Agenda...Members’ attendance record 2017-18: 7 7 8 Mr Robert Armstrong Chair (in the Chair) Mr Bill Anderton Public Governor, Wigan Mrs Helen Ash Public Governor, Makerfield A Mr

Meeting of the Council of Governors

15 January 2018 | 5.30pm

Boardroom, Trust Headquarters

Royal Albert Edward Infirmary, Wigan Lane, Wigan WN1 2NN

Agenda

PART 1: Held in public

№ Item Time Encl. Purpose Presenter

1. Chairman and quorum 5.30pm Verbal Compliance R Armstrong

2. Apologies for absence 5.30pm Verbal Information P Howard

3. Declarations of interest 5.30pm Verbal Information As required

4. Minutes of the previous meeting 5.30pm Approval R Armstrong

5. Chairman’s opening remarks 5.35pm Verbal Information R Armstrong

6. Chief Executive’s update and discussion

5.40pm Pres. Information A Foster

7. STATUTORY DUTY: HOLDING TO ACCOUNT

7.1 Operational and clinical performance

6.10pm Assurance NEDs

7.2 Financial performance 6.25pm Assurance NEDs

7.3 Agreement of locally-determined indicator for quality account

6.40pm Approval R Armstrong

8. DATE, TIME AND VENUE OF NEXT MEETING

8.1 16 April 2018, 5.30pm in the Boardroom, Trust Headquarters

6.50pm Verbal Information R Armstrong

MINUTES OF A MEETING OF THE COUNCIL OF GOVERNORS

HELD ON 30 OCTOBER 2017, 3.00PM

AT ROYAL ALBERT EDWARD INFIRMARY, WIGAN LANE, WIGAN, WN1 2NN

Members’ attendance record 2017-18:

31 M

ay 2

017

19 J

un

2017

30 O

ct

2017

15 J

an

2018

Mr Robert Armstrong Chair (in the Chair)

Mr Bill Anderton Public Governor, Wigan

Mrs Helen Ash Public Governor, Makerfield A

Mr Tim Board Staff Governor, Medical and Dental A A

Mr Les Chamberlain Public Governor, Makerfield

Mrs Kathryn Drury Public Governor, Makerfield A ---

Mr Tom Frost Public Governor, Rest of England and Wales

Mr Howard Gallimore Public Governor, Makerfield --- ---

Mr Bill Greenwood Public Governor, Wigan A

Mrs Pauline Gregory Public Governor, Wigan A

Dr Dawne Gurbutt Appointed Governor, UCLAN A

Mrs Marie Hart Staff Governor, Nursing and Midwifery A A A

Mrs Jean Heyes Appointed Governor, Staff Side

Mr Alex Hilton Staff Governor, Other staff --- ---

Dr Mustapha Koriba Public Governor, Rest of England and Wales A

Mrs Diane Lawrenson Staff Governor, Nursing and Midwifery A A

Mr James Lee Public Governor, Makerfield

Mrs Lisa Lymath Public Governor, Rest of England and Wales A

Mr Reg Nash Appointed Governor, Age UK A

Mr Andy Savage Staff Governor, Other staff ---

Dr Louise Sell Appointed Governor, 5 Boroughs Partnership A

Dr S Shah Appointed Governor, Local Medical Committee A

Mrs Maggie Skilling Public Governor, Wigan

Mrs Linda Sykes Public Governor, Leigh

Dr Corinne Taylor-Smith Public Governor, Leigh A A

Mr David Thompson Public Governor, Rest of England and Wales

Mr Geoff Vaughan Public Governor, Leigh A A

Councillor Fred Walker Appointed Governor, Wigan Council

Mrs Mavis Welsh Public Governor, Leigh A A

Dr Gen Wong Appointed Governor, Wigan Borough CCG

Mr James Yates Staff Governor, Other Staff A A

Key:

: attended | A: apologies sent | : did not attend

--- not a member of the council at the date of the meeting

Minutes of a meeting of the Council of Governors held on 30 October 2017 2

In attendance:

Mrs A Arkwright, Head of Engagement

Mrs E Bradbury, Associate Non-Executive Director

Mrs M Fleming, Director of Operations and Performance

Mr R Forster, Director of Finance and Informatics/Deputy Chief Executive

Mr A Foster, Chief Executive

Mr M Guymer, Non-Executive Director

Mr P Howard, Trust Secretary

Mrs C Hudson, Non-Executive Director

Mr J Lloyd, Non-Executive Director

Prof T Warne, Non-Executive Director

The Chair opened by welcoming Howard Gallimore and Alex Hilton to their first meeting of the

Council of Governors.

1. Chair and quorum

Robert Armstrong took the Chair and noted that due notice had been given to all governors

and that a quorum was present. The meeting was declared duly convened and constituted.

2. Apologies for absence

Apologies for absence were received as indicated in the members’ attendance record.

3. Declaration of interests

There were no opening declarations of interest.

4. Minutes of the previous meeting

The minutes of the Council of Governors meeting held on 19 June 2017 were agreed as a true

and accurate record.

5. Chair and Chief Executive’s opening remarks

The Chair referred governors to his written report which had been circulated with the agenda.

There were no questions on the content. He also noted that the organisation was currently

undergoing high levels of regulatory activity, with a Use of Resources assessment being

undertaken by NHS Improvement on 7 November 2017, an unannounced Care Quality

Commission (CQC) inspection expected in the coming few weeks and an announced CQC

well-led inspection over the period 28-30 November 2017.

The Chief Executive delivered a short presentation which covered the following key areas:

Highlights at the mid-year point, including being named as the number one NHS

organisation for 62-day cancer performance and number seven for 18-week referral-to-

treatment performance;

Mid-year lowlights, including pressures in the Accident and Emergency department, a surge

in nurse vacancies and an adverse variance to the financial plan;

A summary of important developments, both within WWL and across the local area;


Areas of focus over the coming months; and

The WWL Way 4wards strategy

A discussion was held on the staffing challenges, particularly within the nursing workforce, and

confirmation was provided that appropriate support is provided by the foundation trust. Diane

Lawrenson commented that, in some areas, staff are experiencing high levels of stress and

note was made of the various initiatives that have been introduced in order to encourage a

greater number of vacant shifts to be filled.

Bill Anderton congratulated WWL on its performance in the recently-released BBC

performance tables.

The Chair summarised this item by acknowledging a national shortage of nurses which has

also been recognised the Secretary of State, and confirmed that WWL is looking at various

options to address this on both a medium- and a long-term basis.

The Council of Governors received the report and noted the content.

6. Performance report

The month 6 corporate performance and finance reports had been circulated with the agenda

for information. Governors were invited to question the Non-Executive Directors in attendance.

In response to a question from Pauline Gregory, Tony Warne provided an overview of the

manner in which the Quality and Safety Committee monitors Methicillin-Sensitive

Staphylococcus Aureus levels and, in response to a supplementary question from Tom Frost,

Carole Hudson provided a summary of the assurance mechanisms in use to ensure the quality

of data. The Council of Governors was pleased to note that committees are not simply reactive,

and that proactive consideration of emergent concerns is undertaken.

In response to a question from Maggie Skilling surrounding the commentary on page 7 of the

performance report, Tony Warne noted that the board had recently discussed the issue of

theatre capacity at its away day and that a subsequent action plan will be reviewed by both

the Quality and Safety and the Finance and Investment Committees. Carole Hudson

described the existence of a perfect storm, with an increased demand for services and a

reduced workforce, and the need for prioritisation and risk assessment was acknowledged.

