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PART 1 AGENDA ITEM 6

Title of Board paper

Chief Executive’s Report

Board meeting date 31 July 2014

Purpose

To draw the Board’s attention to key issues

Actions Recommended

Discussion / Noting / Decision

Publication

This paper will be published in line with the Tameside Hospital NHS Foundation Trust publication scheme, subject to any redactions approved by the Board.

Unusual acronyms None

Any communications actions after the meeting

None

Report of Karen James

Paper prepared by Tom Neve

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Quarter 1 Monitor Submission

The Trust has to make its Quarter 1 In-Year Submissions to Monitor by the end of

July 2014 covering:

- A declaration of risks against healthcare targets and indicators for 2014/15

- An In-Year governance statement from the Board

Information about Board changes and Governor elections will be reported to reflect

the recent Executive Director appointments and the most recent public Governor

election.

The declaration of risks against healthcare targets and indicators for 2014/15 will

reflect that the trust was unable to complete the submission for incomplete RTT

pathways.

The submission will also reflect that the Trust remains in Special Measures.

The Trust is complaint with all other targets and standards in respect of quarter 1.

An In-Year Governance statement from the board is required and the board is

required to respond “confirmed” or “not confirmed” to the following statements:

The board anticipates that the trust will continue to maintain a Continuity of Service

risk rating of at least 3 over the next 12 months.

The board is asked to approve a “not confirmed” response.

For governance, that:

The board is satisfied that plans in place are sufficient to ensure on going

compliance with all existing targets (after the application of thresholds) as set out in

Appendix A of the Risk Assessment Framework; and a commitment to comply with

all known targets going forward.

In light of the trust’s not being in a position to submit data for incomplete RTT

pathways, the board is asked to approve a “not confirmed” response.

Otherwise:

The board confirms that there are no matters arising in the quarter requiring an

exception report to Monitor (per the Risk Assessment Framework page 21, diagram

6) which have not already been reported.

The board is asked to approve a “confirmed” response.

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Plans to encourage the recovery of migrant NHS healthcare costs.

The department has announced plans to help the NHS to recover more of the costs

of migrant and visitor healthcare.

Some patients from outside Europe using the NHS will be charged 150% of the cost

of treatment under new incentives for the NHS to recover costs from visitors and

migrants using the NHS. Visitors and migrants can currently get free NHS care

immediately or soon after arrival in the UK. The government is now asking the NHS

to identify these patients more effectively so costs can be recovered from them.

This will make sure that by the middle of the next parliament, the NHS will recover

up to £500 million a year from treating foreign visitors and migrants.

In June it was revealed that the NHS will receive and extra 25% on top of the cost of

every procedure they perform for an European Economic Area (EAA) migrant visitor

with a European Health Insurance Card (EHIC). A non-EAA visitor will be charged

for their care plus an extra 50%.

Steps are being taken to help the NHS charge more effectively and consistently and

a clear timetable is being issued and a new National Intensive Support Team will be

on hand to assist.

Financial sanctions will be put in place for trusts who fail to identify and bill

chargeable patients.

Requirements for registration with the Care Quality Commission

The Department of Health has published a combined response to three separate

consultations recently undertaken:

• Introducing fundamental standards: consultation on proposals to change

CQC registration regulations

• Consultation on the fit and proper persons test

• Introducing the statutory Duty of Candour

Following these consultations, the DH has decided to introduce these measures in

the following sequence:

• The Duty of Candour will be introduced for NHS bodies only in October 2014

• The fit and proper persons requirement will be introduced for NHS bodies

only in October 2014

• The fundamental standards will be introduced for all providers in April 2015.

• The Duty of Candour and fit and proper persons requirements will be

extended to all CQC registered providers from April 2015

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Further detail of what is included in these measures can be found in the Department

of Health’s publication Requirements for registration with the Care Quality

Commission published in July 2014.

Sign up to Safety

Sign up to Safety is a new national patient safety strategy campaign. Launched on

24 June 2014 with the mission to strengthen patient safety in the NHS and make it

the safest healthcare system in the world.

Organisations and individuals who sign up to the campaign commit to setting out

actions they will undertake in response to the following five pledges

1. Put safety first. Commit to reduce avoidable harm in the NHS by half and

make public the goals and plans developed locally.

2. Continually learn. Make their organisations more resilient to risks, by acting

on the feedback from patients and by constantly measuring and monitoring

how safe their services are.

3. Honesty. Be transparent with people about their progress to tackle patient

safety issues and support staff to be candid with patients and their families if

something goes wrong.

4. Collaborate. Take a leading role in supporting local collaborative learning, so

that improvements are made across all of the local services that patients use.

5. Support. Help people understand why things go wrong and how to put them

right. Give staff the time and support to improve and celebrate the progress.

A National Co-ordinating and Support Group has been established, chaired by Sir

David Dalton who is supported by Dr Suzette Woodward as Campaign Director.

This Trust will be signing up to the campaign and the organisation will commit to

strengthening patient safety by:

• Setting out the actions it will undertake in response to the five Sign up to

Safety pledges and agree to publish this on the website for staff, patients and

the public to see.

• Commit to turn the trust’s actions into a safety improvement plan which will

indicate how this organisation intends to save lives and reduce harm for

patients over the next 3 years.

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NHS England Launches Integrated Personal Commissioning (IPC)

Simon Stevens the CEO of the NHS has set out plans for a new Integrated

Personal Commissioning (IPC) programme. Speaking recently at a Local

Government Association conference he stated that high-need individuals are to be

offered the ability to control their own blended NHS and community care, in

partnership with voluntary sector.

The NHS will offer local councils across England a radical new option in which

individuals could control their combined health and social care support.

Four groups of high-need individuals are likely to be included in the first wave from

next April 2015, although councils, voluntary organisations, and NHS clinical

commissioning groups may also propose others. These are:

• people with long term conditions, including frail elderly people at risk of care

home admission

• children with complex needs

• people with learning disabilities, and

• people with severe and enduring mental health problems.

At the same time, voluntary/Third Sector organisations will be commissioned locally

to support personal care planning, advocacy and service ‘brokerage’ for these

individuals enrolled in the IPC programme.

This new approach builds upon, but is in addition to, the joint work now under way

locally on the Better Care Fund.

Under the new IPC programme, a combined NHS and social care funding

endowment will be created based on each individual’s annual care needs. This will

blend funds contributed from local authorities and NHS commissioners (CCGs and

NHS England). Individuals enrolled in the programme will be able to decide how

much personal control to assume over how services are commissioned and

arranged on their behalf.

NHS care will in all cases remain free at the point of use, and available according to

individual need.

NHS England will now work with partners in local government, CCGs, patient

groups and the voluntary sector to develop an IPC Prospectus which will be

published at the end of July. This will formally invite local expressions of interest in

jointly developing and participating in the IPC programme from April 2015.

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NHS England will provide technical support to develop projects, and fund

independent evaluation. Wider scale rollout of successful projects is envisaged from

2016/17.

The Friends and Family Test for Staff Introduction NHS England announced earlier this year that all NHS organisations providing acute, community, ambulance and mental health services are required to implement the Staff Friends and Family Test (FFT) between 1 April and 30 June 2014. The FFT for Staff asks how likely staff are to recommend the services they have received, or work in, to friends and family who need similar treatment or care to that which they have received or deliver. Implementation All staff must have at least one opportunity to complete per year. The Trust has taken the opportunity to include an additional 23 questions around our values and behaviours. The Results

Q1 2014

Description Target %

Q1 2014

1 How likely are you to recommend this organisation to friends and family if they needed care or treatment?

67 77

2 How likely are you to recommend this organisation to friends and family as a place to work?

61 71

5 I work in a clean, safe environment. 0 90

6 Staff at this Trust take responsibility for all the things that they do.

0 64

7 Staff at this Trust are confident to challenge others to improve standards.

0 62

8 Safety and quality are extremely important to all staff at this Trust.

0 73

9 Staff at this Trust are always caring and compassionate. 0 71

10 Staff at this Trust always offer and show comfort, support and understanding.

0 71

11 I always involve patients and their relatives in their care. 0 74

12 The Trust cares about staff and their welfare. 0 58

13 Staff at this Trust respect privacy and confidentiality at all 0 80

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times.

14 The Trust promotes and encourages my learning. 0 63

15 I motivate myself. 0 97

16 I try to help other colleagues develop. 0 96

17 In my team we recognise and celebrate achievements. 0 75

18 In my team we learn from incidents, complaints and compliments received.

0 90

19 Staff at this Trust are always recognised, valued and respected.

0 44

20 All staff and patients are treated with dignity and kindness at the Trust.

0 63

21 Staff at this Trust are always polite and professional. 0 68

22 The Trust encourages staff to actively listen to patients, their relatives, carers and colleagues

0 83

23 Staff at this Trust are always open and honest. 0 60

24 The Trust encourages and welcomes feedback from staff and patients.

0 83

25 I know what the Trust’s priorities are. 0 85

26 I know how well the Trust is performing. 0 79

27 I know how my role contributes to the success of the Trust. 0 87

Staff awards 2014 As many of you will be aware, we held this year’s staff awards on the 11th July 2014. Unlike previous years, we hired, thanks to our sponsors, the summer marquee at the Village Hotel in Ashton-under-Lyne – just to make it that little bit special. Our staff certainly weren’t disappointed on the night. The venue looked fabulous with over 250 members of staff, partners and sponsors attending the evening, it was a roaring success. All the ladies wore dinner dresses and the gentlemen wore suits and tuxedos, everybody looked wonderful. The awards were closely followed by a summer disco in the marquee for all staff, where they had the opportunity to let their hair down after a very challenging year for the hospital. I want to pay a special tribute to all of our finalists and winners on the evening. They have all gone the extra mile over the last 12 months and fully deserved their recognition on the night. It is this kind of dedication and commitment to the hospital which gives our patients an excellent service. Well done to all.

CQC Report

We are obviously disappointed with the “Inadequate” rating given to the trust arising

out of the CQC inspection in May 2014. The report does however acknowledge a

number of examples of excellent care and the significant and positive change in the

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culture of the organisation. The trust will remain in special measures until it is re-

inspected towards the end of the calendar year. An action plan is being developed

to address the remaining concerns of the CQC in order to ensure it is removed from

special measures.

PART 1

AGENDA ITEM 7


Improvement Update

Board meeting date 31st July 2014

Purpose

The purpose of this paper is to update the Board on the future monitoring arrangements for the actions that were determined from the following reviews: Deanery Change Plan July 2013 Keogh Responsive Review Change Plan Recovery Plan based on The ECIST & GMUMT Reviews at TFT April 2013 Monitor Letter on 2nd July 2013 CQC July 2103 CQC May 2014

Actions Recommended


Publication This paper will be published in line with the Tameside Hospital NHS Foundation Trust publication scheme, subject to any redactions approved by the Board.

Unusual acronyms

ICPA – Improvement Central Action Plan KPIs – Key Performance Indicators MAU – Medical Assessment Unit UHSM – University Hospital of South Manchester CIP – Cost Improvement Programme KPI- Key Performance Indicator SPC- Statistical Process Charts PMO- Project Management Office BAF-Board Assurance Framework QIA-Quality Impact Assessment CQUIN-Commissioning for Quality and Innovation


The content of this report will be communicated to external stakeholders.

Report of Karen James Interim Chief Executive

Paper prepared by Naomi Ledwith Programme Director Improvement

Tameside Hospital NHS Foundation Trust

Keogh Update

1. Background

The Board has been receiving monthly reports on the Improvement Central Action Plan (ICPA) since October 2013. The ICAP was created to allow the Trust to articulate the Improvement Strategy, in response to the reviews listed below, and to align business to that strategy.

• Deanery Action Plan July 2013

• Keogh Responsive Review Change Plan

• Recovery Plan based on The ECIST & GMUMT Reviews at TFT April 2013

• Monitor Letter on 2nd July 2013

• CQC Inspection visit July 2103 In recognition of the importance of the programme the ICAP has been delivered and monitored through its own bespoke governance structure; both internally within the Trust and externally to the Clinical Commissioning Group (CCG). The ICAP is delivered and monitored through the Improvement Board, which is accountable to the Trust Board. The Improvement Board provides assurance to the Clinical Commissioning Group (CCG) through reports to the monthly Trust/CCG Interface meeting and attendance, by the Trust, to the CCG Quality Committee. The Improvement Board also provides assurance to Monitor via the submission of monthly progress reports on the ICAP. In addition updates are provided to the Health and Wellbeing Board.

2. Refresh of Improvement Central Action The May 2014 Care Quality Committee (CQC) Inspection recognised that the Trust is on a journey and significant improvement has been made in the 10 months since the Keogh review. The majority of the actions within the ICAP have been delivered; therefore it is appropriate to refresh the plan to reflect the recent CQC inspection ensuring that we continue to look forward on our improvement journey. The proposal is that the work streams within this plan continue to be monitored through the Improvement Board and reported to the Trust Board on a monthly basis, for the time that the Trust remains in Special Measures. The Programme Management Office will act as the delivery unit for the RICAP working with the transformational, clinical, governance, managerial and operational teams within the Trust to ensure delivery. The RICAP will be closely linked to the Board Assurance Framework and be reported on through a risk based approach. See Appendix 1 for the Governance Structure. The Board should expect to receive a report on progress against the RICAP at the August 2014 meeting.

3. Historic Improvement Central Action Plan

In the time that the ICAP governance structure has been operational, the CCG’s and the Trust’s governance structures have both matured significantly. Therefore it has been recommended by the Improvement Board that those historic ICAP actions that have been delivered (ie Green or Blue), and that are not recommended for improvement in the CQC report will be monitored on an on-going basis through core governance process from August 2014. Internally within the Trust historic ICAP actions will be reported on a risk based approach through the Board Assurance Framework (BAF). The CCG will seek assurance from the Trust through the Performance and Quality Contract Groups. 5. Conclusion The key to ensuring permanent change and a culture of continuous improvement is to enable operational and clinical staff to take ownership for improvement and monitoring. Transferring the monitoring of delivered historic ICAP actions to core governance will encourage ownership and delivery within divisions, directorates and wards. Maintaining focus on the key actions recommend by CQC in July 2014 will continue to be managed through the PMO Delivery Unit. The Trust’s Service Transformation team is also currently being enhanced to create the additional capacity required to secure the pace of change that is required over the next ten to twelve months. A more detailed report which outlines the approach and plan to deliver the on-going service transformation and operational improvements will be submitted to the August Board meeting.

Appendix 1 Refreshed ICAP Governance Structure


Title of Board paper Integrated Quality Report : June 2014


Purpose The Board is asked to review current performance

Actions Recommended


Publication This paper will be published under the THFT publication scheme

Unusual acronyms

ADT Admission, Discharge, Transfer C DIFF Clostridium difficile CIP Cost Improvement Plan CQC Care Quality Commission CT Computerised Tomography CWT Cancer Waiting Times DNA Did-not-Attend DPH Director of Public Health FFT Friends & Family Test GMCCN Greater Manchester & Cheshire Cancer Network HSMR Hospital Standardised Mortality Ratio HAS Hospital Arrival Screen MRSA Methicillin-resistant staphylococcus aureus MSA Mixed-sex Accommodation RAMI Risk-adjusted Mortality Index RCA Root Cause Analysis RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RTT Referral-to-Treatment SHMI Summary Hospital-level Mortality Indicator STAR Staff Accident Rate

StEIS Strategic Executive Information System

TIA Transient Ischaemic Attack

VTE Venous Thromboembolism

YTD Year-to-Date

Any communication actions after meeting

None

Report of

Trish Cavanagh, Director of Operations Brendan Ryan, Medical Director John Goodenough, Director of Nursing Amanda Bromley, Director of HR Barbara Herring, Director of Finance

Paper prepared by Kay Holland, Deputy Chief Operating Officer

QUALITY ACCOUNT: July 2014 Board (June 2014 performance)

Board of Directors’ Meeting: 31st July 2014

Quality Account 2014/15 Contents Introduction 3 Quality Dashboard June 2014/15 4 Exception Reports Director of Operations

Readmission 5

RTT- 18 Week incomplete pathways 6

Outpatient slot utilisation 7

Outpatient Did-Not-Attend (DNA) rate 7

Theatre Utilisation 8

Stroke 9

Director of Nursing

Nutrition Risk Assessment 10

Director of Human Resources

Staff Attendance 11

Appraisals (rolling 12 months) 11

Trust induction 11

Mandatory Training compliance 11


Quality Account Report – June 2014 Performance

Introduction

The Quality Account report provides the Trust Board with an overview of the Trusts performance across a range of quality and operational indicators for the month of June 2014 and year to date performance, along with a RAG rating of performance to support the Board in evaluating how the Trust is performance against each indicator.

Exception Reports

Alongside the Quality and Performance Dashboard, the report includes exception reports which responds to the performance data and will allow the Executive team and Trust Board to be assured of and contribute to plans to rectify performance and quality issues.

June Performance

The issue previously reported to Board around consistency of compliance with standard operating procedures and their impact on tracking 18 week performance continues, specifically in relation to incomplete pathways. An RTT validation team have been appointed who are systematically working through the issues. We have been unable to report our compliance with the incomplete pathway indicator and have discussed the issues with both Monitor and the Health & Social Care Information Centre and an exception report is provided to inform the Board of the issues and actions.

NHS England requires all Trusts to reduce the number of patients waiting longer than 18 weeks during July and August even if it results in a dip in monthly performance; the one month forecast for July has been amended to reflect this requirement.

Recommendation

The Trust Board is asked to review the quality and performance standards noted in the Quality Account.

