure increased funding to roll out the people strategy may result in an inability to fully deliver the strategy and the benefits to the NCA Failure to secure CPD funding for all staff may result in an inability to equip our workforce with the skills they need to meet the needs of our patients and service users

Full business case to be developed

Measurement of key performance metrics e.g. Clinical outcomes –

changing way care is delivered

Staff Satisfaction Time to fill posts Retention

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Failure to achieve the investment required in digital systems will impact on the effectiveness of the implementation CF 2.0, digitally enabled learning and shared service development. Failure to influence Health Education England to support our workforce supply and education requirements, could result in us failing to secure sufficient staff with the right skills or lead to the diversion of funding from patient care to support education

WRES & DES data

Enables identification of our strengths and hotspots; empowers leaders and staff to own being at top of their game

Greater accessibility to adaptive and responsive learning – can be shared with our local health economies and provide income source

Build the relationship with HEE to develop even stronger links and influence of funding of key roles

Maximise funding opportunities through strong bids which demonstrate innovation and impact on the LHE

Leverage the apprenticeship levy funding

Motivation If culture change is not role modelled from the top teams then we will not accelerate cultural change and adoption of best practice across group and local levels will be sub-optimal Failure to establish and maintain a true partnership approach with our staff side colleagues may result in poor employee relations which will lead to mistrust, disengagement of staff and barriers to us progressing NCA business priorities If we work in alignment with GM this may result in progress on some aspects of our Strategy being delayed by the slower pace and risk aversion of other providers or through the competitive

CiC will coach CO counterparts to build cohesion and grip; this will be kick started through using the CF2.0 & development centres

Change will be cascaded via direct reports and create golden thread

CO held to account for cultural transformation at each quarterly review and hold equal importance to performance delivery

Greater emphasis on collaborative working with joint delivery objectives and common purpose that drives through positive change for our people

Role modelling from our top leaders to influence change

Seek to influence the pace of change within GM and work outside of their timescales and programmes as necessary to meet the NCA requirements

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behaviours of organisations seeking to benefit individually from their own innovations If national legislation and policy such as Home Office restrictions on international recruitment does not change and uncertainties of Brexit, etc persist this may impact on our ability to employ sufficient numbers of staff with the skills we need

Pay close attention to local and national agendas to understand and counteract impact on implementation

Seek to influence national policy through NHS Employers and NHSI.

Develop and adopt different types of workers, models of working or technologies

9.0 Conclusion

The People Strategy is dynamic and a live document designed to leverage the added value of people in driving the mission and building a solid platform for continuous improvement and sustainability. It will evolve through partnership with all our communities ensuring it is inclusive and taps into the potential of diversity to provide the highest quality of care.

It provides the foundation‟s in achieving our ultimate ambition of being a magnet organisation for the most talented staff and has in place the conditions and structures to enable all of our staff to fulfil their career ambitions in an organisation that is not only „right‟ for them, but also challenges them and supports their development. The NCA becomes „The Place to Be.‟

This can only be achieved through steadfast support from the NCA‟s top leadership teams and the investment required to deliver our ambitions.

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


Author (s) Jane Burns, Director of Corporate Services/Group Secretary

Presented by Jim Potter, Chairman

Date 4th June 2018

Executive Summary

Two of SRFT’s longest serving Non-Executive Directors, Mr John Willis, Vice Chairman and Chairman of Audit Committee, and Mrs Diane Brown, Senior Independent Director, will retire from their positions on 31st March 2019. The Group Council of Governors will be asked to start the search, selection and recruitment processes for the two successors in June 2018, to enable appointments to be made at the December 2018 meeting of the Council of Governors. Induction and shadowing arrangements will take place during Q4, 2018/19.

It is for the Group CiC, on behalf of the SRFT Board of Directors, to confirm the skills and expertise required of new Non-Executive Directors, as aligned to the organisation’s strategic direction. With due regard to the strategic ambition of the Northern Care Alliance, including current priorities and associated risks, it is proposed that the specific skills and expertise for the two non-executive director positions are set to reflect those currently described for Mr Willis and Mrs Brown. These are:

a) Financial Strategy:Professionally qualified financial accountant. Recent and relevant financial experience. Experience of successfully leading the financial strategy of a large, complex organisation. The ability to shape and influence the organisation’s financial strategy, identifying financial risks and seeking robust assurance with respect to mitigation plans.

b) Organisational Development:Professionally qualified HR or OD practitioner. Recent track record of successfully leading transformational change, at a senior level, in a large, complex organisation. The ability to shape and influence the Trust’s organisational change programme, identifying workforce-related risks and seeking robust assurance with respect to mitigation plans.

The Non-Executive Director Role Description is attached at Appendix A.

The two proposed Person Specifications are appended at Appendix B and Appendix C.

Title of Report Board Composition: Non-Executive Director Skills and Expertise

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Recommendations Group Committees in Common is asked to review and approve the required skills and expertise for the two new non-executive directors.


Communication N/AFreedom of Information Please ‘cross’ one of the boxes below:




X

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Appendix A

SALFORD ROYAL NHS FOUNDATION TRUST

ROLE DESCRIPTION

Role: Non-Executive Director

Accountable to: The Council of Governors

Reports to: Chairman

Role summary: The Non-Executive Director will work with other Non-Executive Directors, the Chairman, Chief Executive and the Executive Directors, as an equal member of the Board of Directors. (S)he will also work in partnership with the Council of Governors. (S)he will be expected to use his/her skills (specific requirements for which are set out in the accompanying person specification) to best benefit for the Trust.

PrinciplesThe Board is collectively responsible for promoting the success of the Trust, by directing and supervising its affairs (Review of the role and effectiveness of Non-Executive Directors (January 2003) ‘The Higgs Review)’. Non-Executive Directors must demonstrate high standards of corporate and personal conduct.

Key functions

To work as part of a unitary Board, to provide active leadership of the Foundation Trust in ensuring quality and safety of healthcare services.

To ensure that the Trust establishes clear objectives to deliver the agreed plans and meet the terms of its licence and to regularly review performance against these objectives.

To ensure the best use of financial resources to maximise benefits for patients and that effective financial control arrangements are developed across the Trust to secure high levels of probity and value for money.

To ensure that processes and procedures are in place to deliver high standards of professional, clinical, administrative and personal behaviours across the Trust.

To ensure that financial and clinical quality controls and systems of risk management are robust and defensible.

To uphold the values of the Trust, be an appropriate role model and to ensure that the Trust promotes equality and diversity for all its patients, staff and other stakeholders.

To support and challenge, where appropriate, the Chairman, Chief Executive and other Directors of the Board of Directors to ensure that the Board conforms to the highest standards of corporate governance and makes appropriate decisions.

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To represent the Trust’s views with national, regional or local bodies or individuals, to ensure that the views of a wide range of stakeholders are considered and to be an ambassador for the Trust.

To participate in committees or sub-groups of the Board, charged with specific activities, to support the delivery of services, as required.

To act as a trustee of charitable funds.

Time commitment

There is likely to be a need for ‘on site’ presence for the equivalent of 3 days per month (on average) plus some time for reading and meeting preparation. This may be during the working day or in the evening.

All members of the Board of Directors are required to: undertake appropriate induction training; attend Board meetings and Board Away Days; attend meetings of:

- the Audit Committee (except the Trust Chairman);- the Nominations, Remuneration and Terms of Service Committee;- the Charitable Funds Committee- the Strategy and Investment Committee- the Council of Governors.

Remuneration

Remuneration, as determined by the Council of Governors, ranges from £16,000 to £20,000 for non-executive directors. Remuneration commences on appointment at £16,000 and increases incrementally, in accordance with each non-executive directors’ annual performance review rating. Progression takes place where performance review results in a fully satisfactory rating, and to the ‘top band’ where performance review results in an ‘outstanding’ performance rating for two consecutive years.

Non-Executive Director Remuneration - incremental bandings:

£16,000 £18,000 £20,000

Remuneration is taxable under Schedule E and subject to Class I National Insurance contributions. It is not pensionable.

Non-Executive Directors are also eligible to claim allowances, currently in line with national rates, for travel and subsistence costs necessarily incurred on Trust business.

Appointment, tenure and termination of office

Non-Executive Directors are appointed for an initial period of three years, subject to satisfactory appraisal by the Chairman. Appointments may be renewed at the end of the first period of office, subject to the recommendations of the Council of Governors’ Nominations Committee and approval by the Council of Governors, for a second three-

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year term. Further re-appointment will only be considered in exceptional circumstances. Non-Executive Directors may be removed from office by the Council of Governors, in line with its constitution.

These posts are statutory offices and are not subject to the provisions of employment law. Non-Executive Directors are appointees not employees. To ensure that public service values are maintained at the heart of the NHS, all Directors of NHS Boards are required, on appointment, to agree to and abide by the Code of Conduct for the Trust’s Board of Directors.

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Appendix B

SALFORD ROYAL NHS FOUNDATION TRUST

Non-Executive Director Person Specification – Financial Strategy

Summary:

Competencies/attributes

Essential/ desirable

Short listing assessment Weighting

Professionally Qualified Accountant E CV - qualifications

Pre Qualification

Experience of leading financial strategy of a large organisation

ECV – career record to demonstrate significant experience at Finance Director or equivalent of a large organisation

25

Self Belief and Drive E CV – personal and career achievements15

Intellectual Flexibility ECV – academic record, professional attainment, evidence of achievement of strategic organizational goals

10

Patient and Community Focus D

CV – contribution to community achievements; understanding of patient requirements

10

Strategic Direction E CV – evidence of planning; balancing needs and constraints

15

Holding to Account E CV – evidence of delivery of goals through others15

Risk ManagementD

understanding can be developed post appointment -

Business/FinanceE included in second quality above

-

Team WorkingE to be assessed post short listing

-

Effective Influencing and Communication Skills

E CV – how does the way that the CV is written demonstrate effective influencing and communication skills

10

Total 100

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DETAILED PERSON SPECIFICATION: Non Executive Director – Financial Strategy

1. Residence Preference will be given to those who live in the area served by the Trust.

2. Professionally Qualified Accountant: Failure to demonstrate compliance with the criterion will bar candidate from being included in short listing.

The post demands that the individual has a technical level of understanding that comes from being a professionally qualified accountant.

Why it matters. The Non Executive Team need to be able to contribute to and critically appraise strategies, including the Trust financial strategy. The complexity of Trust finances, including the PFI scheme, requires the team to have the capacity to be supported by an individual who is able to scrutinise technical financial reports.

3. Experience of leading financial strategy of a large organisation

The ability to shape and influence the Trust financial strategy, identifying financial risks and seeking robust assurance of mitigation plans.

Why it matters. Having a financial qualification alone does not imply that an individual has the ability outlined above. This ability will support the Trust in developing robust financial strategies that are the foundation of service improvement.

4. Strength of Character and Drive

The motivation to improve performance in the health service and the strength of character to overcome obstacles, so that the Foundation Trust can make a real difference to the health and quality of life of all those it serves.

Why it matters. This quality describes the capacity for chairs and non-executives to make a difference. Making changes in the pressurised and rapidly changing environment of the health service requires toughness, stamina and emotional resilience. Their drive and strength of character will motivate and support chairs and non-executives when faced with ambiguity and uncertainty. They are needed to underpin their determination to improve services.

5. Intellectual Flexibility

The ability to handle uncertainty and complexity and to be open to creativity in leading and developing services.

Why it matters. Chairs and non-executives need to be able to get a grip on short- and long-term priorities, especially where resources are finite, in order to ensure the board can provide direction to the organisation. This requires the ability to move rapidly between big picture thinking and paying sufficient attention to significant detail.

Keeping an open mind is important if radical and creative thinking is to flourish. Chairs

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and non-executives need to be receptive to new ideas to define and drive through change and reorganisation or to support the Executive in the reconfiguration and reorganisation of services so that they are more responsive to the needs of diverse user groups.

6. Patient and Community Focus

Demonstrating a high level of commitment to patients, carers and the community.

Why it matters. There is a public expectation that non-executives bring to the board an understanding of patient, carer and community issues, recognising the importance of a diversity of viewpoints and equal opportunities.

7. Strategic Direction

The ability to bring astuteness and understanding to shape a strategic vision and to encourage a full commitment to it.

Why it matters. The Board is there to set the direction for the organisation and provide a vision for service improvement and modernisation which is both challenging yet attainable. The board must be prepared to take some risks, to be creative, and to provide constructive challenge to the way that things are done.

8. Holding to Account

The strength of resolve to hold others to account for agreed targets and the readiness to be held accountable as a board for delivering a high level of service.

Why it matters. Good governance is the key to ensuring quality and consistency of care. The board is accountable for clinical and corporate standards of governance. The chair and non-executives have a key role in setting the climate for high standards and for holding others accountable for the performance of the organisation and its services, as well as being held accountable themselves.

9. Risk Management

Understanding how the Trust is managing critical predictable and probable variables through robust assessment frameworks to ensure the delivery of objectives.

Why it matters. The non executive’s role in ensuring that the organisation has robust systems of risk management is vital. The Trust has reviewed its risk management systems and is developing a strong risk management culture. The Trust is looking to develop its risk management systems further to pursue safe and effective conduct of organisational operations and strategies as the environment changes.

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10. Business/Finance

Understanding how the organisation functions, how resources flow and key drivers for effective and legitimate resource utilisation.

Why it matters. The new funding regime, coupled with Foundation Trust status, requires the Trust to develop its already sound and robust financial information systems and controls. In addition, Foundation Trust status offers the potential to exploit financial freedoms and business opportunities denied to NHS Trusts.

11. Team Working

Being committed to working as a team with the board whilst respecting the different roles of executive and non-executive members and accepting collective responsibility for leading the organisation and achieving real change.

Why it matters. Team working is critical if the board is to deliver measurable and radical health improvements in a complex and changing health and social care environment. A board team working in harmony sets an example of collaborative working for the whole organisation and sets the tone for wider collaboration with external stakeholders.

Chairs and non-executives have a particular responsibility to motivate and empower the executive team and to ensure that the board provides a strong lead to the organisation as well as acting as a corporate part of the NHS without compromising the operational responsibilities of Executives.

12. Effective Influencing and Communication

Being able and prepared to adopt a number of ways to gain support and influence people with the aim of securing health changes.

Why it matters. Health improvements can only be brought about by people working collaboratively.

Chairs and non-executives need to be adept at sophisticated influencing to build a consensus across issues to give the organisation a firm platform for influencing other stakeholders. Influencing needs to be subtle in order to empower others and to create ownership of the change agenda and will draw on a range of communication skills.

13. Managing change in a complex environment.

Outstanding non executive directors are focused on articulating the vision with compelling clarity. They keep up the focus by constructively challenging and contributing to the development of change strategies and through inspiring others to be positive in their support of service improvement.

Why it matters. The environment we exist in is complex with strong influences from local communities, universities, politicians, Department of Health and patients to name a few. In response the Trust pursued Foundation Trust status and strengthened partnership working with local organisations engaged in SHIFT. Competing demands will need to be managed and inertia tackled to meet the transformation agenda.

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Appendix C SALFORD ROYAL NHS FOUNDATION TRUST

Non Executive Director

PERSON SPECIFICATION SUMMARYCompetencies/attributes Essential/

desirableShort listing assessment Weighting

Professionally Qualified e.g. CIPD or HRM-related qualification

D CV - qualificationsPre

Qualification

Leading transformational change in a large, complex organisation

ECV – career record to demonstrate successful track record of leading transformational change at a senior level in a large complex organisation

25

Self Belief and Drive E CV – personal and career achievements15

Intellectual Flexibility ECV – academic record, professional attainment, evidence of achievement of strategic organisational goals

10

Patient and Community FocusD

CV – contribution to community achievements; understanding of patient requirements

10

Strategic Direction E CV – evidence of planning; balancing needs and constraints

15

Holding to Account E CV – evidence of delivery of goals through others15

Risk ManagementD

understanding can be developed post appointment -

Business/PeopleE included in second quality above

-

Team WorkingE to be assessed post short listing

-

Effective Influencing and Communication Skills

ECV – how does the way that the CV is written demonstrate effective influencing and communication skills

10

Total 100

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DETAILED PERSON SPECIFICATION: Non Executive Director – Organisational Development 1. Residence Preference will be given to those who live in the area served by the Trust.

2. Professionally Qualified in the area of HR/OD e.g. CIPD: Compliance with this criterion is ‘desirable’ and failure to do so will not bar candidates from being included in short listing.

The post demands that the individual has a technical level of understanding that comes, ideally, from being a professionally qualified OD or HR practitioner.

Why it matters. The Non-Executive team needs to be able to contribute to and critically appraise strategies, including the Trust’s organisational change agenda linked to Quality Improvement. The scale and complexity of the Trust’s workforce and change agenda, requires the team to have the capacity to be supported by an individual who understands how change is best introduced and is able to advise on employee engagement tactics.

3. Successful, recent track record of leading transformational change, at a senior level, in a large, complex organisation.

The ability to shape and influence the Trust’s organisational change programme, identifying workforce-related risks and seeking robust assurance of mitigation plans.

Why it matters. Having an HR-related qualification alone does not imply that an individual has the ability outlined above. This ability will support the Trust in developing robust workforce strategies that deliver service improvement.

4. Strength of Character and Drive

The motivation to improve performance in the health service and the strength of character to overcome obstacles, so that the Foundation Trust can make a real difference to the health and quality of life of all those it serves.

Why it matters. This quality describes the capacity for Chairs and Non-Executives to make a difference. Making changes in the pressurised and rapidly changing environment of the health service requires toughness, stamina and emotional resilience. Their drive and strength of character will motivate and support Chairs and Non-Executives when faced with ambiguity and uncertainty. They are needed to underpin their determination to improve services.

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5. Intellectual Flexibility

The ability to handle uncertainty and complexity and to be open to creativity in leading and developing services.

Why it matters. Chairs and Non-Executive Directors need to be able to get a grip on short and long-term priorities, especially where resources are finite, in order to ensure the Board can provide direction to the organisation. This requires the ability to move rapidly between big picture thinking and paying sufficient attention to significant detail.

Keeping an open mind is important if radical and creative thinking is to flourish. Chairs and Non-Executives need to be receptive to new ideas to define and drive through change and reorganisation or to support the Executive in the reconfiguration and reorganisation of services so that they are more responsive to the needs of diverse user groups.

6. Patient and Community Focus

Demonstrating a high level of commitment to patients, carers and the community.

Why it matters. There is a public expectation that Non-Executives bring to the Board an understanding of patient, carer and community issues, recognising the importance of a diversity of viewpoints and equal opportunities.

7. Strategic Direction

The ability to bring astuteness and understanding to shape a strategic vision and to encourage a full commitment to it.

Why it matters. The Board is there to set the direction for the Trust and provide a vision for service improvement and modernisation which is both challenging yet attainable. The Board must be prepared to take some risks, to be creative, and to provide constructive challenge to the way that things are done.

8. Holding to Account

The strength of resolve to hold others to account for agreed targets and the readiness to be held accountable as a board for delivering a high level of service.

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Why it matters. Good governance is the key to ensuring quality and consistency of care. The board is accountable for clinical and corporate standards of governance. The Chair and Non-Executives have a key role in setting the climate for high standards and for holding others accountable for the performance of the Trust and its services, as well as being held accountable themselves.

9. Risk Management

Understanding how the Trust is managing critical predictable and probable variables through robust assessment frameworks to ensure the delivery of objectives.

Why it matters. The Non-Executive Director’s role in ensuring that the organisation has robust systems of risk management is vital. The Trust has reviewed its risk management systems and is developing a strong risk management culture. The Trust is looking to develop its risk management systems further to pursue safe and effective conduct of organisational operations and strategies as the environment changes.

10. Business/People

Understanding how the organisation functions and how its human resources are key to achieving quality and service improvement targets, as well as external/internal targets.

Why it matters. The contribution of people, to the continuing success of the organisation, through its ambitious plans for quality and service improvement, is vital. Foundation Trust status offers the potential to exploit financial freedoms and business opportunities denied to NHS Trusts, from which staff may benefit, hence benefiting the patients to whom we provide services..

11. Team Working

Being committed to working as a team with the Board whilst respecting the different roles of Executive and Non-Executive members and accepting collective responsibility for leading the organisation and achieving real change.

Why it matters. Team working is critical if the Board is to deliver measurable and radical health improvements in a complex and changing health and social care environment. A Board team, working in harmony, sets an example of collaborative working for the whole organisation and sets the tone for wider collaboration with external stakeholders.

Chairs and Non-Executives have a particular responsibility to motivate and empower the Executive team and to ensure that the Board provides

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a strong lead to the organisation as well as acting as a corporate part of the NHS without compromising the operational responsibilities of Executives.

12. Effective Influencing and Communication

Being able and prepared to adopt a number of ways to gain support and influence people with the aim of securing health changes.

Why it matters. Health improvements can only be brought about by people working collaboratively.

Chairs and non-executives need to be adept at sophisticated influencing to build a consensus across issues to give the organisation a firm platform for influencing other stakeholders. Influencing needs to be subtle in order to empower others and to create ownership of the change agenda and will draw on a range of communication skills.

13. Managing change in a complex environment.

Outstanding Non-Executive Directors are focused on articulating the vision with compelling clarity. They keep up the focus by constructively challenging and contributing to the development of change strategies and through inspiring others to be positive in their support of service improvement.

Why it matters. The environment we exist in is complex with strong influences from local communities, universities, politicians, Department of Health and patients to name a few. In response, the Trust pursued Foundation Trust status and strengthened partnership working with local organisations. Competing demands will need to be managed and inertia tackled to meet the transformation agenda.

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Northern Care Alliance NHS Group

Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

Group Risk and Assurance Committee (GRAC)

Summary of meeting on 21 May 2018 at 2.30pm,

Frank Rifkin Lecture Theatre, Mayo Building, Salford Royal

Present Raj Jain, Chief Strategy and OD Officer (Chair) Judith Adams, Chief Delivery Officer Chris Brookes, Chief Medical Officer Elaine Inglesby-Burke CBE, Chief Nursing Officer Jayne Downey, Director of Governance and Corporate Nursing Jane Burns, Director of Corporate Services and Group Secretary Paul Downes, Director of Patient Safety Nicola Firth, Interim Chief Officer/Director of Nursing, Oldham Care Organisation James Sumner, Chief Officer, Salford Care Organisation Tyrone Roberts, Director of Nursing, Bury and Rochdale Care Organisation Stephanie Gibson, Managing Director, North Manchester Care Organisation Simon Featherstone, Director of Nursing, North Manchester care Organisation Emma Wright, Director of Information and Business Intelligence Nicky Tamanis, Group Deputy Director of Finance In Attendance Su Statom, Head of Corporate Governance Andrew Montgomery, Group Associate Director of Estates

Apologies for Absence Sir David Dalton, Chief Executive Officer Damien Finn, Chief Officer, North Manchester Care Organisation Ian Moston, Chief Financial Officer Rachel Dunscombe, Group Director of Digital Lindsay McCluskie, Group Director of Capital, Estates and Facilities

1. Declarations of interest

The Chair asked Directors to declare any interest relevant to the business of the meeting. No

interests declared.

2. Minutes from previous meeting 19 March 2018

Confirmed as an accurate record.

3. Ratification / Approvals from Previous Meeting

The GRAC received a summary report at the 23 April 2018 GRAC meeting which provided an

overview of key themes from the Care Organisation Well led developmental reviews that had

taken place during 2017/18, and a proposed approach for Group and Care Organisation Well

Led Governance Reviews in 2018/19. As the meeting on 23 April 2018 was not quorate, this

was presented again for ratification.

The Director of Governance and Corporate Nursing queried whether there was a requirement

for both the CQC and MIAA to undertake external reviews.

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ACTION: The GRAC requested the Director of Governance and Corporate Nursing to

review this matter with the Director of Corporate Services to gain clarification and on

this basis the schedule was approved.

3. Actions from PAHT EARC

Governance arrangements with respect to PAHT Corporate Functions to be reported at next

meeting 18 June 2018.

4. Care Organisations’ 2018/19 Annual Plan Presentations

The GRAC received and reviewed the four Care Organisations 2018/19 Annual Plans. The Director of Governance and Corporate Nursing expressed concern that the Care Organisations plans and the Corporate services plans may not be aligned. The Chief Delivery Officer stated that work was currently being undertaken with the Corporate services and that plans would be shared with the Care Organisations to ensure alignment. The Chief Nursing Officer raised a concern that there may be a risk of disempowerment from the Divisions if the development of plans were viewed as being a ‘top down’ approach. The GRAC agreed specific Divisional objectives should be developed by each of the Care Organisations’ Divisions and delivery monitored via the Care Organisations’ governance structures. The GRAC requested that the following actions be undertaken:

Each Care Organisation to review its annual plan against the plans set by the other Care Organisations

Methods to measure success to be included/enhanced within each annual plan

Specific Divisional objectives to be identified

Care Organisation Chief Officers to ensure each Care Organisation Annual Plan is aligned with Corporate Services annual plans

The following specific elements to be included in the Care Organisation Annual Plans: o Urgent care pathways / ambulatory pathways / Trauma provision o Resilience planning o Contribution to SOM / DOM o Working differently / with Group / Shared services including pace / scale and

standardisation o North Manchester – to include medical engagement around the transaction and

ensure explicit regarding establishment / rota management o Bury and Rochdale – emphasis on embedding change and include Bury LCO

leadership. 5. Care Organisation 2018/19 Opening Board Assurance Frameworks (BAF) The GRAC received principal and operational risks, scored at 12 or above, on the Care

Organisations’ Board Assurance Frameworks/Corporate Risk Registers. These risks will now be referenced within the Group Board Assurance Framework, and where necessary the Principal Risks will be adjusted accordingly.

A general in-depth discussion ensued regarding the Care Organisations BAF’s / Corporate risk

registers. Key matters and actions included::

All BAFs had been reviewed and rescored. GRAC challenged the scoring of some risks and requested further review.

Oldham Care Organisation reported that the Divisional risks scored 12 and above were currently under review and would be included once approved

The Chief Delivery Officer confirmed that the Care Organisations should set objectives and consider risk to the delivery of locally agreed targets, where applicable, rather than the national standard

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Current and future risks relating to changing infection control issues to be reviewed at Group level and reported to the July meeting of GRAC

North Manchester to ensure risks associated with the Transaction, A&E / Community services disaggregation and Estates were included within the CO BAF

Bury and Rochdale to clarify and rescore the risk relating to the Mortality review process

The Associate Directors of Governance within each Care Organisation to meet separately with the Director of Corporate Services and Group Secretary to ensure a continued consistent approach.

6. Care Organisations Statements of Assurance 6.1. Salford Care Organisation

The Chief Officer for Salford Care Organisation (SCO) presented the Statement of Assurance, including key risks, to GRAC providing the current and forward look to achievement of standards and objectives. GRAC confirmed:

Quality – for the period: 4 SI’s reported to StEIS and 4 Cdiff cases.

Finance – behind plan for the period but confidence in plans in place to deliver.

Performance – confidence in current plans to achieve the access targets reported as low. Urgent care had seen an improvement in month – reliability not yet achieved. RTT and Cancer targets achieved. Diagnostics failed for period, plan is in place to outsource capacity and a business case in progress for longer term solution. Trajectories to be discussed / agreed at the Operations Board on 21 May 2018

New Interim Director of Social Care now in post

CQC identified issue regarding Critical Care stepdown / mix sex breaches. Issues of flow identified as a risk and discussions with Directorate and GM Critical Care Group had taken place. Further review currently being undertaken.

6.2. Oldham Care Organisation

The Interim Chief Officer for Oldham Care Organisation (OCO) presented the Statement of Assurance, including key risks, to GRAC providing the current and forward look to achievement of standards and objectives. GRAC confirmed:

Quality - 5 SI’s reported. Investigations and initial Duty of Candour underway. 1 Cdiff reported and thresholds set for the CPE acquisition and VRE bacteraemia

JAG accreditation – external review planned 22 – 24 May. Additional lists continue through May 2018 to help to secure the diagnostic position.

Finance – Reporting an adverse variance against planned surplus mainly due to BCLC underperformance. Agency pressures continue and are above trajectory but recent appointments to substantive medical post expected to slow trend.

Performance – Urgent Care - April performance 87.4%, just below trajectory and improvement noted from previous month. The teams continue to explore opportunities to improve performance. Cancer performance in line with recovery trajectory. The Chief Delivery Officer requested the recovery plans and trajectory be discussed / agreed at the OP Board 21 May 2018. RTT remains below National Standards but will meet agreed improvement trajectory.

6.3. North Manchester Care Organisation The Managing Director and the Director of Nursing for North Manchester Care Organisation (NMCO) presented the Statement of Assurance, including key risks, to GRAC providing the current and forward look to achievement of standards and objectives. GRAC confirmed:

Quality – Cdiff cases lower than trajectory and HSMR reducing over the last 3 rolling 12 month periods. The Chief Nursing Officer requested further information about pressure ulcer cases to determine themes.

Finance – Work so far had been undertaken in setting the Care Organisation’s financial plans. Further work had been completed with the Divisional teams and the plan had been disaggregated and delegated down to each clinical division providing each with their own financial control. The Divisional teams had been engaged throughout the

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process and now in the process of signing them off. Changes had been made to the medical rota and booking process to improve locum and agency usage and currently undergoing a ‘test of change’ to ensure there was no adverse impact on performance and quality.

Performance – workforce issues reported as being the main contributor to under performance in urgent care, cancer and urology services. Action plans in place and being actively implemented.

6.4. Bury and Rochdale Care Organisation The Director of Nursing for Bury and Rochdale Care Organisation (B&RCO) presented the Statement of Assurance, including key risks, to GRAC providing the current and forward look to achievement of standards and objectives. GRAC confirmed:

Quality – Quality indicators on track. Zero delay in incidents and no overdue validated incidents. Statically significant reduction in CDiff in ‘days between’. 20% reduction in moderate / harm falls from previous year.

Finance – Plans in place to deliver agreed financial control total for the quarter. BCLC high level targets devolved to each Division and currently working up pipeline schemes

Performance – RTT achieved for April. ED performance 94% for April, in line with local trajectory. Ophthalmology – Improvement plan in place monitored by the Improvement Board chaired by the Care Organisation Medical Director. Pressure persists within the service which concern primarily capacity, leadership, governance, compliance against targets, data quality and morale

Strategic change –Rochdale LCO – S Taylor, B&RCO Chief Officer has assumed post of LCO Chief Officer. LCO leadership group established. LCO Development group, Thematic group and structures agreed. Bury LCO – Investment plans re-submitted. The LCO have requested the Transforming Emergency Care work stream to expedite the development of the Urgent Care Treatments Centre.

7. Corporate Functions 7.1 Estates and Facilities Risk register The GRAC received a comprehensive report from Estates and Facilities. The report served to

inform GRAC of the Corporate risks scoring 10 and above identified across the NCA on a site by site basis.

Risks scoring 12 and above were identified as:

NM –Theatre environment and ventilation management – 12

NM – Steam System failure

TROH – Linen Supplies

SRFT – Heating installation – Brook Building

SRFT – Vacuum pump – Tunberg building

NCA – Recruitment and retention

GRAC discussed the report in detail and in particular noted concern regarding the issues at NM theatres. An in depth discussion ensued regarding issues relating to the building estate and facilities of the NM Theatres. GRAC requested that a thorough further assessment of the air ventilation systems, including microbial testing, and the building fabric, including the electrical systems, be undertaken to provide assurance that the theatres were safe and that the air quality and facilities were of a high standard to enable safe general surgical procedures to continue. GRAC requested assurance that whilst testing was carried out that patients would not be affected or operations cancelled. GRAC was assured that patients would undergo operation at alternative theatres on the NM site. GRAC was informed that an external review would be carried out, which would be reviewed at the Resilience forum, to be established by the Chief Delivery Officer, scheduled for 25 May 2018. Report to be made to GRAC in June 2018. GRAC agreed that the NM Theatre risk was correctly scored at 12, and should therefore be included on the Group BAF/Risk Register.

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7.2 Corporate Functions: Annual Plans & Board Assurance Frameworks/Risk Registers GRAC was informed by the Director of Corporate Services and Group Secretary that the Annual Plans and Board Assurance Frameworks/Risk Registers for key corporate functions would be submitted to GRAC in June 2018, which would inform the continuing development of the Group Board Assurance Framework/Group Risk Register.

8. Closing 2017/18 Board Assurance Frameworks for SRFT and PAHT 8.1 GRAC received the closing positions of the PAHT Board Assurance Framework / Corporate

Risk Register (BAF) and Salford Royal Foundation Trust Board Assurance Framework / Corporate Risk Register (BAF) for 2017/18 Both BAF’s incorporated all updates from 2017/18 Q3 North East Sector CO BAFs, updates from closing position 2017/18 Salford CO BAF and the risk scores validated by the Group Executive Officers (in March 2018). GRAC confirmed the 2017/18 closing position of the PAHT BAF/CRR and the transfer of risks, as reflected in the 2018/19 Opening NCA Board Assurance Framework.

9. Opening 2018 / 19 Group Board Assurance Framework GRAC received the opening 2018 /19 Group Board Assurance Framework. GRAC were informed by the Director of Corporate Services and Group Secretary that Principal Risks, to the delivery of the Group’s approved principal objectives for 2018/19, had been identified by Group Chief Officers and those risks were set out in the Group Board Assurance Framework. The Director of Corporate Services and Group Secretary asked GRAC to confirm the significant principal and operational risks, scored at 12 or above, on the Care Organisations’ Board Assurance Frameworks/Corporate Risk Registers which were required to be incorporated within the Group Board Assurance Framework, and presented to Group Committees in Common as the integrated Group Board Assurance Framework/Group Risk Register for final approval.

GRAC reviewed and confirmed the Group’s principal risks for 2018/19, reviewed and confirm significant principal and operational risks, scored at 12 above on the Care Organisations’ Board Assurance Frameworks/Corporate Risk Registers, for inclusion within an integrated Group Board Assurance Framework/Group Risk Register. GRAC confirmed that once the Care Organisation risks 12 and above had been referenced the Group Board Assurance Framework/Group Risk Register was to be presented to Group Committees in Common (Part 1) on 4th June 2018 for final approval

10. Corporate Services Incident Management The GRAC reviewed the Corporate Services Incident Management Report. GRAC requested that a clear line of sight on all SI’s across the NCA was maintained via the

Corporate Services Incident Management Report and Care Organisations’ Statements of Assurance.

11. Summary and Key Matters from Audit Committee The GRAC received a summary from the meeting of Audit Committee on 24th April 2018. Audit

committee had requested the approved Internal Audit Plan 2018/19 was presented to GRAC, highlighting the intention to present a Care Organisation Assurance Opinion at year-end 2018/19. Chief Officers noted the Plan and confirmed that it would be presented/monitored via COARCs throughout the year.

12. Any Other Business No further business raised. 13. Date and Time of Next Meeting

Monday 18 June 2018, 2:30pm – 4.30pm, Seminar Room 1/2, Level 2, Mayo Building

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Group Governance Framework Manual

Reference Number: TT1(06) Version Number: 16

Final draft for approval

Issue Date:

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

Group Governance Framework ManualLead Author: Jane Burns, Director of Corporate Services and Group

SecretaryAdditional author(s) Rebecca McCarthy, Deputy Group SecretaryDivision/ Department: Trust ExecutiveApplies to: Northern Care Alliance* Date approved:Expiry date: April 2021

* This includes documents relevant to multiple Care Organisations, Corporate and Support ServicesContents Contents

Section Page

1 What is this policy about? 22 Where will this document be used? 23 Why is this document important? 24 What is new in this version? 25 Structure of Group 36 Chairman and Chief Executive7 Non-Executive Directors8 Executive Directors (Group Chief Officers)9 Care Organisations10 Council of Governors11 Membership12 Committees of Group Committees in Common13 Values and Principles14 Internal Control15 Independent Ccontrol and Regulation16 Roles and responsibilities?17 Monitoring document effectiveness18 Abbreviations and definitions 19 References and Supporting Documents20 Document Control Information21 Equality Impact Assessment (EqIA) screening tool

AppendicesAppendix 1: NHS Foundation Trust Accounable Officer MemorandumAppendix 2: Care organisation Chief Officer ‘accountable officer’ memorandumAppendix 3: Group Standing Orders (Board)Appendix 4: Terms of Reference Group Committees in CommonAppendix 5: Standing Orders Council of GovernorsAppendix 6: Terms of Reference Shadow Group Council of Governors

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

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Appendix 7: Standing Financial InstructionsAppendix 8: Reservation of Powers and Delegation of Powers

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1. What is this policy about?

1.1 From the 1st April 2017, the new Northern Care Alliance NHS Group (NCA) was launched, bringing together over 17,000 staff, 2000 beds and serving a population of over 1 million through four ‘Care Organisations’. Whilst Salford Royal and Pennine remain statutory bodies, the Trust Boards of both organisations delegated the exercise of their functions to a Group Committees in Common (Group CiC). The Group CiC is responsible for the exercise of those functions delegated to it by the SRFT and PAHT Boards, as set out in the Scheme of Reservation and Delegation of Powers.

1.2 Four Care Organisations including Salford, Oldham, Bury & Rochdale and North Manchester, are responsible for providing high quality and reliable care to the local communities they serve.

1.3 The Group Governance Framework Manual takes full account of the NHS Foundation Trust Code of Governance which was published by Monitor (now NHS Improvement) to assist NHS Foundation Trust Boards in improving their governance arrangements by bringing together the best practice of public and private sector corporate governance.

1.4 The purpose of the Group Governance Framework Manual is to bring together the key governance documents that describe the control framework within which the Group’s objectives are delivered. These documents include:

The Standing Orders of the Board The Terms of Reference for Group Committees in Common The Standing Orders of the Council of Governors The Standards of Business Conduct The Scheme of Reservations of Powers and Delegation of Powers The Detailed Scheme of Delegation The Standing Financial Instructions

1.5 The Manual is to be read in conjunction with:

Authorisation of Salford Royal NHS Foundation Trust (which includes the Constitution)

Establishment Order of Pennine Acute Hospitals NHS Trust 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

1.6 If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Where will this document be used?

2.1 The Group Governance Framework Manual applies throughout the NCA.

3. Why is this document important?

3.1 The Group Governance Framework Manual describes the control framework within which the Group’s objectives will be delivered, risks mitigated and standards of business conduct adhered to.

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4. What is new in this version?

4.1o Revision to Counter Fraud Sections, recognising establishment of the NHS

Counter Fraud Authority.o Updated CQC Section, recognising new CQC Inspection regimeo Inclusion of Decisions delegated to SRFT Acquisition Committee o Updated Detailed Scheme of Delegation

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5. Structure of the Group

5.1 Group Committees in Common - The SRFT and PAHT Boards of Directors have established the Group Committees in Common (Group CiC) with delegated responsibility for the exercise of functions of the SRFT and PAHT, as defined within the Scheme of Reservation and Delegation of Powers.

5.2 The Group CiC meet at the same time, around one table, to make decisions in relation to SRFT and PAHT. Since both of the committees have delegated powers from their Board, the decisions of each committee is final and there is no need for ratification by the SRFT and PAHT Boards.

5.3 The SRFT and PAHT Boards and Group CiC are made up of a Chairman (who is a Non-Executive Director) plus up to six other Non-Executive Directors and up to six Executive Directors, with the number of Executive Directors not exceeding the number of Non-Executive Directors. The Chairman has the casting vote. Other Directors attend in a non-voting capacity.

5.4 The Group Board, operating as Committees in Common, will substantially operate as the Boards for the two constituent Trusts. There will be specific but limited occasions where Board members who are not members of the Committees in Common will comprise the membership of individual Board meetings of the two Trusts e.g. approval of annual plans and annual accounts.

5.5 The two respective Boards (SRFT and PAHT) are ultimately responsible for their

individual organisations and have oversight of the delegation arrangement. Each Board retains the power to change or revoke the authority delegated to its committee at any stage.

5.6 SRFT and PAHT have established combined Standing Orders (Group Standing Orders for Board) that ensure effective and appropriate corporate governance arrangements are in place for the two sovereign organisations whilst in transition to a single organisation. The detailed arrangements for the SRFT and PAHT Boards and Group CiC are set out within the Group Standing Orders for Board (Appendix 3). The Terms of Reference for Group CiC (Appendix 4) set out specific provisions, and should be read in conjunction with Group Standing Orders for Board.

5.7 The Group CiC is accountable for the overall performance and quality of its services to the regulators, NHS Improvement (NHSI) and the Care Quality Commission (CQC), and the Shadow Group Council of Governors.

5.8 Shadow Group Council of Governors – The Shadow Group Council of Governors

(known as Group Council of Governors) is established as a sub-committee of the SRFT Council of Governors, as defined within the Scheme of Reservation and Delegation of Powers.

5.9 The powers of SRFT’s Council of Governors are established under statute. The Council of Governors may not delegate any of its powers to a committee or sub-committee, but it has appointed this committee to assist the SRFT Council of Governors in carrying out its functions, in particular, the Group Council of Governors Committee is expected to assist by carrying out those functions set out in the SRFT Scheme of Reservation and Delegation of Powers.

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5.10 The Group Council of Governors will assist the SRFT Council of Governors in fulfilling its responsibilities, which include the appointment of the Chairman and Non-Executive Directors. The Council of Governors’ responsibilities are set out in the SRFT Constitution.

5.11 Group membership – it is the Group-wide membership, comprising public and staff members, that elects the elected component of the Group Council of Governors. Key partner organisations appoint the appointed component of the Group Council of Governors.

6. Chairman and Chief Executive

6.1 There is a clear division of responsibility between the Chairing of the Group CiC and Group Council of Governors (N.B. and Chairing the Boards of the two constituent Trusts) on the one hand and the executive responsibility for the running of the Trust’s business on the other. ‘No one individual should have unfettered powers of decision’ (NHS FT Code of Governance 2014, p.19).

