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COUNCIL OF GOVERNORS 15 June 2017
12.30-2.30pm
Board Room, Aintree Lodge
AGENDA
d = document v = verbal p = presentation
No Item Reference
Preliminary Business – Chairman
12.30 1. Apologies for Absence
To note the apologies
CG17-18/001 (v)
2. Declarations of Interest
To receive declarations of interest in agenda items and/or any changes
to the register of governors’ declarations of interest pursuant to
Standing Orders
CG17-18/002 (v)
3. Minutes from the last meeting (15 March 2017)
To approve the minutes from the last meeting and discuss any matters arising:
Exit Interviews (Director of People & Corporate Affairs)
Annual Business Plan (Director of Finance)
Directors Dragons’ Den - Innovations Approved (Director of People & Corporate Affairs)
CG17-18/003 (d)
CG17-18/004 (d)
CG17-18/005 (d)
CG17-18/006 (d)
Overview
12.45 4. Strategic Update
Chairman/Chief Executive
To note
CG17-18/007 (p)
1.00 5. Lead Governor Report
To note
CG17-18/008 (d)
Quality & Performance Management
1.10 6. Assurance on Key Indicators:
Quality & Safety
Finance & Performance
Non-Executive Directors
CG17-18/009 (p)
Internal System of Control
1.40 7. Key Issues & Assurances
Audit
Non-Executive Director
CG17-18/010 (p)
Governance
1.50 8. PwC Long Form Report (External Assurance on QA)
PwC Representative
To approve
CG17-18/011 (d)
Cou
ncil
of G
over
nors
' Mee
ting
Age
nda
- 15
Jun
e 20
17
Page 1 of 78
Aintree University Hospital NHS Foundation Trust
Agenda: Council of Governors’ Meeting15 June 2017 2/2
2.05 9. Governor Committees:
Committee Chairs
Membership Committee (8 May 2017) for noting & approval of Terms of Reference
Quality of Care Committee (17 May 2017) for noting & approval of Terms of Reference
Nominations Committee approval of Terms of Reference
CG17-18/012 (d)
2.15 10. CoG Draft Objectives 2017/18
Chairman & Associate Director Corporate Governance/Board Secretary
To approve
CG17-18/013 (d)
2.20 11. Appointment of Lead Governor & Deputy Lead Governor
To approve the process
CG17-18/014 (d)
Concluding Business
2.25 12. Any Other Business
Chairman
CG17-18/015 (v)
13. Date and Time of Next Meeting:
Wednesday 18 October 2017 at 5.00-7.00pm
PRIVATE BUSINESS
No Item Reference
2.35 1. Appraisal of the Chairman
Senior Independent Director
CGP17-18/001 (d)
2. Appraisal of the Non-Executive Directors
Associate Director of Corporate Governance/Board Secretary
CGP17-18/002 (d)
Page 2 of 78
1/7
Council of Governors
Wednesday 15 March 2017 5:00pm
Board Room Aintree Lodge
MINUTES
Present: Neil Goodwin - Chairman
Steve Warburton - Chief Executive
Pamela Peel - Lead Governor
Sharon Bird - Public Governor
Mike Booth - Public Governor
Mike Bowker - Public Governor
Tony Byrne - Public Governor
John Johnson - Public Governor
Tony Kneebone - Pubic Governor
Julie Naybour - Public Governor
Stephen Thornhill - Public Governor
Rose Milnes - Public Governor
Tracey Barnes - Public Governor
Rosemary Urion - Public Governor
Lorraine Heaton - Staff Governor (AHPs)
John Wilding - Appointed Governor (University of Liverpool)
Kerry McManus - Staff Governor (Other)
Paul Cummins - Appointed Governor (Sefton Council)
-
In Attendance: David Fillingham Non-Executive Director
Michael Games - Corporate Governance Manager
Steve Evans - Medical Director
Sue Green - Director of People & Corporate Affairs
Tim Johnston - Non-Executive Director
Joanne Clague - Non-Executive Director
Caroline Keating - Associate Director of Corporate Governance/Board
Secretary
Emily Kelso - Corporate Governance Officer
Kevan Ryan - Non-Executive Director
Andrea Thomas - Acting Director of Nursing & Quality
Beth Weston - Deputy Chief Operating Officer
Apologies: Gerry Hill - Public Governor
Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)
Brian Lawless - Public Governor
Andrew Swift - Staff Governor (Medical)
Helen Frankland - Staff Governor (Nursing)
Ian Jones - Director of Finance & Business Services
Angie Smithson - Deputy Chief Executive/Chief Operating Officer
Mandy Wearne - Non-Executive Director
Paul Fitzpatrick - Director of Estates & Facilities
Juliet Herzog - Non-Executive Director
5 members of the public were in attendance
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 15 March 2017 2/7
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Preliminary Business
CG16-17/033 Apologies for Absence
The apologies were noted as above.
CG16-17/034 Declarations of Interest
There were no declarations of interest.
CG16-17/035 Minutes from the last meeting (8 December 2016)
The minutes from the previous meeting held on 8 December 2016 were approved as an
accurate record.
CG16-17/036 Exit Interviews
Sue Green, Director of People & Corporate Affairs, presented the report which provided
details on the development of a Trust wide approach to exit interviews to enable trends
and themes to be more easily identified and remedial action to be initiated in a more
timely way. She advised that by using the data provided, and through close working
between HR and the Divisions, the Trust could identify if there were any particular
actions required to improve retention in key areas.
Governors welcomed the initiative and sought and received confirmation that improved
processes would be in place by the end of Q1 2017/18 and that bespoke training would
be provided for areas identified within the Divisions. A further update was to be
provided to Governors in June 2017.
The Council noted the report
Overview
CG16-17/037 Strategic Update
The Chairman and Chief Executive advised the meeting of the following matters:
Budget Statement – no additional financial assistance was to be provided to the
NHS but there was money to be made available for social care
Annual Plan – the Trust was awaiting formal feedback from NHS Improvement
(NHSI) on its submitted financial plan and Governors would be kept informed
accordingly
Sustainability & Transformation Plan (STP) – the Trust continued to work within
the North Mersey footprint of the wider Cheshire & Merseyside STP. There
continued to be negative media coverage but the local delivery plan was considered
to be credible and the proposed merger with the Royal Liverpool (RLBUHT) formed
a significant part of those plans
Aintree/Royal Merger – work continued on the development of the outline
business case and a recent meeting with NHSI had discussed the detail required
for inclusion within the document alongside the clinical work. Governors would
continue to be kept informed of developments in this regard
Community Health Services – some concerns had been raised locally with NHSI
in regard to the awarding of the contract for community services within Liverpool
through the Bridgewater consortium. The outcome was awaited but the Trust
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 15 March 2017 3/7
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remained committed to the vertical integration of services
Contracts – the Trust had received agreement from Liverpool, Sefton and
Knowsley Commissioning Groups to move to a block contract arrangement for
2017/18.
Members of the Council then sought and received clarification in relation to the following
matters:
The use of charitable funds by Aintree and the Royal Liverpool Hospital to look for
opportunities and innovations that NHS funding cannot provide. Reference was
made to the Trust’s recent initiative for the use of Dementia Pods which was funded
by the Charitable Funds Committee
It remained the intention for the proposed merger between Aintree and RLBUHT to
be in place by 1 April 2018. However, there were a number of external factors that
could impact including the potential scrutiny by the Competitions & Markets Authority.
The Council noted the update.
CG16-17/038 Lead Governor Report
The Lead Governor made reference to the report and highlighted the following matters:
Aintree Volunteer Inductions – Governors were encouraged to attend these
sessions to recruit new members who were already committed to the Trust.
Governor Activity – there had been positive involvement by Governors at recent
events including Aintree Volunteer Inductions, Catering and Food Quality work
stream, Multi-disciplinary Accelerated Discharge Event (MADE) sessions, Well-Led
Governance Review Governor focus group, Aintree Champions Excellence Panel,
Focus on Kidney Event, prospective new Governor information session, staff
inductions and the helipad turf cutting
Governor Development – arrangements had been made for a Media Awareness
session which would cover a wider remit than that previously presented to
Governors. Other topics for future Governor sessions had been identified and
arrangements would be made in this regard
Induction/Development of New Governors – arrangements were to be made for
newly elected Governors to receive an induction session from the Board Secretary
and for current Governors to meet and assist in their development.
The Council noted the update.
Quality & Performance Management
CG16-17/039 Emergency & Acute Care Programme
Beth Weston, Deputy Chief Operating Officer, gave a presentation which covered the
following matters:
the progress made within the Medical Assessment Unit
the revised processes within AED with particular emphasis on patient streaming and
the rapid assessment and treatment process
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Minutes: Council of Governors’ Meeting 15 March 2017 4/7
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an overview of the Frailty Model including the improvement in discharge home rate
performance
the improved SAFER ward processes also linked to the safe discharge of patients
before noon and at weekends
the changes introduced to delayed transfers of care through the rapid improvement
event.
The key themes arising from the questions posed by members of the Council were as
follows:
the assurance gained from sustained performance that systems and processes
were embedded within certain areas and the continued work being undertaken to
embed consistency in other areas
the EAC programme being the biggest change project undertaken by the Trust with
a suite of metrics in place to monitor performance
the performance of the various teams to improve A&E performance, the accolades
given to the Frailty Unit for the service it provides and the significantly improved
ambulance handover processes put in place
the significant reduction in the number of long waits for those patients classed as
Ready for Discharge but further improvements were required to reduce the levels
and improve patient flow. Any failed discharges resulting in readmission were
reviewed by the Discharge Matron with lessons learned cascaded accordingly
the involvement of the consultant leads, registrars, nursing staff and site team as
part of the Acute Medical Scrums to speed up assessments
the inclusion of information relating to patient experience metrics within future
presentations and the possibility of providing patient/staff stories to Governors.
The Council note the presentation.
CG16-17/039 Assurance on Key Indicators
Quality & Safety Kevan Ryan (Non-Executive Director), member of the Quality & Safety Committee, gave
a presentation which covered assurance on key indicators relevant to quality and safety
including the key areas of focus, where on-going assurance was received and where
assurance was sought on areas of concern. He highlighted the main areas of focus
including serious incidents, mortality, infection prevention & control, the Quality Strategy
delivery plan and the risk register. He also referred to the ongoing assurance sought on
workforce, patient experience and pressure ulcer prevention as well areas of concern on
the Advancing Quality programme, ophthalmology and improvement in emergency
laparotomy. An overview was also provided on the Trust’s performance against the main
clinical quality indicators.
The key themes arising from the questions posed by members of the Council were as
follows:
The recording of falls and their severity. It was explained that the majority of falls
were occurring between 4.30pm and 10.30pm. Work was being undertaken to
understand the reasons for this and make the necessary improvements.
The Trust was treating a more elderly population with a noticeable increase in the
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 15 March 2017 5/7
Ref Minute
number of patients with co-morbidities, frailty, dementia and confusion. This tended
to lend itself to patient falls due to being in unfamiliar surroundings. Every effort
was made to reduce the risk of falls through the assessments undertaken
The concerns raised by the Trust with the Governor of HM Prisons in Liverpool on
the security of prisoners attending the Trust for treatment and the potential impact
on safety for the Trust’s staff, the prison guards and the general public
The commitment of the Trust to reduce the level of pressure ulcers and the work
being undertaken with the community and training of Health Care Assistants on
early detection and management of pressure ulcers. It was agreed that details of
aspirational targets for pressure ulcers for 2017/18 and trends for 2016/17
would be provided at the next meeting.
The Council noted the presentation. Finance & Performance Joanne Clague (Non-Executive Director), Chair of the Finance & Performance
Committee, gave a similar presentation on assurance on key indicators relevant to
finance and performance. This covered the Referral to Treatment recovery plan,
divisional deep dives, theatre productivity & efficiency and plans for closures. She also
highlighted the areas of on-going assurance in relation to emergency & acute care,
operational & financial performance, transformation and progress against the annual
business plan priorities. Reference was also made to the areas of concern relating to
A&E data quality and agency staffing. An overview was also provided on performance
against the financial and activity indicators, including access to services and workforce
targets.
The key themes arising from the questions posed by members of the Council were as
follows:
The intention to repeat the Dragons Den initiative during the course of the year. It
was agreed that Governors would be provided with information in relation to
the return on investment received from previous innovations at the next
meeting
The use of agency staff and the impact it has on quality and safety. Governors
were advised that changes had been implemented on block booking agency staff
where appropriate and providing them with the necessary training on the systems
and processes to undertake other duties within the Trust
The Trust’s sickness absence rate was good compared to the benchmark across
North Mersey with the level of other acute Trusts over 2% higher. The Trust now
provided Occupational Health services to other Trusts and the implementation and
delivery of the Health & Wellbeing Strategy should reduce absenteeism levels
further.
The Council noted the presentation.
Internal System of Control
CG16-17/040 Key Issues & Assurance (Audit)
Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a
presentation which covered the key areas of assurance obtained from the Committee’s
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Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 15 March 2017 6/7
Ref Minute
deliberations which included internal audit reports on car parking concessions and
incident reporting, together with assurance sought on areas of concern relating to Bank,
Agency & Locum staff and Trust Policy compliance.
The Council was informed that the Trust was due to receive a CQC inspection anytime
from April 2017 and it was noted that Governors would be involved where appropriate.
The Council noted the presentation
Governance
CG16-17/041 Appointment of External Auditor
Tim Johnston, Non-Executive Director, advised the Council of the audit tender process
undertaken by the Audit Committee and Governor representatives. He provided a brief
overview of the work that would be undertaken by the External Auditors and explained
that the Committee had followed the prescribed framework to invite firms to tender. The
Trust had only received one response from PricewaterhouseCoopers (PwC) but still went
through a proper process via an assessment panel. Tony Byrne, Public Governor,
advised that he and Gerry Hill, Public Governor, had been the Governor representatives
and explained that he had been part of the panel assessment which had gone through a
robust Q&A session and PwC had answered proactively. He stated that he fully
supported the recommendation to appoint PwC.
The Council approved the recommendation to appoint PwC for external audit services for
3 years with the option to extend for a further 2 years.
CG16-17/041 Reports of Governor Committee Chairs
Membership Committee – 1 February 2017
The Council of Governors received the report of the Committee which was taken as read
and noted.
Quality of Care Committee – 9 February 2017
The Council of Governors received the report of the Committee which was taken as read
and noted.
Nominations Committee –15 March 2017
The Council of Governors noted that the Committee had met to discuss the re-
appointment of the Chairman.
Concluding Business
CG15-16/032 Any Other Business
Re-appointment of Chairman
The Chairman left the meeting at this point and Tim Johnston, Non-Executive Director
and Senior Independent Director, chaired the remainder of the meeting.
TJ advised the Council that the Nominations Committee had met to discuss the re-
appointment of the Chairman for a second term of office. Committee members provided
Page 8 of 78
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors’ Meeting 15 March 2017 7/7
Ref Minute
a brief overview of their deliberations in relation to the performance and leadership
qualities of the Chairman. The Committee sought and received approval by the Council
of Governors that Dr Neil Goodwin, Chairman, be appointed for a second 3 year term of
office concluding on 30 September 2020.