THFT Quality Dashboard June 2014/15

* Governance indicators, which appear in Monitor's Compliance Framework

Target Actual 4-mth Actual Current 1-mth Target Actual 4-mth Actual Current 1-mth Target Actual 4-mth Actual Current 1-mth

14/15 YTD Trend Month Period F'cast 14/15 YTD Trend Month Period F'cast 14/15 YTD Trend Month Period F'cast

Mortality Stroke Waiting times

≤100 91.2 NA ≥90% 90.17% 90.10%

SHMI (rolling 12 months)# ≤100 NA ≥95% 97.26% 98.11%

Infection Prevention & Control ≥80% 77.50% 73.91% ≥92% - -

0 0 0 RTT waits (>52 weeks) 0 0 0

41 9 2 ≤1% 0.50% 0.36%

NHS Safety Thermometer A&E

N/A 96.99% 95.91% Target Actual 4-mth Actual Current 1-mth ≥95% 95.40% 94.55%

≥95% 99.43% 100.00% 14/15 YTD Trend Month Period F'cast Trolley waits in A&E (>12 hrs) 0 0 0

Patient Safety 0 4 0 HAS compliance ≥95% 76.06% 74.03%

≥95% 95.42% 96.97% Cancer

93% 98.50% 97.34%

NA 101 0 NA NA 93% 100.00% 100.00%

≥90% 91.26% 79.31% 96% 98.18% 96.00%

Staff accident rate# 94% 100.0% 100.00%

(STAR) 98% 100.0% 100.0%

0 0 0 85% 86.89% 88.57%

0 12 2 Target Actual 4-mth Actual Current 1-mth 85% 92.86% 89.47%

0 0 0 14/15 YTD Trend Month period F'cast

0 0 0 ≥96.6% 95.37% 95.20% Target Actual 4-mth Actual Current 1-mth

0 2 1 ≥95% N/A 83.60% 14/15 YTD Trend Month Period F'cast

Moves after 11pm (% of Admissions) NA 3.13% 2.70% NA - ≥95% N/A 96.60% ≥85% 68.57% 68.74%

Safer Staffing ≥95% N/A 86.60% ≤7.5% 11.05% 11.51%

TBA 93.08% 93.63% ≥85% 71.43% 73.09%

TBA 113.16% 114.95% Target Actual 4-mth Actual Current 1-mth ≤0.8% 0.77% 0.55%

14/15 YTD Trend Month Period F'cast

Target Actual 4-mth Actual Current 1-mth Green R - NA R -

14/15 YTD Trend Month Period F'cast 3 1 - NA 1 -

0 0 0 None 8 - NA 8 - Actual 4-mth Actual Current Yr-end

FFT Net Promoter Score 50 48 47 YTD Trend Month Period F'cast

FFT positive responses NA 87.21% 87.19% NA - Cum. Net surplus (£'m) -7161 -2,109 -17500

FFT response rate 15% 29.38% 35.36% strong improvement Cum. CIP (% of plan) 90.6% 96.8% 100%

Complaints received N/A 113 39 NA improvement Cum. Capital (% of plan) +/-15% of plan 67.5% 97.3% 100%

Complaints responded to within ≥90% 65.77% 84.85% no change Cum. CQUIN (% of plan) 70.0% 70.0% 70%

agreed timescale deterioration

Ombudsman cases upheld 0 1 0 strong deterioration

≤-£17500

The one-month forecast is an informed prediction of the

next month's performance, which may be based on part-

month data, operational intelligence and historical

trends.

≥100% of plan

≥70% of plan

1-month forecast 4-month trend

Patient Experience

Theatre utilisation

RegulatoryCancelled operations (last-minute)

MSA breaches

Urgent operations cancelled

Governance Risk Rating* for second time0

RN/RM hrs on shift (% of planned)

HCA hrs on shift (% of planned)

Financial Risk Rating*

CQC concerns*Finance

Target

0 0

14/15

Never Events reported (StEIS) Staff attendanceOperational Efficiency

Regulation 28 reports (inquests) Appraisals - rolling 12 mths

Trust induction Outpatient slot utilisation#

Mandatory training Outpatient DNA rate

Failure of safer-surgery process 62-day from referral*#

<10 0.13 0.00

Serious Incidents reported (StEIS)People

62-day from upgrade of urgency*#

'Duty of Candour' breaches

Nutrition risk assessment# due to staff accidents 31-day treatment*#

Emergency re-admissions within10.0% 14.98% 14.14%

31-day surgery*#

30 days (rolling 3 months)# 31-day drug treatment*#

Lost-time accidents 2-week referral*

on admission# Calendar days lost 2-week breast symptomatic*

RIDDOR incidents reported

VTE risk assessments Consecutive safe days

Medicines reconciled≥94% - Qtrly Qtrly

C-difficile - actual cases YTD* within 24 hours Diagnostic wait time, 6 weeks

Harm-free care (all harms)Staff Health & Safety

4-hour wait*

Harm-free care (new harms)

% time on Stroke Unit 18-week incomplete*

MRSA - actual cases YTD* High-risk TIA cases treated ≥60% 21.74% 21.05%

18-week admitted*

from arrival (<4 hours)# 18-week non-admitted*

Actual year-to-date (YTD) is June 2014 unless otherwise indicated. # identifies indicators reporting on previous months data

Overall Clinical Quality Specialty Clinical Quality Patient Access

HSMR # (rolling 12 months) Time to stroke bed≥80% 62.50% 57.14%


June 2014

QUALITY ACCOUNT EXCEPTION REPORTS: Director of Operations (1/5)

Overall Clinical Quality Target Trend Position (last 4 months)

Cum Performance 2014/15 Forecast

Emergency Readmissions within 30 days (rolling 3 months) 10%

14.98%

ISSUE: The 30 day readmission rate has started to improve during this reporting period. An audit of 100 readmissions was carried out which established that chronic disease management of chronic obstructive pulmonary disease, cardiac related issues and urinary tract infections accounted for the vast majority of cases. It is recognised that all complex patients are reviewed by a multi-agency team prior to discharge and thus any actions taken must be on a cross-economy, pathway basis, rather than by the acute provider in isolation. ACTIONS COMPLETED:

1. Audit of 100 cases completed. New audit pro-forma drafted 2. Coding reviewed and work in progress to further refine

FUTURE ACTIONS:

1. Re-admission audit being planned into regular audit cycle 6 monthly 2. COPD – Further pathway development with other providers to redesign out of

hospital respiratory pathways (pre and post admission) as part of the Care Together programme.

3. Develop a business case to be submitted to the Care Together Programme Board in August.

4. Cardiac – A similar workstream is planned with the CCG. However, the audit also established some data quality issues within this area which are being rectified.

5. UTI – An ambulatory care pathway is being introduced, which will ensure that all patients are treated in accordance with established best practice. This will be in practice by August 14.

ASSESSING IMPROVEMENT: Improvement will be tracked by visualising an improving trend.

Emergency Readmission rate

Expected date to meet target

End Q4 Signed off by Mike Griffiths

Signed off by Trish Cavanagh


Patient Access (Waiting Times) Target Trend Position (last 4 months)

Cum Performance

2014/15 Forecast

Referral to Treatment time (RTT) – 18 week incomplete pathways 92%

ISSUE: The number of patients on incomplete pathways increased substantially following implementation of Lorenzo. This is mainly due to data quality issues and the Trust has been unable to submit Incomplete Pathway data to NHS England. The data quality issues relate to the creation of multiple pathways for patients due to system and procedural processes. ACTIONS COMPLETED:

1. The 18 week validation team continue to validate the backlog as a priority. Due to the lack of a confirmed date for a system fix from CSC the July 2014 deadline for completion of this will not be achieved.

2. Collaboration with other Lorenzo organisations is underway to share areas of concern and potential process changes.

3. Mandatory Lorenzo system training for targeted users is underway and will be completed by the end of July 2014.

PROPOSED ACTIONS: 1. The validation process has been amended to prioritise patients >18 weeks to enable

the trust to recommence external reporting of incomplete pathways. This is likely to take 3 months to complete.

2. Additional data entry clerks are being recruited on a temporary basis to support and speed up the validation process.

3. CSC providing on-site system support before the end of July 2014. 3. A robust action plan is in place to pick up, address and monitor all issues identified, to

ensure swift resolution and compliance. ASSESSING IMPROVEMENT: Consistent reporting of performance against all national targets. Compliance against the 18 week incomplete pathway target of 92%.

Incomplete Pathway Backlog


TBC – Dependent on CSC System Fix

Signed off by Angela Brierley



Operational Efficiency (Outpatients) Target Trend Position (last 4 months)

Cum Performance

2014/15 Forecast

Outpatient Slot Utilisation Outpatient DNA Rate

85%

7.5%

68.57%

11.05%

ISSUE: Templates continue to be reviewed as part of the Clinic Template Reconfiguration project in conjunction with the Outpatient Efficiency project. Progress has been delayed due to a review of benefits and a revised proposal is due for sign off on 24

th July 2014. Until the revised templates have been fully rolled out, the

clinic utilisation will remain low as we currently hold a large number of unusable slots in our templates. The DNA rate was impacted in June 14, due to an issue relating to non-delivery of appointment letters. This has now been resolved. Work has started on procurement of an alternative appointment reminder service.

PROPOSED ACTIONS: Support sign-off for Clinic Template restructure project and implement changes. Commence Procurement process for Appointment Reminder Service. Continue to pilot further DNA reduction initiatives with Paediatrics service.

ASSESSING IMPROVEMENT: Increased outpatient slot utilisation Reduction in the DNA Rate Increase in OP appointment availability Reduction in OP Waiting time


December 2014 Signed off by S Ashworth



Operational Efficiency (Theatre Utilisation) Target Trend Position (last 4 months)

Cumulative Performance

2014/15 Forecast

In theatre operating utilisation (Capped) Last Minute Cancelled Operations

92%

0.8%

71.43%

0.77%

ISSUES:

Late starts remain high, but a number of workshops have been run to address bed pressures on lists and late starts. Cancellations and DNA’s have impacted utilisation which is tracking close to target trajectory. SUMMARY OF PROGRESS TO DATE

Theatre utilisation continues to improve in line with the trajectory and the planned utilisation and management of lists has improved. Theatre Policy has been drafted and is under review. Successfully recruited Theatre Scheduler, to commence on 18

th August 2014

The project continues to focus effort on late starts and is reviewing the issues relating to bed availability, consenting and delays in getting patients to theatre on time. Proposal centralisation of booking processes under review and revision. PROPOSED ACTIONS:

Continued focus on late starts

Establish improvements in patient preparation and bed availability

Commence implementation of Theatres Policy

Complete draft of Centralised Booking Proposal ASSESSING IMPROVEMENT:

Improved theatre utilisation, productivity, reduction in cancellations and a reduction in waiting list initiatives being undertaken out of hours.

Theatre Utilisation Trajectory for Improvement

Expected date to meet target April 15 Signed off by S Ashworth



Specialist Clinical Efficiency (Stroke) Target Trend Position (last 4 months)

Cum Performance

2014/15 Forecast

Stroke – time to stroke bed from arrival (4hr target) Stroke - % of time on Stroke unit TIA – high risk TIA’s treated within 24hrs

80%

80%

60%

62.50%

77.50%

21.74%

ISSUE: Time on Stroke Ward / Direct Admission

Early identification of Stroke patients in the ED remains a problem. Any training initiatives are having limited success due to the high number of ad hoc locums at middle grade level that deliver variation in consistency. This can mean that patients are admitted through the AMU pathway before a formal stroke diagnosis is made. TIA Key issues: The historical issues of GP referral processes, patient choice and internal booking practices have been thoroughly discussed in previous Boards. The TIA Ambulatory Pathway is now live, although issues with referral practice via GP’s continue. PROPOSED ACTIONS

TIA: The ambulatory TIA pathway has commenced. Engagement work with the CCG continues via monthly meetings with the designated commissioner to ensure the correct referral pathway is used. Weekly monitoring of TIA is established with individual cases being reviewed and action taken where issues have been identified. A newsletter explaining our Ambulatory Pathways has been circulated to GP Practices. Direct Admission / Time on a Stroke Ward: Identification of new strokes using ROSIER scoring as part of the ED React Process and continued feedback of issues to clinicians is being taken through the ED Governance channel. Robust breach analysis and cascade through specialist teams is now incorporated into a daily report which is sent to speciality teams to respond. The stroke co-ordinator rota has been reviewed to provide enhanced cover for ED inreach ASSESSING IMPROVEMENT:

Improvements in SSNAP data / Improving trajectory against direct admissions / Improving trajectory against TIA metrics. Auditing the number of patients accessing services through TIA AEC

% Time on Stroke Unit (4 month trend)

Time to Stroke Bed (4 month Trend)

Expected date to meet target August 2014 Signed off by M Griffiths


QUALITY ACCOUNT EXCEPTION REPORTS: Director of Nursing (1/1)

Overall Clinical Quality Target Trend Position (last 4 months)

Cum Performance 2014/15 Forecast

Nutrition Risk Assessment ≥90%

91.26%

ISSUE:

Introduction of new Nutrition Screening Document (Malnutrition Universal Screening Tool – MUST).

Slow uptake of E Learning for new MUST document.

Change of reporting tool (no longer using North West Care Indicator document) no clear tool to use in its replacement.

No clear guidance on required sample size (possibly too small).

ACTIONS COMPLETED:

Ward managers to record screening tool data on a weekly basis to identify areas of poor compliance.

Ward Managers to support staff in access and completion of MUST e-learning package to improve understanding.

FUTURE ACTIONS:

Weekly reviews of compliance with nutritional screening tool use.

Weekly review of staff completion of MUST e-learning. ASSESSING IMPROVEMENT:

Spot check ward reviews completed by Nutrition Nurse in Q3 to ensure on projected target for compliance.

Nutrition Risk Assessment

Expected date to meet target End Q4 Signed off by

Signed off by John Goodenough

QUALITY ACCOUNT EXCEPTION REPORTS: Director of Human Resources (1/1)

People Target Trend Position (last 4 months)

Month Performance

2013/14 Forecast

Staff attendance Appraisals - rolling 12 mths Trust induction Mandatory training

96.6%

95%

95%

95%

95.20%

83.60%

96.60%

86.60%

ISSUE: The following are below the Trust target - sickness absence, mandatory training and PDR compliance. Compliance with induction is now above target, following changes in the way that induction is provided and new starters are processed. PROPOSED ACTIONS: The following actions are taking place to improve compliance:

Divisions have been asked to provide an improvement trajectory to meet 95% compliance with PDR and Mandatory Training

A review of the delivery of Mandatory Training has taken place to ensure there are enough sessions for staff to attend.

Sickness absence meetings are held monthly with Divisional managers and the Director of HR

Attendance Management Training for managers is now run on a regular basis, and is being targeted to areas with a low take up to-date, or where sickness absence is high.

ASSESSING IMPROVEMENT: Improvements will be measured through a reduction in sickness absence and an increase in compliance with induction, mandatory training and PDRs.

Sickness Absence

Monthly Sk Abs %

4.8% Trust Target

3.4%

Long Term Sick %

2.9% 12 Month Sk Abs % 4.7%

Short Term Sick %

1.9% Calendar Days Lost 3891

Estimated Monthly Cost

£246,602 Number of Episodes 384

PDR

PDR Completion % 84%

Mandatory Training Wkbook incld IG Completion %

86% Resus % 82%

Manual Handling % 91% Overall Compliance

86%

Expected date to meet target Signed off by E Devlin

Signed off by Amanda Bromley

1


Title of paper

Finance & Activity Report – June 2014


Purpose

To update the Trust Board on the financial position

Actions Recommended

To note the contents of the report and discuss




None

Report of Director of Finance – Barbara Herring

Paper prepared by Deputy Director of Finance – Suzanne Holroyd

2

Summary Financial Position Key Financial Metrics: Month 03 – June 2014

The waterfall graphs below bridge the financial planned position to the actual position.

Financial Position– The Trust is reporting a cumulative normalised deficit of £7.16m at the end of June, against a planned deficit of £4.95m, £2.207m behind plan, and a Continuity of Service Risk Rating of 1 against an expected rating of 1, the worst possible rating. In month the Trust is £1.1m behind plan with an in month deficit of £2.6m.

PlannedSurplus/(Deficit)

ClinicalIncome

OtherIncome

PayCosts

Non PayCosts

Depreciation

PFIInterest

&contingent Rent

Dividends

Othertechnica

lcosts/in

come

ActualSurplus/(Deficit)

Value (4,954) (1,751) 153 (1,109) 413 87 2 0 (2) (7,161)

(4,954)

(1,751)

153

(1,109)

413 87 2 0

(2)

(7,161) (8,000)

(7,000)

(6,000)

(5,000)

(4,000)

(3,000)

(2,000)

(1,000)

0

1,000

Surp

lus

(De

fici

t)

£'0

00

Planned (Deficit) v Actual (Deficit)

Current Month Plan

£000

Current Month Actual £000

Current Month

Variance £000

YTD Plan

£000

YTD Actual

£000

YTD Variance

£000

FY Plan

£000

Income – Clinical activity 11,539 10,781 (758) 34,429 32,678 (1,751) 140,021

Income - Other 903 946 43 2,726 2,879 153 10,921

Expenditure (13,199) (13,612) (413) (39,800) (40,496) (696) (159,057)

EBITDA (757) (1,886) (1,129) (2,645) (4,939) (2,294) (8,115)

Financing (767) (739) 28 (2,309) (2,222) 87 (9,385)

Exceptional Items 0 0 0 0 0 0 0

Net (Deficit) Surplus (1,524) (2,625) (1,101) (4,954) (7,161) (2,207) (17,500)

Exceptional Items 0 0 0 0 0 0 0

Normalised (Deficit)Surplus

(1,524) (2,625) (1,101) (4,954) (7,161) (2,207) (17,500)

CoSRR 1.0 1.0 0 1

Capital expenditure 87 25 62 203 137 66 3,175

Cash 500 2,650 2,150 500

CIP 408 385 (24) 1,129 1,023 (106) 6,100

3

The main driver of the deficit is below planned activity/income performance and above planned pay expenditure as shown in the bridge chart above.

No funding has been released in month or cumulatively to support the financial position.

EBITDA is behind plan by £2,294k.

Income – Clinical income, is below plan in June and has under-performed by £758k, and £1.75m year to date. The chart below details the reasons. In June clinical income is behind plan due to underperformance on non-elective admissions of £696k, elective of £368k, outpatients £135k, offset by over-performance on other of £417k, and A&E of £24k.

Activity remains well below plan and activity levels at this time last year across the key points of delivery, with the exception of accident and emergency, and ambulatory care which are up against plan and last years’ activity. June – Activity (Spells / attendances)

Activity Plan Month

Actual Month

Variance Plan Cum

Actual Cum

Variance June 13 Actual Cum

Elective 1,863 1,832 (31) 5,462 5,094 (368) 5,336

Non Elective 2,187 1,923 (264) 6,690 5,979 (711) 6,730

Ambulatory Care

55 155 100 165 536 371 125

Outpatients 20,482 19,154 (1,328) 59,510 57,538 (1,972) 58,846

A & E 6,495 6,710 215 19,698 20,429 731 19,545

Expenditure Costs are overspending by £413k in the month, and £696k year to date. The chart below tracks the causes of the overspend. Further information can be found in Appendix C. The main cause of the deterioration both in month and year to date is pay costs.

4

Analysis of pay variance – Year to June

Variance £’000

Comment

Medical Pay 6 Vacancy & use of agency staff

Nursing Pay (648) Over-establishment & agency

Other Pay (467) Lorenzo, IT, and Information, UHSM recharge

Total (1,108)

The graph below analyse the actual WTE compared with budgeted WTE for the main staff groups. The main issue is the over-establishment on nursing. This is due to non-delivery of CIP and having escalation beds open, along with ward staffing being above approved levels in many of the wards.

PlannedExpendit

ure

PayCosts

Drugs

ClinicalSupplies

&Services

GeneralSupplies

&Services

Establishment

Expenses &

Costs

Premises &

FixedPlant

OtherCosts

ActualExpendit

ure

Value (39,800) (1,108) 113 (54) 194 (107) (43) 311 (40,496)

(39,800)

(1,108)

113

(54)

194

(107) (43)

311

(40,496) (45,000)

(40,000)

(35,000)

(30,000)

(25,000)

(20,000)

(15,000)

(10,000)

(5,000)

0

5,000

£'0

00

Planned Expenditure V Actual

332

1,096 1,013

317

1,267

936

-

200

400

600

800

1,000

1,200

1,400

Pay Medical Pay Nursing Pay Other

Current month Budget v Actual WTE Trust Total

Sum of Wte Budget SUM Sum of Wte Actual SUM

Values

Summary pay category

Sum of Wte Budget SUM Sum of Wte Actual SUM

Period Num Division

5

CIP - Underperformance against the CIP target is £24k in June, and £3.36m

in year. Of the in-year savings achieved to date of £2.77m, £1.63m has been achieved non-recurrently and £1.14m being recurrent. Recurrently the full year effect of identified savings is £1.212m.