In response to a question from Bill Anderton on the financial position, Jon Lloyd provided a

summary of the work of the Finance and Investment Committee in monitoring financial

performance and in seeking assurances around areas of underperformance.

With regard to the issue of mortality, Tony Warne confirmed that the Quality and Safety

Committee monitors Hospital Standardised Mortality Rate (HSMR) data on a monthly basis. In

addition, it has recently established a clinically-led mortality working group, including external

representation, to consider the matter in more detail. A summary of the lessons learnt to date

was provided.

Corinne Taylor-Smith noted that the friends and family test question about whether staff would

recommend WWL as a place to work had fallen short of the target, with consistent

underperformance. In response, Jon Lloyd advised that this had been the subject of challenge

by the Non-Executive Directors. The work of the staff engagement team and the development

of a new strategy were cited as examples of how action is being taken to address this issue.


The Council received and noted the verbal update.

7. Development of a subsidiary company

The Director of Finance and Informatics delivered a presentation to brief governors on the

establishment of a subsidiary company, WWL Solutions Limited. The rationale for the

establishment of a subsidiary company was provided, along with a summary of the intended

benefits to WWL.

The Council received the presentation and noted the content.

8. The 9-point plan

The Director of Operations and Performance delivered a presentation to provide assurance to

the Council of Governors around the actions taken by WWL in preparation for winter.

The Council received the presentation and noted the content.

9. Policy on the composition of the Council of Governors

The Trust Secretary presented a draft Policy on the Composition of the Council of Governors,

as required by Annex 3 to the constitution, for approval.

The Council approved the policy as presented.

10. Review of Code of Conduct for Governors

The Trust Secretary presented an updated Code of Conduct for Governors for approval.

The Council approved the revised code of conduct as presented.

11. Update on the NHSI/CQC inspections and well-led review

The Trust Secretary provided a verbal update on the NHSI Use of Resources assessment and

the CQC unannounced inspection and announced well-led inspection.

The Council noted the verbal update.

12. NHS Providers’ Governor Advisory Committee nomination

The Trust Secretary presented a report in order to seek a nominee for the forthcoming elections

to the NHS Providers Governor Advisory Committee.

No nominations were received, and potential candidates were requested to confirm their

interest to the Trust Secretary by 17 November 2017, otherwise no nomination would be put

forward by WWL.

ACTION: All (if interested)

The Council received the report and noted the content.

13. Lead governor

The Trust Secretary presented a report to seek to identify a new lead governor. The Council

of Governors agreed that the role would be undertaken as per the summary contained in

Appendix B to the NHS Foundation Trust Code of Governance, i.e. to be a point of contact for


the regulator when the normal communication channels of Chair/Trust Secretary are not

appropriate.

Following discussion, the Council of Governors appointed Maggie Skilling as lead governor.

The Trust Secretary was directed to inform NHS Improvement of the appointment.

ACTION: Trust Secretary

The Chair and the collective Council of Governors thanked the outgoing lead governor, Pauline

Gregory, for her service in this regard.

14. Cycle of business

The Trust Secretary presented a draft cycle of business for the period 2017-21 for approval.

The Council approved the cycle of business as presented.

15. Items for information

The Council received the following reports for information:

(a) Provision of neurological rehabilitation services from 1 April 2018;

(b) Annual Members’ Meeting 2017; and

(c) Summary governor workshop held on 14 September 2017

16. Resolution to exclude press and public

The Council of Governors resolved to exclude representatives of the press and members of

the public from the remainder of the meeting.

17. Date, time and venue of next meeting

The next meeting of the Council of Governors will be held on 15 January 2018, 5.30pm at

Royal Albert Edward Infirmary.

REPORT

AGENDA ITEM: 7.1

To: Council of Governors Date: 15 January 2018

Subject: Operational and clinical performance

Presented by: Non-Executive Directors Purpose: Assurance

Executive summary

The month 8 corporate performance report (i.e. to 30 November 2017) is attached for information.

This report was presented to the Board of Directors on 20 December 2017 and received detailed

scrutiny by the board at that meeting.

The purpose of presenting the report to the Council of Governors is to not specifically to discuss

performance in detail but rather to provide an overview of performance, to help in holding the Non-

Executive Directors to account for the performance of the board.

Governors are invited to question the Non-Executive Directors around the Board’s discussions,

non-executive challenges and any assurances that may have been been sought.

Risks associated with this report

One of the organisation’s corporate objectives is to meet all national waiting time standards and

targets. This report outlines the risk to achievement of this objective.

Link(s) to The WWL Way 4wards

☐

Patients ☒

Performance

☐

People ☐

Partnerships

Performance Report November 2017

Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) is a major acute Trust serving the people of the Borough of Wigan a population of over 300,000.

The Trust employs approximately 5,000 members of staff, all of whom play their part in delivering high quality, safe and effective patient care from the following facilities:

Royal Albert Edward Infirmary – our main district general hospital site, located in central Wigan, that hosts our Accident and Emergency Department

Wrightington Hospital – a specialist centre of orthopaedic excellence

Leigh Infirmary – an outpatient, diagnostic and treatment centre

Thomas Linacre Centre – a dedicated outpatient centre in central Wigan

WWL Eye Unit – a specialist ophthalmology unit based at Boston House in central Wigan

Change Log

45 2.0 Change of Wording to 'Booked by 12+6 Weeks' on Page 5.1: Midwifery - Part 1 14/11/2017 Mary Fleming BI

44 2.0 Inclusion of GP Streaming Attendances in 4 Hour A&E Breach Performance on NHSI M… 14/11/2017 Mary Fleming BI

43 2.0 Inclusion of GP Streaming Attendances in 4 Hour A&E Breach Performance on Page 3.… 14/11/2017 Mary Fleming BI

42 2.0 Removal of Targets and RAG Ratings for MSSA and E-coli on Page 1.2: Harm Free … 14/11/2017 Pauline Law BI

41 2.0 Removal of 'Diagnostics: Physiological Measurement - Urodynamics - Pressures … 10/08/2017 Mary Fleming BI

40 2.0 Removal of 'Diagnostics: Physiological Measurement - Neurophysiology - Periphe… 10/08/2017 Mary Fleming BI

39 2.0 Removal of 'Diagnostics: Physiological Measurement - Cardiology' from Access P… 10/08/2017 Mary Fleming BI

38 2.0 Removal of 'Diagnostics: Physiological Measurement - Audiology' from Access Pa… 10/08/2017 Mary Fleming BI

37 2.0 Removal of 'Diagnostics: Imaging - Non-Obstetric Ultrasound' from Access Part 2 10/08/2017 Mary Fleming BI

36 2.0 Removal of 'Diagnostics: Imaging - Magnetic Resonance Imaging' from Access Part 2 10/08/2017 Mary Fleming BI

35 2.0 Removal of 'Diagnostics: Imaging - DEXA Scan' from Access Part 2 10/08/2017 Mary Fleming BI

34 2.0 Removal of 'Diagnostics: Imaging - Computed Tomography' from Access Part 2 10/08/2017 Mary Fleming BI

33 2.0 Removal of 'Diagnostics: Imaging - Barium Enema' from Access Part 2 10/08/2017 Mary Fleming BI

32 2.0 Removal of 'Diagnostics: Endoscopy - Gastroscopy' from Access Part 1 10/08/2017 Mary Fleming BI

31 2.0 Removal of 'Diagnostics: Endoscopy - Flexi Sigmoidoscopy' from Access Part 1 10/08/2017 Mary Fleming BI

ID Version No. Change Change Date

Requested By

Authorised By

About the Report

This report is designed to provide a clear insight into the Quality & Performance of the Trusts services.