6.2 ‘The overall role of the Chairman is one of enabling and leading so that the attributes and specific roles of the executive and team and the non-executives are brought together in a constructive partnership to take forward the organisation’ (Code of Accountability in the NHS, 2004, p.5).

6.3 The Chairman is responsible for: providing ‘leadership of the Group CiC and the Shadow Group Council of

Governors, ensuring their effectiveness on all aspects of their role and leading on setting the agenda for their meetings’;

ensuring ‘that the Group CiC and the Shadow Group Council of Governors work together effectively’;

ensuring ‘that directors and governors receive accurate, timely and clear information which enables them to perform their duties effectively’;

ensuring ‘effective and open communication with patients, service users, members, staff, the public and other stakeholders’;

ensuring ‘constructive relations between Executive and Non-Executive Directors’; (Quotations from NHS FT Code of Governance, 2014)

appraising the performance of the Chief Executive and the Non-Executive Directors; facilitating the effective contribution of all Executive and Non-Executive Directors to

the Group CiC’s affairs and ensuring that the Group CiC act as a team.

6.4 ‘The Chief Executive is accountable to the Chairman and Non-Executive Directors for ensuring that the Board is empowered to govern the Trust and that the objectives it sets are accomplished through effective and properly controlled executive action. The Chief Executive should be allowed full scope, within clearly defined delegated powers, for action in fulfilling the decisions of the Board’ (Code of Accountability in the NHS, 2004, p. 5-6)

6.5 The Chief Executive is responsible for: performing the duties of ‘Accounting Officer’ as set out in the Health and Social

Care (Community Health and Standards) Act 2003 (See Appendix 1, NHS Foundation Trust Accounting Officer Memorandum);

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overseeing risk management within the Trust and signing the Annual Governance Statement;

organising, managing and staffing the Trust; developing and maintaining procedures for the Trust; protecting the Trust’s reputation and integrity locally and nationally, by ensuring the

Trust is open and honest in its communications and through the development of strong partnerships with all stakeholders;

ensuring the quality of service provision.

7. Non-Executive DirectorsNational Drivers for member, patient and public engagement7.1 As members of a unitary board, Non-Executive Directors have a duty to ensure that

there is constructive challenge prior to decisions of the Board.

7.2 Non-Executive Directors are responsible for:

− bringing independent judgement to bear on issues of strategy, performance, risk management and key appointments;

− ‘satisfying themselves on the integrity of financial information and that financial controls and systems of risk management are robust and defensible’

− determining ‘appropriate levels of remuneration of Executive Directors (through the Remuneration Committee)’;

− ‘appointing and where necessary removing Executive Directors, and succession planning’;

− (Quotations from NHS FT Code of Governance, 2014);− ensuring that ‘the Board acts in the best interests of the public and is fully

accountable to the public for the services provided by the Trust and the public funds it uses’ (Code of Accountability in the NHS, 2004, p.5-6);

− undertaking the work of the Audit Committee.

8. Executive Directors (Group Chief Officers)

8.1 The Executive Directors of SRFT are also Group Chief Officers and voting members of the Group CiC:− Chief Executive Officer (Group Chief Executive Officer)− Executive Director of Finance (Chief Financial Officer)− Executive Medical Director (Chief Medical Officer)− Executive Nurse Director (Chief Nursing Officer)− Executive Director of Corporate Strategy (Chief Strategy and Organisational

Development Officer)− Executive Director of Group Delivery (Chief Delivery Officer)

8.2 They have responsibilities as members of the SRFT Board and Group CiC and as the most senior managers of the operations of Group.

8.3 The Executive Directors of the PAHT Board currently comprise:− the Chief Executive Officer (Group Chief Executive Officer)− Executive Director of Finance − Executive Medical Director − Executive Nurse Director (Chief Nursing Officer).

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9. Care Organisations

9.1 Currently, Group comprises four Care Organisations:− Salford− Oldham− Bury & Rochdale− North Manchester

9.2 Each Care Organisation has a leadership team comprising:− Managing Director − Medical Director− Director of Nursing− Finance Director

Together the leadership team is responsible for the day to day running of the hospital services and, as applicable, primary, community, mental health and social care services of a Care Organisation.

One member of the Care Organisation leadership team is appointed as the Care Organisation Chief Officer. The Care Organisation Chief Officer is accountable to the Group Chief Executive Officer and is a non-voting members of Group CiC.

10. Council of Governors

10.1 As described earlier, to enable the public and staff members and communities served by the Group to be represented, SRFT’s Council of Governors (CoG) have established a subcommittee, to assist the SRFT CoG in carrying out its functions; this subcommittee is the Group Council of Governors committee. The Group Council of Governors will have a close working relationship with the Group CiC.

10.2 The Group Council of Governors comprises: − elected public and shadow public;− elected staff and shadow staff;− appointed and shadow appointed governors

Elected governors represent two broad groups: staff and members of the public. Each of these groups is divided into constituencies as detailed within the Constitution and Group Council of Governors Committee Terms of Reference. Appointed governors represent key stakeholders of the NCA.

10.3 In broad terms, the Council of Governors is responsible for: − holding the Non-Executive Directors individually and collectively to account for the

performance of the Board of Directors− representing the interests of the members of the Foundation Trust as a whole and the

interests of the public

10.4 To this end, it prepares and from time to time reviews the NCA Membership and Public Engagement Strategy.

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10.5 Governors provide their views to the Group CiC on the NCA’s forward plans and are presented with the annual report and accounts. Particular responsibilities of the Council are:− to appoint or remove the Chairman and the other Non-Executive Directors;− to approve the appointment (by the Non-Executive Directors) of the Chief Executive;− to decide the remuneration and allowances, and the other terms and conditions of

office, of the Non-Executive Directors;− to appoint or remove the Trust’s financial auditor;

10.6 The Standing Orders of the Council of Governors are included within the Group Governance Framework Manual.

11. Membership

11.1 The members provide a means by which the NCA can engage with the communities it serves with regard to their views of its services and their needs and wishes in respect of future development.

There are two classes of members: staff members and public members. SRFT has two public constituencies, Salford and Rest of Engalnd and Wales. Details of the constituencies are set out in the Constitution. PAHT has three public constituencies, North Manchester, Oldham and Bury & Rochdale.

Both staff and public members elect the governors who represent their constituencies. All Governors and Non-Executive Directors have to be members of one of the NCA’s Trusts and the constituency they represent.

12. Committees of Group CiC

12.1 The Group CiC has established the following committees:

− Audit Committee− Nominations, Remuneration and Terms of Service Committee− Charitable Funds Committee− Strategy and Investment Committee− Group Executive Risk and Assurance Committee− Group Executive Development Committee

The terms of reference of these committees are available on Trust’s intranet site. The powers that the Group CiC has delegated to the committees are listed in the Reservation and Delegation of Powers. A brief description of their role in corporate governance follows.

12.2 Audit CommitteeThere will be a single Audit Committee at group level comprising non-executives. In a transitional setting this Committee will fulfil the Audit Committee responsibilities for all statutory bodies within group. The single Audit Committee will review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of Group and across all of Group’s activities that support the achievement of Group objectives.

In particular, the single Committee shall review the adequacy and effectiveness of:

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− all risk and control and related disclosure statements, (in particular the Annual Governance Statement(s)) together with any accompanying Head of Internal Audit Opinions for the Group and the Care Organisations, prior to submission to the Group Board;

− all the processes of corporate governance to enable the organisation to implement best practice as set out in appropriate guidance. This will include the Assurance Framework together with any accompanying internal audit opinion;

− the structures, processes and responsibilities for identifying and managing key risks facing the organisation;

− the policies for ensuring that there is compliance with relevant regulatory, legal and code of conduct requirements and other relevant guidance, including a review of the Trust Corporate Governance Framework Manual prior to submission to the Group Board;

− the policies and procedures for all work related to fraud and corruption as required by Commissioners and NHS Counter Fraud Authority.

The Audit Committee will work closely with the Group Executive Risk and Assurance Committee. The work of the two committees needs to be linked so that the Group Board can be confident that there is an aligned independent and executive focus on strategic risk and assurance. This will be achieved through committee work plans underpinned by the Assurance Framework, agreed priorities, routine referral of issues between committees so that there is respective understanding of risk and assurance concerns.

The development of the Annual Governance Statement should be a shared endeavour from the beginning of the year so that any significant control concerns are the focus for both committees through the different lenses of their work.AGS’s and Heads of Internal Audit Opinion can be produced at CO level to enable aggregating at Group level and to fulfil statutory reporting in transition.

In order to maximise the overview and scrutiny capability of the Group CiC, the membership of the Audit Committee comprises all Non-Executive Directors, with the exception of the Trust Chairman. The Trust Chairman may attend by invitation of the Audit Committee Chairman.

12.3 Group Nominations, Remuneration, and Terms of Service (NRTS) CommitteeThe Nominations, Remuneration and Terms of Service Committee is established as a Non-Executive committee of the Board(s). The Committee will consider matters pertinent to the nomination, remuneration and associated terms of service for Executive Directors (including the Chief Executive), matters associated with the nomination of Non-Executive Directors and remuneration policy and practice of senior managers/clinical leaders. The committee gives full consideration to succession planning, taking into account the future challenges, risks and opportunities facing the trusts and the skills and expertise required within the board of directors to meet them.

The membership of the Nominations, Remuneration and Terms of Service Committee comprises the Trust Chairman and all Non-Executive Directors.

12.4 Charitable Funds Committee

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The SRFT and PAHT are the Corporate Trustee of the Charity governed by the laws applicable to the Trusts, principally the Trustees Act 2000 and the Charities Act 1993.

The Group CiC has devolved responsibility for the on-going management of the funds to the Charitable Funds Committee which administers the funds on behalf of the Corporate Trustees. The membership of the Charitable Funds Committee comprises of all Non-Executive Directors.

12.5 Strategy and Investment Committee

The Strategy and Investment Committee is established as a standing committee of the Group CiC to provide independent and objective review of, and assurances, in relation to major strategic initiatives, including investments/divestments of activities which significantly broaden, diversify or reduce the NCA activity base, and ensuring their alignment with Group Board approved strategy and risk framework.

12.6 Group Executive Risk and Assurance CommitteeThe Group Executive Risk and Assurance Committee is established as a standing committee of the Group CiC to provide assurance on the control of risk.

Group Executive Risk and Assurance Committee will: review and aggregate evidence from Care Organisations that there is ongoing compliance with terms of authorisation and statutory duties and assure Group CiC (and transitional statutory boards); review corporate performance of Group; have overarching responsibility for risk management including monitoring of all group level risks and reporting to Group CiC; oversee the Care Organisation Single Oversight Framework and review Care Organisation Assurance Frameworks/Risk Registers.

12.7 Group Executive Development CommitteeThe Group Executive Development Committee is established as a standing committee of the Group CiC, the committee has delegated power from Group CiC to oversee the development and delivery of Group’s strategic ambitions, and to take appropriate action to mitigate risk.

13. Values and Principles

13.1 The Group CiC sets the Group-wide mission and vision, aligned to the Trust’s governing objectives. The Group CiC also sets the Group’s strategic direction and objectives (supported through analysis and assessment performed by the Strategy Function).

Care Organisations will hold operational autonomy, with responsibility to inform and implement strategy and standards as set by the Group and instil the Group’s vision and values

13.2 ValuesConsultation is currently underway to determine Group values. During transition, the values of SRFT and PAHT remain:

SRFT Values:

Patient Focus Communicates effectively with patients, families and internally with colleagues Proactively personalises the service, connecting with patients and carers

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Adopts and practises ‘Safe, Clean, Personal’ ethos

Continuous Improvement Looks at ways of measuring and auditing improvements Proactively develops goals and objectives in support of the Trust’s vision Identifies opportunities to reduce waste and inefficiency

Accountability Acts with integrity and is results-focused Displays personal accountability towards problem-solving Recognises and accepts accountability beyond the job role

Respect Supports and empowers staff involvement Considerate of others’ contribution and needs Is a guardian of the Trust’s reputation and resources

PAHT Values:

Quality Driven To provide excellent quality safe, evidence-based patient care that exceeds national

standards. To push the boundaries of care delivery and efficiency by adopting best practice and

building on our clinical and technical knowledge. To individually be the best we can in our actions and interactions. To work as one team with both our colleagues and partners to deliver the best care

both in and out of hospital.

Responsible To be honest, open and transparent in all our commitments, actions and results. To be personally accountable for the things we do, our services and the Trust’s

reputation. To be alert to the potential for errors and always strive to correct things that go wrong. To acknowledge and celebrate success. To be resourceful and open to new, innovative, evidence-based ideas.

Compassionate To treat you with empathy, professionalism and a positive, friendly attitude. To act with integrity and respect at all times. To listen to you, understand your perspective, value differences and be

approachable, sensitive and considerate. To organise our services around the individual needs of our patients and their carers,

creating the best patient experience possible.

13.3 As a public body, the Group upholds the public service values detailed within the Nolan Report (The First Report of the Nolan Committee on Standards in Public Life, 1995):

Selflessness - Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their families or their friends.

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Integrity - Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that may influence them in the performance of their official duties.

Objectivity - In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

Accountability - Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

Openness - Holders of public office should be as open as possible about all their decisions and the actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

Honesty - Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

Leadership - Holders of public office should promote and support these principles by leadership and example.

14. Internal Control

14.1 OverviewInternal control entails having in place processes and procedures which together ensure that the Trust is meeting the terms of its authorisation, running effectively, smoothly and safely and keeping risks to a minimum.

14.2 Annual Governance Statement NHS Foundation Trusts and NHS Trusts are required to include a governance statement in their annual report and accounts. The Annual Governance Statement(s) will cover the following:

the scope of the responsibility of the Accounting Officer/Accountable Officer (Chief Executive);

the purpose of the system of internal control; a summary of action plans to improve the governance of quality; the Trust’s capacity to handle risk; the risk and control framework; the process used to ensure that resources are used economically, efficiently and

effectively; confirmation that a review of effectiveness has been undertaken and that a plan is in

place to address any weaknesses; the process for maintaining the system of internal control and details of actions

planned or taken to deal with any significant internal control issues. These might include:

o an issue which seriously prejudiced or prevented achievement of a principal objective;

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o an issue which resulted in a need to seek additional funding, or in a significant diversion of resources;

o an issue which the External Auditor or the Head of Internal Audit or the Audit Committee considers to be significant;

o an issue which attracted significant adverse public interest or seriously damaged the reputation of the Trust.

14.3 The Annual Governance Statement (AGS) to be signed by the Accountable Officer, on behalf of the Board, is a helpful reference point to test assurance arrangements in the group setting. Focusing on that responsibility alone highlights that group-designed and led risk and assurance arrangements need to be in place. In that context consistently designed Assurance Frameworks/risk registers, risk escalation and audit is critical. These processes need to be locally owned.

The Head of Internal Audit provides an annual opinion on the adequacy and effectiveness of the risk management, control and governance processes to support the Annual Governance Statement.

14.5 The development of a the Annual Governance Statement reflects the shared endeavour for the Group Risk and Assurance Committee and the Audit Committee from the beginning of the year so that any significant control concerns are the focus for both committees through the different lenses of their work.

14.6 Processes and ProceduresThere are two broad categories of internal processes and procedures which ensure the proper running of the Trust. First, there are those which provide a comprehensive framework for the proper conduct of business:

Standing Orders of the Board of Directors (see Appendix 3) Terms of Reference of the Group Committees in Common (Appendix 4) Standing Orders of the Council of Governors (see Appendix 5) Terms of Reference of the Shadow Group Council of Governors (Appendix 6) Reservation and Delegation of Powers (see Appendix 7) Standing Financial Instructions (see Appendix 8)

All Board members and managers should be aware of the existence of these documents and, where appropriate, should be familiar with the detailed provisions. In particular, staff should pay attention to the detailed scheme of delegation (see Appendix 7) as any action that they take that is outside of their delegated authority could have serious consequences for both the Trust and the individual.

Secondly, there are the internal processes and procedures which together constitute the Group Board Assurance Framework.

At Group level the core governance responsibilities in this area are as follows: Overseeing constitutional, regulatory and legal compliance Ensuring effective corporate governance systems & processes, including committee

structures and flow of information Board development: ensuring appropriate appointment of Directors Establish the Group Assurance Framework/Corporate Risk Register and ensure

effectively delivered across the Group Identify Principal Risks to the delivery of the Annual Business Plan’s Objectives

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Cascade Group Principal Objectives to Care Organisations and develop into relevant and effective Care Organisation Objectives

Preparation and approval of Annual Report and Accounts Statutory registers and use of Company Seal Provision of comprehensive legal support/services, including Group litigation

management

At Care Organisation level the responsibilities are as follows: Effectively deploy and manage the governance processes set by Group Set relevant and effective Divisional Objectives, which collectively ensure the delivery

of Care Organisation/Group objectives Identify Principal Risks to the delivery of the Care Organisation Objectives, and

establish the Care Organisation Assurance Framework/Risk Register Guard Care Organisation /Divisional Assurance Frameworks/Risk Registers and

escalate risks as appropriate Local membership, patient and public engagement

14.7 Assurance FrameworksAn Assurance Framework is a simple but comprehensive method for: The management of the principal risks defined as those that threaten the

achievement of the organisation’s principal objectives; Documenting the key strategies, systems, policies, processes, plans and people that

are in place to mitigate the principal risks and that make up the system of internal control;

Mapping the main sources of assurance that give confidence to Group Committees in Common about the achievement of the Group’s principal objectives through the active management of risk;

Providing evidence to allow the Group Committees in Common to sign its statutory declarations.

Guidance on the production of the Annual Governance Statement requires that Trusts have in place a Board Assurance Framework which: Covers all of the organisation’s main activities; Identifies which objectives and targets the organisation is striving to achieve; Identifies the risks to the achievement of objectives and target; 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 the Board to address control and assurance gaps.

The Group Committees in Common employs assessment processes to identify its development requirements to enhance its ability to effectively utilise the Board Assurance Framework.

Assurance Frameworks are based on six key elements (Fig. 4.1): Clearly defined principal objectives together with clear lines of responsibility and

accountability Clearly defined principal risks together with an assessment of their potential impact

and likelihood The key controls which are in place to mitigate against the principal risks

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The board reports, performance reports, dashboards and committee reports (assurance mechanisms) by which the Board can be confident that the principal risks are being managed and objectives achieved

The areas where there are gaps observed, either in the system of internal control or in the assurances offered

Board action plans which ensure the delivery of objectives, the strengthening of risk controls and improvements in assurances

Fig 4.1

14.8 The Group’s Mission and the Principal ObjectivesThe Group is embarking on a mission to “Save Lives, Improve Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering.”

To ensure the Group completes its mission and fulfils its statutory duties the Group Committees in Common identify principal objectives which must be achieved within the year. These principal objectives are consolidated into Group and Care Organisation Operational Plans which are rigorously monitored by the organisations committee structure throughout the year to ensure delivery. The operational plans are comprehensive in nature and fully detail the steps that will be taken in year to achieve the principal objectives. The Board Assurance Framework/Corporate Risk Register accounts for the key controls in place to deliver the annual plans and details any further action required where gaps are identified.

The content of the Operational Plans is influenced by a number of factors including; national mandatory standards such as the NHS Outcomes Framework, Care Quality Commission Registration Standards and NHS Improvement’s Single Oversight Framework, National Strategic Developments such as the Devolution Agenda for Greater Manchester, and local priorities identified via the Groups’ governance processes and by the organisation’s partners and stakeholders such as the local Clinical Commissioning Groups and patient advisory groups such as HealthWatch.

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Care Organisation, Divisional and Departmental objectives as detailed in Care Organisation, Divisional and Departmental plans must align with the Group principal objectives in order that their activities contribute to the achievement of the Group principal objectives.

The Board Assurance Framework/Corporate Risk Register (BAF/CRR) supports the Group Chief Executive Officer to provide assurance to the Group Committees in Common about the delivery of the Principal Objectives by focussing the discussion on principal risks. The BAF/CRR maps the system of internal control in place to manage the Trust’s Principal Risks and maps the assurances that give confidence that it is operating effectively. Where further action is needed the BAF/CRR includes the detail of any further actions being undertaken to mitigate the principle risks.

14.9 What is a principal objective?Principal Objectives are statements of the crucial measurable results which the organisation must achieve in order to achieve its overall goals in line with its mission.

The Principal Objectives will be stated in terms which are:− Specific− Measurable− Achievable− Realistic− Time-based

14.10 Risks and Risk Assessment Process Risks are defined as uncertain events which, should they occur will have an adverse effect which threatens the achievement of objectives. Risk Management is the activities required to identify, understand and control exposure to uncertain events which may threaten the achievement of objectives.

There are many sources by which a risk can be identified including: Proactive planning; Health and safety inspections; Assurance reports; Exception reports; Clusters of risks (divisional, departmental etc); Serious incident reports; Clusters of incidents; Clusters of serious incidents; Lessons learned themes; Serious complaints; Complaint clusters; Claims; External assessments and recommendations.

Risk assessment is the process by which risks are identified, quantified and prioritised for action. Once a risk has been identified it must be assessed to determine the level of priority that should be assigned to the risk in ensuring that active management is taking place.

This prioritisation of risk is based on the impact (how bad it would be if it occurred) and likelihood (how certain it is) that a risk will stop the organisation achieving its principal

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objectives. This is set against the context of all the activities we undertake to either prevent a risk from happening, or limiting the impact it has if it were to occur (controls). We quantify this by assigning a risk score to each risk. This enables risks to be ranked with high scores dictating a higher priority for action and review. The highest scoring risks indicate the biggest threats to the achievement of the principal objectives and therefore require Board level oversight.

Risk scores are the sum of the likelihood of the risk and the impact of the risk.

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

A risk’s impact on the organisation must be given a score between 1 and 5 using the following criteria:1 Almost non - no obvious harm*2 Minor - no permanent harm (recovery within month)*3 Moderate - semi-permanent harm (recovery takes longer than 1 month but no more

than 1 year) and/or adverse publicity for the Trust. *4 Major - permanent harm not resulting in death or severe disability to a person or

persons and/or start of a national investigation into the Trust and/or disruption of key Trust services which significantly hinder the Trust in meeting its responsibilities.*

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

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

Key controls are the means by which the principal risk’s impact or likelihood is being reduced. Controls can be quite wide in scope and can include the following

Soft Controls:− Plans – Operational, Financial− Strategies− Policies − Systems− Processes

Hard Controls:− People – Job Roles− Physical barriers − Equipment

If controls are extensive enough, are operating effectively or are being adhered to by staff then risks should be adequately mitigated and therefore the organisation should remain on track to achieve its principal objectives.

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The key risk controls are captured in the Board Assurance Framework and are scored through a risk profiling process.

Risk profiling gives a "Risk Control" score of:1 Risk is fully under control2 Risk is adequately controlled3 Action to control risk adequately has started and appears effective4 Action to control risk is agreed but no action started5 No actions to control risk identified

Each risk is then given a Risk Profile score which is the sum of the scores "Likelihood", "Impact" and "Risk Control". The Risk Profile score is summarised on the Risk Register:3 – 5 Minor risks which are adequately managed and may be retained if further

control limits the capacity to control higher ranking risks. Managed at Departmental level.

6 and over

Moderate risks which must be managed by the Division’s governance structures.

10 and over

Serious risks which must be managed and reported through the Performance Risk and Assurance Groups Committee to Care Organisation Senior Management Boards.

12 and over

Significant risks to the Trust which must be managed and reported through the Group Committees in Common via the Care Organisation Senior Management Boards and the Group Risk and Assurance Committee.

Once a risk assessment has been completed it must be validated to ensure the risk has been described correctly, that the controls and assurances are accurate, and that the scoring is a true reflection of the current position. Once a risk has been validated, it is added to the appropriate Risk Register.

The same process is to be followed when undertaking risk assessments at all levels of the organisation. It is important that the language and methodology we use when assessing and managing risks is uniform to ensure a consistent process that allows locally identified risks to be escalated through the organisation to the appropriate level.

To support this uniformity Assurance Frameworks/Risk Registers are the same format at all levels of the organisation. The only difference between Group, Care Organisation, Divisional and Departmental Assurance Framework/Risk Registers is that the objectives referenced will be relevant to each specific area in line with operational plans.

14.11 Assurances on ControlsThe fourth component of Assurance Frameworks is the documentary evidence that enables the Group Board to be assured that the controls it has in place are effectively managing the principal risks.

There are three types of assurance, which are referred to as the three lines of defence:

Internal Assurance- Local Oversight – Management Assurance- Corporate Oversight – Committee Assurance

Independent Assurance

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- Independent – External Auditors, Internal auditors, regulators etc.

14.11.1 Internal AssuranceInternal assurance is provided by the Group Risk and Assurance Committee which has a core membership of all Group Executive Directors, Care Organisation leadership teams together with designated officers relevant to the business of that committee.

Assurances are coordinated on behalf of the Group by its Group Risk and Assurance Committee. Group CiC has established a Single Oversight Framework, which requires the Care Organisation Chief Officers to submit a monthly Statement of Assurance supported by quarterly presentation of each CO BAF/CRR to the Group Risk and Assurance Committee.

The Statements of Assurance provide regular assurance reports regarding the key components of the Care Organisations’ systems of internal control including; reports on the management of risk and progress reports in the delivery of operational plans which if successfully delivered should enable the achievement of the principal objectives. The Group CiC then receives reports from the Group Risk and Assurance Committee, together with Audit Committee reports and makes a final judgement on the level of assurances received and any actions required to ensure delivery of the Group’s objectives and obligations.

The relationship between the Group’s authoritative bodies and their sub-committees is set out below:

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

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14.12 The Assurance ProcessThe Group CiC monitors performance through the use of a set of information sources. This is underpinned by electronic information systems which allow graduated enquiry throughout each level of the Group – enabling personal and collective accountability to be exercised.

The performance of Care Organisations is reviewed though the Group Single Oversight Framework which engages the Group Executive with Care Organisations on a monthly basis via a Statement of Assurance and is designed to:

provide assurance regarding the delivery of the Care Organisation annual plan objectives;

build strong relationships between Care Organisations and Group; harness and spread good practice (standardised at scale); connect our leaders and teams and support quality and performance improvement

The Group Executive Risk and Assurance Committee oversees the Care Organisations using the Single Oversight Framework and ensures that there is alignment between the Statements of Assurance and the Care Organisation Board Assurance Framework/Risk Registers.

14.13 Group Board Reports and Levels of AssuranceEvery quarter the Group Chief Officer responsible for the achievement of specific principal objectives reviews their part of the Board Assurance Framework/Corporate Risk Register. Action plans are drawn up and agreed via the Group Executive Risk and Assurance Committee to deal with principal risks and other risks scoring 12 and above. These risks, and associated action plans, are reviewed by the Group CiC until the risk is reduced to less than 12 or is considered to be acceptable.

The Group CiC decides the extent to which any gaps in the effective control of risks are 'significant control issues' by considering whether:

the issue seriously prejudices or prevents achievement of a principal objective; the issue has resulted in a need to seek additional funding to allow it to be resolved, or

has resulted in significant diversion of resources from another aspect of the business; the external auditor regards it as having a material impact on the accounts; the Audit Committee advises it should be considered significant for this purpose; the Head of Internal Audit reports on it as significant, for this purpose, in their annual

opinion on the whole of risk, control and governance; the issue, or its impact, has attracted significant public interest or has seriously

damaged the reputation of the Trust; there has been a significant clinical impact.

When making its decision, the Group CiC takes into account the assurances it has received and, where there is a conflict of opinion between different assurers, the Group CiC makes a judgement as to whether there has been:

inappropriate or incomplete coverage (e.g. where the assurance was required on all waiting times and the review considered only outpatients);

lack of robust evidence, (e.g. where the assurance work was a desktop review of procedures, rather than a review of the system in operation).

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Significant discrepancies in assurance are explained in the Annual Governance Statement.

The Group Executive Risk and Assurance Committee reports on progress against the Assurance Framework and makes clear the extent to which assurances have been received and reviewed and highlights any gaps in assurance. At the end of the year, these Assurance Framework reports, the Opinion of the Head of Internal Audit and other major sources of assurance are taken into account by the Chief Executive in the preparation of the Annual Governance Statement. The Opinion of the Head of Internal Audit and the draft Annual Governance Statement are reviewed by the Audit Committee, prior to submission to the Group CiC.

The assurance process is subject to annual independent audit which is reported to the Audit Committee.

The Board Assurance Framework and Risk Management Strategy together with templates for the risk register and action plans are available on the Trust’s intranet site.

15. Independent Control and Regulation

15.1 Internal Audit

15.1.1The Internal Audit Charter provides the Group with the framework for the provision and conduct of an Internal Audit service, in accordance with the requirements of the NHS Internal Audit Standards, the NHS Audit Committee Handbook (2014) and the Group’s Standing Financial Instructions

15.1.2 Internal Audit is an independent and objective appraisal service which has no executive responsibilities within the line management structure. It pays particular attention to any aspects of risk management, control or governance affected by material changes to the Group’s risk environment, subject to Audit Committee approval.

15.1.3Role of Internal Audit

The role of Internal Audit embraces two key areas: The annual provision of an independent and objective opinion to the Accounting

Officer, the Board and the Audit Committee on the degree to which risk management, control and governance support the achievement of the organisation’s agreed objectives.

The provision of an independent and objective consultancy service specifically to help line management improve the Group’s risk management, control and governance arrangements.

- Provision of an OpinionThe Head of Internal Audit’s annual report presents the opinion on the overall adequacy and effectiveness of the Group’s risk management, control and governance processes. This opinion encompasses the Assurance Framework as well as conclusions arising from internal audit assignments across the organisation’s critical business systems. Specifically the report provides:

a) a clear opinion on the effectiveness of internal controls in accordance with current assurance framework guidance issued by the Department of Health;

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b) any qualifications to that opinion, together with the reasons for the qualification such as any major internal financial control weaknesses;

c) a summary of the audit work undertaken to formulate the opinion, including progress on the implementation of internal audit recommendations and reliance placed on work by other assurance bodies accredited by Internal Audit;

d) a statement on any issues the Head of Internal Audit judges particularly relevant to the preparation of the Annual Governance Statement;

e) a comparison of work actually undertaken with the work which was planned and a summary of performance of the internal audit function against its performance measures criteria;

f) a commentary on compliance with NHS Internal Audit Standards and the results of the internal audit quality assurance programme.

In addition to the formal annual report, the Head of Internal Audit reports interim progress to the Audit Committee and Accounting/Accountable Officer in the course of the year. Such interim reports detail objectives, findings and performance against plan. Additionally, progress against the implementation of agreed recommendations is followed up and reported to the Audit Committee.

Internal audit plans and opinions will be in place at group and care organization level. The Audit Committee will focus upon the detail in terms of group audit coverage but in respect of care organisations the emphasis will be upon concluding upon the overall arrangements in place. The professional links will be through the Group Director of Finance and the CO CFOs. Consideration may be given at CO level to establish an Assurance Programme Group to facilitate the oversight and progression of internal audit activity and recommendations.

- Provision of a Consultancy ServiceInternal Audit may provide, at the request of management, a consultancy service which evaluates the policies, procedures and operations put in place by management.

A specific contingency should be made in the Internal Audit plan to allow for management requests or consultancy work.

The Head of Internal Audit must consider the effect on the Opinion Work Plan before accepting consultancy work or management requests over and above the contingency allowed for in the Internal Audit Annual Plan. In the event that the proposed work may jeopardise the delivery of the Internal Audit Opinion, the Head of Internal Audit must advise the Accounting/ Accountable Officer before commencing the work.

15.1.4 The Head of Internal AuditThe Senior Audit Manager, as appointed by Internal Audit, acts as Head of Internal Audit. He/she reports to the Accounting/Accountable Officer via the Director of Finance at Group level (except when this may impinge on the objectivity of the audit). A Head of Internal Audit will be assigned to each Care Organisation.

The Group Head of Internal Audit, or an appropriate representative of the internal audit team, attends meetings of the Audit Committee unless, exceptionally, the Audit Committee decides that they should be excluded from either the whole meeting or for particular agenda items.

The Head of Internal Audit has an independent right of access to the Chairman of the Audit Committee. In exceptional circumstances, where normal reporting channels may

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be seen to impinge on the objectivity of the audit, he/she may report directly to the Chairman of the Trust.

If the Head of Internal Audit considers that the level of audit resources or the terms of reference in any way limit the scope of internal audit, or prejudice the ability to deliver a satisfactory service, he/she will advise the Audit Committee accordingly.

15.1.5 Responsibilities of the Trust

The Accounting/Accountable Officer makes appropriate arrangements for the provision of the Internal Audit Service. This includes the formal adoption of the Internal Audit Terms of Reference by the Audit Committee and the adoption of corresponding elements in the Standing Financial Instructions. The Group is responsible for ensuring that Internal Audit is provided with all necessary assistance and support to ensure that it meets its standards.

The Group has to take all necessary steps to provide Internal Audit with information on its objectives, risks, and controls to allow the proper execution of the Internal Audit Annual Plans and adherence to Internal Audit standards.

It is the Group’s responsibility to ensure the provision of relevant audit rights of access in any contract or Service Level Agreement the Trust enters into, either as provider or purchaser of the service.

Responsibility for monitoring and ensuring the implementation of agreed recommendations rests with the approriate level of governance.

15.1.6 Internal Audit Access RightsDesignated auditors are entitled, without necessarily giving prior notice, to require and receive:-a) access to all records, documents and correspondence relating to any financial or other

relevant transactions, including documents of a confidential nature;b) access at all reasonable times to any land, premises or employee of the Group;c) the production of any cash, stores or other property of the Group under an employee’s

control; d) explanations concerning any matter under investigation.

15.2 Countering Fraud, Bribery and Corruption

15.2.1 Managing the risk of fraud is the responsibility of line management. The Group has comprehensive Anti-Fraud, Bribery & Corruption Policies in place governing the local anti-fraud services at Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust, through the nominated Local Anti-Fraud Specialist and Lead Local Counter Fraud Specialist.

15.2.2The relationship between the Trust’s Anti-Fraud Specialist, Lead Local Counter Fraud Specialist, the Head of Internal Audit and the Group Chief Financial Officer is formally defined in accordance with the contractual requirements. An Anti-Fraud Specialist and Lead Local Counter Fraud Specialist are assigned at both Group and CO level.

15.2.3 Counter Fraud Strategy

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The NHS Counter Fraud Authority (NHS CFA) is a new special health authority dedicated to tackling fraud, bribery and corruption within the health service.

The NHS CFA provides a clear focus for both the prevention and investigation of fraud across the health service and works with NHS England and NHS Improvement to properly uncover fraud and tackle it effectively.

NHS CFA deliver anti-crime work that cannot be carried out by NHS health bodies regionally or in isolation. They use intelligence to identify serious and complex economic crime, reduce the impact of crime and drive improvements in anti-crime work.

Local NHS organisations are primarily accountable for dealing with crime risks in the NHS. NHS CFA provides information and guidance to local Anti-Fraud Specialists to improve anti-fraud, bribery and corruption work across the NHS.

NHS CFA’s main objectives are:

− to deliver the Department of Health (DH) strategy, vision and strategic plan, and be the principal lead for counter fraud activity in the NHS in England;

− to be the single expert intelligence led organisation providing a centralised investigation capacity for complex economic crime matters;

− to lead, guide and influence the improvement of standards in counter fraud work, in line with HM Government Counter Fraud Professional Standards, across the NHS and wider health group, through review, assessment and benchmark reporting of counter fraud provision across the system;

− to take the lead and encourage fraud reporting across the NHS and wider health group, by raising the profile of fraud and its effect on the health care system.

15.2.4 Anti-Fraud Specialist (AFS)/Lead Local Counter Fraud Specialist (LCFS)Each Trust is required to appoint an AFS and/or LCFS to implement the counter fraud strategy at a local level. This may be an employee of the Group or another body (such as the Internal Audit provider). The AFS and LCFS reports to the Group’s Chief Financial Officer and works with staff from the NHS CFA in accordance with its contractual requirements within Service Condition 24 of the NHS Standards Contract and the guidance given in the NHS Fraud and Corruption Manual. An AFS and LCFS areassigned at CO level as well as at Group.

15.3 External Audit

15.3.1 All trusts must have their accounts audited by independent external auditors.

The External Auditor’s opinion on the annual accounts reports on whether:

the financial statements give a true and fair view, in accordance with the accounting policies of the state of the organisation’s affairs and of its income and expenditure for the year as then ended;

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the part of the Remuneration and Staff Reports Remuneration and Staff Report to be audited has been properly prepared in accordance with the relevant accounting and reporting framework;

other information which comprises the information included within the Annual Report other than the financial statements the auditors report thereon, is consistent with the financial statements.

The External Auditor also provides opinion on value for money arrangements in place at the Trust for securing economy, efficiency and effectiveness in the use of resources.

The Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General, prescribes the way in which external auditors carry out their functions.

15.4 NHS Improvement (NHSI)

15.4.1 NHSI supports foundation trusts and NHS trusts to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. They provide strategic leadership and practical help to the sector, supporting and holding providers to account to achieve a single definition of success. To achieve this they work closely alongside providers, work with national partners to create the conditions for providers to flourish and have developed a single definition of success.

15.4.2 NHS Improvement’s Single Oversight FrameworkNHSI’s Single Oversight Framework provides the framework for overseeing providers

and identifying potential support needs. The framework covers five themes:− Quality of care− Finance and use of resources− Operational performance− Strategic change− Leadership and improvement capability (well-led)

15.5 Foundation Trusts planning and reporting

15.5.1 NHSI requires each NHS trust board to submit an annual plan. Performance against the plan will be monitored by NHSI using a core set of data that will be collected in year following a regular in year monitoring cycle, using monthly, quarterly or lower frequency collections as appropriate. This will be in addition to the annual provider submission. Using these mechanisms NHSI will hold boards of foundation trusts to account.

NHSI (formerly Monitor) has published a Code of Governance (2014), based on the Combined Code of Corporate Governance (2003, 2006 and 2012) to promote the key principles of good governance.

NHSI works closely with a number of organisations, including the Care Quality Commission (CQC), in order to carry out its role.

15.6 Care Quality Commission (CQC)

15.6.1 The CQC is the independent regulator of health and adult social care services in England. They make sure that the care provided by hospitals, dentists, ambulances, care homes and home-care agencies meet the standards of quality and safety expected.

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The CQC register all health and adult social care services across England and carry out regular checks on them. Inspections take place regularly and at any time in response to concerns. In between inspections the CQC continually monitor all the information they hold about a service. This information comes from CQC inspections, the public, care staff, care services and from other organisations.

15.6.2 The aim of CQC inspections is to get to the heart of patients experiences and is a mixture of announced, unannounced or focused inspections. The CQC will look at the quality and safety of the care provided based on the things that matter to people. They will ask five questions of all services:

Are they safe? Patients are protected from abuse and avoidable harm Are they effective? Care, treatment and support achieves good outcomes, helps to

maintain quality of life and is based on the best available evidence. Are they caring? Staff involve and treat patients with compassion, kindness, dignity and

respect. Are they responsive to people’s needs? Services are organised so they meet needs

of patients. Are they well-led? The leadership, management and governance of the organisation

make sure it’s providing high quality care that is based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

15.6.3 From March 2018, NHS Improvement has introduced a Use of Resources assessment for all non-specialist acute trusts. For those Trusts who undergo a Use of Resources assessment they will receive a combined trust-level rating of Care Quality Commission’s (CQC's) five quality questions and a Use of Resources rating.

15.6.4 Use of Resources assessments are designed to improve understanding of how effectively and efficiently trusts are using their resources – including their finances, workforce, estates and facilities, technology and procurement – to provide high quality, efficient and sustainable care for patients. The assessments will form part of NHS Improvement’s approach to oversight and improvement through the Single Oversight Framework (SOF), identifying support needs and good practice to help drive improvement.

15.6.5 The Use of Resources assessment will also generate a report and rating which will be published by the Care Quality Commission (CQC). The assessment should be a useful improvement tool, enabling trusts to demonstrate to patients, communities and taxpayers that they are delivering services efficiently and effectively, while providing care that meets the CQC five key domains: safe, effective, caring, responsive and well-led.

15.6.6 The CQC sources and analyses a range of data sources, both qualitative and quantitative, in preparation for inspections and to build each CQC Insight dashboard report. These include: Other regulatory bodies – for example the National Patient Safety Agency Strategic Executive Information System (STEIS) system Public Health England Dr Foster National Reporting and Learning System (NRLS) Health and Social Care Information Centre (HSCIC) National Clinical Audit datasets

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15.6.7 Inspection reports are published by the CQC and the trust is notified of its rating against each of the five key questions and provided an overall rating: Outstanding Good Requires Improvement Inadequate

By law, the trust must display its CQC rating in areas it provides care and also publish on its website.

15.6.8 The CQC will deliver proportionate enforcement action when serious breaches in standards of quality and safety are identified using requirement notices, or, warning notices to set out what improvements must be taken. They can also make changes to the trusts registration limiting the care provided, for example imposing a condition for a period of time or place the trust into special measures.

15.6.9 The CQC use the CQC Insight dashboard to monitor potential changes in quality of care as it brings together all the information held about the services in one place and analyses it.

15.7 CQC Insight for Acute NHS Trusts Reports

15.7.1 On a monthly basis CQC publish the ‘CQC Insight’ dashboard reports. Northern Care Alliance is able access two reports covering Pennine Acute Hospitals NHS Trust and Salford Royal NHS Foundation Trust.