Cash - Cash balances are above plan by £2,150k. This performance has been mainly driven by below plan I&E performance, offset by a net increase in liabilities compared with plan. Cash Flow performance information can be found in Appendices F1 to F3. The Trust has received the planned £622k PDC requested from the DoH for June. This is currently only temporary PDC which would need to be repaid on the 4th of August. However, the department has indicated that this should be made permanent prior to the required repayment date.

The detailed I&E report can be found at Appendix A.

Conclusion At the end of June the Trust is cumulatively behind plan by £2.2m, with a deficit of £7.2m. The Trust is behind plan by £1.1m in the month with a deficit of £2.63m against a planned deficit of £1.52m. The main factors driving this position are;

below planned levels of activity

continued high levels of pay expenditure at premium rates, and over-establishments

Non-delivery of CIP by 9% cumulatively The Trust is increasing the level of financial control such that all areas manage within the available funds. In order to support this process the Trust is undertaking a full review of activity and income recording. In addition recovery plans for activity, income and expenditure are being finalised by two Directorates to address the financial position. Recommendation The Committee is requested to discuss and note the contents of this report.

Key Measures

Cumulative

Plan

Cumulative

Actual Variance

£000 £000 £000

EBITDA (2,645) (4,939) (2,294)

Net Surplus/(Deficit) (4,954) (7,161) (2,206)

Net Surplus/(Deficit) before Exceptional Items (4,954) (7,161) (2,206)

CIP 1,129 1,023 (106)

Margins Annual Plan

Cumulative

Actual Variance

% % %

EBITDA Margin % -5.38% -13.89% -8.52%

EBITDA % Achieved of Plan 99.40% 186.73% 87.33%

I&E Surplus Margin % 1.10% -20.14% -21.24%

Annual Plan

Cumulative

Actual

COSRR 1 1

1. Key risk is the non-delivery of CIP, and its associated impact on achieving financial recovery.

2. Activity underperformance.

3. In year cost pressures.

FINANCE DASHBOARD AS AT 30 JUNE 14

Key Risks

-3000.00

-2500.00

-2000.00

-1500.00

-1000.00

-500.00

0.00

500.00

1000.00

1500.00

April May June July Aug Sept Oct Nov Dec Jan Feb March

Su

rplu

s/(D

efi

cit)

£0

00

Month

Normalised Monthly Surplus/(Deficit)

Plan Actual 14/15 Actual 13/14

-

200

400

600

800

1,000

1,200

1,400

£0

00

Month

Capital Programme

Plan Actual

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

£0

00

Month

Cash Balances

Plan Actual

Appendix A

Budget Actual Variance Budget Actual VarianceAnnual

budget

£000 £000 £000 £000 £000 £000 £000

IncomeClinical Income 11,539 10,781 (758) 34,429 32,678 (1,751) 140,021

Research & Development 11 34 23 32 137 105 129

Education & Training 309 329 20 928 954 26 3,714

Other Clinical & other non-clinical income 583 574 (9) 1,765 1,729 (36) 7,078

PFI Specific Income (transitional) 0 8 8 0 59 59 0

Total Income 12,442 11,726 (715) 37,155 35,557 (1,599) 150,942

ExpenditurePay Costs (8,981) (9,529) (548) (26,969) (28,078) (1,108) (107,785)

Non-pay cost (incl internal recharges) (3,980) (3,837) 144 (12,111) (11,639) 472 (48,384)

PFI Specific Expenditure - UP (237) (238) (0) (720) (721) (0) (2,888)

PFI Specific Expenditure - transitional 0 (9) (9) 0 (59) (59) 0

Total Costs (13,199) (13,612) (413) (39,800) (40,496) (696) (159,057)

EBITDA (757) (1,886) (1,129) (2,645) (4,939) (2,294) (8,115)

EBITDA as a % of Income -6.09% -16.08% -10.00% -7.12% -13.89% -6.77% -5.38%

Technical Items

Profit/(loss) on asset disposal 0 0 0 0 0 0 0

Exceptional income ( fixed asset impairment) 0 0 0 0 0 0

Exceptional costs ( fixed asset impairment) 0 0 0 0 0 0

Restructuring Costs 0 0 0 0 0 0

Plus Income from Donated Assets 0 0 0 0 0 0

Less Total Depreciation (423) (396) 28 (1,270) (1,183) 87 (5,219)

Plus Total Interest Receivable 2 3 1 5 7 2 20

Less Total Interest payable on loans and leases - PFI (200) (200) 0 (607) (607) (0) (2,437)

PFI Contingent Rent (64) (64) (0) (193) (194) (1) (775)

Less Other Finance Cost - Unwinding Discount (1) (2) (1) (4) (5) (1) (15)

Less PDC Dividend (80) (80) 0 (240) (239) 0 (960)

Net Surplus/(deficit) (1,524) (2,625) (1,101) (4,954) (7,161) (2,207) (17,500)

For Information

Net Surplus/(deficit) before exceptional items (1,524) (2,625) (1,101) (4,954) (7,161) (2,207) (17,500)

INCOME & EXPENDITURE REPORT JUNE 14

In Month Year to Date

Appendix B1

Budget Actual Variance Budget Actual VarianceAnnual

budget

£000 £000 £000 £000 £000 £000 £000

Clinical Income by type

Elective 2,006 1,638 (368) 5,874 5,029 (845) 23,360

Non-Elective 3,776 3,080 (696) 11,466 10,127 (1,339) 47,371

Outpatient 2,239 2,104 (135) 6,508 6,273 (234) 26,065

A&E 695 719 24 2,108 2,190 81 8,455

Other 2,822 3,239 417 8,474 9,059 585 34,770

Total 11,539 10,781 (758) 34,429 32,678 (1,751) 140,021

Clinical Income by Commissioner

Tameside CCG 9,903 9,020 (883) 29,573 28,188 (1,385) 119,985

Manchester CCG 435 379 (56) 1,302 1,121 (181) 5,265

Oldham CCG 607 567 (40) 1,799 1,553 (246) 7,250

Stockport CCG 91 80 (11) 272 245 (28) 1,103

Specialised Services 576 561 (15) 1,707 1,579 (128) 6,872

All other income contracts and CIP (74) 174 248 (223) (7) 216 (454)

Total 11,539 10,781 (758) 34,429 32,678 (1,751) 140,021

Other income:Research & Development 11 34 23 32 137 105 129

Education & Training 309 329 20 928 954 26 3,714

Other clinical & other non-clinical income 583 574 (9) 1,765 1,729 (36) 7,078

PFI Specific Income - Transitional 0 8 8 0 59 59 0

Total 903 946 43 2,726 2,879 153 10,921

Total Income 12,442 11,726 (715) 37,155 35,557 (1,599) 150,942

Activity (Spells/ attendances)

Elective 1,863 1,832 (31) 5,462 5,094 (368) 21,893

Non Elective 2,187 1,923 (264) 6,690 5,979 (711) 27,775

Ambulatory Care 55 155 100 165 536 371 660

Outpatients (inc OPPROC) 20,482 19,154 (1,328) 59,510 57,538 (1,972) 238,370

A&E Attendances 6,495 6,710 215 19,698 20,429 731 78,999

31,081 29,774 (1,307) 91,525 89,576 (1,949) 367,697

In Month Year to Date

INCOME REPORT JUNE 14

APPENDIX C

ANALYSIS OF EXPENDITURE

Annual

Budget Actuals Budget Actuals Variance Budget Actuals Variance Budget

wte wte £000's £000's £000's £000's £000's £000's £000's

Expenditure

Pay Costs:-

Medical 332 275 (2,592) (2,322) 270 (7,793) (7,009) 784 (30,999)

Medical Agency - 42 (160) (517) (357) (479) (1,257) (777) (1,947)

Nursing 1,083 1,216 (3,589) (3,664) (74) (10,777) (10,739) 38 (43,233)

Nursing Agency - 50 (0) (160) (159) (1) (687) (686) (3)

Other 1,002 936 (2,618) (2,591) 27 (7,854) (7,616) 238 (31,341)

Other Agency 11 - (22) (276) (254) (65) (771) (705) (262)

0

Total Pay Costs 2,429 2,520 (8,981) (9,529) (548) (26,969) (28,078) (1,108) (107,785)

Non-Pay Costs:-

Drugs (658) (631) 28 (1,994) (1,881) 113 (7,853)

Clinical Supplies & Services (1,002) (1,020) (18) (3,088) (3,143) (54) (12,243)

General Supplies & Services (530) (473) 57 (1,615) (1,421) 194 (6,458)

Establishment Expenses (119) (128) (8) (361) (445) (83) (1,359)

Other Establishment Costs (610) (607) 3 (1,831) (1,855) (24) (7,317)

Premises & Fixed Plant (547) (556) (10) (1,682) (1,725) (43) (7,009)

Other (514) (422) 92 (1,540) (1,170) 370 (6,145)

PFI - UP (237) (238) (0) (720) (721) (0) (2,888)

PFI - Transitional Costs 0 (9) (9) 0 (59) (59) 0

Total Non-Pay Costs 0 0 (4,218) (4,083) 135 (12,831) (12,418) 413 (51,272)

Total Expenditure 2,429 2,520 (13,199) (13,612) (413) (39,800) (40,496) (696) (159,057)

The above table excludes expenditure on technical items as detailed in Appendix A such as depreciation, dividends and exceptional items.

Year-to-Date

EXPENDITURE REPORT JUNE 14

In Month

TAMESIDE HOSPITAL NHS FOUNDATION TRUST Appendix D

Column A Column B Column C Column D

Period Ending

31 March

2014

£'000s

Period Ending

31 May

2014

£'000s

Period Ending

30 June

2014

£'000s

Movement in the

month May

- June 2014

£'000s

Non Current Assets

Property, plant and equipment 69,396 68,862 68,562 (300)

PFI: Property, plant and equipment 36,798 36,657 36,586 (71)

Trade and Other Receivables

> Accrued Income (CRU Income grt than 1 yr) 203 71 109 39

> Prepayments - PFI Related 2,309 2,421 2,476 55

Total Non Current Assets 108,707 108,010 107,733 (277)

Current Assets

Inventories - Stock - Finished Goods 1,300 1,461 1,358 (103)

Trade & Other Receivables:-

> NHS Trade Receivables 1,432 1,653 1,189 (464)

> Non NHS Trade Receivables 730 98 117 19

> Other Receivables 531 618 471 (147)

> Accrued Income 2,105 2,463 2,298 (165)

> Prepayments - Non PFI Related 740 1,171 1,399 229

0

Cash 2,586 2,292 2,650 358

Investments 2,000 1,500 0 (1,500)

Total Current Assets 11,424 11,255 9,482 (1,773)

Current Liabilities

Trade & Other Payables:-

> NHS Trade Creditors (1,501) (1,442) (1,134) 308

> Non NHS Trade Creditors (2,548) (3,092) (2,004) 1,089

> Other Creditors (3,105) (4,453) (4,481) (28)

> Capital Creditors (491) (133) (111) 22

Other Liabilities:-

> Accruals (10,808) (12,728) (14,419) (1,691)

> Deferred Income (1,880) (1,863) (1,520) 343

>PFI Leases (1,428) (1,428) (1,428) 0

>PDC Dividend Creditor (40) (200) (279) (80)

Provisions (190) (182) (174) 7

Total Current Liabilities (21,991) (25,519) (25,549) (30)

Net Current Assets/Liabilities (10,567) (14,264) (16,068) (1,803)

Non Current Liabilities

Other Financial Liabilities:-

> Deferred Income (312) (698) (698) 0

> PFI Leases (57,440) (57,202) (57,084) 117

Provisions (638) (632) (632) 0

Total Non Current Liabilities (58,390) (58,532) (58,415) 117

TOTAL ASSETS EMPLOYED 39,749 35,213 33,250 (1,963)

Financed By Taxpayers Equity

PDC 53,168 53,168 53,830 662

Revaluation Reserve 19,347 19,347 19,347 0

I&E Reserve (33,895) (33,895) (33,895) 0

I&E Reserve 2013/14 1,130 1,130 1,130 0

I&E reserve 2014/15 0 (4,536) (7,161) (2,625)

TOTAL TAXPAYERS EQUITY 39,749 35,213 33,250 (1,963)

STATEMENT OF POSITION 2014/15

Appendix E1

Actual April

2014 £'000

Actual

May 2014

£'000

Actual

June 2014

£'000

YTD Actual

£'000

YTD

Movement to

plan £'000

Q2

2014/15

£'000

Q3

2014/15

£'000

Q4

2014/15

£'000

Revised

Plan

2014/15

£'000

Operating Surplus/(deficit) after tax (2,427) (2,109) (2,625) (7,161) (2,206) (4,150) (4,591) (1,598) (17,500)

Depreciation and Amortimisation 394 394 396 1,184 (85) 1,266 1,336 1,433 5,219

Impairment losses/(reversals) 0 0 0 0 0 0 0 0 0

PDC Dividend 80 80 80 240 (0) 240 240 240 959

Gain/loss on disposal of property, plant and equipment 0 0 0 0 0 0 0 0 0

Other increases/(decreases) to reconcile to profit/(loss) from operation items 262 272 262 796 (7) 803 803 810 3,212

Non-Cash flows in operating surplus/(deficit) total 736 746 737 2,219 (92) 2,309 2,378 2,483 9,389

Operating Cash Flows before movement in working capital (1,691) (1,363) (1,888) (4,942) (2,299) (1,841) (2,213) 885 (8,111)

Increase/(Decrease) in working capital

(Increase)/Decrease in inventories (62) (99) 103 (58) (58) 58 0 0 (0)

(Increase)/Decrease in NHS Trade Receivables 11 (232) 464 243 (244) 244 (70) (417) (0)

(Increase)/Decrease in Non NHS Trade Receivables 573 59 (19) 613 (97) 44 (100) (15) 542

(Increase)/Decrease in other receivables 66 (153) 147 60 27 (27) 0 (33) 0

(Increase)/Decrease in accrued income (316) (42) 165 (193) 181 12 (171) 352 (0)

(Increase)/Decrease in prepayments (346) (85) (229) (660) 298 (764) 50 1,374 0

Increase/(Decrease) in Trade Creditors 677 (193) (1,397) (913) (1,147) (34) 0 1,555 608

Increase/(Decrease) in Other Creditors 1,292 56 28 1,376 228 (278) 0 50 1,148

Increase/(Decrease) in accruals 1,264 655 1,691 3,610 5,122 (2,145) (1,045) (3,115) (2,695)

Increase/(Decrease) in Deferred Income (exl Donated Assets) 615 (246) (343) 27 27 (27) 0 0 (0)

Increase/(Decrease) in provisions (16) 1 (7) (22) (22) 22 0 0 (0)

Increase/(Decrease) in other - Other Financial Liabilities 0 0 0 0 0 0 0 0 0

Increase/(Decrease) in working capital total 3,758 (279) 604 4,083 4,315 (2,895) (1,336) (249) (397)

Net cash inflow/(outflow) from operating activities 2,067 (1,642) (1,284) (859) 2,017 (4,736) (3,549) 636 (8,508)

Net cash inflow/(outflow) from Investing activies

Property, plant and equipment - maintenance expenditure (71) (41) (25) (137) 66 (441) (1,895) (702) (3,175)

Increase/(decrease) in Capital Creditor (304) (54) (22) (380) 66 226 697 (908) (365)

Net cash inflow/(outflow) from Investing activies - Total (375) (95) (47) (517) 132 (215) (1,198) (1,610) (3,540)

Net cash inflow/(outflow) before financing 1,692 (1,736) (1,331) (1,375) 2,149 (4,951) (4,747) (974) (12,048)

Net cash inflow/(outflow) from Financing activities

Public Dividend Capital Received 0 0 662 662 0 4,675 6,141 2,822 14,300Public Dividend Capital Repaid 0 0 0 0 0 0 0 0 0

PDC Dividends paid 0 0 0 0 0 (479) 0 (480) (959)

Interest element of finance lease rentals on balance sheet (264) (273) (264) (801) (1) (809) (809) (792) (3,212)

Capital element of finance lease rental payments - on balance sheet (172) (178) (172) (522) 1 (530) (530) (519) (2,101)

Interest received on cash and cash equivalent 2 2 3 7 2 5 5 5 22

(Increase)/decrease in non-current receivables 177 (44) (39) 94 (86) (60) (60) (60) (86)

Net cash inflow/(outflow) from Financing activities - Total (257) (493) 190 (560) (84) 2,802 4,747 976 7,964

Net increase/(decrease) in cash and cash equivalents 1,435 (2,229) (1,141) (1,936) 2,065 (2,150) (0) 2 (4,083)

Opening cash and cash equivalents 4,586 6,021 3,792 4,586 86 2,650 500 500 4,586

Closing cash and cash equivalents 6,021 3,792 2,650 2,650 2,150 500 500 500 500

Monitor Plan 14/15 4,370 3,178 500 500 0 500 500 500 500

Variance to Monitor Plan 14/15 1,651 614 2,150 2,150 2,150 0 0 0 (0)


Cashflow Statement 2014/15

Plan

July

2014

£'000

Plan

August

2014

£'000

Plan

Sept

2014

£'000

Plan

October

2014

£'000

Plan

November

2014

£'000

Plan

December

2014

£'000

Plan

January

2015

£'000

Plan

February

2015

£'000

Plan

March

2015

£'000

Revised Plan

2014/15 £'000

Operating Surplus/(deficit) after tax (1,230) (1,421) (1,498) (1,346) (1,400) (1,846) (1,144) (1,664) 1,210 (17,500)

Depreciation and Amortimisation 422 422 422 445 445 445 478 478 478 5,219

Impairment losses/(reversals) 0 0 0 0 0 0 0 0 0 0

PDC Dividend 80 80 80 80 80 80 80 80 80 959

Gain/loss on disposal of property, plant and equipment 0 0 0 0 0 0 0 0 0 0

Other increases/(decreases) to reconcile to profit/(loss) from operation items 268 268 268 268 268 268 268 268 275 3,212

Non-Cash flows in operating surplus/(deficit) total 770 770 770 793 793 793 825 825 832 9,389

Operating Cash Flows before movement in working capital (461) (652) (729) (553) (607) (1,053) (318) (839) 2,042 (8,111)

Increase/(Decrease) in working capital

(Increase)/Decrease in inventories 58 0 0 0 0 0 0 0 0 (0)

(Increase)/Decrease in NHS Trade Receivables 544 (200) (100) (90) 220 (200) 100 (250) (267) (0)

(Increase)/Decrease in Non NHS Trade Receivables 97 (53) 0 0 0 (100) (15) 0 0 542