We hope you find the report intuitive however please feel free to send any queries to [email protected] who will be more than happy to help.

Key Contacts

Andrew FosterRob ForsterMary FlemingPauline LawRichard MundonAlison BalsonSanjay Arya

About the Trust

Chief ExecutiveDeputy Chief Executive & Director of FinanceDirector of Operations & PerformanceDirector of NursingDirector of Strategy & PlanningDirector of WorkforceMedical Director

Report ConsiderationsProvisional Positions

Other

(based on information still being validated)

- 18 weeks, Diagnostics, Total Pay vs Budget, Clinical & Non Clinical Vacancy Rate and Cancer

Date Printed/Run: 13/12/2017 Page 2 of 18

4 3 0 4 11

4 7 0 1 12

4 1 1 3 9

1 3 0 2 6

1 7 0 0 8

0 8 0 1 9

6 0 0 1 7

4 1 0 3 8

0 0 0 4 4

0 4 0 7 11

1 7 0 2 10

1 7 1 1 10

0 2 2 1 5

0 4 1 5 10

1 8 0 1 10

1.1 : Harm Free

1.2 : Harm Free - Infections

2 : Mortality

3.1 : Access

3.2 : Access - Cancer

3.3 : Access - Tumour Pathways

3.4 : Access - A&E

4.1 : Productivity - Part 1

4.2 : Productivity - Part 2

5.1 : Midwifery - Part 1

5.2 : Midwifery - Part 2

6.1 : Patient Experience - Part 1

6.2 : Patient Experience - Part 2

7 : Workforce

NHSI

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Objective

Total

Page(s) NoTarget

27

GreenMetrics

62

AmberMetrics

5

RedMetrics

36

TotalMetrics

130

* Summary based on latest available data ~ RAG based on whether actual is achieving target

Performance against 18 weeks , diagnostics and cancer targets remains strong and the Trust remains in the top 10% in the country for 18 weeks and cancer. Still no grade 3/4 pressure ulcers year to date. Patient Experience Survey - discharge question improved by 29% from last month.

Continued pressures in unscheduled care continues to impact A&E, cancelled operations, stroke performance, theatre effectiveness and length of stay. 1 Never Event in November. Further 2 Clostridum Difficile cases, which took the Trust over the 19 trajectory, with 2 cases judged to be lapses in care.

Highlights

Lowlights

94.52% 96.30% 99.62% 73.11% 21 1 2 1

Target: >=92.0%

Cancer 62 Day:GP Referral

Diagnostics:6 Weeks

A&E:4 Hour Target

C. DifficileInfections Serious Falls Never Events MRSA18 Weeks:

Incomplete

Target: >=85.0%

Target: >=95.0% YTD Target: 11 FY Target:

0 FY Target:

0 FY Target:

0

Month Year To Date

Target: >=99.0%


1.1 : Harm Free Sparkline - Latest 13 MonthsLatest Previous YTD

Commentary (Page Owner : Director of Nursing) *Threshold not confirmed**Threshold not confirmed ~ based on assumption

During November there were four incidents which were reported to the Strategic Executive Information System (StEIS); one of which was a Never Event. Additionally, during November, there was a further Never Event but this was reported to STEIS in December and will feature in December’s Serious Incident figures. During December there was a Never Event identified from October; this again will feature in December’s figures. As at the 11th December, there have been 4 Never Events, year to date. Investigation teams are being established to look into these incidents and action plans will be developed thereafter. There were no breaches to the deadline date for submission to the Commissioners. The Safety Thermometer was undertaken on the 15th November 2017. 401 patients were surveyed, of whom 2% had suffered harm whilst in hospital. 4 patients had a VTE, 1 patient had suffered a grade 2 pressure ulcer, 2 patients had suffered a fall with harm and 1 patient had contracted a CA-UTI.

** 78 Nov-17 98 Oct-17 597 65 111 Nov-16 to Nov-17

** 7 Nov-17 5 Oct-17 50 3 12 Nov-16 to Nov-17

<=0 1 Nov-17 0 Oct-17 2 0 1 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 1 0 1 Nov-16 to Nov-17

** 0 Nov-17 0 Oct-17 0 0 1 Nov-16 to Nov-17

<=0 4 Nov-17 3 Oct-17 20 0 5 Nov-16 to Nov-17

** 5 Nov-17 3 Oct-17 19 0 6 Nov-16 to Nov-17

<=0 1 Nov-17 3 Oct-17 10 0 3 Nov-16 to Nov-17

>=95.0% 98.00% Nov-17 99.00% Oct-17 98.38% 96.56% 99.73% Nov-16 to Nov-17

** 4 Nov-17 1 Oct-17 27 0 8 Nov-16 to Nov-17

>=90.0% 86.04% Nov-17 85.53% Oct-17 84.67% 76.34% 89.04% Nov-16 to Nov-17

Harms: Total

Serious Harms: Total

Serious Harms: Number of Never Events

Serious Harms: Number of Serious Falls

Serious Harms: Grade 3-4 Pressure Ulcers

Number of Serious Incidents

Mod/Low Harms: Hospital Acquired Pressure Ulcer Grade 2

Mod/Low Harms: Number of Moderate Falls

Mod/Low Harms: Safety Thermometer

Mod/Low Harms: Settled Clinical Litigation Cases

Mod/Low Harms: VTE Assessments (% of Admissions)

Metric Title Target Actual Period RAG Trend Actual Period Actual RAG Chart Min.Value

Max.Value Period


1.2 : Harm Free - Infections Sparkline - Latest 13 MonthsLatest Previous YTD


In November 17: 0 MRSA bacteraemia, 2 MSSA bacteraemia, 2 E. coli bacteraemia, 1 Klebsiella bacteraemia, 2 cases C.difficile diarrhoea. Year to date total for C.difficile = 21 cases, which has exceeded the annual reduction target of 19. Two cases judged as "lapses in care" to date. Numbers of other bacteraemia episodes remain low despite significant pressures in the system

** 8 Nov-17 7 Oct-17 64 3 13 Nov-16 to Nov-17

<=2 2 Nov-17 1 Oct-17 21 0 7 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 2 0 1 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 0 0 1 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 0 0 0 Nov-16 to Nov-17

<=0 1 Nov-17 0 Oct-17 5 0 1 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 1 0 1 Nov-16 to Nov-17

** 0 Nov-17 0 Oct-17 0 0 0 May-17 to Nov-17

** 2 Nov-17 1 Oct-17 9 0 3 Nov-16 to Nov-17

** 2 Nov-17 3 Oct-17 16 0 7 Nov-16 to Nov-17

** 1 Nov-17 1 Oct-17 8 0 2 Apr-17 to Nov-17

** 0 Nov-17 1 Oct-17 4 0 1 Apr-17 to Nov-17

Infections/Bacteraemias: Total

Serious Harms: Infections: Clostridium Difficile

Serious Harms: Infections: Clostridium Difficile Lapses in Care

Serious Harms: Infections: Central Line

Serious Harms: Infections: Ventilator Acquired Pneumonia

Infections: Catheter Associated Urinary Tract

Serious Harms: Bacteraemias: MRSA

Serious Harms: Bacteraemias: MRSA - Avoidable Cases

Serious Harms: Bacteraemias: MSSA

Serious Harms: Bacteraemias: E-coli

Bacteraemias: Klebsiella

Bacteraemias: Pseudomonas


Max.Value Period


2 : Mortality Sparkline - Latest 13 MonthsLatest Previous YTD

Commentary (Page Owner : Medical Director) *Threshold not confirmed**Threshold not confirmed ~ based on assumption

This month’s Mortality Data is very similar to last months. We remain around the average HSMR for the country – an improvement from previously. SHMI remains high, but reflects a different, earlier time period. We are able to make predictions about the mortality rates for the months through to November. They will also be average or below average. Crude death rates have been relatively low through these months and the admission rates have been high.