15.7.2 The aim of the dashboard is to reflect historic performance and to assist with monitoring improvement or early identification of areas for improvement. The dashboard is primarily aimed at inspectors to assist with the monitoring of trust performance and use as part of ongoing engagement.

15.7.3 The dashboard fits in with the Single Oversight Framework (SOF) which is designed to help NHS providers attain, and maintain, CQC ratings of ‘Good’ or ‘Outstanding’. There is an indictor within the dashboard that allows CQC to monitor how trusts are performing and level of potential support required.

15.7.4 The data and information contained within the dashboard are updated on a monthly basis and are uploaded onto CQC’s QRP online website. The data streams updated are identified and the data source and time period used displayed below.

15.7.5 The dashboard displays the ratings for Safe, Effective, Caring, Responsive and Well-led for the trusts as an overall, each trust location, urgent & emergency care, medical care, surgery, critical care, maternity, children & young people, end of life care and outpatients. The ratings are:

Outstanding Good Requires Improvement Inadequate Inspected but not formally rated Not rated

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The performance data and information contained within the dashboard is categorised by Performance level:

Much better Better About the same Worse Much Worse Non-submission No data

15.8 Health and Safety Executive

At a national level both the Health and Safety Executive (HSE) and the Health and Safety Commission (HSC) are responsible for the regulation of almost all the risks to health and safety arising from work activity http://www.hse.gov.uk

Together, these bodies are responsible for ensuring that the NHS is fulfilling its legal obligations with regards to Health and Safety. The HSE has recently introduced online information and guidance specifically aimed at the health services: http://www.hse.gov.uk/healthservices/index.htm

The Trust has a comprehensive Health and Safety Policy that is available on the Trust’s intranet: http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-general/grimhsc/tg2105/?locale=en

The Trust’s Health and Safety team and specialist advisors provide an advisory service on health, safety, fire, hygiene, health and safety training and related matters. They work with managers to ensure, so far as is reasonably practicable, the health and safety of staff, patients and anyone else who may be affected by the Trust’s activities.

15.9 NHS Litigation Authority (NHS LA)

A key function for the NHSLA, as set out in their Framework Document, is to “contribute to the incentives for reducing the number of negligent or preventable incidents”. The aim is to achieve this through an extensive risk management programme.

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http://www.hse.gov.uk/healthservices/index.htm

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16. Roles and responsibilities

Roles and responsibilities are clearly definied within the Manual.

17. Monitoring document effectiveness

Document effectivess will be monitored via the Group Assurance Framework structure. The Annual Governance Statement (AGS) to be signed by the Accountable Officer, on behalf of the Board, will provide a reference point to test assurance arrangements. Continual review of Assurance Frameworks/Risk Registers, Statements of Assurance, Internal Audit Report, External Audit Report and the broader reporting schedule within the Group Assurance Framework committee structure will ensure the principles and assurance processes are embedded.

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18. Abbreviations and definitions

All abbreviations defined within the Manual.

19. References and Supporting Documents

N/A

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20. Document Control Information

Nominated Lead author:

Name:Janes Burns

Role:Group Secretary

Lead author contact details:

Full contact telephone number0161 206 5185

Full trust email [email protected]

Lead Author’s Manager:

Name:Sir David Dalton

Role:Chief Executive

Please indicate which Care Organisation(s) this document applies to:Applies to:Salford CO

X

Oldham CO

X

North Manchester CO

X

Bury & Rochdale CO

X

Northern Care Alliance Group (NCA)

XDocument developed in consultation with :

Audit CommitteeGroup Risk and Assurance Committee

Keywords/ phrases:

Governance, Framework, Standards if Business Conduct, Internal Audit, External Audit, Interests, Risk, Assurance, Group Committees in Common, Council of Governors

Communication plan:

The Manual will be made available on the SRFT and PAT intranet, and communicated via Team Brief/SiREN. The document will be publicly available via the SRFT and PAT internet.

Document review arrangements:

This document will be reviewed by the Audit Committee on an annual basis or earlier should a change in legislation, best practice or other change in circumstance dictate.

Audit Committee

Chairman: John Willis

Insert full approval date: dd/mm/yyyy

Approval:

How approved: Chair’s actions:NA

Formal Committee decision:Manual approved

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21. Equality Impact Assessment (EqIA) screening tool

Legislation 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.

YesEngagement with Audit Committee/Specific Staff

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?NA

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?NA

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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Group Governance Framework Manual – Appendix 1 : NHS Foundation Trust Accounting Officer Memorandum



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Appendix 1:

NHS Foundation Trust Accounting Officer Memorandum

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NHS foundation trust accounting officer memorandum

IRG 24/155 August 2015

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Introduction

1. The National Health Service Act 2006 (the Act) designates the chief executive of an NHS foundation trust as the accounting officer.

2. The principal purpose of the NHS foundation trust is the provision of goods and services for the purposes of the health service in England. The NHS foundation trust has a general duty to exercise its functions effectively, efficiently and economically.

3. The Act specifies that the accounting officer has a duty to prepare the accounts in accordance with the Act. An accounting officer has the personal duty of signing the NHS foundation trust’s accounts. By virtue of this duty, the accounting officer has the further duty of being a witness before the Public Accounts Committee (PAC) to deal with questions arising from those accounts or, more commonly, from reports made to Parliament by the Comptroller and Auditor General (C&AG) under the National Audit Act 1983.

4. Associated with these duties are the further responsibilities that are the subject of this memorandum. It is incumbent on the accounting officer to combine these duties with their duties to the board of directors of the NHS foundation trust.

5. It is an important principle that, regardless of the source of the funding, accounting officers are responsible to Parliament for the resources under their control.

Responsibilities of Monitor

6. In relation to NHS foundation trusts, it is the responsibility of Monitor to be satisfied that the NHS foundation trust is compliant with its NHS provider licence.

The general responsibilities of an NHS foundation trust accounting officer

7. The accounting officer has responsibility for the overall organisation, management and staffing of the NHS foundation trust and for its procedures in financial and other matters.

The accounting officer must ensure that: there is a high standard of financial management in the NHS foundation trust as a

whole, the NHS foundation trust delivers efficient and economical conduct of its business

and safeguards financial propriety and regularity throughout the organisation, financial considerations are fully taken into account in decisions by the NHS

foundation trust.

The specific responsibilities of an NHS foundation trust accounting officer

8. The essence of the accounting officer's role is a personal responsibility for:

the propriety and regularity of the public finances for which he or she is answerable the keeping of proper accounts prudent and economical administration in line with the principles set out in

‘Managing public money’ the avoidance of waste and extravagance the efficient and effective use of all the resources in their charge.

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9. As accounting officer you must:

personally sign the accounts and, in doing, so accept personal responsibility for ensuring their proper form and content as prescribed by Monitor in accordance with the Act;

comply with the financial requirements of the NHS provider licence; ensure that proper financial procedures are followed and that accounting records are

maintained in a form suited to the requirements of management, as well as in the form prescribed for published accounts (so that they disclose with reasonably accuracy, at any time, the financial position of the NHS foundation trust);

ensure that the resources for which you are responsible as accounting officer are properly and well managed and safeguarded, with independent and effective checks of cash balances in the hands of any official;

ensure that assets for which you are responsible such as land, buildings or other property, including stores and equipment, are controlled and safeguarded with similar care, and with checks as appropriate;

ensure that any protected property (or interest in) is not disposed of without the consent of Monitor;

ensure that conflicts of interest are avoided, whether in the proceedings of the board of directors, or council of governors or in the actions or advice of the NHS foundation trust’s staff, including yourself;

ensure that, in the consideration of policy proposals relating to the expenditure for which you are responsible as accounting officer, all relevant financial considerations, including any issues of propriety, regularity or value for money, are taken into account, and brought to the attention of the board of directors.

10. An accounting officer should ensure that effective management systems appropriate for the achievement of the NHS foundation trust’s objectives, including financial monitoring and control systems, have been put in place. An accounting officer should also ensure that managers at all levels:

have a clear view of their objectives, and the means to assess and, wherever possible, measure outputs or performance in relation to those objectives;

are assigned well-defined responsibilities for making the best use of resources (both those consumed by their own commands and any made available to organisations or individuals outside the NHS foundation trust), including a critical scrutiny of output and value for money;

have the information (particularly about costs), training and access to the expert advice which they need to exercise their responsibilities effectively.

11. Accounting officers must make sure that their arrangements for delegation promote good management and that they are supported by the necessary staff with an appropriate balance of skills. Arrangements for internal audit should accord with the objectives, standards and practices set out in the Public Sector Internal Audit Standards.

Advice to the board

12. An accounting officer has particular responsibility to see that appropriate advice is tendered to the board of directors and the council of governors on all matters of financial propriety and regularity and, more broadly, as to all considerations of prudent and economical administration, efficiency and effectiveness. Accounting officers will need to

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determine how and in what terms such advice should be tendered, and whether in a particular case to make specific reference to their own duty as accounting officer to justify, to the Public Accounts Committee (PAC), transactions for which they are accountable.

13. The board of directors and the council of governors of an NHS foundation trust should act in accordance with the requirements of propriety or regularity. If the board of directors, council of governors or the chairman is contemplating a course of action involving a transaction which you as accounting officer consider would infringe these requirements, however, you should set out in writing your objection to the proposal and the reasons for this objection. If the board of directors, council of governors or chairman decides to proceed, you should seek a written instruction to take the action in question. You should also inform Monitor of the position, if possible before the decision is taken or in any event before the decision is implemented, so that Monitor, if it considers it appropriate, can intervene in accordance with its responsibilities under the Act. If the outcome is that you are overruled, the instruction must be complied with, but your objection and the instruction itself should be communicated without undue delay to the NHS foundation trust's external auditors and to Monitor. Provided that this procedure has been followed, the PAC can be expected to recognise that the accounting officer bears no personal responsibility for the transaction.

14. If a course of action is contemplated which raises an issue not of formal propriety or regularity but relating to your wider responsibilities for economy, efficiency and effectiveness, it is your duty to draw the relevant factors to the attention of the board of directors and the council of governors and to advise them in whatever way you deem appropriate. If your advice is overruled, and the proposal is one which as accounting officer you would not feel able to defend to the PAC as representing value for money, you should seek a written instruction before proceeding. Monitor should be informed of such an instruction, if possible, before the decision is implemented. It will then be for Monitor to consider the matter, and decide whether or not to intervene.

15. If, because of the extreme urgency of the situation, there is no time to submit advice in writing in either of the eventualities referred to in paragraphs 13 and 14 before the decision is taken, you must ensure that, if the advice is overruled, both the advice and the instructions are recorded in writing immediately afterwards.

Appearance before the Public Accounts Committee

16. The C&AG may, under the National Audit Act 1983, carry out examinations into the economy, efficiency and effectiveness with which the NHS foundation trust has used its resources in discharging its functions. An accounting officer may expect to be called upon to appear before the PAC from time to time to give evidence on the reports arising from these examinations or reports following the annual certification audit, and to answer the PAC's questions concerning expenditure and receipts for which he or she is accounting officer. An accounting officer may be supported by one or two other senior officials, who may, if necessary, assist in giving evidence.

17. An accounting officer will be expected to furnish the PAC with explanations of any indications of weakness in the matters covered by paragraphs 8 to 15 above, to which their attention has been drawn by the C&AG or about which they may wish to question the accounting officer.

18. In practice, an accounting officer will normally have delegated authority to others, but cannot on that account disclaim responsibility or dilute his or her accountability. Nor, by

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convention, does the incumbent accounting officer decline to answer questions where the events took place before they took up their appointment: the PAC may be expected not to press the incumbent's personal responsibility in such circumstances.

19. The PAC has emphasised the importance it attaches to accuracy of evidence, and the responsibility of witnesses to ensure this, in order to ensure that relevant lines of enquiry may be pursued at its hearings. The accounting officer should ensure that he or she is adequately and accurately briefed on matters that are likely to arise at the hearing. The accounting officer may, however, ask the PAC for leave to supply information not within his or her immediate knowledge by means of a later note. Should it be discovered subsequently that the evidence provided to the PAC has contained errors, these should be made known to the PAC at the earliest possible moment.

20. In general, the rules and conventions governing appearances of officials before parliamentary committees apply to the PAC, including the general convention that officials do not disclose the advice given to the board. Nevertheless, in a case where the procedure described in paragraph 13 was used concerning a matter of propriety or regularity, the accounting officer's advice, and its overruling by the board, would be disclosed to the PAC. In a case covered by paragraph 14, where the advice of an accounting officer has been overruled in a matter not of propriety or regularity but of prudent and economical administration, efficiency or effectiveness, the C&AG will have made clear in the report to the PAC that the accounting officer was overruled. The accounting officer should seek to avoid disclosing the advice given to the board, though subject to their agreement the accounting officer should be ready to explain the reasons for their decision.

Absence of an accounting officer

21. An accounting officer should ensure that he or she is generally available for consultation, and that in any temporary period of unavailability due to illness or other cause, or during the normal period of annual leave, there will be a senior officer in the NHS foundation trust who can act on his or her behalf if required.

22. If it becomes clear to the board of directors that an accounting officer is so incapacitated that he or she will be unable to discharge these responsibilities over a period of four weeks or more, the board of directors should appoint an acting accounting officer, usually the director of finance, pending the accounting officer's return. The same applies if, exceptionally, the accounting officer plans an absence of more than four weeks during which he or she cannot be contacted.

23. The PAC may be expected to postpone a hearing if the relevant accounting officer is temporarily indisposed. Where the accounting officer is unable by reason of incapacity or absence to sign the accounts in time for submission, the NHS foundation trust may submit unsigned copies pending the accounting officer's return. If the accounting officer is unable to sign the accounts in time for printing, the acting accounting officer should sign instead.

SourcesThis document is based on the guidance outlined in Managing public money, published in July 2013.

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Group Governance Framework Manual – Appendix 2 : Care Organisation Chief Officer’s accountable officer memorandum (Letter provided to each Care Organisation Chief Officer from the Chief Executive)



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Appendix 2Care Organisation Chief Officer’s accountable officer memorandum

(Letter provided to each Care Organisation Chief Officer from the Chief Executive)

Dear [ ]

I am writing to you in my capacity as Accounting Officer for Salford Royal NHS Foundation Trust (SRFT) and as Accountable Officer for The Pennine Acute Hospitals NHS Trust (PAT) (to be known as Principal Accounting Officer for Group). As you will be aware, my responsibilities as Principal Accounting Officer are set out in a memorandum sent to me on appointment. In essence, I am responsible for the propriety and regularity of public finances for Group and its constituent Trusts; for the keeping of proper accounts; for prudent and economical administration; for the avoidance of waste and extravagance; and for the efficient and effective use of all the resources in my charge.

The position of Chief Officer is to be established for each Care Organisation of Group, effective from 1 April 2017, to which I shall formally designate delegated “accountable officer” status.

You are hereby appointed as Chief Officer, effective from 1 April 2017, and, as such, designated delegated accountable officer status with responsibility and accountability for funds entrusted to

[ ], as a Care Organisation of Group. This memorandum describes your responsibilities as an “accountable officer”, and relates them to my overall accountability. In fulfilling your role as “accountable officer” you will also wish to bear in mind your responsibilities to the Care Organisation leadership team of which you are a member and the Group Board (Group Committees in Common during transition) where you are held to account.

As Chief Officer, your role as “accountable officer” for your Care Organisation is very similar to mine as Principal Accounting Officer for Group. I require you to observe the same general requirements as are laid on me, and to ensure that the Care Organisation’s officers also abide by them. Your Care Organisation is an integral part of Group.

OverviewThe breadth of your role encompasses:

Vision and values: Instilling the Group vision and values throughout the Care Organisation, within the unique cultural environment of the Care Organisation

Care Organisation Strategy: Developing the Care Organisation strategy (in line with the Group strategic framework)

Implementation of Strategy-Planning: Work with Group to develop operational, workforce and financial plans for the Care Organisation

Delivery: Delivery of plans (clinical and non-clinical) to deliver the Care Organisation Strategy (i.e. the Care Organisation Annual Plan)

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Day-to-day operations: Managing operations to meet agreed targets (Group’s internal and external (regulatory) targets) (RTT, A&E, Cancer etc.), including all day-to-day operational decision making

Workforce leadership: Performance, development & management of workforce, participate in Group led Talent Management & Workforce development strategies

Clinical performance: Delivering clinical standards and patient experience in line with Group (developed through CPG) targets. Appropriate clinical governance and audit

Financial performance: Managing financial performance in line with agreed targets

Stakeholder management: Interacting with local external stakeholders, including commissioners and patient and public representatives

Data collection: Ensuring data capture and quality to provide assurance of performance against KPIs and targets, in line with Group requirements

Group contribution: ‘Freeing-up’ resources to support Group-wide initiatives and programmes (e.g. lead clinicians for CPG).

Your role as accountable officer is to see that the Care Organisation carries out these functions in a way which ensures the proper stewardship of public money and assets. The Care Organisation has a general duty to exercise its functions effectively, efficiently and economically.

You have a duty to prepare accounts, as applicable to your Care Organisation, in accordance with The National Health Service Act 2006 (the Act). As Principal Accounting officer, I have the personal duty of signing the accounts of the constituent trusts but I will be relying on your signature in that regard. I have the further duty of being a witness before the Public Accounts Committee (PAC) to deal with questions arising from those accounts or, more commonly, from reports made to Parliament by the Comptroller and Auditor General (C&AG) under the National Audit Act 1983. I assign a duty upon you to accompany me in respect of these responsibilities.

It is an important principle that, regardless of the source of the funding, accounting officers are responsible to Parliament for the resources under their control. As an “accountable officer” you are accountable to the Group Board.

The general responsibilities of an “accountable officer”The “accountable officer” has responsibility for the overall Care Organisation, management and staffing and for its procedures in financial and other matters (except as defined by Group). The “accountable officer” must ensure that:

there is a high standard of financial management in the Care Organisation

the Care Organisation delivers efficient and economical conduct of its business and safeguards financial propriety and regularity throughout the organisation

financial considerations are fully taken into account in decisions by the Care organisation.

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The specific responsibilities of an “accountable officer”The essence of the “accountable officer’s” role is a personal responsibility for:

the propriety and regularity of the public finances for which he or she is answerable the keeping of proper accounts prudent and economical administration the avoidance of waste and extravagance the efficient and effective use of all the resources in their charge.

As “accountable officer” you must:

o comply with the financial requirements of Group and the NHS provider licence

o ensure that proper Group defined financial procedures are followed and that accounting records are maintained in a form suited to the requirements of management, as well as in the form prescribed for published accounts

o ensure that the resources for which you are responsible as “accountable officer” are properly and well managed and safeguarded, with independent and effective checks of cash balances in the hands of any official

o ensure that assets for which you are responsible such as land, buildings or other property, including stores and equipment, are controlled and safeguarded with similar care, and with checks as appropriate

o ensure that any protected property (or interest in) is not disposed of without the consent of Group

o ensure that conflicts of interest are avoided, whether in the proceedings of the leadership team or in the actions or advice of the Care Organisation’s staff, including yourself

o ensure that, in the consideration of policy proposals relating to the expenditure for which you are responsible as “accountable officer”, all relevant financial considerations, including any issues of propriety, regularity or value for money, are taken into account, and brought to the attention of the leadership team or Group Board as appropriate.

You should ensure that effective management systems appropriate for the achievement of the Care Organisation’s objectives, including financial monitoring and control systems, have been put in place. An “accountable officer” should also ensure that managers at all levels:

o have a clear view of their objectives, and the means to assess and, wherever possible, measure outputs or performance in relation to those objectives

o are assigned well-defined responsibilities for making the best use of resources (both those consumed by their own commands and any made available to organisations or individuals outside the Care Organisation), including a critical scrutiny of output and value for money

o have the information (particularly about costs), training and access to the expert advice which they need to exercise their responsibilities effectively.

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“Accountable officers” must make sure that their arrangements for delegation promote good management and that they are supported by the necessary staff with an appropriate balance of skills. Arrangements for internal audit will be Group defined but should accord with the objectives, standards and practices set out in the Public Sector Internal Audit Standards.

Advice to the CO leadership team and Group BoardAn “accountable officer” has particular responsibility to see that appropriate advice is tendered to the CO leadership team, on all matters of financial propriety and regularity and, more broadly, as to all considerations of prudent and economical administration, efficiency and effectiveness. “Accountable officers” will need to determine how and in what terms such advice should be tendered, and whether in a particular case to make specific reference to their own duty as “accountable officer” to justify, to the Group Board and Group Audit Committee transactions for which they are accountable.

The CO leadership team should act in accordance with the requirements of propriety or regularity. If the CO leadership team is contemplating a course of action involving a transaction which you as “accountable officer” consider would infringe these requirements however, you should set out in writing your objection to the proposal and the reasons for this objection. If the CO leadership team decides to proceed, you should seek a written instruction to take the action in question. You should also inform Group Board of the position, if possible before the decision is taken or in any event before the decision is implemented, so that Group, if it considers it appropriate, can intervene in accordance with its responsibilities.

If a course of action is contemplated which raises an issue not of formal propriety or regularity but relating to your wider responsibilities for economy, efficiency and effectiveness, it is your duty to draw the relevant factors to the attention of the Group Board and to advise them in whatever way you deem appropriate.

Appearance before the Public Accounts CommitteeThe Comptroller and Auditor General (C&AG) may, under the National Audit Act 1983, carry out examinations into the economy, efficiency and effectiveness with which the NHS foundation trust and NHS trust has used its resources in discharging its functions. An accounting officer may expect to be called upon to appear before the PAC from time to time to give evidence on the reports arising from these examinations or reports following the annual certification audit, and to answer the PAC's questions concerning expenditure and receipts for which he or she is accounting officer. An accounting officer may be supported by one or two other senior officials, who may, if necessary, assist in giving evidence. As “accountable officer” you would fulfil that support role.

I would expect you to furnish me with explanations of any indications of weakness in the matters covered above, to which the PAC attention has been drawn by the C&AG or about which they may wish to question me.

You cannot disclaim responsibility or dilute your accountability.

The PAC has emphasised the importance it attaches to accuracy of evidence, and the responsibility of witnesses to ensure this, in order to ensure that relevant lines of enquiry may be pursued at its hearings. I will expect you to be adequately and accurately briefed on matters that are likely to arise at the hearing.

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Absence of an “accountable officer”An “accountable officer” should ensure that he or she is generally available for consultation, and that in any temporary period of unavailability due to illness or other cause, or during the normal period of annual leave, there will be a senior officer in the Care Organisation who can act on his or her behalf if required.

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Group Governance Framework Manual – Appendix 3: Group Standing Orders (Board)



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Appendix 3:

GROUP STANDING ORDERS(Board)

For Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

SRFT specific provisions are highlighted in a box as follows example

PAHT specific provisions are highlighted in light grey as follows example.

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CONTENTS: STANDING ORDERS OF THE BOARD OF DIRECTORS

INTRODUCTIONStatutory FrameworkDelegation of powers

1. INTERPRETATION

2. THE BOARD OF DIRECTORSComposition of the BoardAppointment of the Chairman and Non-Executive DirectorsTerms of Office of the Chairman and Members Terms and conditions of Office of the Chairman and Non-Executive Directors Appointment of Vice ChairmanPowers of Vice-ChairmanJoint DirectorsLead Roles for Board MembersRole of Members

3. MEETINGS OF THE BOARD OF DIRECTORSCalling MeetingsNotice of MeetingsAgenda and Supporting PapersAnnual Public MeetingAnnual Members MeetingNotice of MotionEmergency MotionMotions: Procedure at and during a meetingMotion to Rescind a ResolutionChairman of meetingChairman’s RulingQuorumVotingSuspension of Standing Orders Variation and Amendment of Standing Orders Record of AttendanceMinutesAdmission of the Public and the Press

4. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATIONEmergency PowersDelegation to OfficersOverriding Standing Orders

5. COMMITTEESAppointment of CommitteesConfidentiality

6. DECLARATIONS OF INTERESTS Declaration of InterestRegister of InterestsFit and Proper Persons Test

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7. DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY

INTERESTWaiver of Standing Orders made by the Secretary of State for Health

8. STANDARDS OF BUSINESS CONDUCTPolicyInterest of Officers in ContractsCanvassing of, and Recommendations by, directors in relation to appointmentsRelatives of Directors or Officers

9. CUSTODY OF SEAL AND SEALING OF DOCUMENTSCustody of SealSealing of DocumentsRegister of Sealing

10. SIGNATURE OF DOCUMENTS

11. MISCELLANEOUSStanding Orders to be Given to Directors and OfficersDocuments having the standing of Standing OrdersPolicy statements: general principlesReview of Standing Orders

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INTRODUCTION

These standing orders are equally applicable to both Salford Royal NHS Foundation Trust (“SRFT”) and Pennine Acute Hospitals NHS Trust (“PAHT”).

Where a provision is specific to either SRFT or PAHT that is made clear within these standing orders; SRFT specific provisions are highlighted in a box with no shading and PAHT specific provisions are highlighted in box with shading.

Where no specific reference to an organisation is made or a reference is made to “Trust” or “Trusts,” that provision is applicable to both SRFT and/or PAHT.

The Chairman of the Trusts shall be the final arbiter of any point of interpretation within these Standing Orders, on which he shall be advised by the Trust Secretary.

As set out in Standing Order 5.3 below, “the Standing Orders and Standing Financial Instructions of the Trust, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Trust.”

Statutory Framework

The Salford Royal NHS Foundation Trust (“SRFT”) is a statutory body, which became a public benefit corporation on 1 August 2006 following its approval as a NHS Foundation Trust by the Independent Regulator of NHS Foundation Trusts, Monitor.

The principal place of business of SRFT is:

Salford Royal, Stott Lane, Salford M6 8HD

SRFT’s head office is at Chief Executive’s Office, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD or such other place as decided from time to time.

NHS Foundation Trusts are governed by Act of Parliament, mainly the National Health Service Act 2006 as amended.

Monitor has authorised SRFT to become an NHS Foundation Trust subject to the conditions set out in Section 3 of SRFT’s Authorisation Document available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/293920/Salford_terms_of_authorisation_010806.pdf.

Delegation of Powers

SRFT has certain powers to delegate and make arrangements for delegation. The Standing Orders set out the detail of these arrangements.

The Pennine Acute Hospitals NHS Trust (“PAHT”) is a statutory body which came into existence on 1 April 2002 under the “Pennine Acute Hospitals NHS Trust (Establishment) and the Bury Health Care NHS Trust, the Rochdale Healthcare NHS Trust, the Oldham NHS Trust and the North Manchester Healthcare NHS Trust (Dissolution) Order 2002” SI(2002)308).

The principal places of business of PAHT are:

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/293920/Salford_terms_of_authorisation_010806.pdf





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North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB; Fairfield General Hospital, Rochdale Old Road, Bury, Lancashire BL9 7TD; Rochdale Infirmary, Whitehall Street, Rochdale, Lancashire OL12 0NB; Royal Oldham Hospital, Rochdale Road, Oldham, Lancashire OL1 2JH; and associated hospitals, establishments and facilities.

PAHT’s head office is based at North Manchester General Hospital, at the address set out above, or such other place as decided from time to time.

NHS Trusts are governed by Act of Parliament, mainly the National Health Service Act 2006 as amended.

In addition to this statutory framework, the Secretary of State, through the Department of Health and/or the NHS Trust Development Authority (now known as NHS Improvement) may issue further directions and guidance to PAHT and other NHS Trusts.

Delegation of Powers

PAHT has certain powers to delegate and make arrangements for delegation. The Standing Orders set out the detail of these arrangements.

The NHS regulatory framework, specifically the Code of Accountability for NHS Boards (2004) requires all Trusts to adopt Standing Orders for the regulation of their proceedings and business. The Trusts must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals. The Trusts’ delegated powers are also covered in a separate document (Reservation of Powers to the Board and Scheme of Delegation). This document has effect as if incorporated into these Standing Orders. The document sets out the decisions reserved to the Trusts’ Boards and what responsibility has been delegated by each Trust to others.

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1. INTERPRETATION

1.1 Save as otherwise permitted by law, at any meeting the Chairman of the Trust shall be the final authority on the interpretation of Standing Orders on which he should be advised by the Chief Executive and the Secretary.

1.2 Any expression to which a meaning is given in the National Health Service Act 2006 and other Acts relating to the National Health Service or in the Financial or other Regulations made under the Acts or in the Authorisation or Constitution shall have the same meaning in this interpretation and in addition:

"Principal Accounting Officer” means the Officer responsible and accountable for funds entrusted to the Trust in accordance with the role of Accounting Officer for Salford Royal NHS Foundation Trust role of Accountable Officer for The Pennine Acute Hospitals NHS Trust. He shall be responsible for ensuring the proper stewardship of public funds and assets. This shall be the Chief Executive.

"AUTHORISATION" means the authorisation of SRFT by the Independent Regulator of NHS Foundation Trusts

"BOARD" means the Board of Directors comprising the Chairman, Executive Directors and Non-Executive Directors.

"CHAIRMAN" is the person appointed in accordance with the Constitution to lead the SRFT Board of directors and the Council of Governors and to ensure that they successfully discharge their overall responsibility for the Trust as a whole.

"CHAIRMAN" is the person appointed by the Secretary of State for Health to lead the PAHT Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole.

The expression “the Chairman of the Trust” shall be deemed to include the Vice-Chairman of the Trust if the Chairman is absent from the meeting or is otherwise unavailable.

"CHIEF EXECUTIVE" means the Chief Executive Officer of the Trust.

"COMMITTEE" means a committee created and appointed by the Board.

"COMMITTEE MEMBERS" mean persons formally appointed by the Board to sit on or to chair specific committees.

"CONSTITUTION" means the constitution of SRFT

"DIRECTOR" may encompass either an Executive Director or a Non-Executive Director.

"DIRECTOR OF FINANCE" means the Chief Finance Officer of the Trust.

"ESTABLISHMENT ORDER" means the Pennine Acute Hospitals NHS Trust (Establishment) and the Bury Health Care NHS Trust, the Rochdale Healthcare NHS Trust, the Oldham NHS Trust and the North Manchester Healthcare NHS Trust (Dissolution) Order 2002

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"EXECUTIVE DIRECTOR" means a director of the Board with voting rights, who is an officer of the Trust or a director of the Board who is not an officer of the Trust but is nevertheless regarded as an executive rather than Non-Executive Director of the Trust by virtue of regulation 5 of the Members, Procedure and Administration Arrangements Regulations. An Executive Director is included as part of the quorum of the Board. This term may include the Chief Executive or Director of Finance.

"FUNDS HELD ON TRUST" shall mean those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument, or chooses subsequently to accept under powers under the NHS Act 2006. Such funds may or may not be charitable.

"MOTION" means a formal proposition to be discussed and voted on during the course of a meeting.

"MEMBERSHIP, PROCEDURE AND ADMINISTRATION ARRANGEMENTS REGULATIONS” means the NHS Trusts (Membership and Procedure) Regulations (SI 1990/2024) as amended.

"NOMINATED OFFICER" means an officer charged with the responsibility for discharging specific tasks within these SOs and SFIs.

"NON-EXECUTIVE DIRECTOR" means a director of the Board with voting rights, who is not an officer of the Trust. A Non-Executive Director is included as part of the quorum of the Board. This term may include the Chairman.

"OFFICER" means an employee of the Trust or any other person holding a paid appointment or office with the Trust.

"SFIS" means Standing Financial Instructions.

"SOS" mean Standing Orders.

"SECRETARY" means a person appointed to act independently of the Board to provide advice on corporate governance issues to the Board and the Chairman and monitor the Trust’s compliance with the law, SOs, SFIs and applicable guidance.

"TRUST" means the Salford Royal NHS Foundation Trust.

"Trust" means The Pennine Acute Hospitals NHS Trust.

"VICE-CHAIRMAN" means the Non-Executive Director appointed by the Board to take on the Chairman’s duties if the Chairman is absent for any reason or is otherwise unable to discharge their office as Chairman.

1.3 References to legislation include all amendments, replacements or re-enactments made.

1.4 Words importing the masculine gender only shall include the feminine gender; words importing the singular shall import the plural and vice-versa.

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2. THE BOARD OF DIRECTORS

2.1 All business shall be conducted in the name of the Trust.

2.2 The powers of the Trust established under statute shall be exercised by the Board. The Board shall define and regularly review the functions it exercises.

2.3 The Trust is the sole charity trustee of the charitable funds in its corporate capacity (‘a corporate trustee’). Accountability for charitable funds held on trust is to the Charity Commission and the Board is jointly responsible for the management of those charitable funds. (In this respect, Directors are therefore acting in a quasi-trustee role albeit they are not, individually, charity trustees; the only charity trustee is the Trust as a corporate body.) The Board must therefore retain direct control of key decision making for charitable funds although the Board may set up a charitable funds committee to administer such arrangements.

2.4 The Board has resolved that certain powers and decisions may only be exercised or made by the Board in formal session. These powers and decisions are set out in the “Reservation of Powers to the Board and Scheme of Delegation” and have effect as if incorporated into the Standing Orders. Those powers which the Board has delegated are set out in the Reservation of Powers to the Board and Scheme of Delegation.

2.5 In accordance with the Constitution, the composition of the Board of the Trust shall beThe Chairman of the TrustNot less than four and not more than six other Non-Executive DirectorsExecutive Directors including;

− The Chief Executive− The Director of Finance− A registered medical practitioner or a registered dentist− A registered nurse or midwife− And not more than three other Executive Directors.

Save that at all times the number of Executive Directors will not exceed the number of Non- Executive Directors.

2.5 The composition of the Board shall be in accordance with the Establishment Order:

The Chairman of the Trust (appointed by NHS Improvement);

7 Non-Executive Directors excluding the Chairman (appointed by NHS Improvement) one of whom shall be appointed from the University of Manchester; and

7 Executive Directors including:

the Chief Executive;

the Director of Finance.

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2.6 Appointment of Chairman and Non-Executive Directors - the Chairman is appointed by the Secretary of State in accordance with the NHS Act 2006 Schedule 4 paragraph 3(a) (a) but otherwise the appointment and tenure of office of the Chairman and Non-Executive Directors are set out in the Membership, Procedure and Administration Arrangements Regulations.

2.7 Terms of Office of the Chairman and Members - The regulations setting out the period of tenure of office of the Chairman and Non-Executive Directors and for the termination or suspension of office of the Chairman and Non-Executive Directors are set out in the Membership, Procedure and Administration Arrangements Regulations.

2.6 Appointment of the Chairman and Non-Executive Directors - The Chairman and Non-Executive Directors are appointed by the Council of Governors in accordance with the procedures in paragraph 12 of the Constitution.

2.7 Terms and conditions of Office of the Chairman and Non-Executive Directors - The terms and conditions of office of the Chairman and the Non-Executive Directors are to be decided by the Council of Governors in accordance with the procedures in paragraph 12 of the Constitution.

2.8 Appointment of Vice Chairman – The Board shall elect one of the Non-Executive Directors to be Vice-Chairman of the Board for such period (not exceeding the remainder of his term) as they may specify on appointing him.

2.9 Any Non-Executive Director so elected may at any time resign from the office of Vice-Chairman by giving notice in writing to the Chairman and the Board may thereupon appoint another Non-Executive Director as Vice-Chairman in accordance with Standing Order 2.8.

2.10 Powers of Vice Chairman - Where the Chairman of the Trust has died or has otherwise ceased to hold office, or where he is unable to perform his duties as Chairman owing to illness, absence or any other cause, the Vice-Chairman shall take on the duties of the Chairman until a new Chairman is appointed or the existing Chairman is able to resume their duties as the case may be. In taking on the duties of the Chairman, the Vice-Chairman cannot simultaneously be the Chairman of Audit Committee. References to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform those duties, be taken to include references to the Vice-Chairman.

2.11 Joint Directors – Where more than one person is appointed jointly to a post in the Trust, those persons shall become appointed as a Director jointly, and, in addition:

a. either or all of those persons may attend or take part in meetings of the Board;

b. any of those persons if present shall be eligible to vote in the case of agreement between them and if all are present at a meeting they should cast one vote between them;

c. in the case of disagreements no vote should be cast;

d. the presence of any or all of those persons should count as the presence of one person for the purposes of considering quorum and numbers of Directors on the Board.

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2.12 Lead Roles for Board Members - The Chairman will ensure that the designation of Lead roles or appointments of Board members as required by the Department of Health or as set out in any statutory or other guidance will be made in accordance with that guidance or statutory requirement (e.g. appointing a Lead Board Member with responsibilities for Infection Control or Child Protection Services etc.).

2.13 Role of Members The Board will function as a corporate decision-making body. Executive and Non-Executive Directors will be full and equal members. Their role as members of the Board will be to consider the key strategic and managerial issues facing the Trust, as the Trust carries out its statutory and other functions.

2.13.1 Executive DirectorsExecutive Members shall exercise their authority within the terms of these Standing Orders and Standing Financial Instructions and the Scheme of Delegation.

2.13.2 Chief Executive The Chief Executive shall be responsible for the overall performance of the Trust. He is the Principal Accounting Officer for the Trust and shall be responsible for ensuring the discharge of obligations under Standing Financial Instructions and in line with ‘Managing Public Money’and the requirements of the Accountable Officer Memorandum for Chief Executives of NHS Trusts.

and the requirements of the NHS Foundation Trust Accounting Officer Memorandum.

2.13.3 Director of Finance The Director of Finance shall be responsible for the provision of financial advice to the Trust and to its members and for the supervision of financial control and accounting systems. He shall be responsible along with the Chief Executive for ensuring the discharge of obligations under relevant Standing Financial instructions.

2.13.4 Non-Executive Members The Non-Executive Members shall not be granted nor shall they seek to exercise any individual executive powers on behalf of the Trust. They may however, exercise collective authority when acting as members of or when chairing a committee of the Trust which has delegated powers.

2.13.5 Chairman The Chairman shall be responsible for the operation of the Board and chair all Board meetings when present. The Chairman must comply with his terms of appointment and with these Standing Orders.

The Chairman shall liaise with NHS Improvement over the appointment of Non-Executive Directors and once appointed shall take responsibility either directly or indirectly for their induction, their portfolios of interests and assignments, and their performance.

The Chairman shall work in close harmony with the Chief Executive and shall ensure that key and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions.

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3. Meetings of the Trust

3.1 Calling meetings

3.1.1 Ordinary meetings of the Board shall be held at regular intervals at such times and places as the Board may determine.

3.1.2 The Chairman of the Trust may call a meeting of the Board at any time.

3.1.3 Five Directors (i.e. one third of the whole number of the Chairman and Directors) may requisition a meeting by written notice to the Chairman. If the Chairman refuses, or fails, to call a meeting within seven days of a requisition being presented, the Directors signing the requisition may forthwith call a meeting.

3.1.4 Save in the case of emergencies or the need to conduct urgent business, the Secretary shall give to all Directors reasonable notice in writing of the date, time and place of every meeting of the Board of Directors for each year.

3.2 Notice of Meetings and the Business to be transacted

3.2.1 Before each meeting of the Board, a written notice specifying the business proposed to be transacted shall be delivered to every Director, or sent by post to the usual place of residence of each member or delivered by electronic means to each member on contact details notified by a Director to the Trust Secretary for such purpose, so as to be available to Directors at least three clear days before the meeting. Want of service of such a notice on any Director shall not affect the validity of a meeting.

3.2.2 In the case of a meeting called by Directors in default of the Chairman calling the meeting, the notice shall be signed by those Directors.

3.2.3 No business shall be transacted at the meeting other than that specified on the notice of meeting.

3.2.4 A Director desiring a matter to be included on an agenda shall make his/her request in writing to the Chairman at least 10 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the Chairman.

3.2.5 Before each meeting of the Board a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust’s principal offices at least three clear days before the meeting. (required by the Public Bodies (Admission to Meetings) Act 1960 Section 1 (4) (a)).

3.3 Agenda and Supporting Papers

3.3.1 Setting the Agenda - The Board may determine that certain matters shall appear on every agenda for a meeting of the Trust and shall be addressed prior to any other business being conducted as agreed by the Board. (Such matters may be identified within these Standing Orders or following subsequent resolution shall be listed in an Appendix to the Standing Orders.)

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3.3.2 The Agenda will be made available to members six days before the meeting and supporting papers, whenever possible, shall accompany the agenda, but will certainly be available no later than three clear days before the meeting, save in emergency.

3.3.3 Before holding a meeting, the Board of Directors must send a copy of the agenda of the meeting to the Council of Governors

3.3.3 Annual Public Meeting – The Trust will publicise and hold an annual public meeting in accordance with the NHS Trusts (Public Meetings) Regulations 1991 (SI(1991)482).

3.3.4 Annual Members Meeting – The Trust will publicise and hold an annual members meeting in accordance with the Constitution.

3.4 Notice of Motion

3.4.1 Subject to the provision of Standing Orders 3.7 ‘Motions: Procedure at and during a meeting’ and 3.8 ‘Motions to rescind a resolution’, a member of the Board wishing to move or amend a motion shall send a written notice to the Secretary who will ensure that it is brought to the immediate attention of the Chairman.

3.4.2 The notice shall be delivered at least ten clear days before the meeting. The Chairman shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

3.5 Emergency Motions

Subject to the agreement of the Chairman, and subject also to the provision of Standing Order 3.7 ‘Motions: Procedure at and during a meeting’, a member of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chairman's decision to include the item shall be final.

3.6 Motions: Procedure at and during a meeting

i) Who may propose A motion may be proposed by the Chairman of the meeting or any member present. It must also be seconded by another member.

ii) Contents of motions The Chairman may exclude from the debate at their discretion any such motion of which notice was not given on the notice summoning the meeting other than a motion relating to: - the receipt of a report; - consideration of any item of business before the Board; - the accuracy of minutes; - that the Board proceed to next business;

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- that the Board adjourn; - that the question be now put.

iii) Amendments to motions A motion for amendment shall not be discussed unless it has been proposed and seconded.