Date and Time of Next Meeting:
Wednesday 15th June 2017 in the Board Room Aintree Lodge at
The meeting closed at 7.00pm Chair’s Signature: Date:
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Agenda Item (Ref) CG17-18/004 Date of Meeting: 15 June 2017
Report to Council of Governors
Report Title Exit Interviews
Executive Lead Sue Green, Director of People and Corporate Affairs
Lead Officer Steven Richardson, Acting Head of Business HR
Action Required Progress Update
Substantial assurance
High level of confidence
in delivery of existing
mechanisms / objectives
Acceptable
assurance
General confidence
in delivery of existing
mechanisms/
objectives
Partial assurance
Some confidence in
delivery of existing
mechanisms /
objectives
No
assurance
No
confidence
in delivery
Key Messages of this Report (2/3 headlines only)
A Trust-wide approach to exit interviews is being developed to enable trends and themes to be
more easily identified and remedial action to be initiated in a more timely way.
By using the data provided and through close working between HR and the Divisions the Trust
can identify if there are particular actions required to improve retention in key areas.
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must
accompany the report)
Strategy Policy Service Change
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance (is the report a……?)
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for Board submission required:
Next Steps (actions following agreement by Board/Committee of recommendation/s)
Review the outputs from the current Nursing Retention Review underway;
Engage key stakeholders in reviewing the Policy/toolkit
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Aintree University Hospital NHS Foundation Trust
Exit Interviews: Council of Governors 15 June 2017 2/5
REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of key issues raised and actions
Council of
Governors
CG16-17/
036
Exit Interviews 15 March
2017 A Trust-wide approach
to exit interviews is
being developed
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Aintree University Hospital NHS Foundation Trust
Exit Interviews: Council of Governors 15 June 2017 3/5
Exit Interviews
Executive Summary
1. The purpose of this report is to update the Council of Governors on progress made on exit
process and interviews and how the Trust uses these and will use these to gain an
understanding of the main themes of reasons for staff leaving the Trust. This is an update of
the previous report submitted to the Council of Governors in March 2017.
Key Issues / Proposals
2. The previous report identified that a more effective Trust wide approach and process is
necessary in order to gain a better understanding of why staff choose to leave; this will help
to provide legitimate intelligence around issues or interventions that can be deployed to
change outcomes and improve retention
3. Key Actions identified were as follows:
To identify how many staff have left the Trust, broken down by Division, job role, and
grade and identify what the reasons for leaving have been and whether or not the
reason for leaving was voluntary or as a result of action taken by the Trust
To identify the destination of leavers, and to understand how many of our leavers left
the organisation to work elsewhere within the NHS; and how this level compares to the
number leaving to further their education and/ or training and the number of leavers
exiting the NHS altogether.
Review in detail the reason groups – Work Life Balance, Better Reward Package and
the Other/Not Known
Develop an exit interview template and process to be used as a consistent approach to
be applied across the Trust; Divisions will be encouraged to carry out exit interviews on
every leaver following the new structured process
Current Positon
4. An Exit Review Policy and framework is in development which will look to provide a structure
for managing the exit process for staff. This is due to be presented to WELG later this
month; it will look to address the issue of retention on 3 levels.
i. Through good management practice; implementing an approach for managers to speak
to leavers to gain valuable information as to the reasons (exit interviews)
ii. Identification of unusual changes in exit information; triggering conversations between
HR Teams and Managers to understand the reasons for spikes for early intervention
iii. Trend analysis; focussed pieces of work where significant trends are identified for
gathering in depth understanding and developing tailored interventions
5. A number of initiatives have already been implemented to support the delivery of the Policy
and framework.
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Exit Interviews: Council of Governors 15 June 2017 4/5
6. A detailed data set and information has been produced to provide a more in depth
quantitative understanding of attrition rates; this information has also now been incorporated
as standard into the monthly pipeline report for Divisions and reviewed at NSSG. This report
provides a specific focus on band 5 nursing leavers as a starting point, as this is the key area
of concern with one of our biggest vacancy gaps.
7. This intelligence has identified some significant trends that are now being investigated in
more detail, for example, AED and MAU accounts for approximately 50% of all leavers within
the Division of Medicine over the last 12 months; moreover it has shown that of these almost
50% are staff whose service is less than 2 years. At the moment the vast majority of newly
qualified nurses are deployed to these departments and there is a concern that something is
happening that is resulting in these staff exiting. More focussed intervention has
commenced and will be concluded by the end of June; this will identify if there is an issue
with the loss of NQNs, the causes and interventions to drive change and improvement.
8. The Business HR Team are working closely with the respective Divisions on the
development of Resource Plans; these will incorporate the same data and intelligence on exit
for all staff groups, to ensure that the Policy and processes are embedded, data analysed,
areas for intervention identified and activity initiated and monitored.
9. In addition to this, a Trust Exit interview template has been developed that will shortly be
presented to the Divisions for review, comment and implementation; this will look to provide a
more structured approach to undertaking exit interviews.
10. It is recognised that an exit interview process in itself may not provide a complete picture of
the reasons for leaving, particularly if the reasons are of a sensitive nature or relate to
relationship issues with colleagues. Consequently, a process has already been put in place
to give every leaver the opportunity to provide confidential feedback, completely separate to
the exit interview process, which will look to address this gap.
Additional Strategies
11. A QEP initiative has been identified that will look to review the current shift patterns and skill
mix to identify improvements; the exit process and information will provide valuable data and
intelligence to inform that review.
Implications / Impact
Quality
12. Retention of trained, qualification and professional staff will improve the quality of care our
patients receive.
Finance
13. It is widely acknowledged that the cost of retaining staff is much lower than the cost of
recruiting new staff, so improvements in retention rates will support effective use of
resources.
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Exit Interviews: Council of Governors 15 June 2017 5/5
Workforce
14. Maintaining a stable, committed workforce is a key objective within the 2017 / 2018 strategic
plan. A reduction in staff turnover will likely have a positive impact on staff morale and
therefore staff survey results, and will likely have a positive impact of sickness absence rates
and ultimately will help the Trust develop a workforce capable of meeting the challenges
faced by the organisation over the coming years.
Equality & Diversity
15. The revised process and Policy will be subject to an Equality Impact Assessment. In addition,
Exit Interviews will include an assessment of any opportunities to promote Equality and
Diversity as well as ensuring no detrimental impact on people within the protected
characteristic groups.
Legal
16. The provisions of the Data Protection Act will apply in relation to data produced and stored
as a result of exit interviews.
Conclusion
17. The development of the Exit Review Policy and framework will provide a clear structure and
methodology to drive improvement.
18. The steps implemented so far have started to drive a better understanding of retention issues
and hotspot areas.
19. Focussed interventions have already commenced or are about to begin to address some
initial identified hotspots.
Recommendation
20. To note the contents of this report and support the proposed methodology.
Author: Alan Evans; Head of Workforce and Payroll Systems
Date: 7 June 2017
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Agenda Item (Ref) CG17-18/005 Date of Meeting: 15 June 2017
Report to Council of Governors
Report Title Annual Business Plan 2017/18
Executive Lead Ian Jones, Director of Finance
Lead Officer Alistair Leinster, Head of Corporate Planning and Performance
Angela Whittaker, Associate Director of Strategy, Service Development
and BI
Action Required To approve
Substantial assurance
High level of confidence
in delivery of existing
mechanisms / objectives
Acceptable
assurance
General confidence
in delivery of existing
mechanisms/
objectives
Partial assurance
Some confidence in
delivery of existing
mechanisms /
objectives
No
assurance
No
confidence
in delivery
Key Messages of this Report (2/3 headlines only)
This report gives and overview of the annual business planning considerations for the Trust and
approach taken to the planning process.
It summarises the priorities that have been included in the Annual Business Plan for 2017/18
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must
accompany the report)
Strategy Policy Service Change
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance (is the report a……?)
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for Board submission required:
Next Steps (actions following agreement by Board/Committee of recommendation/s)
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Aintree University Hospital NHS Foundation Trust
Annual Business Plan 2017/18: Council of Governors 15 June 2017 Page 2
REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of key issues raised and actions
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Aintree University Hospital NHS Foundation Trust
Annual Business Plan 2017/18: Council of Governors 15 June 2017 Page 3
Annual Business Plan 2017/18
Executive Summary
1. This report summarises the priorities that have been identified for inclusion in the Trust’s
2017/18 Annual Business Plan.
2. The Annual Business Plan outlines the Trust priorities in delivery of its strategic vision and how
it aims to contribute to the wider emerging strategic vision for the health economy. It should be
considered alongside other Trust assurance processes and reporting mechanisms including a
range of business as usual activities.
3. In order to ensure that the Annual Business Plan represents a manageable overview of Trust
priorities, schemes are divided into those reported at Trust level and those reported at
Divisional / Executive Led Group level. A total of 33 schemes are prioritised to be reported in
the Trust level report, with a further 19 schemes to reported at Divisional and Executive Led
Group level (total = 52 schemes).
Introduction/Background
4. The Trust’s Annual Business Plan for 2017/18 outlines how Aintree aims to; (i) achieve its
strategic vision, (ii) contribute to the delivery of the emerging strategic vision for the health
economy and (iii) deliver against its mandated operational performance targets and quality
standards.
5. Divisions and Corporate Services Departments have identified their priorities for inclusion
within the 2017/18 Annual Business Plan.
6. The emerging business plan priorities have been aligned to the Trust’s strategic objectives and
also triangulated against the Quality Strategy and QEP programme.
National Priorities / Planning Guidance
7. National policy signals a further move towards system-based working with a key focus being
the requirement for Trust plans to align with Sustainability and Transformation Plans (STP).
Within Cheshire and Merseyside the main themes of the STP are; hospital reconfiguration,
demand management, population health and digital first. The Trust continues to progress the
acute merger with the Royal Liverpool and Broadgreen University Hospitals NHS Trust as a
strategic priority.
8. Finance, activity and workforce plans are required to be consistent with the wider STP plans,
with all organisations being held accountable for delivery of their own and system STP
financial control totals.
9. Local commissioners are unequivocal in their approach to service developments for 2017 -
2019, stating that CCGs will not agree to any service development where there is a net
increase in costs to commissioners.
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10. Local commissioner and national priorities both look to outpatients as an area of focus
through; new to follow ratios, mandating the use of e-referral system, requirement to develop
‘advice and guidance’ services as well as a shift from daycase procedure to outpatient setting.
Local Strategic Priorities
11. During 2016/17 the Trust focused on a number of work programmes that support the principles
set out in the emerging Sustainability and Transformation Plans and are central to delivery of
Local Delivery System plans. A number of these issues remains as key priorities for the Trust
in 2017/18:
Working towards acute provider merger, delivering horizontal integration. Clinical teams
are developing integrated models of care to deliver patient benefits across the city.
Active engagement in the Healthy Liverpool and Shaping Sefton programmes to
improve pathways and support demand management. This has included working on
city-wide pathways that offer the potential to reduce demand for acute services, as well
as exploring opportunities to reduce duplication of support services.
Progression of shared electronic patient record system across three of the acute
providers within the city. This will support future organisational reconfiguration as well
as offer benefits of additional functionality and record sharing capabilities.
Working collaboratively with partners across health and social care to resolve some of
the key challenges facing the Trust. This includes a multi-professional workshop with
partners, including social care, focused on accelerating discharge and addressing
delays.
Maintain a focus on the delivery of high quality community services through
collaboration with others.
Trust Planning Considerations
12. In developing its Annual Business Plan the Trust has to ensure that it is aligned to the Trust’s
overarching strategic plan, the priorities set out in National Planning guidance and the
priorities set out by our local Commissioners in the emerging Sustainability and
Transformation Plan.
13. The Trust’s strategic vision and objectives are included in the diagram below;
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14. In identifying key priorities for action, Divisions were asked to ensure their key priorities align
with the strategic direction for the Trust and the wider NHS, and support of one of the following
key principles:
Support delivery of the Sustainability and Transformation Plans;
Related to existing redesign workstream (e.g. CVD, Ortho, Trauma, Stroke, Respiratory,
IV therapy, Community Services);
Support delivery of operational standards / address operational pressures or risk /
address clinical risk;
Support delivery of CIP;
Support delivery of the Trust Quality Strategy.
15. In reviewing potential priorities, account was taken of progress against schemes agreed as
part of the 2016/17 business plan (i.e. consider inclusion of schemes not delivered by end of
2016/17). Plans should also reflect delivery of key operational targets.
16. Teams were advised that the business planning processes should not be considered as a
means of bidding for new money. The aim was to set out Divisional business plans which are
financially balanced at Clinical Business Unit and departmental level. Potential service
developments or business opportunities will need to have Commissioner Support and be
funded through:
Internal service redesign to release efficiency savings.
Approval of a business including financial approval.
Securing a new funded service through competitive tender.
17. Divisions were encouraged to engage with operational teams and develop plans at
departmental and specialty level to support their alignment with wider Trust plans.
Annual Business Plan Priorities
18. Work has been undertaken with Divisional and Corporate leads to identify schemes for
inclusion in the 2017/18 Annual Business Plan, and to provide details including proposals and
quarterly milestones for each. Currently the business plan consists of 52 reporting lines; with a
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proposal to report 33 at Trust level (see section ‘Annual Business Plan Reporting’ below for
details).
19. Annual Business Plan schemes are summarised in Appendix 1, by Trust strategic objective
and in Appendix 2 by the Executive Led Group they report to. In addition they are listed in
Table 1 and Table 2 below.
20. Detailed proposals relating to each Annual Business Plan priority for 2017/18 are presented in
Appendix 3. Here details of each scheme for inclusion in the business plan are included,
noting the Division they are associated with, details of the proposal, its quarterly milestones,
reporting theme and whether the scheme will be reported at Trust or Divisional / Executive Led
Group level.
Annual Business Plan Reporting
21. The planning process for 2017/18 has focused on ensuring that the annual business plan
represents a manageable overview of Trust priorities. The aim is to give an overview of the
extent of schemes undertaken to support Trust objectives, without presenting a level of detail
that is overwhelming. In order to achieve this, and to manage the number of schemes reported
at Trust level, the following steps have been taken when developing the Annual Business
Plan:
Schemes are grouped into themes (‘Joint working’, ‘Workforce redesign’, ‘Efficiency’,
‘Clinical / Operational practice’, ‘Quality’) in order to support the interpretation of
reports.
Reporting of the Quality Strategy progress against the four high level themes included
in the strategy; ‘Care that is safe: reducing harm’, ‘Care that is safe: reducing avoidable
mortality’, ‘Care that is clinically effective’ and ‘Care that provides a positive experience
for patients and their families’ – with full progress reporting of each Quality Strategy
initiative provided through a quarterly Quality Strategy update.
Overall Quality and Efficiency Programme (QEP) progress will be reported in the
Annual Business Plan as delivery of savings against plan – with full progress reporting
delivered through the QEP programme via the Transformation Steering Group.
Where appropriate, related schemes are grouped for Trust level reporting, with detailed
progress monitored on Divisional basis – quarterly Divisional progress reports will be
produced alongside the Trust level report.
A number of schemes to be reported at Divisional and Executive Led Group level,
rather than as part of Trust level report (see Table 1 and 2 below) – as above quarterly
Divisional and Executive Led Group progress reports will be produced alongside the
Trust level report, maintaining a focus on delivery of those schemes.
22. Reporting will be undertaken on a quarterly basis. The process for completion of reports will be
largely based on that which was in place during 2016/17, in that it will rely on the reporting
lead updating on progress via a centralised template, against each scheme. The one notable
change for 2017/18 will be the additional production of Divisional level annual business plan
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quarterly update reports. This will not require any more work from those providing quarterly
update, with a smaller overall number of reporting lines seen in 2017/18.
