Board of Directors' Part 1 Agenda - 25 April 2018 · 25/04/2018 · Minutes ± Board of Directors 28 March 2018 3/11 Ref Item Action 151 The Chief Executive highlighted the following

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BOARD OF DIRECTORS

Wednesday 25 April 2018 Board Room, Aintree Lodge

9am

AGENDA v = verbal d = document p = presentation

© = consent agenda item

Time Item Lead Reference

PRELIMINARY BUSINESS

9.00 1. Apologies for Absence

To note the apologies for absence Chairman B18-19/001 (v)

2. Declarations of Interest

To receive declarations of interest in agenda items and / or any

changes to the register of directors’ declarations of interest

pursuant to Section 7 of Standing Orders

Chairman B18-19/002 (v)

3. Minutes of the Previous Meeting (28 March 2018)

To approve the minutes of the Board of Directors, review the

Board Action Log and discuss any matters arising

Chairman B18-19/003 (d)

9.05 4. Patient, Staff and Volunteer Story

To note Chief Nurse B18-19/004 (v)

STRATEGIC CONTEXT

9.20 5. Chief Executive’s Report

To note Chief Executive B18-19/005 (d)

9.35 6. Board Assurance Framework

• Q4 2017/18

To note

Director Corporate Governance

B18-19/006 (d)

QUALITY & SAFETY

9.50 7. Quality Committee – Assurance Report (16 April 2018)

To discuss and note the report and gain assurance from the

Committee, with particular focus on the following reports and key

risk areas:

• Safeguarding Services – Risk Update

• CQC Improvement Plan - Update

Committee Chair

Chief Nurse

B18-19/007 (d)

B18-19/008 (d)

B18-19/009 (d)

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Aintree University Hospital NHS Foundation Trust

Item Lead Reference

Board Agenda: 25 April 2018 2/3

FINANCE & PERFORMANCE

10.00 8. Finance & Performance Committee – Assurance

Report (26 April 2018)

To discuss and note the report and gain assurance from the

Committee, with particular focus on the following reports and key

risk areas:

• Corporate Performance Report (March 2018)

• Non-Elective Flow Programme (including Ernst & Young Report)

• Finance Report (March 2018)

Committee Chair

Chief Operating Officer


Director of Finance

B18-19/010 (d)

B18-19/011 (d)

B18-19/012 (p/d)

B18-19/013 (d)

GOVERNANCE/WELL LED

© 9. Annual Business Plan – Progress Report Q4 2017/18

To note

Director of Finance

B18-19/014 (d)

10.30 10. Aintree Annual Business Plan 2018/19

To approve

Director of Finance

B18-19/015 (d)

10.35 11. Board Objectives 2017/18 – Final Report

To note


10.40 12. Well Led Governance Review 2017/18 – Final Report

To note


© 13. Modern Slavery Act 2015 – Update to Statement

To approve

Chief Executive B18-19/018 (d)

© 14. Board Committees’ Evaluation 2017/18

To note and approve the terms of reference

Director Corporate Governance

B18-19/019 (d)

CONCLUDING BUSINESS

10.45 15. Any Other Business

To consider any other matters of business Chairman B18-19/020 (v)

16. Items for the Risk Register/ Changes to the Board

Assurance Framework (BAF)

To identify any additional items for the Risk Register or changes

to the BAF arising from discussions at this meeting


17. Chair’s Log – Key Messages from the Board

To agree the key messages to be cascaded from the Board

throughout the organisation


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Item Lead Reference

Board Agenda: 25 April 2018 3/3

18. Date and Time of Next Formal Meeting:

Wednesday 23 May 2018 at 10am in the Boardroom, Aintree Lodge

Close 10.50

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Board of Directors

28 March 2018

Boardroom 10.00am

MINUTES

Present:

Neil Goodwin NG Chairman

Steve Warburton SW Chief Executive

Dianne Brown DB Chief Nurse

Joanne Clague JC Non-Executive Director

Tristan Cope TC Medical Director

David Fillingham DF Deputy Chairman/Non-Executive Director

Tim Johnston TJ Non-Executive Director

Ian Jones IJ Director of Finance & Business Services

Kevan Ryan KR Non-Executive Director

Angie Smithson AS Deputy Chief Executive / Integration Director

Mandy Wearne MW Non-Executive Director

In

attendance:

Caroline Keating CK Director of Corporate Governance/ Board Secretary

Michael Games MG Corporate Governance Manager

Sue Green SG Director of People & Corporate Affairs

Beth Weston BW Chief Operating Officer

Guests: Ruth Hoyte RH Acting Director of HR & OD (Item B17-18/162 only)

Claire Knowles CKn Prehabilitation Lead Therapist (Item B17-18/150 only)

Liz Roden LR Assistant Director of Nursing & AHPs (Item B17-18/150

only)

1 public governor, 2 staff governors and 1 member of the public attended the meeting.

Ref Item Action

CONSENT AGENDA

B17-18/

167

Directors & Officers Liability Insurance Declaration

The Board approved the statement of declaration.

B17-18/

168

Board of Directors’ Forward Plan 2018/19

The Board approved the Forward Plan for 2018/19.

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Minutes – Board of Directors 28 March 2018 2/11

Ref Item Action

PRELIMINARY BUSINESS

B17-18/

147

Apologies

None

B17-18/

148

Declarations of Interest

David Fillingham, Chief Executive of Advancing Quality Alliance (AQuA)

Dr Neil Goodwin, Interim Chair Liverpool Health Partners

B17-18/

149

Minutes of the Previous Meeting (31 January 2018)

The minutes of the previous meeting held on 31 January 2018 were approved as a

correct record. The Action Log was reviewed and noted.

B17-18/

150

Patient & Staff and Volunteer Story

The Board was joined by Claire Knowles, Prehabilitation Lead Nurse, who

provided a presentation highlighting the benefits that can be derived from the

Prehab programme. This is a pilot service funded by Macmillan, and the only

service of its kind in Cheshire/Merseyside which aims to promote the importance

of physiotherapy in cancer care. The programme helps improve a patient’s

nutrition and physical state prior to treatment for major surgery in bowel, liver and

head & neck cancer. CKn advised that, from the data collected so far, there were

encouraging signs that the majority of patients felt more able to manage with

having surgery and were more likely to make long term health and lifestyle

changes. In terms of next steps, CKn advised that it was the intention to secure

future funding from Macmillan, hold patient engagement sessions and widen the

inclusion criteria to Upper GI. Lung and Vascular patients.

CKn then read a brief story of a patient who had been through the Prehab

programme prior to undergoing major surgery for cancer and how the

physiotherapy sessions had helped with recovery afterwards as well as altering

the patient’s mindset to exercise in order to enjoy a more healthy lifestyle.

DF commented that the presentation and the story emphasised the importance of

building patient confidence as well as providing emotional support. CKn advised

that the programme encourages patients to be more proactive and has been

helped by the involvement of dieticians and physiotherapists to offer a

personalised service that benefits patients by making them feel ready for surgery.

KR sought and received confirmation that there was a link between the service

and the Trust’s health & wellbeing strategy in providing advice to both patients and

staff. MW commented that the data collection can help provide meaningful

measurement of patient outcomes and reductions in length of stay.

The Board noted the presentation and the patient story.

STRATEGIC CONTEXT

B17-18/ Chief Executive’s Report

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Ref Item Action

151 The Chief Executive highlighted the following key items:

• NHS Pay Deal – agreement had been reached between the Government and

Trade Unions on pay rises for staff on Agenda for Change although a formal

Union ballot was required. The increase would be fully funded by the Treasury

and work was being done internally on the impact on the Trust of the increases

on the various pay bandings

• CQC Whole System Review – the Trust was visited by the CQC along with

Liverpool City Council as part of the review to look at the care journey for

patients over 65 years of age through the system. The high level feedback

received was generally positive in terms of the alignment of services but there

would be specific actions for the Trust and the Council when the final report

was made available

• Flu Vaccination – the Trust had exceeded its previous year’s level of staff

vaccinations and had been shortlisted in the National Flu Fighter Awards.

However, it was important that the Trust was not complacent in future years

and continued to promote immunisation and maintain momentum

• Liverpool Health Partners (LHP) – the Board had previously supported the

direction of travel and the final Business Plan was approved by the LHP

Board. Arrangements would now be made to recruit a Chief Executive and

there was renewed enthusiasm by the University of Liverpool to take the plans

forward for the benefit of the City.

The Board noted the report.

QUALITY & SAFETY

B17-18/

152

Quality Committee – Assurance Reports (19 February 2018 and 19 March

2018)

The Board received and noted the assurance reports from the Quality Committee

meetings held on 19 February and 19 March 2018. MW, Chair of the Committee,

highlighted the following key items:

• The recommendation of approval for partial compliance against NICE

guidance for Spinal Injury relating to early referral (within 12 hours) to

specialties which was considered to be inappropriate

• The quality discussion was set at the outset through considering the Corporate

Performance Report and Hospital Management Board Report together

• There remained concerns with the level of Serious Incidents and, in particular,

Never Events. A meeting had taken place with NHS England and the Clinical

Commissioning Groups to strengthen the learning as well as improve systems

and controls. An independent review had been commissioned but, in the

meantime, an internal review was being undertaken around safety processes

and culture. However, no common themes had been identified from the

investigations undertaken to date

• The CQC follow-up inspection on Safeguarding had acknowledged

improvements made to the systems and processes and seen evidence of the

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Ref Item Action

provision of high quality training. There was still work to do to improve the

regulatory and compliance framework for Deprivation of Liberty Safeguard

(DoLS) applications and Mental Capacity (MC)

• The presentation on medicines management had reiterated the need for more

reporting of incidents in order to improve safety and reduce harm.

DF enquired about the progress of the external review on Never Events and TC

advised that the timescales may be back on track with the initial scope expected to

be just after Easter but confirmation was awaited. In the meantime, the Clinical

Governance Team, with support from the Associate Director of Human Factors,

was to undertake a review against the National Safety Standards for Invasive

Procedures (NatSIPPs) to see if there were any gaps. The timescale for

completion of this work and the detailed action plans arising were to be

determined.

TJ commented on the increased trend in C.Difficile cases and enquired as to

actions in place to improve the position. DB advised that the reported position

included those cases which were the subject of appeal but, from the cases

reported, there was no commonality between wards and no recontamination

amongst patients. The position was being closely monitored by the Infection

Prevention & Control Team.

JC made reference to the deterioration in the Safety Thermometer scores and it

was agreed that the Quality Committee would review this at its next meeting.

The Board noted the reports and approved the partial compliance against

NICE guidance for Spinal Injury.

MW

B17-18/

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Safeguarding Update

The Board received the report which provided an update on the actions taken

following receipt of the warning notice.

DB made reference to the Safeguarding training and advised that the DoLS and

MC training was below expected for Level 2 and 3, hence the twice weekly

sessions put in place to help improve the position. Furthermore, clinical areas

were being monitored on Safeguarding and daily reporting was in place with

details of any patient with cognitive inability being shared with the Safeguarding

Team. Improvements were being seen in the quality of referrals as staff began to

understand the new process using Best Interest Assessments. The lead

Commissioner was satisfied with the approach being undertaken by the Trust. KR

commented on the importance of Divisions releasing staff for training and DB

advised that this remained a challenge, particularly as it impacted on mandatory

training requirements and the forthcoming training on the Electronic Patient

Records system also needed to be factored into the programme. However, the

importance of the training was being reinforced with staff. DF suggested that the

trajectory to determine progress against the plan be included in future monthly

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Ref Item Action

Safeguarding reports to the Quality Committee and Board.


DB

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154

CQC Inspection 2017-18

Final Inspection Report – October 2017

The Board formally noted the report.

B17-18/

155

Final Inspection Report – January 2018

The Board formally noted the report.

B17-18/

156

CQC Inspection – Improvement Plan

The Board received the report and DB advised that the Trust was required to

complete its improvement plan and submit it to the CQC by 31 March 2018. The

reports had identified 12 actions that the Trust must do to comply with its legal

obligations and a further 56 actions that it should take. DB further advised that

whilst the list was not exhaustive, it had addressed the specific issues raised but

not the cultural and behavioural aspects that will also need to be addressed.

Further assurance would also be required on the embedding of compliance and

how it could be delivered more robustly. NG advised that further discussion on the

cultural and staff engagement issues would take place at the Board Away Day on

12 April 2018.

DF commented that the improvement plan was comprehensive in addressing the

issues highlighted but questioned whether additional information should be

provided to the CQC on how the Trust was dealing with the underlying causes.

DB advised that there were a number of enabling strategies behind the plan to

deliver and sustain the improvement required to address the cultural aspects and

these would be shared with the CQC. Furthermore, work with the Divisions would

include regular audits to keep monitoring and improving in order to strengthen the

compliance framework and the Aintree Assessment & Accreditation (AAA)

process. The intention was for assurance levels to be enhanced through a variety

of methodologies, each providing the necessary evidence of improvements. BW

commented that it was important to test embeddedness between areas to ensure

that there was a consistent approach; undertaking mock inspections would benefit

and support the process.

NG remarked that there needed to be balance between the day to day

requirements and the expectations from the improvement plan to meet the CQC

standards. However, it was vitally important that the Trust achieved all of what

was required within the next six months. DB sought and received agreement to

share the improvement plan with the Clinical Commissioning Groups. DB added

that, having a clear understanding of the hotspots and bringing together all the

actions into one plan, provided a better picture of the totality of what was required.

The Board approved the Improvement Plan and agreed that it be submitted

to the CQC by 31 March 2018

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Ref Item Action

B17-18/

157

Ward Acuity and Dependency Study

The Board received the report and DB advised that it was designed to provide the

Board with assurance that the Trust was staffed safely and that there were

appropriate processes in place to assess staffing requirements on a daily basis.

The report also described the work undertaken on the acuity and dependency

modelling which highlighted that there had been an increase in the trend of Level

1b category patients i.e those who required additional nursing support. Patients

also required assistance with feeding and walking and, despite help from family

members, a considerable amount of nursing time was taken up with providing

basic levels of care. The remodelling work of ward establishments had resulted in

the proposal to reduce the level of Registered Nurses by 27 whilst increasing the

number of Health Care Assistants by 120. This would bring the vacancy rate

down to circa 30, provided the posts proposed were filled. DB further advised that

ward staffing was reviewed three times a day to keep areas safe and there were

plans to enhance the ‘red flag’ system and the use of Datix to improve reporting in

relation to safe staffing. The investment required was £1.7m and would be

considered as part of the Divisional Cases of Need by the Board in private

session.