Amendments to motions shall be moved relevant to the motion, and shall not have the effect of negating the motion before the Board.

If there are a number of amendments, they shall be considered one at a time. When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

iv) Rights of reply to motions

a) Amendments The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion.

b) Substantive/original motion The member who proposed the substantive motion shall have a right of reply at the close of any debate on the motion.

v) Withdrawing a motion concurrence of the seconder and the consent of the Chairman.

vi) Motions once under debate When a motion is under debate or immediately prior to debate, no motion may be moved other than: - an amendment to the motion; - the adjournment of the discussion, or the meeting; - that the meeting proceed to the next business; - that the question should be now put; - the appointment of an 'ad hoc' committee to deal with a specific item of business; - that a member/director be not further heard; - a motion under Section 1(2) or Section 1(8) of the Public Bodies (Admissions to Meetings) Act 1960 resolving to exclude the public, including the press (see Standing Order 3.17).

No amendment to the motion shall be admitted if, in the opinion of the Chairman of the meeting, the amendment negates the substance of the motion.

In those cases where the motion is either that the meeting proceeds to the ‘next business’ or ‘that the question be now put’ in the interests of objectivity these should only be put forward by a member of the Board who has not taken part in the debate and who is eligible to vote.

If a motion to proceed to the next business or that the question be now put, is carried, the Chairman should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote.

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3.7 Motion to Rescind a Resolution

3.7.1 Notice of motion to rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the member who gives it and also the signature of four other members. Before considering any such motion of which notice shall have been given, the Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation.

3.7.2 When any such motion has been dealt with by the Trust Board it shall not be competent for any director/member other than the Chairman to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive.

3.8 Chairman of meeting

3.8.1 At any meeting of the Board the Chairman, if present, shall preside. If the Chairman is absent from the meeting, the Vice-Chairman (if the Board has appointed one), if present, shall preside.

3.8.2 If the Chairman and Vice-Chairman are absent, such Non-Executive Director as the Directors present shall choose shall preside.

3.8.3 If the Chairman is absent from a meeting temporarily on the grounds of a declared conflict of interest the Vice-Chairman, if present, shall preside. If the Chairman and Vice-Chairman are absent, or are disqualified from participating, such Non-Executive Director as the directors present shall choose shall preside.

3.9 Chairman's ruling

3.9.1 The decision of the Chairman of the meeting on questions of order, relevancy and regularity (including procedure on handling motions), their interpretation of the Standing Orders and Standing Financial Instructions and any other matters at the meeting, shall be final.

3.10 Quorum

3.10.1 No business shall be transacted at a meeting unless at least five Directors are present (i.e. one third of the whole number of the Chairman and Directors) including at least:

a) two Executive Directors of the Trust and b) two Non-Executive Directors of the Trust.

By exception, the Board may decide that Directors may participate in meetings either by telephone, video or computer link. Participation in a meeting in this manner shall be deemed to constitute presence in person at the meeting and as such shall count towards the quorum.

3.10.2 An Officer in attendance for an Executive Director but without formal acting up status may not count towards the quorum.

3.10.3 If the Chairman or a Director has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see Standing Orders 6 and 7) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a

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resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. The above requirement for at least two Executive Directors to form part of the quorum shall not apply where the Executive Directors are excluded from a meeting (for example when the Board considers the recommendations of the Nominations and/or Remuneration and Terms of Service Committee).

3.11 Voting

3.11.1 Save as provided in Standing Orders 3.13 - Suspension of Standing Orders and 3.14 - Variation and Amendment of Standing Orders, every question put to a vote at a meeting shall be determined by a majority of the votes of the Directors present and voting on the question. In the case of an equal vote, the person presiding (i.e.: the Chairman of the meeting) shall have a second, and casting vote.

3.11.2 At the discretion of the Chairman all questions put to the vote shall be determined by oral expression or by a show of hands, unless the Chairman directs otherwise. A paper ballot may also be used if a majority of the directors present so request.

3.11.3 If at least five Directors present so request, the voting on any question may be recorded so as to show how each Director present voted or did not vote (except when conducted by paper ballot).

3.11.4 If a Director so requests, their vote (except when conducted by paper ballot) shall be recorded by name.

3.11.5 In no circumstances may an absent Director vote by proxy. Absence is defined as being absent at the time of the vote.

3.11.6 An Officer who has been formally appointed to act up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Executive Director.

3.11.7 An Officer attending the Trust Board meeting to represent an Executive Director during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Executive Director.

3.11.8 A Officer’s status when attending a meeting shall be recorded in the minutes.

3.11.9 For the voting rules relating to joint members see Standing Order 2.11.

3.12 Suspension of Standing Orders

3.12.1 Except where this would contravene any statutory provision, any direction made by the Secretary of State any provision of the Authorisation or of the Constitution or the rules relating to the Quorum (Standing Order 3.11), any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the whole number of the members of the Board are present (including at least two Executive Directors and two Non-Executive Director) and that at least two-thirds of those Directors present signify their agreement to such suspension. The decision and reason(s) for the suspension shall be recorded in the Trust Board's minutes.

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3.12.2 A separate record of matters discussed during the suspension of Standing Orders shall be made and shall be available to the Chairman and to the directors.

3.12.3 No formal business may be transacted while Standing Orders are suspended.

3.12.4 The Audit Committee shall review every decision to suspend Standing Orders.

3.13 Variation and amendment of Standing Orders

These Standing Orders shall not be varied except in the following circumstances:

Upon a notice of motion under Standing Order 3.5;

Upon a recommendation of the Chairman or Chief Executive included on the agenda for the meeting;

That two thirds of the Board members are present at the meeting where the variation or amendment is being discussed, and that at least half of the Trust’s Non- Executive Directors vote in favour of the amendment;

Providing that any variation or amendment does not contravene a statutory provision or direction made by the Secretary of State, provision of the Authorisation or the Constitution.

3.14 Record of Attendance

The names of the Chairman and Directors present at the meeting shall be recorded.

3.15 Minutes

3.15.1 The minute of the proceedings of a meeting shall be drawn up by the Secretary and submitted for agreement at the next ensuing meeting where they shall be signed by the person presiding at it.

3.15.2 No discussion shall take place upon the minute except upon their accuracy or where the Chairman considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.

3.15.3 Minutes shall be circulated in accordance with directors' wishes and shall be provided to the Council of Governors as soon as practicable after a Board meeting. Where providing a record of a public meeting the minutes shall be made available to the public

3.16 Admission of public and the press

3.16.1 Admission and exclusion on grounds of confidentiality of business to be transacted The public and representatives of the press may attend all meetings of the Board, but shall be required to withdraw upon the Board resolving that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

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3.16.2 General disturbances The Chairman (or Vice-Chairman if one has been appointed) or the person presiding over the meeting shall give such directions as he thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Board’s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the Chairman may exclude any member of the public or representatives of the press to suppress or prevent disorderly conduct or other misbehaviour at a meeting that is interfering with or preventing the proper conduct of the meeting.

3.16.3 Use of Mechanical or Electrical Equipment for Recording or Transmission of Meetings

Nothing in these Standing Orders shall require the Board to allow members of the public or representatives of the press to record proceedings in any manner whatsoever, other than writing, or to make any oral report of proceedings as they take place (such as via recording, transmitting, video or similar apparatus) without the prior agreement of the Board.

3.17 Observers at Trust meetings

The Trust will decide what arrangements and terms and conditions it feels are appropriate to offer in extending an invitation to observers to attend and address any of the Board's meetings and may change, alter or vary these terms and conditions as it deems fit.

4 ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION

4.1 The Board of Directors may delegate any of its powers to a committee of Directors or to an Executive Director.

4.1 The Board shall agree from time to time to the delegation of executive powers to be exercised by committees or sub-committees which it has formally constituted in accordance with directions issued by the Secretary of State. The terms of reference of these committees or sub-committees and their specific executive powers shall be approved by the Board in respect of its sub-committees.

4.2 Emergency Powers - The powers which the Board has retained to itself within these Standing Orders may in emergency be exercised by the Chief Executive and the Chairman after having consulted at least two Non-Executive Directors. The exercise of such powers by the Chief Executive and the Chairman shall be reported to the next formal meeting of the Board, for ratification.

4.3 Delegation to Officers - Those functions of the Trust which have not been retained as reserved by the Board or delegated to an executive committee or sub-committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Trust.

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4.4 The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals, which shall be considered and approved by the Board, subject to any amendment agreed during the discussion. The Chief Executive may periodically propose amendments to the Scheme of Delegation, which shall be considered and approved by the Board as indicated above.

4.5 Nothing in the Scheme of Delegation shall impair the discharge of the direct accountability to the Board of the Director of Finance or other Executive Directors to provide information and advise the Board in accordance with any statutory requirements. Outside these statutory requirements the roles of the Director of Finance shall be accountable to the Chief Executive for operational matters.

4.6 The arrangements made by the Board as set out in the "Reservation of Powers to the Board and Delegation of Powers" shall have effect as if incorporated in these Standing Orders.

4.7 Overriding Standing Orders – If for any reason these Standing Orders are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board for action or ratification. All directors of the Board and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive as soon as possible.

5. COMMITTEES

5.1 Appointment of Committees - Subject to the provider licence, the constitution Subject to such directions as may be given by the Secretary of State for Health and the NHS Act 2006, the Board may appoint committees of directors consisting wholly or partly of directors of the Trust or wholly of persons who are not directors of the Trust.

5.2 A committee may, in accordance with the Constitution and these Standing Orders, appoint sub-committees of directors consisting wholly or partly of directors of the Trust or wholly of persons who are not directors of the Trust.

5.3 The Standing Orders and Standing Financial Instructions of the Trust, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Trust. In which case the term “Chairman” is to be read as a reference to the Chairman of the committee as the context permits, and the term “Director” is to be read as a reference to a member of the committee also as the context permits. (Except for the Group Committees in Common, there is no requirement to hold meetings of committees established by the Trust in public.)

5.4 Each such committee shall have such terms of reference and powers and be subject to such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation or direction issued by the Secretary of State. Such terms of reference shall have effect as if incorporated into the Standing Orders.

5.5 Where committees are authorised to establish sub-committees and have delegated executive powers, they may not delegate executive powers to the sub-committee unless expressly authorised by the Board.

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5.6 The Board shall approve the appointments to each of the committees, which it has formally constituted. Where the Board determines, and legislation permit, that persons, who are neither directors nor officers, shall be appointed to a committee the terms of such appointment shall be within the powers of the Board. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance and its constitution.

5.7 Where the Board is required to appoint persons to a committee and/or to undertake statutory functions as required by the Secretary of State, and where such appointments are to operate independently of the Board such appointment shall be made in accordance with the regulations and directions made by the Secretary of State.

5.8 The committees established by the Trust must include:

• Audit Committee• Remuneration, Nominations and Terms of Service Committee• Charitable Funds Committee

Such other committees may be established, as required, to discharge the Board's responsibilities.

5.9 Confidentiality - A member of a committee shall not disclose a matter dealt with by, or brought before, the committee without its permission until the committee shall have reported to the Board or shall otherwise have concluded on that matter.

5.10 A Director of the Trust or a member of a committee shall not disclose any matter reported to the Board or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board or committee shall resolve that it is confidential without the permission of the Board/committee as applicable.

5.11 Nothing in the above sections shall restrict staff acting within the law on whistleblowing (currently found within the Employment Rights Act 1996 as amended by the Public Interest Disclosure Act 1998).

6. DECLARATIONS OF INTERESTS/FIT AND PROPER PERSONS

6.1 Declaration of Interests - The Constitution The NHS Code of Accountability requires directors to declare interests, which are relevant and material to the Board of which they are a Director. All existing Directors should declare such interests. Any Directors appointed subsequently should do so on appointment.

6.2 A material interest is:

a) any directorship;

b) any interest (excluding a holding of shares in a company whose shares are listed on any public exchange where the holding is less than 2% of the total shares in issue) or position held by a Director in any firm or company or business which, in connection with the matter, is trading with the Trust, or is likely to be considered as a potential trading partner with the Trust;

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c) any interest in a voluntary or other organisation providing health and social care services to the National Health Service;

d) a position of authority in a charity or voluntary organisation in the field of health and social care;

e) any connection with any organisation, entity or company considering entering into a financial arrangement with the Trust including not limited to lenders or banks.

f) arrangement with the Trust, including but not limited to, lenders or banks.

6.3 At the time Directors' interests are declared, they should be recorded in the Board of Directors' minutes and made publicly available on the Trust’s website. Any changes in interests should be officially declared at the next Board meeting following the change occurring.

6.4 Directors' directorships of companies likely or possibly seeking to do business with the NHS should be published in the Annual Report. The information should be kept up to date for inclusion in succeeding Annual Reports.

6.5 During the course of a Board meeting, if a conflict of interest is established, the director concerned should withdraw from the meeting and play no part in the relevant discussion or decision. For the avoidance of doubt, this includes not voting on any issue where a conflict is established.

6.6 The interests of Directors’ spouses/co-habiting partners and close associates should also be regarded as relevant.

6.7 If Directors have any doubt about the relevance or materiality of an interest, this should be discussed with the Chairman and/or Secretary. Influence rather than the immediacy of a relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.

6.8 Register of Interests – The Secretary will ensure that a register of interests is established to record formally declarations of interest of all Directors and committee members. In particular the Register will include details of all directorships and other relevant and material interests which have been declared by both Executive and Non-Executive directors.

6.8 These details will be kept up to date by means of an annual review of the register in which any changes to interests declared during the preceding twelve months will be incorporated.

6.9 The Register will be available to the public and the Trust Secretary will take reasonable steps to bring the existence of the Register to the attention of the local population and to publicise arrangements for viewing it.

6.10 The “Fit and Proper Persons Test” (FPPT) - requirements came into force 27 November 2014. The CQC regulate compliance with the FPPT which focusses on holding senior leaders to account ensuring the accountability of directors of NHS bodies.

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6.11 The FPPT applies to “Directors and equivalents” namely those who are Board members or who regularly attend the Board and have a responsibility and are accountable for the delivery of care, irrespective of their voting rights

6.12 The Trust has a duty to ensure that the chair, the non-executives and executive directors it appoints meet the requirements of the ‘fit and proper persons’ regulations. They must:

be of good character; have the necessary qualifications, competence, skills and experience; by reason of their health, be able to properly perform tasks which are intrinsic to the

role (after reasonable adjustments have been made); supply certain information (including a Disclosure and Barring Service (DBS) check

and a full employment history); and have not been responsible for, privy to, contributed or facilitated any serious

misconduct or mismanagement (whether unlawful or not) in carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity.

6.13 The Chairman is responsible for ensuring that the FPPT is carried out for all of the Board members and a register is maintained by the Trust Secretary.

7. DISABILITY OF CHAIRMAN AND DIRECTORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY INTEREST

7.1 Subject to the following provisions of this Standing Order, if the Chairman or a director of the Trust has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Trust at which the contract or other matter is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

7.2 The Secretary of State may, subject to such conditions as he may think fit to impose, remove any disability imposed by this Standing Order in any case in which it appears to him in the interests of the National Health Service that the disability shall be removed.

7.3 The Board may exclude the Chairman or a director of the Board from a meeting of the Board while any contract, proposed contract or other matter in which he has a pecuniary interest, is under consideration.

7.4 Any remuneration, compensation or allowances payable to the Chairman or a Non-Executive Director in accordance with the constitution shall not be treated as a pecuniary interest for the purpose of this Standing Order.

7.5 For the purpose of this Standing Order the Chairman or a director shall be treated, subject to Standing Orders 7.2 and 7.6, as having indirectly a pecuniary interest in a contract, proposed contract or other matter, if:

a) he, or a nominee of his, is a director of a company or other body, not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration;

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or

(b) he is a partner of, or is in the employment of a person with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration;

and in the case of married persons living together the interest of one spouse shall, if known to the other, be deemed for the purposes of this Standing Order to be also an interest of the other.

7.6 The Chairman or a director shall not be treated as having a pecuniary interest in any, proposed contract or other matter by reason only:

(a) of his/her membership of a company or other body, if he/she has no beneficial interest in any securities of that company or other body;

(b) of an interest in any company, body or person with which he/she is connected as mentioned in Standing Order 7.5 above which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a director in the consideration or discussion of or in voting on, any question with respect to that contract or matter.

7.7 Where the Chairman or a director:

(a) has an indirect pecuniary interest in a contract, proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body;

(b) the total nominal value of those securities does not exceed £5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less, and

(c) if the share capital is of more than one class, the total nominal value of shares of any one class in which he/she has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class,

This Standing Order shall not prohibit him/her from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it without prejudice however to his/her duty to disclose his/her interest.

7.8 This Standing Order applies to a committee or sub-committee as it applies to the Board and applies to any member of any such committee or sub-committee (whether or not he/she is also a director of the Trust) as it applies to a director.

7.9 Waiver of Standing Orders made by the Secretary of State for Health

(1) Power of the Secretary of State to make waivers

Under regulation 11(2) of the Membership, Procedure and Administration Arrangements Regulations, there is a power for the Secretary of State to issue waivers if it appears to the Secretary of State in the interests of the health service that the disability in regulation 11 (which prevents a chairman or a member from taking part in the consideration or discussion of, or voting on any question with respect to, a matter in which he has a

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pecuniary interest) is removed. A waiver has been agreed in line with sub-sections (2) to (4) below.

(2) Definition of ‘Chairman’ for the purpose of interpreting this waiver

For the purposes of paragraphs (3) and (4) (below), the “relevant chairman” is – (a) at a meeting of the Trust, the Chairman of that Trust;

(b) at a meeting of a Committee –

i. in a case where the member in question is the Chairman of that Committee, the Chairman of the Trust;

ii. in the case of any other member, the Chairman of that Committee.

(3) Application of waiver

A waiver will apply in relation to the disability to participate in the proceedings of the Trust on account of a pecuniary interest.

It will apply to:

i) A member of the Trust who is a healthcare professional, within the meaning of regulation 5(5) of the Membership, Procedure and Administration Arrangements Regulations, and who is providing or performing, or assisting in the provision or performance, of –

(a) services under the National Health Service Act 2006; or

(b) services in connection with a pilot scheme under the National Health Service Act 2006; for the benefit of persons for whom the Trust is responsible.

ii) Where the ‘pecuniary interest’ of the member in the matter which is the subject of consideration at a meeting at which he is present:-

(a) arises by reason only of the member’s role as such a professional providing or performing, or assisting in the provision or performance of, those services to those persons;

(b) has been declared by the relevant chairman as an interest which cannot reasonably be regarded as an interest more substantial than that of the majority of other persons who:–

i are members of the same profession as the member in question,

ii are providing or performing, or assisting in the provision or performance of, such of those services as he provides or performs, or assists in the provision or performance of, for the benefit of persons for whom the Trust is responsible.

(4) Conditions which apply to the waiver and the removal of having a pecuniary interest

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The removal is subject to the following conditions: (a) the member must disclose his/her interest as soon as practicable after the commencement of the meeting and this must be recorded in the minutes;

(b) the relevant chairman must consult the Chief Executive before making a declaration in relation to the member in question pursuant to paragraph (3)(ii)(b) above, except where that member is the Chief Executive;

(c) in the case of a meeting of the Trust:

i) the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

ii) may not vote on any question with respect to it.

(d) In the case of a meeting of the Committee:

i) the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

ii) may vote on any question with respect to it; but

iii) the resolution which is subject to the vote must comprise a recommendation to, and be referred for approval by, the Trust Board.

8. STANDARDS OF BUSINESS CONDUCT

8.1 Policy - Staff must comply with the guidance contained in “Standards of Business Conduct for NHS staff” and the Trust’s Standards of Business Conduct Policy (Annex A). The following provisions should be read in conjunction with these documents.

8.2 Interest of Officers in Contracts - If it comes to the knowledge of a director or an officer of the Trust that that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him has any pecuniary interest, direct or indirect he shall, at once, give notice in writing to the Chief Executive or Trust Secretary of the fact that he is interested therein. In the case of (married) persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

8.3 An officer must also declare to the Chief Executive or Trust Secretary any other employment or business or other relationship of his/hers, or of a cohabiting partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust. The Trust requires interests, employment or relationships so declared by staff to be entered in a register of interests of staff.

8.4 Canvassing of and Recommendations by Directors in Relation to Appointments - Canvassing of directors or of the Board or members of any committee of the Board directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

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8.5 A director shall not solicit for any person any appointment under the Trust or recommend any person for such appointment: but this paragraph of this Standing Order shall not preclude a director from giving written testimonial of a candidate's ability, experience or character for submission to the Trust or taking part in the appointment process.

8.6 Informal discussions outside appointments panels or committees, whether solicited or unsolicited, should be declared to the panel or committee.

8.7 Relatives of Directors or Officers - Candidates for any staff appointment shall when making application disclose in writing whether they are related to any director or the holder of any office under the Trust. Failure to disclose such a relationship may disqualify a candidate and, if appointed, may render him/her liable to instant dismissal.

8.8 The Chairman, directors and every officer of the Trust shall disclose to the Chief Executive any relationship with a candidate of whose candidature that director or officer is aware. It shall be the duty of the Chief Executive to report to the Trust any such disclosure made. Relationships to which this order applies are those of husband and wife or co-habitees or where either of the two or the spouse of either of them is the son or daughter or grandson or granddaughter or brother or sister or nephew or niece of the other or the spouse of the other.

8.9 On appointment, directors (and prior to acceptance of an appointment in the case of Executive Directors) should disclose to the Board whether they are related to any other director or holder of any office under the Trust.

8.10 Where the relationship of an officer or another director to a director of the Trust is disclosed, the Standing Order headed “Disability of the Chairman and directors in proceedings on account of pecuniary interest” shall apply.

8.11 It is essential that Directors are transparent and understand the need to ensure that their actions cannot be misunderstood. If there is any doubt as to whether an interest should be declared then it should be declared in the correct way for transparency.

9. CUSTODY OF SEAL AND SEALING OF DOCUMENTS

9.1 If deeds are not executed under seal then specified wording needs to be included in the deed, “executed as a deed by [name of Trust], in the presence of Printed name, Job Title, Signature, Date.”

9.2 Custody of Seal - The Common Seal of the Trust shall be kept by the Secretary in a secure place.

9.3 Sealing of Documents - The Trust is to have a seal. Before any building, engineering, property or capital document is sealed it must be approved and signed by the Director of Finance (or an officer nominated by him/her) and authorised and countersigned by the Chief Executive (or an officer nominated by him/her who shall not be within the originating directorate).

9.5 Register of Sealing - An entry of every sealing shall be made and numbered consecutively in a book provided for that purpose, and shall be signed by the persons who shall have approved and authorised the document and those who attested the seal. A report of all sealing shall be made to the Group Committees in Common at least six-monthly. (The

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report shall contain details of the seal number, the description of the document, date of sealing and signatories). The book will be held by the Trust Secretary.

9.6 Where approval has taken place below Board level, in accordance with the Detailed Scheme of Delegation, confirmation of the approval process shall be included in the repot of all sealings made to the Group Committees in Common.

10. SIGNATURE OF DOCUMENTS

10.1 Where the signature of any document will be a necessary step in legal proceedings involving the Trust, unless any enactment otherwise requires or authorises, it shall be signed by the Chief Executive or any Executive Director or (if the Board shall have given the necessary authority to some other person for the purpose of such proceedings) such other duly authorised person. The Trust’s relevant Legal Services Manager and HR Manager shall be authorised by the Board to sign Statements of Truth for legal proceedings.

10.2 The Chief Executive or nominated officers shall be authorised by resolution of the Board to sign on behalf of the Trust any agreement or other document (not required to be executed as a deed) the subject matter of which has been approved by the Board or committee or sub-committee to which the Board has delegated appropriate authority. In land transactions, the signing of certain supporting documents will be delegated to managers as set out clearly in the Scheme of Delegation but will not include the main or principal documents affecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).

11. MISCELLANEOUS

11.1 Standing Orders to be given to Directors and Officers - It is the duty of the Chief Executive to ensure that existing Directors and officers and all new appointees are notified of and understand their responsibilities within Standing Orders and SFIs. Copies will be available on the Trust’s Intranet system.

These documents are incorporated within the Corporate Governance Framework Manual (CGFM). All staff receive Standards of Business Conduct Information on appointment and direction to the relevant section of the website for further information.

11.2 Documents having the standing of Standing Orders - Standing Financial Instructions, Reservation of Powers to the Board and Delegation of Powers shall have effect as if incorporated into Standing Orders.

11.3 Policy statements: general principlesThe Trust may agree and approve policy statements/procedures which will apply to all or specific groups of staff employed by the Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Board minute and will be deemed to be an integral part of the Trust’s Standing Orders and Standing Financial Instructions.

11.4 Review of Standing Orders - Standing Orders shall be reviewed annually by the Board. The requirement for review extends to all documents having effect as if incorporated in Standing Orders.

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Annex A to GROUP STANDING ORDERS (Board)

Contents

Who should read this documentKey MessagesWhat is new in this version

IntroductionKey TermsStaffDecision Making StaffIdentification, declaration and review of interestsHow to make a declarationProactive review of interestsMaintenancePublicationWider transparency initiativesManagement of Interests Common situations

− Clinical private practice − Outside employment (including self-employment)− Shareholdings and other ownership issues− Patents− Loyalty interests− Sponsored research− Sponsored posts− Gifts− Hospitality− Donations− Sponsored events

Strategic Decision GroupsProcurementConfidentiality AgreementDealing with breachesAppendix 1: Nolan PrinciplesAppendix 2: Confidentiality Agreement

Standards of Business Conduct Policy

Classification: PolicyLead Author: Jane Burns, Group SecretaryAdditional author(s): Rebecca McCarthy, Deputy Trust Secretary, Alun Gordon James, PAT Local Counter Fraud SpecialistAuthors Division: Trust ExecutiveUnique ID: Issue number: 1Expiry Date: April 2019

Group Arrangements:

Salford Royal NHS Foundation Trust (SRFT)Pennine Acute Hospitals

NHS Trust (PAT)

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Appendix 3: Potential sanctions for breaches of this policy

Who should read this document?

All employees, including volunteers, as well as governors, Executive and Non-Executive members (including co-opted members) and honorary members.

Key Messages

The Standards of Business Conduct Policy describes the public service values which underpin the work of the NHS and reflects guidance and best practice to which all staff are expected to have regard to.

In addition, all staff must abide by the Seven Principles of Public Life, the ‘Nolan Principles’ set out in Appendix 1 of this policy.

This policy will help staff manage conflicts of interest risks effectively. It:• introduces consistent principles and rules, • provides simple advice about what to do in common situations,• supports good judgement about how to approach and manage interests

Policy/ Guideline/ Protocol

1. Preface

Salford Royal NHS Foundation Trust (SRFT) Board has set out parameters to establish a Group, with Pennine Acute Hospitals NHS Trust (PAT) being the first member.

It is intended that in due course Group will be established as a single NHS foundation trust, however it is important to note that currently SRFT and PAT remain sovereign statutory bodies.

In 2016/17 the Board of Directors at SRFT and the Trust Board at PAT reviewed and approved the architecture for the Group, including the establishment of Group Committees in Common (Group CiC). The Group CiC involved the Board of Directors at SRFT and the Trust Board at PAT each establishing a committee, to which each Board delegated the exercise of its functions. In recognition of the long term intention of SRFT and PAT to become a single NHS foundation trust, the Group CiC will meet at the same time, around one table, to make the decisions in relation to SRFT and PAT. Since each of the committees has delegated powers from their Boards, the decisions of each committee on matters within its remit will be final and will not need to be ratified by the SRFT and PAT Boards.

Group CiC, in collaboration with Group Audit Committee, will establish the Group Governance Framework Manual, ensuring effective and appropriate corporate governance arrangements are in place for the two sovereign organisations whilst in transition to Group.

The Standards of Business Conduct Policy is incorporated within the Group Governance Framework Manual.

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The Standards of Business Conduct Policy is equally applicable to both SRFT and PAT. Where no specific reference to an organisation is made or a reference is made to the “organisation” it is applicable to, and incorporates, both SRFT and PAT.

For the purposes of this policy, ‘staff’ includes all SRFT staff, PAT staff, volunteers, as well as governors, Executive and Non-Executive members (including co-opted members) and honorary members. To this end, if an SRFT staff member has a material relationship with a supplier to PAT then this would need to be declared, and vice versa.

2. Introduction

Providing best value for taxpayers and ensuring that decisions are taken transparently and clearly, are both key principles in the NHS Constitution. The organisation is committed to maximising resources for the benefit of all the communities it serves. The people who work for the organisation collaborate closely with other companies and suppliers to deliver high quality care for our patients and service users. These partnerships have many benefits and should help ensure that public money is spent efficiently and wisely. But there is a risk that conflicts of interest may arise. As an organisation, and as individuals, we have a duty to ensure that all our dealings are conducted to the highest standards of integrity so that we are using our finite resources in the best interests of patients and service users.

3. Key Terms

A ‘conflict of interest’ is:“A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”

A conflict of interest may be: Actual – there is a material conflict between one or more interests Potential – there is the possibility of a material conflict between one or more interests in

the future

Staff may hold interests for which they cannot see potential conflict. However, caution is always advisable because others may see it differently and perceived conflicts of interest can be damaging. All interests should be declared where there is a risk of perceived improper conduct.

Interests fall into the following categories:

Financial interests: Where an individual may get direct financial benefit1 from the consequences of a decision they are involved in making.

Non-financial professional interests: Where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making, such as increasing their professional reputation or promoting their professional career.

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Non-financial personal interests: Where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit, because of decisions they are involved in making in their professional career.

Indirect interests: Where an individual has a close association2 with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest and could stand to benefit from a decision they are involved in making.

4. StaffThe organisation utilises the skills of many different people, all of whom are vital to our work. This includes people on differing employment terms, who for the purposes of this policy we refer to as ‘staff’ and include:

All salaried employees All prospective employees – who are part-way through recruitment Contractors and sub-contractors; and Agency staff

In addition, volunteers, as well as governors, are for the purposes of this policy, considered as ‘staff’.

5. Decision Making Staff

Some staff are more likely than others to have a decision making influence on the use of taxpayers’ money, because of the requirements of their role. For the purposes of this guidance these people are referred to as ‘decision making staff.’

Decision making staff in the organisation are: Executive and Non-Executive Directors (or equivalent roles) who have decision making

roles which involve the spending of taxpayers’ money Those at Agenda for Change Band 7 and above, or on Senior Manager grades Medical and Dental Consultants, SAS Doctors and GP’s Administrative and clinical staff (of any band) who have the power to enter into contracts

on behalf of their organisation Administrative and clinical staff (of any band) involved in decision making concerning

the commissioning of service, purchasing of goods, medicines, medical devices or equipment, and formulary decisions.

6. Identification, Declaration and Review of Interests

An individual Register of Interests for SRFT & PAT and an individual Register of Gifts and Hospitality for SRFT & PAT will be established as follows:

Register of Interests to include: Clinical private practice Outside employment (including self-employment) Shareholding and other ownership interests Patents Loyalty interests Sponsored research

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Sponsored posts

Register of Gifts and Hospitality to include: Gifts Hospitality Donations Sponsored events

6.1 When should a declaration of interests/gifts or hospitality be made?

a. Interests

- StaffStaff should declare any actual or potential interest: On appointment with the organisation (and on an annual basis thereafter) When staff move to a new role or their responsibilities change significantly As soon as circumstances change and new interests arise (for instance, in a meeting

when interests staff hold are relevant to the matters in discussion)

If staff are in any doubt as to whether a declaration of interests should be made, then they should declare it, so that it can be considered.

- Decision Making StaffDecision making staff should declare any actual or potential interest or confirm that they have nothing to declare: On appointment with the organisation (and on an annual basis thereafter) When staff move to a new role or their responsibilities change significantly As soon as circumstances change and new interests arise (for instance, in a meeting

when interests staff hold are relevant to the matters in discussion)

If staff are in any doubt as to whether a declaration of interests should be made, then they should declare it, so that it can be considered.

b. Gifts and HospitalityAll staff should declare any offered or received gifts and hospitality at the earliest opportunity (and in any event within 28 days). If staff are in any doubt as to whether a declaration of gifts and hospitality should be made, then they should declare it, so that it can be considered.

6.2 How to Make a DeclarationDeclarations of interests and gifts and hospitality can be made on the respective online form available in the ‘Declarations’ section of the organisations intranet, allowing submissions to be added at any time.

Further clarity about what you should declare and where you can make these declarations can be sought from the Group Secretary [0161 206 5185], or the Anti-Fraud Specialist at SRFT (for SRFT staff) or PAT (for PAT staff) if staff are uncertain about what is acceptable.

6.3 Requesting staff to submit a declaration to the Register of Interests

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All staff will be made aware of the requirement to make an on-line declaration on the Register of Interests on appointment, as part of the recruitment and induction process and/or by their employment contract.

In addition, we will:

- StaffPrompt all staff, as part of their annual appraisal and/or by completing anti-fraud training, to complete an annual, or up to date, on-line declaration of interest if they have an actual or potential interest to declare; however there will be no necessity to make a nil return.

- Decision Making StaffPrompt decision making staff twice yearly via internal communications, and as part of their annual appraisal and/or by completing anti-fraud training, to complete an annual, or up to date, on-line declaration of interests or confirm that they have nothing to declare.

6.4 Requesting staff to submit a declaration to the Register of Gifts and Hospitality All staff will be made aware of the requirement to make an on-line declaration regarding gifts and hospitality on appointment, as part of the recruitment and induction process and/or by their employment contract.

In addition, we will prompt all staff via anti-fraud training of the requirement to make an on-line declaration regarding gifts and hospitality.

Furthermore, a dedicated section of the organisations intranet will provide all staff with access to the Standards of Business Conduct Policy, supporting information and the online declaration form for the Register of Interests and the Register of Gifts and Hospitality at any time.

The organisation will utilise its internal communication channels to make staff aware of the requirement to declare interests and gifts and hospitality.

6.5 PublicationAll declarations of interest and gifts and hospitality will be reviewed by the Group Secretary on a monthly basis.

The organisation will publish, and make available to the public on its website, its Register of Interests and Register of Gifts and Hospitality (including decision making staff and staff) on a twice yearly basis. Historic Registers of Interests and Registers of Gifts and Hospitality will be maintained for 6 years.

If staff have substantial grounds for believing that publication of their interests should not take place then they should contact the Group Secretary to explain why. In exceptional circumstances, for instance where publication of information might put a member of staff at risk of harm, information may be withheld or redacted on public registers. However, this would be the exception and information will not be withheld or redacted merely because of a personal preference.

7. Wider transparency initiativesThe organisation fully supports wider transparency initiatives in healthcare, and we encourage staff to engage actively with these.

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Relevant staff are strongly encouraged to give their consent for payments they receive from the pharmaceutical industry to be disclosed as part of the Association of British Pharmaceutical Industry (ABPI) Disclosure UK initiative. These “transfers of value” include payments relating to:

Speaking at and chairing meetings Training services Advisory board meetings Fees and expenses paid to healthcare professionals Sponsorship of attendance at meetings, which includes registration fees and the

costs of accommodation and travel, both inside and outside the UK Donations, grants and benefits in kind provided to healthcare organisations

Further information about the scheme can be found on the ABPI website:

http://www.abpi.org.uk/our-work/disclosure/about/Pages/default.aspx

Staff must also disclose the above information on the relevant Register of Interest or Register of Gifts and Hospitality.

8. Management of Interests – General If an interest is declared but there is no risk of a conflict arising then no action is warranted. However, if a material interest is declared then the general management actions that could be applied include:

restricting staff involvement in associated discussions and excluding them from decision making

removing staff from the whole decision making process removing staff responsibility for an entire area of work removing staff from their role altogether if they are unable to operate effectively in

it because the conflict is so significant

Each case will be different and context-specific, and the Group Secretary will always clarify the circumstances and issues with the individuals involved. Staff should maintain a written audit trail of information considered and actions taken.

Staff who declare material interests should also make their line manager or the person(s) they are working to aware of their existence.

9. Management of Interests – Common SituationsThis section sets out the principles and rules to be adopted by staff in common situations, and what information should be declared.

9.1 Clinical Private PracticeConsultants and associate specialists employed under the Terms and Conditions of Service of Hospital Medical and Dental Staff are permitted to carry out private practice or other work for the private sector, providing they do not do so within the time they are contracted to the organisation. Specific queries relating to individual contracts of employment should be clarified with the Human Resources department. Any work should be subject to the conditions outlined in “A Guide to the Management of Private Practice in

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the NHS.” Consultants who have signed new contracts with the relevant organisation will be subject to the terms applied to private practice in those contracts.

In summary, clinical staff should declare all private practice on appointment, and/or any new private practice when it arises1 including:

Where they practise (name of private facility). What they practise (specialty, major procedures). When they practise (identified sessions/time commitment).

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):

Seek prior approval of their organisation before taking up private practice and seek agreement for their NHS Medical Secretary or any other NHS support staff who support their private practice by disclosing details of NHS staff they pay to support their clinical private practice.

Ensure that, where there would otherwise be a conflict or potential conflict of interest, NHS commitments take precedence over private work.2

Not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines: https://assets.publishing.service.gov.uk/media/542c1543e5274a1314000c56/Non-Divestment_Order_amended.pdf

Hospital Consultants should not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on their behalf.

What should be declared Staff name and their role with the organisation. A description of the nature of the private practice (e.g. what, where and when staff

practise, sessional activity, etc.). Relevant dates. Any other relevant information (e.g. action taken to mitigate against a conflict,

details of any approvals given to depart from the terms of this policy).

9.2 Outside Employment (including self-employment)Staff must declare any existing outside employment on appointment and any new outside employment when it arises. This includes setting up a business at home, self-employment and running or assistance in private practice e.g. Consultant Medical Secretaries.

Where a risk of conflict of interest arises, the general management actions outlined in this policy should be considered and applied to mitigate risks.

1 Hospital Consultants are already required to provide their employer with this information by virtue of Para.3 Sch. 9 of the Terms and Conditions – Consultants (England) 2003: https://www.bma.org.uk/-/media/files/pdfs/practical advice at work/contracts/consultanttermsandconditions.pdf2 These provisions already apply to Hospital Consultants by virtue of Paras.5 and 20, Sch. 9 of the Terms and Conditions – Consultants (England) 2003: https://www.bma.org.uk/-/media/files/pdfs/practical advice at work/contracts/consultanttermsandconditions.pdf)

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https://assets.publishing.service.gov.uk/media/542c1543e5274a1314000c56/Non-Divestment_Order_amended.pdf

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Where contracts of employment or terms and conditions of engagement permit, staff may be required to seek prior approval from the organisation to engage in outside employment or self-employment.

The organisation may also have legitimate reasons within employment law for knowing about outside employment of staff, even when this does not give rise to risk of a conflict.

Staff are advised that working for a secondary employer or in self-employment, whilst absent from work due to being medically certified unfit is not permitted, unless under the direction of medical advice with agreement from the Occupational Health Department and the Line Manager. Where an employee is suspected of secondary employment or self-employment working whilst absent due to sickness these matters will be investigated in accordance with the organisation’s Anti-Fraud, Bribery and Corruption Policy and the Disciplinary Policy.

What should be declared Staff name and their role with the organisation. The nature of the outside employment or self-employment (e.g. who is the

secondary organisation or trading name if self- employed, a description of duties, time commitment).

Relevant dates. Other relevant information (e.g. action taken to mitigate against a conflict, details

of any approvals given to depart from the terms of this policy).

9.3 Shareholdings and other ownership issuesStaff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with the organisation.

Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.

There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts.

What should be declared Staff name and their role with the organisation. Nature of the shareholdings/other ownership interest. Relevant dates. Other relevant information (e.g. action taken to mitigate against a conflict, details


9.4 PatentsStaff should declare patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by the organisation.

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Staff should seek prior permission from the organisation before entering into any agreement with bodies regarding product development, research, work on pathways etc., where this impacts on the organisation’s own time, or uses its equipment, resources or intellectual property.

Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.

What should be declared Staff name and their role with the organisation. A description of the patent. Relevant dates. Other relevant information (e.g. action taken to mitigate against a conflict, details

of any approvals given to depart from the terms of this policy)

9.5 Loyalty interestsLoyalty interests should be declared by staff involved in decision making where they:

Hold a position of authority in another NHS organisation or commercial, charity, voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role.

Sit on advisory groups or other paid or unpaid decision making forums that can influence how an organisation spends taxpayers’ money.

Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners.

Are aware that their organisation does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities.

What should be declared Staff name and their role with the organisation. Nature of the loyalty interest. Relevant dates. Other relevant information (e.g. action taken to mitigate against a conflict, details


9.6 Sponsored research Funding sources for research purposes must be transparent.

Any proposed research must go through the relevant health research authority or other approvals process.

There must be a written protocol and written contract between staff, the organisation, and/or institutes at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services.

The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service.

Staff should declare involvement with sponsored research to the organisation.

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What should be declaredThe organisation will retain written records of sponsorship of research, in line with the above principles and rules.

Staff should declare: their name and their role with the organisation. Nature of their involvement in the sponsored research. relevant dates. Other relevant information (e.g. what, if any, benefit the sponsor derives from the

sponsorship, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

9.7 Sponsored postsExternal sponsorship of a post requires prior approval from the organisation.

Rolling sponsorship of posts should be avoided unless appropriate checkpoints are put in place to review and withdraw if appropriate.

Sponsorship of a post should only happen where there is written confirmation that the arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. This should be audited for the duration of the sponsorship. Written agreements should detail the circumstances under which organisations have the ability to exit sponsorship arrangements if conflicts of interest which cannot be managed arise.