23. Table 1 contains the 33 x Trust reported lines in the Annual Business, and Table 2 list the
further 19 x schemes that are only reported at Divisional and Executive Led Group level.
Table 1: Trust Level Reported Schemes
Theme ABP Ref Priority description
1 Proposed Merger Transaction
3 Maintain a focus on the delivery of high quality community services through collaboration with
others
15 Work with Merseycare to improve crisis care for people with mental health problems who
present to AED.
16 Collaborative working with the stroke network and other local providers in implementing new
stroke pathways
17 Contribution to Cardiology city wide service reconfiguration
18 Contribution to Respiratory and City-wide Service Reconfiguration
19 Haemato-Oncology Transfer of Services
42 North Mersey Orthopaedic & Trauma Service (MOATS)
6 Cancer Services Support - Radiology
7 IT EPR Implementation
23 AED flow measures: improving access to GP, primary care at front door, maximise patient
flow to ambulatory emergency care (combined reporting line see ABP Ref 15, 25, 26)
24 Deliver Stroke standards for all of our patients and to deliver sustainability across the clinical
teams.
45 To develop safe and sustainable Dermatology services for Aintree university Hospital in
partnership with local provider or providers
46 Improving Acute Surgery flow, in the surgical assessment unit and across the Surgical
Division.
47 To continue to reduce risks to Ophthalmology patients due to insufficient capacity to see
patients in a timely way.
14 Outpatient productivity
40 Delivery of Quality of Efficiency Programme savings against plan
49 To improve Theatre productivity and efficiency, by increasing the number of theatre sessions
running and increasing the use of theatre time in session.
2 Working collaboratively with partners across health and social care to resolve some of the
key challenges facing the Trust
36 Care that is Safe: Reducing Harm
37 Care that is Safe: Reducing Avoidable Mortality
38 Care that is Clinically Effective
39 Care That Provides a Positive Experience for Patients and their Families
41 Consideration of case for increased capacity within the Intravenous (IV) Team
50 Implementation of ‘National Guidance on Learning from Deaths’ from the National Quality
Board on structured review of deaths
51 Seven day services – Diagnostics and Support Services
52 Seven day services – Medicine
53 Seven day services – Surgery
31 People and Corporate Affairs High Impact Improvement Plan - Culture
32 People and Corporate Affairs High Impact Improvement Plan – Capacity
33 People and Corporate Affairs High Impact Improvement Plan – Competence
34 People and Corporate Affairs High Impact Improvement Plan - Communication
43 Seven Day working - Acute Surgery flow
Joint working
Quality
Workforce
Clinical /
operational
practice
Efficiency
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Table 2: Divisional Level / Executive Led Group Reported Schemes
Financial Considerations
24. Under the ‘Acting as One’ agreement, the Trust along with all other provider organisations in
the North Mersey Local Delivery System (NMLDS), have agreed a block contract for 2017/18
and 2018/19 with our four main commissioners, Liverpool CCG; South Sefton CCG (incl
Southport & Formby CCG); Knowsley CCG; and NHS England Specialised Commissioning.
25. This agreement has been put in place to support the delivery of the NMLDS plans, providing
the required financial stability for implementation of the system transformation considered
necessary to deliver a clinically and financially sustainable future, in line with the aspirations of
the Healthy Liverpool Programme and Shaping Sefton.
26. The ‘Acting as One’ financial envelope has been developed on the basis of no anticipated
changes to activity levels. In order to support this on-going monitoring will take place with
material movements reported to allow corrective action to be formulated.
27. A more detailed briefing has been circulated to senior management teams for wider
dissemination within the organisation. It is intended to help guide management and
operational teams in decision making in relation to financial management and service
developments / change, in response to changes in the contracting environment.
Implications / Impact
28. Completion of the business planning process will support the delivery of quality, finance and
workforce development across the Trust.
Theme ABP Ref Priority description
4 Divisional Orthopaedic Service Re-design
5 Hydrotherapy Pool / Facilities
20 Deliver sustainable Respiratory outpatient services in a community setting for Knowsley
CCG
8 Imaging of Stroke Patients
9 Cardiac Imaging Service
10 Inpatient Demand - Radiology
11 MCAS Sefton /Liverpool
12 Early Supported Discharge (Stroke)
13 Out of Hours MRI Imaging
25 Improving access to GP/primary care services at the ‘front door’ of the ED
26 Maximise patient flow to ambulatory emergency care
27 Implement dialysis service changes
28 Outpatients - address existing pressures through provision of capacity and redesign
48 Increasing outpatient access through exploration of advice and guidance and telephone
follow ups to reduce the number of outpatient attendances
29 Review of the medical daycase unit
30 Cardiology diagnostics utilisation service review
21 Implement medicine workforce strategy linked to medical workforce
22 Reduce pay costs from premium rate and agency sessions across Divisional footprint
44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia Division
Clinical /
operational
practice
Efficiency
Joint working
Workforce
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Conclusion
29. The annual business planning process represents an opportunity to support the organisation in
focusing on achievement of its strategic and operational objectives. The annual business
planning process for 2017/18 has focused on delivery of a list of schemes that represent
organisational priorities in achievement of these objectives.
30. Divisional and Corporate leads have provided detail related to proposed annual business plan
schemes related to their area for inclusion in the Trust business plan. The outputs from this
exercise have been collated and presented here as the Trust Annual Business Plan for
2017/18.
31. Reporting will be undertaken on a quarterly basis providing a progress update against each
scheme at Divisional and Executive Led Group, as well as Trust level.
Recommendation
32. The Council of Governors is asked to note the proposed Annual Business Plan for 2017/18 as
set out in this paper and outlined in Appendices 1 and 2
Author: Alistair Leinster, Head of Corporate Planning and Performance
Date: 9th May 2017
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Appendix 1 – List of Annual Business Plan Schemes by Strategic Objective
ABP Ref Scheme Title Executive Led Group
1 Proposed Merger Transaction HMB
15 Work with Merseycare to improve crisis care for people with mental health
problems who present to AED.
Ops and Performance
21 Implement medicine workforce strategy linked to medical workforce Workforce
24 Deliver Stroke standards for all of our patients and to deliver sustainability
across the clinical teams.
Clinical Effectiveness
27 Implement dialysis service changes Ops and Performance
32 People and Corporate Affairs High Impact Improvement Plan – Capacity Workforce
36 Care that is Safe: Reducing Harm Safety and Risk
39 Care That Provides a Positive Experience for Patients and their Families Patient Experience
41 Consideration of case for increased capacity within the Intravenous (IV)
Team
Clinical Effectiveness
44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia
Division
Workforce
45 To develop safe and sustainable Dermatology services for Aintree university
Hospital in partnership with local provider or providers
Ops and Performance
1 Proposed Merger Transaction HMB
8 Imaging of Stroke Patients Clinical Effectiveness
9 Cardiac Imaging Service Clinical Effectiveness
24 Deliver Stroke standards for all of our patients and to deliver sustainability
across the clinical teams.
Clinical Effectiveness
33 People and Corporate Affairs High Impact Improvement Plan – Competence Workforce
37 Care that is Safe: Reducing Avoidable Mortality Clinical Effectiveness
38 Care that is Clinically Effective Clinical Effectiveness
43 Seven Day working - Acute Surgery flow Ops and Performance
50 Implementation of ‘National Guidance on Learning from Deaths’ from the
National Quality Board on structured review of deaths
Clinical Effectiveness
51 Seven day services – Diagnostics and Support Services Ops and Performance
52 Seven day services – Medicine Ops and Performance
53 Seven day services – Surgery Ops and Performance
1 Proposed Merger Transaction* HMB
1. Deliver outstanding care - by being a patient-centred organisation that provides high quality, safe and compassionate
services
2. Achieve best patient outcomes - by providing effective treatment to achieve best possible patient outcomes and promote
quality of life
3. Promote research and education - by delivering the benefits of education, research and innovation for our patients and staff
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ABP Ref Scheme Title
1 Proposed Merger Transaction HMB
6 Cancer Services Support - Radiology Ops and Performance
10 Inpatient Demand - Radiology Clinical Effectiveness
13 Out of Hours MRI Imaging Ops and Performance
14 Outpatient productivity Ops and Performance
16 Collaborative working with the stroke network and other local providers in
implementing new stroke pathways
Ops and Performance
22 Reduce pay costs from premium rate and agency sessions across
Divisional footprint
Workforce
23 AED flow measures: improving access to GP, primary care at front door,
maximise patient flow to ambulatory emergency care (combined reporting
line see ABP Ref 15, 25, 26)
Ops and Performance
25 Improving access to GP/primary care services at the ‘front door’ of the ED Ops and Performance
26 Maximise patient flow to ambulatory emergency care Ops and Performance
28 Outpatients - address existing pressures through provision of capacity and
redesign
Ops and Performance
29 Review of the medical daycase unit Ops and Performance
30 Cardiology diagnostics utilisation service review Ops and Performance
40 Delivery of Quality of Efficiency Programme savings against plan Ops and Performance
46 Improving Acute Surgery flow, in the surgical assessment unit and across
the Surgical Division.
Ops and Performance
47 To continue to reduce risks to Ophthalmology patients due to insufficient
capacity to see patients in a timely way.
Safety and Risk
48 Increasing outpatient access through exploration of advice and guidance and
telephone follow ups to reduce the number of outpatient attendances
Ops and Performance
49 To improve Theatre productivity and efficiency , by increasing the number of
theatre sessions running and increasing the use of theatre time in session.
Ops and Performance
2 Working collaboratively with partners across health and social care to
resolve some of the key challenges facing the Trust
Ops and Performance
3 Maintain a focus on the delivery of high quality community services through
collaboration with others
HMB
4 Divisional Orthopaedic Service Re-design Ops and Performance
5 Hydrotherapy Pool / Facilities Ops and Performance
7 IT EPR Implementation Ops and Performance
11 MCAS Sefton /Liverpool Ops and Performance
12 Early Supported Discharge (Stroke) Ops and Performance
17 Contribution to Cardiology city wide service reconfiguration Ops and Performance
18 Contribution to Respiratory and City-wide Service Reconfiguration Ops and Performance
19 Haemato-Oncology Transfer of Services Ops and Performance
20 Deliver sustainable Respiratory outpatient services in a community setting
for Knowsley CCG
Ops and Performance
42 North Mersey Orthopaedic & Trauma Service (MOATS) Ops and Performance
31 People and Corporate Affairs High Impact Improvement Plan - Culture Workforce
34 People and Corporate Affairs High Impact Improvement Plan -
Communication
Workforce
6. Be a well-governed and clinically-led organisation - by developing and supporting effective leadership across the
organisation to enable our people to achieve our vision
4. Deliver sustainable healthcare to meet people’s needs - by delivering efficient, cost effective services to ensure their long-
term sustainability
5. Provide strong system leadership - by working together to support seamless pathways across all sectors
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Appendix 2 - List of Annual Business Plan Schemes by Executive Led Group
ABP
Ref Scheme Title Division
Trust
Reported
8 Imaging of Stroke PatientsDiagnostics and
SupportN
9 Cardiac Imaging ServiceDiagnostics and
SupportN
10 Inpatient Demand - RadiologyDiagnostics and
SupportN
24 Deliver Stroke standards for all of our patients and to deliver sustainability across the clinical teams. Medicine Y
37 Care that is Safe: Reducing Avoidable MortalityMedical Dir /
Nurse DirY
38 Care that is Clinically EffectiveMedical Dir /
Nurse DirY
41 Consideration of case for increased capacity within the Intravenous (IV) Team Medical Dir /
Nurse DirY
50Implementation of ‘National Guidance on Learning from Deaths’ from the National Quality Board on
structured review of deaths
Medical Dir /
Nurse DirY
1 Proposed Merger Transaction Corporate Y
3 Maintain a focus on the delivery of high quality community services through collaboration with othersCorporate
Y
2Working collaboratively with partners across health and social care to resolve some of the key
challenges facing the TrustCorporate Y
4 Divisional Orthopaedic Service Re-designDiagnostics and
SupportN
5 Hydrotherapy Pool / FacilitiesDiagnostics and
SupportN
6 Cancer Services Support - RadiologyDiagnostics and
SupportY
7 IT EPR ImplementationDiagnostics and
SupportY
11 MCAS Sefton /LiverpoolDiagnostics and
SupportN
12 Early Supported Discharge (Stroke)Diagnostics and
SupportN
13 Out of Hours MRI ImagingDiagnostics and
SupportN
14 Outpatient productivityDiagnostics and
SupportY
15Work with Merseycare to improve crisis care for people with mental health problems who present to
AED. Medicine Y
16Collaborative working with the stroke network and other local providers in implementing new stroke
pathwaysMedicine Y
17 Contribution to Cardiology city wide service reconfiguration Medicine Y
18 Contribution to Respiratory and City-wide Service Reconfiguration Medicine Y
19 Haemato-Oncology Transfer of Services Medicine Y
20 Deliver sustainable Respiratory outpatient services in a community setting for Knowsley CCG Medicine N
23AED flow measures: improving access to GP, primary care at front door, maximise patient flow to
ambulatory emergency care (combined reporting line see ABP Ref 15, 25, 26)Medicine Y
25 Improving access to GP/primary care services at the ‘front door’ of the ED Medicine N
26 Maximise patient flow to ambulatory emergency care Medicine N
27 Implement dialysis service changes Medicine N
Clinical Effectiveness (8 annual business plan reporting lines)
HMB ( 2 annual business plan reporting lines)
Ops and Performance (32 annual business plan reporting lines)
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ABP
Ref Scheme Title Division
Trust
Reported
28 Outpatients - address existing pressures through provision of capacity and redesign Medicine N
29 Review of the medical daycase unit Medicine N
30 Cardiology diagnostics utilisation service review Medicine N
40 Delivery of Quality of Efficiency Programme savings against plan Corporate Y
42 North Mersey Orthopaedic & Trauma Service (MOATS) Surgery Y
43 Seven Day working - Acute Surgery flow Surgery Y
45To develop safe and sustainable Dermatology services for Aintree university Hospital in partnership
with local provider or providers Surgery Y
46 Improving Acute Surgery flow, in the surgical assessment unit and across the Surgical Division. Surgery Y
48Increasing outpatient access through exploration of advice and guidance and telephone follow ups to
reduce the number of outpatient attendances Surgery N
49To improve Theatre productivity and efficiency , by increasing the number of theatre sessions running
and increasing the use of theatre time in session. Surgery Y
51 Seven day services – Diagnostics and Support ServicesDiagnostics and
SupportY
52 Seven day services – Medicine Medicine Y
53 Seven day services – Surgery Surgery Y
39 Care That Provides a Positive Experience for Patients and their FamiliesMedical Dir /
Nurse DirY
36 Care that is Safe: Reducing HarmMedical Dir /
Nurse DirY
47To continue to reduce risks to Ophthalmology patients due to insufficient capacity to see patients in a
timely way.Surgery Y
21 Implement medicine workforce strategy linked to medical workforce Medicine N
22 Reduce pay costs from premium rate and agency sessions across Divisional footprint Medicine N
31 People and Corporate Affairs High Impact Improvement Plan - Culture People and OD Y
32 People and Corporate Affairs High Impact Improvement Plan – Capacity People and OD Y
33 People and Corporate Affairs High Impact Improvement Plan – Competence People and OD Y
34 People and Corporate Affairs High Impact Improvement Plan - Communication People and OD Y
44 Multi- Disciplinary workforce developments in the Surgical and Anaesthesia Division Surgery N
Workforce Executive Led Group (7 annual business plan reporting lines)
Patient Experience Executive Led Group (1 annual business plan reporting line)
Safety and Risk Executive Led Group ( 2 annual business plan reporting lines)
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Agenda Item (Ref) CG17-18/006 Date of Meeting: 15 June 2017
Report to Council of Governors
Report Title Directors Dragons Den – Review of approved schemes
Executive Lead Sue Green, director People & Corporate Affairs
Lead Officer Ruth Hoyte, Associate Director OD
Action Required To review & agree any actions arising
Substantial assurance
High level of confidence
in delivery of existing
mechanisms / objectives
Acceptable
assurance
General confidence
in delivery of existing
mechanisms/
objectives
Partial assurance
Some confidence in
delivery of existing
mechanisms /
objectives
No
assurance
No
confidence
in delivery
Key Messages of this Report (2/3 headlines only)
Provides a summary of schemes approved by Director Dragons Den
Outlines investment to date and completed schemes
Indicates benefits including return on investment, benefits and areas for improvement
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must
accompany the report)
Strategy Policy Service Change
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance (is the report a……?)