** 1.41% Nov-17 1.34% Oct-17 1.52% 1.30% 2.42% Nov-16 to Nov-17

** 103 Nov-17 98 Oct-17 831 88 155 Nov-16 to Nov-17

** 0 Nov-17 1 Oct-17 4 0 2 Nov-16 to Nov-17

** 28 Nov-17 34 Oct-17 263 24 46 Nov-16 to Nov-17

<=90 119.3 Mar-17 117.5 Dec-16 N/A 108.4 119.3 Dec-15 to Mar-17

<=90 100.3 Aug-17 92.3 Jul-17 N/A 92.3 122.9 Nov-16 to Aug-17

* 105.6 Aug-17 106.3 Jul-17 N/A 103.8 112.8 Mar-17 to Aug-17



Hospital Crude Death Rate

Number of Hospital Deaths

PFD Coroner Notifications

Deaths after Readmission

SHMI over rolling 12 months

HSMR (Latest Month)

HSMR (Latest YTD)

HSMR Weekday

HSMR Weekend


Max.Value Period


3.1 : Access Sparkline - Latest 13 MonthsLatest Previous YTD

Commentary (Page Owner : Director of Operations & Performance) *Threshold not confirmed**Threshold not confirmed ~ based on assumption

All three clinical divisions continue to achieve the 18-week incomplete target in November, despite continued pressures in unscheduled care. In order to help alleviate bed pressures all overnight routine elective cases were cancelled for a two-week period which has impacted specific specialties. The patient who is reported over 52 weeks which was also reported in the previous month will continue to be reported until the patient has their treatment on their chosen date in January. Unfortunately, we did not achieve the 80% stroke target due to two patients not moving to a stroke ward due to continued bed pressures. Yet another strong month for Radiology, with a month end radiology diagnostics position of only 8 patients waiting beyond 6 weeks, an excellent performance considering the volume of activity undertaken by this service.

>=92.0% 94.52% Nov-17 95.03% Oct-17 95.13% 94.52% 96.05% Nov-16 to Nov-17

<=0 1 Nov-17 1 Oct-17 2 0 1 Nov-16 to Nov-17

** 10,615 Nov-17 10,622 Oct-17 N/A 8,992 10,779 Nov-16 to Nov-17

>=60.0% 72.00% Nov-17 82.61% Oct-17 79.71% 50.00% 88.89% Nov-16 to Nov-17

>=80.0% 77.14% Oct-17 79.49% Sep-17 79.10% 75.00% 85.37% Nov-16 to Oct-17

>=99.0% 99.62% Nov-17 99.05% Oct-17 98.85% 97.61% 99.62% Nov-16 to Nov-17

Access: 18 Weeks Referral To Treatment Incomplete Pathway

Access: Referral to Treatment over 52 weeks wait

Outpatients: Backlog of Follow Ups

Stroke - High Risk TIA Patients Treated within 24 Hrs

Stroke - Stroke Patients spending 90% of their Hospital Stay on a Stoke unit

Diagnostics: Patients waiting over 6 weeks


Max.Value Period


3.2 : Access - Cancer Sparkline - Latest 13 MonthsLatest Previous YTD


All 14, 31 and 62-day Cancer Waiting times targets have been achieved for October 2017. Our 62-day performance remains consistent with over 90% of suspected cancer GP referrals, consultant upgrades and screening patients treated within 62 days. We have had 1.5 accountable breaches of the 62-day standard in October. These have been reviewed to identify the cause and where applicable make improvements. One of the breaches was mainly due to diagnostic delays and repeat tests that were required to gain a definitive diagnosis. The other was a shared breach with the treating trust which was patient choice to be treated beyond day 62.

>=93.0% 97.44% Nov-17 97.42% Oct-17 96.85% 95.65% 99.19% Nov-16 to Nov-17

>=93.0% 97.60% Nov-17 93.52% Oct-17 95.78% 93.52% 97.60% Nov-16 to Nov-17

>=96.0% 100.00% Nov-17 100.00% Oct-17 99.52% 98.92% 100.00% Nov-16 to Nov-17

>=98.0% 100.00% Nov-17 100.00% Oct-17 100.00% 100.00% 100.00% Nov-16 to Nov-17

>=94.0% 100.00% Nov-17 100.00% Oct-17 100.00% 100.00% 100.00% Nov-16 to Nov-17

** 95.41% Nov-17 96.30% Oct-17 94.49% 92.31% 100.00% Nov-16 to Nov-17

>=85.0% 96.30% Nov-17 96.30% Oct-17 93.01% 85.23% 98.15% Nov-16 to Nov-17

>=90.0% 96.55% Nov-17 100.00% Oct-17 98.90% 95.35% 100.00% Nov-16 to Nov-17

Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected)Two week wait from referral to date first seen: symptomatic breast patients (cancer not initally suspected)

All Cancers: 31 day wait for diagnosis to first treatment

All Cancers: 31 day wait for second or subsequent treatment: anti cancer drug treatmentsAll Cancers: 31 day wait for second or subsequent treatment: surgeryAll Cancers: 62 Day Cancer Standard Treated - Pre AllocationAll Cancers: 62 day wait for first treatment from urgent GP referral to treatmentAll Cancers: 62 day wait for first treatment from consultant screening service referral


Max.Value Period


3.3 : Access - Tumour Pathways Sparkline - Latest 13 MonthsLatest Previous YTD


All 14, 31 and 62-day Cancer Waiting times targets have been achieved for October 2017. Our 62-day performance remains consistent with over 90% of suspected cancer GP referrals, consultant upgrades and screening patients treated within 62 days. We have had 1.5 accountable breaches of the 62-day standard in October. These have been reviewed to identify the cause and where applicable make improvements. One of the breaches was mainly due to diagnostic delays and repeat tests that were required to gain a definitive diagnosis. The other was a shared breach with the treating trust which was patient choice to be treated beyond day 62.

>=85.0% 100.00% Oct-17 100.00% Sep-17 100.00% 100.00% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 100.00% Sep-17 95.74% 60.00% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 71.43% Sep-17 94.29% 55.56% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 100.00% Sep-17 75.00% 0.00% 100.00% Nov-16 to Oct-17

>=85.0% 33.33% Oct-17 100.00% Sep-17 85.71% 33.33% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 100.00% Sep-17 91.67% 60.00% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 100.00% Sep-17 100.00% 100.00% 100.00% Nov-16 to Oct-17

>=85.0% 100.00% Oct-17 76.47% Sep-17 72.09% 40.00% 100.00% Nov-16 to Oct-17

>=85.0% 92.31% Oct-17 100.00% Sep-17 97.33% 83.33% 100.00% Nov-16 to Oct-17

Cancer - Breast 62 Day Wait

Cancer - Colorectal 62 Day Wait

Cancer - Gynaecology 62 Day Wait

Cancer - Haematology 62 Day Wait

Cancer - Head & Neck 62 Day Wait

Cancer - Lung 62 Day Wait

Cancer - Skin 62 Day Wait

Cancer - Upper GI 62 Day Wait

Cancer - Urology 62 Day Wait


Max.Value Period


3.4 : Access - A&E Sparkline - Latest 13 MonthsLatest Previous YTD


Despite a reduction in the number of attendances to A&E, the position in November worsened when compared with the previous month. Performance for the Trust at 73.11% remains significantly lower than expected, and is 81.37% when including the Leigh Walk-in Centre activity. An intensive program of work is ongoing in order to refine the Health Information system in and work is also ongoing to ensure flow from A&E to inpatient areas is efficient as possible and bed capacity meets demand. Although the out of area attendances have seen a reduction they have not returned to levels seen prior to pressures in neighbouring Trusts.