Sponsored post holders must not promote or favour the sponsor’s products, and information about alternative products and suppliers should be provided.

Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.

What should be declared The organisation will retain written records of sponsorship of posts, in line with the

above principles and rules. Staff should declare any other interests arising as a result of their association with

the sponsor, in line with the content in the rest of this policy.

9.8 GiftsStaff should not accept gifts that may affect, or be seen to affect, their professional judgement.

Gifts from suppliers or contractors: Gifts from suppliers or contractors doing business (or likely to do business) with

the organisation should be declined, whatever their value. Low cost branded promotional aids such as pens or post-it notes may, however,

be accepted where they are under the value of £63 in total, and need not be declared.

3 The £6 value has been selected with reference to existing industry guidance issued by the ABPI: http://www.pmcpa.org.uk/thecode/Pages/default.aspx

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Gifts from other sources (e.g. patients, families, service users): Gifts of cash and vouchers to individuals should always be declined. Staff should not ask for any gifts. Gifts valued at over £25 should be treated with caution and only be accepted on

behalf of the Group, and/or its constituent organisations, wherever possible not in a personal capacity. These should be declared by staff.

Modest gifts accepted under a value of £25 do not need to be declared but should be shared with team colleagues where practical e.g. box of chocolates or biscuits.

A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £25 where the cumulative value exceeds £25.

What should be declared Staff name and their role with the organisation. A description of the nature and value of the gift, including its source. Date of receipt. Any other relevant information (e.g. circumstances surrounding the gift, action

taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

9.8 HospitalityStaff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement.

Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable. Senior approval must be obtained.

Meals and refreshments: Under a value of £25 - may be accepted and need not be declared. Of a value between £25 and £754 - may be accepted and must be declared. Over a value of £75 - should be refused unless (in exceptional circumstances)

senior approval is given. A clear reason should be recorded on the organisation’s Register(s) of Gifts and Hospitality as to why it was permissible to accept.

A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or a reasonable estimate).

Travel and accommodation: Modest offers to pay some or all of the travel and accommodation costs related to

attendance at events may be accepted and must be declared. Offers which go beyond modest, or are of a type that the organisation itself might

not usually offer, need approval by senior staff (e.g. Group Officer, Executive Director, Managing Director, Chair of Division, Clinical Director or Corporate Head of Service) should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on Register of Gifts and Hospitality

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as to why it was permissible to accept travel and accommodation of this type. A non-exhaustive list of examples includes:

o offers of business class or first class travel and accommodation (including domestic travel)

o offers of foreign travel and accommodation.

What should be declared Staff name and their role with the organisation. The nature and value of the hospitality including the circumstances. Date of receipt. Any other relevant information (e.g. action taken to mitigate against a conflict,

details of any approvals given to depart from the terms of this policy).

9.10 Donations Donations made by suppliers or bodies seeking to do business with the organisation

should be treated with caution and not routinely accepted. In exceptional circumstances they may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value.

Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for the organisation, or is being pursued on behalf of the organisation’s own registered charity or other charitable body and is not for their own personal gain.

Staff must obtain permission from the organisation if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign for a charity other than the organisation’s own.

Donations, when received, should be made to a specific charitable fund (never to an individual) and a receipt should be issued.

Staff wishing to make a donation to a charitable fund in lieu of receiving a professional fee may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

What should be declaredThe organisation will maintain records in line with the above principles and rules and relevant obligations under charity law.

9.11 Sponsored events Sponsorship of events by appropriate external bodies will only be approved if a

reasonable person would conclude that the event will result in clear benefit for the Group, and its constituent organisations, and the NHS.

During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

No information should be supplied to the sponsor from whom they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

At the organisation’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.

The involvement of a sponsor in an event should always be clearly identified.

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Staff within the Group, and its constituent organisations, involved in securing sponsorship of events should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.

Staff arranging sponsored events must declare this.

What should be declared The organisation will maintain records regarding sponsored events in line with the

above principles and rules.

10. Strategic Decision Making GroupsThe organisation utilises a robust assurance framework and committee structure, as detailed in the Group Governance Framework Manual, to make key strategic decisions about things such as:

Entering into (or renewing) large scale contracts Awarding grants Making procurement decisions Selection of medicines, equipment, and devices

The interests of those who are involved in these committees should be well known so that they can be managed effectively.

These committees should adopt the following principles: Chairs should consider any known interests of members in advance, and begin

each meeting by asking for declaration of relevant material interests. Members should take personal responsibility for declaring material interests at the

beginning of each meeting and as they arise. Any new interests identified should be added to the organisation’s register(s). The vice chair (or other non-conflicted member) should chair all or part of the

meeting if the chair has an interest that may prejudice their judgement.

If a member has an actual or potential interest the chair should consider the following approaches and ensure that the reason for the chosen action is documented in minutes or records:

Requiring the member to not attend the meeting. Excluding the member from receiving meeting papers relating to their interest. Excluding the member from all or part of the relevant discussion and decision. Noting the nature and extent of the interest, but judging it appropriate to allow the

member to remain and participate. Removing the member from the group or process altogether.

The default response should not always be to exclude members with interests, as this may have a detrimental effect on the quality of the decision being made. Good judgement is required to ensure proportionate management of risk.

11. ProcurementProcurement should be managed in an open and transparent manner, compliant with procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour - which is against the interest of patients, service users and the public.

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Those involved in procurement exercises for and on behalf of the organisation should keep records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes. At every stage of procurement steps should be taken to identify and manage conflicts of interest to ensure and to protect the integrity of the process.

12. Confidentiality AgreementPrior to or in entering a contract with an organisation/s, parties may wish to disclose to each other certain confidential information in relation to the purpose of the contract. In these circumstances, to ensure each party maintains the confidentiality of the information it will be necessary to complete a Confidentiality Agreement to comply with strict terms and conditions in connection with the disclosure and use of confidential information. A template ‘Confidentiality Agreement’ is at Appendix 2 and advice should be sought from the Group Secretary.

13. Dealing with breachesThere may be situations when interests will not be identified, declared or managed appropriately and effectively. This may happen innocently, accidentally, or because of the deliberate actions of staff or other organisations. For the purposes of this policy these situations are referred to as ‘breaches’.

13.1 Identifying and reporting breachesTo ensure that interests are effectively managed staff are encouraged to speak up about actual or suspected breaches. Every individual has a responsibility to do this.

Staff who are aware about actual breaches of this policy, or who are concerned that there has been, or may be, a breach, should follow the procedure highlighted in the SRFT (for SRFT staff) or PAT (for PAT staff) policies:

Anti-Fraud, Bribery and Corruption Policy and Response Plan Whistleblowing and Concerns Reporting Policy

The organisation will investigate each reported breach according to its own specific facts and merits, and give relevant parties the opportunity to explain and clarify any relevant circumstances.

Following investigation the organisation will: Decide if there has been or is potential for a breach and if so what the severity of

the breach is. Assess whether further action is required in response – this is likely to involve any

staff member involved and their line manager, as a minimum. Consider who else inside and outside the organisation should be made aware Take appropriate action as set out in the next section.

13.2 Taking action in response to breachesAction taken in response to breaches of this policy will be in accordance with the procedures of the organisation and could involve organisational leads for staff support (e.g. Human Resources), fraud (e.g. Local Counter Fraud Specialists), members of the management or executive teams and organisational auditors.

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Breaches could require action in one or more of the following ways: Clarification or strengthening of existing policy, process and procedures. Consideration as to whether HR/employment law/contractual action should be

taken against staff or others. Consideration being given to escalation to external parties. This might include

referral of matters to external auditors, NHS Counter Fraud Authority (from July 17) the Police, statutory health bodies (such as NHS England, NHS Improvement or the CQC), and/or health professional regulatory bodies.

Inappropriate or ineffective management of interests can have serious implications for the organisation. There will be occasions where it is necessary to consider the imposition of sanctions for breaches.

Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrong-doing or fault then the organisation can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach.

This includes: Internal action with staff, which might include Informal action (such as reprimand, or signposting to training and/or guidance). Formal disciplinary action (such as formal warning, the requirement for additional

training, re-arrangement of duties, re-deployment, demotion, or dismissal). Reporting incidents to the external parties described above for them to consider

what further investigations or sanctions might be. Contractual action, such as exercise of remedies or sanctions against the body or

staff which caused the breach. Legal action, such as investigation and prosecution under fraud, bribery and

corruption legislation.

Further advice and information on the consequences of breaches and the range of potential sanctions is shown at Appendix 3

13.3 Learning and transparency concerning breachesReports on breaches, the impact of these, and action taken will be considered by the Group Audit Committee, as part of its review of ways in which staff can raise issues about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters and review of counter fraud work.

To ensure that lessons are learnt and management of interests can continually improve, anonymised information on breaches, the impact of these, and action taken will be made available for inspection by the public upon request.

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Appendix 1 [to Annex A] – Nolan Principles

The seven principles of public - the ‘Nolan Principles’

Selflessness Holders of public office should take decision solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family or their friends

Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties

Objectivity In carrying out public business, including making public appointments,awarding contracts or recommending individuals for awards or benefits, holders of public office should make choices on merit

Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office

Openness Holders of public office should be as open as possible about all decisions and actions they take. They should give reasons for their decisions, and restrict information only when the wider public interest clearly demands

Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest

Leadership Holders of public office should promote and support these principles by leadership and example

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Appendix 2 [to Annex A] – Template Confidentiality Agreement

TEMPLATE CONFIDENTIALITY AGREEMENT

THIS AGREEMENT is dated on the day that the last party has signed the Agreement between:

1. Salford Royal NHS Foundation Trust whose registered office is at Stott Lane, Salford M6 8HD (“SRFT”); and,

2. (ENTER NUMBER OF ADDITIONAL PARTNER’S AS REQUIRED)

BACKGROUNDThe Parties wish to disclose to each other certain information in relation to (the “Confidential Information”). ENTER THE PURPOSE OF THE AGREEMENT (the “Purpose”). Each Party wishes to ensure that the other Party maintains the confidentiality of its Confidential Information and, therefore, the Parties have agreed to comply with the following terms and conditions in connection with the disclosure and use of Confidential Information.

AGREED TERMS

1.0 THE CONFIDENTIAL INFORMATION

1.1 The Confidential Information includes all information disclosed or made available, directly or indirectly, in any form by a Party or its affiliates (the “Disclosing Party”) to the other Party (the “Recipient”), including but not limited to: (i) the fact that discussions are taking place concerning the Purpose and the status of those discussions; (ii) any confidential or proprietary information, data or opinions communicated or disclosed by either Party, including any information, data or opinions relating to the Disclosing Party’s business practices, its products (including but not limited to chemical structures, biological data, formulation recipes, technology), clinical study programme documentation, plans or relationships, or any of its processes, operations and/or intellectual property; (iii) any information or analysis derived from the Confidential Information; (iv) any other information or material that the Disclosing Party indicates is confidential.

1.2 In consideration of the Disclosing Party disclosing or making its Confidential Information available to the Recipient, the Recipient shall keep the Confidential Information confidential at all times and maintain it securely. The Recipient shall not without the Disclosing Party’s prior written consent: (i) use the Confidential Information in any way except for the Purpose; (ii) publish, make available or disclose any Confidential Information to any third party; (iii) copy the Disclosing Party’s Confidential Information except as strictly necessary for the Purpose; or (iv) disclose that there is any relationship between the Parties.

1.3 The Recipient will notify the Disclosing Party immediately of any loss or compromise of the Confidential Information and shall cooperate with the Disclosing Party’s reasonable instructions in order to minimise the consequences of the same.

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1.4 The confidentiality obligations of each Party shall continue for a period of ten (10) years from the date of this Agreement, or until the Parties enter into a separate agreement relating to the Purpose which addresses the use of the Confidential Information. Termination of this Agreement shall not affect any accrued rights or remedies.

1.5 After completion of the Purpose, termination of this Agreement, or at the Disclosing Party’s request, the Recipient shall cease all use of the Confidential Information. The Recipient shall promptly (i) return or, at the Disclosing Party’s option, destroy all Confidential Information and all documents and materials containing any Confidential Information; (ii) use reasonable endeavours to erase all Confidential Information from its computer systems; and (iii) confirm to the Disclosing Party in writing that it has complied with the requirements of this Clause.

2.0 EXCEPTIONS AND PERMITTED DISCLOSURES

2.1 The confidentiality obligations set out in this Agreement shall not apply to information that is: (i) generally available to the public other than as a result of any breach of this Agreement by the Recipient; (ii) obtained from a third party who had the full right to disclose it; (iii) lawfully in the Recipient’s possession (with full rights to disclose) before its disclosure under this Agreement; (iv) was developed independently by or for the Recipient without reference to the Confidential Information; or (v) has been approved for release by the Disclosing Party; or is required to be disclosed under the provisions of the Freedom of Information Act 2000.

2.2 The Recipient may retain one (1) copy of the Confidential Information for lawful purposes provided it obtains consent from the Disclosing Party, such consent not to be unreasonably withheld.

2.3 The Recipient may disclose the Confidential Information to those of its officers, employees, consultants and professional advisors (“Representatives”) who need to know such Confidential Information for the Purpose, provided that it (i) informs those Representatives of the confidential nature of the Confidential Information before disclosure; (ii) ensures that all such Representatives maintain the confidentiality of all such Confidential Information in accordance with the provisions of this Agreement; and (iii) remains liable for any unauthorised disclosure of Confidential Information by any of its Representatives as if it had made such disclosure itself.

2.4 The Recipient may disclose the Confidential Information to the extent required by law, by any governmental or other regulatory authority or by a court or other authority of competent jurisdiction, provided always that: (i) to the extent it is legally permitted to do so, it gives the Disclosing Party as much notice of such disclosure as possible; and (ii) it complies with the Disclosing Party’s reasonable directions for taking legally available steps to resist or narrow such requirement (at the Disclosing Party’s reasonable expense), and in any event restricts the disclosure to only those parts of the Confidential Information lawfully required to be disclosed.

3.0 RIGHTS TO AND ACCURACY OF CONFIDENTIAL INFORMATION

3.1 All rights, title and interest in and to the Confidential Information (including all intellectual property rights) shall remain the exclusive property of the Disclosing

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Party or its licensors. No rights in respect of the Confidential Information are granted to the Recipient other than those set out in this Agreement.

3.2 The Disclosing Party does not give any representation or warranty concerning the Confidential Information, its accuracy or its completeness, and neither the Disclosing Party nor any of its Representatives accept any liability to the Recipient for the accuracy or completeness of any of the Confidential Information or for any opinions, errors, omissions or misstatements contained in the Confidential Information.

4.0 GENERAL

4.1 The Recipient acknowledges that damages alone would not be an adequate remedy for the breach of any of the terms of this Agreement, and that, without prejudice to any other rights and remedies it may have, Disclosing Party shall be entitled to the granting of equitable relief (including without limitation injunctive relief) concerning any threatened or actual breach of any of the provisions of this Agreement.

4.2 Neither Party may assign, sub-license or otherwise transfer any or all of its rights or obligations under this Agreement without the prior written consent of the other Party.

4.3 This Agreement constitutes the entire agreement between the Parties and supersedes all prior written or oral agreements or understandings with respect to the subject matter of this Agreement.

4.4 Any amendment or modification to this Agreement must be in writing and signed by authorised representatives of each Party.

4.5 If any provision of this Agreement is held by any court or other competent authority to be invalid or unenforceable in whole or in part, this Agreement shall continue to be valid as to its other provisions and the remainder of the affected provision.

4.6 This Agreement is made under the laws of England and shall be subject to the non-exclusive jurisdiction of the English Courts regardless of place of execution or place of performance.

4.8 This Agreement may be executed in two or more counterparts, each of which will be deemed an original and all of which will together be deemed to constitute one agreement. The Parties agree that the execution of this Agreement by exchanging PDFs of wet-ink signatures shall have the same legal force and effect as the exchange of original signatures, and that in any proceeding arising under or relating to this Agreement.

4.9 Notwithstanding the date of this Agreement, this Agreement is deemed to take effect on (ENTER DATE).

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AGREED by the Parties on the dates indicated below

SIGNED for and on behalf of SIGNED for and on behalf ofBy: By:Name: Name:

Title: Title:

Date: Date:

(ENTER DETAILS FOR ALL PARTNERS)

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Appendix 3 [to Annex A] – Potential Sanctions

Disciplinary sanctionsStaff who fail to disclose any relevant interests or who otherwise breach this policy relating to the standards of business conduct are subject to investigation and, where appropriate, to disciplinary action. This may include:

Internal sanctions

Internal action with staff, might includeo Informal action (such as reprimand, or signposting to training and/or guidance).o Formal disciplinary action (such as formal warning, the requirement for additional

training, re-arrangement of duties, re-deployment, demotion, or dismissal).

Professional regulatory sanctionsStatutorily regulated healthcare professionals who work for, or are engaged by the organisation, are under professional duties imposed by their relevant regulator to act appropriately with regard to conflicts of interest. The organisation will consider reporting statutorily regulated healthcare professionals to their regulator if they believe that they have acted improperly, so that these concerns can be investigated. These healthcare professionals should be made aware that the consequences for inappropriate action could include fitness to practise proceedings being brought against them, and that they could, if appropriate be struck off by their professional regulator as a result.Information and contact details for the healthcare professional regulators are accessible from the Professional Standard Authority website:http://www.professionalstandards.org.uk/what-we-do/our-work-with-regulators/find-a-regulator

Civil sanctions

If conflicts of interest are not effectively managed, the organisation may face civil challenges to decisions it makes – for instance if interests were not disclosed that were relevant to the bidding for, or performance of contracts. In extreme cases, staff and other individuals could face personal civil liability, for example a claim for misfeasance in public office.

Criminal sanctionsFailure to manage conflicts of interest could lead to criminal proceedings including for offences such as fraud, bribery and corruption. This could have implications for the organisation concerned and linked organisations, and the individuals who are engaged by them.The Fraud Act 2006 created a criminal offence of fraud and defines three ways of committing it:• Fraud by false representation• Fraud by failing to disclose information and• Fraud by abuse of position.In these cases an offender’s conduct must be dishonest and their intention must be to make a gain, or a cause a loss (or the risk of a loss) to another. Fraud carries a maximum sentence of 10 years imprisonment and/or a fine and can be committed by a body corporate.

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The Bribery Act 2010 makes it easier to tackle this offence in public and private sectors. Bribery is generally defined as giving or offering someone a financial or other advantage to encourage a person to perform certain activities and can be committed by a body corporate. Commercial organisations (including NHS bodies) will be exposed to criminal liability, punishable by an unlimited fine, for failing to prevent bribery.

The offences of bribing another person or being bribed carries a maximum sentence of 10 years imprisonment and/or a fine. In relation to a body corporate the penalty for these offences is a fine.

The organisation does not, and will not, pay bribes or offer improper inducements to anyone for any purpose; nor will it accept bribes or improper inducements. It is important that all employees, contractors and agents are aware of the standards of behaviour expected of them contained in this policy

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Appendix: 4Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS

Trust

Group Committees in Common (Group CiC)Terms of Reference

1. Preface

1.1. At meetings in November 2016, the Board of Directors at SRFT and the Trust Board at PAHT reviewed and approved the architecture for Group, including the establishment of Group Committees in Common (Group CiC) in principle.

1.2. To establish the Committees in Common, the Board of Directors at SRFT and the Trust Board at PAHT shall each establish a committee, to which each Board shall delegate the exercise of its functions.

1.3. The committees will meet at the same time, around one table, to make the decisions in relation to SRFT and PAHT. Since each of the committees has delegated powers from their Boards, the decisions of each committee on matters within its remit will be final and will not need to be ratified by the SRFT and PAHT Boards.

1.4. To ensure best practice, Group CiC will be established to reflect, as closely as possible, all NHS Foundation Trust governance requirements and, as such, will comprise a Chairman, Voting Non-Executives and Voting Directors. Other Directors will attend in a non-voting capacity.

1.5. SRFT and PAHT have established Group Standing Orders (Board) that ensure effective and appropriate corporate governance arrangements are in place for the two sovereign organisations whilst in transition to Group.

1.6. The Group CiC shall follow and apply the Group Standing Orders (Board), save as modified within these Terms of Reference.

2. Establishment

2.1. The Board of Directors of SRFT and the Trust Board of PAHT have agreed to establish and constitute a committee with these terms of reference to be known as Group CiC.

3. Functions of the Committee:

3.1. The powers of SRFT and PAHT are established under statute. The Boards of SRFT and PAHT have resolved that certain powers and decisions are delegated to Group CiC and may only be exercised or made by Group CiC in formal session. These powers and decisions are set out in a Group Reservations of Powers to Board and Scheme of Delegation for the two sovereign organisations.

3.2. All business shall be conducted in the respective name of the Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust as applicable.

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4. Membership

4.1. Group CiC will comprise:

Voting Non-Executives Voting Executives Chairman Chief Executive Officer (CEO) Vice-Chairman Chief Medical Officer Senior Independent Director Chief Nursing Officer Non-Executive Director Chief Finance Officer Non-Executive Director Chief Strategy & Organisational Development Officer Non-Executive Director Chief Delivery Officer Non-Executive Director

4.2. Accountable Officers, for each Care Organisation within the Group, will be non-voting Group CiC members.

4.3. Executive and Non-Executive Directors of the SRFT and PAHT Boards, who are not appointed as voting members of Group CiC, will be non-voting Group CiC members.

5. Secretary

5.1. The Director of Corporate Services/Group Secretary will act as Secretary and will ensure all required information, support and advice is provided to Group CiC.

6. Meetings

6.1. The Group CiC shall at all times comply with the Group Standing Orders (including but not limited to provisions as to notice, quorum, papers and procedure at meetings), Standing Financial Instructions and the combined Board Schemes of Reservations of Powers & Delegation of Powers.

7. Reporting

7.1. The Group CiC shall report to the Boards of SRFT and PAHT [a minimum of three times per year or at such other intervals as the respective Boards may direct from time to time].

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Appendix 5:STANDING ORDERS OF THE COUNCIL OF GOVERNORS

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STANDING ORDERS OF THE COUNCIL OF GOVERNORS

CONTENTS

INTRODUCTIONStatutory Framework

1. INTERPRETATION

2. THE COUNCIL OF GOVERNORSComposition of the CouncilRole of the Chairperson

3. MEETINGS OF THE COUNCIL OF GOVERNORSAdmission of the Public and the PressCalling MeetingsNotice of MeetingsSetting the AgendaPetitionsChairman of MeetingNotices of MotionWithdrawal of Motion or AmendmentsMotion to Rescind a ResolutionMotionsChairperson’s RulingVotingMinutesSuspension of Standing OrdersVariation and Amendment of Standing OrdersRecord of AttendanceQuorum

4. COMMITTEESAppointment of Committees

5. DECLARATIONS OF INTERESTS Declaration of Interests

6. DISABILITY OF THE CHAIRPERSON OR GOVERNORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY INTEREST

7. STANDARDS OF BUSINESS CONDUCTPolicyInterest of Officers in ContractsCanvassing of, and Recommendations by, Directors in relation to appointmentsRelatives of Governors or Officers

8. MISCELLANEOUSStanding Orders to be Given to Directors and OfficersReview of Standing Orders

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INTRODUCTION

Statutory Framework

The Salford Royal NHS Foundation Trust (“SRFT”) is a statutory body, which became a public benefit corporation on 1st August 2006 following its approval as a NHS Foundation Trust by the Independent Regulator of NHS Foundation Trusts, Monitor.

The principal place of business of SRFT is:

Salford Royal, Stott Lane, Salford, M6 8HD

SRFT’s head office is at Chief Executive’s Office, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD or such other place as decided by the SRFT Board of Directors from time to time.

NHS Foundation Trusts are governed by an Act of Parliament, mainly the National Health Service Act 2006 as amended.

Monitor has authorised SRFT to become an NHS Foundation Trust subject to the conditions set out in Section 3 of SRFT’s Authorisation Document available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/293920/Salford_terms_of_authorisation_010806.pdf.

The NHS regulatory framework requires all Trusts to adopt Standing Orders for the regulation of their proceedings and business. Trusts must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals.

As set out in Standing Order 4.3 below, “the Standing Orders of the Council, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Council.”

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1. INTERPRETATION

1.1 Save as otherwise permitted by law, at any meeting the Chairman of the Trust shall be the final authority on the interpretation of Standing Orders on which he should be advised by the Chief Executive and the Secretary.

1.2 Any expression to which a meaning is given in the National Health Service Act 2006 and other Acts relating to the National Health Service or in the Financial or other Regulations made under the Acts or in the Authorisation or Constitution shall have the same meaning in this interpretation and in addition:

"AUTHORISATION" means the authorisation of the Trust by Monitor.

"BOARD” means the Board of Directors comprising the Chairman, Executive Directors and Non-Executive Directors.

"CHAIRMAN" is the person appointed in accordance with the Constitution to lead the Board of Directors and Council of Governors and to ensure that they successfully discharge their overall responsibility for the Trust as a whole.

The expression “the Chairman of the Trust” shall be deemed to include the Vice-Chairman of the Trust if the Chairman is absent from the meeting or is otherwise unavailable.

"CHIEF EXECUTIVE" means the Chief Executive Officer of the Trust.

"COMMITTEE" means a committee of the Council of Governors.

"COMMITTEE MEMBERS" means persons formally appointed by the Council of Governors or Board of Directors to sit on or to chair specific committees.

"CONSTITUTION" means the Constitution of the Trust.

"COUNCIL OF GOVERNORS" OR "COUNCIL” means the Council of Governors of the Trust as defined in the Constitution.

"DIRECTOR" may encompass either an Executive Director or a Non-Executive Director.

"EXECUTIVE DIRECTOR" means a Director of the Board with voting rights, who is an Officer of the Trust.

"MEMBER OF THE COUNCIL OF GOVERNORS" means a Governor of the Trust. (Member of the Council in relation to the Council of Governors does not include the Chair.)

"NON EXECUTIVE DIRECTORS" means a Director of the Board with voting rights, who is not an Officer of the Trust.

"OFFICER" means an employee of the Trust or any other person holding a paid appointment or office with the Trust.

"SOS" mean Standing Orders.

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"SECRETARY" means a person appointed to act independently of the Board to provide advice on corporate governance issues to the Board and the Chairman and monitor the Trust’s compliance with the law, SOs, Standing Financial Instructions and applicable guidance.

"TRUST” means the Salford Royal NHS Foundation Trust

"VICE-CHAIR" means the Non-Executive Director appointed by the Board to take on the Chairman’s duties if the Chairman is unable to discharge their office as Chairman.

1.3 References to legislation include all amendments, replacements or re-enactments made.

1.4 Words importing the masculine gender only shall include the feminine gender; words importing the singular shall import the plural and vice-versa.

2. THE COUNCIL OF GOVERNORS

2.1 Composition of the Council of Governors – In accordance with the constitution of the Foundation Trust, the composition shall be:

7 Public Governors4 Staff Governors1 Local Authority Governor appointed by Salford City Council 1 University Governor appointed by University of Manchester

2.2 Role of The Chair

Under the Trust’s regulatory framework, the Chairman presides at meetings of the Council and has a casting vote.

Where the Chairman of the Trust has died or has otherwise ceased to hold office, or where he is unable to perform his duties as Chairman owing to illness, absence or any other cause, the Vice-Chairman shall take on the duties of Chairman until a new Chairman is appointed or the existing Chairman resumes his duties, as the case may be; and references to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform those duties, be taken to include references to the Vice-Chairman.

3. MEETINGS OF THE COUNCIL OF GOVERNORS

3.1 Admission of the Public – The public shall be afforded facilities to attend all formal meetings of the Council of Governors except where the Council resolves:

That members of the public be excluded from the remainder of a meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public and /or;

That in the interest of the public order of the meeting, the Council shall adjourn for a period to be specified in such resolution to enable the Council to complete business without the presence of the public;

Nothing in these Standing Orders shall require the Council to allow members of the public to record proceedings in any manner whatsoever, other than writing or making any oral report of proceedings as they take place, without the prior agreement of the Council.

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3.2 Calling Meetings – The Council of Governors is to meet at least three times in each financial year. Save in the case of emergencies or the need to conduct urgent business, the Secretary shall give at least fourteen days’ written notice of the date and place of every meeting of the Council of Governors to all Governors. Notice of every meeting of the Council of Governors which is open to the public will also be published in the Trust’s members’ newsletter and on the Trust’s website.

3.3 Meetings of the Council of Governors may be called by the Secretary, or by the Chairman, or by six Governors who give written notice to the Secretary specifying the business to be carried out. The Secretary shall send a written notice to all Governors as soon as possible after receipt of such a request. The Secretary shall call a meeting on at least fourteen but not more than twenty-eight days’ notice to discuss the specified business. If the Secretary fails to call such a meeting then the Chairman or six Governors, whichever is the case, shall call such a meeting.

3.4 Notice of Meetings - At least fourteen days before each meeting of the Council, a written notice of the meeting, specifying the business proposed to be transacted at it, and signed by the Chairman or by an Officer of the Trust authorised by the Chairman to sign on his behalf shall be delivered to every Member of the Council, or sent by post to the usual place of residence of such Member of the Council, so as to be available to him at least three clear days before the meeting.

3.5 Lack of service of the notice on any Member of the Council shall not affect the validity of a meeting.

3.6 In the case of a meeting called by Members of the Council in default of the Secretary and / or the Chairman, those Members of the Council shall sign the notice and no business shall be transacted at the meeting other than that specified in the notice.

3.7 Fourteen days before each meeting of the Council a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust’s office.

3.8 Setting the Agenda - The Council may determine that certain matters shall appear on every agenda for a meeting and shall be addressed prior to any other business being conducted.

3.9 A Member of the Council desiring a matter to be included on an agenda shall make his request in writing to the Chairman and Secretary at least 10 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the Chairman.

3.10 Petitions – Where a petition has been received by the Trust the Chairman shall include the petition as an agenda item of the next Council meeting.

3.11 Chair of Meeting –The Chairman of the Foundation Trust or, in their absence, the Vice Chairman of the Board of Directors, or in their absence one of the Non-Executive Directors is to preside at meetings of the Council of Governors. If the person presiding at any such meeting has a conflict of interest in relation to the business being discussed, the Lead Governor of the Council of Governors will chair that part of the meeting.

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3.12 Notices of Motion - A Member of the Council desiring to move or amend a motion shall send a written notice thereof at least 10 clear days before the meeting to the Chairman, who shall insert in the agenda for the meeting all notices so received subject to the notice being permissible under the appropriate regulations. This paragraph shall not prevent any motion being moved during the meeting, without notice on any business mentioned on the agenda.

3.13 Withdrawal of Motion or Amendments - A motion or amendment once moved and seconded may be withdrawn by the proposer with the concurrence of the seconder and the consent of the Chair.

3.14 Motion to Rescind a Resolution - Notice of motion to amend or rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the Member of the Council who gives it and also the signature of 4 other Members. When any such motion has been disposed of by the Council, it shall not be competent for any Member other than the Chairman to propose a motion to the same effect within six months; however the Chairman may do so if he/she considers it appropriate.

3.15 Motions - The mover of a motion shall have a right of reply at the close of any discussion on the motion or any amendment thereto.

3.16 When a motion is under discussion or immediately prior to discussion it shall be open to a Member of the Council to move:

An amendment to the motion. The adjournment of the discussion or the meeting. That the meeting proceed to the next business. (*) The appointment of an ad hoc committee to deal with a specific item of business. That the motion be now put. (*) A motion under Section 1 (2) of the Public Bodies Admission to Meetings) Act

1960 resolving to exclude the public (including the press). *

In the case of sub-paragraphs denoted by (*) above to ensure objectivity motions may only be put by a Member of the Council who has not previously taken part in the debate.

No amendment to the motion shall be admitted if, in the opinion of the Chair of the meeting, the amendment negates the substance of the motion.

3.17 Chair’s Ruling – Statements of Members of the Council made at meetings of the Council shall be relevant to the matter under discussion at the material time and the decision of the Chair of the meeting on questions of order, relevancy, regularity, and any other matters shall be final.

3.18 Voting - Every question at a meeting shall be determined by a majority of the votes of the members of the Council present and voting on the question and, in the case of the number of votes for and against a motion being equal, the Chair of the meeting shall have a casting vote. No resolution of the Council of Governors shall be passed if it is opposed by all of the Public Governors present.

3.19 All questions put to the vote shall, at the discretion of the Chair of the meeting, be determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the members of the Council present so request.

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3.20 If at least one third of the members of the Council present so request, the voting (other than by paper ballot) on any question may be recorded to show how each member of the Council present voted or abstained.

3.21 If a member of the Council so requests, his/her vote shall be recorded by name upon any vote (other than by paper ballot).

3.22 The Council of Governors may agree that its members can participate in its meetings by telephone, video or computer link. Participation in a meeting in this manner shall be deemed to constitute presence in person at the meeting. In no circumstances may an absent member of the Council vote by proxy. Absence is defined as being absent at the time of the vote.

3.23 Minutes - The Minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where the person presiding at it will sign them.

3.24 No discussion shall take place upon the minutes except upon their accuracy or where the Chair considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.

3.25 Minutes shall be circulated in accordance with members’ wishes.

3.26 Suspension of Standing Orders - Except where this would contravene any statutory provision or any provision of the Authorisation or of the Constitution or the rules relating to the Quorum, any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the Council are present and that a majority of those present vote in favour of suspension.

3.27 A decision to suspend Standing Orders shall be recorded in the minutes of the meeting.

3.28 A separate record of matters discussed during the suspension of Standing Orders shall be made and shall be available to the Chairman and Members of the Council.

3.29 No formal business may be transacted while Standing Orders are suspended.

3.30 Variation and Amendment of Standing Orders - These Standing Orders shall be amended only if:

a notice of motion under Standing Order 3.12 has been given; and

no fewer than half of the Trust’s Council of Governors vote in favour of amendment; and

at least two-thirds of the Council of Governors are present; and

the variation proposed does not contravene a statutory provision or provision of the Authorisation or of the Constitution

3.31 Record of Attendance - The names of the Chair and Members of the Council present at the meeting shall be recorded in the minutes.

3.32 Quorum - Eight Governors, regardless of type, shall form a quorum.

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4. COMMITTEES

4.1 Appointment of Committees - The Council of Governors may not delegate any of its powers to a committee or sub-committee, but it may appoint committees consisting of its members, Directors, and other persons to assist the Council of Governors in carrying out its functions. The Council of Governors may, through the Secretary, request that advisors assist them or any committee they appoint in carrying out its duties.

4.2 A committee appointed under this regulation may, subject to such directions as may be given by the Monitor, the independent regulator, appoint sub-committees consisting wholly or partly of members of the committee.

4.3 The Standing Orders of the Council, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Council. In which case the term “Chair” is to be read as a reference to the Chair of the committee as the context permits, and the term “Member of the Council” is to be read as a reference to a member of the committee also as the context permits.

4.4 Each such committee shall have such terms of reference and powers and be subject to such conditions (as to reporting back to the Council), as the Council shall decide and shall be in accordance with the regulatory framework and any direction or guidance issued by Monitor. Such terms of reference shall have effect as if incorporated into the Standing Orders.

4.5 The Council shall approve the appointments to each of the committees, which it has formally constituted.

4.6 Where the Council is required to appoint persons to undertake statutory functions and where such appointments shall be made independently of the Council such appointments shall be made in accordance with applicable statute and regulations and with guidance issued by Monitor.

4.7 The Committees and sub-committees established by the Council shall be such committees as are required to assist the Council in carrying out its function.

5. DECLARATIONS OF INTERESTS

5.1 Declaration of Interests - The constitution requires Members of the Council of Governors to declare interests, which are relevant and material to the Council of which they are a member. All existing Members should declare such interests. Any Members appointed subsequently should do so on appointment.

5.2 Subject to the exceptions below, a material interest is:

a) any directorship of a company;

b) any interest or position held by a Governor in any firm or company or business which, in connection with the matter, is trading with the Trust, or is likely to be considered as a potential trading partner with the Trust;

c) any interest in an organisation providing health and social care services to the National Health Service;

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d) a position of authority in a charity or voluntary organisation in the field of health and social care;

e) any connection with any organisation, entity or company considering entering into a financial arrangement with the Trust including but not limited to lenders or banks.

The exceptions, which shall not be treated as material interests are as follows:

a) shares not exceeding 2% of the total shares in issue held in any company whose shares are listed on any public exchange;

b) an employment contract held by Staff Governors;

c) an employment contract with, or a position of authority in, a local authority held by a Local Authority Governor;

d) an employment contract with, or a position of authority, in a university held by a University Governor.

5.3 At the time Members' interests are declared, they should be recorded in the Council minutes. Any changes in interests should be officially declared at the next Council meeting following the change occurring.

5.4 Members' directorships of companies likely or possibly seeking to do business with the NHS should be published in the Annual Report. The information should be kept up to date for inclusion in succeeding Annual Reports.

5.5 During the course of a Council meeting, if a conflict of interest is established, the member concerned should withdraw from the meeting and play no part in the relevant discussion or decision. For the avoidance of doubt, this includes voting on such an issue where a conflict is established. If there is a dispute as to whether a conflict of interest does exist, majority will resolve the issue with the Chair having the casting vote.

5.6 There is no requirement for the interests of Members' spouses or partners to be declared. However Standing Order 7, which is based on the regulations, requires that the interests of Members’ spouses or partners, in contracts should be declared. Therefore the interests of Members’ spouses and cohabiting partners should also be regarded as relevant.

5.7 If Members have any doubt about the relevance or materiality of an interest, this should be discussed with the Chairman and Secretary. Influence rather than the immediacy of a relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.

6. DISABILITY OF CHAIR OR GOVERNORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY INTEREST

6.1 Subject to the following provisions of this Standing Order, if the Chair or a member of the Council has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Trust at which the contract or other matter is the subject of consideration, he shall at the meeting and as soon as practicable after its

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commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

6.2 The Council may exclude the Chair or a Member of the Council from a meeting of the Council while any contract, proposed contract or other matter in which he has a pecuniary interest, is under consideration.

6.3 Any remuneration, compensation or allowances payable to the Chair or a Member of the Council in accordance with the Constitution shall not be treated as a pecuniary interest for the purpose of this Standing Order.

6.4 For the purpose of this Standing Order the Chairman or a Member of the Council shall be treated as having indirectly a pecuniary interest in a contract, proposed contract or other matter, if:

(a) he, or a nominee of his, is a director of a company or other body, not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or

(b) he is a partner of, or is in the employment of a person with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration.

In the case of married persons living together the interest of one spouse shall, if known to the other, be deemed for the purposes of this Standing Order to be also an interest of the other.

6.5 The Chair or a Member of the Council shall not be treated as having a pecuniary interest in any, proposed contract or other matter by reason only:

(a) of his membership of a company or other body, if he has no beneficial interest in any securities of that company or other body;

(b) of an interest in any company, body or person with which he is connected as mentioned in SO 6.4 above which is so remote or insignificant that it cannot reasonably be regarded as likely to influence an individual in the consideration or discussion of or in voting on, any question with respect to that contract or matter.

6.6 Where the Chair or a member of the Council:

(a) has an indirect pecuniary interest in a contract, proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body;

(b) the total nominal value of those securities does not exceed £5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less, and

(c) if the share capital is of more than one class, the total nominal value of shares of any one class in which he/she has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class,

this Standing Order shall not prohibit him from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it without prejudice however to his duty to disclose his interest.

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6.7 This Standing Order applies to a committee or sub-committee as it applies to the Council and applies to any member of any such committee or sub-committee (whether or not he/she is also a member of the Council) as it applies to a member of the Council.

7. STANDARDS OF BUSINESS CONDUCT

7.1 Policy - Governors must comply with the Code of Conduct for Governors, the “Standards of Business Conduct for NHS Staff” and the Trust’s Standards of Business Conduct Policy. Governors shall receive a copy of the Standards of Business Conduct during their induction. The following provisions should be read in conjunction with the Code of Conduct for Governors.

7.2 Interest of Officers in Contracts - If it comes to the knowledge of a Governor or an Officer of the Trust that a contract in which he has any pecuniary interest not being a contract to which he is himself a party, has been, or is proposed to be, entered into by the Trust he shall, at once, give notice in writing to the Chief Executive of the fact that he is interested therein. In the case of (married) persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

7.3 A Governor must also declare to the Chief Executive any other employment or business or other relationship of his, or of a cohabiting partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

7.4 Canvassing of, and Recommendations by, Members of the Council in Relation to Appointments - Canvassing of Governors of the Trust or of any Committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

7.5 A member of the Council shall not solicit for any person any appointment under the Trust or recommend any person for such appointment: but this paragraph of this Standing Order shall not preclude a member of the Council from giving written testimonial of a candidate's ability, experience or character for submission to the Trust or taking part in the appointment process.

7.6 Informal discussions outside appointments panels or committees, whether solicited or unsolicited, should be declared to the panel or committee.

7.7 Relatives of Members of the Council or Officers - Candidates for any staff appointment shall when making an application disclose in writing whether they are related to any member of the Council or the holder of any office under the Trust. Failure to disclose such a relationship may disqualify a candidate and, if appointed, may render him liable to instant dismissal.

7.8 The Chairman, Members of the Council and every Officer of the Trust shall disclose to the Chief Executive any relationship with a candidate of whose candidature that Member of the Council is aware. It shall be the duty of the Chief Executive to report to the Trust any such disclosure made. Relationships to which this order applies are those of husband and wife or co-habitees or where either of the two or the spouse of either of them is the son or daughter or grandson or granddaughter or brother or sister or nephew or niece of the other or the spouse of the other.

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7.9 On appointment, Members of the Council (and prior to acceptance of an appointment in the case of Officer members) should disclose to the Council whether they are related to any other Member of the Council or holder of any office under the Trust.