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for Board submission required:
Next Steps (actions following agreement by Board/Committee of recommendation/s)
To identify further reporting arrangements
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REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of key issues raised and actions
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Directors Dragons Den – Review of approved schemes
Executive Summary
1. This report provides a summary of schemes which have been supported through Directors
Dragons Den since its inception in October 2014. It focusses only on those bids which
approved and provides an update on progress of the schemes. The report also outlines
returns on investment, benefits, learning points and areas to improve.
Key Issues / Proposal
2. The Directors Dragons Den (DDD) was created as a concept in October 2014 following
feedback from Listening into Action and other staff engagement the some improvements
require “start - up money” and there was commitment from the executive team at the time to
establish a process for this.
3. The DDD has evolved since then and is now composed of the Executive Team, Associate
Director OD, a non-executive Director and representative of the Academic healthcare
Science Network. The process is organised and supported by OD.
4. There are two rounds of DDD in each financial year when staffs at all levels are encouraged
to bid for financial support to support an improvement or innovation in their areas. There
are 6 steps to the process:
- Submission of proposal
- Shortlisting
- Presentation to the DDD
- Award of financial support and allocation of “Dragon”
- Completion of scheme
- Poster presentation
5. Staff or teams can bid for up to £25k including VAT for their idea and £250k is ring-fenced
for each round per year.
6. Bids are received from staff of all levels and representative of all roles in the organisation.
Summary of successful schemes
7. Appendix 1 provides an overview of all the approved schemes, funding allocated and
funding spent from October 2014 until the most recent DDD in March 2017.
8. Since October 2014 35 schemes have been approved with a total of £419k allocated to
support the schemes. The smallest amount allocated was £540 and some bids have been
allocated the full amount of £25k for their proposal.
9. The table indicates that 17 bids are fully completed, 13 are partially completed, 5 haven’t
started yet and 1 scheme has been withdrawn.
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10. Of the £419k allocated within the DDD £171k has been spent. This is due to numerous
reasons including bidders have spent less than allocated, some schemes have not yet
started and some have withdrawn. Also in allocating funds the DD will often commit to
funding up to a sum of money conditional on certain outcomes or delivery. Some bids will
not have been fully financially modelled so on occasions will require less or more to deliver.
There is flexibility to support this but the limit of £25k cannot be exceeded.
Benefits of DDD
11. A short summary of return on investment for the completed schemes is included in the
appendix 1. Returns can either be quantitative such as having financial or performance
benefit or qualitative in terms of patient experience or staff experience.
12. The benefits of DDD to our patients and staff are much wider and broader. The principles of
DDD help to deliver the trust mission, vision and values. Each of the schemes will meet at
least one of the strategic aims and supports the common purpose of “getting it right for
every patient every time”.
13. Benefits of the schemes to our patients will include:
- Delivering safer care
- Enhancing care or patient experience
- Improving access to services
- Reducing length of stay
- Preventing admission
- Reducing risks e.g. IPC
- Improving communication
14. In addition there are numerous benefits to staff:
- Encouraging a culture of improvement and generating ideas from frontline staff
- Developing proposals without the need to develop formal business cases
- Support to present and sell ideas
- Opportunity to meet and engage with executive
- Developing confidence that ideas will be held
- Developing financial awareness
- Project planning
- Use of improvement methodologies
Learning points & areas to improve
15. Each round of DDD has been a learning experience and it has evolved responding to
changes to the executive team and the needs of the organisation. Since it was conceived
other development such as AQUIS and QEP have emerge. DDD has been linked to these.
For example the DDD & AQUIS showcase events are now aligned and are one event to
celebrate success of either. Consistency in improvement methodologies and project
planning is encouraged.
16. Some proposals are easier to implement than others and the success of the schemes can
be influenced by factors other than finance. For the future more robust tracking of schemes
is required and consistency of support needs to be addressed.
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17. The process for allocation of funds has become easier and more transparent but further
review is needed to ensure funds are deployed successfully and meet the needs of the
scheme.
18. Where schemes are delayed there needs to be a clear decision making process on the
duration of the offer of funding support to avoid the process being open ended.
Implications / Impact
Quality – DDD has demonstrated a positive impact on quality both in terms of patient care and
experience
Finance –Positive impact of small non-recurring investment on patient and staff experience
Workforce – positive impact on staff engagement particularly in feeling valued and supported.
Promotes team working and innovation and learning.
Conclusion
19. In summary DDD has demonstrated that a relatively small financial commitment can result
in significant patient and staff benefits. There is also benefit for the organisation in
promoting innovation and improvement as well as reputation. DDD requires an approach of
continuous improvement to ensure its continued success including review of schemes and
ensuring delivery and return on investment.
Recommendation
20. It is recommended DDD continues to operate with 2 windows in the year for staff to bid for
non-recurring funds to support improvements
References and further reading
Author: Ruth Hoyte, Associate Director OD
Date: 2nd June 2017
3.
CG
17-1
8/00
6 -
Dire
ctor
s D
rago
ns’ D
en -
Inno
vatio
ns A
ppro
ved
Page 32 of 78
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29
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Page 34 of 78
1/2
Lead Governors Report
Report to Council of Governors
Date 15 June 2017
Committee Name Council of Governors
Chair’s Name & Title Pamela Peel, Lead Governor
Core Governor Activity
Attendance at Board meetings and Board Feedback sessions with the Chairman
Appraisals of the Non Executive Directors including the Chairman
Quality Accounts
Director Walkabouts
Quality of Care Committee
Membership Committee
Quarterly Informal Council of Governors – the meeting on 6 June was chaired by Lorraine Heaton
Governor Development
Media Awareness Session led by Fin McNicol, 3 April – attended by 10 Governors
Serious Incidents Session, led by Tristan Cope, 8 May – attended by 11 Governors
Wider Trust Activity
Staff Induction each month – Staff Governors are taking it in turn to make a brief presentation on
membership to new staff on their first day in the Trust
Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members
from amongst people who are already committed to the Trust, and also to engage with them, hear
their ‘stories’ and recognise the contribution they make to the smooth running of the hospital.
Workstream – Tony Kneebone continues to be involved in the Catering Food Quality Group. At the
last meeting the cost of patient meals was discussed. Aintree is in the middle range of costs
compared to other hospitals, spending £10 per day per patient, this figure includes food, staff and all
the associated costs. The Group then tasted the four full meals on offer that evening and discussed
the quality, they made some suggestions to improve things but generally were satisfied with the
menu.
PLACE Validation – Sharon Bird was a member of the team that undertook a review on 27 April 2017
External Activity
Healthwatch Sefton, 29 March – Pam Peel attended. A useful networking opportunity, particularly
interesting was the demo of the new online feedback centre, and how it is used to identify trends and
themes. There was a presentation by Southport & Ormskirk Hospital senior management team on
progress with their CQC report
Edge Hill Return to Nurse Practice Programme – Pam Peel attended a Seminar presentation on 20
April as a follow-up to the interview panel she participated in last November. The presentations take
the form of a 15 minute reflection on a critical incident from practice or taught session which the
5. C
G17
-18/
008
- Le
ad G
over
nor
Rep
ort
Page 35 of 78
Aintree University Hospital NHS Foundation Trust
2/2
student finds surprising, disturbing or puzzling. All were thought provoking. Pam Peel also attended
a networking lunch with the Nursing and Midwifery Council on 26 April when the assessment team
visited Aintree to speak with Return to Practice students and their mentors to evaluate their overall
experience.
Meeting with Shadow Lead Governor RLBUHT, 27 April
Lead Governor Network – topics under discussion include Governor Expenses and the
length/number of terms Governors are permitted to serve.
Recommendation
The Council of Governors is asked to note the report.
Page 36 of 78
Co
un
cil o
f G
ov
ern
ors
15 J
un
e2017
6 &
7. C
G17
-18/
009
& 0
10 -
Ass
uran
ce o
n K
ey In
dica
tors
: Qua
lity
& S
afet
y; F
inan
ce &
Per
form
ance
; A
udit
Page 37 of 78
Str
ate
gic
Up
da
te
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intr
ee
/Roya
l Liv
erp
ool m
erg
er
•C
are
Qualit
y C
om
mis
sio
n I
nspe
ctio
n
Page 38 of 78
Key A
rea
s o
f A
ssu
ran
ce
Inte
rnal
Syste
m o
f C
on
tro
l (A
ud
it)
Tim
Jo
hn
sto
n, N
on
Execu
tive D
irecto
r
Key
Are
as
of
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cu
sO
n-g
oin
gA
ssu
ran
ce
As
su
ran
ce
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ug
ht
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are
as
of
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ncern
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Assura
nce F
ram
ew
ork
2017-1
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Bank,agency a
nd locum
sta
ffS
afe
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ing
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ll
Annual A
ccounts
Appro
val and
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rnal A
udit
Losses &
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pensations
Reduction in o
vera
ll score
report
ed
for
Info
rmation G
overn
ance
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rnal A
udit -
Annual R
eport
and F
utu
re W
ork
pla
n
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st P
olic
y C
om
plia
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rnal A
udit R
eport
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afe
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ayro
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andato
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rain
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r F
raud A
nnual R
eport
and
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ork
pla
n
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rmation G
overn
ance A
nnual
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6 &
7. C
G17
-18/
009
& 0
10 -
Ass
uran
ce o
n K
ey In
dica
tors
: Qua
lity
& S
afet
y; F
inan
ce &
Per
form
ance
; A
udit
Page 39 of 78
Qu
ality
& P
erf
orm
an
ce
Ma
na
ge
me
nt
As
su
ran
ce o
n K
ey I
nd
ica
tors
Kevan
Ryan
, N
on
Execu
tive D
irecto
r
Jo
an
ne C
lag
ue, N
on
Execu
tive D
irecto
r
Page 40 of 78
Key A
reas
of
Ass
ura
nce
Qu
ality
& S
afe
ty
Key
Are
as
of
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cu
sO
n-g
oin
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ssu
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ce
As
su
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ce
so
ug
ht
on
are
as
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nc
ern
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ncid
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eport
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pact
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cute
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Pre
ssure
son S
afe
ty &
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of
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Modifie
d E
arly W
arn
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m (
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WS
)
Pra
ctice,
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vem
ent
&
Lessons L
earn
ed
Ophth
alm
olo
gy
Medic
ines M
anag
em
ent
Patient experience
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C I
nspection –
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vem
ent
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n
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trate
gy 2
01
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fection P
revention &
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ol
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ES–
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r A
ccess
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k R
egis
ter
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tree A
ssessm
ent &
Accre
ditation F
ram
ew
ork
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6 &
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G17
-18/
009
& 0
10 -
Ass
uran
ce o
n K
ey In
dica
tors
: Qua
lity
& S
afet
y; F
inan
ce &
Per
form
ance
; A
udit
Page 41 of 78
Leg
en
d
Ind
icato
rT
ren
d
On
Targ
et
On
ta
rget
and im
pro
vin
g
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arg
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ut
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et
Off targ
et,
but
impro
vin
g
Off ta
rget,
no c
hange
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et
and
dete
riora
ting
Page 42 of 78
Cli
nic
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dic
ato
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TA
RG
ET
2016-1
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ithin
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ey In
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tors
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lity
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afet
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Page 43 of 78
Key A
reas
of
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ura
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an
ce
& P
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orm
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yA
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cute
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eep D
ives:
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iagnostic &
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Page 44 of 78
Fin
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Page 45 of 78
Acc
ess
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Page 46 of 78
Acc
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-18/
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Ass
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ey In
dica
tors
: Qua
lity
& S
afet
y; F
inan
ce &
Per
form
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; A
udit
Page 47 of 78
Wo
rkfo
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Page 48 of 78
ww
w.p
wc.
co.u
k
Ain
tre
eU
niv
er
sit
yH
os
pit
al
NH
SF
ou
nd
ati
on
Tr
us
tQ
ua
lity
Rep
ort
20
16/1
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ove
rnm
ent
an
dP
ub
lic
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tor
Ma
y2
017
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G17
-18/
011
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wC
Lon
g F
orm
Rep
ort (
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erna
l Ass
uran
ce o
n Q
A)
Page 49 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C
Co
nte
nts
Ba
ck
gr
ou
nd
an
ds
co
pe
1
Su
mm
ar
yo
ffi
nd
ing
s3
De
tail
ed
fin
din
gs
5
Ap
pe
nd
ice
s11
Ap
pe
nd
ixA
:M
att
er
sa
ris
ing
fro
mo
ur
lim
ite
da
ss
ur
an
ce
re
vie
wo
fth
eF
ou
nd
ati
on
Tr
us
t’s
20
16/1
7Q
ua
lity
Re
po
rt:
Pe
rfo
rm
an
ce
ind
ica
tor
s12
Sc
op
eo
fth
isw
or
k
We
ha
vep
erfo
rmed
this
wo
rkin
acc
ord
an
cew
ith
the
NH
SF
ou
nd
ati
on
Tru
stA
nn
ua
lR
epo
rtin
gM
an
ua
l(“
FT
AR
M”)
an
dth
e“D
eta
iled
req
uir
emen
tsfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”is
sued
by
Mo
nit
or
(op
era
tin
ga
sN
HS
Imp
rove
men
t)(“
NH
SI”
).
Rep
ort
sa
nd
lett
ers
pre
pa
red
by
exte
rna
la
ud
ito
rsa
nd
ad
dre
ssed
tog
ove
rno
rs,
dir
ecto
rso
ro
ffic
ers
are
pre
pa
red
for
the
sole
use
of
the
NH
SF
ou
nd
ati
on
Tru
st,
an
dn
ore
spo
nsi
bil
ity
ista
ken
by
au
dit
ors
toa
ny
go
vern
or,
dir
ecto
ro
ro
ffic
erin
thei
rin
div
idu
al
cap
aci
ty,
or
toa
ny
thir
dp
art
y.T
he
ma
tter
sra
ised
inth
isre
po
rta
reo
nly
tho
sew
hic
hh
av
eco
me
too
ur
att
enti
on
ari
sin
gfr
om
or
rele
van
tto
ou
rw
ork
tha
tw
eb
elie
ve
nee
dto
be
bro
ug
ht
toyo
ur
att
enti
on
.T
hey
are
no
ta
com
pre
hen
sive
reco
rdo
fa
llth
em
att
ers
ari
sin
g,
an
din
pa
rtic
ula
rw
eca
nn
ot
be
hel
dre
spo
nsi
ble
for
rep
ort
ing
all
risk
sin
you
rb
usi
nes
so
ra
llin
tern
al
con
tro
lw
eak
nes
ses.