>=95.0% 73.11% Nov-17 79.98% Oct-17 85.03% 73.11% 92.66% Nov-16 to Nov-17

** 6,959 Nov-17 7,460 Oct-17 59,435 6,604 7,796 Nov-16 to Nov-17

** 232.0 Nov-17 240.6 Oct-17 243.6 221.0 257.9 Nov-16 to Nov-17

** 865 Nov-17 937 Oct-17 7,189 787 968 Nov-16 to Nov-17

** 312 Oct-17 318 Sep-17 2,013 254 373 Nov-16 to Oct-17

* 2,201 Nov-17 2,291 Oct-17 17,609 1,761 2,291 Nov-16 to Nov-17

* 31.08% Nov-17 28.72% Oct-17 30.51% 28.72% 34.34% Nov-16 to Nov-17

4 Hour A&E Breach Performance % (inc GP Streaming Activity)

Number of A&E Attendances

Average Daily A&E Attendances

A&E Attendances: Out of Area

NWAS: Conveyances from Care Homes

A&E Attendances that result in an admission

A&E Attendances: % Result in Admissions - Aged 75+


Max.Value Period


4.1 : Productivity - Part 1 Sparkline - Latest 13 MonthsLatest Previous YTD


There has been a slight improvement in patients having their outpatient appointments cancelled. There are a variety of reasons why appointments are cancelled and this will include appointments brought forward or booked into a more appropriate clinic. We have however seen an increase in the number of operations cancelled which is representative of the pressures in unscheduled care and D&V outbreak on the Wrightington site. The average length of stay for elective patients in Surgery reduced to 1.3 days in November, as a result of cancelling inpatient cases to help ease the bed pressures. Average Length of Stay for Primary joint replacement is static at 4 days. Projects are underway to improve the provision of Enhanced Recovery to further reduce Length of Stay.

<=5.0% 6.94% Nov-17 7.09% Oct-17 6.95% 5.97% 7.87% Nov-16 to Nov-17

<=0.0% 5.40% Nov-17 5.47% Oct-17 5.36% 4.67% 6.13% Nov-16 to Nov-17

<=0.8% 1.71% Nov-17 1.67% Oct-17 1.70% 1.17% 2.65% Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 0 0 0 Nov-16 to Nov-17

* 3.8 Days Nov-17 3.3 Days Oct-17 3.3 Days 3.0 Days 3.8 Days Nov-16 to Nov-17

* 3.7 Days Nov-17 3.4 Days Oct-17 3.9 Days 3.4 Days 5.0 Days Nov-16 to Nov-17

** 42 Nov-17 47 Oct-17 339 29 64 Feb-17 to Nov-17

** 138 Nov-17 197 Oct-17 1,493 131 253 Feb-17 to Nov-17

Hospital Cancelled OP Appointments %

Hospital Cancelled OP Appointments < 6 weeks

Cancelled Operations %

Cancelled Operations: 2nd Urgent Hospital

Average Spell Length of Stay (Elective Inpatient)

Average Spell Length of Stay (Non Elective)

Delayed Transfers of Care

Delayed Transfer of Care Days


Max.Value Period


4.2 : Productivity - Part 2 Sparkline - Latest 13 MonthsLatest Previous YTD


Theatre effectiveness across the RAEI and Wrightington sites is lower than the previous month, primarily due to a high number of on the day cancellations due to continued pressures in unscheduled care and a D&V outbreak on the Wrightington site. The Leigh site remained unaffected and saw a slight increase in theatre effectiveness, this is expected to increase in January when an additional theatre closes.

>=70.0% 62.05% Nov-17 65.90% Oct-17 N/A 60.83% 67.00% Nov-16 to Nov-17




Theatre Effectiveness % - Total

Theatre Effectiveness % - RAEI

Theatre Effectiveness % - Wrightington

Theatre Effectiveness % - Leigh


Max.Value Period


5.1 : Midwifery - Part 1 Sparkline - Latest 13 MonthsLatest Previous YTD


There has been an increase in bookings, however, the number of births has remained within the target parameters. The midwife to birth ratio based on Birth rate + is at 1:29 and below the 1:28 recommendations. The Induction Of Labour rate remains consistently high due to the thresholds of the reduced fetal movements /fetal growth pathways. A Regional review of the reduced fetal movement pathway is currently in progress.

<=1.30 1.29 Nov-17 1.29 Oct-17 N/A 1.25 1.29 Nov-16 to Nov-17


>=240 256 Oct-17 226 Sep-17 1,722 0 280 Nov-16 to Nov-17

>=90.0% 89.43% Oct-17 87.61% Sep-17 N/A 87.61% 97.15% Nov-16 to Oct-17

<=30.0% 32.21% Nov-17 36.07% Oct-17 N/A 29.46% 40.50% Nov-16 to Nov-17


>=8 10 Nov-17 17 Oct-17 98 5 19 Nov-16 to Nov-17





Maternity: Midwife / Birth Ratio

Maternity: Skills drills/2 day Mandatory Training Attendance

Maternity: Total monthly bookings

Maternity: Booked by 12+6 Weeks

Maternity: Induction of Labour

Maternity: Normal Deliveries

Maternity: Water Births

Maternity: Instrumental Deliveries

Maternity: Elective Caesarean Sections

Maternity: Emergency / Non Elective Caesarean Sections

Maternity: Total Caesarean Sections


Max.Value Period


5.2 : Midwifery - Part 2 Sparkline - Latest 13 MonthsLatest Previous YTD


Booking by 12+6 weeks’ gestation remains below 90% for the third consecutive month. A full review is in progress to explore reasons and for us to address accordingly. There are no known issues with clinic booking capacity. The total caesarean section rate has increased in November. However, there has been significant reduction of 5.28% in elective caesarean sections. Three quarters of the total caesarean sections have been emergency deliveries. There has been a decrease of 4.61% in instrumental births. A further increase of 1.4% in the initiation of breast feeding is noted, however, it is still below the Trust target of 55%. Continued work to promote breast feeding initiation and maintenance is ongoing supported by the infant feeding team. Mandatory training has exceeded the planned trajectory for 2 consecutive months with continued plans to increase training compliance that will address the deficits from previous months.

>=240 241 Nov-17 259 Oct-17 1,924 204 270 Nov-16 to Nov-17




<=1.8 1.7 Nov-17 1.6 Oct-17 N/A 1.5 1.8 Nov-16 to Nov-17

<=1 0 Nov-17 0 Oct-17 3 0 4 Nov-16 to Nov-17

<=5 2 Nov-17 1 Oct-17 11 0 3 Nov-16 to Nov-17

<=2 3 Nov-17 1 Oct-17 5 0 3 Nov-16 to Nov-17

<=2 1 Nov-17 3 Oct-17 11 0 3 Nov-16 to Nov-17

* 0 Nov-17 0 Oct-17 1 0 1 Dec-16 to Nov-17

Maternity: Total Births

Maternity: Episiotomy with normal birth

Maternity: 3rd/4th degree tears

Maternity: Initiation of breastfeeding

Maternity: Average post-natal length of stay

Maternity: Still Births (>24 weeks)

Maternal Readmissions within 30 Days

Maternal admissions to ICU

Maternity Complaints

Maternity: New Claims


Max.Value Period


6.1 : Patient Experience - Part 1 Sparkline - Latest 13 MonthsLatest Previous YTD


During November, 20 out of the 30 complaint responses were sent within the timescales agreed with the complainant at the start of the complaints process (67%), representing a decrease in performance when compared with last month. No reports were issued by the Parliamentary Health Service Ombudsman (PHSO). Comprehensive, open and transparent responses to complainants are incredibly important and improve patient experience and satisfaction. For Real Time Patient Survey commentary, please see overleaf.