7.10 Where the relationship to a Member of the Council is disclosed, the Standing Order headed “Disability of the Chair and Members in proceedings on account of pecuniary interest” (SO 6) shall apply.

8. MISCELLANEOUS

8.1 Standing Orders to be made available to Members of the Council - It is the duty of the Chief Executive to ensure that existing members of the Council and all new appointees are notified of and understand their responsibilities within Standing Orders and SFIs. Updated copies can be obtained from the Secretary’s Office. New members of the Council shall receive a copy of the Standing Orders of the Council of Governors during their induction.

8.2 Review of Standing Orders Governing Council - These shall be reviewed annually by the Council. The requirement for review extends to all documents having effect as if incorporated in Standing Orders.

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Appendix 6: Terms of Reference: Shadow Group Council of Governors

Contents

Section

Who should read this documentKey MessagesWhat is new in this version

IntroductionKey Responsibilities and MeetingsFrequency of MeetingsMembershipChairmanshipQuorumAttendanceMeetingsReporting ArrangementsSecretary

Classification: Terms of Reference for Shadow Group Council of GovernorsAdditional author(s): Lead Author: Jane Burns, Associate Director of Corporate Affairs / Trust Secretary Authors Division: Trust Executive

Unique ID: Issue number: 1Expiry Date: March 2019

Group Arrangements:

Salford Royal NHS Foundation Trust

(SRFT)Pennine Acute

Hospitals NHS Trust (PAT)

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Who should read this document?

All Governors, including Shadow Governors Group Secretariat

Key Messages

In recognition of Salford Royal NHS Foundation Trust (Salford Royal) setting out parameters to establish a Group, with Pennine Acute Hospitals NHS Trust (PAHT) being the first member, the Council of Governors of Salford Royal has agreed to establish and constitute a committee with these terms of reference to be known as Shadow Group Council of Governors Committee. The committee will include both Salford Royal Governors and Shadow Governors.

This Committee will:

− ensure effective representation of the interests of SRFT and PAHT members and the public served by Group;

− engage with and ensure the involvement of local stakeholders of both SRFT and PAHT;

− enable views to be provided to the Group Committees in Common (CiC) as part of the Group forward planning process whilst maintaining and assisting an effective SRFT Council of Governors to perform its functions; and

− provide the Group CiC a forum that bears similarity to the Council of Governors that may be established if and when SRFT and PAHT ultimately come together into a single NHS foundation trust.

What is new in this version?

N/A

Policy/Guideline/Protocol

1. Introduction

1.1. The SRFT Council of Governors has resolved to establish a committee of existing Governors from SRFT together with representatives of PAHT to be known as Shadow Group Council of Governors Committee.

1.2. SRFT’s Council of Governors has established Standing Orders to ensure effective and appropriate corporate governance arrangements are in place for its operation. The Shadow Group Council of Governors shall follow and apply the Standing Orders (Council of Governors), save as modified within these Terms of Reference

2. Key Responsibilities and Duties

2.1. The powers of SRFT’s Council of Governors are established under statute. The Council of Governors may not delegate any of its powers to a committee or sub-committee, but it has appointed this committee to assist the SRFT Council of Governors in carrying out its functions, in particular, the Shadow Group Council of Governors Committee is expected to

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assist by carrying out those functions set out in the SRFT Scheme of Reservation and Delegation of Powers.

2.2. The Shadow Group Council of Governors Committee may establish committees to assist the Shadow Group Council of Governors Committee in performing its functions, including on such terms as to reporting and membership, as it sees fit.

2.3. All business shall be conducted in the respective name of the Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust as applicable.

3. Frequency of Meetings

3.1 The Committee will meet a minimum of three times per year or at such other intervals as SRFT Council of Governors may direct from time to time.

4. Membership

4.1. Membership will comprise:

4.1.1. All members of the SRFT Council of Governors; and

4.1.2. 20 PAHT representatives (who shall be known as “Shadow Governors” “Shadow Public Governors” “Shadow Staff Governors” and/or “Shadow Appointed Governors” as the case may be) comprising:

4.1.2.1. 10 Shadow Public Governors elected using the PAHT membership base as follows: 5 from Bury and Rochdale 3 from Oldham 2 from North Manchester

4.1.2.2. 6 Shadow Staff Governors elected using the PAHT membership base as follows: 2 from Bury and Rochdale 2 from North Manchester 2 from Royal Oldham

4.1.2.3. 4 local authority governors appointed from Manchester, Bury, Rochdale and Oldham Local Authorities.

4.2.All elections to the role of Shadow Governor shall be conducted in accordance with the Model Election Rules as appended to the SRFT Constitution.

5. Chairmanship

5.1 The Chairman of the Shadow Group Council of Governors Committee will be the Chairman of Salford Royal NHS Foundation Trust.

6. Quorum

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6.1. 21 members (approximately two thirds) of the Shadow Group Council of Governors Committee (which must include 8 members of the SRFT Council of Governors) shall be a quorum.

7. Attendance

7.1 Members must make every effort to attend all meetings.

7.2 Attendance will be monitored. Governors may be required to cease office if they fail to attend three consecutive meetings (see Constitution Paragraph 12.19).

8. Meetings

8.1. The Shadow Group Council of Governors Committee shall at all times comply with SRFT Standing Financial Instructions, the SRFT Scheme of Reservation of Powers & Delegation of Powers and the SRFT Council of Governors’ Standing Orders (including but not limited to provisions as to notice, papers and procedure at meetings including voting, save that no resolution of the Shadow Group Council of Governors Committee shall be passed if it is opposed by all of the SRFT Council of Governors present at the meeting of the Shadow Group Council of Governors Committee).

9. Reporting Arrangements

9.1. The Shadow Group Council of Governors shall formally report to the SRFT Council of Governors [a minimum of three times per year or at such other intervals as SRFT Council of Governors may direct from time to time].

10. Secretary

10.1.The Director of Corporate Services/Group Secretary will act as Secretary and will ensure all required information, support and advice is provided to Shadow Group Council of Governors Committee.

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Appendix 7:STANDING FINANCIAL INSTRUCTIONS

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STANDING FINANCIAL INSTRUCTIONS

1. INTRODUCTIONGeneralTerminologyResponsibilities and Delegation

2. AUDITAudit CommitteeFraud, Bribery and CorruptionExecutive Director of FinanceRole of Internal AuditExternal Audit

3. BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORINGPreparation and approval of Business Plans and BudgetsBudgetary DelegationBudgetary Control and ReportingCapital ExpenditureMonitoring Returns

4. ANNUAL ACCOUNTS AND REPORTS

5. BANK ACCOUNTSGeneralBank AccountsBanking ProceduresTendering and Review

6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTSIncome SystemsFees and ChargesDebt RecoverySecurity of Cash, Cheques and other Negotiable Instruments

7. CONTRACTING FOR PROVISION OF SERVICESNHS Service AgreementsNHS Non Commercial Agreements

8. TERMS OF SERVICE AND PAYMENTS OF DIRECTORS AND EMPLOYEESRemuneration and Terms of ServiceFunded EstablishmentStaff AppointmentsPayrollContracts of Employment

9. NON PAY EXPENDITUREDelegation of AuthorityChoice, Requisitioning, Ordering, Receipt & Payment for Goods and Services

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10. EXTERNAL BORROWING AND INVESTMENT

Public Dividend CapitalCommercial Borrowing and InvestmentInvestment of Temporary Cash Surplus

11. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETSCapital InvestmentPrivate FinanceAsset RegistersProtected PropertySecurity of Assets

12. STORES AND RECEIPT OF GOODS

13. DISPOSALS & CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTSDisposals and CondemnationsLosses and Special PaymentsInsurance

14. INFORMATION TECHNOLOGY

15. PATIENTS’ PROPERTY

16. ACCEPTANCE OF GIFTS BY STAFF

17. RETENTION OF DOCUMENTS

18. RISK MANAGEMENT AND INSURANCE

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1. INTRODUCTION

1.1 General

1.1.1 These Standing Financial Instructions (SFIs) are issued in accordance with the Financial Directions issued by the Secretary of State under the provisions of Sections 99(3), 97(A)(4) and (7) of the National Health Service Act 1977 for the regulation of the conduct of the Trust in relation to all financial matters. the Financial Directions issued by the Secretary of State – under the provisions of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) – for the regulation of the conduct of the Trust in relation to all financial matters. They shall have effect as if incorporated in the Standing Orders (SOs) of the Trust.

1.1.2 These SFIs detail the financial responsibilities, policies and procedures to be adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Reservations of Powers to the Board and the Scheme of Delegation to Group Committees in Common.

1.1.3 These SFIs identify the financial responsibilities that apply to everyone working for the Trust and its constituent organisations including Trading Units These SFI’s also apply to the Services “Hosted” by the Trust as if they are a part of the core business. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures in place within the Trust, both inside the Finance Department and in other Departments of the Trust, must be approved by the Chief Financial Officer.

1.1.4 Should any difficulties arise regarding the interpretation or application of any of the SFIs then the advice of the Executive Director of Finance MUST BE SOUGHT BEFORE ACTING. The user of these SFIs should also be familiar with and comply with the provisions of the Trust's Standing Orders (SOs).

1.1.5 FAILURE TO COMPLY WITH SFIs AND SOs IS A DISCIPLINARY MATTER WHICH COULD RESULT IN DISMISSAL.

1.1.6 Overriding Standing Financial Instructions – If for any reason these Standing Financial Instructions are not complied with full details of the non-compliance and any justification for non-compliance and the circumstances around the non- compliance shall be reported to the next formal meeting of the Audit Committee for referring action or ratification. All members of the Board of Directors and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Executive Director of Finance as soon as possible.

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1.2 Terminology

1.2.1 Any expression to which a meaning is given in Health Service Acts, or in the Financial Directions made under the Acts, shall have the same meaning in these instructions. The following terms apply equally to the SFI and the SORD:

a) “Principal Accounting Officer” means the Officer responsible and accountable for funds entrusted to the Trust in accordance with the role of Accounting Officer for Salford Royal NHS Foundation Trust role of Accountable Officer for The Pennine Acute Hospitals NHS Trust . He shall be responsible for ensuring the proper stewardship of public funds and assets. This shall be the Chief Executive.

b) "Board " means the Board of Directors of the Salford Royal NHS Foundation Trust the Trust Board of The Pennine Acute Hospitals NHS Trust

c) "Budget" means a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;

d) "Budget Holder" means the director or employee with delegated authority to manage finances for a specific area of the organisation;

e) "Care Organisation Management Board" means the most senior decision making committee of the Care Organisation;

f) "Chief Financial Officer" means the Chief Financial Officer of the Group Committees in Common;

g) “Chief Executive" means the Chief Executive Officer of the Trust;

h) "Director of Finance" means the most senior financial officer of the Care Organisation;

i) "Executive Director of Finance" means the most senior financial officer of the Trust;

j) “Funds held on trust” shall mean those funds which the Trust holds on the date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable.

k) “Group CiC” – means Group Committees in Common

l) “Hosted Services” means services that the Trust provides the full range of support services to but which is not part of Trust core healthcare activity.

m) “Independent Regulator” means NHS Improvement, Monitor and the Trust Development Authority.

n) "Legal Adviser" means the properly qualified person appointed by the Trust to provide legal advice.

o) “SFIs” – means Standing Financial Instructions.

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p) "Trust" means the Salford Royal NHS Foundation Trust The Pennine Acute Hospitals NHS Trust

1.2.2 Wherever the title Chief Executive, Chief Financial Officer, Executive Director of Finance, or other nominated officer is used in these instructions, it shall be deemed to include such other Director or employee who have been duly authorised to represent them.

1.2.3 Wherever the term "employee" is used and where the context permits it shall be deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.

1.3 Responsibilities and Delegation

1.3.1 The Board exercises financial supervision and control by:

(a) formulating the financial strategy, which is articulated through the Annual Plan,

(b) setting the Standing Orders and Standing Financial instructions for the regulation of its financial proceedings and business, and

(c) defining specific responsibilities placed on directors and employees as indicated in the Detailed Scheme of Delegation document.

1.3.2 The Board has resolved that certain powers and decisions may only be exercised by the Board in formal session. These are set out in the “Reservations of Powers to the Board”.

1.3.3 The Board will delegate responsibility for the performance of its functions in accordance with the Scheme of Delegation.

1.3.4 Within the SFIs, it is acknowledged that the Chief Executive is ultimately accountable to the Board and as accountable office to the Secretary of State, for ensuring that the Board meets its obligations to perform its functions with the available financial resources. The Chief Executive has overall executive responsibility for the Trust's activities, is responsible to the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

1.3.5 The Chief Executive and Executive Director of Finance will, as far as possible, delegate their detailed responsibilities but they remain accountable for financial control and the powers vested in them by the Board or the Independent Regulator.

1.3.6 It is a duty of the Chief Executive to ensure that existing directors and employees and all new appointees are notified of and understand their responsibilities within these Instructions.

1.3.7 The Executive Director of Finance is responsible for:

(a) implementing the Trust financial policies and for co-ordinating any corrective action necessary to further these policies,

(b) maintaining an effective system of internal financial control including ensuring that

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detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions,

(c) ensuring that sufficient records are maintained to show and explain the Trust transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time,

and, without prejudice to any other functions of directors and employees to the Trust, the duties of the Executive Director of Finance include:

(d) the provision of financial advice to the Trust and its directors, employees and governors.

(e) the design, implementation and supervision of systems of internal financial control, and

(f) the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

1.3.8 All directors and employees, severally and collectively, are responsible for:

(a) the security of the property of the Trust,

(b) avoiding loss,

(c) exercising economy and efficiency in the use of resources, and

(d) conforming with the requirements of Standing Orders, Standing Financial Instructions, Financial Procedures and the Scheme of Delegation.

1.3.9 Any contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

1.3.10 For any and all directors and employees who carry out a financial function, the form in which financial records are kept and the manner in which directors and employees discharge their duties must be to the satisfaction of the Executive Director of Finance.

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SECTION 2

AUDIT

2.1 Audit Committee

2.1.1 In accordance with Standing Orders, the Board shall formally establish an Audit Committee, with clearly defined terms of reference, which will provide an independent and objective view of internal control by:

(a) overseeing Internal and External Audit services (b) receiving the annual management letter received from the external auditor and

agree proposed action,(c) receiving an annual report from the Internal Auditor and agree action on

recommendations where appropriate(d) reviewing financial systems and monitoring the integrity of the financial statements

and reviewing significant financial reporting judgments;(e) reviewing the establishment and maintenance of an effective system of integrated

governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objective.

(f) monitoring compliance with Standing Orders and Standing Financial Instructions,(g) reviewing schedules of losses and compensations and making recommendations

to the Group CIC.(h) reviewing schedules of debtors/creditors balances over 6 months old and £10k

and explanations/action plans. (i) reviewing and approving accounting policies(j) review and approving write-off of non-NHS debtors(k) reviewing the arrangements in place to support the Assurance Framework

process prepared on behalf of the Group CiC and advising the Group CiC accordingly.

(l) reviewing the arrangements in place for Counter Fraud, Bribery and Corruption by receiving the annual work plan and report and by receiving information regarding on-going cases.

(m) reviewing the effective implementation of corporate governance measures to enable the Trust to implement best practice as set out in appropriate guidance. This will include the Assurance Framework and control related disclosure statements, for example the Annual Governance Statement and supporting assurance process; together with any accompanying audit statements, prior to endorsement by the Board of Directors.

2.1.2 Where the Audit Committee feels there is evidence of ultra vires transactions, evidence of improper acts, or if there are other important matters that the committee wishes to raise, the Chairman of the Audit Committee should raise the matter at a full meeting of the Group CiC.

2.1.3 It is the responsibility of the Executive Director of Finance to ensure adequate internal and external audit services are provided and the Audit Committee shall be involved in the selection process when an audit service provider is changed, with the selection process for External Auditors being the responsibility of the Council of Governors, guided by the Executive Director of Finance and Audit Committee.

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2.2 Fraud, Bribery and Corruption

2.2.1 The Trust shall take all necessary steps to ensure that NHS funds and resources are protected and safeguarded against those minded to commit fraud, bribery and corruption and that appropriate measures to combat fraud, bribery and corruption are put in place in accordance with its requirement to comply with all the Standards for Providers for Counter Fraud as outlined in Service Conditions 24 of the NHS Standard Contract.

The Chief Executive and Executive Director of Finance shall monitor and ensure compliance with the above.

2.2.2 In line with their responsibilities, the Chief Executive and Executive Director of Finance is responsible for overseeing and providing strategic management and support for all anti-fraud, bribery and corruption work..

2.2.3 Each Trust shall contract in an accredited, nominated person (or persons) to undertake the full range of anti-fraud, bribery and corruption work as detailed in four key sections that follow NHS CFA’s strategy and shall report to the Executive Director of Finance regarding all aspects of anti-fraud, bribery and corruption wok carried out.

2.2.4 The Anti-Fraud Specialist and Lead Counter Fraud Specialist will develop a Group Annual Workplan that details the activities to be undertaken across the four key areas and shall provide a written report, at least annually, detailing progress on anti-fraud, bribery and corruption work carried out across each Care Organisation and Group.

2.3 Executive Director of Finance


(a) ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control including the establishment of an effective internal audit function,

(b) ensuring that the internal audit is adequate and meets the NHS mandatory audit standards,

(c) ensuring that there are arrangements in place to involve the police, as necessary, in cases of fraud, bribery, misappropriation, and other irregularities,

(d) ensuring that annual internal audit reports are prepared (which include the Head of Internal Audit Opinion, Annual Report and Internal Audit Plans) for the consideration of the Audit Committee and the Board of Directors. These reports must cover:

(i) a clear statement on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and internal control;

(ii) major internal [financial] control weaknesses discovered,

(iii) progress on the implementation of internal audit recommendations,

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(iv) progress against plan over the previous year,

(v) strategic audit plan covering the coming three years,

(vi) a detailed plan for the coming year.

2.3.2 The Executive Director of Finance and/or designated internal auditors are entitled without necessarily giving prior notice to require and receive:

(a) access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature,

(b) access at all reasonable times to any land, premises or employee of the Trust,

(c) the production of any cash, stores or other property of the Trust under an employee's control, and

(d) explanations concerning any matter under investigation.

2.4 Role of Internal Audit

2.4.1 Internal Audit will review, appraise and report upon:

(a) the extent of compliance with, and the financial effect of, relevant established policies, plans and procedures,

(b) the adequacy and application of financial and other related management controls,

(c) the suitability of financial and other related management data,

(d) the extent to which the Trust’s assets and interests are accounted for and safeguarded from loss of any kind, arising from:

(i) fraud, bribery, corruption and other offences,

(ii) waste, extravagance, inefficient administration,

(ii) poor value for money or other causes.

2.4.2 Whenever any matter arises which involves, or is thought to involve, irregularities concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Executive Director of Finance must be notified immediately.

2.4.3 The Head of Internal Audit will normally attend Audit Committee meetings and has a right of access to all Audit Committee members, the Chairman and Chief Executive of the Trust.

2.4.4 The Head of Internal Audit shall be accountable to the Executive Director of Finance. The reporting system for internal audit shall be agreed between the Executive Director of Finance, the Audit Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the Public Sector

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Internal Audit Standards. The reporting system shall be reviewed at least every 3 years.

2.4.5 Where, in exceptional circumstances, the use of normal reporting channels is thought to limit the objectivity of the audit, the Head of Internal Audit shall have access to report direct to the Chairman or a non-executive member of the Trust’s Audit Committee.

2.4.5 Managers in receipt of audit reports referred to them have a duty to take appropriate remedial action within the agreed time-scales specified within the reports. The Executive Director of Finance shall identify a formal review process to monitor the extent of compliance with the audit recommendations. Where appropriate remedial action has failed to take place within a reasonable time period the matter shall be reported to the Executive Director of Finance.

2.5 External Audit2.5.1 The external auditor is appointed by the Council of Governors the Trust Board and

paid for by the Trust.

2.5.2 The Code of Audit Practice (“The Audit Code”) contains directions of the Comptroller and Auditor General under Schedule 13(3)(1) and Schedule 6 of the Local Audit and Accountability Act 2014 with respect to the standards, procedures and techniques to be adopted by the auditor.

2.5.3 The Trust shall comply with Schedule 10 of the NHS Act 2006 (Audit of Accounts of NHS Foundation Trusts) and the specific provisions within Monitor’s NHS Foundation Trust Code of Governance C3. Audit Committee and Auditors.

2.5.4 The Auditor shall comply with the Audit Code.

2.5.5 References 2.4.3 and 2.4.5. relate equally to internal and external audit.

2.5.6 In the event of the Auditor issuing a Public Interest report the Auditor shall send the report as soon as reasonably practical after it is made to the Trust and the Secretary of State immediately or within 14 days of the conclusion of the audit where not an immediate report to the Council of Governors of the Trust, the Board of Directors of the Trust and NHS Improvement.

2.6 Security Management

2.6.1 In line with their responsibilities, the Trust Chief Executive will monitor and ensure compliance with Directions issued by the Secretary of State for Health on NHS security management.

2.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local Security Management Specialist (LSMS) as specified by the Secretary of State for Health guidance on NHS security management.

2.6.3 The Trust shall nominate a Non-Executive Director to be responsible to the Board for NHS security management.

2.6.4 The Chief Executive has overall responsibility for controlling and coordinating security. However, key tasks are delegated to the Director of Capital, Estates and Facilities and the Areas Security Management Specialist (ASMS) together with the appointed Local

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Security Management Specialist (LSMS).

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SECTION 3

SERVICE PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING

3.1 Preparation and approval of Business Plans and Budgets

3.1.1 The Chief Executive will compile and submit to the Board of Directors an Annual Plan document which encompasses an annual business plan and takes into account financial targets and forecast limits of available resources. The annual business plan will contain:

(a) a statement of the significant assumptions on which the plan is based;

(b) details of major changes in workload, delivery of services or resources required to achieve the plan.

3.1.2 Prior to the start of the financial year, the Executive Director of Finance will, on behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will:

(a) be in accordance with the aims and objectives set out in the Trust’s annual business plan, and the local commissioning intentions (or equivalent documents).

(b) accord with workload and manpower plans,

(c) be produced following discussion with appropriate budget holders,

(d) be prepared within the limits of available funds, and

(e) identify potential risks

(f) be based on reasonable and realistic assumptions.

(g) enable the Trust to comply with the requirements set out by the independent regulator.

3.1.3 The Chief Financial Officer shall monitor financial performance against budget and business plan, periodically review them, and report to the Group CiC. Any significant variances should be reported by the Chief Financial Officer to the Group CiC as soon as they come to light and the Group CiC shall be advised of actions to be taken in respect of such variances.

3.1.4 All budget holders must provide information as required by the Executive Director of Finance to enable budgets to be compiled. On completion of the budget setting all budget holders will be asked to confirm in writing their acceptance of their allocated budgets at the start of the financial year.

3.1.5 The Executive Director of Finance has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully.

3.2 Budgetary Delegation

3.2.1 The Chief Executive may delegate the management of a budget to permit the

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performance of a defined range of activities, including pooled budget arrangements under Section 75 of the 2006 Act. This delegation must be in writing and be accompanied by a clear definition of:

(a) the amount of the budget,

(b) the purpose(s) of each budget heading,

(c) individual and group responsibilities,

(d) authority to exercise virement,

(e) achievement of planned levels of service, and

(f) the provision of regular reports.

3.2.2 The Chief Executive and delegated budget holders must not exceed the budgetary total or virement limits set by the Board.

3.2.3 Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive, subject to any authorised use of virement.

3.2.4 Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Executive.

3.3 Budgetary Control and Reporting

3.3.1 The Executive Director of Finance will devise and maintain systems of budgetary control. These will include:

(a) monthly financial reports to the Group CiC in a form approved by the Group CiC containing:

- income and expenditure to date showing trends and forecast year-end position

- movements in working capital- movements in cash and capital- capital project spend and projected outturn against plan- expectations of any material variances from plan- details of any corrective action where necessary and the Chief Executives

and/or Chief Financial Officer’s view of whether such actions are sufficient to correct the situation.

(b) the issue of timely, accurate and comprehensible advice and financial reports to each budget holder, covering the areas for which they are responsible,

(c) investigation and reporting of variances from financial, workload and manpower budgets,

(d) monitoring of management action to correct variances, and

(e) arrangements for the authorisation of budget transfers.

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(n) advising the Chief Executive of the consequences of changes in policy, pay awards and other events and other trends affecting budgets and shall advise on the economic and financial impact of future plans and projects; and

(o) review of the bases and assumptions used to prepare the budgets.

In performance of these duties the Executive Director of Finance will have access to all budget holders and budget managers on budgetary matters and shall be provided with such financial and statistical information as is necessary.

3.3.2 Each Budget Holder is responsible for ensuring that:

(a) any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board of Directors,

(b) the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement, and

(c) no permanent employees are appointed without the approval of the Chief Executive other than those provided for in the budgeted establishment as approved by the Board of Directors.

(d) that any proposal to increase revenue spending has an appropriate funding stream identified and that this has been agreed by the Chief Executive. Proposals to increase revenue spending should also be signed off by the Executive Director of Finance. This applies to all revenue developments whether part of the Commissioning Intentions [or other appropriate plans of commissioners] discussions or separate initiatives, however funded.

3.3.3 The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Annual Plan and in accordance with the financial plan.

3.4 Capital Expenditure

3.4.1 The general rules applying to delegation and reporting shall also apply to capital expenditure. (The particular applications relating to capital are contained in Section 11.)

3.5 Monitoring Returns

3.5.1 The Chief Executive is responsible for ensuring that the requisite monitoring forms are submitted to the appropriate monitoring organisation within the required time-scale.

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SECTION 4

ANNUAL ACCOUNTS AND REPORTS

4.1 The Executive Director of Finance, on behalf of the Trust, will:

(a) keep accounts, and in respect of each financial year must prepare annual accounts, in such form as the Independent Regulator may, with the approval of the Treasury, direct.

(b) ensure that, in preparing the annual accounts, the Trust complies with any directions given by the Independent Regulator Department of Health with the approval of the Treasury as to;

the methods and principles according to which the accounts are to be prepared and

the information given in the accounts

(c) ensure that a copy of the annual accounts and any report by the external auditor on them, are laid before Parliament and that copies of these documents are sent to the Independent Regulator Department of Health, within the prescribed timetable.

4.2 The Trust will prepare annual reports as required by the NHS Foundation Trust Annual Reporting Manual Department of Health and Social Care Group Accounting Manual. This will be received by the Council of Governors at a public meeting. The Trust will publish an annual report, in accordance with guidelines on local accountability, and present it at a public meeting. A copy will be forwarded to the Independent Regulator Department of Health.

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SECTION 5

BANK ACCOUNTS

5.1 General

5.1.1 The Executive Director of Finance is responsible for managing the Trust’s banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/ directions issued from time to time by the Independent Regulator.

5.1.2 The Group CiC shall approve the banking arrangements other than mandated government banking service accounts where any proposed changes will be reported to the Audit Committee.

5.1.3 No employee may open or hold a bank account in the name of the Trust or of its constituent hospitals/departments. Any employee aware of the existence of such an account shall report the matter to the Executive Director of Finance.

5.2 Bank Accounts


(a) bank accounts and Government Banking Services (GBS) [accounts and other forms of working capital that may be available].

(b) establishing separate bank accounts for the Trust’s non-exchequer funds,

(c) ensuring payments made from bank or GBS accounts do not exceed the amount credited to the account except where arrangements have been made. The GBS accounts (one for payments and one for receipts) are treated as one account for the purposes of calculating the overall balance,

(d) reporting to the Group CiC of any external borrowing requirements

(e) ensuring that best value is obtained in securing loan finance and other sources of external funding, including Working Capital funding.

(f) monitoring compliance with DH&SC guidance on the level of cleared funds.

5.3 Banking Procedures

5.3.1 The Executive Director of Finance will prepare detailed instructions on the operation of bank and GBS accounts, which must include:

(a) the conditions under which each bank and GBS account is to be operated,

(b) the limit to be applied to any overdraft, and

(c) those authorised to sign cheques or other orders drawn on the Trust’s accounts.

(d) the policy and terms of operation of any Working Capital facility or working capital funding support in place

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5.3.2 The Executive Director of Finance must advise the Trust’s bankers in writing of the conditions under which each account will be operated.

5.4 Tendering and Review of Banking Services

5.4.1 The Executive Director of Finance will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business.

5.4.2 Competitive tenders should be sought at least every 5 years unless the Board determines otherwise. The results of the tendering exercise should be reported to the Group CiC.

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SECTION 6

INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

6.1 Income Systems

6.1.1 The Executive Director of Finance is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.

6.1.2 The Executive Director of Finance is also responsible for the prompt banking of all monies received.

6.1.3 Self-funding private patients and overseas visitors (who are required to pay for their treatment) will be required to make a pre-payment equal to the estimated cost of treatment prior to admission.

6.2 Fees and Charges

6.2.1 The Trust shall follow the Department of Health and Social Care advice in the Payment by Results (PBR) guidelines and code of conduct in setting prices for NHS Service contracts.

6.2.2 The Executive Director of Finance is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health and Social Care or by Statute. Independent professional advice on matters of valuation may be taken as necessary.

6.2.3 All employees must inform the Executive Director of Finance promptly of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

6.3 Debt Recovery

6.3.1 The Executive Director of Finance is responsible for the appropriate recovery action on all outstanding debts.

6.3.2 Income not received should be dealt with in accordance with losses procedures.

6.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated in line with Trust policy.

6.4 Security of Cash, Cheques and other Negotiable Instruments


(a) approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable,

(b) ordering and securely controlling any such stationery,

(c) the provision of adequate facilities and systems for employees whose duties

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include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines, and

(d) prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust.

6.4.2 Official money shall not under any circumstances be used for the encashment of private cheques.

6.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the Executive Director of Finance. Organisations/Individuals owing monies to the Trust should be encouraged, wherever practical to make payment in the form of cheques rather than cash, such cheques should be crossed and made payable to the Trust.

6.4.4 The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

6.4.5 Any loss or shortfall of cash, cheques or other negotiable instruments, however occasioned, shall be monitored and recorded within the Finance Department. Any significant trends should be reported to the Executive Director of Finance and Internal Audit. Where there is prima facie evidence of fraud or corruption this should be dealt with using the Trust’s Anti Fraud, Bribery and Corruption Policies and the guidance provided by the NHS Counter Fraud Authority. Where there is no evidence of Fraud, Bribery or Corruption it should be dealt with under the Trust’s Losses and Compensations procedures.

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SECTION 7

CONTRACTING FOR PROVISION OF SERVICES

7.1 NHS Service Agreements

7.1.1 The Chief Executive of the Trust shall regularly review and shall at all times maintain and ensure the capacity and capability of the Trust to provide mandatory goods and services referred to in the Trust’s Licence Establishment Order.

7.1.2 The Chief Executive, as the accounting officer, is responsible for ensuring the Trust enters into suitable legally binding Service Level Agreements with CCGs, NHS England and other commissioners for the provision of NHS services. The Trust will follow the priorities contained within the schedules of the contract, and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Chief Executive should take into account:

(a) the standards of service quality expected;

(b) the relevant national service framework and other national guidance (if any);

(c) the provision of reliable information on cost and volume of services;

(d) the Performance Assessment Framework contained within the Trust Service Level Agreements

(e) that Trust Service Level Agreements builds where appropriate on existing partnership arrangements;

7.1.3 A good Trust Service Level Agreement will result from a dialogue with clinicians, users, carers, public health professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required.

7.1.4 The Chief Executive, as the accounting officer, will need to ensure that regular reports are provided to the Group CiC detailing actual and forecast income from the Trust Service Level Agreements. This will include appropriate payment by results performance information, and other such information as deemed appropriate by the Executive Director of Finance

7.1.5 The Chief Executive, will ensure that Trust has in place suitable Service Level Agreements with other NHS Providers for both the delivery and receipt of services (known locally as Provider to Provider agreements). These agreements should be based upon the actual levels of service provided (or received) at an appropriate price to ensure all costs are covered). The Executive Director of Finance will ensure that appropriate systems are in place to agree and monitor such SLA’s on a regular basis.

7.2.1 Non Commercial Contracts

7.2.1 Where the Trust enters into a relationship with another organisation for the supply or

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receipt of other services – clinical or non-clinical, the responsible officer should ensure that an appropriate non-commercial contract is present and signed by both parties.

7.2.2 This should incorporate:

(a) indicative activity levels and a description of the service

(b) the term of the agreement

(c) the value of the agreement

(d) the lead officers

(e) performance and dispute resolution procedures

(f) risk management and clinical governance arrangements

7.2.3 Non-commercial contracts should be reviewed and agreed on an annual basis or as determined by the term of the agreement so as to ensure value for money and to minimise the potential loss of income.

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SECTION 8

TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES

8.1 Remuneration and Terms of Service

8.1.1 In accordance with Standing Orders the Board of Directors shall establish a Nominations, Remuneration and Terms of Service Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

8.1.2 The Committee will:

(a) advise the Board on the appropriate remuneration options and terms of service for the Chief Executive and other Executive Directors (and any other employees specified within the Terms of Reference), including:

(i) all aspects of salary (including any performance-related elements / bonuses),

(ii) provisions for other benefits, including pensions and cars,

(iii) arrangements for termination of employment and other contractual terms;

(b) determine on behalf of the Board, noting that the terms of reference for the Nominations, Remuneration and Terms of Service Committee provide for the Chairman and all Non-Executive Directors to participate, the remuneration and terms of service of Executive Directors and any other employees specified within the Terms of Reference to ensure they are fairly rewarded for their individual contribution to the Trust - having proper regard to the Trust’s circumstances and performance and to the provisions of any national arrangements for such staff where appropriate;

(c) monitor and evaluate the performance of individual Executive Directors (and other senior employees); and

(d) advise on and oversee appropriate contractual arrangements for such staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

8.1.3 The Committee shall report in writing to the Group CiC the basis for its recommendations. The Group CiC will report these to the Board of Directors who shall use the report as the basis for requirements for public disclosure in the Annual Report.

8.1.4 The Board of Directors is responsible for ensuring appropriate systems and processes are in place for setting remuneration and conditions of service for those employees not covered by the Committee.

8.1.5 The Council of Governors at the General Meeting will decide the remuneration and allowances and other terms and conditions of office of the Chairman and Non-Executive Directors. The Trust will remunerate the Chairman and Non-Executive Directors in accordance with instructions issued by the Secretary of State.

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8.2 Funded Establishment

8.2.1 The workforce plans incorporated within the annual budget will form the funded establishment.

8.2.2 The funded establishment of any department may not be varied without the approval of the Chief Executive (subject to the limits set out in the Scheme of delegation).

8.3 Staff Appointments

8.3.1 No director or employee may engage, re-engage, or regrade employees, either on a permanent or temporary basis, or hire agency staff, or agree to changes in any aspect of remuneration unless:

(a) authorised to do so by the Chief Executive , or

(b) within the limit of the approved budget and funded establishment

8.3.2 The Board of Directors will approve procedures presented by the Chief Executive for the determination of commencing pay rates, conditions of service, etc, for employees.

8.4 Payroll

8.4.1 The Executive Director of Finance (via the Shared Services Provider) is responsible for:

(a) specifying timetables for submission of properly authorised time records and other notifications,

(b) the final determination of pay,

(c) making payment on agreed dates, and

(d) agreeing method of payment.

8.4.2 The Executive Director of Finance (via the shared services provider) will issue instructions regarding:

(a) verification and documentation of data,

(b) the timetable for receipt and preparation of payroll data and the payment of employees,

(c) maintenance of subsidiary records for superannuation, income tax, social security and other authorised deductions from pay,

(d) security and confidentiality of payroll information,

(e) checks to be applied to completed payroll before and after payment,

(f) authority to release payroll data under the provisions of the Data Protection Act,

(g) methods of payment available to various categories of employee,

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(h) procedures for payment by cheque, bank credit, or cash to employees,

(i) procedures for the recall of cheques and bank credits,

(j) pay advances and their recovery,

(k) maintenance of regular and independent reconciliation of pay control accounts,

(l) separation of duties of preparing records and handling cash, and

(m) a system to ensure the recovery from leavers of sums of money and property due by them to the Trust.

8.4.3 Appropriately nominated managers have delegated responsibility for:

(a) submitting time records, and other notifications in accordance with agreed timetables,

(b) completing time records and other notifications in accordance with the Executive Director of Finance's instructions and in the form prescribed by the Executive Director of Finance, and

(c) submitting termination forms in the prescribed form immediately upon knowing the effective date of an employee's resignation, termination or retirement. Where an employee fails to report for duty in circumstances that suggest they have left without notice, the Executive Director of Finance must be informed immediately.

8.4.4 Regardless of the arrangements for providing the payroll service, the Executive Director of Finance shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures, and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

8.5 Contracts of Employment

8.5.1 The Board of Directors shall delegate responsibility to the Chief Strategy and Organisational Development Officer for:

(a) ensuring that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation,

(b) dealing with variations to, or termination of, contracts of employment.

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SECTION 9

NON-PAY EXPENDITURE

9.1 Delegation of Authority

9.1.1 The Board of Directors will approve the level of non-pay expenditure on an annual basis and the Chief Executive will determine the level of delegation to budget managers (via the Scheme of Delegation).

9.1.2 The Chief Executive will set out:

(a) the list of managers who are authorised to place requisitions for the supply of goods and services, and

(b) the maximum level of each requisition and the system for authorisation above that level.

9.1.3 The Executive Director of Finance shall set out procedures on the seeking of professional advice regarding the supply of goods and services.

9.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services

9.2.1 The requisitioner, in choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust’s adviser on procurement shall be sought. Where this advice is not acceptable to the requisitioner, the Executive Director of Finance (and/or the Chief Executive) shall be consulted.

9.2.2 The Executive Director of Finance shall be responsible for the prompt payment of accounts and claims. Payment of invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

9.2.3 The Executive Director of Finance will:

(a) advise the Board of Directors regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in standing orders and regularly reviewed,

(b) ensure that procedural instructions on the obtaining of goods, works and services (incorporating the thresholds) are prepared, distributed and regularly reviewed,

(c) be responsible for the prompt payment of all properly authorised accounts and claims,

(d) be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for:

(i) a list of directors/employees (including safe procedures to accept electronic authorisation) authorised to certify invoices,

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(ii) certification that:

- goods have been duly received, examined and are in accordance with specification and the prices are correct,

- work done or services rendered have been satisfactorily carried out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct,

- in the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined,

- where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained,

- the account is arithmetically correct,

- the account is in order for payment.

(iii) a timetable and system for submission to the Executive Director of Finance of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.

(iv) instructions to employees regarding the handling and payment of accounts within the Finance Department.

(e) be responsible for ensuring that payment for goods and services is only made once the goods and services are received (except as below).

9.2.4 Prepayments are only permitted where exceptional circumstances apply. In such instances:

(a) Prepayments should demonstrate that the financial advantages outweigh the disadvantages

(b) the appropriate Executive Director must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments,

(c) the Executive Director of Finance will need to be satisfied with the proposed scheme before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above the stipulated financial threshold) and

(d) the budget holder is responsible for ensuring that all items due under a prepayment contract are received and he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.

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9.2.5 Official Orders must:

(a) be consecutively numbered,

(b) be in a form approved by the Executive Director of Finance, and

(c) state the Trust terms and conditions of trade

9.2.6 Managers must ensure that they comply fully with the guidance and limits specified by the Executive Director of Finance and that:

(a) all contracts other than for a simple purchase permitted within the Scheme of Delegation or delegated budget, leases, tenancy agreements and other commitments which may result in a liability are notified to the Executive Director of Finance in advance of any commitment being made,

(b) contracts above specified thresholds are advertised and awarded in accordance with EU rules on public procurement

(c) where consultancy advice is being obtained, the procurement of such advice must be in accordance with good practise,

(d) no order shall be issued for any item or items to any company (or individual) which has made an offer of gifts, reward or benefit to directors or employees, other than:

(i) isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars,

(iv) conventional hospitality, such as lunches in the course of working visits,

provided that any such gift / hospitality is in line with the guidance contained within the Trust’s Standards of Business Conduct

(e) no requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Executive Director of Finance on behalf of the Chief Executive,

(f) all goods, services, or works are ordered on an official order except works and services executed in accordance with an existing contract and purchases from petty cash,

(g) verbal orders must only be issued very exceptionally - by an employee designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation Order",

(h) orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds,

(i) goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase. Any equipment on loan to the Trust and/or on Trust property must be notified to the Executive Director of Finance, together with any conditions attached to the loan of that equipment.

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(j) changes to the list of directors/employees authorised to certify invoices are notified to the Executive Director of Finance,

(k) purchases from petty cash are restricted in value and by type of purchase in accordance with instructions issued by the Executive Director of Finance, and

(l) petty cash records are maintained in a form as determined by the Executive Director of Finance.

9.2.7 The Executive Director of Finance shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with current guidance. The technical audit of these contracts shall be the responsibility of the relevant Director.

9.2.8 Under no circumstances should goods or services be ordered through the Trust for personal or private use.

9.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies

9.3.1 Payments to Local Authorities and voluntary organisations shall comply with procedures laid down by the Executive Director of Finance which shall be in accordance with the relevant Acts.

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SECTION 10

EXTERNAL BORROWING AND INVESTMENTS

10.1 Public Dividend Capital

10.2.1 On authorisation as a Foundation Trust the Public Dividend Capital held immediately prior to authorisation continues to be held on the same conditions.

10.2.2 Additional Public Dividend Capital may be made available on such terms the Secretary of State (with the consent of the Treasury) decides.