(Increase)/Decrease in other receivables (27) 0 0 0 0 0 0 0 (33) 0

(Increase)/Decrease in accrued income 12 0 0 (205) 0 34 100 126 126 (0)

(Increase)/Decrease in prepayments (481) (183) (100) 0 100 (50) 50 662 662 0

Increase/(Decrease) in Trade Creditors 247 (100) (181) 100 (100) 0 45 250 1,260 608

Increase/(Decrease) in Other Creditors (228) (50) 0 0 0 0 0 0 50 1,148

Increase/(Decrease) in accruals (2,036) (9) (100) (102) 96 (1,039) 1,050 (969) (3,196) (2,695)

Increase/(Decrease) in Deferred Income (exl Donated Assets) 531 (279) (279) 558 (279) (279) 558 (279) (279) (0)

Increase/(Decrease) in provisions 22 0 0 0 0 0 0 0 0 (0)

Increase/(Decrease) in other - Other Financial Liabilities 0 0 0 0 0 0 0 0 0 0

Increase/(Decrease) in working capital total (1,261) (874) (760) 261 37 (1,634) 1,888 (460) (1,677) (397)

Net cash inflow/(outflow) from operating activities (1,722) (1,526) (1,489) (292) (570) (2,687) 1,570 (1,299) 365 (8,508)

Net cash inflow/(outflow) from Investing activies

Property, plant and equipment - maintenance expenditure (57) (133) (251) (506) (1,258) (131) (236) (203) (263) (3,175)

Property, plant and equipment - non -maintenance expenditure 0 0 0 0 0 0 0 0 0 0

Increase/(decrease) in Capital Creditor 32 76 118 255 817 (375) (1,022) (33) 147 (365)

Proceeds from sale of assets 0 0 0 0 0 0 0 0 0 0

Net cash inflow/(outflow) from Investing activies - Total (25) (57) (133) (251) (441) (506) (1,258) (236) (116) (3,540)

Net cash inflow/(outflow) before financing (1,747) (1,583) (1,622) (543) (1,011) (3,193) 312 (1,535) 249 (12,048)

Net cash inflow/(outflow) from Financing activities

Public Dividend Capital Received 66 2,053 2,556 1,012 1,466 3,663 158 1,963 701 14,300Public Dividend Capital Repaid 0 0 0 0 0 0 0 0 0 0

PDC Dividends paid 0 0 (479) 0 0 0 0 0 (480) (959)

Interest element of finance lease rentals on balance sheet (273) (273) (264) (273) (264) (273) (273) (246) (273) (3,212)

Capital element of finance lease rental payments - on balance sheet (177) (177) (176) (177) (176) (177) (177) (165) (177) (2,101)

Interest received on cash and cash equivalent 0 0 5 0 5 0 0 5 0 22

(Increase)/decrease in non-current receivables (20) (20) (20) (20) (20) (20) (20) (20) (20) (86)

Net cash inflow/(outflow) from Financing activities - Total (404) 1,583 1,622 542 1,011 3,193 (312) 1,537 (249) 7,964

Net increase/(decrease) in cash and cash equivalents (2,150) (0) 0 (0) (0) 0 0 0 0 (4,083)

Opening cash and cash equivalents 2,650 500 500 500 500 500 500 500 500 4,586

Closing cash and cash equivalents 500 500 500 500 500 500 500 500 500 500

Monitor Plan 14/15 500 500 500 500 500 500 500 500 500 500

Variance to Monitor Plan 14/15 0 0 0 0 0 0 (0) (0) (0) (0)


Rolling 12 Month Cashflow Statement July 2014 - June 2015

Variance

MonthActual

April 14

Actual

May 14

Actual

June 14

Total YTD

2014/15

YTD Variance

To Plan

2014/15

Plan

July 14

Plan

August 14

Plan

September 14

Plan

October 14

Plan

November 14

Plan

December 14

Plan

January 15

Plan

February 15

Plan

March 15Total 2014/15

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Bank Accounts

Current Account (RBS/Lloyds/Citi) 2,558 4,014 2,272 2,643 494 493 493 493 493 493 494 493

Patient Monies (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2)

Petty Cash 8 8 8 8 8 8 8 8 8 8 8 8

National Loans Fund 2,000 2,000 1,500 0 0 0 0 0 0 0 0 0

Total Cash Balance 4,565 6,021 3,779 4,565 65 2,650 500 500 500 500 500 500 500 500 4,565

Cash Income Receipts

NHS Contract Income 11,334 11,791 11,706 34,831 (154) 12,161 11,989 11,602 11,989 11,759 11,419 11,918 11,312 12,125 141,106

Overperformance/(Underperformance) 62 0 7 68 1,337 (2,174) 0 0 0 0 0 0 0 0 (2,106)

NCA Income 73 54 109 235 43 114 100 100 140 100 100 100 100 70 1,160

Other Income 744 712 1,411 2,868 424 1,039 664 663 1,090 685 685 985 686 685 10,050

Total Income 12,212 12,557 13,232 38,002 1,650 11,140 12,753 12,365 13,219 12,544 12,204 13,003 12,098 12,880 150,208

Cash Expenditure Payments

Payroll (4,375) (4,515) (4,517) (13,407) (75) (4,447) (4,444) (4,444) (4,444) (4,444) (4,444) (4,444) (4,444) (4,444) (53,406)

Tax, NI & Superannuation (1,784) (3,051) (3,083) (7,918) 31 (3,080) (3,080) (3,080) (3,080) (3,081) (3,081) (3,081) (3,081) (3,081) (35,640)

Agency/Other Pay (1,321) (1,024) (958) (3,303) 375 (1,147) (1,099) (1,099) (1,200) (1,200) (1,200) (1,200) (1,200) (1,200) (13,848)

NHSP (479) (551) (830) (1,860) (34) (600) (600) (600) (600) (600) (600) (600) (600) (600) (7,260)

Total Pay (7,959) (9,141) (9,388) (26,488) 297 (9,275) (9,223) (9,223) (9,324) (9,325) (9,325) (9,325) (9,325) (9,325) (110,155)

Non Pay Revenue (3,212) (5,309) (5,213) (13,734) 648 (4,435) (5,295) (4,855) (5,023) (4,119) (5,066) (4,025) (4,373) (3,322) (54,246)

PFI Payment, all monthly outgoing inc VAT (821) (679) (851) (2,351) (120) (834) (834) (834) (834) (807) (834) (834) (753) (834) (9,749)

PDC Dividend 0 0 0 0 0 0 0 (479) 0 0 0 0 0 (520) (999)

Total Non Pay (4,032) (5,988) (6,065) (16,085) 528 (5,269) (6,129) (6,168) (5,857) (4,926) (5,900) (4,859) (5,126) (4,676) (64,995)

Total Expenditure (11,991) (15,129) (15,452) (42,573) 825 (14,544) (15,352) (15,391) (15,181) (14,251) (15,225) (14,184) (14,451) (14,001) (175,150)

Income/Expenditure 221 (2,572) (2,220) (4,571) 2,476 (3,404) (2,598) (3,025) (1,962) (1,707) (3,020) (1,180) (2,353) (1,120) (24,942)

Other cash receipts/payments

Capital (375) (95) (47) (517) 132 (25) (57) (133) (251) (361) (1,245) (180) (211) (187) (3,167)

VAT Debtor 518 437 529 1,484 47 500 500 500 500 500 500 500 500 500 5,984

Recharges/Payroll Deductions 448 (13) (53) 382 (615) 114 102 102 102 102 102 102 102 106 1,316

Deferred Income 645 0 0 645 45 600 0 0 600 0 0 600 0 0 2,445

PDC Drawdown 0 0 662 662 0 66 2,053 2,556 1,012 1,466 3,663 158 1,963 701 14,300

Total Other 1,236 330 1,091 2,656 (391) 1,255 2,598 3,025 1,963 1,707 3,020 1,180 2,354 1,120 20,878

Cash Movement in the month 1,456 (2,242) (1,129) (1,915) 2,085 (2,149) 0 0 0 0 0 0 0 0 (4,065)

Opening cash Balance 4,565 6,021 3,779 4,565 65 2,650 500 500 500 500 500 500 500 500 4,565

Closing Monthly Cash Balance 6,021 3,779 2,650 2,650 2,150 500 500 500 500 500 500 500 500 500 500

Monitor Plan 14/15 4,370 3,178 500 500 0 500 500 500 500 500 500 500 500 500 500

Movement to Monitor Plan 14/15 1,651 601 2,150 2,150 2,150 0 0 0 0 0 0 0 0 0 0

Summary 12 Month Cash Plan Forecast 2014/15

Actual 13 Week Cashflow Forecast

Appendix E3

1



Sealed Documents – Quarter 1 – 2014/15


Purpose

To notify the Board of the documents to which the Trust seal has been applied in Quarter 1

Actions Recommended





None

Report of Barbara Herring, Director of Finance

Paper prepared by Barbara Herring, Director of Finance

2

TAMESIDE HOSPITAL NHS FOUNDATION TRUST

Sealed Documents - Quarter 1 – 2014/15 The Trust’s Standing Orders require a quarterly report to the Trust Board identifying all documents to which the Common Seal has been applied during the preceding quarter. These documents were secured and sealed under the “Tameside Hospital NHS Foundation Trust”. The Trust’s seal was used on one occasion during Quarter 1.

• Contract for building works – Ladysmith Building.

Part 1

Agenda Item 11

Title of paper

Significant Risk Report

Meeting date 31st July 2014

Purpose

The significant risk register report provides the Trust Board with details on all identified significant risk exposure through the Risk Register and Board Assurance Framework throughout Tameside Hospital NHS Foundation Trust

Actions Recommended





Dissemination and communication

Report of

Karen James Chief Executive

Paper prepared by Peter Weller Director of Quality and Governance

of 34

July 2014 - Significant Risk Register Report

1.0 Summary Narrative

1.1 The significant risk register report provides Trust Board with details on all identified significant risk exposure through the Risk Register and Board Assurance Framework throughout Tameside Hospital NHS Foundation Trust. These risks were subject to review by the Quality and Governance Unit following discussion with each responsible Director.

1.2 The Trust has identified a range of significant risks, which are currently

being mitigated, whose impact could have a direct bearing on compliance with Monitors Provider Licence, CQC registration or the achievement of corporate objectives in the following areas should the mitigation plans be ineffective. Currently, the significant risks relate to the following areas:

• Infection Prevention (C. difficile target)

• Finance (Cost control, CIP delivery and liquidity)

• Compliance (Monitors Provider Licence and CQC Registration ) • Lorenzo ( Lorenzo related implementation issues, IM&T infrastructure) • Discharge Processes

• Recruitment 1.3 The main controls and action plans for each significant risk in each area are

being reviewed and collated in the Trust Electronic Risk Register. The programme has incorporated the Corporate Risks and aligned them to the Board Assurance Framework. The new risk number and the previous risk number are included in the report to ensure continuity. Appendix 1 summarises the current significant risks. Appendix 2 provides the Board with the controls and mitigation for the significant risk analysis. Detailed and focussed work is taking place within the Divisions to ensure risk registers are updated and monitored. The responsible Committees are identified on the report.

1.4 New Significant Risks None

1.5 Increased Risk Scores There are no increased risk scores from the previous report. Controls are in

place and further actions are on-going to minimise risk.

of 34

1.6 Downgraded Risks The risks are currently being fully reviewed in light of the CQC regulatory inspection report published in July 2014. All risk handlers and risk owners are systematically meeting with the Quality and Governance Unit senior staff to review their risks for assurance and controls. 1.7 Notable Changes / Update Appendix 2 of the significant risk report includes updated information on notable actions.

of 34

Appendix 1

CORPORATE SUMMARY – SIGNIFICANT RISK THFT SHOWING RISKS 15 OR ABOVE

� Residual Risk Score (Current Risk) Risk Trend Unmitigating Risk Score �

� (Target Risk / Risk Appetite Threshold) � Reducing � Increasing � Static * New Risk

Risks scoring 25 on the Corporate Risk Register and Assurance Framework

Risk 723

Previously

C2 also

AF2.5

Description Responsible

Committee

Very Low

Risk Low Risk Medium

Risk

High

Risk Significant Risk

CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to meet, deliver Trusts

financial plan

financial/contractual/demand

targets including CIP delivery

Finance and

Performance

Committee

� �

�

Risk 718

Previously

C24


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Continuing implementation of

Lorenzo (risks to patient safety

quality, information governance

and performance trajectories)

Quality and

Governance

Committee

� �

�

Risk

AF1.17


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to discharge patients

with adequate information

Quality and

Governance

Committee

� �

�

Risk

AF 4.2


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to ensure on-going

compliance with terms of FT

authorisation (monitor

requirements)

Trust Board � �

�

of 34

Risks scoring 15 - 20 on the Corporate Risk Register and Assurance Framework

Risk AF4.4


Committee

Very Low


Risk

High


ACCIDENT &

EMERGENCY 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to achieve A&E

quality indicators

Executive

Management

Team/

Finance and

Performance

Committee

� �

�

Risk 743

Previously

C57 also

AF1.17


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Effective discharge of Patients

ensuring adequate information and

knowledge of medication

Quality and

Governance

Committee

�

�

�

Risk

AF1.13


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to comply with the CQC

Essential Standards of Quality

and Safety relating to record

keeping

Quality and

Governance

Committee

� �

�

Risk

AF4.1


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25


Essential Standards of Quality

and Safety

Quality and

Governance

Committee

� �

�

Risk 3132


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Incomplete referral to

treatment (RTT) pathway data

submission

Executive

Management

Team/Finance

and

Performance

� �

�

Risk 758

Previously

C16 also

AF1.3


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Trust SHMI indicating potential

areas of concern regarding

mortality and equality

Quality and

Governance

Committee

� �

�

Risk 734

Previously Risk EM4


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Nursing vacancies, leadership

and Nursing staffing

recruitment across Medicine

and the ability to provide safe

care

Executive

Team � �

�

Risk 737

Previously

C8 also

AF1.7


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Healthcare associated infection

prevention

(MRSA, C-DIFF, MSSA, E-Coli)

Quality and

Governance

Committee

� �

�

of 34

Risk 770

Previously

C53


Committee Very Low Risk Low Risk

Medium

Risk

High


DIAGNOSTIC AND

THERAPEUTIC 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Reduced sustainability of

Radiology Services due to

inability to recruit to key

radiology posts

Executive

Management

Team/Finance

and

Performance

� �

�

Risk 775

Previously

C54


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Risks relating to Deanery

expectations and maintaining

standards for doctors in training

resulting in reduced ability to

provide safe care for patients

Quality and

Governance

Committee

� �

�

Risk

1845 previously

EM1



Medium

Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Trust fails to achieve national

best practice e.g. , Stroke and

TIA pathways, Critical Care

Pathway, NICE, Bundles of

Care, NSFs Sentinel Audits etc

Executive

Management

Team / Trust

Board

� �

�

Risk

AF1.1


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Assessing and Monitoring Quality

of Service provision

Quality and

Governance

Committee

� �

�

Risk

AF1.6


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to ensure appropriate focus

on privacy and dignity for patient

and relatives

Quality and

Governance

Committee

� �

�

Risk

AF1.9

also CR

576


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to Safeguard people who

use services from abuse

Quality and

Governance

Committee

� �

�

Risk

AF1.16


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to meet CQC regulation

requirements in relation to quality &

management specifically incidents &

organisational learning

Quality and

Governance

Committee

� �

�

Risk

AF1.18


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to ensure requirements for

consent to treatment

Quality and

Governance

Committee

� �

�

of 34

Risk

AF1.22


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to ensure that staff have the

relevant mandatory skills and

training to ensure safe practice.

Quality and

Governance

Committee

� �

�

Risk

AF1.23


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to ensure adequate staffing

levels to ensure patient safety and

quality of services.

Executive

Management

Team / Trust

Board

� �

�

Risk

AF1.24



Medium

Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Increased demands beyond

predicted levels which is outside

current capacity

Executive

Management

Team /

Finance and

Performance

Committee

� �

�

Risk

AF1.25


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to fulfil CQC requirements

with management of Complaints

Quality and

Governance

Committee

� �

�

Risk

AF4.6


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to minimise delayed

transfers of care

Improveme

nt Board

� �

�

Risk

AF4.8


Committee

Very Low


Risk

High


CORPORATE 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Failure to have in place a IM&T

infrastructure and Service

supporting organisational

objectives

Executive

Management

Team and

Board

� �

�

� Residual Risk Score (Current Risk) Risk Trend Unmitigating Risk Score �

� (Target Risk / Risk Appetite Threshold) � Reducing � Increasing � Static * New Risk

of 34

July 2014

APPENDIX 2: SIGNIFICANT RISK ANALYSIS Regulatory | National Target | CORPORATE

Potential Risk Location Owner/Responsible

Committee/Group RR Main Controls Key Actions

Action

Overdue

not being

addressed

Risk Source

CORPORATE All Clinical

and

Corporate

directorates

Director of Finance

Directors of all

services

Finance and

Performance

Committee

25

RED

��

• Monthly monitoring

reports to Trust

Board

• Reporting to Trust

Board Sub-

Committees of

constituent actions

and plans to reduce

risk.

• Divisions to risk

assess impact,

manage and monitor

activity, performance

targets and progress

of CIPs and escalate

any potential or

actual performance

issues or clinical risks

arising out of the

financial plan to

Directors.

• Local and Board

monitoring of

performance and

patient experience

indicators.

• Monitor oversight

and reporting

framework

• Turnaround Director and

revised programme

• Greater Manchester

‘Healthier Together’

Strategy

• Certify that all material

non recurrent CIP's have

also been subject to a

rigorous QIA

• Fully develop schemes to

deliver the full 2014/15 CIP

target on a recurrent basis

• Commission a review of

2015/16 CIPs.

• Develop and submit to

regulators milestones and

financial modelling

None

Operational

Performance

Incidents

Complaints

and Claims

Risk

723

(C2)

Also

AF2.5

Failure to meet, deliver Trusts

financial plan financial/

contractual/demand targets

including CIP delivery Review

Date /

Frequency

September

2014

Quarterly

ANTICIPATED EFFECT ON CONTROL

The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level.

of 34

July 2014

Regulatory | National Target | CORPORATE


Committee RR Main Controls Key Actions

Action

Overdue

not being

addressed

Risk Source

CORPORATE All

Clinical

&

Corporate

Directorates

CIO & Chief

Operating Officer

Executive

Management

Team

25

RED

��

• Initial

implementation plan

complete which

involved clinicians

from each area and

Clinical Reference

Group.

• Medway overlap to

ensure continuity.

• EPR Group

monitoring of post

implementation

performance.

• Live action log

• On-going monitoring

of Lorenzo reported

incidents and

triangulation of

information.

• Monitoring progress

report to Trust Board

• Prioritisation of

urgent information

requests to delivery

of safe and effective

patient care.

• Post-implementation issue

specific plans progressed

and monitored by the EPR

Group, Quality and

Governance Committee and

sub committees.