** 0 Nov-17 0 Oct-17 0 0 2 Nov-16 to Nov-17

** 66.67% Nov-17 75.00% Oct-17 69.74% 48.48% 92.00% Nov-16 to Nov-17

>=90.0% 88.00% Nov-17 93.02% Oct-17 93.25% 88.00% 97.22% Nov-16 to Nov-17

>=90.0% 76.00% Nov-17 89.15% Oct-17 86.69% 76.00% 90.71% Nov-16 to Nov-17

>=90.0% 90.00% Nov-17 96.90% Oct-17 95.29% 90.00% 98.40% Nov-16 to Nov-17

>=90.0% 96.00% Nov-17 96.12% Oct-17 97.69% 96.00% 100.00% Nov-16 to Nov-17

>=90.0% 94.00% Nov-17 89.92% Oct-17 93.25% 87.10% 97.73% Nov-16 to Nov-17

>=90.0% 98.00% Nov-17 96.12% Oct-17 95.75% 88.64% 99.26% Nov-16 to Nov-17

>=90.0% 94.00% Nov-17 96.12% Oct-17 96.67% 93.50% 99.40% Nov-16 to Nov-17

>=90.0% 92.00% Nov-17 100.00% Oct-17 98.98% 92.00% 100.00% Nov-16 to Nov-17

Number of Complaints Upheld by Ombudsman

Percentage of Complaints Responded to on Time

RTPS: Did you find someone to talk to about your worries and fears?RTPS: Do you know which Doctor/Consultant is treating or looking after you?RTPS: Do you think the hospital staff did everything they could to help control your pain?RTPS: During your stay have you been treated with compassion by the hospital staff?

RTPS: Has there been healthy food on the hospital menu?

RTPS: Have staff treating and examining you introduced themselves?RTPS: Have you always had access to a call bell when you needed it?RTPS: Have you been given enough privacy when being examined treated or discussing your care?


Max.Value Period


6.2 : Patient Experience - Part 2 Sparkline - Latest 13 MonthsLatest Previous YTD


In relation to the Real Time Patient Survey, the discharge question improved significantly (29.09%), the highest score recorded for this metric. On the whole, the results for November on average have decreased slightly with 8 out of 13 questions decreasing, including privacy and dignity which had previously been at 100%. Three of the larger decreases in scores were pain control, being given the care and treatment required when the patient felt they needed it most (both have previously scored well) and knowledge of which consultant is currently treating you.

>=90.0% 88.00% Nov-17 96.12% Oct-17 96.77% 88.00% 100.00% Nov-16 to Nov-17

>=90.0% 88.00% Nov-17 58.91% Oct-17 65.80% 55.88% 88.00% Nov-16 to Nov-17

>=90.0% 84.00% Nov-17 82.17% Oct-17 90.76% 82.17% 95.17% Nov-16 to Nov-17

>=90.0% 96.00% Nov-17 98.45% Oct-17 96.95% 95.00% 99.24% Nov-16 to Nov-17

>=90.0% 96.00% Nov-17 95.35% Oct-17 94.45% 88.82% 96.00% Nov-16 to Nov-17

RTPS: Have you been given the care you felt you required when you needed it most?RTPS: Have you been involved as much as you wanted to be about your discharge home?RTPS: Have you been involved as much as you wanted to be in decisions about your care and treatment?RTPS: Have you been offered a choice of food during your stay?RTPS: If your family or someone else close to you wanted to talk to a doctor did they have enough opportunity to do …


Max.Value Period


7 : Workforce Sparkline - Latest 13 MonthsLatest Previous YTD

Commentary (Page Owner : Director of Workforce) *Threshold not confirmed**Threshold not confirmed ~ based on assumption

Rolling 12-month sickness from Nov 16 - Oct 17 has increased marginally to 4.23% (compared to 4.21% last reported). The in-month sickness for Oct 17 has also increased to 4.44% (from 3.98% last reported). Temporary spend in Nov 17 has increased to £1,453k from £1,211k in Oct 17 (an increase of £242k). The results of the October 2017 Staff Engagement Quarterly Pulse Check highlights an increased level of engagement within the Trust since the previous quarter.

<=£ 457 k £ 474 k Nov-17 £ 358 k Oct-17 £ 3,100 k £ 298 k £ 615 k Nov-16 to Nov-17

>=80.0% 83.11% Nov-17 83.11% Oct-17 N/A 80.55% 83.33% Jan-17 to Nov-17

>=75.0% 73.78% Nov-17 73.78% Oct-17 N/A 70.83% 75.99% Jan-17 to Nov-17

<=£ 0 k £ 1,676 k Nov-17 £ 1,270 k Oct-17 £ 7,773 k £ -25 k £ 1,676 k Nov-16 to Nov-17

<=4.5% 6.23% Nov-17 6.05% Oct-17 6.52% 2.62% 7.31% Dec-16 to Nov-17

<=4.0% 4.44% Oct-17 3.98% Sep-17 4.08% 3.77% 4.69% Nov-16 to Oct-17

>=4.00 4.02 Nov-17 4.02 Oct-17 N/A 0.00 4.02 Nov-16 to Nov-17


>=100.0% 11.19% Nov-17 13.26% Oct-17 N/A 11.19% 20.59% Nov-16

to Nov-17


Agency vs NHSI Ceiling

Friends & Family Test - Recommendation as place for treatment

Friends & Family Test - Recommendation as place to work

Total Pay vs Budget

Clinical & Non Clinical Overall Vacancy Rate

Sickness absence - Total

Quarterly Engagement Score

Appraisals over rolling 12 months

Job Plan Compliance over rolling 12 months

Mandatory Training over rolling 12 months


Max.Value Period


Sparkline - Latest 13 MonthsLatest PreviousNHSI Metrics YTD

*Threshold not confirmed**Threshold not confirmed ~ based on assumptionThe updated Single Oversight Framework has been published, this will be reviewed and metrics developed accordingly.

>=95.0% 73.11% Nov-17 79.98% Oct-17 85.03% 73.11% 92.66% Nov-16 to Nov-17

>=92.0% 94.52% Nov-17 95.03% Oct-17 95.13% 94.52% 96.05% Nov-16 to Nov-17

>=99.0% 99.62% Nov-17 99.05% Oct-17 98.85% 97.61% 99.62% Nov-16 to Nov-17

>=93.0% 97.44% Nov-17 97.42% Oct-17 96.85% 95.65% 99.19% Nov-16 to Nov-17

>=93.0% 97.60% Nov-17 93.52% Oct-17 95.78% 93.52% 97.60% Nov-16 to Nov-17

** 95.41% Nov-17 96.30% Oct-17 94.49% 92.31% 100.00% Nov-16 to Nov-17

>=85.0% 96.30% Nov-17 96.30% Oct-17 93.01% 85.23% 98.15% Nov-16 to Nov-17

>=90.0% 96.55% Nov-17 100.00% Oct-17 98.90% 95.35% 100.00% Nov-16 to Nov-17

<=2 2 Nov-17 1 Oct-17 21 0 7 Nov-16 to Nov-17

<=0 0 Nov-17 0 Oct-17 2 0 1 Nov-16 to Nov-17

4 Hour A&E Breach Performance % (inc GP Streaming Activity)Access: 18 Weeks Referral To Treatment Incomplete Pathway

Diagnostics: Patients waiting over 6 weeks

Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected)Two week wait from referral to date first seen: symptomatic breast patients (cancer not initally suspected)All Cancers: 62 Day Cancer Standard Treated - Pre AllocationAll Cancers: 62 day wait for first treatment from urgent GP referral to treatmentAll Cancers: 62 day wait for first treatment from consultant screening service referral