10.2.3 Draw down of Public Dividend Capital should be authorised in accordance with the mandate held by the Department of Health Cash Funding Team, and is subject to approval by the Secretary of State.

10.2.4 The Trust shall be required to pay annually to the Department of Health a dividend on its Public Dividend Capital at a rate to be determined from time to time, by the Secretary of State.

10.3 Commercial Borrowing and Investment

10.3.1 The Trust may borrow money from any commercial source for the purposes of or in connection with its functions, subject to Board approval.

10.3.2 The Trust may invest money for the purposes of or in connection with its functions. Such investment may include forming, or participating in forming, or otherwise acquiring membership of bodies corporate.

10.3.3 The Trust may also give financial assistance (whether by way of loan guarantee or

otherwise) to any person for the purposes of or in connection with its functions. This must only be given under specific approval of the Executive Director of Finance on a case by case basis.

10.4 Investment of Temporary Cash Surpluses

10.4.1 Temporary cash surpluses must be held only in such public and private sector investments as set out in the approved Group policy.

10.4.2 The Care Organisations’ Finance and Information and Capital Committee is responsible for monitoring compliance with the Group investment strategy and policy.

10.4.3 The Chief Financial Officer is responsible for advising on investments and shall report periodically to the Group CiC concerning the performance of investments held.

10.4.4 The Chief Financial Officer will prepare detailed procedural instructions on investment operations and on the records to be maintained. The Group’s Treasury Management Policy will incorporate guidance from the Independent Regulator as appropriate.

10.5 Working Capital Facility

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10.5.1 The Trust may choose to have funds are available for short-term cash flow management by negotiating an irrevocable Working Capital Facility with a lender.

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SECTION 11

CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

11.1 Capital Investment

11.1.1 The Chief Executive:

(a) shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans,

(b) shall ensure that management arrangements are in place in line with the Capital Development Booklet Series

(c) is responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost, and

(d) shall ensure that the capital investment is not undertaken without confirmation of commissioners support and the availability of resources to finance all revenue consequences, including capital charges.

11.1.2 For every major capital expenditure proposal (as defined in the Scheme of Delegation) the Chief Executive shall ensure:

(a) that a business case is produced setting out:

(i) an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs, and

(ii) appropriate project management and control arrangements, and

(b) that the Executive Director of Finance has certified professionally the costs and revenue consequences detailed in the business case.

11.1.3 For capital schemes where the contracts stipulate stage payments, the Chief Executive will issue procedures for their management

The Executive Director of Finance shall issue procedures for the regular reporting of actual expenditure and commitment against authorised expenditure.

11.1.4 The Group CiC approves the capital programme. In year monitoring will be will be undertaken by the relevant Group and Care Organisation capital committee on a monthly basis. Should a tender value be in excess of the value in the approved capital then this will be taken back to the Group CiC for Approval

The Chief Executive shall issue to the manager responsible for any scheme (within the framework set out above):

(a) specific authority to commit expenditure,

(b) authority to proceed to tender,

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(c) approval to accept a successful tender.

The Chief Executive will issue a scheme of delegation for capital investment management in accordance with the Trust’s Standing Orders.

11.1.5 The Chief Financial Officer shall issue procedures governing the financial management, including variations to contract, of capital investment projects and valuation for accounting purposes.

11.2 Private Finance

11.2.1 The Group CiC should normally test for PFI when considering capital procurement. When the Group CiC proposes to use finance that is to be provided other than through its allocations, the following should apply:

(a) The Chief Financial Officer shall demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.

(b) The proposal must be specifically agreed by the Group Group CiC.

(c) Where the sum involved exceeds delegated limits, the business case must be referred to the appropriate external reviewer.

11.3 Asset Registers

11.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking account of the advice of the Chief Financial Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

11.3.2 The Trust will maintain an asset register recording fixed assets. The minimum data set to be held within these registers shall be as specified in the Capital Charges Manual as issued by the Independent Regulator.

11.3.3 Additions to the fixed asset register must be clearly identified to an appropriate budget holder and be validated by reference to:

(a) properly authorised and approved agreements, architect's certificates, supplier's invoices and other documentary evidence in respect of purchases from third parties,

(b) stores, requisitions and wages records for own materials and labour including appropriate overheads, and

(c) lease agreements in respect of assets held under a finance lease and capitalised.

11.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

11.3.5 The Chief Financial Officer shall approve procedures for reconciling balances on fixed

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assets accounts in ledgers against balances on fixed asset registers.

11.3.6 The value of each equipment asset shall be indexed to current values using current Department of Health published indices.

11.3.7 The value of each asset shall be depreciated using methods and rates as specified in the relevant Annual Reporting Manual issued by the Independent Regulator.

11.3.8 The Chief Financial Officer shall calculate and pay capital charges as specified by the Department of Health and / or Independent Regulator

11.4 Property used to deliver Commissioner Requested Services

11.4.1 A register of property is maintained setting out property used to deliver commissioner requested services (“protected” property).

11.4.2 The Trust must have regard to Independent Regulator’s current guidance on arrangements to dispose of protected property should it decide that such property is surplus to requirement

11.5 Security of Assets

11.5.1 The overall control of fixed assets is the responsibility of the Chief Executive.

11.5.2 Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Chief Financial Officer. This procedure shall make provision for:

(a) recording managerial responsibility for each asset,

(b) identification of additions and disposals,

(c) identification of all repairs and maintenance expenses,

(d) physical security of assets,

(e) periodic verification of the existence of, condition of, and title to, assets recorded,

(f) identification and reporting of all costs associated with the retention of an asset, and

(g) reporting, recording and safekeeping of cash, cheques, and negotiable instruments.

11.5.3 The up to date maintenance and annual checking of asset records is the responsibility of the designated budget holder for all items for which the initial purchase or replacement is within their responsibility. All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Executive Director of Finance.

11.5.4 Whilst each employee has a responsibility for the security of property of the Trust, it is the responsibility of directors and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined

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by the Group CiC. Any breach of agreed security practices must be reported in accordance with instructions.

11.5.5 Any damage to the Trust’s premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by directors and employees in accordance with the procedure for reporting losses.

11.5.6 Where practical, assets should be marked as Trust property.

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SECTION 12

STORES AND RECEIPT OF GOODS

12.1 Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be:

(a) kept to a minimum,

(b) subjected to annual stocktake,

(c) valued at the lower of cost and net realisable value.

12.2 Subject to the responsibility of the Executive Director of Finance for the systems of control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Executive Director of Finance. The control of Pharmaceutical stocks shall be the responsibility of a designated Head of Pharmacy; the control of fuel oil and coal of a designated Estates Manager.

12.3 The responsibility for security arrangements and the custody of keys for all stores and locations shall be clearly defined in writing by the designated manager / Head of Pharmacy. Wherever practicable, stocks should be marked as health service property.

12.4 The Chief Financial Officer shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses.

12.5 Stocktaking arrangements shall be agreed with the Executive Director of Finance and there shall be a physical check covering all items in store at least once a year.

12.6 Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the Executive Director of Finance.

12.7 The designated Manager / Head of Pharmacy shall be responsible for a system approved by the Executive Director of Finance for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Executive Director of Finance any evidence of significant overstocking and of any negligence or malpractice (see also 13 Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

12.8 For goods supplied via the NHS Supply Chain, the Chief Executive shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Executive Director of Finance who shall satisfy himself that the goods have been received before accepting the recharge.

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SECTION 13

DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

13.1 Disposals and Condemnations

13.1.1 The Executive Director of Finance must prepare detailed procedures for the disposal of assets including condemnations, and ensure that these are notified to managers.

13.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised deputy will determine and advise the Executive Director of Finance of the estimated market value of the item, taking account of professional opinion including that of the Trust’s supply adviser where appropriate.

13.1.3 Where it is proposed to dispose or sell an asset that may impact on the delivery of a protected service, then prior Authorisation is required from key stakeholders.

13.1.4 All unserviceable articles shall be:

(a) condemned or otherwise disposed of by an employee authorised for that purpose by the Executive Director of Finance,

(b) recorded by the Condemning Officer in a form approved by the Executive Director of Finance which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Executive Director of Finance.

13.1.5 The Condemning Officer shall satisfy himself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Executive Director of Finance who will take the appropriate action.

13.2 Losses and Special Payments

13.2.1 The Chief Financial Officer must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments. The Executive Director of finance must also prepare a ‘fraud response plan’ that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

13.2.2 Any employee discovering or suspecting a loss of any kind must either immediately inform their head of department, who must immediately inform the Chief Executive. In the case of discovering or suspecting fraud, bribery or corruption, the employee must contact the Trust’s Anti- Fraud Specialist/Lead Local Counter Fraud Specialist who will ensure that the Executive Director of Finance is informed in accordance with the Trust’s Anti-Fraud, Bribery and Corruption Policies. Where a criminal offence is suspected, the Executive Director of Finance must immediately inform the police if theft or arson is involved. In cases of fraud, bribery or corruption the Anti-Fraud Specialist/Lead Local Counter Fraud Specialist will record the allegation on the NHS Counter Fraud Authority’s Investigation and Reporting System Toolkit (FIRST) in accordance with the Standards for Providers for Fraud, Bribery and Corruption and conduct investigations in accordance with the NHS Anti-Fraud Manual in consultation with the Executive Director of Finance to ensure the most appropriate course of action is taken.

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13.2.3 The Executive Director of Finance must notify NHS Counter Fraud Authority and the External Auditor of all frauds subject to the provisions of the Trust’s Anti-Fraud, Bribery and Corruption Policies.

13.2.4 For losses apparently caused by theft, fraud, bribery, corruption, arson, neglect of duty or gross carelessness, except if trivial and where fraud, bribery or corruption is not suspected, the Executive Director of Finance must immediately notify:

(a) the Board of Directors, and(b) the External Auditor.

13.2.5 Within limits delegated to it by the Department of Health & Social Care, the Group CiC shall approve the writing-off of losses. For losses below the level set out in the Scheme of Delegation this function may be delegated to the Audit Committee (6 monthly report to be made to the committee on Losses and Special Payments).

13.2.6 The Executive Director of Finance shall be authorised to take any necessary steps to safeguard the Trust's interests in bankruptcies and company liquidations.

13.2.7 For any loss, the Executive Director of Finance should consider whether any insurance claim could be made.

13.2.8 The Executive Director of Finance shall maintain a Losses and Special Payments Register in which write-off action is recorded.

13.2.9 No special payments exceeding delegated limits shall be made without the prior approval of the Department of Health & Social Care, or in the case of non-contractual payments to employees relating to loss of employment, without prior approval of HM Treasury.

13.3 Insurance

13.3.1 The Executive Director of Finance shall ensure that insurance arrangements exist in accordance with the risk management programme.

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SECTION 14

INFORMATION TECHNOLOGY

14.1 The Executive Director of Finance, who is responsible for the accuracy and security of the computerised financial data of the Trust, shall:

(a) be responsible for ensuring the design, implementation and documentation of effective information systems.

(b) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Trust's data, programs and computer hardware, for which he/she is responsible, from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998,

(c) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system,

(d) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment,

(f) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews, as he/she may consider necessary are being carried out.

(g) maintain a ‘Freedom of Information Publication Scheme’

14.2 The Executive Director of Finance shall satisfy him/herself that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation.

14.3 In the case of computer systems which are proposed general applications (i.e. normally those applications which the majority of organisations in the NHS locally or nationally wish to sponsor jointly) all responsible directors and employees will send to the Executive Director of Finance:

(a) details of the outline design of the system,

(b) in the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

14.4 The Executive Director of Finance shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

14.5 Where another health organisation or any other agency provides a computer service for

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financial applications, the Executive Director of Finance shall periodically seek assurances that adequate controls are in operation.

14.6 Where computer systems have an impact on corporate financial systems the Executive Director of Finance shall satisfy him/herself that:

(a) systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy,

(b) data produced for use with financial systems is adequate, accurate, complete and timely, and that a management (audit) trail exists,

(c) Executive Director of Finance staff have access to such data, and

(d) such computer audit reviews as are considered necessary are being carried out.

14.7 The Trust shall disclose to the Independent Regulator and directly to any third parties, as may be specified by the Secretary of State, the information, if any, specified in the Terms of Authorisation, Schedule 6. Other information, as requested shall be provided to the Independent Regulator.

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SECTION 15

PATIENTS' PROPERTY

15.1 The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.

15.2 The Chief Executive is responsible for ensuring that patients or their guardians, as appropriate, are informed before or at admission by:

- notices and information booklets,- hospital admission documentation and property records,- the oral advice of administrative and nursing staff responsible for admissions,

that the Trust will not accept responsibility or liability for patients' property brought into Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.

15.3 The Executive Director of Finance must provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

15.4 Where NHS instructions require the opening of separate accounts for patients' moneys, these shall be opened and operated under arrangements agreed by the Executive Director of Finance.

15.5 In all cases where property of a deceased patient is of a total value in excess of £5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

15.6 Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of the property of patients.

15.7 Where patients' property or income is received for specific purposes and held for safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

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SECTION 16

ACCEPTANCE OF GIFTS BY STAFF

16.1 The Executive Director of Finance (via the Group Secretary) shall ensure that all staff are made aware of the Trust policy on acceptance of gifts and other benefits in. This policy should follow the guidance contained in the Standards of Business Conduct Policy. (also included within the Group Governance Framework Manual)

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SECTION 17

RETENTION OF DOCUMENTS

17.1 The Chief Executive shall be responsible for maintaining archives for all documents required to be retained under the direction contained in Department of Health & Social Care: NHS Code of Practice.

17.2 The documents held in archives shall be capable of retrieval by authorised persons.

17.3 Documents held under Department of Health & Social Care: NHS Code of Practise shall only be destroyed at the express instigation of the Chief Executive. Records shall be maintained of documents so destroyed.

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SECTION 18

RISK MANAGEMENT & INSURANCE

18.1 Risk Management

18.1.1 The Chief Executive shall ensure that the Trust has a programme of risk management, which must be approved and monitored by the Group CiC.

18.1.2 The programme of risk management shall include:

(a) a process for identifying and quantifying risks and potential liabilities;

(b) engendering among all levels of staff a positive attitude towards the control of risk;

(c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

(d) contingency plans to offset the impact of adverse events;

(e) audit arrangements including; internal audit, clinical audit, health and safety review;

(f) decision on which risks shall be insured.

(g) arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of Internal Control within the Annual Report and Accounts as required by current Department of Health guidance.

18.2 Insurance

18.2.1 The Group CiC shall decide if the Trust (bearing in mind the Trusts independent legal status) will insure through the risk pooling schemes administered by the NHS Litigation Authority or self insure for some or all of the risks covered by the risk pooling schemes, along with those risks not covered by the pooling scheme. If the Group CiC decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.

18.2.2 Where the Group CiC decides to use the risk pooling schemes administered by the NHS Litigation Authority the Chief Financial Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Financial Officer shall ensure that documented procedures cover these arrangements.

18.2.3 Where the Group CiC decides not to use the risk pooling schemes administered by the NHS Litigation Authority for one or other of the risks covered by the schemes, the Chief Financial Officer shall ensure that the Group CiC is informed of the nature and

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extent of the risks that are self-insured as a result of this decision. The Executive Director of Finance will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.

18.2.4 All the risk-pooling schemes require members to make some contribution to the settlement of claims (the ‘deductible’). The Executive Director Finance should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

End.

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Appendix 8:Reservations of Powers & Delegation of Powers

For Group: Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust

0. GLOSSARY

‘Board’ means the Board of Directors of the Salford Royal NHS Foundation Trust and/or the Trust Board of the Pennine Acute Hospitals NHS Trust as the context permits.

‘PAT’ means the Pennine Acute Hospitals NHS Trust.

‘SFI’s means Standing Financial Instructions

‘SRFT’ means the Salford Royal NHS Foundation Trust.

‘SOs’ means Standing Orders.

‘Trust’ means the Salford Royal NHS Foundation Trust and/or the Pennine Acute Hospitals NHS Trust as the context permits.

1. INTRODUCTION

1.1 Purpose

1.1.1 The purpose of this document is to define those powers, which are reserved to the Board and delegated to committees established by the Board, whilst at the same time delegating to the appropriate level the detailed application of Trust policy and procedures.

This Combined Scheme of Reservation and Delegation of Powers should be read in conjunction with the Combined Standing Orders (Appendix 3) and Combined Standing Financial Instructions (Appendix 5). In addition, all staff members, including Directors should be aware of the policies and procedures that underpin all Trust activities. Details of the Trust’s current policies are available on the intranet.

SRFT specific provisions are highlighted in a box as follows example

PAHT specific provisions are highlighted in light grey as follows example.

1.2 Statutory Requirements

1.2.1 Foundation Trusts (as applicable to SRFT)Within the Terms of Authorisation and NHS Provider Licence issued by Monitor, NHS Foundation Trusts are required to demonstrate the existence of comprehensive

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governance arrangements in accordance with the NHS Act 2006 and Health and Social Care Act 2012.

With respect to SRFT, the NHS Act 2006 Schedule 7 paragraph 15(2) confirms that every Foundation Trust’s constitution “must provide for all the powers of the [Foundation Trust] to be exercisable by the Board of Directors on its behalf.” Sub paragraph (3) of that paragraph continues that the constitution “may provide for any of those powers to be delegated to a committee of directors or to an executive director” (emphasis added). These provisions are replicated within the current constitution for SRFT at paragraphs 4.7 and 4.8.

1.2.2 NHS Trusts (as applicable to PAHT)The Code of Accountability for NHS Boards (originally published by the Department of Health in April 1994, EL (94) 40 updated in 2004) requires that Boards draw up Standing Orders, a schedule of decisions reserved to the Board and Standing Financial Instructions.

With respect to PAHT, the NHS Trusts (Membership and Procedure) Regulations 1990 (“the 1990 Regulations”) provides as follows:

a. Regulation 15(1) An NHS Trust may appoint committees of the Trust consisting wholly or partly of directors of the Trust or wholly of persons who are not directors of the Trust.

b. Regulation 15(2) A committee appointed under paragraph 15(1) may appoint subcommittees which may comprise wholly or partly of members of the committee (whether or not they are directors of the Trust) or wholly of persons who are not member of the committee (again, whether or not they are directors of the Trust).

c. Regulation 16 provides that an NHS Trust may make arrangements for the exercise of any of the Trust’s functions on behalf of the Trust by a committee or subcommittee appointed under regulation 15 subject to such restrictions and conditions as the Trust thinks fit.

There are some limited exceptions to regulations 15 and 16, such as the Trust must appoint a committee of the Chairman and Non-Executive Directors to appoint the Chief Executive (known as the Chief Officer within the 1990 Regulations) and a committee of the Chief Executive, the Chairman and Non-Executive Directors to appoint the other executive officers.

The NHS Act 2006 Schedule 4 paragraph 18 also confirms that an NHS Trust “may enter into arrangements for the carrying out, on such terms as the NHS trust considers appropriate, of any of its functions jointly with any . . . . . . Special Health Authority, Local Health Board or other NHS trust, or any other body or individual.”

All of the above requirements, as applicable to SRFT as an NHS foundation trust and PAT as an NHS trust, are provided for within the Combined Standing Orders for the Board of Directors of SRFT and PAT, and reflected within this Scheme of Reserved and Delegated Powers.

1.3 Codes of Conduct

1.3.1 Board Directors and Governors have specifically subscribed to their respective Codes of Conduct and should be aware that the principles of the Codes of Conduct, and The NHS

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Code of Accountability as incorporated in the Group Governance Framework Manual, remain fundamental in exercising their responsibilities for regularity and probity. Directors should promote their observance of these principles to all staff.

1.4 Accountability

1.4.1 The Board remains accountable for all of its functions, including those delegated to the Chairman, individual directors or officers, and committees, and must therefore receive information about the exercise of delegated functions to enable it to receive appropriate assurance about performance and maintain an overall monitoring role.

1.5 Role of the Chief Executive

1.5.1 All powers of the Trust which have not been retained as reserved by the Board or delegated to a committee or sub-committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall prepare a Scheme of Delegation identifying which functions he/she shall perform personally and which functions have been delegated to other directors and officers.

1.6 Caution over the Use of Delegated Powers

1.6.1 Powers are delegated to directors and officers on the understanding that they would not exercise delegated powers in a matter that in their judgment was likely to be a cause for public concern.

1.7 Absence of Director or Officer to whom Powers have been Delegated

1.7.1 In the short-term absence of a director or officer to whom powers have been delegated those powers shall be exercised by that director or officer's superior unless alternative arrangements have been approved by Board. In the short-term absence of the Chief Executive, powers delegated to him/her may be exercised by the Chairman, having taken the advice of the Executive Director of Finance, unless alternative arrangements have been approved by Board.

1.8 Directors' Ability to Delegate their own Delegated Powers

1.8.1 The Scheme of Delegation shows only the "top level" of delegation within the Trust. The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust.

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SECTION 1 – DECISIONS RESERVED TO THE COUNCIL OF GOVERNORSThe Governors of SRFT must act in the best interests of SRFT and Group. Shadow Governors should act in the best interests of PAT, SRFT and Group. All Governors should adhere to Group values and codes of conduct.

Notwithstanding the statutory duty of Governors to hold the SRFT Non-Executive Directors to account for the performance of the SRFT Board, it is important that the SRFT Board of Directors and the SRFT Council of Governors (and, in recognition of the long term aim of SRFT to establish a Group with PAT as the first member, the Group CiC and the Shadow Group Council of Governors Committee) see their interaction as primarily being one of constructive partnership.

The SRFT Council of Governors and the Shadow Group Council of Governors Committee should acknowledge the overall responsibility of the SRFT Board of Directors for the oversight of the running of SRFT, and the Group CiC for the running of SRFT and PAT, and should not try to use the powers of the Council of Governors to veto the decisions of the Board of Directors or the Group CiC.

The SRFT Board of Directors and SRFT Council of Governors should seek to work together effectively in their respective roles and avoid unconstructive adversarial interaction. The SRFT Board of Directors and SRFT Council of Governors have established a clear policy detailing how disagreements between the SRFT Council of Governors and Board of Directors will be resolved. This policy should also be applied to disagreements affecting the Group CiC, the SRFT Council of Governors and/or the Shadow Group Council of Governors Committee.

In accordance with the NHS Act 2006, all powers vested in the SRFT Council of Governors are reserved to the SRFT Council of Governors and cannot be delegated. The SRFT Council of Governors may establish committees to undertake specific duties and provide recommendations for decision by the SRFT Council of Governors. These arrangements are described below.

REF RESERVED TO DECISIONS RESERVED TO THE COUNCIL OF GOVERNORS

N/A Council of Governors

In accordance with the Standing Orders of the Council of Governors and the Trust’s legal framework, the Council of Governors may not delegate any of its powers to a committee or sub-committee, but it may appoint committees consisting of its members, Directors, and other persons to assist the Council of Governors in carrying out its functions. The Council of Governors may, through the Secretary, request that advisors assist them or any committee they appoint in carrying out its duties.

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N/A Council of Governors Regulations and Control

1 To hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors

2 Approve, suspend, vary or amend the Standing Orders (SOs) of the Council of Governors for the regulation of its proceedings and business

3 Receive reports from committees to take appropriate action thereon4 Confirm the recommendations of the committees

5 Establish terms of reference and reporting arrangements of all committees that are established by the Council of Governors

6Require and receive the declaration of Governors’ interests which may conflict with those of the Trust and determining the extent to which that member may remain involved with the matter under consideration

Appointments/Dismissal1 To appoint or remove the Trust's external auditor2 To appoint or remove an external auditor of any other aspect of the Trust affairs

N/A Council of Governors

3 To approve an appointment (by the Non-Executive Directors) of the Chief Executive4 To appoint or remove Non-Executive Directors (including the Chairman)5 To appoint the Lead Governor of the Council of Governors

6 To appoint or remove the Chairman and the other Non-Executive Directors or Governors, subject to complying with the procedures incorporated in the Constitution

N/A Council of

GovernorsStrategy, Business Plans and Budgets

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1 To decide the remuneration and allowances and other terms and conditions of office, of the Non- Executive Directors (including the Chairman)

2 Approve significant transactions as defined within the Trust’s Constitution

3 Approve an application by the Trust to merge with or acquire another trust, separate the trust or to be dissolved

4Approve any increase of 5% or more in income attributable to activities other than the provision of goods and services for the purposes of the health service in England (including but not limited to private health service provision i.e. any non-NHS income) in a financial year

Policy determinationN/A Council of

Governors1 Preparation and review of the Trust's Membership and Public Engagement Strategy and the policy for

the composition of the Council of Governors and of the Non-Executive Directors

2 Provide views to the Board of Directors when the Board of Directors is preparing the document containing information about the Foundation Trust’s forward planning

N/A Council of Governors Audit – No decisions reserved

N/A Council of Governors Annual Report and Accounts

1 To receive and accept the Annual Accounts and any report of the External Auditor on them and the Trust’s Annual Report

N/A Council of Governors Monitoring – no decisions reserved

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SECTION 2 – FUNCTIONS/DUTIES TO BE PERFORMED BY COUNCIL OF GOVERNORS’ COMMITTEES

REF COMMITTEE FUNCTIONS OF THE COUNCIL OF GOVERNORS’ COMMITTEESN/A Shadow-Group

Council of Governors Committee

1. To ensure effective representation of the interests of SRFT and PAT members and the public served by Group.

2. To effectively engage with and involve local stakeholders of SRFT and PAT. 3. Provide views to the Group Committees in Common (CiC) as part of the Group forward

planning process.4. To support the SRFT Council of Governors in its performance of its statutory and other

duties, including but not limited to: Reviewing and providing recommendations for the approval, variation or amendment

of the Standing Orders (SOs) of the Council of Governors for the regulation of its proceedings and business

Reviewing and making a recommendation as to the appointment or removal of SRFT's external auditor

Reviewing and making a recommendation as to the appointment or removal of an external auditor of any other aspect of SRFT’s affairs

Reviewing and making a recommendation as to the approval of significant transactions as defined within SRFT’s Constitution

Reviewing and making a recommendation as to the approval of any application by SRFT to merge with or acquire another trust, separate the trust or to be dissolved

Reviewing and making a recommendation as to the approval of any increase of 5% or more in income attributable to SRFT activities other than the provision of goods and services for the purposes of the health service in England (including but not limited to private health service provision i.e. any non-NHS income) in a financial year

Reviewing and making recommendations to the policy for the composition of the SRFT Council of Governors and of the SRFT Non-Executive Directors

Provide views to the Board of Directors when the Board of Directors is preparing the document containing information about SRFT’s forward planning

Reviewing and making recommendations to the SRFT Council of Governors as to the Group Membership and Public Engagement Strategy (including the SRFT

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REF COMMITTEE FUNCTIONS OF THE COUNCIL OF GOVERNORS’ COMMITTEESMembership and Public Engagement Strategy)

To review the Annual Accounts and any report of the External Auditor on them and the Trust’s Annual Report and to provide a recommendation to the Council of Governors as to whether to accept them

5. The Committee will consider any reports from the Nominations, Remuneration and Terms of Office Committee on its work and make such recommendations as it sees fit to the SRFT Council of Governors, to be presented to the SRFT Council of Governors at the same time as any reports from the Nominations, Remuneration and Terms of Office Committee.

6. In collaboration with Group CiC, the Committee will review assurances on the overall performance of Group, and as part of this, report to the SRFT Council of Governors on assurances sought with respect to SRFT’s overall performance.

7. The Committee will also seek to engage with both SRFT and PAT members and key stakeholders and will represent their views in any discussions with the Group CiC.

8. The Committee may establish terms of reference and reporting arrangements of any committee that may be established by the Shadow Group Council of Governors Committee.

N/A Nominations, Remuneration and

Terms of Office Committee

1. The Committee will oversee the process for making appointments to the position of Non-Executive Director and the Chairman and will recommend appointments, to such positions, to the Council of Governors.

2. The Committee shall consider the remuneration, allowances and other terms and conditions of office, of the Chairman and other Non-Executive Directors, taking into account benchmarking against other similar organisations, including NHS Foundation Trusts and taking specialist advice.

3. The Committee will develop, monitor and seek feedback on a process for the evaluation of performance and contribution on the part of Non-Executive Directors and the Chairman.

4. The Committee will receive summarised reports as to the performance of the Non-Executive Directors (from the Chairman) and the Chairman (from the Senior Independent Director) on an annual basis.

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REF COMMITTEE FUNCTIONS OF THE COUNCIL OF GOVERNORS’ COMMITTEES5. The Committee will provide assurance on these matters to the Council of Governors.

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SECTION 3 – DECISIONS RESERVED TO THE BOARD

DECISIONS RESERVED TO THE BOARDGeneral enabling provision

The Board may determine any matter, for which it has delegated or statutory authority, it wishes in full session within its statutory powers.

1 Standing Orders: To approve Standing Orders (SOs), a schedule of matters reserved to the Board and Standing Financial

Instructions for the regulation of its proceedings and business. To suspend Standing Orders. To vary or amend the Standing Orders. To ratify any urgent decisions, which the Board has retained to itself, taken by the Chairman and Chief

Executive in accordance with SO 4.2. To ratify or otherwise instances of failure to comply with Standing Orders by the Board brought to the

Chief Executive’s attention in accordance with SO 4.7. To discipline members of the Board who are in breach of statutory requirements or SOs.

2 Scheme of Delegation: To approve a scheme of delegation of powers from the Board to committees.

3 Declaration of Interests: To require and receive the declaration of Board members’ interests that may conflict with those of the

Trust and determining the extent to which that member may remain involved with the matter under consideration.

4 Funds Held on Trust: To approve arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for

funds held on trust.

Regulation and Control

5 Committees and sub-committees: To establish terms of reference and reporting arrangements of all committees and sub-committees that

are established by the Board. To confirm the recommendations of the Board’s committees (including the Group Committees in

Common) where those committees do not have the delegated power/authority.

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DECISIONS RESERVED TO THE BOARD To confirm the appointment and the Terms of Reference of the Audit Committee, Nominations Committee

and (and Charitable Funds Committee - to be confirmed) by the Group Committees in Common. 1 Vice Chairman:

To appoint the Vice Chairman of the Board.2 Secretary:

To appoint and dismiss the Secretary in consultation with the Council of Governors.

Appointments/Dismissal

3 Committees: To appoint and dismiss committees (and individual members) that are directly accountable to the Board.

1 Strategy:To receive and approve the Trust’s Strategic Plan.

Strategy and Annual Plan

2 Annual Plan: To receive and approve the Trust’s Annual Plan (including financial plan).

Audit

1

External Auditor: To approve the appointment (and where necessary dismissal) of External Auditors. To approve external auditors’ arrangements for the separate audit of funds held on trust, and the

submission of reports to the Audit Committee meetings who will take appropriate action

1 To receive the Trust's Annual Report, Quality Account and Annual Accounts prior to approval by the Audit Committee.

Annual Report and Accounts

2 To receive the Trust’s Annual Report and Accounts for funds held on trust prior to approval by the Charitable Funds Committee.

Monitoring 1 To receive such reports as the Board sees fit from committees in respect of their exercise of powers delegated.

SECTION 4 – DECISIONS / DUTIES DELEGATED BY THE BOARD TO COMMITTEES

4.1 Decisions Delegated To SHADOW GROUP BOARD (Group Committees in Common – herein “Group CiC” )

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DECISIONS DELEGATED TO GROUP CiCGeneral enabling provision

Save as otherwise required by law, the Board delegates the exercise of all functions other than as set out within this Scheme of Reservation of Powers & Delegation of Powers to the Group CiC.

1 Standing Orders: To suspend Standing Orders in so far as they relate to Group CiC. To recommend any required variation or amendment of Standing Orders for approval by the Board. To ratify or otherwise instances of failure to comply with Standing Orders by the Group CiC brought to the

Chief Executive’s attention in accordance with SO 4.7. 2 Declaration of Interests:

To require and receive the declaration of Group CiC members’ interests that may conflict with those of the Trust and determining the extent to which that member may remain involved with the matter under consideration.

To require that Audit Committee ensures appropriate policy and process is in place for the declaration and review of officers’ interests that may conflict with those of the Trust.

3 Structures, Processes and Procedures: To adopt the organisation structures, processes and procedures to facilitate the discharge of business by

the Trust and to agree modifications thereto. 4 Committees:

To receive reports from committees, including Audit Committee and Nominations/Appointments, Remuneration and Terms of Service Committee (and Charitable Funds Committee - to be confirmed) and to take appropriate action.

To confirm the recommendations of the Trust’s committees where the committees do not have executive powers and the Group CiC does.

Regulations and Control

5 Bailer for Patients’ Property: To approve arrangements relating to the discharge of the Trust’s responsibilities as a bailer for patients’

property.1 Vice-Chairman:

To confirm the Vice Chairman of the Group CiC.Appointments/Dismissal

2 Secretary:

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DECISIONS DELEGATED TO GROUP CiC To confirm the Secretary of the Group CiC.

3 Committees: To appoint, and confirm to the Board, the terms of reference of an Audit Committee,

Nominations/Appointments Committee (and Charitable Funds Committee - to be confirmed) in accordance with statutory requirements, and receive and review regular reports with respect to the delivery of their objectives.

To report to the Board with respect to the delivery of the objectives of the Audit Committee, Nominations/Appointments Committee (and Charitable Funds Committee - to be confirmed), without prejudice to the ability of such committee to report directly to the Board on any other matter where it considers it necessary in light of the Board’s statutory duties and responsibilities to do so.

To appoint and dismiss committees (and individual members), other than Audit Committee, Nominations/ Appointments Committee (and Charitable Funds Committee - to be confirmed), that are directly accountable to the Group CiC, including setting of their terms of reference and determining any delegation of powers and functions that may be appropriate.

To confirm appointment of members of any committee of the Trust as representatives on outside bodies.

1Group Governing Objectives:

To set the Trust’s vision and governing objectives, and with due regard to the ultimate intention of SRFT to establish a Group operation.

2Group strategy and planning:

To set the Group and Trusts’ strategy, and with due regard to the ultimate intention of SRFT to establish a Group operation, to make strategic decisions and provides direction to the Care Organisations (including strategic analysis).

3

Workforce & Talent Management Strategy: To lead the development of the Trust’s workforce and deliver the Trust’s Workforce and Talent Management

Strategy in conjunction with Care Organisations and with due regard to the ultimate intention of SRFT to establish a Group operation.

Strategy, Business Plans and Budgets

4 Resource Allocation: To allocates and directs resource based on clear methodology for prioritisation (OPEX budgets and

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DECISIONS DELEGATED TO GROUP CiCCAPEX)

5 Business Development: To identify and investigate business development opportunities (clinical and commercial)

6 Brand: To establish and manage the Trust brand to complement development of an ultimate Group brand (in

recognition of the ultimate intention of SRFT to establish a Group operation) and to support Care Organisation local branding

7 Asset Management: To ensure the strategic management of the Group’s assets.

8 Business Cases: To approve Outline and Final Business Cases for Capital Investment.

9 Land and Buildings: To ratify proposals for acquisition, disposal or change of use of land and/or buildings.

10 Finance: To approve PFI proposals. To approve the opening of bank accounts.

11 Contracts and Leases: To approve proposals on individual contracts (other than NHS contracts) of a capital or revenue nature in

line with SFIs To approve any contract or lease being entered into by any of the Trust’s Hosted Services in line with the

SFIs12 Compensation:

To approve individual compensation payments (except where part of the NHS Litigation Authority or employment tribunal arrangements) in line with SFIs. Approve proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and Director of Finance (for losses and special payments).

13 Insurance: To review use of NHSLA risk pooling schemes (e.g. LPST/CNST/RPST) or approve and review use of other

appropriate insurance arrangements.

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DECISIONS DELEGATED TO GROUP CiC1

1Definition of Group Policy on policies, processes and standards:

To set Group-wide processes and standards (clinical and non-clinical) applicable across Trusts and all Care Organisations.

2 Risk Management: To approve the Trust’s policies and procedures for the management of risk

3 Knowledge Management: To ensures cross-sharing and external learning

4 Improvement Science & Change Management: To lead capability development and provide scale for improvement in Care Organisations

Policy

5 Shared Services: To identifies/prioritise opportunities to centralise services and to hold to account management of the

shared services centreAudit 1 Audit:

To ensures effective processes are in place for regular audit of clinical standards and patient experience to support performance data provided by the Care Organisations.

Annual Report and Accounts

1 Annual Report and Accounts: To ensure appropriate delegation of the review and approval of the Annual Report, Quality Account and

Annual Accounts to the Audit Committee. To receive the Annual Report, Quality Account and Annual Accounts prior to approval by the Audit

Committee. To ensure the Board receives the Annual Report, Quality Account and Annual Accounts prior to approval by

the Audit Committee.2 Annual Report and Accounts for Funds Held on Trust:

To ensure appropriate delegation of the review and approval of the Trust's Annual Report and Accounts for Funds Held on Trust to the Charitable Funds Committee.

To receive the Annual Report and Accounts for Funds Held on Trust prior to approval by the Charitable Funds Committee.

To ensure that the Board receives the Annual Report and Accounts for Funds Held on Trust prior to approval

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DECISIONS DELEGATED TO GROUP CiCby the Charitable Funds Committee.

1 Assurance: To provide assurance to stakeholders (including but not limited to the Council of Governors, regulators,

members and the public)2 Performance Management:

To ensure effective arrangements are in place for holding the Care Organisations to account for the performance of the business.

3 Reporting: To receive such reports as the Group CiC sees fit from committees in respect of their exercise of powers

delegated. To ensure continuous appraisal of the affairs of the Trust by means of the provision of reports to the Group

CiC as the Group CiC may require from directors, committees, and officers of the Trust as set out in management policy statements. All monitoring returns required by the DH and the Charity Commission shall be reported, at least in summary, to the Group CiC

Receive reports from the Chief Finance Officer on financial performance against budget and Local Delivery Plan.

Receive reports on actual and forecast income from Service Level Agreements.

Monitoring

4 Self-certifications and associated assurances Where permitted by the law and/or by the regulator, receive, review and approve all self-certifications and

associated assurances.

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4.2 Decisions Delegated by the SRFT Board to the SRFT Acquisition Committee

REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESGroup

GovernanceFramework

Manual

SRFT Acquisition Committee

The Committee shall:

Develop the transaction Strategic Case, Full Business Case (FBC) and Long Term Financial Model (LTFM) for approval by the SRFT Board of Directors, which will be aligned to Group strategy. These documents will confirm the benefit and viability of acquiring PAT assets, and will finalise post procurement arrangements. The outputs will give due consideration to work undertaken for the Group strategy to date and with due consideration of Commissioner and regulator governance processes and also exploring future governance options for the Trust.

Provide the SRFT board with assurances that any executed transaction is the right direction for the Trust and its stakeholders, and ensure that it is completed safely and without detriment to the long-term sustainability of the Trust.

Provide SRFT Board of Directors with recommendations of the legal form most suitable to deliver the expected benefits of the business case.

Ensure that the transaction programme continues to deliver against the agreed timetable aligning the Northern Care Alliance (NCA) NHS Group and the Manchester University NHS Foundation Trust (MFT) transaction programmes, as set out by the Joint Transaction Board.

Provide programme oversight to ensure that the programme meets its objectives an delivers the expected benefits and outcomes, and ensure that the SRFT Board of Directors has oversight and visibility during the transaction process.

Manage stakeholders including regulatory and health economy partners such as NHSI Clinical Commissioning Group (CCG)s and Greater Manchester Health & Social Care Partnership (GMHSCP); and internal stakeholders including directors and governors.

Monitor and mitigate escalated risks associated with the transaction programme.

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SECTION 5 – DECISIONS/DUTIES DELEGATED BY THE SHADOW GROUP BOARD (GROUP CiC) TO STATUTORY COMMITTEES

REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESGroup

GovernanceFramework

Manual

Audit Committee (Group Audit

Committees in Common)

The Committee shall: Review the establishment and maintenance of an effective system of integrated governance,

risk management and internal control, across the whole of Group, SRFT and PAT’s activities (both clinical and non-clinical), that support the achievement of the organisations’ objectives.

Review the adequacy of:- all risk and control related disclosure statements (in particular the Annual Governance

Statement), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances;

- underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

- policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements

- policies, plans and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by NHS Counter Fraud Authority;

- system of risk management across the whole of the organisations’ activities (clinical and non-clinical) and receive regular monitoring information against the management of risks judged as ‘significant’ and provide verification to the Group Committee on the systems in place for the management of risk across the Group;

- 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;

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.

Receive all Head of Internal Audit Opinions (Group, statutory bodies and Care Organisations). Review and monitor the external auditor’s independence and objectivity and the effectiveness

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REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESof the audit process. In particular, review the work and findings of the External Auditor appointed by the SRFT Council of Governors and PAT Board and consider the implications and management's responses to their work.

Consider the appointment and performance of the External Auditor for SRFT and establish an Auditor Panel to make recommendations to the Board on the appointment of an External Auditor for PAT.

Review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses

Ensure that there is in place a clear policy for the engagement of external auditors to supply non audit services, with particular reference to the fee cap and prohibited services

Review the Annual Accounts on behalf of the Boards and approve the signing of the relevant annual accounts certificates (both Exchequer and Charitable Funds).

Review that actions falling out from reports by external or internal auditors have been implemented.

Review and agree the External Auditors Annual Letter, and management response to it. Consider any report issued involving the Trusts by the Public Accounts Committee or

Comptroller and Auditor General and advise the Group CiC and Boards on the appropriate response.

Review annually the Corporate Governance Framework documents and circumstances and instances when the Group Standing Orders (Board) are waived.