DF commented that the report evidenced a thorough piece of work and a good

argument for downsizing Registered Nurses but queried if there would be any

adverse impact on patient care. DB advised that the study demonstrated that the

needs of patients had changed to the extent that the level of care they required

could be done more effectively by Health Care Assistants which, in turn, would

allow nurses to focus on leading on other aspects of patient care. Ward nurse

managers were classed as supervisory but they fill gaps in rotas when necessary

and there had been a marked increase in this, particularly during winter and when

there were high levels of complex cases. The challenge was to release the nurses

in order to fulfil their proper role going forward as they were seen as the

gatekeepers of care. BW commented that consistency in care had been

challenging and the proposal addresses this issue so there should be

improvement seen at an early stage as well as a reduction in the level of agency

staff which would have a financial benefit on the Trust. MW made reference to the

measures of success to demonstrate that patients were receiving exceptional care

and the importance of explaining the rationale for the Board’s decision clearly to

both staff and Governors.

The Board noted the report and agreed to support the changes to ward

establishments subject to the discussions on the Operational Plan 2018/19

in private session.

FINANCE & PERFORMANCE

B17-18/

158

Finance & Performance Committee – Assurance Reports (26 February and

26 March 2018)

The Board received and noted the assurance reports of the Finance &

Performance Committee meetings held on 26 February and 26 March 2018. JC,

Chair of the Committee, highlighted the following matters:

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Ref Item Action

• Diagnostics performance had improved with a significant reduction in the

number of patients waiting from 262 to 65. However, this was due to

additional premium rate sessions being scheduled to reduce the backlog and

there was concern that this was not sustainable

• Cancer 62-day performance had been achieved in February 2018 and was

expected to meet the standard for the quarter

• The Trust’s financial position remained on track to achieve its underlying deficit

target despite continued high levels of spend on agency staff for medics and

nursing. The release of Tranche 1 funding from NHS Improvement had been

agreed which would help towards the achievement of the control total

• The Operational Plan and Capital Plan had been reviewed and the Committee

was recommending approval to the Board

• A verbal update was provided on the EPR programme which was largely on

track but further work was required on the development of the theatre module.

A detailed written report was requested for the next meeting

• Planned savings from the Transformation programme were on track but this

was largely due to the release of balance sheet reserves. Next year, a realistic

2% target of savings had been agreed but there was concern that it was reliant

on efficiencies from theatre utilisation which had not come to fruition in

previous years

• A review of the effectiveness of the Committee had been undertaken and the

three areas of focus for 2018/19 had been agreed together with the Forward

Plan.

DF made reference to the budget setting process and the agreement for final sign-

off to be undertaken with the Divisional leadership teams to ensure that there was

ownership and accountability for individual budgets. IJ advised that the Divisions

had been fully engaged in the budget process but the additional element in terms

of sign-off would be undertaken.

The Board noted the reports.

TC

IJ

B17-18/

159

Corporate Performance Report (February 2018)

The Board received the report and noted that a number of the areas within the

report were discussed as part of other items on the agenda. However, the

following points were raised:

• Ready for Discharge patients remained high. A review over the winter period

had been undertaken following additional resources by external providers

being put in place which revealed that there had been little movement in the

number of patients discharged over the period. This matter would be raised

with the A&E Delivery Board

• Referral to Treatment standards had not been met in February 2018 due to the

high level of cancellations for day cases which, in turn, had increased waiting

lists

BW

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Ref Item Action


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160

Emergency & Acute Care Update

BW gave a presentation which highlighted the following matters:

• The performance trajectory graph which depicted that the 4-hour performance

for the Trust was behind expectation but was significantly better when

compared to the previous year. Attendances had been 9% higher month on

month

• Details of the interventions and impact arising from the rapid improvement

events in non-admitted assessment areas, the site team grip and Emergency

Department Super Week

• An overview of progress on the SAFER roll-out programme together with the

impact on key performance indicators and the next steps including details of

the main enablers

• Details of the four stages to deliver the step changes to further improve

performance with a key focus on capacity and demand rightsizing

• An overview of the sustainability planning and handover arrangements from

Ernst & Young culminating in the workstreams being monitored by the Elective

Care Work Group reporting through to the Board.

BE advised that performance in March 2018 had been challenging but was better

than the national average. An assessment of process over the last weekend

evidenced that the Trust was doing all it could to deal with the pressures being

faced.

DF praised the Team for the significant improvements that had been made,

particularly over the winter period through a well co-ordinated plan of activity.

However, there remained a high level of ready for discharge patients that

impacted on flow and this needed to be addressed by the whole system to get the

response required to improve the position. SW advised that this was a huge

challenge for the Trust with increased acuity and dependency as well as care in

the community being under pressure. However, whilst the Trust would continue to

work with its external providers, it also needed to improve on those areas that it

was responsible for. NG was keen for the Trust to move to the next level of

performance and requested that the Board receive a robust high level RAG rated

action plan so that progress could be monitored. BW advised that a presentation

was to be provided by Ernst & Young at the next meeting of the Board which

would aid discussion on what was required to take performance to the next level.

The Board noted the presentation.

BW

B17-18/

161

Finance Report (February 2018)

The report was received by the Board and IJ highlighted the following matters:

• The Trust continued to experience the same financial pressures particularly in

agency staffing which impacted on the achievement of the underlying financial

deficit but the release of the Tranche 1 funding would alleviate some of the

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Ref Item Action

pressure

• No Sustainability and Transformation Fund monies had been received for A&E

performance throughout the year and there was no right of appeal available.


GOVERNANCE/WELL-LED

B17-18/

162

National Staff Survey 2017 – Headline Report

The Board received the report and RH advised that there had been a significant

improvement in the response rate by 7% to 50% on the previous year and a small

increase in the overall engagement score to 3.72 (3.7 last year). The report

included details of the trends in engagement scores since 2013 and, whilst there

had been some improvement in the last 12 months, the Trust had not recovered to

its 2015 position. RH advised that there was evidence that engaged staff improve

the quality of care for patients and consideration would need to be given to using a

suite of staff engagement methods to help improve the position. Analysis had also

been undertaken on staff groups and locations which had highlighted large

variations in engagement and further work was to be done to understand the

reasons for this.

MW commented that the trend analysis would help in understanding how the Trust

would make the transformational leap and how the use of technology could assist

in change, as well as how the Trust can learn from other Trusts locally and

nationally. TC remarked that improving staff engagement was not just about

Board visibility but using the tiers of management to develop and encourage

managers within their service to engage with staff.


B17-18/

163

Gender Pay Gap Reporting

The Board received the report and SG advised that the Trust was required under

the Equality Act to publish its gender pay gap data as at March 2017 on its

website. SG highlighted that the report included details of the required

calculations, the mean and median pay gap, bonus payments and benchmarking.

Work was also being undertaken on reviewing recruitment and Local Employer

Based Awards processes to ensure gender balance in decision making.

SG further advised that the Trust pays wages in accordance with national terms

and conditions but the higher paid staff were predominately in medical staff. A

summary of time allocated for different medical roles would demonstrate that there

was no bias and transparency for equal opportunities for these roles.

JC made reference to the Excellence Awards and encouraging women to put

themselves forward by way of representation on panels. SG advised that there

needed to be a balance on panels and this could be enshrined within a Policy. NG

sought and received confirmation that those on local contracts were included in

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Ref Item Action

the reporting.

The Board approved the publishing of the data on the Trust’s website.

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164

Amendment to Scheme of Delegation

CK presented the report which referenced the amendment to the Trust’s

Constitution made by the Board on 31 January 2018 to delegate authority to

enable Mersey Care to assume responsibility for exercising powers under section

23 of the Mental Health Act 1983. The Council of Governors also approved the

amendment to the Constitution at its meeting on 20 March 2018.

CK explained that the Board was now required to pass the following resolution to

delegate its functions to Mersey Care’s hospital managers and have this reflected

in the Trust’s Scheme of Delegation:

“The Board agrees that Mersey Care NHS Foundation Trust properly understands

the role and working of the Mental Health Act 1983 and recognises Mersey Care’s

expertise in this area.

Accordingly, and pursuant to section 23(6) Mental Health Act 1983, the Board

hereby resolves that the powers conferred on the Trust under that section may be

exercised by the current hospital managers’ review panel of Mersey Care (as long

as they are not also employees or executive directors of this Trust) until 31 March

2019, in accordance with the provisions of the Mental Health Act 1983 and

associated Code of Practice.”

The Board agreed to pass the above resolution.

B17-18/

165

Assurance & Escalation Framework

NG advised that the document had been updated and revised to take account of

changes to internal systems and processes in year. He added that the document

would form the basis of discussions at the Board Away Day on 12 April 2018.

CK advised that, once the Board approved the document, it would be made

available on the Trust’s document management system.

The Board approved the revised Framework

B17-18/

166

Council of Governors – Key issues Report (20 March 2018)

NG made reference to the report and advised that it was important to

acknowledge that Governors were equally concerned about the same issues as

the Board. He added that it was for the Board to reflect on how it can provide

greater reassurance and assurance to the Council of Governors in the coming

months.


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CONCLUDING BUSINESS

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Any Other Business

TJ enquired about the Trust’s progress for the new General Data Protection

Requirements (GDPR). IJ advised that a Working Group had been established to

ensure the Trust was 75% compliant by 25 May 2018 and that plans were in place

to progress this further. Arrangements were also in place to review the insurance

policies to indemnify the Trust against the risk of a potential fine.

On behalf of the Board, NG thanked SG for her contribution to the Trust during her

time in office and wished her every success in her future role at Betsi Cadwaladr

Trust.

B17-18/

170

Items for the Risk Register/Changes to the Board Assurance Framework

(BAF)

None identified

B17-18/

171

Chair’s Log - Key Messages from the Board

The following messages were highlighted:

• The innovative Prehab programme provided by the Trust and the positive

impact it had on patients prior to and after major surgery

• Approval of the improvement plan to address the shortcomings identified by

the CQC Inspection with regular reporting to Board on progress

• The increase in patient acuity and dependency arising from the modelling work

undertaken and the impact this has had on ward establishments going forward

• The improvements made in A&E performance particularly against the national

picture for the four hour standard and the need to consider what is required to

improve performance to the next level

• The approval of the Gender Pay Gap reporting for inclusion on the Trust’s

website

Date and Time of Next Meeting

Wednesday 25 April 2018 at 9am, Boardroom, Aintree Lodge.

The meeting ended at 12.35pm

Chair’s Signature: Date:

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Board Action Log (28 March 2018) – Part I

‘BRAG’ rating to assess progress:

Blue Action completed & independently/externally validated Amber : Action on track but not complete

Green Action complete & evidenced Red Action overdue for completion or may not be completed

Lead Date of

Meeting

Minute /

Reference

Action Action

Deadline

Action

Status

Agenda Item

SW November

2018

B17-18/119 Freedom to Speak Up Guardian

Future report to include, if appropriate, staff group

demographics and themes

May 2018 A

DB March 2018 B17-18/153 Safeguarding Update

Future reports to QC and Board to include trajectory of progress

April 2018 G

On Agenda

BW B17-18/160 Emergency & Acute Care

High level action plan (RAG rated) to be developed to monitor progress. Presentation by Ernst & Young

April 2018 G

On Agenda

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Never Events

Our Patients Experience

Sharon Scott

DMD Surgery

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The Event

• Wrong site surgery

• Recorded as ‘no harm’

• Trustwide learning points

Completion of safety checklists

Consent forms shouldn’t be reused

Surgical site mark visible once draped

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The Patient

• Long standing spinal patient

• Hard to get out patient review

• Flare up of symptoms

• Accepted injection 4. B

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Patient Reflections• Thought there should have been checks

• Patient felt they were on a conveyor belt

• Didn’t feel able to could say anything to clinical team

• Patient felt uncomfortable and started feeling hot and unwell

• Didn’t feel that appropriate checks had been made

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Post Events

• Felt unwell

• Contacted NHS Direct

• Reoccurrence of original symptoms

• Time off work

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Patient’s View

Understands things can go wrong, but

doesn’t want this to happen to anyone else

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1/7

Agenda Item (Ref) B18-19/005 Date of Meeting: 25 April 2018

Report to Board of Directors

Report Title Chief Executive’s Report

Executive Lead Steve Warburton, Chief Executive

Lead Officer Caroline Keating, Director of Corporate Governance

Action Required To review and agree any actions arising

Substantial assurance

High level of confidence

in delivery of existing

mechanisms / objectives

Acceptable

assurance

General confidence


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)

•

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:

Best practice

Next Steps (actions following agreement by Board/Committee of recommendation/s)

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Chief Executive’s Report - 28 March 2018 2/7

REPORT HISTORY

Committee /

Group Name

Agenda

Ref

Report Title Date of

submission

Brief summary of key

issues raised and

actions

Board of

Directors

B17-18/… CEO Report monthly noted

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Chief Executive’s Report – 25 April 2018 3/7

Chief Executive’s Report – April 2018

National & Regional

In recent weeks the Government has given a clear commitment to review the longer term financial

settlement for the NHS. Whilst the prime minister’s commitment to higher NHS funding is very welcome

there are many obvious and difficult tensions that still need to be resolved.

There is also likely to be a large gap between the extra funding needed by the NHS and what the

government thinks is affordable in the context of pressures to increase public spending, a lower tax base

and a range of looming potential economic risks e.g. Brexit.

The independent Office of Budget Responsibility (OBR) has indicated that the NHS requires immediate,

real term annual increases of around 4.5%, just to keep up with increasing NHS demand and costs. That

compares to an annual NHS funding growth rate of 1.2% since 2010.

The NHS will be expected to make significant performance improvements in exchange for any extra

funding. However, this will be in the context of a £5 billion backlog maintenance bill to repair crumbling

buildings and update crucial equipment; £3 to 4 billion to recover key A&E and surgery waiting time

targets; an underlying NHS trust sector financial deficit of around £4 billion and a £1 billion annual NHS

pay rise cost that also requires funding.

Local

Regulatory

Care Quality Commission (CQC) Inspection – the Trust’s improvement plan was submitted to the

CQC by the specified deadline. We have now set up fortnightly meetings, chaired by the Chief Nurse, to

monitor the progress of actions and are looking to incorporate this into an overarching improvement plan

for the Trust. In addition the Trust is planning to develop an explicit Patient Safety culture based on a

Human Factors approach in order to improve the quality of care provided to our patients.