• Routine reporting to Board

• Assessment of issues by

maintenance and

monitoring of Operational

Performance

• All key operational standards

continue to be monitored

• Business Continuity Plans

implemented if required to

ensure staff assisted and

able to continue delivering

their services.

None

Risk

Register

Incident,,

Operational

Performance

Risk

718

(C24)

Implementation of Lorenzo

information system (Risks to

Patient Safety Quality,

Information Governance and

Performance Trajectories) Review Date /

Frequency

August 2014

Monthly



of 34

July 2014


Potential Risk Location

Owner /

Responsible

Committee

RR Main Controls Key Actions

Action

Overdue

not being

addressed

Risk

Source


and

Corporate

Directorates

Director of

Nursing and

Medical

Director

Quality and

Governance

Committee

Risk

Management

Group

25

RED

��

• Discharge policy and

procedures in place

• Monitoring of

operational

performance activity

and review of discharge

and transfer services

undertaken.

• Pre - printed discharge

summaries given to

each patient,

addressing all the

discharge issues

• Divisional Governance

Monitoring

• Audit programme

• Key Metrics monitored

• Trust wide implementation

of the discharge and patient

flow action plan through the

Discharge task and finish

group.

• Discharge and Patient Flow

Work Stream None

Third

party

reviews

Patient

feedback

Incidents

complaints

and claims

Risk

AF1.17

Failure to discharge patients with

adequate information

Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014




Action

Overdue not

being

addressed

Risk Source

CORPORATE Corporate

Directorates

Director of Finance

Trust Board

25

RED

��

• Board reporting in

line with FT provider

licence

requirements

• Board Financial

reporting

procedures fit for

purpose

• FT metric

performance

framework.

• Regular contact with

Monitor and Board

reporting re actions

taken to maintain

authorisation

• Continuous

implementation of

required actions by all

staff at levels required

• Implementation of

action plan re CIP

identification and

implementation of Trust

Improvement

Programme and Agreed

Monitoring action

None

Monitors

Provider

licence

requirements

and

Regulatory

Monitoring

Risk

AF4.2

Failure to ensure on-going

compliance with terms of FT

authorisation (monitor

provider licence

requirements)

Review Date

/ Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate to assure Monitor requirements are being discussed and progressed with this.

of 34

July 2014




Action

Overdue

not being

addressed

Risk Source

CORPORATE Trust wide

Chief Operating

Officer

Executive

Management Team

/ Finance and

Performance

Committee

20

RED

��

• Detailed recovery plan

in place

• Aim to see patients

within 2 hours of

attendance in the

Emergency

Department;

• Potential admissions to

be identified early by

the Emergency

Department;

• Wards to actively seek

to admit patients from

the Emergency

Department as soon as

bed available;

• The use of early senior

review will be assessed

and ‘best practice’

principles developed;

• Additional consultant

ward rounds during the

weekend over the

winter period;

• Bed management

meetings strategic

• Board rounds in ED;

• Non-elective health-

economy (NWAS,

Primary Care, Social

Care, TGH) action plan

generated;


agreed Medical Model

• Non-Elective Action

Plan includes:

• Rapid Assessment and

Treatment (RAT)

model:

• ED in-reach by

consultants

• Board rounds in ED;

• Provision of

Ambulatory Care

Services

• Discharge and patient

flow work stream

• Review ward round

‘timetable’.

None Performance

management

Risk

AF4.4

Failure to achieve Emergency

Department quality indicators

Review

Date /

Frequency

August

2014

Monthly


Mitigation plans are designed to achieve compliance with performance target.

of 34

July 2014




Action

Overdue not

being

addressed

Risk Source

CORPORATE Trust wide

Director of Nursing

Chief Operating

Officer

Executive

Management Team

and Quality and

Governance

20

RED

��

• Workforce planning

and recruitment

plans.

• Nurse staffing levels

based on acuity –

Daily close

monitoring and

management of

staffing, escalation

process and provision

of cover by Senior

Nursing staff.

• Completion of

staffing

levels/incident

reports forms to

enable analysis of

impact.

• Recruitment in to the

vacant posts is

underway and to

continue under

monitoring.

• Monitoring of KPI’s

• Utilisation of a

partnership model and

secondment

opportunities from

other trusts.

• Recruitment from

abroad

None

Operational

Performance

Risk register

Incident and

Complaint

Risk

734

(EM4)

Nursing vacancies, leadership

and Nursing staffing

recruitment across Medicine

and the ability to provide safe

care

Review

Date /

Frequency

August

2014

Monthly


Mitigation plan is designed to effect recruitment to agreed staffing complement and reduce reliance on agency staffing,

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source

CORPORATE All clinical

and

Corporate

directorates

Director of

Nursing/Director

of Infection

Prevention and

Control and

Chief Operating

Officer ( for

Delivery)

Quality and

Governance

Committee

20

RED

��

• Systematic monitoring of

performance by Infection

Prevention & Control

Team,

• IC assurance framework

• RCA process used in every

case of MRSA, C.Diff,

MSSA and E Coli.

• Recovery plan and

monitoring report

presented to Board

• District Wide Infection

Prevention and Control

Group Meetings.

• Hospital Infection Control

Committee meetings.

• Zero tolerance approach

to HCAI

• Infection Prevention and

control policies and

procedures

• Antimicrobial Policy

framework and

prescribing policy and

stewardship

• Systematic

monitoring

determines actions

to be taken.

• Trust working to

recovery plan agreed

with CCG and

regulators.

• ICA framework

actions

None

Operational

performance

Patient

Safety

Quality

Incidents

complaints

and claims

Risk

737

(C8)

Also

AF1.7

Healthcare associated infection

prevention (MRSA, C-DIFF,

MSSA, E-Coli) Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk

Source


and

Corporate

directorates

Medical

Director and

Director of

Nursing

Quality and

Governance

Committee

20

RED

��

• Discharge policy and

procedures in place

• Monitoring of

operational

performance activity

and review of

discharge and transfer

services undertaken.

• Board reporting

• Patient experience

sampling and

monitoring

• Audit programme

• Review during Senior clinician

and/Nursing walk round

• Implementation of processes

to support ward based

intervention and

reconciliation.

• Monitoring of the on-going

usage of Care Bundles

through Patient Safety

Programme

• Implementation of the

Urgent Care Recovery Plan.

• Discharge and patient flow

action plan monitored by

task and finish group

• Board Rounds

None

External

reports

Patient

feedback,

incidents

and

complaints

Risk

743

(C57)

Also

AF1.17

Effective discharge of Patients

ensuring adequate information and

knowledge of medication Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


and

corporate

directorates

Medical

Director

Quality and

Governance

Committee

20

RED

��

• Health records

standards and policies

in place.

• Professional Standards

for record keeping

• Clinical Coding

Standards

• Clinical Coding

awareness training for

Clinicians.

• Monitoring of coding

completeness and data

quality

• Electronic access to

“intelligence” on best

practice. Electronic

access to Policies and

Protocols.

Development of EPR

• Health Records

Committee

• Clinical audit and

Effectiveness

programme

• Assurance via Clinical

leads and Senior Nurse

walk round/visits

• Assurance from First

Friday visit programme

• Executive Walk round

programme

• NED Walk round

programme.

• Audit programme

None

Operational

Performance

Incidents

Complaints

and Claims

Risk

AF1.13


Essential Standards of Quality and

Safety relating to record keeping Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


And

Corporate

Directorates

Trust Board

Quality and

Governance

Committee

20

RED

��

• Trust Governance and

reporting arrangements

• Review and analysis of

CQC Intelligence

monitoring - risk areas

identified and action taken

to understand if not

already aware

• Reported to Service

Quality and Operational

Governance group

• Key risk related areas are

built into the clinical

audit/audit forward plan.

• Constituent quality and

safety reports to Board

and Board Sub Committees

– provide assurance


monitoring and reporting

• Mandatory training and

induction programmes

• CQUIN and key standards

measures monitoring

• First Friday visit

programme

• Senior Nursing/Senior

Clinical reviews and

unannounced visits

• Systematic Programme to

address essential

standards

Implementation of

• Trust agreed

strategies and

actions associated

with their

implementation and

monitoring

None

Regulatory 3rd

Party

assessment

Patient

feedback

Operational

Performance

Incidents

Complaints

and Claims

Risk

AF4.1


Essential Standards of Quality and

Safety Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


Directorates

16

RED

��

The Trust has

implemented the interim

controls;

• established a

dedicated validation team

to validate each and every

patient on an incomplete

pathway in order to be

able to report our

incomplete pathway

performance accurately

The Trust:

• Has developed a

comprehensive recovery

plan within a clear project

management and

governance structure to

ensure this problem is

rectified appropriately

within agreed timescales

• Is working with our

Corporate Information

Team to develop a solution

to manage RTT reporting

outside of Lorenzo using

our own data warehouse

• Have informed Monitor

(our regulator) and our

local commissioners of our

current technical problems

None

External

Monitoring,

National

reports,

Operational

performance

Incidents

inquests

complaints

and claims

Risk

3132 Incomplete Referral To Treatment

pathway (RTT) data submission Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and

mitigations will mitigate and reduce the risk to an

organisationally acceptable level.

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


Directorates

Medical

Director

Quality and

Governance

Committee

15

RED

��

• Trust Mortality

Steering group in place

• Internal mortality plan.

• Patient Safety

Programme developed

with work streams and

identified KPI’s

• Use of National

benchmarking tools

• Reports on Mortality

To Quality and

Governance

Committee

• Mortality reviews

undertaken on all

hospital deaths

• Trust agreed strategies

and actions associated

with their

implementation and

monitoring

• Detailed drill downs and

mortality analysis of

alerts Dr Foster and

mortality reviews

None

External

Monitoring,

National

reports,

Operational

performance

Incidents

inquests

complaints

and claims

Risk

758

(C16)

Also

AF1.3

Trust SHMI indicating potential

areas of concern regarding

mortality and equality Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an


of 34

July 2014


Potential Risk Location Owner RR Main Controls Key Actions

Action

Overdue not

being

addressed

Risk Source

CORPORATE Diagnostic

and

Therapeutic

Chief

Operating

Officer

Executive

Management

Team /

Finance and

Performance

Committee

15

RED

��

• Trust recruitment

strategy to vacancies

• Collaboration with a

Partnership to provide

a long term strategy for

provision of services.

• The Trust has

outsourced reporting

to address service

pressures across

radiology

• Use of waiting list

initiatives for substantive

consultants to help

address shortfall.

• Use of external locums to

support breast service.

• Further recruitment of a

Breast Radiologist being

considered further

• Agency options being

explored.

• Consideration of training

for Breast Surgeon to

perform breast

ultrasound.

None

Operational

Performance

Incidents

Complaints

and Claims

Risk

770

(C53)

Reduced sustainability of

Radiology services due to inability

to recruit to key Radiology posts Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will assist mitigate and reduce the risk to an organisationally acceptable level.

of 34

July 2014

•



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk

Source


and

Corporate

Directorates

Medical

Director &

Director of

Human

Resources

Quality and

Governance

Committee

15

RED

��

• Medical Education

coordinated within an

agreed framework

• Monitoring of Deanery

action plan

• Clinical Leaders forum

• Improvement

Programme for doctors

in training.

• Regular scheduled

meetings with Junior

doctor

• Monitoring of incident

reporting and support

for Junior doctors with

reporting- monitored

through Quality and

Governance Committee

• Accessibility of reporting

system - monitored

through Quality and

Governance Dept.

• Analysis of the themes

of reporting included in

the Trust Quality and

Governance Summary

report.

• Deanery Action plan

• Trust agreed strategies and

actions associated with their

implementation and

monitoring

None

Deanery

and Junior

Doctor

feedback

External

review,

incidents,

complaints

Risk

775

(C54)

Failure to ensure the requirements

of the Deanery are being met) and

therefore those doctors in training

receive adequate supervision and

support) resulting in reduced

ability to provide safe care and the

Deanery withdrawing doctors in

training and therefore

unsustainability of services.

Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level. .

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


Directorates

Director of

Nursing

Quality and

Governance

Committee

15

RED

��

The use of the ROSIER

scoring has commenced as

part of Emergency

Department “React

Process” along with

feedback to clinicians.

Robust breach analysis

and cascade through

specialist teams is now

incorporated into a daily

reporting which is sent to

speciality teams to

respond. In addition the

stroke co-ordinator rota

has been reviewed to

ensure maximum

availability of response to

ED.

The Stroke Action plan is

being reviewed to ensure

it captures the issues

arising from SSNAP Audit

and will be assertively

progressed through the

Trust Stroke Group.

Plans to co-locate the

Acute Stroke Ward (W5)

and Stroke Rehabilitation

Ward (W45) are being

reviewed to ensure that

• Delivery of Consolidated

action plan actions

• Detailed drill downs and

analysis of performance

• Progress against these

actions will continue to

be systematically

monitored and reported

on through the

Divisional and Corporate

structures, by the

Executive teams and

Trust Board

None

External

Monitoring,

National

reports,

Operational

performance

Incidents

inquests

complaints

and claims

Risk 1845

Previously

EM1

Trust fails to achieve national

best practice e.g. Stroke and TIA

pathway, Critical Care Pathway,

NICE, Bundles of Care, NSFs,

Sentinel Audits etc

Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014

the proposed bed

numbers remain correct

and we have the capacity

required.

TIA- the ambulatory

assessment room has now

been completed,

guaranteeing capacity to

assess patients. The

ambulatory TIA pathway

has commenced and is

being audited. Further

work is being undertaken

by the division to consider

how we July be able to

provide partial cover at

weekends the Emergency

Department.

The Critical Care Pathway

is being reviewed to

identify specific areas of

improvement and actions

required.

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk Source


and

Corporate

Directorates

Director of

Nursing

and

Medical

Director

Quality and

Governance

Committee

15

RED

��

• Revised Quality and

Governance committee and

reporting structure in place

• Systematic process for review

being implemented

• Patient Safety Programme

developed with key work

streams and KPI’s

• Review and analysis of CQC

QRP risk areas identified and

action taken to understand if

not already aware

• Reported to Service Quality

and Operational Governance

group

• Key risk related areas are built

into the clinical audit forward

plan. These are reviewed an

monitored within key Quality

and Governance

• Constituent quality and safety

reports to Board and Board

Sub Committees – provide

assurance

• Patient experience monitoring

and reporting



• CQUIN Key measures

monitoring

• First Friday visit programme

• Senior Nursing /Clinician

reviews/unannounced visits

Implementation of

• Constituent action

plans

• revised and

strengthened

Governance

Systems

• Organisational

Leadership and

Staffing structures

• Patient Safety

programme

• Patient Experience

programme

• Values and

Behaviour work

streams.

• Oversight by the

Board, EMT and

Quality and

Governance

Committee

Structure

None

Third party

review/

inspection

Operational

Performance,

Incidents,

Complaints,

Claims, Inquests

external reviews

Risk

AF1.1

Assessing and Monitoring

Quality of Service provision

Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level. Review process based on regulator assessment

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


and

Corporate

Directorates

Director of

Nursing/Medical

Director

Quality and

Governance

Committee

15

RED

��

• Revised Quality and

Governance committee

and reporting structure in

place

• Programme developed

with key work streams

and KPI’s

• Reported to Service

Quality and Operational

Governance group

• Key risk related areas are

built into the clinical audit

forward plan.

• Constituent quality and

safety reports to Board

and Board Sub

Committees – provide

assurance


monitoring and reporting



• CQUIN measures

monitoring

• First Friday visit

programme

• Senior Nursing reviews

and unannounced visits

• Values and Behaviours

work programme

• Board Reports Assurance

Reports

• Quality Account

Implementation of

• Constituent action

plan

• revised and

strengthened

Governance Systems

• Organisational

Leadership and

Staffing structures

• Patient Safety

programme


programme

• Values and

Behaviour work

streams.


Improvement board

and Quality and

Governance

Committee Structure

• Ward Accreditation

framework in use

and challenge in

system

None

Third party

review/

inspection

Operational

Performance,

Incidents,

Complaints,

Claims,

Inquests

external

reviews

Risk

AF1.6

Failure to ensure appropriate

focus on privacy and dignity

for patient and relatives Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level. Review process based on regulator assessment

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk Source


and Corporate

Directorates

Director of

Nursing

Quality and

Governance

Committee

15

RED

��

• Policies, procedures and

guidelines for children and

adults and constituent policies

impacting upon safeguarding.

• Contractual requirements

against specific standards/

requirements

• Deprivation Of Liberty (DOLS)

arrangements,

• IMCA ( Advocacy arrangements)

• Revised Mental Health Act

infrastructure and partnership

agreement with Pennine Care

• Staff awareness training

• Collaboration with other care

agencies

• Mandatory Training in place.

• Trust fully engaged with child

protection /adult protection

structures.

• Audit Tools and programme.

• Trust is a member of TMBC

Safeguarding Boards

• Specific initiatives on Prevent,

Mental Health and Learning

Disability Work streams, Specific

Unborn and Children's

safeguarding work streams

• Internal Safeguarding Board

established monitoring key

metrics reporting through to

Quality & Governance

Committee

• Increased staff awareness

of safeguarding concerns

• Increase utilisation of

DOLS

• Review of systems and

implementation of Mental

Health act process

agreement in place with

Pennine Care

• Rollout of training plans

• System of receipt of

Mental Health Act papers

to be monitored with

Pennine Care now agreed

None

Operational

management

incidents

safeguarding

concerns

Risk

AF1.9

Also

CR

576

Failure to Safeguard

people who use services

from abuse Review Date /

Frequency

August 2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk

Source


and

Corporate

Directorates

Director of

Nursing and

Medical

Director

Quality and

Governance

Committee

15

RED

��

• Revised Governance committee

and reporting structures

• Policies and procedures

highlight the standards to be

achieved in respect of the

requirements e.g. handling and

investigating such events-

inquests, claims, incidents and

how associated learning is

disseminated

• External Assessment of claims

by NHSLA

• Coronial Involvement for

Inquests and reporting of deaths

• Systematic process for incident

reporting and handling

• Process for reporting deaths in

place

• Key risk related areas are built

into the clinical audit forward

plan. These are reviewed an

monitored within key Quality

and Governance

• Aggregated learning reports

• Patient experience monitoring

and reporting



• CQUIN measures monitoring

• First Friday visit programme

• Senior Nursing /Clinician

reviews and unannounced visits

Implementation of

• Consolidated/constituent

action plan

• revised and

strengthened

Governance Systems

• Organisational

Leadership and Staffing

structures

• Patient Safety

programme


programme

• Values and Behaviour

work streams.