Serious Harms: Infections: Clostridium Difficile

Serious Harms: Infections: Clostridium Difficile Lapses in Care

MetricTitle Target Actual Period RAG Trend Actual Period Actual RAG Chart Min.Value

Max.Value Period


REPORT

AGENDA ITEM: 7.2


Subject: Financial performance as at 30 November 2017

Presented by: Non-Executive Directors Purpose: Assurance

Executive summary

The finance report (as at 30 November 2017) is attached for information. Like the performance

report, this report was presented to the Board of Directors on 20 December 2017 and received

detailed scrutiny at that meeting.

Governors are invited to ask questions of the Non-Executive Directors.


One of the organisation’s corporate objectives is to achieve two-year budget stability. This report

outlines the risk to achievement of this objective.


☐

Patients ☒

Performance

☐

People ☐

Partnerships

Finance report

Finance Report Month 8

Page 2 of 6

Contents

Executive Summary ....................................................................................................... 3 1.

Capital Expenditure & Statement of Financial Position ................................................... 3 2.

Cash, Liquidity and UOR ................................................................................................ 3 3.

Appendix 1 – I&E Summary .................................................................................................. 4

Appendix 2 – Statement of Financial Position ....................................................................... 5

Appendix 3 – Cash Flow Statement ...................................................................................... 6


Page 3 of 6

Executive Summary 1.

The Trust is reporting a year to date trading deficit (pre impairments) of £3.3m which 1.1.is £1.9m worse than plan.

After impairments the Trust is reporting a technical deficit of £4.4m which is £3.0m 1.2.behind plan.

Cumulative income of £197.1m is £5.6m better than plan. 1.3.

Cumulative expenditure is £200.4m which is £7.5m worse than plan. 1.4.

The UOR rating for the Trust in month is a 2 which is behind the plan of 1. 1.5.

The Income & Expenditure summary can be seen at Appendix 1. 1.6.

Capital Expenditure & Statement of Financial Position 2.

The Trust has spent £3.2m on capital expenditure versus planned expenditure of 2.1.£4.4m.

The statement of financial position can be found in Appendix 2. 2.2.

Cash, Liquidity and UOR 3.

The cash balance is £11.1m, which is £5.1m higher than the planned balance. 3.1.

The UOR rating is a 2 against a plan of 1. YTD the UOR rating is a 3 against a plan 3.2.of 2.

The cash flow statement can be found in Appendix 3. 3.3.

Key Metrics Actual Plan Var Actual Plan Var

UOR 2 1 (1) 3 2 (1)

Operating Surplus / (Deficit) 359 818 (459) (3,309) (1,415) (1,894)

Capital Expenditure 315 312 (3) 3,247 4,458 1,211

Cash 11,085 5,984 5,101 11,085 5,984 5,101

In Month - £000 Year to Date - £000


Page 4 of 6

Appendix 1 – I&E Summary

Actual Plan Var Actual Plan Var

Income

A & E Attendances 978 966 11 7,620 7,700 (79)

Daycase 2,863 2,987 (124) 22,076 22,937 (861)

Elective 2,399 2,764 (365) 20,391 21,247 (856)

Non Electives 5,021 4,632 388 39,712 37,129 2,583

Outpatients 3,721 3,927 (206) 28,400 30,174 (1,773)

Other** 11,275 9,380 1,895 78,896 72,334 6,562

Total Income 26,257 24,657 1,600 197,095 191,521 5,575

Operating Expenses

Pay (16,945) (15,425) (1,520) (131,040) (124,902) (6,138)

Non Pay (8,659) (8,040) (619) (66,995) (64,659) (2,335)

Reserves 0 (75) 75 0 (981) 981

Total Operating Expenses (25,604) (23,540) (2,065) (198,035) (190,542) (7,493)

EBITDA 653 1,117 (464) (940) 978 (1,918)

EBITDA % 2.5% 4.5% (2.0)% (0.5)% 0.5% (1.0)%

Non Operating Expenses (294) (299) 5 (2,369) (2,393) 24

Surplus / (Deficit) 359 818 (459) (3,309) (1,415) (1,894)

Surplus / (Deficit )% 1.4% 3.3% (2.0)% (1.7)% (0.7)% (0.9)%

Impairment (19) 0 (19) (1,061) 0 (1,061)

Tech Surplus/ Def 340 818 (478) (4,370) (1,415) (2,955)

In Month - £000 Year to Date - £000


Page 5 of 6

Appendix 2 – Statement of Financial Position

Opening

31.03.17 -

£'000

Full Year

31.03.18 -

£'000

Actual Actual Plan Variance Last month Movement Plan

Non-current assets

148,658 Property, plant and equipment 146,799 172,813 (26,014) 146,893 (94) 173,408

2,413 Intangibles 1,788 1,849 (61) 2,003 (215) 1,596

169 Trade and other non-current receivables 362 425 (63) 735 (373) 425

151,240 148,949 175,087 (26,138) 149,631 (682) 175,429

Current assets

4,121 Inventories 4,364 4,810 (446) 4,170 194 4,810

25,230 Trade and other receivables 20,112 17,228 2,884 17,960 2,152 11,886

11,669 Cash and cash equivalents 11,085 5,984 5,101 10,795 290 8,209

41,020 35,561 28,022 7,539 32,925 2,636 24,905

192,260 Total assets 184,510 203,109 (18,599) 182,556 1,954 200,334

Current liabilities

(28,711) Trade and other payables (26,911) (27,537) 626 (25,351) (1,560) (25,977)

(4,420) Borrowings (4,421) (2,538) (1,883) (4,421) 0 (2,538)

(329) Provisions (338) (1,361) 1,023 (367) 29 (1,517)

(1,535) Other liabilities (1,942) (2,031) 89 (1,860) (82) (2,031)

(34,995) (33,612) (33,467) (145) (31,999) (1,613) (32,063)

6,025 Net current assets/(liabilities) 1,949 (5,445) 7,394 926 1,023 (7,158)

157,265 Total assets less current liabilities 150,898 169,642 (18,744) 150,557 341 168,271

Non-current liabilities

(25,819) Borrowings (23,545) (25,377) 1,832 (23,545) 0 (23,279)

(3,154) Provisions (2,927) (2,820) (107) (2,927) 0 (2,820)

(300) Other liabilities (150) (150) 0 (150) 0 (150)

(29,273) (26,622) (28,347) 1,725 (26,622) 0 (26,249)

127,992 Total assets employed 124,276 141,295 (17,019) 123,935 341 142,022

Financed by

Taxpayers' equity

95,806 Public dividend capital 96,456 95,806 650 96,456 0 95,806

22,823 Revaluation reserve 22,823 32,410 (9,587) 22,823 0 32,410

9,363 Retained earnings 4,997 13,079 (8,082) 4,656 341 13,806

127,992 Total taxpayers' equity 124,276 141,295 (17,019) 123,935 341 142,022

Movement to previous

month - £'000In Month - £'000


Page 6 of 6

Appendix 3 – Cash Flow Statement

Full Year -

£'000

Actual Plan Variance Actual Plan Variance Plan

Opening cash 10,795 3,359 7,436 11,669 9,422 2,247 9,422

Operating activities

Technical surplus / (deficit) 340 816 (476) (4,370) (1,416) (2,954) (687)