Liverpool / Sefton Integrated Provider Alliances - the Trust is working closely with partners in health,

social care and the voluntary sector to develop more joined up services and to help keep our patients

well and reduce the reliance on hospital based services. Plans are being developed to improve

community service provision, which are being led by Merseycare NHS Foundation Trust which assumed

responsibility for all former Liverpool Community Health services from 1 April 2018.

Merger Update

The Chairman and I were invited to attend the March Board meeting of the Walton Centre NHS

Foundation Trust to discuss the latest position regarding the proposed merger with the Royal Liverpool &

Broadgreen University Hospitals NHS Trust. We had a very positive discussion and the Walton Board

was supportive of our strategic direction of travel.

Other Key Areas / Issues

Appointments

No consultant appointments have been made since my last report to the Board.

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Chief Executive’s Report – 25 April 2018 4/7

Recommendation

To note the report

Author: Steve Warburton, Chief Executive

Date: 19 April 2018

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Report from Hospital Management Board 14 February 2018: Board of Directors 28 March 2018 5/7

Report from Hospital Management Board


Date 25 April 2018

Committee Name Hospital Management Board

Date of Meeting 11 April 2018

Chair’s Name & Title Angie Smithson, Deputy Chief Executive/Integration Director

(Acting Chair)

Executive Lead

Summary

1. The Hospital Management Board (HMB) receives reports from the Executive Led Groups on the

clinical and operational management of the Trust. It also reviews the delivery of the strategic

objectives and mitigation of strategic risk by focussing on clinical quality, performance and

delivery.

Key Issues

HMB Performance & Effectiveness Review 2017/18

2. The Executive Team had discussed the outcome of the review prior to the HMB meeting and

concluded that the Agendas for the meetings tended to be Executive driven whereas the intention

was for the meeting to be more inclusive with Divisions having more opportunities to

input/present items. This was reflected in the comments in the Effectiveness Review. It was

agreed that Divisions will consider topics for future HMB meetings and the presentation of reports

will be considered. The terms of reference were approved.

Chief Executive’s Update

3. The following matters were highlighted:

• Trust Performance – there continued to be significant external scrutiny of the Trust’s

performance from various stakeholders and it was important that there was co-ordination and

consistency in prioritising the key areas of focus in order to provide assurance and confidence

to both internally for staff and externally for partners/regulators. It was acknowledged that

there were challenges to capacity but plans were in place to address a number of areas

following approval of the Divisional Cases of Need. The opportunity was being taken to

engage with Advancing Quality Alliance (AQuA) to provide support to the Trust and the Board

was to further discuss leadership and engagement at its Away Day, the outcome of which

would be provided at the next meeting. Some discussion also took place on better use of

business analysts within Divisional teams and this was to be taken forward by the Deputy

Chief Executive/Integration Director with the Chief Executive and Director of Finance.

• Aintree/Royal – discussions continued to take place with NHS Improvement to secure

external support for the transaction process. Work was continuing in the various work

streams on service reconfiguration. An event was planned on 25 April 2018 to review the

clinical reconfiguration work and the opportunities the delay of moving into the new Royal

hospital afforded.

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Report Hospital Management Board 11 April 2018: Board of Directors 25 April 2018 6/7

Corporate Performance Report (CPR) (including reports of Executive Led Groups)

4. The HMB reviewed the report with particular focus on the following areas:

• A&E performance for the 4-hour trajectory had seen a slight deterioration in February 2018

and had been impacted further during March 2018 by the continued increase in attendances.

Ambulance turnaround times continued to improve particularly in respect of 30/60 minute

waits.

• Improvements had been seen in reducing the level of backlog within Diagnostics although

these had been largely achieved through running additional sessions which had a financial

impact on the Trust and was not considered to be sustainable.

• Cancer 62-day classic performance had achieved the standard for February and was likely to

be achieved for March 2018 as well as for the quarter.

• A meeting between the Stroke Team and the Chief Nurse and Chief Operating Officer was

scheduled for 13 April 2018 to review performance.

• The targets for MRSA and CDI were not being met and work was in progress between the

IPC Team and Divisions on reducing levels. Additional support and advice was being

provided by the IPC Team on antimicrobial prescribing.

• Complaint response rates were still below the expected standard but the quality of the

responses was an issue resulting in more time being spent on reviewing them. Further

training was to be provided but also guidance on dealing with informal complaints for the

PACT was to be given following a recent spike. Weekly complaints performance meetings

are now in place chaired by the Chief Nurse.

• There continued to be improvement by the Divisions in the completion of outstanding serious

incident actions. The number of serious incident investigations was unprecedented and was

placing significant pressure on the corporate teams and investigators. A monthly assurance

report had been requested which would be followed up with a biannual thematic analysis.

• Risk assessments had been undertaken against NICE guidance for Rehabilitation after

Critical Illness and Glaucoma. In both cases capacity was an issue and reviews were to be

undertaken as there was an impact on achieving full compliance against the guidelines.

Progress to be reported in May/June 2018.

• The PICKER National Inpatient Survey results had been received and shared with Divisions.

Workshop with Divisions are to be undertaken in May 2018 with improvement plans to be

developed.

• Friends and Family Test results had improved following the commencement of the automated

messaging for inpatient services.

• The key area of focus was on the Staff Survey results and the sharing of the analysis with the

Board and Divisions particularly in respect of improving staff engagement and how the Trust

makes the step change.

• The Trust had been taken off enhanced reporting by Health Education England.

• Improvement plans within Divisions had been requested for mandatory training and appraisal

compliance.

Draft Quality Account 2017/18

5. The HMB received the report and it was requested that any comments/amendments be fed back

by 18 April 2018.

Ward Acuity & Dependency Study

6. The HMB received the report which provided details of the review of ward establishments from

the acuity and dependency modelling. As a result of the review, it had been proposed, and

subsequently agreed by the Board, to reduce the number of registered nurses and increase the

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Report Hospital Management Board 11 April 2018: Board of Directors 25 April 2018 7/7

level of Health Care Assistants. This, in turn, should reduce the reliance on temporary staffing

and the associated costs.

EPR Liverpool – Update Report

7. The HMB received the report and was advised that there were significant risks associated with

the implementation of the programme. However, it was stressed that it was important to ensure

that the system was safe to implement before going live. It was explained that discussions were

taking place with the Provider as well as the other Trusts to try to deal with the main issues to

rectify the position. A Project Director had been appointed to drive the programme forward.

8. Monthly reports will continue to be provided to HMB and the Finance & Performance Committee

by way of oversight and monitoring of the programme’s progress.

Aintree Assessment & Accreditation (AAA) – Discussion Paper

9. The HMB received the report which identified proposals for the AAA to be revised and enhanced

together with a timeframe for implementation. It was highlighted that AAA does not currently

cover all aspects of the CQC Key Lines of Enquiry and the reassessment timeframe was too

short to enable meaningful improvements to be made. The point was also made that AAA should

also include Doctors within the assessment and not just nursing as well as a review of the

standard to include assessment of discharges and safety & security.

10. The HMB agreed that a Task & Finish Group be established to review the proposals and that a

verbal update be provided next month with an update report in June 2018.

General Data Protection Regulations - Update

11. The HMB was advised that the priority was for all areas within the Divisions to review their asset

Registers and Information Flows. Workshops had been made available and staff within the Chair

& Chief Executive’s Office would provide advice on completion of the spreadsheets.

Decisions Made

N/A

Recommendation

12. The Board is asked to note the summary report.

5.

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Report Title Board Assurance Framework – Q4 2017/18


Lead Officer Caroline Keating, Director Corporate Governance / Board Secretary

Action Required To review & agree actions

Substantial

assurance

High level of

confidence in delivery

of existing

mechanisms /

objectives

Acceptable

assurance

General

confidence in


mechanisms/

objectives

Partial

assurance

Some confidence

in delivery of

existing

mechanisms /

objectives

No

assurance

No

confidence

in delivery


•


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other


Best practice


The 2018/19 BAF, informed by the 2017/18 BAF outturn position, will be submitted to the April

meeting of the Audit Committee with Q1 submitted to the Board in July 2018

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Board Assurance Framework: Board of Directors 25 April 2018 2/6

REPORT HISTORY

Committee / Group Name

Agenda Ref

Report Title Date of submission

Brief summary of key issues raised and actions

Audit Committee AC17-19/

005

Board Assurance

Framework 2017/18

3 May 2017 Format and content

noted

Board of Directors B17-18/ Board Assurance

Framework Q1

2017/18

26 July 2017 Noted


Framework Q2

2017/18

October 2017 Noted


Framework Q3

2017/18

January 2018 Noted

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Board Assurance Framework (BAF) Q4 2017-18

Introduction/Background

1. The Board Assurance Framework (BAF) provides support to the Trust in its strategic

planning arrangements and provides direction to the Board’s governance and assurance

agendas. The BAF sets out the 6 strategic risks against the achievement of each of the

Trust’s strategic objectives and delivery of the Trust’s (Annual) Business Plan. It reflects

the Trust’s risk profile, demonstrates the extent to which assurance can be provided on

mitigating the strategic risks, identifies where further actions are required to reduce these to

an acceptable level, and provides assurance to the Board that these are being effectively

managed.

2. The BAF is one of several mechanisms that comprise the Board’s assurance toolkit which

provides supporting information for the sign-off of the effectiveness of the Trust’s system of

internal control in the Annual Governance Statement submitted to NHS Improvement

(NHSI) as part of the Trust’s Annual Report.

3. As is standard practice, the Executive Directors have been consulted individually and

collectively on the content and the risk scoring which have been updated to reflect the

changes and progress towards the achievement of the strategic objectives. The Executive

Directors are informed through discussions at Executive-Led Groups and Hospital

Management Board. The updates are highlighted in red.

4. In reviewing the BAF for 2017/18, the Board is asked to focus on the gaps in controls and

assurance, whether the progress on action plans is sufficient to address those gaps and

whether there are any out of date assurances or overdue actions. The Board should also

consider the following questions, the responses to which might impact on the BAF for

2018/19:

• Are there any changes required to the causes and effects (the origins and potential

consequences)?

• Are the controls in place sufficient and robust to manage the risks?

• Is there sufficient assurance regarding the operation of controls to manage the risks?

• Is there a danger that any of the strategic risks are more likely to materialise due to an

increase in the number or score of the origins of the risks?

• Is the assurance proportionate to the level of risk?

Key Issues / Proposal

Changes to Strategic Risks

5. Strategic Risk (SR1) Failure to ensure that the care provided for all patients is high

quality, safe and compassionate

O4 – Inadequate systems in place to facilitate timely learning from incidents, risks,

complaints and patient feedback. Due to the number of never events in the Trust, the risk

score has increased to a 4x4 (16) from a 4x3 (12). This also impacts on Strategic Risk 2 03

which has been increased to the same score. The events are referenced in the Reportable

Issues Alert (Part II item)

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O6 – the Trust does not ensure appropriate and safe environments for care delivery.

Incidents have been identified in April 2018 which, although, outside the timescale of this

Q4 report, the Board is alerted to. The risk is currently under review, pending the outcome

of the reports identified below, and will be updated in the 2018/19 BAF, if appropriate:

• Theatre Ventilation Systems – further failure. A risk assessment was undertaken,

resulting in this being logged as an incident. An external company has been

commissioned to provide assurance for all theatre ventilation systems. A report will be

provided to Estates & Facilities and to Safety & Risk Exec Led Group (ELG)

• Water Safety Testing – pseudomonas identified within pipework. This has been

logged as a clinical incident. Assurance is being sought through the Director of Estates

& Facilities and Safety & Risk ELG

• Multi-Storey Car Park Incident. An external SI review has been co-commissioned by

Merseycare and Liverpool CCG at their request. A detailed risk assessment of the car

park is also being undertaken.

The above are also identified in the Reportable Issues Alert (Part II item).

6. Strategic Risk (SR4) Failure to deliver efficient, cost effective and sustainable services

Due to the delivery of the Financial Plan in 2017/18, the following risk scores have been

reduced:

O2 - Inability to achieve Financial Plan in 2017/18. The risk score has been changed to 1x4

(4) from 4x3 (12)

O5 – Inability to deliver planned activity, leading to loss of income. Score changed to a 3x2

(6) from a 3x3 (9)

08 – Lack of identification and delivery of QEP. Annual control total met with QEP delivered

in year although not recurrently. Decrease in risk from 4x4(16) to 4x3 (12) considered

appropriate

7. Strategic Risk (SR6) Failure to be a well governed and clinically-led organisation to enable

our people to achieve the Trust’s common purpose

O2 - staff not engaged or empowered. Although no change to the overall score, the focus

has changed to a 3x4 (12) from a 4x3 (12) in light of the staff survey outcomes (this also

aligns with SR5 O5).

Heat Map

8. Initial versus current risk scores - the heat maps overleaf highlight the positions since the

start of 2017/18 with the initial and current risk scores, which allow identification of any

movement in those scores over the preceding quarter.

9. The overall residual risk score for Strategic Risk 4 (Failure to deliver efficient, cost effective

and sustainable services) has been decreased from a 4x4 (16) to a 3x4 (12) to reflect

delivery of the 2017/18 Financial Plan. The heat map on page 6 reflects this position.

Key:

Inherent Risk Residual Risk Previous Risk Score

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Board Assurance Framework: Board of Directors 31 January 2018 5/6

Q1 2017/18

Likelihood

1 2 3 4 5

Co

nseq

uen

ce

5

4

3

2

1

Q2 2017/18

Likelihood

1 2 3 4 5

Co

nseq

uen

ce

5

4

3

2

1

Q3 2017/18

Likelihood

1 2 3 4 5

Co

nseq

uen

ce

5

4

3

2

1

Q4 2017/18

Likelihood

1 2 3 4 5

Co

nseq

uen

ce

5

4

3

2

1

1 1 2 2

3

4

5 6

3

5 6

4

1 1 2 2

3

4

5 6

3

5 6

4

1 1 2 2

3

4

5 6

3

5 6

4

1 1 2 2

3

4

5 6

3

5 6

4 4

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Additional Assurance

10. The BAF format has continued to be strengthened through the inclusion of Strength of

Assurance against the controls and the assurances. Control Owners and Leads have also

been identified for each control and source of assurance.

11. Work is on-going to align the risk appetite to each strategic risk. A completed example is

located in SR1. Further work is required to link the relevant strategic theme to the strategic

risk to ensure this can be summarised succinctly for BAF presentation.