Th
isre
po
rth
as
bee
np
rep
are
dso
lely
for
you
ru
sein
acc
ord
an
cew
ith
the
term
so
fo
ur
eng
ag
emen
tle
tter
da
ted
19A
pri
l2
017
an
dfo
rn
oo
ther
pu
rpo
sea
nd
sho
uld
no
tb
eq
uo
ted
inw
ho
leo
rin
pa
rtw
ith
ou
to
ur
pri
or
wri
tten
con
sen
t.N
ore
spo
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ity
toa
ny
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dp
art
yis
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epte
da
sth
ere
po
rth
as
no
tb
een
pre
pa
red
for,
an
dis
no
tin
ten
ded
for,
an
yo
ther
pu
rpo
se.
Co
nte
nts
Page 50 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C1
Ba
ckg
rou
nd
NH
Sfo
un
da
tio
ntr
ust
sa
rere
qu
ired
top
rep
are
an
dp
ub
lish
aQ
ua
lity
Rep
ort
each
yea
r.T
he
Qu
ali
tyR
epo
rth
as
tob
ep
rep
are
din
acc
ord
an
cew
ith
the
NH
SF
ou
nd
ati
on
Tru
stA
nn
ua
lR
epo
rtin
gM
an
ua
l(“
FT
AR
M”)
an
dth
e“D
eta
iled
req
uir
emen
tsfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”is
sued
by
Mo
nit
or
(op
era
tin
ga
sN
HS
Imp
rove
men
t)(“
NH
SI”
).
As
you
ra
ud
ito
rs,
we
are
req
uir
edto
un
der
tak
ew
ork
on
you
rQ
ua
lity
Rep
ort
un
der
NH
SI’
s“D
eta
iled
req
uir
emen
tsfo
rex
tern
al
ass
ura
nce
for
qu
ali
tyre
po
rts
for
fou
nd
ati
on
tru
sts
20
16/1
7”
(‘th
ed
eta
iled
gu
ida
nce
’)w
hic
hw
as
pu
bli
shed
inF
ebru
ary
20
17.
Th
ep
urp
ose
of
this
rep
ort
isto
pro
vid
eth
eC
ou
nci
lo
fG
ove
rno
rso
fA
intr
eeU
niv
ersi
tyH
osp
ita
lN
HS
Fo
un
da
tio
nT
rust
(“th
eT
rust
”)w
ith
ou
rfi
nd
ing
sa
nd
reco
mm
end
ati
on
sfo
rim
pro
vem
ents
,in
acc
ord
an
cew
ith
NH
SI’
sre
qu
irem
ents
.It
isre
ferr
edto
by
NH
SI
as
the
“Go
vern
ors
rep
ort
”.
Sco
pe
of
ou
rw
ork
We
are
req
uir
edb
yN
HS
Ito
revi
ewth
eco
nte
nt
of
the
20
16/1
7Q
ua
lity
Rep
ort
,te
stth
ree
per
form
an
cein
dic
ato
rsa
nd
pro
du
cetw
ore
po
rts:
L
imit
eda
ssu
ran
cere
po
rt:
Th
isre
po
rtis
afo
rma
ld
ocu
men
tth
at
req
uir
esu
sto
con
clu
de
wh
eth
era
nyt
hin
gh
as
com
eto
ou
ra
tten
tio
nth
at
wo
uld
lea
du
sto
bel
iev
eth
at:
oT
he
Qu
ali
tyR
epo
rtd
oes
no
tin
corp
ora
teth
em
att
ers
req
uir
edto
be
rep
ort
edo
na
ssp
ecif
ied
inth
eF
TA
RM
an
dth
e“D
eta
iled
req
uir
emen
tsfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”;
oT
he
Qu
ali
tyR
epo
rtis
no
tco
nsi
sten
tin
all
ma
teri
al
asp
ects
wit
hso
urc
ed
ocu
men
tssp
ecif
ied
by
NH
SI;
an
d
oT
he
spec
ifie
din
dic
ato
rsh
ave
no
tb
een
pre
pa
red
ina
llm
ate
ria
lre
spec
tsin
acc
ord
an
cew
ith
the
crit
eria
set
ou
tin
the
FT
AR
Ma
nd
the
“Det
ail
edre
qu
irem
ents
for
exte
rna
la
ssu
ran
cefo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”.
Ali
mit
eda
ssu
ran
ceen
ga
gem
ent
isle
ssin
sco
pe
tha
na
rea
son
ab
lea
ssu
ran
ceen
ga
gem
ent
(su
cha
sth
eex
tern
al
au
dit
of
acc
ou
nts
).T
he
na
ture
,ti
min
ga
nd
exte
nt
of
pro
ced
ure
sfo
rg
ath
erin
gsu
ffic
ien
ta
pp
rop
ria
teev
iden
cea
red
elib
era
tely
lim
ited
com
pa
red
toa
rea
son
ab
lea
ssu
ran
ceen
ga
gem
ent.
G
ove
rno
rsre
po
rt:
Ap
riva
tere
po
rto
nth
eo
utc
om
eo
fo
ur
wo
rkth
at
ism
ad
ea
vail
ab
leto
the
Tru
st’s
Go
vern
ors
an
dto
NH
SI.
Ou
rli
mit
eda
ssu
ran
cere
po
rtis
rest
rict
ed,
as
req
uir
edb
yN
HS
I,to
the
con
ten
to
fth
eQ
ua
lity
Rep
ort
an
dtw
op
erfo
rma
nce
ind
ica
tors
on
ly.
Th
eG
ove
rno
rsre
po
rtco
vers
all
of
ou
rw
ork
an
d,
ther
efo
re,
the
thir
dlo
cal
ind
ica
tor
wh
ich
isch
ose
nb
yth
eG
ove
rno
rs.
Ba
ck
gr
ou
nd
an
ds
co
pe
8. C
G17
-18/
011
- P
wC
Lon
g F
orm
Rep
ort (
Ext
erna
l Ass
uran
ce o
n Q
A)
Page 51 of 78
Ain
tree
Univ
ers
ity
HospitalN
HS
Foundation
Tru
st
Pw
C2
Co
nte
nt
of
the
Qu
ali
tyR
epo
rtW
ea
rere
qu
ired
tois
sue
ali
mit
eda
ssu
ran
cere
po
rtin
rela
tio
nto
the
con
ten
to
fyo
ur
Qu
ali
tyR
epo
rt.
Th
isin
vo
lves
:
R
evie
win
gth
eco
nte
nt
of
the
Qu
ali
tyR
epo
rta
ga
inst
the
req
uir
emen
tso
fN
HS
I’s
pu
bli
shed
gu
ida
nce
,a
ssp
ecif
ied
inth
eF
TA
RM
an
dth
e“D
eta
iled
req
uir
emen
tsfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”a
nd
R
evie
win
gth
eco
nte
nt
of
the
Qu
ali
tyR
epo
rtfo
rco
nsi
sten
cyw
ith
the
sou
rce
do
cum
ents
spec
ifie
db
yN
HS
Iin
the
det
ail
edg
uid
an
ce.
Per
form
an
cein
dic
ato
rsW
ea
rere
qu
ired
tois
sue
ali
mit
eda
ssu
ran
cere
po
rtin
resp
ect
of
two
ou
to
fth
eth
ree
ind
ica
tors
for
acu
ten
ati
on
al
pri
ori
tyin
dic
ato
rssp
ecif
ied
by
NH
SI
inth
eir
det
ail
edg
uid
an
ce.
Th
ein
dic
ato
rsfo
rth
eye
ar
end
ed3
1M
arc
h2
017
wh
ich
wer
ech
ose
nb
yth
eg
ove
rno
rsa
nd
sub
ject
too
ur
lim
ited
ass
ura
nce
(th
e“s
pec
ifie
din
dic
ato
rs”)
are
ma
rked
wit
hth
esy
mb
ol
inth
eQ
ua
lity
Rep
ort
an
dco
nsi
sto
f:
Sp
ec
ifie
dIn
dic
ato
rs
Sp
ec
ifie
din
dic
ato
rs
cr
ite
ria
(Mo
nit
or
sD
eta
ile
d
Gu
ida
nc
e)
Per
cen
tag
eo
fin
com
ple
te
pa
thw
ays
wit
hin
18w
eek
sfo
r
pa
tien
tso
nin
com
ple
tep
ath
wa
ys
at
the
end
of
the
rep
ort
ing
per
iod
An
nex
c–
Pa
ge
19
Per
cen
tag
eo
fp
ati
ents
wit
ha
tota
l
tim
ein
A&
Eo
ffo
ur
ho
urs
or
less
fro
ma
rriv
al
toa
dm
issi
on
,tr
ansf
er
or
dis
cha
rge
An
nex
C–
Pa
ge
20
Ou
rp
roce
du
res
incl
ud
ed:
o
bta
inin
ga
nu
nd
erst
an
din
go
fth
ed
esig
na
nd
op
era
tio
no
fth
eco
ntr
ols
inp
lace
inre
lati
on
toth
eco
lla
tio
na
nd
rep
ort
ing
of
the
spec
ifie
din
dic
ato
rs,
incl
ud
ing
con
tro
lso
ver
thir
dp
art
yin
form
ati
on
(if
ap
pli
cab
le)
an
dp
erfo
rmin
gw
alk
thro
ug
hs
toco
nfi
rmo
ur
un
der
sta
nd
ing
;
b
ase
do
no
ur
un
der
sta
nd
ing
,a
sses
sin
gth
eri
sks
tha
tth
ep
erfo
rma
nce
ag
ain
stth
esp
ecif
ied
ind
ica
tors
ma
yb
em
ate
ria
lly
mis
sta
ted
an
dd
eter
min
ing
the
na
ture
,ti
min
ga
nd
exte
nt
of
furt
her
pro
ced
ure
s;
m
ak
ing
enq
uir
ies
of
rele
van
tm
an
ag
emen
t,p
erso
nn
ela
nd
,w
her
ere
leva
nt,
thir
dp
art
ies;
co
nsi
der
ing
sig
nif
ica
nt
jud
gm
ents
ma
de
by
the
Tru
stin
pre
pa
rati
on
of
the
spec
ifie
din
dic
ato
rs;
an
d
p
erfo
rmin
gli
mit
edte
stin
g,
on
ase
lect
ive
ba
sis
of
evid
ence
sup
po
rtin
gth
ere
po
rted
per
form
an
cein
dic
ato
rs,
an
da
sses
sin
gth
ere
late
dd
iscl
osu
re.
Lo
cal
ind
ica
tor
We
are
als
ore
qu
ired
tou
nd
erta
ke
sub
sta
nti
ve
sam
ple
test
ing
of
on
efu
rth
erlo
cal
ind
ica
tor.
Th
isin
dic
ato
ris
no
tin
clu
ded
ino
ur
lim
ited
ass
ura
nce
rep
ort
.In
stea
d,
we
are
req
uir
edto
pro
vid
ea
det
ail
edre
po
rto
no
ur
fin
din
gs
an
dre
com
men
da
tio
ns
for
imp
rove
men
tsin
this
,o
ur
Go
ver
no
rsre
po
rt.
Th
eT
rust
’sG
ove
rno
rsse
lect
the
ind
ica
tor
tob
esu
bje
ctto
ou
rsu
bst
an
tive
sam
ple
test
ing
.T
he
ind
ica
tor
sele
cted
is:
Per
cen
tag
eo
fp
ati
ent
safe
tyin
cid
ence
sth
at
resu
ltin
sev
ere
ha
rmo
rd
eath
.
Page 52 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C3
Co
nte
nt
of
the
Qu
ali
tyR
epo
rt
No
issu
esh
ave
com
eto
ou
ra
tten
tio
nth
at
lea
du
sto
bel
ieve
tha
tth
eQ
ua
lity
Rep
ort
do
esn
ot
inco
rpo
rate
the
ma
tter
sre
qu
ired
tob
ere
po
rted
on
as
spec
ifie
din
the
FT
AR
Ma
nd
the
“Det
ail
edre
qu
irem
ents
for
qu
ali
tyre
po
rts
for
fou
nd
ati
on
tru
sts
20
16/1
7”:
Lim
ite
dA
ss
ur
an
ce
Re
po
rt
As
are
sult
of
ou
rw
ork
,w
ea
rea
ble
top
rov
ide
an
un
qu
ali
fied
lim
ited
ass
ura
nce
rep
ort
inre
spec
to
fth
eco
nte
nt
of
the
Qu
ali
tyR
epo
rt.
Co
nsi
sten
cyw
ith
Oth
erIn
form
ati
on
No
issu
esh
ave
com
eto
ou
ra
tten
tio
nth
at
lea
du
sto
bel
ieve
tha
tth
eQ
ua
lity
Rep
ort
isn
ot
con
sist
ent
wit
hth
eo
ther
info
rma
tio
nso
urc
esd
efin
edb
yN
HS
I’s
“Det
ail
edre
qu
irem
ents
for
qu
ali
tyre
po
rts
for
fou
nd
ati
on
tru
sts
20
16/1
7
Lim
ite
dA
ss
ur
an
ce
Re
po
rt
As
are
sult
of
ou
rw
ork
,w
ea
rea
ble
top
rov
ide
an
un
qu
ali
fied
lim
ited
ass
ura
nce
rep
ort
inre
spec
to
fth
eco
nsi
sten
cyo
fth
eQ
ua
lity
Rep
ort
wit
hth
eD
eta
iled
req
uir
emen
tfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
.
Sel
ecte
dP
erfo
rma
nce
ind
ica
tors
Ou
rfi
nd
ing
sre
lati
ng
toth
ep
erfo
rma
nce
ind
ica
tors
are
sum
ma
rise
da
sfo
llo
ws:
Su
mm
ar
yo
ffi
nd
ing
s
8. C
G17
-18/
011
- P
wC
Lon
g F
orm
Rep
ort (
Ext
erna
l Ass
uran
ce o
n Q
A)
Page 53 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C4
Pe
rfo
rm
an
ce
ind
ica
tor
sin
clu
de
din
ou
rli
mit
ed
as
su
ra
nc
er
ep
or
tF
ind
ing
s
Per
cen
tag
eo
fin
com
ple
tep
ath
wa
ysw
ith
in18
wee
ks
for
pa
tien
tso
nin
com
ple
tep
ath
wa
ysa
tth
een
do
fth
ere
po
rtin
gp
erio
d
On
eis
sue
iden
tifi
ed;
No
imp
act
on
ou
rli
mit
eda
ssu
ran
ceo
pin
ion
.
Per
cen
tag
eo
fp
ati
ents
wit
ha
tota
lti
me
inA
&E
of
fou
rh
ou
rso
rle
ssfr
om
arr
iva
lto
ad
mis
sio
n,
tra
nsf
ero
rd
isch
arg
e
No
issu
esid
enti
fied
.
Lim
ite
dA
ss
ur
an
ce
Re
po
rt
As
ar
es
ult
of
ou
rw
or
k,
we
ar
ea
ble
top
ro
vid
ea
nu
nq
ua
lifi
ed
lim
ite
da
ss
ur
an
ce
re
po
rt
inr
es
pe
ct
of
the
ma
nd
ate
dp
er
for
ma
nc
ein
dic
ato
rs
.