Improvement board and

Quality and Governance

Committee Structure

None

External

review

Internal

assurance

systems

Risk

AF1.16

Failure to meet CQC regulation

requirements in relation to

quality & management

incidents & organisational

learning

Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014


Potential Risk Location Owner RR Main Controls Key Actions

Action

Overdue not

being

addressed

Risk

Source


Directorates

Medical

Director

Quality and

Governance

Committee

15

RED

��

• Clear procedure and

training in place

• Policies and guidelines

outline expected

standards and process of

audit enables monitoring

of these

• Consultant Staff required

to appraise Juniors on

skills and knowledge

• Medical Director’s

annual appraisal of

senior medical staff

• Professional staff where

delegated consent in

place required to have

appropriate competency

checks and supervision

• Clinical Audit Programme

• Increased staff

awareness of

safeguarding concerns

• Increase utilisation of

DOLS

• Review of systems for

implementation of

Mental Health Act has

taken place

• Focussed consent

programme to be

redeveloped via Patient

safety officers. Task

and finish work stream

reporting through to

Quality and

Governance

None

External

third party

review ,

patient

feedback

and

incidents

complaints

and claims

Risk

AF1.18

Failure to ensure requirements for

consent to treatment Review

Date /

Frequency

August

2014

Monthly


The completion of the agreed implementation plan and mitigations will mitigate and reduce the risk to an organisationally acceptable level. Anticipated date for reduction of risk score to below 15 Quarter 4, 2014/15 Review process based on regulator assessment

of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk

Source


and

Corporate

Directorates

Director of

Human

Resources

and Director

of Nursing

and Chief

Operating

Officer

Quality and

Governance

Committee

15

RED

��

• Annual Mandatory

Training requirements

and review annually of

training needs analysis

• Induction process

• Education Governance

Group to coordinate

and systematically

apply educational

governance

• Delivery of the

consolidated action

plan

• Education Governance

Group Work streams and

Plan

• Training plan aligned to

OD strategy

• Divisional ownership and

actions to be

strengthened further

None

External

review and

internal

monitoring

Risk

AF1.22

Failure to ensure that staff have the

relevant mandatory skills and

training to ensure safe practice.

Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


and

Corporate

Directorates

Director of

Human

Resources

Chief

Operating

Officer

Executive

Management

Team/ Trust

Board

15

RED

��

• Workforce planning

and recruitment

strategy.

• Nurse staffing levels

based on acuity – Daily

close monitoring and

management of

staffing, escalation

process and provision

of cover by Senior

Nursing staff.

• Completion of staffing

levels/incident reports

forms to enable

analysis of impact.

• Introduction of

Divisional Governance

support.

• Recruitment from

abroad has informed

our plans

• Implementation of the

Consolidated action

plan and oversight by

Improvement board

• Trust wide Consolidated

action plan and

implementation

monitored through

Improvement board

• Recruitment in to the

vacant posts is underway

and to continue under

monitoring.

• Weekly monitoring of

KPI’s

• Utilisation of a

partnership and

secondment

opportunities from other

trusts.

None

Third party

review and

internal

monitoring

Incidents

complaints

Claims and

Operational

performance

and impact

Risk

AF1.23

(AF1.21)

Failure to ensure adequate

staffing levels to ensure patient

safety and quality of services Review

Date /

Frequency

August

2014

monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


Directorates

and

Divisions

Chief

Operating

officer

Executive

Management

Team

Finance and

Performance

Committee

15

RED

��

• Capacity Plans in place

• Demand Management

implications are being

implemented.

• Regular meetings with

CCG and other partners

to improve availability

of, and access to,

intermediate care beds.

• Risk assessments are

completed for any areas

used for escalation.

• Patients are required to

be appropriately risk

assessed before being

admitted to escalation

areas.

• Partnership working with

other providers to

ensure a long term

strategy is in place

regarding sustainability

and service provision.

• Development of

integration strategy in

key partners


workforce action s in

consolidated action

plan monitored by

Improvement board

None

Third party

review and

internal

monitoring

Incidents

complaints

Claims and

Operational

performance

Risk

AF1.24

Increased demands beyond

predicted levels which is outside

current capacity Review

Date /

Frequency

September

2014

Quarterly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue

not being

addressed

Risk Source


and

corporate

Directorates

Director of

Nursing

Quality and

Governance

Committee

15

RED

��

• Complaints procedure is

in place and widely

publicised and available

– positive and negative

feedback is encouraged

• Complaints sign off by

CEO

• Complaints and PALS

processes are

divisionally supportive

and operationally

managed centrally in

the Trust Quality and

Governance Unit

• Routine Board reporting

• Detailed reports to

Quality and Governance

Committee

• Divisions routinely

receive detailed

information re

complaints and issues

identified

• Service Quality and

operational Committee

receives assurance and

aggregated learning

reports

• Quality and Governance

Committee receives

assurance and

aggregated learning

reports

•

• Internal Complaints review

continuously taking place.

• Independent review of

complex complaints.

• Complaints management

training package is being

delivered to patient-facing

managers / senior

clinicians Additional

resources addressing

historical outstanding

issues

• Revised process and

actions to be implemented

None

Third party

review and

internal

monitoring

Incidents

complaints

Claims and

Operational

performance

Risk

AF1.25

Failure to fulfil CQC

requirements with management of

Complaints Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


and

corporate

directorates

Chief

Operating

officer

Improvement

Board

15

RED

��

• Capacity Plans in place

• Demand Management

implications are being

implemented.

• Regular meetings with

CCG and other

partners to improve

availability of, and

access to,

intermediate care

beds.

• Risk assessments are

completed for any

areas used for

escalation.

• Patients are to be

appropriately risk

assessed before being

admitted to escalation

areas.

• Partnership working

to ensure a long term

strategy is in place

regarding

sustainability and

service provision.

• Development of

integration strategy in

conjunction with Key

partners


workforce action s in

consolidated action plan

monitored by

Improvement board

None Operational

performance

Risk

AF4.6

Failure to minimise delayed

transfers of care

Review

Date /

Frequency

August

2014

Monthly



of 34

July 2014



Owner /

Responsible

Committee


Action

Overdue not

being

addressed

Risk Source


and

corporate

directorates

Chief

Operating

officer

Executive

Management

Team and

Trust Board

15

RED

��

• IM&T team reporting

the Chief Operating

Officer reporting to an

identified Executive

Director – Director of

Finance with policy

and procedures and

operating framework

to National Standards

• Development of

technology

infrastructure through

capital programme

• Revised IM&T strategy

• Review of resources

• Consistency to address

any gaps in controls

• IM&T Committee and

supporting Committees

to be strengthened and

re-established post

Lorenzo go live to ensure

systematic reporting of

IM&T assurances through

to Board

• Infrastructure to be

proposed and progressed

in line with Governance /

Committee Review

None Operational

performance

Risk

AF4.8

Failure to have in place a IM&T

infrastructure and Service

supporting organisational

objectives Review

Date /

Frequency

September

2014

Quarterly


The completion of the agreed implementation plan and

mitigations will mitigate and reduce the risk to an


PART 1

AGENDA ITEM 12 Title of Board paper

Safe Staffing Report June 2014

Board meeting date 25th July 2014

Purpose

To provide the Board with an update on the safe staffing of wards.

Actions Recommended


Publication


Unusual acronyms

TGH Tameside General Hospital NHSP NHS Professionals ITU Intensive Therapy Unit CCU Critical Care Unit NICE National Institute of Clinical Excellence AUKUH Association of UK Hospitals


Report of John Goodenough - Director of Nursing

Paper prepared by

Anne Alison – E rostering Project Nurse

2

Safe Staffing Update Report

1. Purpose In-line with the ‘Hard Truths Commitments Regarding the Publishing of Staffing Data’, the Trust Board is required to review staffing data on a monthly basis. The aim of this report is to provide the monthly update on the continuing actions and developments to support safe staffing. 2. Current Position The second UNIFY upload of TGH Staffing Data for June occurred on 15th July and will be published via NHS Choices. This data is currently available via our public website in a specific designated section ‘Safe Staffing’. Tameside Hospital - Nurse Staffing (www.tamesidehospital.nhs.uk/nurse-staffing.htm) 3. June 2014 Staffing Each month the data collection compares the number of staff hours ‘Planned’ against the number of staff hours used ‘Actual’. This is collected by ward, by shift, and is reported by calendar month as a % fill rate by day and by night: Appendix 1 Provides a summary of the June position. It has been suggested that in the future a RAG rating will be applied to the results, but this has yet to be clarified by NHS England. The overall Trust position for June is:

Day Night

RN/RM Average Fill rate 91.7 % (74 – 100.5%) 96.4% (84.4 – 108.3%)

Care Staff Average Fill rate 112.1% (80.4 – 151.2%) 119.9% (96.7 – 166.7%)

0

20

40

60

80

100

120

140

May-14 Jun-14 Jul-14

% F

ill

Rate

Average Fill Rates

RN Fill DAY

RN Fill NIGHT

Care Staff FillDAY

Care Staff FillNIGHT

3

4. Exception Report The exception report looks at the information broken down by the two key staff groups Registered Nurse / Midwife and Care Staff Registered Nurse/Midwife 7 areas are reporting <85% fill rates for Registered Nurses (RN). These are : Area Fill (%) Comments

Surgical Unit 83.4% Day 2.42wte Sickness & Mat Leave

Ward 5 74% Day 2.1wte Vacancies AP bridges RN requirements but is reported in Care Staff %

Ward 43 79.7% Day 3.0wte vacancies 1.54wte sickness



WHU 81.4% Day 0.63wte Establishment currently under review

The main reasons for the shortfalls are current vacancies, sickness, maternity leave, supernumerary staff and special leave. Table1 (above) illustrates the main reasons for the low fill-rates (1.0wte equates to 150hrs over a 4-week period). All staffing shortfalls are requested to be filled utilising NHS Professionals with a current NHSP/Agency fill rate of 70.4% for Registered Nurse shifts. Care Staff – Nursing Assistants The majority of areas are reporting fill rates of greater than 100%. The reason for this is due to the number of additional staff requested for 1:1 patient care/specialling due to patient acuity and safety needs. Areas needing additional 1:1 care staff will always report >100% fill rates as these additional staff are not accounted for in the ‘Planned’ staffing numbers as they are not part of the funded and planned staffing establishments due to the adhoc and unpredictable demand. ‘Specialing’ currently accounts for 17% of all Temporary Staffing requests made by the Trust. 5. Actions to address shortfalls All vacancies are currently being advertised and/or are in the process of being actively recruited to, with a trajectory for full recruitment by September 2014.

4

16 International recruits are currently in-post undertaking an enhanced induction/competency programme. These staff should be included within the RN establishments from August/September 2014. Temporary staffing requirements are requested through NHS(P), with escalation to Agency as per the Trust policy. Current NHSP/Agency fill rate is 89.9% for unqualified shifts and 70.5% RN shifts. Incident reports submitted in relation to staffing shortfalls are monitored and addressed divisionally. The table below illustrates no significant increase in incidents reported relating to nursing staff shortfalls:

Staffing issues Mar Apr May Jun

Staffing - Lack Of Nursing Staff 23 17 21 25

Staffing - Lack Of Medical Staff 1 3 4 5

Staffing - Lack Of Other Staff 3 4 4 2

Staffing - Improper Delegation -Unsupervised Staff

2 1 0 0

Grand Total 29 25 29 32

Further work is required/on-going in certain areas to review staffing requirements against current establishments:

• Maternity, Women’s Health Unit, - review underway in relation to clinic staffing, rotation of staff and working across community, led by Head of Midwifery

• ITU,/ MHDU and CCU – proposal to manage patient flows differently and align Cardiology with CCU and merge ICU/MHDU will inform the staffing establishments going forward, and address any shortfalls. This was highlighted as an area of work that needed to be undertaken following the Acuity & Dependency review in February 2014 as referenced in the Board Paper of 29th May 2014.

There has also been a review of the AUKUH staffing tool in relation to Medical Assessment Units which has been used to inform our current MAU establishment in the recent acuity and dependency data collection. The full results of the most recent Acuity & Dependency review will be reported in the next Board Report. NICE published their guidance on ‘Safe Staffing for nursing adult inpatient wards in acute hospitals on 15th July 2014. Work is currently underway to benchmark the Trusts current position against the NICE recommendations.

5

6. Recommendations The Trust Board is requested to receive this update and note the processes that are in place for safe staffing to support the delivery of a high quality care to our patients

Mr John Goodenough Director of Nursing July 2014

6

Appendix 1 : Safe Staffing Data June 2014

June-14 Planned Staff Vs Actual

Comments WARD SPECIALTY SHIFT

Registered Staff

Care Staff

Elective Unit General Surgery

Day 96.3% 104.9% • Additional staff booked for escalation area and 1:1 care.

Night 108.3% 166.7%

Surgical Unit

General Surgery

Day 83.4% 131.4% • Long-term patient requiring 1:1

care.

• Additional staff booked for escalation area.

• 2.42wte RN Sickness & Mat Leave

Night 101.7% 130%

Trauma Unit Trauma &

Orthopaedics

Day 95.7% 111.1%

Night 96.7% 105.8%

ITU Critical Care

Medicine

Day 95.9% 90%

Night 98.7% Not

Applicable

Ward 5 General Medicine

Day 74% 93.9% • AP in-post bridges RN/Care

Staff requirements, inc in Care Staff %

• 2.1wte RN vacancies

• 5.64wte Care Staff vacancies/sickness

• 1.0wte International Recruit *

Night 100% 100%


Day 100.5% 111.3% 1.0wte International Recruit *

Night 100% 116.7%


Day 88.4% 99.4% • 2.0wte International Recruit *


• 0.82wte RN sickness Night 93.3% 106.7%

MAU General Medicine

Day 98.1% 96.2%

Night 91.4% 95.3%

CCU General Medicine

Day 99.4% 87.3% 1.74wte Care Staff vacancies

Night 100% Not

Applicable


Day 96.9% 128.7% 2.0wte International Recruit * 1.2wte RN vacancies

Night 87.8% 155%

7

May-14 Planned Staff Vs Actual

Comments WARD SPECIALTY SHIFT

Registered Staff

Care Staff


Day 90.1% 130.8% • AP in-post bridges RN/Care Staff requirements, inc in Care Staff %



• 1.98wte RN Sickness/Mat Leave

Night 85.6% 160%


Day 96.2% 110.9% 2.0wte International Recruit * 1.4wte RN vacancies 0.53wte RN sickness Night 84.4% 123.3%


Day 79.7% 132.2% • 2.0wte International Recruit *


• 1.54wte RN sickness Night 100% 108.3%


Day 80.4% 151.2% • 1:1’s for patient safety (dementia ward) & supporting RN shortfall



• 1.16wte RN sickness

Night 98.3% 130%


Day 85.8% 98.4% • 0.7wte RN vacancies


Night 100% 110%


Day 80.4% 143% • 2.0wte International Recruit *


• 1.01wte RN sickness Night 100% 156.7%

Maternity Ward 27

Obstetrics Day 100.4% 89.9%

• 2.89wte care staff vacancies

• 1.17wte care staff sickness

Night 95.2% 96.7%

Women’s Health Unit

Gynaecology Day 81.4% 128.9% • 0.63wte Maternity Leave

Establishment currently under review

Night 96.7% Not

Applicable

NICU Obstetrics Day 91.7% 80.4% • 0.56wte RN vacancies


Night 100% Not

Applicable

Children’s Ward

Paediatrics Day 98.8% 92.2%

Night 102.7% Not

Applicable

PART 1

AGENDA ITEM 13


Patient Experience Update

Board meeting date Thursday 31st July 2014

Purpose

To provide the Board with an update and an overview of the work to date that is focusing upon the Patient Experience.

Actions Recommended


Publication


Unusual acronyms FFT – Friends and Family Test


Cascade to divisional and operational forum as appropriate.

Report of Mr John Goodenough, Director of Nursing

Paper prepared by

Lindsay Stewart, Interim Deputy Director of Nursing Helen Howard, Head of Patient Experience

2

Patient Experience Update Purpose

To provide Trust Board with an update and overview of the work to date that is

focusing upon the Patient Experience.

Discussion

Delivering a high-quality experience for patients should, without question, be a

priority for all NHS organisations. This will become increasingly important as the NHS

operates in an ever-more dynamic environment, with patients’ expectations

increasing.

Patients, carers and families utilising our services at TGH have a right to experience

the best care by a Trust that listens to their voice and demonstrates that patient and

family experience is at the heart of the care we provide and is a key measure of

patient care.

As part of the Trusts Quality Improvement Strategy, patient experience forms one of

the quality drivers with the aim that all patients will receive high quality care that is

tailored to their individual needs, which we will be monitored through the delivery of

the Patient Experience Strategy.

This paper will provide an update on how we are monitoring the experiences of our

patients though the following processes.

The Friends and Family test

This is measured by asking patients across A&E, inpatient areas and Maternity a set

question;

“How likely are you to recommend our ward, department or service to your friends

and family if they needed similar care or treatment?”

3

Responses are collected in various ways, cards, volunteers – tablet, internet, SMS

texting service (piloted for 3 months) and are collated on a monthly basis. There is a

2014/15 FFT national CQUIN which requires a response rate for A&E of 15% to be

achieved by the end of Quarter 1 and to maintain improvement.

Table 1 below shows our current position for all areas A&E, Inpatient, Combined (IP

& A&E) and Maternity.

A&E FFT

In May the response rate for A&E reached 26.4% Table 2 shows how we are

performing in A&E in relation to the specific questions, with 82.7% scoring extremely

likely or likely to recommend the department.

4

The chart below demonstrates our position for A & E across Greater Manchester and

England. It is clear work needs to continue to ensure we are capturing feedback for

A&E.

Friends and Family Test - A&E Departments (Type 1 and 2)Friends and Family Test submissions by trust

May 2014

NameTotal

Responses

Total

Eligible

Response

Rate

Friends

and Family

Test Score

Extremely

LikelyLikely Neither Unlikely

Extremely

Unlikely

Don't

Know

England 137,471 721,251 19.1% 54

(63.4%)87

286 31,003 6,030 3,698 5,762 3,692

BOLTON NHS FOUNDATION TRUST 1,155 6,185 18.7% 56 (66.9%)773 227 59 30 46 20

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 1,892 9,741 19.4% 60 (69.9%)1324 331 68 50 90 29

PENNINE ACUTE HOSPITALS NHS TRUST 4,205 12,499 33.6% 51 (57.2%)2409 1,123 198 75 133 267

SALFORD ROYAL NHS FOUNDATION TRUST 1,169 4,136 28.3% 59 (68.7%)804 215 63 27 39 21

STOCKPORT NHS FOUNDATION TRUST 722 4,172 17.3% 41 (55.4%)400 203 54 22 32 11

TAMESIDE HOSPITAL NHS FOUNDATION TRUST 1,101 4,165 26.4% 38 (53.4%)589 322 74 46 57 13

UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST 770 4,440 17.3% 58 (69.3%)534 109 35 33 36 23

Breakdown of Responses

5

Thematic analysis for A&E FFT.

As part of the feedback process there is a free text component. The analysis has

identified themes and feedback has been given to the Divisions for them to

implement changes as appropriate. This month the feedback has been very positive

with key themes being caring; professional, friendly, courteous, staff; prompt

treatment; helpful, supportive and informative staff; excellent doctors and

nurses; porter and all staff fantastic; first class, excellent service. The areas of

concern are generally waiting times but an acknowledgement form the department

that May had a particularly high number of attendees to the department.

Inpatient FFT Survey analysis.

The inpatient survey response rates no longer remain a CQUIN target for 2014/15,

although the FFT element of the survey remains in place with a target of 25% by the

end of quarter 1. Table 3 highlights the inpatient response rate for May was 42.3%.