12. The strategic risk log for the merger is attached at Appendix 3 for information. This sits

between the BAF and the more operational risk register held and co-ordinated by the

Programme Management Office. The risk log was presented to the Transaction

Programme Board in April 2018 and is included at Appendix 3 for information.

13. The BAF for 2018/19 will be submitted to Audit Committee in April 2018. This will allow the

Committee to comment on the BAF format as well as discuss the content at the start of the

financial year before the Q1 report is submitted to the Board in July 2017.

Recommendation

14. To note the BAF for Q4 2017/18 and the controls and assurances identified to mitigate the

strategic risks.

Author: Caroline Keating, Director Corporate Governance / Board Secretary

Mike Games, Corporate Governance Manager

Executive Leads

Date: April 2018

Appendix 1 – The Board Assurance Framework 2017/18 Q4

Appendix 2 – Transaction Risk Log

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Board Assurance Framework 2017-18

1 4 x 3 (12)

4 x 3 (12)

REF

SO1

OWNER

CN/MD

CN

CEO

CEO O6 COO/ DOF /DEFS&R

Ops & Perf4x3 (12)

O7 DoF Audit 4x2 (8)

Control

Owner

Strength of

AssuranceLast Review Date

Next Review

DateO8 COO

Ops & Perf/

F&P4x4 (16)

IJ Partial Jan-18 Apr-18 Op LeadImplementation

DateMonitored by

DB Acceptable Mar-17 May-18

DB/CK Acceptable May-17 May-18

TC Apr-17 May-18

DB Jul-18 IJ Sep-18 IGDQ

IJ monthly monthly

DB Acceptable Jul-17 tbc

TC Feb-17 tbc

BW Partial monthly

SG Partial DB May-18 QC/Board

TC Mar-17 Apr-18

IJ/PF Partial Mar-18 tbc

IJ/PF Jul-17 HMB/F&P

IJ Partial Jan-17 Apr-17

DB Acceptable Aug-17 Feb-18

DB Partial Jul-17 Oct-18

DB Partial Mar-18 monthly

DB Acceptable May-17 annual SGFeb 2018

July 2018WE/G/HMB

DB Acceptable monthly

All Acceptable On-going Op LeadImplementation

DateMonitored by

DB Acceptable Mar-18Oct-18

DB May-18 HMB

IJ/PF Acceptable Mar-17 Oct (tbc)

DB 6 monthly

DB 6 monthly

DB Acceptable May-17 May-18

DB Acceptable quarterly

TC Acceptable Jul-17 Jul-18

DB May-18

SW/CK Acceptable Feb-17 Jul-18

IJ Acceptable monthly

DB Partial May-18

DB Acceptable monthly

DB Acceptable Feb-18 May-18

BW Acceptable monthly

SG

TC Acceptable Mar-18

WELG/F&P/QCSGMar 2018

May 2018

Effective use of E-Roster reporting to provide evidence of spend (junior

medics)

Nursing & AHP Implementation Plan

Non-compliance with MH Act re patient detention

mitigated through SLA with MerseyCare; SLA being

updated. Approved amendments made to Trust

Constitution & Scheme of Delegation March 2018.

Policy approved and published.

Safeguarding - non-compliance with statutory and requlatory

requirements

QC (L2)

Board (L3)

HMB

QCDB May-18

DB HMB/QC/Board April 18

DB

Duty of Candour

Integration of IT/BI departments between AUH/RLBUH

forms part of 18/19 workplan. Need to deveop more

user-friendly front end to BI system; analyst employed

Board (L2)

QC (L2)

QC (L2)

Strength of

assurance

Level of

AssuranceLast Received

Local review of Divisional resource panels undertaken as

part of policy review to understand how system reports

can be used to roster effectively. Aligned to Premium

Rate spend QEP. To be submitted to WELG for

consistency check

New checklist for all services in place; part of sign off by

lead investigator and Exec. Divsional dashboards

developed to monitor compliance through S&R

S&R

S&R

Patient ExpCN/MD

Lack of accessibility, use and intrepretation of data

4x3 (12)HMB

Inadequate systems in place to facilitate timely learning from incidents, risks, complaints and patient

feedback

Inappropriate behaviours underpin a culture that impacts negatively on the Trust's ability to deliver high

quality safe healthcare

MD / CN / COO 4x4 (16)

4x4 (16)

CN / MDLack of adequate systems and processes in place to deliver appropriate care and monitor standards

CEO

Jun-18 Ops& Perf

Potential or actual origins of the risk

Poor performance and practice restricts the Trust's ability to deliver high quality safe healthcare

Inadequate or inappropriate staffing restricts the Trust's ability to deliver high quality safe healthcare

without patient harm

Compliance Framework to be submitted to HMB for final

agreement

Compromised quality of care

The risks are CONTROLLED by:

Patients have high quality

safe and compassionate

care and a positive

experience

Poor patient experience

Regulatory Intervention

Reputational damage

CONTROL

L3 Independent

L2 Oversight

L1 Operational

F&P/Board (L2)

CEELG/QC (L2)

F&P (L2)

F&P (L3)

QC (L2)

TC

O3

O4

O5

STRATEGIC RISK

IMPACT ON STRATEGY

OBJECTIVE OF

MITIGATING THE RISK

S&R

Clin Eff

What are the most significant origins which could or have led to the risk?

REF

Annual Business Plan Priorities

Quality Strategy & Annual Report

RESIDUAL RISK SCORE

(Consequence x Likelihood = Total)

TARGET RISK

SCORE4 x 2 (8)

Exec Lead

Clin Eff

Ops & Perf

Exec Lead

Level of

Assurance

Primary Source of Risk

Assurance

INHERENT RISK SCORE

(Consequence x Likelihood = Total)

CNHMB

Exec Led Groups

QC

POTENTIAL EFFECTS OF THE RISK

Board (L2)

Action Required

Arrows denote movement since the last submission

MD / CN

COO O2

The Trust does not ensure appropriate and safe environments for care delivery

What are the key potential consequences (up to 5) of the risk?

ELG Risk Score CxL

Lack of assurance of accuracy, timeliness and consistency of data

Deliver Outstanding Care

What are the key controls that are in place to mitigate these risks?

4x3 (12)

4x3 (12)

SR1Safe/Caring: failure to ensure that the care provided for all patients is high

quality, safe and compassionate

Risk Appetite - MinimalEnsuring patient care, safety

and experience

O1

Board (L2)

WELG (L1)

81/19 Capital bid submitted; awaiting response from

NHSI. Capital bid = mitigation for spend on medical

equipment (high risk items with impact on patient safety if

not available)

F&P/Board (L2)

QC (L2)

QC / Board (L2)

Board (L2)

Board (L2)

Medicine Safety

Outcome of review of therapies to be incorporated into

staffing review and Nursing & AHP Strategy once

complete

Board (L3)

CQC Assurance Compliance Framework

QC (L2)

Action Plan

QC/Board (L2)

Due Date

SOURCES OF ASSURANCE

What is the evidence received that provided or will provide that assurance?

Capital Programme Priorities

Lead

WELG (L1)

Strategy to Board April 18 . Learning from SIs etc to be

incorporated, following SI review. Controls in place re

reporting, incident management and national learning

reporting system (NRLS)

Board (L3)

GAP

HSB to review risk May 2018

Data Quality

Case of need to HMB Feb 18 for Med Safety Nurse &

Clinical Lead for Med Safety. To be monitored via

improvement plan. Funding agreed for Medicines Safety

Nurse and Clinical Lead. Recruitment to be initiated and

improvement plan to be implemented

Board (L3)

Nurse staffing

Reduction in capital spend on backlog maintenance/H&S increasing risk

of negative impact on maintaining safe and secure estate

Evidence of learning from incidents

Nursing/AHP and Patient Experience Strategies Board (L2)

S&R/QC/Board

(L2)

S&R/HMB/QC

(L2)

F&P/Board (L2)

Audit/QC (L3)

AHP staffing

QC/Board (L2)

Board (L2)

S&R (L1)

Corporate Performance Report

Duty of Candour Divisional Dashboards

Infection Prevention & Control Report

Complaints - Reportable Issues Alert/ Corporate Performance Report

Internal Audit Reports

Safe Nurse Staffing Report (6 monthly) including nurse revalidation Board (L2)

QC/Board (L2)

Serious Incident Reports (Reportable Issues Alert)

Aintree Assessment & Accreditation Report

ECAP Progress Reports

E-Roster Reports

Emergency & Acute Care Programme

Health Roster (junior medics only)

Safeguarding Annual Report

Board Quality Governance Framework Self-Assessment

Patient Experience Improvement Plan

Quality Account (external auditor report)

Clinical Audit Plan

Capital Programme

Quality Schedule (CQUINs) (within CPR)

Aintree Quality Improvement Scheme (AQUIS)

Practice, Incidents & Lessons Learned (PILL) Report

Annual Appraisal / Revalidation Reports

Annual Business Plan Priorities Progress Reports

Quality Strategy Implementation Plan (quarterly reports)

CQC Assurance Reports (Divisional self-assessments)

CQC Improvement Plan - Updates

Clinical Pharmacy Strategy

TC/CK May-18 Board

Performance Concerns (Doctors)

Exit interview In operation. Quarterly audit of Recruitment & Retention

policy (linked to NHSI Retention Support Plan) - policy to

be enactedQC (L2)

GAPS IN CONTROL:

GAP

A&E & Medicine Div improvement plan in place and

being monitored; no SIs in last 6 months and improved

flow. Q&S measures in place in ED. No issues identified

from CQC inspection. Enhanced monitoring of patient

safety in ED.

Management of Deteriorating Patients in A&E (+ activity & flow)

TC OP-ELG/Board

Feb 2018

July 2018

GAPS IN ASSURANCE:

Biannual report to align with financial plan report to

Board; Board approved funding increase Mar 2018. .

Patient Safety risk mitigated by use of agency and bank

staff. 2 yr Nursing & AHP Strategy to Board April July

with quarterly updates on delivery to QC/Board

DBApril 2018

June 2018QC/Board

Medicines Management Deep Dive

Regulatory Framework:

▪ CQC Registration

▪ Provider Licence

BAF Q2 2017/18 Page 1

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Risk ID Date Raised Risk Owner Risk area Programme Risk Risk Description Consequences Likelihood ConsequenceCurrent Risk

Score Mitigating Action Action Owner Status Date Closed Notes

TI004 01/10/17I Jones/ J

Graham

Risk to delivery of the

programme

Financial

Sustainability

Inability to present a balanced LTFM to

programme regulators

Unable to approve the

transaction causing

delay or programme

failure

5 3 15

Financial strategies of both Trusts

aligned demonstrating how

sustainability can be achieved

Discussions with NHSI re expectations

of LTFM

Expert advice sought

I Jones/ J Graham Open

Reviewed 09/01/18

Allocated named owners

28/02/18

Seek permission to close

at TPSG 07/03/18.

Discussion at TPSG rating

amended due to NHS

financial climate

TI018 11/12/17A Kehoe/ J

Graham

Risk to the delivery of

the programmeFinancial

RLBUHT financial position does not allow

commitment of adequate financial support

required to progress the Transaction and

Integration Programme

Inability to deliver the

programme due to

inadequate resource

3 4 12

To be discussed at TPB & TPSG.

Discussions with NHSI to continue re

programme funding, meeting 12/01/18

to discuss support. External support

for financial turnaround plan in place

A Kehoe/ J

GrahamOpen

Reviewed 09/01/18


28/02/18

TI001 01/10/17A Smithson/ P

Williams


programme

Executive leadership

and engagement

Failure to gain the commitment of senior

leaders to programme, with competing

pressures of ‘day job’

Inadequate

development of clinical

and corporate work,

delays and a lack of

leadership

commitment to OBC

3 3 9

Strong Chairs/CEO leadership of the

programme, robust governance

arrangements in place. Governance

forums include: TPSG, TPB, Board

to Boards, JCAG, IPT's, PWG's,

strong Chairs/CEO leadership

A Kehoe/ S

Warburton/ B

Grifiths/ N

Goodwin

Open

Reviewed 09/01/18


28/02/18

TI007 01/10/17I Jones/ J

Graham

Risk of not proceeding

with a merger

Financial

Sustainability

Lack of ability to deliver current

standalone financial models

Failure to improve the

financial positions of

Trusts

3 3 9

Ensure sufficient financial details

provided in FBC to support and

evidence the benefits of a merger, as

opposed to operating as two single

entities. Risk Owners to engage with

NHSI regarding financial positions and

impact of merger.


Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

TI010 01/10/17P Williams/ T

Cope


with a merger

Clinical & Staff

engagement

Loss of clinical support to deliver the

vision for change

Reduce motivation to

support change and

development of patient

benefit case / FBC

Risk of loss of staff

from both Trusts

3 3 9

Effective delivery of communication

plan, HSRG and JCAG to continue

and support shared decision making

P Williams/ T

CopeOpen

Reviewed 09/01/18


28/02/18

TI012 01/10/17

Transaction

Programme

Board

Risk of proceeding with

a merger

Organisational

development

Failure to understand and address the

cultural differences between organisations

Failure to create a new

organisational identity

(vision, values and

common purpose)

3 3 9

Develop and implement OD

programme to support the large scale

change

Workforce PWG

TPB

TPSGClosed Duplication

Reviewed 9.1.18

Permission requested to

close


Williams


a mergerClinical sustainability

Failure to deliver on intended patient

benefits from merger as outlined in BC

Not adding value to

local healthcare3 3 9

Clinical teams supported to realise

and track patient benefits through

IPTs & PWGs,

Specific KPIs to be included in Target

Operating Model

A Smithson/ P

WilliamsOpen

Reviewed 09/01/18


28/02/18

Transaction & Integration Programme Risk Log

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TI014 01/10/17I Jones/ J

Graham


a merger

Financial

Sustainability

Failure to improve financial position of the

new organisation as estimated in BC

Loss of reputation of

combined Trust and

regulatory intervention

3 3 9

Test financial assumptions during FBC

stage to be assured they are realistic

and deliverable


Reviewed 09/01/18


28/02/18


Williams


a mergerRegulatory approval

Failure to obtain approval to proceed from

NHSI or CMA refers proposals to a Phase

2 investigation

Delay to the

Programme3 3 9

Continue discussions with NHSI

Ensure a robust patient benefit case

Use expert advice to support where

necessary

A Smithson/ P

WilliamsOpen

Reviewed 09/01/18


28/02/18


WilliamsDelay to OBC review Regulatory approval

Delay by regulators to review OBC until

summer 2018 causing uncertainty to

programme timeline & lack of motivation

and momentum from staff and

stakeholders of the programme

Lack of clinical and

stakeholder support3 3 9

Continue to work closely with staff and

stakeholders, ensure regular

communication and evidence of

progressing work is shared. Strong

leadership from both Trust Boards

A Smithson/ P

WilliamsOpen

Reviewed 09/01/18


28/02/18

TI020 11/12/17 D WallikerRisk to the delivery of

the programme

Single EPR

implementation

Due to uncertaintly of date for handover of

New Royal Project there is an inability to

align EPR programme timeline with this &

merger programme

Failure to plan

effectively for major

transformation

programmes going on

across the Trusts in

similar timeframes

3 3 9

Chairs, Chief Execs & Programme

Directors to continue regular cross

programme discussions and risk

monitoring

D Walliker Open

Reviewed 09/01/18


28/02/18

Risk to be reviewed at

next Digital & Information

Services workstream

meeting.