Review Losses and Compensations paid and make any recommendations arising there from. Approve write-off of non-NHS debtors. Approve accounting policies. Monitor the implementation of policy of the Standards of Business Conduct and Codes of

Conduct and Accountability on behalf of the Group CiC and Boards. Review the work of other committees within the organisation, whose work can provide

relevant assurance to the Audit Committee's own scope of work. This will particularly include the Executive Assurance and Risk Committee of the Group

Request and review reports and positive assurances from Directors and managers on the

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REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESoverall arrangements for governance, risk management and internal control.

Review the Annual Report and Financial Statements prior to submission to Board. Ensure that the systems for financial reporting to the Group CiC, including those of budgetary

controls, are subject to review as to completeness and accuracy of the information provided to the Group CiC

Monitor procurement and the management of non-pay spend, and specifically have oversight of the Procurement Work Plan.

Group Governance Framework

Manual

Nominations, Remuneration and Terms of Service

Committee(Nominations,

Remuneration and Terms of Service

Committees in Common)

The Committee shall: Determine, as delegated by the Board via Group CiC, appropriate remuneration and terms of

service for the Chief Executive and Executive Directors including:-- All aspects of salary (including any performance related elements). - Provisions of other non-pay benefits including pensions.- Arrangements for termination of employment and other contractual terms. Determine, as delegated by the Board via Group CiC, the remuneration and terms of service of

the Chief Executive and Executive Directors, to ensure that they are fairly rewarded for their individual contribution to the Group having proper regard to the Group and individual Trust’s circumstances and performance.

Approve the design of any performance-related pay schemes operated by the organisation and approve individual payments made under such schemes to Executive Directors, and overall budget for performance-related pay schemes for Senior Leaders and Clinical Leaders

Approve any salary band increases for Executive Directors and Senior Leaders Approve any recruitment and retention allowances for Executive Directors and senior leaders

that fall outside agreed salary bands Monitor and evaluate, through the Chairman, the performance of the Chief Executive; and

monitor and evaluate, through the Chief Executive, the performance of other Executive Directors

Determine Group and Trust performance targets and levels of achievements and assess Group and Trust-level performance

Advise on, and oversee, appropriate contractual arrangements for the Chief Executive and

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REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESother Executive Directors including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

Review the structure, size and composition of the Board and Group CiC and, where appropriate, make recommendations to the Board and Group CiC for change.

Determine succession plans for the Chief Executive and Directors and assist in determining the responsibilities of and procedures for the appointment of Executive Directors, including the Chief Executive

Be responsible for nominating candidates for appointment as Executive Directors on the SRFT Board, for approval by the CEO, Chairman and all other Non-Executive Directors at a meeting of Group CiC and appointing candidates to Executive Director positions on the PAT Board.

Evaluate the balance of skills, knowledge and experience on the Board and Group CiC and, in the light of such evaluation, prepare descriptions of the roles and skills required for Non-Executive Director appointments (including the Chairman).

Approve any locally-determined, major changes in Executive Directors, and Senior Managers’ benefits structures.

Group GovernanceFramework

Manual

Charitable Funds Committee

(Charitable Funds Committees in

Common)

The Committee shall: Apply all SRFT and PAT charitable funds in accordance with NHS Acts, Charities Acts and

good practice and to ensure that decisions on the use or investment of such funds are restricted to the explicit conditions or purpose of each donation, bequest or grant.

Make decisions involving the use of SRFT and PAT charitable funds for investments subject to the powers laid down in the ‘Declaration of Trust’ and with regard to the ‘Trustee Act 2000’ and any subsequent legislation.

Ensure that SRFT and PAT’s policies and procedures for charitable funds and investments are followed.

Appoint Investment Advisors and monitor the performance of SRFT and PAT charitable funds investment portfolio.

Oversee and monitor the functions performed by the SRFT and PAT Executive Directors of Finance and Chief Executive with regard to the investment, accounting and reporting on the use of charitable funds.

Receive the Annual Report and Accounts of the SRFT and PAT charitable funds for approval,

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REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEESor otherwise, before submission to the Charities Commission

Oversee, co-ordinate, review and assess the effectiveness of the day to day management of the charitable funds.


Manual

Group Executive Risk and

Assurance Committee

The Committee shall: Review and monitor the corporate performance of Group. Agree and monitor action plans where remedial steps are indicated to improve performance. Have overarching responsibility for risk and oversee the development and implementation of

the Group’s Assurance Framework and Risk Management Strategy, including the approval of key strategies and policies.

Promote the ‘risk management’ culture and ‘risk appetite’ of Group. Ensure significant risks to the Group’s Principal Objectives are managed effectively and

efficiently. Ensure adequate assurance mechanisms exist and are appropriately monitored to enable self-

certifications and declarations of compliance with national standards and guidance to be confidently given.

Review, and ensure any appropriate action is taken, with respect to matters reported via the Care Organisations’ Board Assurance Frameworks and Statements of Assurance.

Oversee an appropriate programme of Care Organisation Annual Plan Reviews, and ensure any required actions are taken to support the effective delivery of the Care Organisations’ Principal Objectives;

Provide assurance to the Group CiC that ensures ongoing compliance with the constituent statutory bodies’ authorisation and statutory duties.

Establish and maintain an effective relationship with Group Audit CiC, to provide confidence to the Group CiC with respect to the delivery of Group’s Principal Objectives.


Manual

Group Executive Development Committee

The Committee will: Oversee the development and delivery of Group’s Strategic ambitions, identifying and ensuring

effective management of risks, mitigation actions, and resource issues. Ensure adequate assurance mechanisms exist and are appropriately monitored with respect to

the effective delivery Group’s key strategic objectives and deliverables.

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REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEES Ensure significant risks to the delivery of Group’s Strategic Objectives are reported, with

effective mitigation plans, to Group Executive Risk and Assurance Committee. Work in collaboration with the Strategy and Investment Committee in order that it may fulfil its

responsibility to provide independent and objective review of, and assurances, in relation to major strategic change initiatives and investment/divestment programmes that impact upon Group outcomes and direction.

Report to the Strategy and Investment Committee to confirm progress against approved implementation plans for current strategic programmes, any exceptions to these plans and agreed actions to mitigate.

SECTION 6 – DELEGATIONS DERIVED FROM THE ACCOUNTING OFFICER MEMORANDUM(Encompassing the Accountable Officer Memorandum as applicable to PAT)

REF DELEGATED TO DUTIES DELEGATED5 Chief Executive

Officer(CEO)Regardless of the source of the funding, accounting officers are responsible to Parliament for the resources under their control

7 CEO Responsibility for:

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REF DELEGATED TO DUTIES DELEGATED− the propriety and regularity of the public finances for which he or she is answerable − the keeping of proper accounts − prudent and economical administration in line with the principles set out in Managing

public money1 − the avoidance of waste and extravagance − the efficient and effective use of all the resources in their charge.

9 CEO − Personally sign the accounts and, in doing, so accept personal responsibility for ensuring their proper form and content as prescribed by NHSI in accordance with the Act

− comply with the financial requirements of the NHS provider licence − ensure that proper financial procedures are followed and that accounting records are

maintained in a form suited to the requirements of management, as well as in the form prescribed for published accounts (so that they disclose with reasonably accuracy, at any time, the financial position of the NHS foundation trust)

− ensure that the resources for which you are responsible as accounting officer are properly and well managed and safeguarded, with independent and effective checks of cash balances in the hands of any official

− ensure that assets for which you are responsible such as land, buildings or other property, including stores and equipment, are controlled and safeguarded with similar care, and with checks as appropriate

− ensure that any protected property (or interest in) is not disposed of without the consent of NHSI

− ensure that conflicts of interest are avoided, whether in the proceedings of the board of directors, or council of governors or in the actions or advice of the NHS foundation trust’s staff, including yourself

− ensure that, in the consideration of policy proposals relating to the expenditure for which you are responsible as accounting officer, all relevant financial considerations, including any issues of propriety, regularity or value for money, are taken into account, and brought to the attention of the board of directors.

10 CEO Ensure that effective management systems appropriate for the achievement of the NHS foundation trust’s objectives, including financial monitoring and control systems, have been put

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REF DELEGATED TO DUTIES DELEGATEDin place.

11 CEO Make sure that their arrangements for delegation promote good management and that they are supported by the necessary staff with an appropriate balance of skills.

12 CEO Particular responsibility to see that appropriate advice is tendered to the board of directors and the council of governors on all matters of financial propriety and regularity and, more broadly, as to all considerations of prudent and economical administration, efficiency and effectiveness

13 CEO The board of directors and the council of governors of an NHS foundation trust should act in accordance with the requirements of propriety or regularity. If the board of directors, council of governors or the chairman is contemplating a course of action involving a transaction which you as accounting officer consider would infringe these requirements, however, you should set out in writing your objection to the proposal and the reasons for this objection. If the board of directors, council of governors or chairman decides to proceed, you should seek a written instruction to take the action in question. You should also inform NHSI of the position, if possible before the decision is taken or in any event before the decision is implemented, so that NHSI, if it considers it appropriate, can intervene in accordance with its responsibilities under the Act. If the outcome is that you are overruled, the instruction must be complied with, but your objection and the instruction itself should be communicated without undue delay to the NHS foundation trust's external auditors and to NHSI. Provided that this procedure has been followed, the PAC can be expected to recognise that the accounting officer bears no personal responsibility for the transaction.

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SECTION 7 – DELEGATIONS FROM STANDING ORDERS

SO REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED1.1 Chairman Final authority in interpretation of SOs.3.1 Chairman Calling meetings

2.13 Chairman Chair all Board meetings and associated responsibilities.6.8 CEO Register(s) of Interests.

9.16 CEO Ensuring best value for money is demonstrated for all services provided under contract or in-house.9.17 CEO Demonstrating that the use of Private Finance represents best value for money and transfers risk to the

private sector.9.19 CEO Nominating an officer to oversee and manage a contract on behalf of the Trust.9.20 CEO Nominating officers to enter into contracts of employment, regarding staff, agency staff or consultancy

service contracts.9.22 CEO Nominating officers with power to negotiate contracts with commissioners of healthcare and other

authorities.10.1(a) CEO Determining any items to be disposed of by sale or negotiation.

12.1 CEO Keeping Trust Seal in a safe place and maintaining register of sealings.12.3 CEO/CFO Approving and signing all building, engineering, property or capital documents.13.1 CEO Approving and signing all documents which will be necessary in legal proceedings.13.2 CEO or CFO Signing on behalf of the Trust any agreement or document not required to be executed as a deed.14.1 CEO Ensuring all directors and employees are notified of and understand Standing Orders.

Annex A CEO Designating an employee responsible for receipt and custody of tenders before opening.Annex A CEO Designating employees responsible for opening tenders.Annex A CEO or CFO Deciding whether any late tenders should be considered.Annex A CFO Keeping lists of approved firms for tenders.

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Issue Date:

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SECTION 8 – DELEGATION FROM STANDING FINANCIAL INSTRUCTIONS

SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED1.3.6 CEO Ensuring all directors and employees, present and future, are notified of and understand Standing

Financial Instructions.1.3.7 CFO Implementing the Trust's financial policies and coordinating corrective action and ensuring detailed

financial procedures and systems are prepared and documented.1.3.8 CFO Responsible for the security of the Trust's property, avoiding loss, exercising economy and efficiency

in using resources and conforming to Standing Orders, Standing Financial Instructions and financial procedures.

1.3.10 CFO Form and adequacy of financial records of all departments.2.1.1 Audit Committee Providing an independent and objective view on internal control and probity.2.2.1 CFO Investigating any suspected cases of fraud or other irregularity, in conjunction with the Anti-Fraud

Specialist/Local Counter Fraud Specialist.2.4 Audit Committee Reviewing, appraising and reporting in accordance with NHS Internal Audit Manual and best practice.

3 CFO Submitting budgets, monitoring performance against budget, submitting financial estimates and forecasts to the Board.

3 CEO Delegating budgets to budget holders and submitting monitoring returns to the Independent Regulator.

3.3 CFO Devising and maintaining systems of budgetary control.4 CFO Annual accounts and reports.5 CFO Banking arrangements.6 CFO Income systems.7 CFO Negotiating contracts for the provision of patient services.7 CFO Regular reports of actual and forecast contract income and expenditure.8 Remuneration etc

Sub-CommitteeMaking recommendations to the Board concerning remuneration and terms of service of directors and senior employees on MPS Terms and Conditions of Service.

8.4 CFO Payroll9.1 CEO Determining, and setting out, levels of delegation of non-pay expenditure to budget managers.

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Issue Date:

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SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED9.2.2 CFO Prompt payment of accounts.9.2.5 CEO Authorising individuals to use and/or be issued with official orders.9.2.7 CFO Ensuring that Standing Orders are compatible with NHS Executive requirements in respect of building

and engineering contracts.10 CFO Advising Board on borrowing and investment needs and preparing procedural instructions.11 CEO/CFO Capital investment programme.

11.1 CEO/CFO Monitoring the capital programme.11.3 CEO Maintenance of asset registers.11.3 CEO Overall responsibility for fixed assets.11.5 Directors and

EmployeesResponsibility for security of Trust assets including notifying discrepancies to DoF, and reporting losses in accordance with Trust procedures.

12 CFO Responsibility for systems of control over stores and receipt of goods.12.8 CEO Identifying persons authorised to requisition and accept goods from Supplies/Trust stores.13.2 CFO Preparing procedures for recording and accounting for losses and special payments and informing

NHS Counter Fraud Authority of all frauds and informing police in cases of suspected arson or theft, and where appropriate involving the Anti Fraud Specialist/Local Counter Fraud Specialist.

14 CFO Responsibility for accuracy and security of computerised financial data.15 CEO Responsibility for ensuring patients and guardians are informed about patients' money and property

procedures on admission.17 CEO Retention of document procedures.18 CEO Risk management programme.18 CFO Insurance arrangements. See also Section 7 item 25.

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Group Governance Framework Manual – Appendix 8: Reservations of Powers & Delegation of Powers: DETAILED SCHEME OF DELEGATION



Issue Date:

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DETAILED SCHEME OF DELEGATION APPENDIX B

This document provides a framework for decision-making responsibilities within the Trust. Directors are responsible for ensuring that all staff operates within the Scheme of Delegation and in accordance with Standing Orders and Standing Financial Instructions. The Scheme of Delegation identifies the lowest level to which a particular responsibility may be delegated. There is no requirement for Directors to delegate to this level. The levels of management/delegation referred to in this Scheme are as follows (definitions of these roles are set out in the Standing Financial Instructions):

Chief Executive Officer (In the absence of the Chief Executive, urgent matters may be dealt with by the relevant Director and/or the Chairman)

Chief Financial Officer Other (Group) Chief Officers Executive Director of Finance (In the absence of the Director of Finance, urgent matters may be dealt with by the Deputy Director of

Finance) Other Executive Directors Care Organisation (CO) Chief Officers (accountable officers) Director of Finance (CO) Other CO Directors Management Boards Group CiC Divisional Managing Directors and Chairs of Division Service Managers / Assistant Directors of Nursing Senior Manager Authorised Signatories This Scheme of Delegation applies equally to all services “Hosted” by SRFT with detail of authorised signatories found within the

detailed authorised signatories list for those services.

It is for Directors to identify within their Directorate those Officers whom they wish to authorise (Authorised Signatories) to exercise delegated authority within this Scheme of Delegation. Forms for this purpose are available from the Director of Finance and posted on the intranet.

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1. Pay and Non Pay, Revenue and Capital Expenditure/Requisitioning/Ordering/Payment of Goods & Services/Budget virements. All limits exclude VAT. (Note restrictions at Section 4c re leases)

Up to £5,000 (exc VAT) Category A – As defined within the eProcurement system, by the relevant Category D Director

Up to £15,000 (exc VAT) Category B – As defined within the eProcurement system, by the relevant Category D Director

Up to £50,000 (exc VAT) Category C – As defined within the eProcurement system, by the relevant Category D Director

Category DUp to £100,000Care Organisation

Any Divisional/ Directorate Director, subject to procurement sign off

Group Any Group Director

(directly reporting to Group Chief Officer), subject to procurement sign off

£100,000 - £249,999 Care Organisation Any CO Director,

subject to procurement sign off

Group: Any Chief Officer

£250,000 - £499,999 Care Organisation CO Accountable

Officer and Director of Finance (CO)

Where this is the same person, this must include CO Managing Director

Group Chief Officer and

Chief Finance Officer

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£500,000 - £1,499,999*

*Anything £1m+ must be notified to Group S&I for information

Care Organisation CO Management

Board

Group Group Executive

Development Committee

£1,500,000+ Group CiC

In exceptional cases, for the purpose of expediency and practicality, limits may be increased for particular Senior Finance/ Procurement staff to facilitate the approval of invoices in PIMS via non Purchase Order. Any exceptions granted will be approved by the Deputy Chief Finance Officer and reported to the Audit Committee.Guidance with respect to assigning staff to Category A-D is included. Staff assigned to Category D may only assign staff to the limits set as Category A-C.

2. Maintenance/Operation of Bank Accounts

Maintenance/Operation of Bank Accounts Group CiC

3. Management of Budgets – General SFIs Section 3

Responsibility of keeping expenditure within budgets, and for ensuring income is received for services provided.

At individual budget level (Income, Pay and Non Pay) Budget Manager

At service level Service Manager

At Directorate/Departmental level Divisional Directors/Department Director

For all other areas DoF (CO) or Appropriate Delegated Manager

Virements - the transfer of funds between subjective lines within a budget or between budgets. Virement of funds is available

As per the budgetary limits determined above***

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within the delegated limits provided that there is no adverse effect on the Trusts financial position - Virement is available between pay and non-pay budgets provided that it is authorised by the Director of Finance

3.1 Management of Budgets – Pay

Pay budgets are based upon approved establishments and these are an essential aspect of the management of the pay budgets.

(a) Authorisation of timesheets / clock cards / claims for special duty / overtime, on-call etc.

Line Manager

(b) Authorisation of Waiting Lists Initiatives (within the current pay terms and conditions)

Care Organisation Divisional Director

(c) Authorisation of use of temporary staff from Agencies, claims for medical sessional payments and internal bank / casual staff.

i. Clericalii. Medical locumsiii. Nursing

Flowchart to be inserted

(d) Approval of requests to fill vacant posts within the budgeted establishment.

Service Manager / Departmental Manager subject to approval

(e) Approval of changes to budgeted establishment funded from within the CO’s own budget

Divisional Managing Director, Chair of Division or equivalent

(f) Approval of changes to budgets which are backed by additional income

Value to be approved by Director of Finance (CO). Allocation to individual budget lines by Divisional Managing Director, Chair of Division or equivalent

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(g) Approval of other increase in budgeted establishment funded from resources not currently within the CO’s own budget.

Chief Financial Officer

SFI Section 8

3.3 Management of Budgets – Non Pay SFIs Section 9Standing Orders Sec.9Standing Orders – Annex A

(The limits set out below apply equally to Capital Expenditure / Requisitioning / Ordering / Payment of Goods & Services)

No Order should be artificially arranged so as to circumvent financial limits. All orders must be placed using the Trusts approved e-ordering system except where expressly approved by the Director of Finance.

The limits below apply to both stock and non-stock -and the applicable OJEU thresholds for Supplies and Service Contracts (staff should ensure that quotes are obtained via the Procurement Department)

£5000 - £15,000 (exc VAT)(2 verbal quotations or utilisation of an appropriate framework agreement)*

Authorised Signature as defined within the eProcurement system Category B

Between £15,000 (exc VAT) & £50,000 (exc VAT)(3 formal/written quotations or utilisation of the appropriate framework agreement)*

Authorised signature as defined within the eProcurement system Category C

Between £50,000 (exc VAT) and the applicable OJEU threshold (exc VAT) for both NHS Foundation Trusts and NHS Trusts, the required goods or services should be obtained by issuing a tender or utilising an appropriate framework agreement. The selected route should be based on obtaining best value for money. In all cases, advice from the Procurement Department must be sought

Approval limits as per Section 1

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Over the OJEU threshold (exc VAT) for both NHS Foundation Trusts and NHS Trusts a fully compliant EU procurement process must be followed or an appropriate framework agreement must be utilised. The selected route must be based on obtaining best value for money. In all cases, advice from the Procurement Department must be sought.

Approval limits as per Section 1

a) Signing of contracts for goods & services and subsequent variations to contracts, (following the conclusion of the procurement within the levels set at 1.2 above).

Chief Executive, Executive Director or other officer as duly authorised by the Group CiC.

SO (Board) Para 10.1

b) Waivering of quotations (revenue or capital) between the value of £15k (exc VAT) - £50k (exc VAT), subject to SFIs

Head of Procurement/Procurement Director/CO Director of Finance

SFIs 9.2.1

c) Waivering of tenders (revenue or capital) between value of £50k (exc VAT) subject to SFIs

Chief Finance Officer or Care Organisation Director of Finance- All waivers to be reported to Audit Committee

SFIs 9.2.1

Opening Tenders and Quotations All tenders and quotations are opened by an authorised member of the Procurement team using the fully audited electronic Procurement Portal.

3.3 Tender Variations

Approving Tender Variations:up to 10%up to £15k whichever is the lower (within available budget)

All tender / contract variation approvals must be conducted in line with EU procurement directives. In all cases, advice from the Procurement Department must be sought.

In accordance with the agreed authorisation levels within each specialty / department

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Approving Tender Variations > 10% or £15k up to a maximum of £25k (within budget available).

Category D

Approving Tender Variations > 10% or £15k up to a maximum of £25k (outside budget available).

Category D

Approving Tender Variations > than 10% and over £25k Chief Financial Officer – reported to Audit committee

SFIs 9.2.1

4. Capital Programme / Schemes SFIs Section 11Standing Orders Sec.9Standing Orders – Annex A

Authorisation of Capital Projects / Capital Programme. Group CiC with day to day expenditure committed in line with 1.2 above with the exception of the Applicable OJEU threshold for both NHS Foundation Trusts and NHS Trusts which for capital (works) schemes is £4,551,413 (€5,548,000)

Waiving of formal tendering procedures / requirement for written quotation

Authorisation to exceed scheme approved budget.

Group CFO / Director of Finance (CO) subject to approval levels in section 1

Group CiC

Selection of architects, quantity surveyors, consultant engineer and other professional advisors within EU regulations

Director of Capital, Estates and Facilities

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Financial monitoring and reporting on all capital scheme expenditure

Deputy Chief Financial Officer

Granting and termination of leases of >£100,000 Group CiC

5. Setting of Fees and Charges SFIs Sections 6 & 7a) Private Patient, Overseas Visitors, Income Generation

and other patient related services.Group CFO and Director of Finance (CO) in agreement

b) Price of NHS Service Level Agreements Group CFO and Director of Finance (CO) /

c) Signing of Service Level agreements with Commissioners SLA values up to £10 million SLA values over £10 million

CO Director of Finance CO Accountable Officer / Director

of Finance (CO)/Group CFO

6. Engagement of Management Consultancy Staff SFIs Section 9

a) Non Medical Consultancy Staff (subject to procurement routes in 1 above and any extant regulatory requirements e.g. the NHSI consultancy cap).

CO Accountable Officer and Director of Finance (CO) or Group Chief Officer

d) Engagement of Trust's Solicitors Chief Executive / Group CFO/Authorised Directors

7. Expenditure on Charitable and Endowment Funds

Charitable Funds Committee (CFC) should agree in principle expenditure on charitable and endowment funds,

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Up to £5,000Up to £15,000Up to £25,000Up to £50,000Over £50,000

expenditure signatories thereafter are as follows:Fund holdersDivisional DirectorsCO DirectorsGroup CFOCFC

8. Agreements/Licences/Leases SFI Section 7

a) Preparation and signature of all tenancy agreements/licences for all staff subject to Trust Policy on accommodation for staff

CO Director of Finance (Finance will work with CO’s to define delegation requirements)

b) Approval of or Extensions to existing leases Up to £100k

Above £100k

CO Director or Director of Capital, Estates and Facilities Group CiC

c) Letting of premises to outside organisations Chief Executive & Group CFO

d) Approval of rent based on professional assessment Chief Executive & Group CFO

e) Signing of Lease Documentation Group CiC

9. Condemning & Disposal SFIs Section 13

Items obsolete, obsolescent, redundant, irreparable or cannot be repaired cost effectively

Category C

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10.Losses, Write-off & Compensation (Deputy Chief Financial Officer to be informed of all items approved in line with the below limits. Items to be reported to the Audit Committee bi-annually)

All limits in this section apply per case.

Manual for AccountsSFI Section 13CNST and RPST (NHSLA) Membership Rules.

a) Losses and Cash due to theft, fraud, overpayment & others –

i. Up to £50,000ii. Over £50,000

i. Director of Finance (CO)ii. CO Management Board

b) Fruitless Payments (including abandoned Capital Schemes)

i. Up to £250,000ii. Over £250,000


c) Bad Debts and Claims Abandoned. Private Patients, Overseas Visitors & Other

i. Individual debts up to £5,000ii. Individual debts over £5,000


d) Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (eg fraud, theft, arson) or other

i. Up to £50,000ii. Over £50,000


e) Compensation payments made under legal obligation Lead HR Officer for the CO listed under Category D - for staff compensationCO Director of Finance - for non-staff compensation

f) Extra Contractual payments to contractors i. Up to £100,000ii. Over £100,000

i. Category Dii. CO Management Board/Any

Chief Officer

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Extra Contractual payments relating to Capitali. Up to £100,000ii. Over £100,000

i. Associate Director of Estates

ii. Director of Capital, Estates and Facilities

Ex-Gratia Payments (Deputy Chief Financial Officer to be informed of all items approved in line with the below limits. Items to be reported to the Audit Committee bi-annually)

g) Patients and staff for loss of personal effects:i. Less than £2,000 (patients)ii. Over £2000 (patients)iii. Less than £1,000 (staff)iv. Over £1,000 (staff)

i. CO Director of Nursingii. CO Management Boardiii. Divisional Managing Director or

equivalentiv. CO Accountable Officer/Any Chief

Officer

h) For settlement of insured risks: Clinical

Non-Clinical – Up to value of Excess N.B. above excess level is insured risk and therefore no issue for the Trust

Divisional Managing Director or equivalent

i) Settlement of non-insurance claim risks:

Up to £10,000 (Clinical & Non-Clinical) Divisional Managing Director or equivalent

£20,001 - £50,000 (Clinical & Non-Clinical) CO Accountable Officer or Director of Finance (CO)

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£50,001 and above (Clinical & Non-Clinical) Group CiC

j) Employment related settlements:

- Up to £10,000HR Lead for the CO listed under Category D

- Over £10,000 CO Accountable Officer or Director of Finance (CO)

Other, except cases of maladministration where there was no financial loss by claimant

i. Up to £100,000ii. Over £100,000

i. Category Dii. CO Management Board/Any

Chief Officer

k) Write back of NHS Debtors

i. Up to £25,000ii. Over £25,000

i. CO Director of Finance or Deputy Chief Financial Officer

ii. Group CFO

11. Reporting of Incidents to the Police SFIs Sections 2 & 11Trust Policy on Violence & AggressionAppendix 6

a) Where a criminal offence is suspected:

criminal offence of a violent nature other (except fraud)

CO Director Any Chief OfficerSenior Manager or Director on call on call

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b) Where a fraud is involved the police are notified in accordance with the Trust’s Fraud Response Plan

CO Director of Finance/ Deputy Chief Financial Officer

12. Petty Cash Disbursements (not applicable to Central Cashiers Office) SFIs Sections 6

a) Expenditure up to £30 per item Petty Cash Holder

b) Reimbursement of patients monies up to £100

c) Reimbursement of patients monies in excess of £100

All patient monies must be lodged with the central cashiers department of the relevant hospital and receipted.Reimbursement must be requested by the Service Manager.

13. Receiving / Registering Hospitality

Applies to both individual and collective hospitality items of all value.

SFI Section 17 &Code of Conduct for NHS Staff (page 13 section 1.3.1.6).

SFI Section9.2.6(d)

a) Declaration required in Trust’s Gifts and Hospitality Register held by the Director of Corporate Services

All staff

In situations where individuals believe that a supplier has offered an inappropriate inducement this should be reported to the line manager who will refer it upwards as appropriate.

14. Compliance with Relevant Laws

Ensure compliance with relevant laws and regulations, internal policies and procedures and that all expenditure is lawful.

All Senior Managers, General Managers, Line, Ward and Departmental Managers.(The Declaration of Interests document

Group Governance Framework Manual.

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signed each year will provide assurance that compliance with this provision is evidenced.)

15. Implementation of Internal and External Audit Recommendations

Assigned Responsible Officer Section 1.4 (P.20) plus section 2.4 (p.43).SFI Section 2 &Appendix 7A

16.Maintenance & Update on Group Financial Procedures Group CFO Section 1.5 (page 22)

17. Investment of Funds Group CFO SFIs Section 8

18.Contracted Personnel & Pay additional items within existing Terms and Conditions of Employment. (These limits apply to items within the budgets available) NOTE: Expenditure related to non contracted pay is detailed at section 3.1

a) Additional Increments

The granting of additional increments to staff within budget:

o Senior Medical Staff

o Other Staff

HR Lead in the CO listed under Category D

b) Upgrading & Regrading

All requests for upgrading/regrading shall be dealt with in accordance with approved Procedure (value relates to the increase in pay).


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c) Protected Wage / Salary Payments

The protection of wages / salary payments will be in accordance with the approved Policy.


d) Creation of New Management Posts (within available resources and management costs targets)

i. Up to Trust Grade 4 / up to AFC Band 7ii. Trust Grade 3 to 1 / AFC Band 7 and aboveiii. Executive Director

i. Category Cii. Category Diii. Group CiC (NHSI for PAT)

e) Authority to complete standing data forms effecting pay, new starters, variations and leavers.

Line Manager

f) Authority to complete and authorise positive reporting forms

Line Manager

g) Authority to authorise overtime Category B

h) Authority to approve working in a temporary grade:

i. Covering vacanciesii. Temporary Regrading

Category B, seeking advice from Lead HR Officer for the CO

i) Variation to Overtime Payment RatesAll payments to be made in accordance with National Terms and Conditions and approved Terms and Conditions as appropriate

Chief Strategy and Organisational Development Officer

k) Authority to authorise ad-hoc payments (outside of normal terms and conditions) subject to compliance with any Trust or national requirements about rates of pay.

Lead HR Officer for the CO listed under Category D (HR will work with CO’s to define delegation requirements)

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l) Salary / wage payments from Charitable Funds Fund Signatories (See section 7)

m) Renewal of Fixed Term Contract Category B seeking advice from Lead HR Officer for the CO

19. Travel and associated Expenses Re-imbursement

Authority to authorise travel and associated expenses:

Executive Directors Other Staff

Chairman / Chief Executive Line Manager or approved Deputy

20.Leave Conditions of Service

Trust Leave Policy

a) Approval of annual leave Line Manager

b) Annual leave - approval of carry forward (up to maximum of 5 days

Line Manager

c) Annual leave - approval of carry over in excess of 5 days but less than 10 days.

Category B

d) Annual leave - approval to carry forward 10 days or more. Category C

e) Compassionate LeaveCompas

Line Manager

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f) Special leave arrangementsviiS

Maternity Leave Paternity Leave Adoption Leave

Automatic Approval with guidance Automatic Approval with guidance Automatic Approval with guidance

Carers leave Domestic Trade Union Duties / Activities

Line Manager Line Manager Line Manager

viii) g) Leave without pay Line Manager

ix) h) Medical Staff Leave of Absence - paid and unpaid CO Medical Director

i) Time off in lieu Automatic Approval with guidance

j) Sick Leave

Extension of sick leave on half pay up to three months

Line Manager - In line with Trust Sickness Handling Guidelines

Phased return to work on adjusted pay to assist recovery, reviewable on a monthly basis in accordance with sickness guidance.

Line Manager - Trust Sickness Handling Guidelines

Discretionary extension of sick leave on full pay, reviewable monthly.


k) Study Leave Trust Policy

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Non Medical Study leave Divisional Managing Directoror equivalent

Medical staff study leave CO Medical Director

All other study leave Service Manager / Departmental Manager / Category C

21.Removal Expenses, Excess Rent and House Purchases

Authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview)

Up to £8,000 HR Lead in the CO listed under Category D

Expenses over and above the above limit can only be awarded in exceptional circumstances on a case-by-case basis.

CO Accountable Chief Officer or Chief Executive

22.Grievance Procedure All grievances cases must be dealt with strictly in accordance with the Grievance Procedure and the advice of a Human Resources Officer must be sought when the grievance reaches the level of General Manager

Trust Grievance Procedure

23.Authorised Car & Mobile Phone Users

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a) Requests for new posts to be authorised as car users Line Manager

b) Lease Car Approval Divisional Managing Director or equivalent

c) Lease Car Mileage Rates Group CFO

d) Requests for new posts to be authorised as mobile telephone users

Divisional Managing Director or equivalent

24. Redundancy

Redundancy Chief Executive/Chief Financial Officer/Chief Strategy and Organisational Development Officer

Voluntary severance arrangements (as determined and agreed from time to time by the Nominations, Remuneration and Terms of Service Committee)

Group CiC

25. Ill Health Retirement

Decision to terminate on the grounds of ill-health Category C seeking advice from Lead HR Officer for the CO.

26.Dismissal Divisional Managing Directoror equivalent seeking advice from Lead HR Officer for the CO.

Trust Disciplinary Procedures

27.Authorisation of New Drugs Group Medicines Management Group

28.Authorisation of Sponsorship deals Group CEO and Group CFO

29.Authorisation of Research Projects Director of R&D plus CO Director of Finance and Deputy Chief Financial Officer

Trusts Research Policy

30.Authorisation of Clinical Trials Director of R&D plus CO Director of Finance Trusts Clinical

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and Deputy Chief Financial Officer plus Director of Pharmacy.

Trials Policy

31. Insurance Policies and Risk Management Group CiC SFIs Section 19

32.Patients & Relatives Complaints

a) Overall responsibility for ensuring that all complaints are dealt with effectively

Chief Executive/Chief Nursing Officer

b) Responsibility for ensuring complaints relating to a directorate are investigated thoroughly.

CO Associate Director of Governance Managing Director, Chair of Division or equivalent

c) Medico - Legal Claims - Coordination of their management.

Claims Manager

33.Relationships with Press

Enquiries :-

Within Hours Outside Hours

Group Director of Communications Senior Manager on-call

34. Infectious Diseases & Notifiable Outbreaks CO Medical Director / Head of Infection Control

35.Extended Role Activities

Approval of Nurses to undertake duties / procedures which can properly be described as beyond the normal scope of Nursing Practice.

CO Director of Nursing

Nurse/Midwives/ Health Visitors Act Midwives Rules / Code of Practice UKCC Code of Professional Conduct

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36.Patient Services

a) Variation of operating and clinic sessions within existing numbers:

Outpatients Theatres Other

Divisional Managing Director, or equivalent

b) All proposed changes in bed allocation and use

Temporary Change Permanent Change

Contract monitoring Contract reporting

Bed Manager Divisional Managing Director or

equivalent CO Director of Finance CO Director of Finance

37.Facilities for staff not employed by the Trust to gain practical experience

Trust Policy on Student Work Experience

a) Professional Recognition, Honorary Contracts, & Insurance of Medical Staff.

R&D Director

b) Work experience students etc. Work Experience Business Officer

38.Review of fire precautions Director of Capital, Estates and Facilities

39.Review of compliance with all statutory and Health and Safety Executive requirements (including control of Substances Hazardous to Health Regulations)

CO Chief Accountable Officers

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40.Review of Medicines Inspectorate Regulations CO Medical Director

41.Review of compliance with environmental regulations, e.g. those relating to clean air and waste disposal

CO Chief Accountable Officers

42.Review of Trust's compliance with the Data Protection Act Group Chief Information Officer43.Monitor proposals for contractual arrangements between

the Group/Care Organisation and outside bodiesGroup Chief Financial Officer/ CO Director of Finance

44.Review the Trust's compliance with the Access to Health Records Act

Deputy Chief Information Officer IG

45.Review of the Trust's compliance code of Practice for handling confidential information in the contracting environment and the compliance with "safe haven" regulations

Deputy Chief Information Officer IG

46.The keeping of a Declaration of Interests Register. Director of Corporate Services SOs Section 6

47.Attestation of Sealings in accordance with Standing Orders Group CFO and CEO (or nominated officers, not within the originating department)

SOs Section 12

48.The keeping of a register of Sealings Director of Corporate Services SOs Section 1249.The keeping of the Hospitality Register Director of Corporate Services50.Retention of Records Chief Executive

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

Meeting Group Committees in CommonAuthor Rebecca McCarthy, Deputy Trust Secretary

Presented by John Willis, Chairman of Audit Committee

Date 4th June 2018

Executive Summary

A summary is provided for the Group Committees in Common of the key matters and decisions from the Group Audit Committee meeting on 24th May 2018.

Annual Plan Objective

N/A

Principal Associated Risks

N/A

Recommendations The Group Committees in Common is asked to review the summary of the meeting and the agreed actions.

Public and/or Patient Involvement (Including equality related impacts)N/ACommunicationN/AFreedom of Information Please ‘cross’ one of the boxes below:




Title of Report Report from Group Audit Committee – 24th May 2018

X

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1. Annual Self-Certifications including:− General Condition 6− FT Condition 4− Training of Governors− Continuity of Services CoS7

Reviewed and approved including declaration required by General Condition 6 of the NHS Provider Licence and FT Condition 4.

2. Year End Matters – Salford Royal NHS Foundation Trust (SRFT)

− SRFT Annual Report (including Annual Governance Statement) and Quality Accounts 2017/18 – Reviewed and approved

− SRFT Accounts 2017/18 – Reviewed and approved− External Auditor: SRFT Audit Findings Report (ISA 260) – Reviewed and confirmed− External Auditor: Report to Governors on the Quality Report & Draft Independent

Auditors Limited Assurance Report on the Quality Report – Reviewed and confirmed− SRFT Letter of Representation: Financial Statements – Reviewed and confirmed− SRFT Letter of Representation: Quality Report – Reviewed and confirmed

3. Year End Matters – Pennine Acute Hospitals NHS Trust (PAHT)

− PAHT Annual Report (including Annual Governance Statement) and Quality Accounts 2017/18 – Reviewed and approved

− PAHT Audited Accounts 2017/18 – Reviewed and approved− External Auditor: PAHT Audit Findings Report (ISA 260) – Reviewed and confirmed− External Auditor: Draft Independent Auditors Limited Assurance Report on the Quality

Report – Reviewed and confirmed− PAHT Letter of Representation: Financial Statements – Reviewed and confirmed− PAHT Letter of Representation: Quality Report – Reviewed and confirmed

4. Group Reference Costs Assurance Process – Reviewed and approved

5. CQC Assurance Programme 2018/19 – Reviewed and confirmed the proposed process to be implemented across Group and Care Organisations in order to provide assurance against the CQC key lines of enquiry including an independent annual review of the Well-led framework.

6. Group Governance Framework Manual – Reviewed and confirmed revision prior to approval by the Group Committees in Common (Appendix 1)

7. 2018/19 Opening Position Group Board Assurance Framework/Corporate Risk Register including agreement of Deep Dive Risk Programme for 2018/19 – Reviewed; acknowledging opportunity for further discussion and approval at the Group Committees in Common on 4th June 2018. Audit Committee confirmed the selection of risks on which to conduct a deep dive would be discussed further at the Audit Committee workshop to be scheduled in June/July 2018.

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Meeting Group Committees in CommonAuthor Rebecca McCarthy, Deputy Trust Secretary

Presented by John Willis, Vice-Chairman

Date 4th June 2018

Executive Summary

A summary is provided of the key matters and decisions from the Group Charitable Funds Committee meeting on 30th April 2018.

Annual Plan Objective

N/A

Principal Associated Risks

N/A

Recommendations The Group Committees in Common is asked to review and confirm the summary of the Group Charitable Funds Committee meeting on 30th April 2018.

Public and/or Patient Involvement (Including equality related impacts)N/A

CommunicationPublicly available via online publication of Group Committees in Common papers.

Freedom of InformationPlease indicate appropriate box below

A – This document is for full publication

B – This document contains FoIA exempt information

C – This whole document is exempt under the FoIA

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Title of Report Report from the Charitable Funds Committee – April 2018

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1. Investment Managers Update:− PAHT: Brewin Dolphin− SRFT: Investec

Reviewed and confirmed, including respective portfolio values for SRFT and PAHT as at 31st March 2018.

2. Finance Reports: − PAHT− SRFT

Reviewed draft income and expenditure position and the balance sheet position as at 31st March 2018 with respect to Charitable Funds, noting figures would be reviewed and confirmed during the preparation of the Annual Reports, to be presented in July 2018.

3. PAHT Charitable Fundraising Co-ordinator Report Reviewed and confirmed. Charitable Funds Committee requested further consideration and forward view of the fundraising function, including opportunity to extend the current fundraising function at PAHT to SRFT.

4. PAHT: Update Funding Request from the John Mayo Legacy Reviewed and approved funding request following provision of additional information as requested by the committee in January 2018.

5. SRFT: Funding Request – LGBT Network Reviewed and approved funding request to help fund the initial start-up costs of the network and the activities in its inaugural year.

6. PAHT Research & Innovation Funding Request:− Research Assistant – RL Gardner Fund− Research Assistant – NMGH Research Fund− 3 Nurses – RL Gardner/NMGH Research Fund

Reviewed and approved funding requests to support to safe delivery of increased research activity.

7. SRFT: Salix Homes Ltd – Exclusive Use of Alexander GardensReviewed and requested further detail to be presented to a future meeting regarding the exclusivity arrangement for the provision and letting of accommodation for clinical staff/NHS key workers.

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