The chart below demonstrates our inpatient position in comparison to Greater

Manchester and the England FFT results. When calculating the combined responses

6

of extremely likely and likely scores, TGH achieved 93.9% compared to 94.4% for

England and 94.2% for Greater Manchester.

Analysis of the themes from the heat maps for inpatients continues to demonstrate

that noise at night remains a key theme. All areas have been reminded to discuss at

ward meetings the findings from the feedback.

The heat map below represents the question asked with Q19 identifying a consistent

theme relating to noise at night.

Friends and Family Test - InpatientFriends and Family Test submissions by area

team

May 2014Unify2 Data Collection - FFT_IP

NameTotal

Responses

Total

Eligible

Response

Rate

Friends and

Family Test

Score

Extremely

LikelyLikely Neither Unlikely

Extremely

Unlikely

Don't

Know

England (including Independent Sector Providers) 124,169 346,223 35.9% 74 (75.6%)93973 23,228 2,572 880 984 2,532

England (without Independent Sector Providers) 118,552 334,095 35.5% 73 88,899 22,748 2,545 876 961 2,523

Greater Manchester Area Team 7,266 18,855 38.5% 77 (77.4%)5630 1,215 120 51 42 208

Tameside Hospital Foundation Trust 459 1,086 42.3% 66 (70.5%)324 107 13 5 6 4


8

Maternity service FFT Maternity Services response rates have remained static in May, with an overall

response of 24.9%. Further work needs to continue in increasing the response rates

for Maternity. The card redesign is being discussed with the division to ensure it

meets the needs of the service.

9

Maternity services has comparison with England and Greater Manchester

demonstrates an improved position with an improved response rate, an improved net

promoter score and combined responses of extremely likely and likely scores,

achieving 97.4% compared to 94.1 % for England and 97.2% for Greater

Manchester.

Friends and Family Test - Maternity Friends and Family Test

submissions by area team

MAY 2014

NameTotal

ResponsesTotal Eligible

Response

Rate

Friends and

Family Test

Score

Extremel

y LikelyLikely Neither Unlikely

Extremely

Unlikely

Don't

Know

England 8,573 51,905 16.5% 67

(69.3%)

5946 2,128 177 83 58 181

Greater Manchester Area Team 481 2,912 16.5% 70 (70.6%)340 128 5 0 1 7

Tameside Hospital Foundation Trust 189 760 24.9% 80 (81.4%)154 30 4 0 0 1


10

Additional Surveys

A number of additional surveys have been created within the Meridian real time

monitoring system to further gather patient experience relating to this month. These

include :

• audiology,

• breast care services,

• learning disabilities services,

• children’s community nursing team,

• hospital alcohol liaison service.

The individual departments are able to access the data from the system and the plan

going forward, is for these to be monitored at local level through the clinical

governance structures with divisional representatives to report the outcomes and

learning to the patient experience group.

Voluntary Services THFT have a large number of volunteers who contribute on a daily basis to the

operational aspects of the hospital. There are currently 420 volunteers registered

with the hospital.

The voluntary services have implemented the Dining Companions project with formal

training taking place in May. Volunteers are now on two wards in Ladysmith who are

piloting the project.

The plan going forward is to increase the number of Dining Companions to give

every ward access to this service.

11

Ward bed side booklet Plans are in progress to develop an up to date bedside booklet that provides relevant

information for all our inpatients across the Trust. This A5 wipe able booklet will be

available for every in patient and it is hoped this project will be supported by the

League of Friends.

Open and Honest care

The Trust continues to report as part of the open and honest care programme which

publishes on monthly basis information relating to three key categories: safety,

experience and improvement. As well as publishing data relating to FFT, HCAI‟s,

Safety Thermometer, pressure Ulcers and Falls we also use patient stories as an

essential tool to improving the care received by the patients and their families. Each

month a patient story is published alongside an improvement story for the Trust. As

the programme has developed we have tried to link the two together and last month

we used the Hospital Alcohol Liaison service with a patient who had received care

from the team. Formal evaluation of the programme has been commissioned by

NHS England, and THFT will be part of the evaluation with the research being

undertaken by Edge Hill University. The proposed start date is June 2014 with

completion scheduled for December 2014

Local College Engagement

The Trust has been working with Tameside College to facilitate placements for the

year 2 Health and Social Care students. The first cohort of students will commence in

September 2014.

Design and creation of a Dementia friendly garden located in Ladysmith courtyard

area has commenced in partnership with Cofley and Tameside College – art

students. The plan is shown below. It is hoped this will be open in early summer.

12

Ladysmith Building – Sensory Garden Plan

• Trellises / Hanging Baskets - to be placed between the green plant pots (alternately) on each section of brickwork.

• Where green plant pots go the paving slabs will be removed and pots lowered in with stone placed around the bases.

• Refurbished benches will be positioned in the seating areas.

• The centre piece will be a piece of imitation grass and possibly a central feature.

• Gaps between pathways can be filled at a later date.

Patient and Carer feedback from Carer’s supporting a relative with Dementia

The Dementia Strategy supports the ongoing work with Carers of patients with

Dementia. To develop our partnership working going forward with the Tameside

Carers Action group, the Dementia Specialist nurse attends their meetings on a

Concrete pots

Trellis

Hanging

baskets

Grassed area

Sitting areas

Defined path

ways (wheel

chair width+)

13

quarterly basis to gain feedback around the care and support we provide to patients

with dementia from a Carers perspective. We continue to undertake the Carer’s

survey following the discharge of a family member as another method of obtaining

feedback.

Although the responses continue to be small in number it is important to monitor the

returns and continue supporting carer engagement.

Date Chann

el

Pleas

e tell

us

how

old

the

patie

nt is:

Please

tell us

how

old you

are:

What

ward(s

) were

they

on?

Did they

always

have the

help they

needed

to eat

and

drink?

Were you

involved

as much as

you

wanted to

be in

decisions

about

their care

and

treatment?

Did you feel

that the

patient was

treated with

dignity and

respect?

Did you

know who

to speak to

about their

care and

treatment?

Was

the

hospita

l

enviro

nment

clean

and

tidy?

As a carer of a

person with

Dementia who

is in hospital,

did you feel

adequately

supported

during their

hospital stay?

06/05/2

014 Web 80+ 40 - 64

Ward

41 No No

Yes,

sometimes

Yes,

sometimes Good No

12/05/2

014 Web 80+ 80+

Ward

41

Yes,

always

Yes,

always Yes, always

Yes,

always

Very

good Yes, always

27/05/2

014 Tablet 80+ 65 - 69

Ward

44

Yes,

always

Yes,

sometime

s Yes, always

Yes,

always

Very

good Yes, always

29/05/2

014 Tablet 80+ 65 - 69

Ward

41

Yes,

sometim

es

Yes,

sometime

s

Yes,

sometimes

Yes,

sometimes Good

Yes,

sometimes

Tameside Safety and Quality Accreditation Standards

The Accreditation standards assessment process has now been rolled out in a

phased approach. A team of Senior Nurses and representatives from the Quality &

Governance unit have supported the assessment process across all the wards with

the exception of NICU. The outcomes of the Children’s assessment is currently being

validated

14

Tameside Safety and Quality Accreditation Heat map

Org

an

isa

tio

n

an

d

Ma

na

ge

me

nt

of

the

Cli

nic

al

Are

a

Sa

feg

ua

rdin

g p

ati

en

ts

Pa

in M

an

ag

em

en

t

Pa

tie

nt

Sa

fety

En

vir

on

me

nta

l S

afe

ty

Nu

trit

ion

a

nd

Hy

dra

tio

n

En

d o

f L

ife

Ca

re

Me

dic

ine

s

Ma

na

ge

me

nt

Pe

rso

n C

en

tere

d C

are

Pre

ssu

re U

lce

rs

Eli

min

ati

on

Co

mm

un

ica

tio

n

Infe

ctio

n C

on

tro

l

Ov

era

ll S

core

Ward 1 2 3 4 5 6 7 8 9 10 11 12 13

Ward 30 Ambe

r

Ward 31 Red

Ward 40 Red

Ward 41 Ambe

r

Ward 42 Red

Ward 43 Red

Ward 44 Red

Ward 45 Red

Ward 46 Red

Ward 5 (ASU) Red

MAU Red

Elective Unit Ambe

r

Surgical Unit Ambe

r

Trauma unit Ambe

r

WHU Ambe

r

CCU Ambe

r

ITU Ambe

r

A&E Ambe

r

Maternity Ambe

r

Children’s Unit

The heat map identifies the outcome against the 13 standards for all areas that have

been assessed. Discussion at the Nursing and Midwifery Leaders Forum will review

the learning from the assessment programme and start planning the next

reassessment.

15

The Ward Leaders all have action plans for their wards and it is expected that

improvement across all areas should be demonstrated. The Accreditation

programme will now have a rolling timeframe for assessment and reassessment

based on the wards overall level of achievement. The aim is to have “Elite” wards by

end of 2015.

This work now provides a ward accreditation scheme that gives assurance to the

Trust Board, Commissioners and other external inspectors that the provision of

quality care delivered to our patients is assessed and monitored using the Tameside

Safety and Quality accreditation standards as a mechanism to drive up quality.

Summary

Patient experience is so much more than just undertaking surveys and seeking

opinion it is about a way of monitoring the quality of care we give to our patients

through the feedback that we collect. The themes that are identified via the feedback

together with the information we collect in relation to complaints and PALS will give

clinical areas, wards and departments a broader spectrum of information which

together with the performance data will allow them to enhance and improve the

quality of care our patients at TGH receive.

Recommendation

The Trust Board is requested to receive this update and note the processes that are

in place to support the delivery of a high quality experience for patients, families and

carers at TGH.

John Goodenough

Executive Director of Nursing

July 2014

1



Mandatory Training


Purpose

To appraise the Board of the position with regards Mandatory Training and improvements in order to ensure compliance against the Trust target of 95%

Actions Recommended

To note the contents of the paper.

Publication


Unusual acronyms DOL’s – Deprivation of Liberty


To communicate any comments from the Board to the Divisional Teams. TO follow up with Divisions achievement against plans submitted.

Report of Amanda Bromley, HR Director

Paper prepared by Amanda Bromley, HR Director

2

Mandatory Training

Introduction

The purpose of this Board report is to inform the Board of improvements to the

Mandatory Training target.

The current target for Mandatory training is 95%. Mandatory Training is made up of 3

elements – each with an individual target of 95%.

These elements include:

1) The Work Book which includes

• Information Governance, • Infection Prevention and Control for non-clinical staff • Health and Safety, • Safeguarding Children Level 1 • Safeguarding Adults Level 1, • Moving and Handling Level 1, • Equality & Diversity

2) Face to Face Sessions – Manual Handling, Infection Prevention, Resuscitation,

Fire, Conflict Resolution

3) E-Learning – a mixture of national e-learning packages and local packages are in place

The Work Book is a paper based workbook designed to offer a flexible way in which to meet the necessary levels of mandatory training required by Tameside Hospital NHS Foundation Trust. It is recognised by the Trust that releasing staff for face to face sessions on an annual basis is increasingly difficult. The Work Book therefore replaces the need for some staff to attend the face to face Mandatory Training sessions. In principle the workbook is an ideal mechanism for meeting the required levels of mandatory training however in practice the quality of the workbook is poor and training and learning outcomes cannot be measured. Whilst e-learning is proving a useful tool to aid the completion of Mandatory Training,

there are issues with not all staff having access to a Trust e-mail account and access

to a computer.

Known Challenges

At a time when assurance and compliance with standards are required there are

many competing demands for what is known as ‘Mandatory’ training. The list of

training for staff groups to complete training on either an annual or bi-annual basis in

3

associated fields is ever growing e.g. DOLs, Falls, Dementia, Prevent, Conflict

Resolution,

The many Mandatory training elements are not all managed by the Education Team

and therefore the processes for ensuring Mandatory training is recorded on the

central OLM system are not always in place and therefore the issue of data capture

and accuracy is a known challenge.

Currently the Education and Training team are reviewing the process of identifying

who needs what training, the OLM system can capture the ‘competencies’ required

so that accurate systems can be put in place to ensure reminders can be sent to

Managers to identify which staff need the training and when.

Managers receive a monthly email detailing each staff member and the dates their

Mandatory Training is required – staff are RAG (Red, Amber, Green) rated as to their

compliance. Any staff member deemed as Amber is recognised as needing to book

on a session or complete an e-learning package or the workbook. A staff member

showing red is deemed to be non-compliant. Managers are asked to focus on the

staff showing as amber.

As the reports are circulated a month behind the current month, the reports are often

challenged by Managers as not being accurate – real-time recording and reports is

not available unless the Trust chooses to implement Manager/Employee self-service.

The current rates for Mandatory training are identified in the table below:

Mandatory Training

Workbook Target Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Emergency

Services &

Critical Care

95% 86.5

%

87.6% 90.8% 87.8% 90.5% 88.6% 81.4% 77.0% 81.3% 79.9% 84.2% 80.5%

Elective

Services

95% 81.4

%

84.0% 85.3% 91.5% 93.2% 92.2% 87.2% 84.4% 83.9% 79.9% 82.9% 84.4%

Womens

Services

95% 70.9

%

73.5% 79.6% 86.1% 93.8% 95.1% 90.8% 88.1% 91.6% 84.9% 88.0% 88.5%

Childrens

Services

95% 74.6

%

76.6% 81.3% 83.0% 86.1% 87.2% 88.1% 85.9% 81.5% 87.6% 87.6% 87.8%

Diagnostic &

Therapeutic

95% 92.0

%

88.5% 89.1% 89.7% 92.9% 90.6% 90.9% 91.8% 91.2% 88.8% 91.6% 92.2%

Facilities 95% 91.2

%

95.6% 94.6% 98.3% 99.1% 98.3% 87.7% 93.1% 92.2% 97.5% 99.2% 93.0%

Corporate 95% 92.5

%

92.4% 95.3% 94.4% 94.2% 94.2% 91.7% 94.0% 91.3% 91.4% 91.1% 90.9%

Tameside

NHS Trust

95% 84.7

%

85.6% 88.2% 89.5% 92.0% 91.0% 86.7% 85.2% 85.9% 84.4% 86.9% 85.9%

Manual Handling

Target Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Emergency 95% 92.1 90.8% 88.2% 89.3% 89.6% 90.2% 89.6% 89.8% 90.1% 89.1% 88.2% 87.8%

4

Services &

Critical Care

%

Elective

Services

95% 92.1

%

91.7% 85.5% 88.7% 88.8% 90.9% 90.9% 91.7% 91.5% 92.7% 91.7% 90.4%

Womens

Services

95% 90.2

%

90.5% 92.0% 90.0% 91.6% 83.5% 87.5% 91.7% 88.8% 89.7% 88.5% 88.5%

Childrens

Services

95% 87.1

%

88.7% 84.1% 84.4% 84.8% 87.9% 88.1% 88.9% 86.1% 85.6% 80.4% 80.4%

Diagnostic &

Therapeutic

95% 96.6

%

94.2% 93.1% 92.7% 93.7% 92.9% 92.6% 95.8% 96.1% 94.7% 95.2% 93.5%

Facilities 95% 100.

0%

100.0

%

100.0

%

100.0

%

100.0

%

100.0

%

100.0

%

100.0

%

100.0

%

100.0

%

99.2% 99.1%

Corporate 95% 98.9

%

97.8% 98.2% 98.6% 99.0% 99.0% 99.0% 98.1% 99.7% 98.2% 98.1% 96.6%

Tameside

NHS Trust

95% 93.4

%

92.5% 90.1% 91.0% 91.6% 91.6% 91.7% 92.6% 92.5% 92.2% 91.1% 90.3%

Resus Target Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Emergency

Services &

Critical Care

95% 92.0

%

89.2% 90.3% 88.3% 88.8% 89.3% 90.4% 91.2% 90.4% 90.0% 85.2% 83.1%

Elective

Services

95% 91.2

%

87.1% 88.3% 85.3% 88.3% 88.3% 87.5% 89.0% 86.8% 88.5% 84.8% 82.7%

Womens

Services

95% 91.7

%

90.1% 91.8% 87.9% 89.0% 83.7% 82.8% 88.5% 78.2% 82.5% 82.4% 78.4%

Childrens

Services

95% 86.7

%

83.0% 80.2% 78.8% 77.4% 77.7% 81.6% 78.1% 79.8% 76.3% 69.3% 66.7%

Tameside

NHS Trust

95% 91.3

%

88.1% 89.1% 86.4% 87.5% 87.1% 87.8% 89.1% 86.6% 87.6% 83.9% 82.0%

Overall

Compliance

95% 89.6

%

88.8% 89.1% 89.2% 90.7% 90.7% 88.8% 89.0% 88.5% 88.1% 87.7% 86.6%

Improvements Made

In order to achieve the Trust’s target a number of changes have been made centrally

to aid Divisions in achieving the target, these include:

• Education and Training Bulletin has been produced detailing all the

Mandatory training face to face sessions

• Dates have been advertised for the next 6 months following feedback about

unavailability of dates and dates not being available

• More e-learning packages have been developed, development sessions have

been provided to provide guidance to staff not familiar with the e-learning

packages

• A dedicated mandatory training email has been developed so staff can book

on courses more easily using the dedicated email. An on-line booking facility

is currently under development.

• A monthly email highlighting the staff who did not attend sessions (DNA’s) is

to be sent to Managers from next month. Currently this is not provided.

5

Divisional Trajectories

Following a request at the last Board, the Divisional teams were asked to provide

trajectories detailing the improvement to the Mandatory training rates for their areas.

Detailed plans have been supplied outlining how the Divisions plan to achieve the

target of 95%, the majority have plans in place to achieve the target by December

2014. These plans will be monitored through the Operational Board.

Where tables have been supplied these have been attached in appendices 1-3.