TI022 08/01/18P Williams/ T

Cope


programmeClinical input into FBC

Risk of lack of input to clinical models and

business case development as the

workload for FBC increases, limited

capacity of clinical teams

Inability to provide the

input required for FBC3 3 9

PMO to provide as much notice as

possible when planning workshops

and meetings

P Williams/ T

CopeOpen

28/02/18 Risk owner

allocated.

28/02/18 Risk upgraded

following IPT highlight

report as some specialties

experiencing operational

pressure and raising

concerns regarding

capacity.

Approved at TPSG

TI023 08/01/18

S Warburton/ A

Kehoe/ B

Griffiths/ N

Goodwin

Finance

Funding for

Transaction and

Integration support

Risk of NHSI not funding transaction costs

for the merger

Impact on financial

position if Trusts have

to fund, increased

overspend and

reduced financial

synergies, lack of

resources and poor

business case

3 3 9Meeting with NHSI 12/01/18 to

discuss support / resourcing

S Warburton/ A

Kehoe/ B Griffiths/

N Goodwin

Open

Risk owner allocated

28/02/18.

Risk reviewed at TPSG

07/03/18.

TI002 01/10/17 H ShawRisk to delivery of the

programme

Engagement of

stakeholders

Failure to ensure all stakeholders (internal

and external) are engaged and have the

ability to influence the T & I programme

Lack of stakeholder

support and potential

for legal challenge,

resulting in failure to

obtain regulatory

approval to proceed

2 3 6

Comms Working Group established,

Comms strategy, stakeholder

mapping in place, clinical engagement

through IPT's, monthly staff and

stakeholder bulletins, staff side.

Partnership Engagement Lead

currently being recruited to support

activities.

H Shaw Open

Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

TI003 01/10/17 H ShawRisk to delivery of the

programme

Public & Patient

Involvement

Failure to involve patients and the public in

planning during business case

development in accordance with

legislation and guidance

Legal challenge to the

process, resulting in

significant delay or

failure of the

programme

2 3 6

Formal public consultation working

with Liverpool CCG & involving

partners in Knowsley & Sefton,

working with OSC's, public

consultation for Orthopaedics

proposal. Partnership Engagement

Lead currently being recruited to

support activities.

H Shaw Open

Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

TI005 01/10/17 L GrantRisk of not proceeding

with a mergerQuality variation

Lack of flexibility to improve quality of care

by reducing variability in patient outcomes

and experience

Failure to meet clinical

standards & streamline

pathways

Loss of tertiary

services to other

centres

failure in accreditation

2 3 6

Ensure a robust case is provided in

FBC to support and evidence the

clinical benefits of a merger

P Williams Open

Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

TI008 01/10/17S Warburton/ A

Kehoe


with a mergerStrategic direction

Lack of ability to align with Healthy

Liverpool Programme and NHS Cheshire

and Merseyside

Reputational risks to

both organisations

Loss of support from

CCG's, NHS C & M

2 3 6


BC to support and evidence the case

for a merger

S Warburton/ A

KehoeClosed

Reviewed 09/01/18


28/02/18

Permission to close

requested at 07/03/2018

as aligned to TI006

Closed 7/3/18

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Kehoe


with a merger

Transformational

change

Lost opportunity to drive through service

change at scale and pace

Failure to achieve level

of service change

required across North

Mersey

2 3 6

Ensure robust case is provided in BC

to support and evidence the case for a

merger

S Warburton/ A

KehoeOpen

Reviewed 09/01/18


28/02/18

TI011 01/10/17H Shaw/ D

Herring


a mergerStaff support Lack of staff support for the merger

Slow clinical and

support services

integration

2 3 6

Regular staff briefings

consistent staff and public

engagement process

Staff input into development of clinical

case

Early engagement of Staff Side

H Shaw/ D Herring Open

Reviewed 09/01/18


28/02/18

TI015 01/10/17

S Warburton/ A

Kehoe/ B

Griffiths/ N

Goodwin


a merger

Executive leadership

and engagement

Demotivation of Directors not appointed to

Interim Board who remain on existing

Boards

Lack of support to

deliver the vision of

the new organisation

2 3 6

Strong Chair & CEO leadership &

support, importance of existing boards

functions emphasised and supported,

Talent management programme to be

considered for smooth transition to

redeployment

S Warburton/ A

Kehoe/ B Griffiths/

N Goodwin

Open

Reviewed 09/01/18


28/02/18

TI016 01/10/17

A Smithson/ P

Williams/ T

Cope


a merger

Implementation of a

new model

Gaps or confusion appear in patient

pathways during the transition

Lack of clinical and

stakeholder support2 3 6

Development of robust integration

plans for day 1 and day 100 a part of

PTIP, effective comms plan,

clinical accountability and ownership

of PTIP using governance structure in

place for clinical challenge and

clarification.

A Smithson/ P

WilliamsOpen

Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

TI019 11/12/17 P WilliamsRisk to delivery of the

programme

New Royal Liverpool

Hospital opening

Uncertain timescale for handover date and

opening of the New Royal Liverpool

Hospital

Inability to plan

effectively for merger,

new hospital opening

2 2 4

T & I Programme Director also lead

for new Royal project, discussed at

weekly PMO team catch up,

timescales for new Royal programme

delayed allowing Prog Director to

focus on T & I during summer 2018

P Williams Open

Reviewed 09/01/18


28/02/18

For review at TPSG

07/03/18 and if remains

red for discussion at TPB

12/03/18

Updated following TPSG

TI021 11/12/17 A SmithsonRisk to new Royal

Project

Trauma and

orthopaedics project

implementation

Delay in merger / new Royal timelines and

commitment to financial support required

to progress leads to AUHFT Trust board

not committing to the implementation of

the T & O project

Inability to plan

effectively with

changing timescales

and lack of funding

2 2 4

T & I Programme Director also new

Royal Programme Director, regular

discussion and updates to Trust

Boards

Implementation time line agreed as

April 2019

A Smithson/P

WilliamsOpen

Risk Owner allocated

28/02/18.

Risk to be reviewed at

TPSG 07/03/18.

updated following TPSG

7/3/18


Kehoe


with a mergerClinical sustainability

North Mersey landscape continues to be

over populated with the number of acute

and specialist Trusts in the area

Duplication and

variation of services

across both Trusts

1 3 3


BC to support and evidence the

clinical benefits of a merger . Risk

owners to link in with STP

workstreams to maintain

communicaion regarding population

and North Mersey Landscape and

benefits of the merger.

S Warburton/ A

KehoeOpen

Reviewed 09/01/18


28/02/18

Amended Mitigation

28/02/18

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Board Committee Assurance Report


Date 25 April 2018

Committee Name Quality Committee

Date of Committee Meeting 16 April 2018

Chair’s Name & Title Mandy Wearne, Non-Executive Director (Chair)

Executive Lead Dianne Brown, Chief Nurse

Summary

The Quality Committee continues to receive reports and provide assurance to the Board of Directors

against its work programme via a summary report submitted to the Board after each meeting. Full

minutes and enclosures are made available on request.

Key Issues

Corporate Performance Report (CPR) and Report from Hospital Management Board – Partial

Assurance

The Committee reviewed the reports together to set the quality context at the beginning of the meeting.

The following matters arising from these reports were discussed:

• Cancer 62-day standard was expected to be achieved for the month and the quarter once the data

had been validated

• A&E performance continued to work towards the improvement plan although it was highlighted that

attendances were still on the increase and additional bed capacity was still open

• Ready for Discharge patients remained high

• Whilst the Trust’s referral to treatment performance was one of the best in the North West it was still

below the standards expected and needed to get back on track. This had been impacted due to the

enforced planned activity cancellations in January 2018 as per NHS England directive

• Complaints response times continued to be a concern particularly in the Medicine Division. Whilst

there had been some improvements in the quality of responses, additional training had been put in

place to deal with the timeliness of responses. Furthermore, weekly meetings to monitor progress,

chaired by the Chief Nurse, remained in place.

• There had been an increase in the level of Trust apportioned C.Difficile cases, however have met the

Trust annual agreed target , some of which was due to the use of antibiotics with a higher risk of

infection contraction as a result of the worldwide shortage of Tazocin. The focus for 2018/19 was on

improving clinical engagement, establishing a clinically led CDI Working Group and the sharing of

lessons learned. The Committee was keen to see improvements in training for Health Care

Assistants as well as engagement with medical consultants

• There had been a deterioration against the Safety Thermometer in February 2018 principally due to

VTE assessments but this had now improved in March

• The deterioration against the Friends & Family Test results was due the outdated method of

collecting responses manually. The process has now been changed so that an automated test

message was now provided which should have a positive impact on the response rates.

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Quality Committee 16 April 2018: Board of Directors 25 April 2018 2/3

CQC Inspection – Partial Assurance

The Committee was advised that the Improvement Plan had been approved by the Board and sent to the

CQC in March 2018. The Committee had noted that the Trust was under increased surveillance as a

result of the Quality Risk Profile Assessment process and noted that the Improvement Plan was to be

reviewed to include the issues/risks identified through that process. Reference was made to the

discussions at the recent Board Away Day and the request for the Executive Team to develop a

framework to show the direction of travel in terms of the improvement work required on culture and

behaviour as well as staff engagement as highlighted in the Staff Survey Report. The Committee was

also advised that the detailed process to implement the compliance framework was being developed and

would be discussed by the Hospital Management Board.

The Committee received the Trust’s analysis of the CQC Insight Report which highlighted that there

were 17 indicators outside the expected range. The Committee was advised that the improvements

would be managed by each of the Executive Led Groups with specific updates on actions being reported

through by the Executive Leads. The Committee was to receive an update in July 2018.

Serious Incidents (SI) – Partial Assurance

The Committee was advised that the Trust remained an outlier in terms of low levels of incident reporting

and an improvement plan was being monitored through the Safety & Risk ELG looking at different ways

of reporting and simplifying the process. There continued to be an upturn in the number of serious

incidents reported with a theme of failure to act on test results highlighted. The Committee also received

an update on the Never Events investigations and was advised that both internal and external reviews

were being undertaken, with the outcomes from the investigation and the reviews being reported through

to the Committee. Details of each Never Event, including immediate action taken and timelines are to be

circulated to the Committee and Board members. Furthermore, a review was to be undertaken later in

the year by the Royal College of Surgeons to review the implemented actions as advised by the current

work check the outcome of the reviews. The Committee was also advised that the serious incident

investigation process had been strengthened and investment approved to implement the revised process

Safeguarding Services Update – Partial Assurance

The Committee received the update report which highlighted the steady flow of DoLS applications being

reviewed by the Safeguarding Team. Training attendance continued to be of concern as there were

challenges being experienced in releasing staff to attend training sessions due to capacity issues.

However, the importance of the training had been stressed to the Teams so that the Trust could

evidence its compliance with regulatory requirements. The Committee raised concerns about the

deliverability of the training trajectory and was advised that this would be revisited in June 2018.

Draft Quality Account 2017/18

The Committee received the draft and it was requested that any feedback or comments on its content be

referred to the Business Intelligence Team.

Ophthalmology Risk Exception Report – Partial Assurance

The Committee was provided with an update on the implementation of the action plan and was advised

that investigations still show capacity as the root cause for incident reporting as demand was outstripping

capacity. The Committee noted the progress made but recommended that the Division and the Safety &

Risk ELG review the impact of the action plan and assess whether any further actions were needed to

improve the position

Learning from Deaths in the NHS – Acceptable Assurance

The Committee was provided with an update on the progress made by the Trust on the implementation

of the National Quality Board standards and was advised that number of consultants had received

training on the electronic Structured Judgement Review tool but this had not yet been launched. In the

meantime, mortality reviews continued to be undertaken

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Quality Committee 16 April 2018: Board of Directors 25 April 2018 3/3

Deep Dives

• Review of Physical Violence against Staff

The Committee received a report which highlighted that there had been a 70% increase in reported

physical assaults against staff in the past three years. During 2017 there had been an increase in the

level of anti-social behaviour and a sanction system had been introduced to allow the Trust to issue

ASBOs when necessary. The Committee was concerned about the number of physical assaults and

requested that a Task & Finish Group be established to consider training, protection and support for staff

and report through to the Safety & Risk ELG.

• Review of Needlestick Injuries

The Committee received a report which provided an overview of the work that had been undertaken to

reduce the level of sharps incidents within the Trust and, ultimately, a reduction in claims. However,

there had been an increase in incidents within theatres over the last three years and discussions were

taking place with the management team on the themes arising from the incident reports. Over the next

six months there was an expectation that, through increased training and education, there would be a

reduction in the levels of incidents.

Decisions Made

N/A

Recommendation

The Board is asked to note the report.

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Report Title Safeguarding Services Update


Lead Officer Amanda McDonough ADN for Safeguarding

Action Required To note the report

Substantial

assurance

High level of

confidence in

delivery of

existing

mechanisms /

objectives

Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• Progress against the detailed action plan is steadily being completed

• Updates will continue to be provided to the Hospital Safeguarding Board and reported through

to Committee


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal






• Achieve best patient

outcomes

• Promote research and

education






• Annual Business Plan

Priority

• Key Risk

• Service Change

• Other



Complete the actions required to strengthen controls.