Pe
rfo
rm
an
ce
ind
ica
tor
no
tin
clu
de
dw
ith
ino
ur
lim
ite
da
ss
ur
an
ce
re
po
rt
Fin
din
gs
Per
cen
tag
eo
fp
ati
ent
safe
tyin
cid
ence
sth
at
resu
ltin
seve
reh
arm
or
dea
th.
No
issu
esid
enti
fied
.
An
nu
al
Go
ver
na
nce
Sta
tem
ent
We
iden
tifi
edn
ois
sues
rele
van
tto
the
Qu
ali
tyR
epo
rt.
Page 54 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C5
Rev
iew
ag
ain
stth
eco
nte
nt
req
uir
emen
tsW
ere
view
edth
eco
nte
nt
of
the
Qu
ali
tyR
epo
rta
ga
inst
the
con
ten
tre
qu
irem
ents
wh
ich
are
spec
ifie
din
the
FT
AR
Ma
nd
the
“Det
ail
edre
qu
irem
ents
for
qu
ali
tyre
po
rts
for
fou
nd
ati
on
tru
sts
20
16/1
7”.
No
issu
esca
me
too
ur
att
enti
on
tha
tle
du
sto
bel
iev
eth
at
the
Qu
ali
tyR
epo
rth
as
no
tb
een
pre
pa
red
inli
ne
wit
hth
eF
TA
RM
an
dth
e“D
eta
iled
req
uir
emen
tsfo
rq
ua
lity
rep
ort
sfo
rfo
un
da
tio
ntr
ust
s2
016
/17
”.
Rev
iew
con
sist
ency
ag
ain
stsp
ecif
ied
sou
rce
do
cum
ents
At
the
tim
eo
fw
riti
ng
this
do
cum
ent,
we
wer
ein
the
pro
cess
of
fin
ali
sin
gth
isw
ork
.T
he
item
sli
sted
bel
ow
are
the
key
do
cum
ents
tha
tw
eh
av
e/
are
rev
iew
ing
toch
eck
the
con
ten
to
fth
e2
016
/17
Qu
ali
tyR
epo
rtfo
rco
nsi
sten
cya
ga
inst
.T
hes
ea
reso
urc
ed
ocu
men
tssp
ecif
ied
by
NH
SI.
We
wil
lp
rovi
de
you
wit
ha
nu
pd
ate
on
19M
ay.
B
oa
rdm
inu
tes
for
the
per
iod
Ap
ril
20
16a
nd
up
toM
arc
h2
017
;
P
ap
ers
rela
tin
gto
Qu
ali
tyre
po
rted
toth
eB
oa
rdo
ver
the
per
iod
Ap
ril
20
16to
the
da
teo
fsi
gn
ing
the
lim
ited
ass
ura
nce
rep
ort
;
F
eed
ba
ckfr
om
the
Co
mm
issi
on
ers,
So
uth
Sef
ton
CC
Gd
ate
d17
/05
/20
17;
F
eed
ba
ckfr
om
Go
vern
ors
da
ted
11/4
/20
17a
nd
04
/05
/217
;
F
eed
ba
ckfr
om
loca
lH
ealt
hw
atc
ho
rga
nis
ati
on
sH
ealt
hw
atc
hS
efto
nd
ate
12/0
5/2
017
,H
ealt
hw
atc
hK
no
wsl
eyd
ate
12/0
5/2
017
an
dH
ealt
hw
atc
hL
iver
po
ol
da
te12
/05
/20
17;
F
eed
ba
ckfr
om
the
Ov
erv
iew
an
dS
cru
tin
yC
om
mit
tee
da
ted
16/0
5/2
017
T
he
tru
st’s
com
pla
ints
rep
ort
pu
bli
shed
un
der
reg
ula
tio
n18
of
the
Lo
cal
Au
tho
rity
So
cia
lS
ervi
ces
an
dN
HS
Co
mp
lain
tsR
egu
lati
on
s2
00
9,
da
ted
18/0
5/2
017
;
T
he
late
stn
ati
on
al
pa
tien
tsu
rvey
da
ted
20
/01/
20
17;
T
he
late
stn
ati
on
al
sta
ffsu
rvey
da
ted
07
/03
/20
17;
C
are
Qu
ali
tyC
om
mis
sio
nin
spec
tio
nre
po
rt,
da
ted
06
/03
/20
17;
T
he
Hea
do
fIn
tern
al
Au
dit
’sa
nn
ua
lo
pin
ion
ove
rth
eT
rust
’sco
ntr
ol
envi
ron
men
td
ate
d0
3/0
5/2
017
;a
nd
No
issu
esca
me
too
ur
att
enti
on
tha
tle
du
sto
bel
ieve
tha
tth
eQ
ua
lity
Rep
ort
isn
ot
con
sist
ent
wit
hth
ein
form
ati
on
sou
rces
det
ail
eda
bo
ve.
De
tail
ed
fin
din
gs
8. C
G17
-18/
011
- P
wC
Lon
g F
orm
Rep
ort (
Ext
erna
l Ass
uran
ce o
n Q
A)
Page 55 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C6
Per
form
an
cein
dic
ato
rso
nw
hic
hw
ea
rere
qu
ired
tois
sue
ali
mit
eda
ssu
ran
ceco
ncl
usi
on
As
req
uir
edb
yN
HS
Iw
eh
ave
un
der
tak
ensa
mp
lete
stin
go
ftw
op
erfo
rma
nce
ind
ica
tors
on
wh
ich
we
issu
edo
ur
lim
ited
ass
ura
nce
rep
ort
:
1.P
erce
nta
ge
of
inco
mp
lete
pa
thw
ays
wit
hin
18w
eek
sfo
rp
ati
ents
on
inco
mp
lete
pa
thw
ays
at
the
end
of
the
rep
ort
ing
per
iod
2.
Per
cen
tag
eo
fp
ati
ents
wit
ha
tota
lti
me
inA
&E
of
fou
rh
ou
rso
rle
ssfr
om
arr
iva
lto
ad
mis
sio
n,
tra
nsf
ero
rd
isch
arg
e
We
are
req
uir
edto
ob
tain
an
un
der
sta
nd
ing
of
the
key
pro
cess
esa
nd
con
tro
lsfo
rm
an
ag
ing
an
dre
po
rtin
gth
ein
dic
ato
rsa
nd
sam
ple
test
the
da
tau
sed
toca
lcu
late
the
ind
ica
tor.
Ou
rw
ork
isp
erfo
rmed
ina
cco
rda
nce
wit
hth
ed
eta
iled
gu
ida
nce
an
din
clu
ded
:
Id
enti
fica
tio
no
fth
ecr
iter
iau
sed
by
the
Tru
stfo
rm
easu
rin
gth
ein
dic
ato
r;
C
on
firm
ati
on
tha
tth
eT
rust
ha
dp
rese
nte
dth
ecr
iter
iaid
enti
fied
ab
ov
ein
the
Qu
ali
tyre
po
rtin
suff
icie
nt
det
ail
tha
tth
ecr
iter
iaa
rere
ad
ily
un
der
sta
nd
ab
leto
use
rso
fth
eQ
ua
lity
Rep
ort
;
U
pd
ati
ng
ou
ru
nd
erst
an
din
go
fth
ek
eyp
roce
sses
an
dco
ntr
ols
for
ma
na
gin
ga
nd
rep
ort
ing
the
ind
ica
tor
thro
ug
hm
ak
ing
enq
uir
ies
of
Tru
stst
aff
an
dth
rou
gh
per
form
ing
aw
alk
thro
ug
h;
C
hec
kin
gth
eT
rust
’sre
con
cili
ati
on
of
the
rep
ort
edp
erfo
rma
nce
inth
eQ
ua
lity
Rep
ort
toth
ed
ata
use
dto
calc
ula
teth
ein
dic
ato
rfr
om
the
Tru
st’s
un
der
lyin
gsy
stem
s;
T
esti
ng
asa
mp
leo
fre
leva
nt
da
tau
sed
toca
lcu
late
the
ind
ica
tor;
an
d
O
bta
inin
gre
pre
sen
tati
on
sth
at
the
da
tau
sed
toca
lcu
late
the
ind
ica
tor
isa
ccu
rate
lyca
ptu
red
at
sou
rce
an
dth
at
no
sou
rces
of
info
rma
tio
n/d
ata
rele
van
tto
the
ind
ica
tor
per
form
an
ceh
av
eb
een
excl
ud
ed.
We
on
lyte
sted
asa
mp
leo
fd
ata
,a
sst
ate
da
bo
ve,
tosu
pp
ort
ing
do
cum
enta
tio
n.
Th
eref
ore
,th
eer
rors
rep
ort
edb
elo
wa
reli
mit
edto
this
sam
ple
.
We
ha
vea
lso
no
tte
sted
the
un
der
lyin
gsy
stem
s,fo
rex
am
ple
the
pa
tien
ta
dm
inis
tra
tio
nsy
stem
an
dth
ed
ata
extr
act
ion
an
dre
cord
ing
syst
ems.
Ou
rfi
nd
ing
sa
rese
to
ut
bel
ow
.R
eco
mm
end
ati
on
sa
risi
ng
fro
mth
ese
fin
din
gs
are
pre
sen
ted
inA
pp
end
ixB
.
Page 56 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C7
Pe
rc
en
tag
eo
fin
co
mp
lete
pa
thw
ay
sw
ith
in18
we
ek
sfo
rp
ati
en
tso
nin
co
mp
lete
pa
thw
ay
s
Re
po
rte
dp
er
for
ma
nc
e:
20
16/1
7T
hr
es
ho
ld:
92
%2
016
/17
:9
1.2
%
Cr
ite
ria
ide
nti
fie
d:
We
con
firm
edth
eT
rust
use
sth
efo
llo
win
gcr
iter
iafo
rm
easu
rin
gth
ein
dic
ato
rfo
rin
clu
sio
nin
the
Qu
ali
tyR
epo
rt:
T
he
ind
ica
tor
isex
pre
ssed
as
ap
erce
nta
ge
of
inco
mp
lete
pa
thw
ays
wit
hin
18w
eek
sfo
rp
ati
ents
on
inco
mp
lete
pa
thw
ays
at
the
end
of
the
per
iod
;
T
he
ind
ica
tor
isca
lcu
late
da
sth
ea
rith
met
ica
vera
ge
for
the
mo
nth
lyre
po
rted
per
form
an
cein
dic
ato
rsfo
rA
pri
l2
016
toM
arc
h2
017
;
T
he
clo
ckst
art
da
teis
def
ined
as
the
da
teth
at
the
refe
rra
lis
rece
ived
by
the
Fo
un
da
tio
nT
rust
,m
eeti
ng
the
crit
eria
set
ou
tb
yth
eD
epa
rtm
ent
of
Hea
lth
gu
ida
nce
;a
nd
T
he
ind
ica
tor
incl
ud
eso
nly
refe
rra
lsfo
rco
nsu
lta
nt-
led
serv
ice,
an
dm
eeti
ng
the
def
init
ion
of
the
serv
ice
wh
ereb
ya
con
sult
an
tre
tain
so
vera
llcl
inic
al
resp
on
sib
ilit
yfo
rth
ese
rvic
e,te
am
or
trea
tmen
t.
Iss
ue
sid
en
tifi
ed
thr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
.Is
su
eIm
pa
ct
on
lim
ite
da
ss
ur
an
ce
re
po
rt
1.F
or
on
ep
ati
ent
wit
hin
ou
rsa
mp
lew
en
ote
dth
at
the
clo
ckst
art
da
tew
as
dif
fere
nt
fro
mth
ed
ate
on
the
refe
rra
lle
tter
.H
ow
ever
,th
isd
idn
ot
ha
vea
nim
pa
cto
nth
ea
ctu
al
per
form
an
cea
sth
ep
ati
ent
wa
sst
ill
rep
ort
edin
the
corr
ect
per
iod
.
No
imp
act
on
ou
rli
mit
eda
ssu
ran
cere
po
rt.
Ov
er
all
Co
nc
lus
ion
:
Ou
rsu
bst
an
tiv
ete
stin
go
fth
ein
dic
ato
rid
enti
fied
on
eis
sue.
Th
eis
sue
no
ted
wa
sa
dif
fere
nce
an
da
ssu
chh
as
no
tim
pa
cted
the
calc
ula
tio
n.
Th
eref
ore
ther
eis
no
imp
act
on
ou
rli
mit
eda
ssu
ran
cere
po
rtre
sult
ing
ina
nu
nm
od
ifie
dre
po
rtin
resp
ect
of
this
ind
ica
tor.
8. C
G17
-18/
011
- P
wC
Lon
g F
orm
Rep
ort (
Ext
erna
l Ass
uran
ce o
n Q
A)
Page 57 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C8
Pe
rc
en
tag
eo
fp
ati
en
tsw
ith
ato
tal
tim
ein
A&
Eo
ffo
ur
ho
ur
so
rle
ss
fro
ma
rr
iva
lto
ad
mis
sio
n,
tra
ns
fer
or
dis
ch
ar
ge
Re
po
rte
dp
er
for
ma
nc
e:
20
16/1
7T
arg
et:
at
lea
st9
5%
each
qu
art
er2
016
/17
Act
ua
l:8
4.8
9%
Cr
ite
ria
ide
nti
fie
d:
We
con
firm
edth
eT
rust
use
sth
efo
llo
win
gcr
iter
iafo
rm
easu
rin
gth
ein
dic
ato
rfo
rin
clu
sio
nin
the
Qu
ali
tyR
epo
rt:
T
he
ind
ica
tor
isd
efin
edw
ith
inth
ete
chn
ica
ld
efin
itio
ns
tha
ta
cco
mp
an
yE
ver
yo
ne
cou
nts
:p
lan
nin
gfo
rp
ati
ents
20
14/1
5-
20
18/1
9a
nd
can
be
fou
nd
at
ww
w.e
ng
lan
d.n
hs.
uk
/wp
-co
nte
nt/
up
loa
ds/
20
14/0
1/ec
-tec
h-d
ef-1
415
-18
19.p
df
D
eta
iled
rule
sa
nd
gu
ida
nce
for
mea
suri
ng
A&
Ea
tten
da
nce
sa
nd
emer
gen
cya
dm
issi
on
sca
nb
efo
un
da
th
ttp
s://
ww
w.e
ng
lan
d.n
hs.
uk
/sta
tist
ics/
wp
-co
nte
nt/
up
loa
ds/
site
s/2
/20
13/0
3/A
E-A
tten
da
nce
s-E
mer
gen
cy-
Def
init
ion
s-v2
.0-F
ina
l.p
df
Iss
ue
sid
en
tifi
ed
thr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
.Is
su
eIm
pa
ct
on
lim
ite
da
ss
ur
an
ce
re
po
rt
No
issu
esn
ote
d.
No
imp
act
on
ou
rli
mit
eda
ssu
ran
cere
po
rt.
Co
nc
lus
ion
:
Ou
rsu
bst
an
tiv
ete
stin
go
fth
ein
dic
ato
rid
enti
fied
no
issu
es.
No
imp
act
on
ou
rli
mit
eda
ssu
ran
cere
po
rtre
sult
ing
ina
nu
nm
od
ifie
dre
po
rtin
resp
ect
of
this
ind
ica
tor.
Page 58 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C9
Per
form
an
cein
dic
ato
rsn
ot
incl
ud
edw
ith
ino
ur
lim
ited
ass
ura
nce
rep
ort
NH
SI
als
ore
qu
ires
us
tou
nd
erta
ke
sub
sta
nti
ve
sam
ple
test
ing
of
alo
cal
ind
ica
tor
sele
cted
by
the
Go
ver
no
rs,
the
resu
lts
of
wh
ich
are
no
tin
clu
ded
wit
hin
ou
rli
mit
eda
ssu
ran
cere
po
rt.