Net interest accrued 27 32 (5) 255 260 (5) 384

PDC dividend expense 263 346 (83) 2,103 2,768 (665) 4,153

Unwinding of discount 4 4 0 29 32 (3) 48

Operating surplus / (deficit) per annual accounts 634 1,198 (564) (1,983) 1,644 (3,627) 3,898

Depreciation and amortisation 605 647 (42) 4,691 5,179 (488) 7,767

Impairments / (impairment reversals) 19 0 19 1,061 0 1,061 0

(Gain) / loss on disposal 0 0 0 (19) 0 (19) 0

Non cash donations/grants credited to income 0 (10) 10 (26) (80) 54 (120)

Changes in working capital

(Inc)/Dec in Inventories (194) 0 (194) (243) 0 (243) 0

(Inc)/Dec in trade & other receivables (1,775) 961 (2,736) 4,566 (3,314) 7,880 2,033

Inc/(Dec) in trade & other payables 1,264 104 1,160 (1,880) 1,919 (3,799) 1,100

Inc/(Dec) in other liabilities 82 0 82 257 0 257 0

Inc/(Dec) in provisions (33) 35 (68) (249) 281 (530) 422

Other movements in operating cash flows 0 0 0 0 0 0 0

Investing activities

Interest received 3 2 1 22 20 2 30

Purchase of non-current assets (315) (312) (3) (3,247) (4,458) 1,211 (7,330)

Proceeds from sale of equipment 0 0 0 23 0 23 0

Financing activities

Public dividend capital received 0 0 0 650 0 650 0

Loans received from ITFF 0 0 0 0 0 0 0

Other loans received 0 0 0 124 0 124 0

Loan principal repaid 0 0 0 (2,397) (2,324) (73) (4,422)

Interest paid 0 0 0 (219) (229) 10 (438)

PDC dividend paid 0 0 0 (1,715) (2,076) 361 (4,153)

Total net cash inflow / (outflow) 290 2,625 (2,335) (584) (3,438) 2,854 (1,213)

Closing cash 11,085 5,984 5,101 11,085 5,984 5,101 8,209

In Month - £'000 Year to Date - £'000

REPORT

AGENDA ITEM: 7.3


Subject: Agreement of locally-determined indicator for Quality Account 2017-18

Presented by: R Armstrong Purpose: Approval

Executive summary

Further to the workshop held on 27 November 2017 where the matter of the locally-determined

indicator for the Quality Account was discussed in detail, a report is attached for the Council of

Governors’ consideration and agreement of the locally-determined indicator.


The Council of Governors is required to identify a locally-determined indicator for the Quality

Account 2017-18, and the report seeks to ensure that this is completed in a timely manner.


☒

Patients ☒

Performance

☐

People ☐

Partnerships

1. Introduction

Every year NHS trusts are required to publish Quality Accounts. NHS trusts are requested

to seek external audit testing on the data quality of indicators published in the Quality

Account:

2 nationally mandated indicators

1 locally determined indicator (LDI) selected by the Council of Governors

The purpose of selecting an LDI is to review the data quality behind how the indicator is

reported. External Auditors consider the following:

Accuracy: Is data recorded correctly and is it in line with the methodology?

Validity: Has the data been produced in compliance with relevant requirements?

Reliability: Has data been collected using a stable process in a consistent manner over

a period of time?

Timeliness: Is data captured as close to the associated event as possible and available

for use within a reasonable time period?

Relevance: Does all data used generate the indicator meet eligibility requirements as

defined by guidance?

Completeness: Is all relevant information, as specific in the methodology, included in

the calculation?

2. What makes a Good Indicator?

An LDI should be an established indicator that enables external auditors to test to objective

evidence. The performance against the indicator should be factual and not dependent on

clinical judgement.

3. Governors Workshop November 2017

The Associate Director of Governance attended a Governors’ workshop on 27 November

2017 to commence the selection of the LDI. A number of actions were agreed:

3.1 Feedback to Deloitte (the External Auditors) from Governors

Governors expressed concerns regarding how the feedback was provided to

Governors following last year’s audit of the LDI: VTE (venous thromboembolism) risk

assessments completed within 24 hours of admission). Governors explained that

Deloitte did not present the findings in ‘layman’s terms’. The Associate Director of

Governance provided this feedback to Alexandra Gent, Deloitte Manager on 6

December 2017.

3.2 Re-circulation of the last years Deloitte Report

Governors requested that last year’s report outlining Deloitte findings was re-

circulated to Governors. This has been completed.

3.3 An update on progress to resolve VTE risk assessment data quality concerns

Following the selection of this indicator by the Governors as the LDI last year,

performance improved. The Trust is currently at 85% compliance with VTE risk

assessments being undertaken within 24 hours; however, concerns remain regarding

data quality.

The solution requires the programme that captures the date to be rebuilt. The trust

will then be able to accurately identify whether the target is being met and which areas

to focus on to continue to improve performance.

3.4 A view from the Medical Director and Director of Nursing

Governors requested a view from the Medical Director and Director of Nursing

regarding which three indicators they would place the most importance on in terms of

ensuring correct data quality and impact on patient harm. The Medical Director and

Director of Nursing have selected the following:

Sepsis: Red flag sepsis patients receive antibiotics within 1 hour;

MEWS (Modified Early Warning System): To achieve 100% compliance with

appropriate frequency of observations and escalation of the deteriorating

patient.

Hospital Readmissions: The percentage of patients readmitted to a hospital

which forms part of the trust within 28 days of being discharged from hospital

3.5 Internal and External Audit

Governors requested information on whether the above indicators selected by the

Medical Director and Director of Nursing have previously been subject to internal or

external audit. This information is provided in the table below:

‘Top 3’ Indicators Selected by the

Medical Director and Director of

Nursing

Internal or External Audit

Red flag sepsis patients receive

antibiotics within 1 hour.

The data for this indicator is collected

by a clinical audit and reported

externally to Wigan Borough Clinical

Commissioning Group as a CQUIN

(Commissioning Quality and

Innovation) indictor. The data quality

has not been subject to an audit my

Deloitte (external auditors) or

Merseyside Internal Audit (MIAA)

Agency.

‘Top 3’ Indicators Selected by the

Medical Director and Director of

Nursing

Internal or External Audit

To achieve 100% compliance with

appropriate frequency of observations

and escalation of the deteriorating

patient.

The data for this indicator is collected

by a clinical audit and Trust

performance will be reported externally

in the Trust Quality Account published

in June 2018 as it is a quality priority for

2017-18. The data quality has not been

subject to an audit my Deloitte (external

auditors) or Merseyside Internal Audit

(MIAA) Agency.

The percentage of patients readmitted

to a hospital which forms part of the

trust within 28 days of being discharged

from hospital.

This indicator was the LDI selected by

Governors for three consecutive years

prior to last year; therefore it was

subject to data quality testing by

Deloitte as part of the Quality Account

process.

4. Recommendations

Following provision of the information requested at the Governor Workshop outlined above,

the Council of Governors is requested to select this year’s LDI.

Documents

Agenda...Members’ attendance record 2017-18: 7 7 8 Mr Robert Armstrong Chair (in the Chair) Mr Bill Anderton Public Governor, Wigan Mrs Helen Ash Public Governor, Makerfield A Mr