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Safeguarding Service Update –Board of Directors 25 April 2018 2/6

REPORT HISTORY


Agenda Ref



Quality

Committee

QC17-18/

149

Safeguarding

Services Update

19 March

2018

Noted

Quality

Committee

QC18-19/

012

Safeguarding

Services Update

16 April 2018 Noted. Concerns raised

about deliverability of training

trajectory. To be reviewed in

June 2018

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Safeguarding Services Update

Executive Summary

1. Aintree Board of Directors has approved to support an overarching themed improvement

plan to address concerns that had been identified in relation to Safeguarding

2. The Trust is looking to embed a culture of compliance and as such it has been agreed that

the Trust’s Quality Committee will oversee a 3-year Strategy and Operational Work plan

with an inbuilt trajectory of improvement

3. This will be operationally delivered through the Hospital Safeguarding Board (HSB) with

individual action points for the remainder of 2017-18 followed by further phases of

implementation and evaluation in 2018-19 and 2019-20

4. Following each Hospital Safeguarding Board, an assurance paper will be provided outlining

the summary details of key issues for that reporting period; thereby enabling the Quality

Committee to be assured and to seek further information if necessary

Key Issues

5. In addition to the improvement plan, whilst awaiting the development of some processes,

the trust has taken immediate steps to respond to the concerns raised by the CQC. Most

significant among these are:-

Risk Management

6. Currently the strategic risk for Safeguarding (Risk 3898) is scored at 20 (4*5) and is

identified on the Trust’s BAF. To enable the Trust to monitor and audit the operational

actions taken to decrease the risk score robustly it was agreed that all actions would sit

within 4 separate service level risks underneath the BAF. These are categorised as follows

(Appendix 1):

• Safeguarding – Vision, Strategy and Leadership (Risk 3954)

• Safeguarding – Governance, Accountability and Assurance (Risk 3956)

• Safeguarding – Improving Quality and Learning (Risk 3957)

• Safeguarding – Compliance and Effectiveness (Risk 3958)

7. These risks will now be included monthly as appendices for the Committee to view any

progress made.

Mental Capacity Act and Deprivation of Liberty Safeguards (MCA/DoLS)

8. In response to a notification from the CQC in respect to patients being deprived of their

liberty without statutory safeguards being in place, identified during an inspection by the

CQC, a daily report was initiated to identify any inpatient with a cognitive impairment.

9. This initiative commenced on 20 November 2017 and required a daily report to be

submitted to the Trust Safeguarding Team by all wards and departments. This in turn is

reviewed and any required guidance is fed back to the individual ward or department.

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10. Since commencing the new process, there has been a positive response from the ward

areas with more patients with an impairment of the mind or brain being identified.

11. The findings for the past four weeks (in italics) are detailed in the table below:

Time period

Number of patients with a cognitive

impairment where DoLS should be

considered

Number of DoLS applications made following advice

DoLS applications not completed following

advice**

Week 1 104 17 84

Week 2 69 15 54

Week 3 41 12 29

Week 4 42 11 31

Week 5 181 76 105

Week 6 109 39 70

Week 7 81 30 51

Week 8 49 37 12

Week 9 91 46 45

Week 10 89 40 49

w/c 12/03/18 77 28 49

w/c 19/03/18 78 36 42

w/c 26/03/18 48* 23 25

w/c 02/04/18 31* 38 1

*reduction of patients identified caused by the same patients not being added each day, this will help

indicate a truer number of patients requiring assessment daily.

**Patients may have regained capacity or been discharged/transferred to another hospital/home

12. As per the daily mental capacity log, it has been identified that wards continue to submit

DoLS applications prior to formally assessing a patient’s capacity. Unfortunately, without

the mental capacity assessment, the DoLS application is void. Last week’s DoLS

applications highlighted that, out of the 31 urgent authorisations, 8 were submitted without

an appropriate mental capacity assessment having being completed.

13. In addition to these applications, many others have been returned after failing the quality

assurance process now in place within the Safeguarding Team, due to incorrect or a lack of

relevant information being included within the authorisation. In order to address this, the

Safeguarding Team continue to attend targeted wards daily to provide direct support in

respect to assessing a patients capacity, making best interest decisions and the process of

authorising a DoLS.

14. There is however, overall significant improvement in the quality of capacity assessments

pertaining to DoLS that are being completed by the wards. This is likely to be from a

combination of improved knowledge form training, the utilisation of the revised assessment

template to record capacity as well as the direct support from the Safeguarding Team.

Training

15. The Safeguarding Training Strategy (Appendix 2), which includes a specific MCA/DoLS

training framework, was presented at WELG in April and approved.

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MCA/DoLS Level 2 Training

Date Number of Attendees (* booked)

Trust Compliance

16/01/18 36 1.37%

18/01/18 51(87) 3.31%

22/01/18 63 (150) 5.71%

24/01/18 55 (205) 7.80%

29/01/18 34 (239) 9.1%

06/02/18 50 (289) 11.0%

13/02/18 11(300) 11.4%

15/02/18 24 (324) 12.0%

28/02/18 40 (364) 14.0%

01/03/18 27 (391) 15.0%

07/03/18 25 (416) 16%

12/03/18 19 (435) 16.5%

14/03/18 28 (463) 18%

16/03/18 19 (482) 18.5%

23/03/18 20 (502) 19.0%

27/03/18 14(516) 19.5%

29/03/18 15 (531) 20%

20/04/18 20*

30/04/18 22*

09/05/18 18*

25/05/18 20*

30/05/18 0*

06/06/18 8*

14/06/18 2*

20/06/18 3*

22/06/18 3*

16. Attendance at MCA Level 2 training remains low despite concerted efforts by Divisional

Leads to improve. A possible key contributory factor to this could be operational pressures

around staff release. This does jeopardise the forecast trajectory that we will be 80%

complaint by the end of June 2018.

MCA/DoLS Level 3 Training

17. This training has been developed to provide key identified staff within the Trust with the

skills to be able to assess a patient’s mental capacity as a decision maker. This is the first

time this level of training has been delivered within the Trust and will relieve the pressure

on the Trusts medical staff to complete all mental capacity assessments.

18. On 21 March 2018, the pilot MCA/DoLS Level 3 competency based training was delivered

to staff who had previously completed MCA/DoLS Level 2 training. Staff who attended,

provided positive feedback around the key learning from the session; which took 4 hours to

complete, in order for staff to fully understand the documentation process. The

Safeguarding Team will deliver this training twice a month based upon the compliance of

MCA/DoLS Level 2.

19. The Safeguarding Team have now relocated to the PHL building on the 2nd Floor and are

now centralised in one office.

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Conclusion

20. Whilst currently the Trust remains in a position of requiring much to accomplish in the next

6 to 12 months and over the next three years, progress against the detailed improvement

plan is steadily being completed. The continued changes that are being progressed as a

matter of priority will be reported through the monthly HSB meetings and Quality

Committee.

21. The Board of Directors continues to support the improvement plan which will ensure that

Aintree University Hospital NHS Foundation Trust complies with the required safeguarding

legislative framework and requirements and can do so moving forward.

Recommendation

22. To note the report.

Appendices

Appendix 1 – Safeguarding Risks

Author: Amanda McDonough - ADN for Safeguarding

Date: 10 April 2018

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Risk Details

RISK ID 3898

Is this a Trustwide Risk? Yes

Risk TypeOperational Risk or Assurance Framework

Operational Risk

Title Failure to ensure effective arrangements with partners to safeguard vulnerable adults and children

Unit University Hospital Aintree

Division Other Services

Clinical Business unit/Department

Corporate Nursing

Location Safeguarding

Ward / Location Exact

Is this Incident/Risk related to a Estates & Facilities issue?

No

Date of Assessment (dd/MM/yyyy)

03/10/2017

Description of RiskPlease descibe the risk in terms of cause, risk and effect.

Failure to ensure effective arrangements with partners to safeguard vulnerable adults and children, failure to comply with national and local standards for the safeguarding of children and adults.

Cause: Change in management, legislative requirements, lack of direction and control , poor/ineffective systems and processes

Effect: Potential failure to prevent harm, inadequate organisational leadership, assurance and engagement; damage to Trust reputation

Impact: May result in avoidable harm; may result in regulatory action; financial penalty; prosecution

Internal reporting codes Safeguarding

Source of Risk External Recommendation

Initial Risk Rating Consequence (initial)

Likelihood (initial)

None Low Moderate Severe Death or Catastrophic

Almost Certain

Likely

Possible

Unlikely

Rare

Matthew O'Neill

Risk Review and Management Form

Page 1 of 4Datix: Risk Review and Management Form

03/04/2018http://ahtlegal03/live/index.php?action=risk&table=main&recordid=3898&print=1&t...

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Rating (initial): 20 Risk level (initial):

High

Rationale (Initial) Following the 4 recent external reports commissioned by the Chief Nurse, the findings indicated that there is a lack of leadership and assurance around the provision of safeguarding across the Trust.For example, the Trust has not fully complied with their statutory responsibility around the Mental Capacity Act (MCA) 2005 and to the Deprivation of Liberty Safeguards (DoLS) 2009. An SLA between the Trust and the Safeguarding Services from Liverpool Women’s NHS Foundation Trust has been agreed to support the current safeguarding provisions in Aintree University Hospital NHS Foundation Trust and develop a two year Safeguarding Service Strategy with an embedded operational work plan to manage this.

Handler Brown, Dianne - Director of Nursing

Last updated Mr Paul Flynn 15/02/2018 15:45:42

CQC Domains SafeWell Led

Persons who may be harmed PatientsStaffTrust Reputation

Current Risk Rating

Existing Controls • Safeguarding Policies• Seconded Safeguarding management team (LWH) (in post)• Seconded Named Nurse for Safeguarding Adults role (in post)• Redeveloped MCA/DoLS training programme for all staff• Identified staff trained to assess Mental Capacity• Safeguarding Training• Attending Local Safeguarding Adult and Child Boards

Current Consequence (current)

Likelihood (current)


Almost Certain

Likely

Possible

Unlikely

Rare

Rating (current): 20 Risk level

(current): High

Rationale (Current) Following the 4 recent external reports commissioned by the Chief Nurse, the findings indicated that there is a lack of leadership and assurance around the provision of safeguarding across the Trust.For example, the Trust has not fully complied with their statutory responsibility around the Mental Capacity Act (MCA) 2005 and to the Deprivation of Liberty Safeguards (DoLS) 2009. An SLA between the Trust and the Safeguarding Services from Liverpool Women’s NHS Foundation Trust has been agreed to support the current safeguarding provisions in Aintree University Hospital NHS Foundation Trust and develop a two



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year Safeguarding Service Strategy with an embedded operational work plan to manage this.

Review Date

Review date (dd/MM/yyyy) 29/12/2017

Target Risk Rating

Target Consequence (Target)

Likelihood (Target)


Almost Certain

Likely

Possible

Unlikely

Rare

Rating (Target): 10 Risk level (Target):

Moderate

Rationale (Target) To ensure the appropriate resources to be able to immediately start addressing some areas of concern already identified within the Safeguarding Service. In order to reduce the risk, the Trust needs to develop a secure infrastructure and recruit post holders who have the appropriate skillset and experience within the identified roles. This will ensure that the Trust can have a robust and cohesive service and will evidence the Trusts commitment to achieving the required standards. The Trust would be required to demonstrate the effectiveness of safeguarding leadership and governance and assurance processes via policy, procedure, training and audit. The Trust would also need to show compliance with legislation namely; Mental Capacity Act 2005, The Care Act 2013, The Children’s Act 1989 (2004) and The Equality Act 2010.

Presented at

Actions

Risk Approval

Risk Status Active Risk

Current approval status Final approval

Risk Closure

Closed date (dd/MM/yyyy)

Reporter of risk

No actions

Current approval

status

Title Forenames Surname Patient/staff number Type Status Contact role



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Action chains

Approved Matthew O'Neill Reporter of incident

No action chains

DatixWeb 14.0.11 © Datix Ltd 2016



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Risk Details

RISK ID 3954



Operational Risk

Title Safeguarding – Vision, Strategy and Leadership




Corporate Nursing




No


28/03/2018


Failure to ensure effective arrangements with partners to safeguard vulnerable adults and children, failure to comply with national and local standards for the safeguarding of children and adults.Cause: Change in management, legislative requirements, lack of direction and control , poor/ineffective systems and processesEffect: Potential failure to prevent harm, inadequate organisational leadership, assurance and engagement; damage to Trust reputationImpact: May result in avoidable harm; may result in regulatory action; financial penalty; prosecution






Almost Certain

Likely

Possible

Unlikely

Rare


High

Matthew O'Neill




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Handler O'Neill, Matthew - Safeguarding Manager

Last updated Matthew O'Neill 03/04/2018 13:37:18

CQC Domains EffectiveSafeWell Led


Current Risk Rating





Almost Certain

Likely

Possible

Unlikely

Rare


(current): High

Rationale (Current) Following the 4 recent external reports commissioned by the Chief Nurse, the findings indicated that there is a lack of leadership and assurance around the provision of safeguarding across the Trust.For example, the Trust has not fully complied with their statutory responsibility around the Mental Capacity Act (MCA) 2005 and to the Deprivation of Liberty Safeguards (DoLS) 2009. An SLA between the Trust and the Safeguarding Services from Liverpool Women’s NHS Foundation Trust has been agreed to support the current safeguarding provisions in Aintree University Hospital NHS Foundation Trust and develop a two year Safeguarding Service Strategy with an embedded operational work plan to manage this.



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Review Date


Target Risk Rating


Likelihood (Target)


Almost Certain

Likely

Possible

Unlikely

Rare


Moderate


Presented at Board of DirectorsDivisional Assurance GroupHospital Management BoardQuality & Safety Committee

Actions

ID Responsibility ('To')

Assigned by

('From')

Module Action Description Due date Done date

Priority

6577 Dianne Brown Matthew O'Neill

Risk Register

Peer Review of Safeguarding Services commissioned to provide assurances

01/09/2017 31/07/2017

6586 Matthew O'Neill Matthew O'Neill

Risk Register

Create a current Safeguarding Position Paper to inform the Trust Board ASAP

29/09/2017 28/09/2017


Risk Register

Develop the Safeguarding Annual Report 2016-17 to document the safeguarding service work over the previous 12 months.

02/11/2017 01/12/2017



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Risk Approval


Current approval status Awaiting final approval

Risk Closure


Reporter of risk

Action chains


Risk Register

Create a Safeguarding Work Plan to track all work completed to improve the safeguarding service in line with the Corporate Safeguarding Strategy

30/11/2017 03/11/2017


Risk Register

Develop a Corporate Safeguarding Strategy

30/03/2018 31/01/2018


Risk Register

review Trust Safeguarding Training Strategy to ensure it meets legislation and national guidance

30/04/2018


Risk Register

Develop the Safeguarding Annual Report 2017-18 documenting all the work completed to assure the Board and external partners.