We
ob
tain
an
un
der
sta
nd
ing
of
the
key
pro
cess
esa
nd
con
tro
lsfo
rm
an
ag
ing
an
dre
po
rtin
gth
ein
dic
ato
ra
nd
sam
ple
test
the
da
tau
sed
toca
lcu
late
the
ind
ica
tor
ba
ckto
sup
po
rtin
gd
ocu
men
tati
on
.
We
test
edo
nly
asa
mp
le,
as
sta
ted
ab
ove
.O
ur
rep
ort
eder
rors
bel
ow
are
lim
ited
toth
issa
mp
le.
Ou
rfi
nd
ing
sa
red
eta
iled
as
foll
ow
s:
Pa
tie
nt
sa
fety
inc
ide
nts
an
dth
ep
er
ce
nta
ge
tha
tr
es
ult
ed
ins
ev
er
eh
ar
mo
rd
ea
th
Re
po
rte
dp
er
for
ma
nc
e:
As
at
the
da
teo
fo
ur
test
ing
(Ma
y2
017
)N
HS
Ih
as
no
tfo
rma
lly
rep
ort
edth
ep
erfo
rma
nce
of
this
ind
ica
tor
for
20
16/1
7.
As
such
we
ha
vep
erfo
rmed
the
foll
ow
ing
pro
ced
ure
so
ver
this
ind
ica
tor:
1)W
eh
ave
reca
lcu
late
dth
ep
erfo
rma
nce
rep
ort
edin
the
20
16/1
7q
ua
lity
acc
ou
nt.
Th
isre
late
sto
the
pre
vio
us
yea
r’s
fig
ure
,a
sre
po
rtin
go
nto
NH
SI
ha
sa
tim
ela
g.
We
ha
ve
fou
nd
no
exce
pti
on
sin
the
reca
lcu
lati
on
of
this
per
form
an
ce.
2)
Ino
rder
top
rovi
de
com
fort
ove
rth
e2
016
/17
per
form
an
ceo
fth
etr
ust
,w
eh
ave
test
eda
sam
ple
of
15in
cid
ents
in2
016
/17
an
da
gre
edth
eyh
ave
bee
nco
rrec
tly
reco
rded
.N
ois
sues
wer
en
ote
dd
uri
ng
this
test
ing
.
Cr
ite
ria
ide
nti
fie
d:
We
con
firm
edth
eT
rust
use
sth
efo
llo
win
gcr
iter
iafo
rm
easu
rin
gth
ein
dic
ato
rfo
rin
clu
sio
nin
the
Qu
ali
tyR
epo
rt:
T
he
nu
mb
ero
fp
ati
ent
safe
tyin
cid
ents
resu
ltin
gin
seve
rh
arm
or
dea
tha
ta
tru
stre
po
rted
thro
ug
hth
eN
ati
on
al
Rep
ort
ing
an
dL
earn
ing
Ser
vice
(NR
LS
),d
ivid
edb
yth
en
um
ber
of
pa
tien
tsa
fety
inci
den
tsre
po
rted
at
this
tru
stth
rou
gh
the
NR
LS
.
In
cid
ents
are
rep
ort
eda
nd
revi
ewth
rou
gh
the
Da
trix
da
tab
ase
wh
ich
isth
enu
sed
toca
lcu
late
the
nu
mb
ero
fin
cid
ents
resu
ltin
gin
dea
tho
rse
ver
ha
rm.
Th
isis
then
rep
ort
edq
ua
rter
lyto
NR
LS
.
Iss
ue
sid
en
tifi
ed
thr
ou
gh
wo
rk
pe
rfo
rm
ed
:
No
.Is
su
eIm
pa
ct
No
issu
esn
ote
d.
No
imp
act
on
ou
rli
mit
eda
ssu
ran
cere
po
rt.
Co
nc
lus
ion
:
Ou
rsu
bst
an
tiv
ete
stin
go
fth
ein
dic
ato
rid
enti
fied
no
issu
es.
8. C
G17
-18/
011
- P
wC
Lon
g F
orm
Rep
ort (
Ext
erna
l Ass
uran
ce o
n Q
A)
Page 59 of 78
Ain
tre
eU
niv
ers
ity
Ho
sp
ita
lN
HS
Fo
un
da
tio
nT
rust
Pw
C1
0
Th
ere
com
men
da
tio
ns
ass
oci
ate
dw
ith
thes
efi
nd
ing
sa
rep
rese
nte
din
Ap
pen
dix
B.
An
nu
al
Go
ver
na
nce
Sta
tem
ent
NH
SI
req
uir
eF
ou
nd
ati
on
Tru
sts
toin
clu
de
ab
rief
des
crip
tio
no
fth
ek
eyco
ntr
ols
inp
lace
top
rep
are
an
dp
ub
lish
aQ
ua
lity
Rep
ort
as
pa
rto
fth
eA
nn
ua
lG
ove
rna
nce
Sta
tem
ent
(“A
GS
”)in
the
20
16/1
7p
ub
lish
eda
cco
un
ts.
Th
ere
qu
irem
ents
for
the
con
ten
to
fth
eA
GS
are
set
ou
tin
An
nex
5o
fC
ha
pte
r2
of
the
NH
SF
ou
nd
ati
on
Tru
stA
nn
ua
lR
epo
rtin
gM
an
ua
l2
016
/17
.
Th
eA
nn
ua
lG
ov
ern
an
ceS
tate
men
t,w
ith
inth
eF
ou
nd
ati
on
Tru
st’s
20
16/1
7A
nn
ua
lR
epo
rt,
incl
ud
esth
efo
llo
win
gst
ate
men
tsp
ecif
icto
the
Qu
ali
tyR
epo
rt:
Th
ed
irec
tors
are
req
uir
edu
nd
erth
eH
ealt
hA
ct2
00
9a
nd
the
Na
tio
na
lH
ealt
hS
ervi
ce(Q
ua
lity
Acc
ou
nts
)R
egu
lati
on
s2
010
(as
am
end
ed)
top
rep
are
Qu
ali
tyA
cco
un
tsfo
rea
chfi
na
nci
al
yea
r.N
HS
Imp
rov
emen
t(i
nex
erci
seo
fth
ep
ow
ers
con
ferr
edo
nM
on
ito
r)h
as
issu
edg
uid
an
ceto
NH
Sfo
un
da
tio
ntr
ust
bo
ard
so
nth
efo
rma
nd
con
ten
to
fa
nn
ua
lQu
ali
tyR
epo
rts
wh
ich
inco
rpo
rate
the
ab
ove
leg
alr
equ
irem
ents
inth
eN
HS
Fo
un
da
tio
nT
rust
An
nu
al
Rep
ort
ing
Ma
nu
al.
Th
eT
rust
ha
sef
fect
ive
syst
ems,
pro
cess
esa
nd
mec
ha
nis
ms
inp
lace
top
rod
uce
the
Qu
ali
tyA
cco
un
ta
nd
toen
sure
tha
tit
isa
gen
era
la
nd
ba
lan
ced
vie
wa
nd
tha
ta
pp
rop
ria
teco
ntr
ols
are
inp
lace
toen
sure
the
acc
ura
cyo
fth
ed
ata
.T
he
Ex
ecu
tive
lea
dfo
rth
eQ
ua
lity
Acc
ou
nt
isth
eD
irec
tor
of
Nu
rsin
g&
Qu
ali
ty.
Th
eco
nte
nt
of
the
Qu
ali
tyre
po
rtre
flec
tsth
eT
rust
’so
vera
llQ
ua
lity
Str
ate
gy
an
dth
ep
rio
riti
esin
clu
ded
inth
isd
ocu
men
t.
Th
eG
ove
rno
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Page 60 of 78
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8. C
G17
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- P
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Lon
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Page 61 of 78
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G17
-18/
011
- P
wC
Lon
g F
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Rep
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Ext
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Page 63 of 78
1/1
Membership Committee Report
Report to Council of Governors
Date 15 June 2017
Committee Name Membership Committee
Date of Committee Meeting 8 May 2017
Chair’s Name & Title Pamela Peel – Lead Governor
Summary of Meeting
A progress update was provided on the ‘Get Involved with Aintree’ group. Arrangements had been
made to host an informal, initial meeting with interested members on 18 May 2017 principally to
begin to form the group into a cohesive body and to discuss its remit. The meeting would be an
opportunity to begin to bridge the gap between Governors and the most engaged members. An
invitation had been extended to Kerry Higham, Lead Nurse Quality & Safety – Patient Experience, to
provide a short talk on her role and link with patients and members. The opportunity would also be
taken to obtain the views of members on the Governor Toolkit. An update on the meeting would be
provided at the formal Council meeting in June 2017
The Committee reviewed the Membership Strategy Implementation Plan and the tasks arising from
the Governor Development Day in September 2016. The Committee assessed the progress made to
date through the various initiatives and the key areas of focus going forward
Representation of Staff Governors at the monthly Corporate Induction with new staff had been
welcomed as it provided a great opportunity to present and promote membership. Overall, feedback
had been positive particularly with having the Chairman and Chief Executive in attendance as well as
a Staff Governor. Reference was made to the challenges being experienced in promoting the
benefits of membership to both staff and volunteers at Induction
The Committee discussed the promotion of membership and the possibility of more Governors being
involved in this regard within the public areas of the hospital. The Committee discussed the
possibility of having a stand in the Elective Care Centre so that Governors could speak directly with
members of the public in regard to their role and the hospital in general. It was agreed that the
membership leaflet be distributed again at the next Informal Governors meeting to remind colleagues
of the resources available and their responsibility for wider engagement with members
The Committee gave a vote of thanks to Lorraine Heaton for her sterling work and support in regard
to membership during her time on the Committee.
Recommendation
The Council of Governors is asked to note the report.
9. C
G17
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012
- M
embe
rshi
p C
omm
ittee
(8
May
201
7)
Page 64 of 78
Council of Governors Membership Committee Terms of Reference – February 2017
Terms of Reference
Council of Governors – Membership Committee
Authority
1. The Membership Committee has been established as a formal committee of the Council of Governors and recommends processes and activities for the recruitment and engagement of members by or on behalf of the Council of Governors. This includes an overarching recruitment and engagement strategy.
2. The Membership Committee submits recommendations to the Council of
Governors for approval, but does not possess any delegated powers. 3. Governance and election issues are led by the Associate Director of
Corporate Governance and are not covered by this Committee.
Purpose
4. The Membership Committee has responsibility for developing and reviewing processes and activities for the recruitment and engagement of existing and new members of Aintree University Hospital NHS Foundation Trust.
Duties
5. Develop the Membership Strategy and provide strategic guidance on the communication and engagement activities undertaken by or on behalf of the Council of Governors.
6. Oversee the delivery of the action plan to support the Membership Strategy, including advising partners and stakeholders as appropriate.
7. Ensuring that the Membership Strategy is seeking a membership which is
representative of the patients and public served by the Trust.
8. In line with brand guidance, consider all aspects of communication relating to membership of the Trust including development of newsletters, digital and social communications, members’ meetings, media campaigns, membership forms and administration.
9. To advise on the organisation and promotion of the Annual Members’
Meeting. 10. Establish a developmental approach which encourages each Governor to
engage with the Membership as best suits his/her skills and time available.
11. The Committee aims to advise on and support focused recruitment and engagement of FT members. It will use the performance indicators outlined in its recruitment and engagement strategy to measure success.
Membership
12. The Committee will be comprised of 6 Governors.
13. The Chair of the Committee will be elected on an annual basis.
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- M
embe
rshi
p C
omm
ittee
- T
erm
s of
Ref
eren
ce
Page 65 of 78
Aintree University Hospital NHS Foundation Trust
Council of Governors Membership Committee Terms of Reference – February 2017
14. All Governors will be welcome to attend meetings of the Committee although voting
rights will be restricted to the 6 formal Governor members
Requirements of Membership
15. All members will contribute to and support the development and implementation of the recruitment and engagement strategy and support the wider Council of Governors and other partner agencies to participate in all related activities.
16. The Corporate Governance Team will provide administrative support to the
Committee and ensure that all papers and minutes are circulated promptly to
members.
17. In order for a meeting of the Membership Committee to make substantive decisions,
at least three Governors must be present. Any decisions made with fewer than three
Governors are subject to ratification at the next quorate meeting.
Reporting
18. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of the Council of Governors.
19. Minutes of the Committee meetings will be provided to the Council of Governors on
request. 20. The Deputy Chair of the Council of Governors/Lead Governor will attend the Annual
Members’ Meeting to report on activities of the Committee in the previous 12 months.
Administration of Meetings
21. The Committee will meet at least quarterly and then as required to fulfil its responsibilities, as determined by the Chair.
22. The Chair, with support from the Corporate Governance Team and Communications Team, will draft the agenda and enclosures.
23. The Corporate Governance Team will minute the meeting and duly record all decisions and actions. Minutes and related papers will be stored electronically in the Corporate Governance Team’s files.
24. The Committee will review its own performance and terms of reference at least once a year to ensure it is operating effectively. It will use the performance indicators outlined in the recruitment and engagement strategy to measure its effectiveness.
Review
25. Once approved, the Terms of Reference will be reviewed every 12 months. Next review date: February 2018.
Page 66 of 78
1/2
Quality of Care Committee Report
Report to Council of Governors
Date 15 June 2017
Committee Name Quality of Care Committee
Date of Committee Meeting 17 May 2017
Chair’s Name& Title Mike Booth
Summary of Meeting
The annual report on Infection Prevention and Control was provided which included an overview
of the Trust’s Healthcare Associated Infections (HCAIs) Reduction Plan for 2017/18. The main
points arising were:
The total level of CDifficile cases for 2016/17 was 46 with 19 cases successfully appealed by
theTrust as there were no lapses in care. This resulted in a net total of 28 cases at the year
end attributable to the Trust . This evidenced that the Trust was improving year on year in
reducing the number of cases
There had been one Trust attributable case of MRSA but the Trust continued to maintain its
90% standard in respect of patient screening. There had been increased staff training of
Asceptic Non-Touch Techniques (ANTT) and this would continue during 2017/18
The Trust continued with the process for peroxide fogging/deep cleaning programme to
eradicate infection cases.
The Committee had discussed the setting of achievable aspirational targets particularly given the
increased demand on the hospital’s services. The Committee also sought and received
clarification that the staff were informed of ANTT through monthly Divisional reports as well as
within team meetings with positive feedback provided where appropriate.
The Quality Strategy for 2017/18 together with the Delivery Plan was discussed. The main points
identified were:
A one year plan had been developed due to the possibility of the merger between Aintree
University Hospital and the Royal Liverpool Hospital. Discussion would take place between
the Trusts on developing a longer term quality strategy for the merged entity
Overall, 18 objectives had been developed which included a number of IPC projects, the
management of the deteriorating patient, falls, pressure ulcers and patient experience
projects
Medicines safety was a key focus as a number of errors had been reported . This had led to
the Trust relaunching the Medicines Safety Group.