Appendix 1

Elective Division Mandatory Training Improvement Plan

Mandatory Compliance 31st May 2014 WB MH Resus Conflict

recovery trajectory for areas where not

95% compliant

% % % % Aug-14 Sep-14 Oct-14

Anaesthetic Recovery Theatres L5 90% 90% 98% 95% 95%

Anaesthetics - Medical L5 77% 81% 65% 90% 75% 85% 95%

Audiology Services L5 100% 100% 100% 100%

Cancer Data Service L5 81% 100% 50% 100% 75% 85% 95%

Day Endoscopy Unit L5 95% 90% 94% 81% 85% 95%

Day Surg Endoscopy Ward L5 89% 95% 78% 78% 85% 95%

Dental Specialties - Medical L5 17% 83% 100% 67% 75% 85% 95%

Dental Surgery Services L5 100% 100% 88% 88% 95%

Elective - Nursing & support L5 40% 100% 75% 50% 75% 85% 95%

Elective Services - Managers & support L5 82% 96% 50% 0% 75% 85% 95%

Elective Unit L5 93% 96% 80% 76%

ENT Medical L5 40% 60% 20% 60% 75% 85% 95%

ENT Nurse Practitioner-Elective L5 50% 100% 50% 0% 75% 85% 95%

General Outpatients L5 77% 91% 92% 88% 85% 95%

General Surgery Medical L5 71% 82% 76% 82% 85% 95%

Hartshead Theatres 1-10 L5 86% 88% 95% 97% 95%

ITU / Surgical HDU L5 95% 88% 93% 90% 95%

Orthopaedic Nursing Support L5 50% 100% 100% 100% 75% 85% 95%

Orthopaedics - Medical L5 74% 95% 68% 74% 75% 85% 95%

Phlebotomy service L5 77% 100% 46% 31% 75% 85% 95%

Surgical Unit L5 86% 89% 78% 63% 75% 85% 95%

Theatres Support L5 0% 100% 100% 100% 75% 85% 95%

Trauma Unit L5 81% 96% 94% 88% 85% 95%

Urology L5 100% 100% 50% 75% 75% 85% 95%

Vascular L5 100% 100% 100% 100%

Appendix 2

Medicine & Urgent Care Division Mandatory Training Improvement Plan

INDICATOR

CURRENT

PERFORMANCE

30th

June 2014

Mandatory Training

(target 95%)

Manual Handling 88%

Resus 83%

Workbook Completion 80%

Conflict 74%

0

10

20

30

40

50

60

70

80

90

100

Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

PDR

Manual Handling

Resus

Workbook

Conflict

Appendix 3

Children’s Services Mandatory Training Improvement Plan

Workbook Manual Handling Resus

Current position 88% 80% 69% By end of August. 90% 85% 70% By end of Sept 95% 91% 80% By end of Oct 95% 92% 90% By end of December 95% 95% 95%

PART 1

AGENDA ITEM 15a

Title of paper

Summary Paper of the June 2014 meeting of Quality and Governance Committee including Summarised Aggregated Learning Report ( May 2014)

Meeting date 31st July 2014

Purpose Provided for review and awareness

Actions Recommended



Unusual acronyms If present explained in document


Dissemination and communication

Report of Tricia Kalloo – Non Executive Director

Paper prepared by Peter Weller Director of Quality and Governance

2

Quality and Governance Committee

26th June 2014

Summary of discussions The Committee received and accepted the minutes of the last meeting and reviewed the actions arising from these which were all covered on the agenda. At the request of the committee the Head of Patient Flow was in attendance to provide an update and assurance on the changes being implemented to the Discharge process as part of the work programme. An update was provided on changes and integration of the team and progress on more effective use of Intermediate care provision including the quality of handover and transfer. The early commencement of discharge planning from the point of admission was stressed as being key to success in planning early discharge. It was identified that the work programme had been informed by the Keogh review and ECIST review. It was identified that the work was part of the Trust CQUIN for 2014/15 and the impact of changes would be reviewed at the end of Q1 14/15, using Q4 13/14 as the baseline monitoring position. An update of the CQC Inspection to date was received. It was confirmed that the 1st two phases of the inspection had been completed and the CQC were now in the process of compiling the report. It was identified that we were expecting the report by July 2014. The Committee received the Patient Experience update which included the progress with the Friends and Family Test results and the improved response rates for A&E. The development work engaging voluntary services were highlighted and the relationship with the local education college including the potential this may offer was explained. The Dining companion’s project was identified as working well on two wards in the Ladysmith block which was provided for 3 meals a day, and had received positive feedback. It was also highlighted that the Trust were one of two in the North West that were piloting the Macmillan Value based standards which link closely to the Trust Values and Behaviours. A gap analysis was currently being undertaken as a baseline to allow progress to be monitored. Progress was reported against the planned ward accreditation programme and reported that all general and acute wards would have been through an initial review by end of June as expected. The report also identified that the Trust had received the annual organ donation report, and the Initial review identified that the Trust had made good progress with respect to these requirements. It was noted that a full review of the report and outcomes would be undertaken by the HTA and Organ Donation committee to inform the future progression with the requirements. The Serious Incident Update Report was received with discussion, scrutiny and challenge by members on information provided. The strengthened process for sharing and dissemination of the outcome was emphasised. An update was provided in relation to the section 28 Letter from the Coroner in respect of the Emergency Department and Critical Care pathway that related to an event prior to the changes

3

implemented within the service. The issues and themes apparent within the mortality reviews were also discussed and questioned by the NED’s. An update was received on the Significant Risk Report and Board Assurance Framework which is also reported to Trust Board but for assurance monitoring and scrutiny reported to this committee. An update was provided on Mortality and the progress with Mortality Reviews. It was identified that the Trust SHMI was gradually reducing and there was better alignment of this with the HSMR. It was identified that reports and analysis requested and received from Dr Foster on specific speciality areas had been shared with the Divisions for review and understanding and for Divisions to provide assurance to the Mortality Steering Group on actions being taken. The Committee received a presentation on the requested summary aggregated learning report to provide a dashboard view into the current issues related to Incidents, Complaints, and Claims, Safeguarding concerns, Inquests and mortality reviews. The committee discussed the dashboard overview, and emerging or apparent trends. Members welcomed the level of detail and analysis in the presentation and considered what level of detail would be appropriate for routine Trust Board reporting to provide assurance and also ensure the Trust Board had sight of key issues and themes. It was agreed that a revised summary report be produced and was presented to the June Trust Board by the Chair of the meeting along with the summary notes of the May Quality and Governance meeting for review and discussion. Minutes of reporting committees were received and reviewed for assurance and awareness. Under any other business members were made aware of the Risk summit being held that afternoon. It was understood this had been requested by the Deanery following the recent planned review, and also in the context of the THAG (Tameside Hospital Action Group) report which had been circulated to other stakeholders. This event was noted by members of the meeting. Ms T Kalloo Non-Executive Director July 2014

4

Summary Aggregated Learning information – June 2014 **still being validated

Incidents reported Apr 14 May 14 June 14** 4 month

avg trend 12 month avg trend

New incidents (reported in month- includes delayed reports) 761 794 802 � �

Reported with Moderate harm 16 13 32 � �

Reported with Major harm 0 3 4 � �

Reported with Catastrophic harm 1 1 0 � � Never Event 0 0 0 n/a n/a

RIDDOR reported incidents 1 2 0 � �

Complaints and PALS issues Apr 14 May 14 June 14 4 month


New Complaints 39 39 39 � � New MP enquiry 4 0 4 � �

New External complaint 0 1 3 � �

New Enquiry 6 5 5 � �

New PALS issues 167 177 246 � �

Total issues received 217 222 299 � �

Re opened Complaints 3 9 8 � �

Issues /cases responded to 203 209 196 � �

Complaints %age closed in agreed timescale 68% 51% 85% � �

Average time to close issues/cases (days) 18 27 26 � �

Number issues on-going @ time of monthly report 246

Ombudsman Cases upheld 1 0 0

New issues in Month by Division

Indicators Apr 14 May 14 June 14 4 month


0 20 40 60

Facilities

Nursing

Diagnostic & Therapeutic

Womens & Childrens

Elective Services

Emergency & Critical Care

3 months June 14 - Moderate or greater harm by reported Division

3 Moderate

4 Major

5 Catastrophic

0 10 20 30 40 50 60 70

Emergency & Critical Care

Elective Services

Womens & Childrens

Diagnostic & Therapeutic

Planning & Service Impr.

Emergency &

Critical CareElective Services

Womens &

Childrens

Diagnostic &

Therapeutic

Planning &

Service Impr.

Apr 24 11 2 1 1

May 21 12 3 2 1

Jun 17 21 1

Complaints by Division

Top Incident Causes reported with Moderate harm and above (June 2014) Clinical Management issues

Potential Delayed Treatment

Infection Control - HCAI Associated Death

Infection Control - Tested Positive For CDIFF

Pressure Ulcer - Grade 2 Hospital Acquired

Pressure Ulcer - Grade 2 Non Hospital Acquire

Top issues reported (June 2014) related to Medical Care And Treatment

Nursing Care

Communication - Written

Cancellation Of Operations

Medical Care

Diagnosis - Wrong

Waiting List - OP Consultant

Appointment (OP) Cancellation

Appointment (OP) Delay

Discharge Arrangements

Top issues reported (June 2014) related to Appointment (OP) Delay

Communication - Written

Medical Care And Treatment

Appointment (OP) Cancellation

Communication - Verbal

Compliment - Staff

Communication - Admin Staff

Communication/Info to Patients

Waiting List - OP Consultant

Delay In Diagnosis (Results)

5

Mortality reviews required 75 57 81 n/a n/a

Mortality reviews undertaken (@07/0/7/14 73 56 38 n/a n/a

Inquests with TGH involvement closed /heard 10 13 9 n/a n/a

Coroner-Prevention of Future Death report (Rule 43 ) 1 0 1 n/a n/a

Themes reported (June 2014) • Morality – themed feedback to Division for learning from reviews

o Record keeping standards

o Frequency of patient review

o Re-assessment and of patients

o Consistent use of PARS

• Inquest and Coroner

o n/a

Indicators Apr 14 May 14 June 14 4 month


StEIS reports

Internal issue 4 6 2 n/a n/a

External issue 2 4 2 n/a n/a

Never events 0 0 0 n/a n/a

Safeguarding - Adult cases reported

Allegation on hospital care 19 7 6 n/a n/a

Allegation on other care 29 8 9 n/a n/a

Themes reported (June 2014) StEIS

• Related to Infection control and patients admitted with Pressure ulcers

Adult Safeguarding

• Related to issues already identified in Incident reporting and complaints

PART 1 AGENDA ITEM 15b


Finance and Performance Committee Minutes: Meeting held on the 24th June 2014


Purpose

To inform the Board about matters discussed at the Finance and Performance Committee

Actions Recommended

Discussion/Noting/Decision

Publication


Unusual acronyms

CYE – Current Year Effect EDG – Executive Delivery Group FYE – Full Year Effect


None

Report of Anne Dray – Chair of the Finance and Performance Committee

Paper prepared by Barbara Herring, Director of Finance

1

FINANCE AND PERFORMANCE COMMITTEE Agenda item 2

Date of Meeting: 24th June 2014 Time: 10.00 am Location: Meeting Room, Silver Springs Present Position Initial Mrs A Dray Non-Executive Director (Chair) AD Mr T Ward Non-Executive Director TW Mrs B Herring Director of Finance BH Miss S Holroyd Deputy Director of Finance SH Mrs G Parker Director of Estate and Facilities GP Mr P Williams Chief Operating Officer PW Mr C Porter Turnaround Director CP In Attendance Mr T Sivner Chief Pharmacist TS

Item No

Description Action

66/2014 Apologies Paul Williams, Suzanne Holroyd

67/2014 Minutes of the previous meeting 27th May 2014

The minutes were accepted as a correct record with the following amendments: 54/2014 – the following sentence should be reworded to read “the report should have, as in the divisional reports, a note of the actions being taken”. The report should also include divisional reports which give details of actions being taken. 56/2014 – second paragraph SH to provide further details of the pressures of £3.8m to be added to the action log. 56/2014 – b) second paragraph Typographical error – are – should read area. 57/2014 – final sentence Post meeting note – BH advised that the telephone contact information is correct as the actual service does not start until July/August. 57/2014 – sentence beginning “CP stated that” – should read – reprioritise for the EDG agenda – not reprioritise the EDG agenda. 58/2014 – sixth paragraph Typographical error – ace – should read face

SH

2

58/2014 – eighth paragraph Typographical error – wo – should read two 58/2014 – ninth paragraph Typographical error – of – should read also 59/2014 Post meeting note – GP confirmed that the final costs of the scanner has been agreed and it is within the £1.5m budget. 59/2014 – eleventh paragraph Amend the minute to read – …. reviewing the case six months after the new Radiology Manager commences in post. It was agreed that an update on the project management will come to the meeting in August and an overall update will be available in July 2015. 60/2014 AD/BH/TW to clarify actions.

68/2014 Matters arising: There were no matters arising.

69/2014 Action log

3.1 Tier 1 Report BH introduced the report and highlighted the following: The Executive Team have agreed to continue with reduced contracted support for Lorenzo until August. A plan is being drawn up to facilitate moving to business as usual A restructure of corporate services is planned and this will be implemented as soon as possible. BH is to cost the restructure within the existing resources and identify any potential savings. A bid has been submitted to HSCIC for additional funding and a response regarding additional funding of around £500k from Tim Donahue is awaited. A restructure of IM&T is planned to stabilise the infrastructure and systems. Considerable investment has been made in Corporate Nursing and Governance Department which has been funded from Keogh costs. CP to meet with John Goodenough to discuss the Nursing element of the report.

Until appointments are made in the senior interim positions UHSM are recharging at a premium rate. If we come out of special measures the Department of Health will award £500k which UHSM have agreed to refund to the Trust.

CP

3

CP expressed concern regarding the overspend in the communications budget and that stated processes are not being followed. A paper is to be presented to EDG regarding the need for a substantive transformation team to support the agenda over the next few years. CP stressed that additional contracts should not be offered to staff without going through the VAR process. CP to provide an update for the next meeting. A review of the current divisional structure is being undertaken and this will help identify true levels of accountability.

CP

70/2014 Finance and Activity Performance 31st May 2014 BH presented the report to the Committee, highlighting the following areas. AD expressed concern regarding low activity levels. BH advised this issue has been discussed at length with the Executive Team, and it was identified that deflections that are being made in A&E and reduction in length of stay are contributing to the reduction of activity levels. BH is reviewing the conversation rate from A&E activity into non-

elective admissions and once the review has been completed, the possibility of additional funding will be discussed with the CCG. Waiting lists are being validated, and hold files are being look into to determine the exact number of patients waiting for appointments. Length of stay in Trauma and Orthopaedics has increased over the past six months and the reasons for this are being investigated. CP advised that the financial position has deteriorated and meetings have been arranged to review the situation. A Business Case for two additional T&O Consultants is being presented at the next Executive Team meeting. GP referrals have been included into the report and demand is showing a slight upward trend. The level of coding has reduced at month end to 70%; this is due to staffing pressures, the availability of records to code, and clinical outcome sheets not being recorded in real time. The recording of outcomes has been addressed and work is ongoing to ensure this is sustained.

There is still a concern that not all the activity is being collected. A company is to be appointed to ensure every point of activity is being captured correctly. Internal Audit and Cymbio are also reviewing the systems and processes. The Heading for Home project is looking at the cohort of patients who are awaiting intervention from Social Services and moving on a sub-contractual basis into the private sector. This will ensure beds are available and the income is classed as excess bed days where appropriate and the activity will be recorded on our systems. The additional funding from the Department of Health was received on 23rd June and will become permanent funding at the end of July.

4

BH agreed to provide a separate forecast paper for the June position and each month after. To be added to the work programme.

BH

71/2014 Diagnostic Division – Position at 31st May 2014

TS gave an update on the financial position as at 31st May 2014, he reported that the headline figures in terms of the division are:

• Expenditure of the division is £23/24m per annum and off-set by income of about £12/13m. The overall budget is £10.8m per annum.

• The division is showing a £113k over spend plus £50k shortfall in CIP which makes of total of £153k overspent.

• Pathology is effectively underspent at end of Month 2 by £50k.

• Blood product usage is lower than expected, but it is unpredictable to plan for, this is being monitored to see if any CIPs can be identified.

Radiology

• The overspend is predominantly driven by overspend in the Radiology budget which equates to over 90%. The majority of the £153k overspend is due to pay budgets for additional sessions and WLI’s.

• There are issues in the variation of the existing workload for Radiologists. Job planning and productivity issues are being addressed. CP to meet with TS regarding use of agency staff. The long term strategy is to look at partnership with other organisations.

• A Radiologist of the day has been introduced which will look at different ways of working to ensure the service is as effective as possible. They will also review requests to ensure they are appropriate.

• Activity has reduced but demand has increased, and MR scanning is predicted to increase by 13%. TS agreed to provide the figures to CP.

• Ways of educating staff as to the cost of each investigation are being considered.

• Savings have been identified by the use of external reporting partners and once the MR scanner has been installed it will no longer be necessary to hire external scanners.

• Meridian undertook a review which identified capacity; this was disputed by the Radiologists. Dr Brett is conducting a further review to ensure maximum productivity. TS agreed to forward the report to CP.

• CP to share the data with EDG to gain a collaborative understanding.

Pharmacy

• Pharmacy have a slight overspend of £11k which was due to an under achievement on PbR tariff which can vary from month to month.

• Staffing pressures have been experienced as a result of the on-going issues with the prescribing model on Lorenzo. The most critical issues have mostly been resolved, talks are ongoing regarding the timescale for resolving the outstanding 70/80 issues.

CP

TS

TS

5

• A judgement whether or not to continue to use the prescribing model on Lorenzo will be taken next week, once a position statement has been received.

CIP

• Pharmacy is expected to post another £45/50k in Month 3. Some areas in the planned CIP around the collaboration are going to be extremely challenging. CP stressed that divisions need to manage budgets within the resources and this should be the message that is given to front line managers.

• Pharmacy is now opening over the weekend and opening hours have been increased to ensure prescription charges are collected.

• The option of selling over the counter medicines is being considered.

72/2014 Cost Improvement Programme: 31st May 2014 CP presented the report to the Committee, highlighting the following: 97% against the Monitor plan has been achieved for Month 2 accumulative leaves around 80 behind and around 88/89% deliver accumulative in the first two months. There are a number of schemes which are challenged whereby the leads are leaving or additional costs are being incurred to retain staff. A paper detailing the increased posts for the Transformation Team has been produced which includes a Financial band 8b to ensure turnaround work is continued. The meeting of the Controls Group has identified issues with the use of agency staff, and action is being taken to tighten up the processes. Discussions are to take place with Agencies in order to renegotiate commission and headline rates for doctors. Re-admissions are unlikely to reach £300k this year, but there is an opportunities to bring into the length of stay and right sizing beds project. It was agreed to leave the rating for this action as red. The divisional CIP had a target of 1.06 in month and delivered a total of 1.67, of which a significant amount is non-recurrent. Recurrent CIPs are being sought. Length of stay is to remain red as ward 30 has not closed on 1st June as anticipated. The contract with NHSP is due to be reviewed in October. One or two major projects have been identified from the initial meeting of the Innovation and Ideas workstream and the next meeting is scheduled to take place on the 7th July. Focussed meeting are taking place by exception in order to hold colleagues to account for overspend on budgets.

6

73/2014 Banking Arrangements The Committee noted the paper

74/2014 Service Line Reporting BH presented the paper which was taken to Board in November for information only as the 13/14 figures are not available. Once the information is available an updated report will be provided.

75/2014 Minutes of reporting Committees: 9.1 Executive Delivery Group The minutes were noted 9.2 Capital Planning and Estates Committee Deferred until next meeting

76/2014 Committee Workplan The workplan was noted and the following changes and additions agreed.

1. Service Line Reporting – November 2. Deloitte Governance Action Plans – July 3. Risks for BAF – July 4. Forecast Paper – August/September 5. QIA – Q1

BH

77/2014 Any other Business

AD advised that she has been invited to the CCG along with Julie Soboljew to meet with the Dr Alan Dow.

78/2014 Date of Next Meeting 25th July at 2.00 pm Silver Springs Meeting Room