28/09/2018


Risk Register

Plan a Multi-Agency Event to promote the Safeguarding Service in the Trust

02/11/2018

6591 Carl Griffiths Matthew O'Neill

Risk Register

Develop overarching ‘care of patients with a cognitive impairment’ strategy which will include MCA, delirium, dementia, LD and challenging behaviour’

02/11/2018

Current approval

status



No action chains




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Risk Details

RISK ID 3956



Operational Risk

Title Safeguarding - Governance, Accountability and Assurance




Corporate Nursing




No


03/04/2018








Almost Certain

Likely

Possible

Unlikely

Rare


High

Matthew O'Neill




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CQC Domains CaringSafeWell Led


Current Risk Rating





Almost Certain

Likely

Possible

Unlikely

Rare


(current): High




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Review Date


Target Risk Rating


Likelihood (Target)


Almost Certain

Likely

Possible

Unlikely

Rare


Moderate


Presented at Audit CommitteeBoard of DirectorsDivisional Assurance GroupHospital Management Board

Actions


Assigned by

('From')


Priority


Risk Register

Safeguarding Awareness & Responsibilities Training to Exec Board

31/10/2017 22/09/2017


Risk Register

Safeguarding Training Update to Trusts Governors

27/04/2018 23/03/2018


Risk Register

Review Trust Prevent Policy/SOP

30/04/2018 08/12/2017


Risk Register

Complete review of previous CCG Quarterly KPI submissions

31/05/2018

6605 Matthew O'Neill 31/05/2018



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Risk Approval


Current approval status In holding area, awaiting review

Risk Closure


Reporter of risk

Action chains

Matthew O'Neill

Risk Register

Review Safeguarding Childrens Policy (including all RSM identified actions)


Risk Register

Review Trust Safeguarding Adults Policy (including RSM actions)

31/05/2018


Risk Register

Safeguarding Training Update to Senior Managers/GMoCs

29/06/2018


Risk Register

Review MCA & DoLS processes (Consent Forms)

29/06/2018


Risk Register

Review Section 11 submission to LSCB

29/06/2018


Risk Register

Review LD / Dementia Policy 29/06/2018


Risk Register

Review Mental Capacity Act 2005 (incorporating the Deprivation of Liberty Safeguards) Policy

29/06/2018


Risk Register

Review Positive Handling Policy (Restraint)

28/09/2018


Risk Register

Complete a thematic review of all Serious Reviews

28/09/2018


Risk Register

Complete and submit NHS Safeguarding Commissioning Standards Self-Assessment Audit tool to CCG

28/09/2018


Risk Register

Safeguarding Training Update to Exec Board

28/09/2018

Current approval

status



No action chains



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Risk Details

RISK ID 3957



Operational Risk

Title Safeguarding – Improving Quality and Learning




Corporate Nursing




No


03/04/2018








Almost Certain

Likely

Possible

Unlikely

Rare


High

Matthew O'Neill




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Current Risk Rating





Almost Certain

Likely

Possible

Unlikely

Rare


(current): High




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Review Date


Target Risk Rating


Likelihood (Target)


Almost Certain

Likely

Possible

Unlikely

Rare


Moderate



Actions


Assigned by

('From')


Priority


Risk Register

Recruit a Named Nurse for Safeguarding Adults / Lead for MCA/DoLS

31/07/2017 24/07/2017


Risk Register

Recruit an Associate Director for Safeguarding

28/09/2017 24/07/2017


Risk Register

Develop Learning Disabilities basic awareness training

29/09/2017 15/09/2017


Risk Register

Ensure historic safeguarding risks are quality assured and managed appropriately

31/10/2017 29/09/2017

6607 Matthew O'Neill 29/12/2017 24/11/2017



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Risk Approval



Risk Closure


Reporter of risk

Matthew O'Neill

Risk Register

Deliver MCA/DoLS awareness sessions to Trust staff


Risk Register

Develop a new MCA/DoLS Level 2 training package for delivery

29/12/2017 15/12/2017


Risk Register

Review the Safeguarding Children processes in AED

29/12/2017 22/12/2017


Risk Register

Create an overarching risk identifying Trusts current position

29/12/2017 15/12/2017


Risk Register

Review dementia training - SCIE model (3 tiers)

30/03/2018 23/03/2018


Risk Register

To review DHR 6 and Trust action plan for assurance

30/04/2018 23/03/2018


Risk Register

Review current FAIR process (Dementia)

31/05/2018


Risk Register

Develop Safeguarding Champions

29/06/2018


Risk Register

Raise awareness through distribution of Safeguarding material to Clinical areas and on updated Safeguarding Website and via Comms

29/06/2018


Risk Register

Develop Unannounced Safeguarding Inspection Programme

29/06/2018


Risk Register

Review support documentation for dementia patients

29/06/2018


Risk Register

Recruit a Safeguarding Service Manager

31/07/2018 24/07/2017


Risk Register

Review the Referral System for Safeguarding

31/07/2018


Risk Register

Develop a Reasonable Adjustment SOP

28/09/2018 15/09/2017


Risk Register

Develop a Reasonable Adjustment training package

28/09/2018


Risk Register

Complete CQC Action Plan 28/12/2018



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Action chains

Current approval

status



No action chains




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Risk Details

RISK ID 3958



Operational Risk

Title Safeguarding – Compliance and Effectiveness




Corporate Nursing




No


03/04/2018








Almost Certain

Likely

Possible

Unlikely

Rare


High

Matthew O'Neill




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Current Risk Rating

Existing Controls Safeguarding Policies• Seconded Safeguarding management team (LWH) (in post)• Seconded Named Nurse for Safeguarding Adults role (in post)• Redeveloped MCA/DoLS training programme for all staff• Identified staff trained to assess Mental Capacity• Safeguarding Training• Attending Local Safeguarding Adult and Child Boards




Almost Certain

Likely

Possible

Unlikely

Rare


(current): High




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Review Date


Target Risk Rating


Likelihood (Target)


Almost Certain

Likely

Possible

Unlikely

Rare


Moderate



Actions


Assigned by

('From')


Priority


Risk Register

Comply with attendance at External Board meetings

29/09/2017 22/09/2017


Risk Register

Comply with external adult agenda (SAB and CCG partnerships)

29/09/2017 22/09/2017


Risk Register

Join membership of local LD Health Task Group

29/09/2017 22/09/2017


Risk Register

Comply with attendance at Serious Review Panels

29/09/2017 22/09/2017


Risk Register

Comply with CSE process and attendance at MACSE

29/12/2017 22/12/2017



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Risk Approval



Risk Closure


Reporter of risk

Action chains


Risk Register

Develop a secure safeguarding infrastructure, recruitment of key posts

29/06/2018

Current approval

status



No action chains




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Report Title CQC Improvement Plan - Update


Lead Officer Gregory Hope, Associate Director of Quality Governance

Action Required To note





Acceptable assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in delivery of existing mechanisms / objectives

No assurance

No

confidence

in delivery

Key Messages of this Report

• The CQC have issued their final reports following their inspection of the Trust. An improvement

plan in response has been formulated and was shared with the CQC on 29 March.

• The action plan is being managed through a fortnightly CQC Delivery Group, chaired by the Chief

Nurse.

• No actions are currently overdue. Current progress is as was expected when the action plan was

submitted.

Impact

• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal

Equality Impact Assessment









Governance



• Key Risk

• Service Change

• Other


Next Steps

Deliver the improvement plan operationally through a fortnightly CQC Delivery Group

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REPORT HISTORY

Committee /

Group Name

Agenda

Ref

Report Title Date of

submission

Brief summary of key

issues raised and

actions

CQC Delivery

Group

CQC Inspection

Report

10 Apr 2018 Discussed all items on

the dashboard.

Highlighted items with

a target date of April

and took assurance

these would be closed

within date

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Care Quality Commission Improvement Plan Dashboard

Executive Lead % Complete

Assurance Committee % Complete

Beth Weston 0%

Operations & Performance ELG

0%

Dianne Brown 4%

Clinical Effectiveness ELG 0%

Ian Jones 0%

Safety & Risk ELG 4%

Paul Fitzpatrick 0%

Hospital Management Board 0%

Ruth Hoyte 8%

Hospital Safeguarding Board 0%

Tristan Cope 0%

Patient Experience ELG 0%

Workforce ELG 8%

Surgery DAG 0%

Medicine DAG 0%

0

11

1

Must Do Actions

Overdue

On Track

Completed

0

54

2

Should Do Actions

Overdue

On Track

Completed

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F&P Committee Assurance Report (23 April 2018): Board of Directors 25 April 2018 1/2

Board Committee Assurance Report


Date 25 April 2018

Committee Name Finance & Performance Committee

Date of Committee Meeting 23 April 2018

Chair’s Name & Title Jo Clague, Non-Executive Director (Chair)

Executive Lead Ian Jones, Director of Finance & Business Services

Summary

The Finance & Performance Committee continues to receive reports and provide assurance to the Board

of Directors against its work programme via a summary report submitted to the Board after each

meeting. Full minutes and enclosures are made available on request.

Key Issues

Corporate Performance Report (CPR) (Month 12) - Partial Assurance

The following key areas were discussed:

• AED 4 hour – attendances remained high although they had been lower than those experienced in

December/January. Performance had been slightly below the trajectory target for March 2018.

Nationally the Trust had improved its overall position. Rapid Improvement Events would continue to

be undertaken to ensure that processes were embedded. Ambulance handover had also seen a

slight deterioration in performance and was a key focus for improvement. The roll out of the SAFER

programme across the wards continued to take place and there was evidence of improved

discharges before midday but the overall number of discharges had not been at the same levels as

in December and January and not sufficient to meet the number of admissions in March 2018..

• Diagnostics – performance had improved although this had been as a result of additional activity

which was not sustainable. Discussions were taking place within Surgery on clearing the backlog but

using minimal additional activity in order to reduce costs

• Referral to Treatment – had not achieved the standard in March 2018 and there were some

concerns over the growth in waiting lists. Additional activity would be required to make in-roads into

the backlog but this would be minimised where possible

• Cancer 62-Day – the target had been achieved for March 2018 and it was expected to meet the

quarter standard. Out of the eight other Cancer domains, the Trust had failed on only two – breast

symptomatic and consultant upgrades (internal target).

• Ready for Discharge – numbers of patients continued to be high and there has been a reduction in

the level of simple discharges which was being analysed

• Stroke – the standard had been achieved for March 2018. Work was being undertaken with the

Team to review the variability in performance and the support needed to maintain the level required

• Complaints – performance against the response times had deteriorated and it was noted that there

was variability in the quality of responses. Further training was to be provided to staff but some

analysis would need to be undertaken to ensure that it was having the desired impact

• Agency Spend – this was a key area of focus to ensure that there were robust systems and

processes in place to minimise the financial impact on the Trust during 2018/19

• Appraisal – a review of the current approach was to be considered by the Workforce ELG with a

view to simplifying the process and improving the quality

• Mandatory Training – performance had slightly deteriorated. The Committee noted the variances in

performance by Division.

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F&P Committee Assurance Report (23 April 2018): Board of Directors 25 April 2018 2/2

Finance Report (Month 12) – Acceptable Assurance

The Trust was marginally better than its planned deficit at the year-end which would result in additional

funding being received from the centre together with a cash bonus for achieving the control total. This

would have a positive impact on the Trust’s cash position and would delay any potential application for

cash support. There remained some areas of overspend with agency expenditure the highest for the

year and this would need to be explored further to understand the reasons for the increase. The

Committee requested that they be advised next month. The capital programme for 2017/18 had been

finalised and work would now commence on the plans for 2018/19.

The Trust’s final Operational Plan was to be submitted next week and there had been a negotiated

increase in the Acting as One arrangement for the Trust to receive 0.4% of the growth allocated to the

Commissioning bodies.

Electronic Patient Record (EPR) – Update Partial Assurance

The Committee was advised that there were some significant issues to be resolved on the development

of certain modules and so progress had not been as planned, putting additional risk on the ‘go live’ date

of October 2018. Discussions were continuing to take place with the system provider to rectify the

position. In terms of assurance, the programme was required to pass through a number of gateways

before it could go live and a report had been requested on the impact and risks associated with non-

achievement. The Committee remained concerned and requested that a report be provided at its next

meeting on the other potential windows for going live as well as the financial implications for delays.

Transformation Programme Update Partial Assurance

The Committee was advised that the Trust had achieved its QEP target for 2017/18 but this had largely

been due to the release of balance sheet reserves. The Trust had met with NHS Improvement and had

been challenged on its ability to achieve its QEP target for 2018/19. It had been explained that the 2%

savings target was stretching but it was expecting to make in-roads into the target from the schemes

identified to date. However, it was important that the Divisions managed within their respective budgets

in-year. The Committee was also advised that an interim solution had been agreed for director

leadership of the programme.

Apprentice Reforms

The Committee was provided with an update on the apprenticeship activity, the deployment of the

apprentice levy, activity against the Trust’s Public Sector Duty and future developments. The Committee

was advised that a new policy was to be introduced allowing levy paying employers to support other

employers by up to 10% of its levy. The Committee discussed the proposed employer to receive the

levy and requested that Executive colleagues sought clarity on the governance arrangements for

working with third parties with particular emphasis on the reputational implications and financial

timescales. The Committee agreed in principle to approve the transfer of the 10% levy subject to the

issues raised being addressed.

Decisions Made

• Agreed in principle to approve the transfer of the 10% levy to the recommended local employer.

Recommendation

The Board is asked to note the report.

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1/2



Report Title Corporate Performance Report, M12 2017-18


Beth Weston, COO

Lead Officer Paul Brannelly, Deputy Director of Finance

Action Required To review & agree any actions arising


High level of confidence in delivery of existing mechanisms / objectives


General confidence in delivery of existing mechanisms/ objectives

Partial assurance


No assurance

No confidence in delivery


• National standards re CDiff / AED / Diagnostics / RTT / Cancer 62-day / Cancer 31-Day surgery /

Cancer Breast Symptoms/ Cancer Consultant Upgrades / Stroke were missed.

• Local targets for complaints response rates were also missed

• Bed pressures continue, RFDs remain high and AED attendances up

• Underlying financial position achievable with receipt of Tranche 1 of the national AED monies.

Pressures in putting on additional capacity to meet winter demand have increased the risk of

delivering the control total without these funds being made available.