The Committee reviewed the results of the Quality Strategy Delivery Plan for Q4 2016/17 and the
following matters were highlighted:
o The increased demand coupled with winter pressures had been challenging for the Trust but
it had demonstrated that, whilst not every objective had been met, there had been
improvements in a number of areas.
o There had been year on year improvement in the reduction of falls but there had been an
increase in moderate/severe cases and this would be taken forward during 2017/18
o Patient acuity and dependency had also increased particularly in relation to patients with co-
mobidities, dementia, confusion and those requiring help to maintain their deprivation of
liberties
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012
- Q
ualit
y of
Car
e C
omm
ittee
(17
May
201
7)
Page 67 of 78
Aintree University Hospital NHS Foundation Trust
Quality of Care Committee Report – 17 May 2017: Council of Governors 15 June 2017 2/2
o Pressure ulcers had also seen an improvement year on year but there were an umber that
had come through from the community which was being monitored
o The Trust was performing well against the Advancing Quality metrics across the North West
and was the top performer in a number of areas
o The palliative care work stream had performed well and there had been some good
improvements made in Acute Kidney Injury and the deteriorating patient. All this work
evidenced that the Trust was doing all it could to reduce the number of avoidable deaths
A report was presented on the Aintree Assessment & Accreditation Framework Q2 2016/17 and
it was highlighted that there were 12 Aintree Champions Excellence (ACE) Wards, 7 Green Wards
and 10 Amber Wards. No Wards/Departments were rated Red. The programme would continue to
be rolled out to other areas of the hospital such as theartes and outpatients during 2017/18.
A review of the Trust Mortality report highlighted the following:
HSMR remains in the expected range and was below 100%. .The SHMI had moved from
below expected into the as expected range but this was not considered ot be of concern.
Crude mortality had fallen to 2.83% on a rolling 12 month basis but was likely to be due to the
increased number of patients admitted against a decrease in the number of actual deaths.
Palliative Care was excluded from the HSMR figures but included in the SHMI which, when
excluded, give the Trust a SHMI rating of 98%.
A new process had been implemented to review the case notes for all deaths to learn lessons
and determine if any deaths could have been avoided.
Other matters raised at the meeting were:
The Trust’s reputation in the community had significantly improved
Recent PLACE inspection undertaken by Governors evidenced that the hospital was
extremely clean and that staff have a very positive attitude
There was evidence of overcrowding in Clinic G particularly when a number of clinics were
held on the same day and the overall environment within this clinic may need to be reviewed
Consideration would need to be given to the plans and future location of Clinic G going
forward.
All the matters raised would be discussed by the Executive Team.
Recommendation
The Council of Governors is asked to note the report.
Page 68 of 78
Quality of Care Committee: Terms of Reference February 2017 1/2
Quality of Care Committee
TERMS OF REFERENCE
Authority
1. The Quality of Care (QoC) Committee is authorised by the Council of Governors (CoG) and will
be Governor-led.
Purpose
2. To act as a focal point for work involving the care and safety of patients and to enable Governors
to become better informed on issues of concern to members and the public.
Membership
3. The QoC will be comprised of seven Governors.
4. The Chair of the Committee will be elected by the QoC Committee on an annual basis.
5. The Director of Nursing & Quality and the Medical Director or their respective deputies will be in
attendance. Other members of the Executive Team will be asked to attend as appropriate
6. Membership of the Committee will be reviewed annually at the first meeting of the Council of
Governors after the Annual Members Meeting. Governors will be invited to express an interest in
membership of the Committee prior to that meeting of the Council of Governors.
7. Vacancies will be filled by open self nomination and election by the Council of Governors if
necessary for the appropriate term.
8. All Governors will be welcome to attend meetings of the Committee although voting rights will be
restricted to the seven formal Governor members.
Quorum
9. A quorum shall be four members of the Committee.
10. Any decisions reached at an inquorate meeting shall be referred to the next quorate meeting for
approval.
Requirements of Membership
11. It is essential that all members participate in the meetings and punctuality must be observed.
12. The Chair will ensure that the key issues identified are highlighted as appropriate to the Hospital
Management Board and/or lead executive director/manager as required.
9. C
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- Q
ualit
y of
Car
e C
omm
ittee
- T
erm
s of
Ref
eren
ce
Page 69 of 78
Aintree University Hospital NHS Foundation Trust
Quality of Care Committee: Terms of Reference February 2017 2/2
Duties
13. In order to fulfil its role, the duties of the Committee will be:
To understand, support and be engaged with the Trust’s Quality Strategy
To receive reports on progress towards achieving the quality priorities, namely:
o care that is safe
o care that is clinically effective
o care that provides a positive experience for patients and their families
To receive and comment on indicators on safety, clinical effectiveness and patient
experience, in line with the national direction on quality. At present, these include:
Healthcare Associated Infections (HCAI), Mortality, Cleanliness and Patient Satisfaction. As
further indicators are developed or more detailed work is necessary, Governors may be
asked to contribute to additional working groups.
To review the results of patient satisfaction surveys, both national and local and to
understand the impact on patient care
To comment on the Trust’s declaration(s) to the Care Quality Commission on compliance with
its registration on behalf of the Council of Governors
Reporting
14. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of
the Council of Governors.
15. Minutes of the Committee meetings will be provided to the Council of Governors on request.
Administration of Meetings
16. The Committee will meet quarterly and the duration of each meeting shall be approximately 1.5
hours
17. The Associate Director Corporate Governance/Board Secretary will make arrangements to
ensure that the Committee is supported administratively. Duties in this respect will include
preparation of agendas and taking minutes of the meeting.
18. Agendas and papers will be circulated at least 4 working days (or 3 working days plus a
weekend) in advance of the meeting.
19. Minutes will be circulated to Committee members as soon as is reasonably practicable.
Review
20. The Terms of Reference shall be reviewed annually (next review date: February 2018) and
submitted to the Council of Governors for approval following a review by the QoC of its
performance against the terms of reference.
Page 70 of 78
Council of Governors
Nominations Committee
Terms of Reference
1. Purpose
A Nominations Committee (the Committee) is to be established for the purposes of identifying
appropriate candidates and for making recommendations to the Council of Governors on the terms
and conditions of office for non-executive directors of Aintree University Hospitals NHS Foundation
Trust (the Trust).
2. Membership
The standing membership of the Committee will be in accordance with the Trust’s Constitution and
will consist of:
The Chairman of the Trust (or Deputy-Chairman/Senior Independent Director in relation
to the appointment of the Chairman)
The Lead Governor
One Appointed Governor
Two Elected Governors
The Chief Executive of the Trust (where appropriate)
An external assessor, with appropriate skills and experience, may be appointed to advise the
Committee as and when required i.e. for each appointment process.
Members of the Committee may be required to undertake training and development commensurate
with the responsibilities outlined in Section 5.
3. Chairman of the Nominations Committee
The chair of the Committee will be the Chairman of the Trust, unless the discussion relates to the
appointment of the Chairman of the Trust, in which case, the Deputy Chairman will chair the
Committee. In the event that the Deputy Chairman or Senior Independent Director stands for the
appointment of Chairman, the Committee will be chaired by another non-executive director.
4. Support for the Nominations Committee
The Director of People & Corporate Affairs will provide advice to the Nominations Committee to
ensure that the recruitment and appointment processes are managed in accordance with best
practice and that the recommendations to the Council of Governors on terms and conditions of
office are appropriate and relevant to local circumstances.
The Associate Director of Corporate Governance/Board Secretary will make arrangements to
ensure that the Committee is supported administratively. Duties in this respect will include taking
minutes of the meeting and providing appropriate support to the Chairman and committee
members.
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012
- N
omin
atio
ns C
omm
ittee
- T
erm
s of
Ref
eren
ce
Page 71 of 78
Aintree University Hospital NHS Foundation Trust 5. Responsibilities of the Committee
Receive job descriptions and person specifications detailing the skills, knowledge and experience
required for non-executive directors, as approved by the Board of Directors.
Approve the recruitment and selection process for non-executive directors, elements of which are
likely to include:
Arrangements for advertising/raising of local awareness of the post(s).
Arrangements for shortlisting of candidates against agreed criteria.
Arrangements for formal interviews
Recommendation of the successful candidate(s) for approval by the Council of
Governors.
Receive reports in relation to the terms and conditions of office of current or newly appointed
Chairman and non executive directors and make recommendations to the Council of Governors.
Develop, monitor and seek feedback on a process for the evaluation of performance and
contribution on the part of Non-Executive Directors and the Chairman
Receive summarised reports as to the performance of the Non-Executive Directors (from the
Chairman) and the Chairman (from the Senior Independent Director) on an annual basis.
The Committee will provide assurance on these matters to the Council of Governors.
6. Quorum
The quorum necessary for the transaction of business will be three members of the Committee.
7. Frequency of Meetings
The standing membership of the Committee will meet at least annually and then as required to fulfil
its responsibilities, as determined by the Chairman.
8. Notice of Meetings
Meetings of the Committee will be called at the request of the Chairman.
Details of each meeting, including agenda and supporting papers will be forwarded to each
member of the Committee seven working days before the date of the meeting.
9. Minutes of Meetings
Minutes of the meetings will be circulated promptly to all members of the Committee and to all
other members of the Council of Governors as soon as reasonably practical.
10. Reporting Arrangements
The Chair of the Committee will report on the proceedings of each meeting to the next meeting of
the Council of Governors. This discussion will take place in a private session, i.e. not open to
members or the public, if the names and details of individuals are being discussed.
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Aintree University Hospital NHS Foundation Trust
The Chair will attend the Annual Members’ Meeting to report on the activities of the Committee in
the previous twelve months.
11. Authority
The Committee is authorised to seek information and advice either within the Trust or externally on
any matters within its terms of reference.
12. Review
The Committee will review its own performance, relevant sections of the constitution, and terms of
reference at least once a year to ensure it is operating effectively. Any proposed changes will be
submitted to the Council of Governors for approval.
These terms of reference will be approved by the Council of Governors and formally reviewed at
intervals not exceeding two years. [Next review: March 2019]
9. C
G17
-18/
012
- N
omin
atio
ns C
omm
ittee
- T
erm
s of
Ref
eren
ce
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Co
un
cil
of G
ove
rno
rs J
un
e 2
01
7
Co
un
cil
of
Go
vern
ors
Ob
jecti
ves 2
01
7/1
8
•To m
onitor
the p
erf
orm
ance o
f th
e B
oard
of D
irecto
rs thro
ugh h
old
ing
the N
on-E
xecutive D
irecto
rs indiv
idually
and c
olle
ctively
to a
ccount
1
•To d
eliv
er
its s
tatu
tory
duties in lin
e w
ith r
egula
tory
requirem
ents
2
•To c
om
munic
ate
and e
ngage w
ith m
em
bers
of th
e T
rust in
lin
e w
ith t
he
mem
bers
hip
str
ate
gy o
bje
ctives
3
•To f
urt
her
develo
p s
kill
s a
nd k
now
ledge b
ase in o
rder
to c
olle
ctively
unders
tand a
nd c
onstr
uctively
challe
nge a
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upport
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ualit
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rovid
ed b
y t
he T
rust
4
10. C
G17
-18/
013
- C
oG D
raft
Obj
ectiv
es 2
017/
18
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1/4
Agenda Item (Ref) CG17-18/014 Date of Meeting: 15 June 2017
Report to Council of Governors
Report Title Appointment of Lead Governor and Deputy Lead Governor
Executive Lead Neil Goodwin, Chairman
Lead Officer Caroline Keating, Associate director of Corporate Governance/Board Secretary
Action Required To approve
Substantial assurance
High level of confidence in delivery of existing mechanisms / objectives
Acceptable assurance
General confidence in delivery of existing mechanisms/ objectives
Partial assurance
Some confidence in delivery of existing mechanisms / objectives
No assurance
No confidence in delivery
Key Messages of this Report (2/3 headlines only)
To agree the reprocess for the appointment of the Lead Governor and Deputy Lead Governor for
a term of 12 months
Impact (is there an impact arising from the report on the following?)
Quality
Finance
Workforce
Equality
Risk
Compliance
Legal
Equality Impact Assessment (if there is an impact on E&D, an Equality Impact Assessment must accompany the report)
Strategy Policy Service Change
Strategic Objective(s)
Deliver outstanding care
Achieve best patient outcomes
Promote research and education
Deliver sustainable healthcare to meet people’s needs
Provide strong system leadership
Be a well-governed and clinically-led organisation
Governance (is the report a……?)
Statutory requirement
Annual Business Plan Priority
Key Risk
Service Change
Other
rationale for Board submission required:
Next Steps (actions following agreement by Board/Committee of recommendation/s)
Board Secretary to seek expressions of interest from the Council of Governors for the roles and
undertake an election if necessary
11. C
G17
-18/
014
- A
ppoi
ntm
ent o
f Lea
d G
over
nor
& D
eput
y Le
ad G
over
nor
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Aintree University Hospital NHS Foundation Trust
2/4
REPORT HISTORY
Committee / Group Name
Agenda Ref
Report Title Date of submission
Brief summary of key issues raised and actions
Page 76 of 78
Aintree University Hospital NHS Foundation Trust
Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2017 3/4
Executive Summary
1. The report provides the Council of Governors with a brief overview of the process to be undertaken
to source a Lead Governor and Deputy Lead Governor of the Trust
Background
Regulatory Requirements and the Trust Constitution
2. The NHS Foundation Trust Code of Governance, published by Monitor (now NHS Improvement),
contains a section relating to the role of the nominated lead governor which highlights that the role
is largely to facilitate direct communication between NHS Improvement and the Trust’s council of
governors.
3. Annex 5 of the Trust’s Constitution states the following:
The Council of Governors shall appoint one of the Governors to be Lead Governor of the
Council of Governors. The Lead Governor may be a Public Governor, an Appointed
Governor or a Staff Governor.
The term of office of the Lead Governor shall be 12 months. A Governor may be re-
appointed as the Lead Governor by the Council of Governors at the end of that term. Only
in exceptional circumstances would a Lead Governor serve for more than 2 years.
Key Issues / Proposals
4. In June 2015, the Council of Governors approved the appointment of Pamela Peel as Lead
Governor and Lorraine Heaton as Deputy Lead Governor for a term of 12 months. These two
individuals were reappointed into their respective roles in June 2016.
5. It is, therefore, now necessary to source nominations from the current Council of Governors for the
positions of Lead Governor and Deputy Lead Governor for a 12 month term of office. The Board
Secretary will write to the Council of Governors following this meeting to seek expressions of
interest for both roles. Nominations for both roles are to be submitted by close of play on Monday
19 July 2017
6. If only one nomination is received for either or both roles, the person(s) so nominated will be
automatically appointed and the Council of Governors informed accordingly.
7. If, however, more than one nomination is received for either or both roles, an election will be held
which will be undertaken by email the day after the closing date for nominations.
8. In terms of the process, each Governor will be emailed with the names of the nominated
candidates and will be asked to indicate their preferred candidate(s) only by return email.
9. The votes will be counted by the Board Secretary (acting as Returning Officer) and the result
provided by email. The candidates receiving the highest number of votes will be declared
appointed as the Lead Governor and Deputy Lead Governor.
Recommendation
10. Council of Governors to approve the process for the appointment of Lead Governor and Deputy
Lead Governor for a term of 12 months.
11. C
G17
-18/
014
- A
ppoi
ntm
ent o
f Lea
d G
over
nor
& D
eput
y Le
ad G
over
nor
Page 77 of 78
Aintree University Hospital NHS Foundation Trust
Lead & Deputy Lead Governor Nominations: Council of Governors – 15 June 2017 4/4
Author: Michael Games, Corporate Governance Manager
Date: 12 June 2016
Page 78 of 78
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