• 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)












• Key Risk

• Service Change

• Other



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REPORT HISTORY


Agenda Ref



Finance & Performance Committee


Monthly

Board of Directors


Monthly

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Contents

Metrics by CQC domain:

Safe

Caring

Effective

Responsive

Well led

Exception reports:

A&E 4 hour standard

RTT

Diagnostics - Endoscopy

Diagnostics - Radiology

Falls

Pressure Ulcers

HCAI - Clostridium Difficile

Cancer standards - Breast Symptomatic

Cancer standards - Consultant upgrade

Further reading (available on request):

Nurse staffing Return

Mortality report

22

23

Exec Lead:

24

29

30

25

26

27

28

TC

31 and 32

Integrated Corporate Performance Report

March 2017

Page number:

2-5

6-7

8-9

10-16

17-21

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Board Assurance metricsMarch 2017

Qu

ality

Co

mm

itte

eQ

ua

lity

Co

mm

itte

eQ

ua

lity

Co

mm

itte

eQ

ua

lity

Co

mm

itte

e

No more than 57

grade 2 pressure

ulcers

Inpatient falls with harm

83 falls in March.

No harm - 52

Low harm - 36

Moderate harm - 0

Severe harm - 2

Death - 0

421 falls caused harm to-date, compared to 416

last year

.

Exception report on page

10% Improvement on

last year

March 95%, below the national median

performance of 97.93%.

Compare to National

Median +/- 0.5%

Tool to survey a snapshot

of harm free patient care.

Includes pressure ulcers,

falls, catheters, UTIs and

VTE.

No never events.

Improvement on

previous years

recorded Sis

8 SIs in March 2018:

- two relating to never events

- two relating to falls

-one incident (Theatre ventilation issue)

-one grade three pressure ulcer

-one delayed anticoagulation

-one injury during lap cholecystectomy

Seven level 1 harms and five level 2 harms in

month

Level 1 - Moderate harm

Level 2 - Severe harm or

death to patient.

Never events are serious

largely preventable patient

safety incidents

Description Current position/comments Trend Target

Number of hospital

acquired pressures ulcers

There were 11 grade 2 pressure ulcers in March,

64 to-date against a trajectory of 57 for the year (61

in 2016/17).

There were zero grade 3/4 pressure ulcers in

month, seven to-date (six in total for 2016/17).

Exception Report on page????.

05

1015202530

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

No

of

inci

den

ts

Never event Level 2 Level 1

0

10

20

30

40

50

020406080

100120

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Falls

wit

h h

arm

Falls

Total Falls Falls with harm

Are we safe?

BAF ref: SR1

90%

92%

94%

96%

98%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Pat

ien

ts h

arm

fre

e

No new harms National median

0

10

20

30

40

50

60

70

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Cas

es

Grade 2 cumulative Grade 3/4 cumulative Grade 2 target

Serious Incidents

Inpatients Falls with

Harm

Safety Thermometer

Pressure Ulcers

Lead Committee

Serious Incidents

Inpatients Falls with

Harm

Safety Thermometer

Pressure Ulcers

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Qu

ali

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mit

tee

Qu

ali

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tee

Qu

ali

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om

mit

tee

Qu

ali

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tee


Number of cases of

hospital acquired MRSA

bacteraemia (methicillin-

resistant staphylococcus

aureusis)

0 x cases of MRSA were reported in March.

1 x avoidable case reported this year.

Zero avoidable cases

for the year

Number of beds closed

due to infectionA total of 32 bed days have been lost to the Truat

due to infection in current financial reporting year.

<0.5%

Number of cases of

hospital acquired MSSA

bacteraemia

4 cases of MSSA were reported in month.

Cumulatively this takes the total to 26 cases against

target of 20.9.

17% improvement on

the 23 cases reported

cumulatively to Nov

2016/17

There have been 3 cases of C-Diff in month when

compared to the monthly trajectory of 3.8 cases.

Year-to-date the Trust has had 43 cases compard to

the contractual trajectory of 43. This takes into

account 20 successful appeals to date.

Exception Report on page???

External requirement of

no more than 46

cases.

Internal stretch target

of a 50% improvement

Number of cases of

CDifficile

MSSA

CDIFF

Bed Days lost to Infection

0

10

20

30

40

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

No

of

pat

ien

ts

Cumulative cases Target

05

101520253035404550

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Cas

es

Monthly C Diff cases C Diff cumualtive

C Diff trajectory (contract) C Diff trajectory (internal)

0.00%

0.10%

0.20%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

0

1

2

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

No

of

pat

ien

ts

Cases Cumulative

MRSA

Are we safe?

BAF ref: SR1 Lead Committee

CDIFF

MSSA

MRSA

Bed Days lost to

Infection

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Average length of stay

observed compared to

expected length of stay

reported by Dr Foster

intelligence

DFI expected LoS: 6.28 days

DFI observed LoS: 7.08 days

(Oct 2017 most recent Dfi data)

The Trust LoS continues to be consistently above

expected rates.

Better than DFI

Positive is better than

DFI expected (i.e. a

lower ALoS)

Number of patients not

attending their outpatient

appointment as a

proportion of total

attendances

OPFU DNA rates were 10.61% against a target level

of 10.0%.

This continues to be monitored via the Outpatient

Improvement Group.

<10%

Bed occupancy %

measured at midnight

March occupancy levels were 97.3% which is a

slight increase on Februarys performance, the

overall trend in terms of occupancy from April 16 is

an increasing one.

Occupancy levels remain high despite the trust

having 140 additional beds open above baseline

capacity (+105 since Nov/Dec). Withouth these

extra beds, bed occupancy would be 100%

<92%

OPFA DNA rate was 11.04%.

This continues to be monitored via the Outpatient

Improvement Group.

<10%

Number of patients not

attending their outpatient

appointment as a

proportion of total

attendances

Bed Occupancy

Outpatient DNA First

Attendance

Outpatient DNA

Follow-up Attendance

ALoS

0%

5%

10%

15%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

% o

f le

tter

s

0%

5%

10%

15%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

-2.0

-1.5

-1.0

-0.5

0.0

0.5

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Dif

fere

nce

to

DFI

Are we safe?

BAF ref: SR1

500.0

600.0

700.0

800.0

900.0

88%

90%

92%

94%

96%

98%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bed

occ

up

ancy

%

Bed days Inpatients Target

Lead Committee

Outpatient DNA First

Attendance

Outpatient DNA

Follow-up Attendance

Bed Occupancy

ALoS

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CQC registration

requirements

The latest CQC report shows that the overall

position is that the Trust required improvement. The

Trust has developed an improvement plan which

addresses the issues identified.

Of the 29 domains covered, the Trust was rated

good in 29 areas and required improvement in nine.

There was one patient safety alerts issued in

February that required action.

During the month zero alerts were closed within

timescale.

Cumulatively four alerts remain open within

timescale and five are open outside of timescale.

(The details above are the position as of 1 March

2018, since this date 3 of the overdue alerts outside

of the timescale have been completed and only 2

Closure of monthly

alerts within timescale

Blue - alerts within

timescale

Red - alerts outside

timescale

Response to patient safety

alerts issued by NHS


Actual staffing compared to

planned for registered

nurses/ midwives and care

staff

This month five wards reported a daytime fill rate of

less than 80% for Registered Nurses (RNs)

The Corporate Nursing Team have supported Ward

25 to ensure Safe Nurse Staffing in place.

See further reading pages ?????

>95% per month

CQC

Patient Safety Alerts

Safe Staffing

0

5

10

15

20

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18N

o. o

f al

erts

clo

sed

Within timescale Outside of timescale

88%

93%

98%

103%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Fill

rate

Days Nights Target

Are we safe?


Patient Safety Alerts

CQC registration

Safe Staffing

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Would patients

recommend service to

friends & family.

Introduced in 2013 for

Inpatients

March: 90.97% of patients would recommend

Aintree, an increase on February's performance.

Graph indicates a declining trend in performance.

February performance was below both the NHSE

average of 95.77% and local benchmarking for

Merseyside Trusts of 94.78%.

> national average

No. of compliments

received by the Trust

This month 781 compliments from all sources (incl.

social media) were received.

No target

Would patients


friends & family.

Introduced in 2013 for AED

March: 83.22% of patients would recommend AED,

a decrease of 0.99% on February's performance.

February performance of 84.21% was lower than

NHSE average of 85.66% but higher than local

benchmarking for Merseyside Trusts of 83.46% for

the same month.

> national average

March: 93.97% of patients would recommend

outpatient services, a marginal decrease on last

month's performance.

February performance of 94.29% was above the

NHSE average of 94.10% but fractionally below

local benchmarking or Merseyside Trusts of 94.30%.

> national average

Would patients


friends & family.

Introduced in 2013 for

Outpatients

Friends & Family - %

AED

Friends & Family - %

Outpatients

Compliments

Friends & Family - % inpatients

75%

80%

85%

90%

95%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

AUH National Local

75%

80%

85%

90%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

AUH National Local

90%

92%

94%

96%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

AUH National Local

250

500

750

1,000

1,250

1,500

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Are we caring?


Friends & Family

Outpatients

Compliments

Friends & Family AED

Friends & Family

Inpatients

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Number of unjustified

breaches to the mixed sex

accommodation standard

Zero unjustified cases in March.

0 breaches of MSA reported for the year

Zero cases of

unjustified breaches

per month

75% of complaints

received responded to

within 25 days

No complaints

responded to after 60

days

New complaints since Apr

17:

50% cleared within 23

days;

75% witih 37 days; and

90% within 50 days

Complaints below 0.1%

of trust workload

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Monthly Trust complaints

The Trust received 26 new complaints in March

2018 which are being dealt with by the Patient

Advice and Complaints Team. There were 2 re-

opened complaints in March 2018.

Number of complaints

responded to within 25

days and 60 days

Response rate decreased to 28%.

9 cases closed <25 days, 10 >25 days.

February of 32 new complaints received. 9

responded to within 25 working days (28%);

10 over 25 days (31%) and 13 still open

During March there was one new investigation

opened and one officially closed by the

Parliamentary and Health Service Ombudsman. (16

ongoing).


Complaint Response

Rate

Mixed Sex Accommodation

Complaints & Concerns

0.00%

0.02%

0.04%

0.06%

0.08%

0

10

20

30

40

50

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lain

ts

Complaints Complaint rate

10%20%30%40%50%60%70%80%90%

100%

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

25 day response rate Target

Are we caring?


Complaint Response Clearence

Distribution

Complaint Response

Rate

Complaints & Concerns

Mixed Sex Accommodation

0

1

2

3

4

5

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Bre

ach

es

Mixed sex breaches

Mixed Sex Accommodatio

n

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Qu

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Ratio is the number of

observed deaths divided

by predicted deaths.

HSMR looks at diagnoses

which most commonly

result in death.

Improvement in HSMR to 91.2.

Position remains better than expected.

HSMR performance -

blue

As expected - Red

March crude mortality: 2.74%, (2016/17 av. 2.78%).

Mortality is considered and discussed as part of

mortality report to Quality and Safety Committee.

Improved trajectory

Number of deaths as a

proportion of admissions.


Risk adjusted mortality

ratio based on number of

expected deaths. National

published figure from

HSCIC.

SHMI for the period Jul16 - Jun17 (latest available

from Dfi) 102.85 is marginally better and within

tolerance levels.

SHMI performance -

blue

Above expected - Red

Below expected -

Green

Mortality HSMR

Mortality Crude Rate

Mortality SHMI

80

85

90

95

100

105

110

115

Jun

-16

Au

g-1

6

Oct

-16

Dec

-16

Feb

-17

Ap

r-1

7

Jun

-17

Rat

io

80859095

100105110115120

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Rat

io

HSMR Benchmark

2%

3%

4%

5%

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

% o

f d

eath

s

Previous year average Crude

Are we effective?

BAF ref: SR2/SR3 Lead Committee

Mortality Crude Rate

Mortality HSMR

Mortality SHMI

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tee Q1:

- Antibiotic prescribing +3.5%;

- Carbapenem prescribing +1.0%:

- Piperacillen/tazobacatam -22.0% due to a national

shortage of the drug. Trust is in discussion with

Commissioners regarding a local contract variation

for this element of the CQUIN. Guidance is being

sought from NHSE.

Description Current position/comments

National CQUIN

National CQUIN

Data will be available during Q3 to Q4

Year round plan of implementation of the Health and

Wellbeing CQUINS for 2017/18 has been

developed. Delivery against the plan is on track.

Uptake of flu vaccinations by frontline healthcare

workers is at 87.5% against a target of 70%

Q2- Eligible patient data:

- 100% screened for sepsis;

- 72.7% got antibiotics <1 hr of diagnosis;

- 95.1% had an antibiotic review <72 hrs.

Improvement actions: Sepsis training modules

established, new sepsis screening tool, guidance

and clerking pro-forma developed, approved and

launched. Sepsis boxes being used on wards.

National CQUIN

Trend

By Qtr. 4

- 5% improvement in 2 of

3 staff survey questions

- Healthy food initiatives:

to document + provide

evidence to Board

meeting

- 70% uptake of flu

vaccinations

Target

AED - 90% eligible

patients screened and

receive antibiotics <1

hour

Inpatient - 90% eligible

patients screened and

received antibiotics <1

hour

AED - 90%

Inpatient - 90%

Improving Staff Health

and Wellbeing

Are we effective?

BAF ref: SR2/SR3

Reducing the Impact of Serious Infections

(2a-c) 25%

50%

75%

100%

com

plia

nce

% screened% received IV Ax in 1 hr% Ax documented / reviewed within 72hrs

Reducing the Impact of Serious Infections

(2d) -100%

-50%

0%

50%

com

plia

nce

Antibiotic consumption > 1% or 2%Carbapenem > 1% or 2%Piperacillin-tazobactam > 1% or 2%

Lead Committee

Reducing the Impact of Serious

Infections (2d)

Reducing the Impact of Serious

Infections (2a-c)

Improving Staff Health

and Wellbeing

0.0%20.0%40.0%60.0%80.0%

100.0%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

% front line staff vaccinated Target

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Fin

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an

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Maximum wait time of 4

hours in A&E from arrival

to admission, transfer or

discharge. Target of 95%.

March performance 81.61%.

In month there were 1972 breaches and zero 12

hour trolley waits.

Exception Report is included at page ????

>95% per month

Key performance indicator.

All patients expected to

see a decision making

clinician within 60 minutes

In March patients saw a senior decision making

clinician within 83 mins against a planned threshold

of 60 minutes.

<60 mins

March performance 20.37 mins.

237, 30-60 min handovers delays;

133, >60 mins delays. Aintree performance was 7th

out of 10 in the Cheshire & Merseyside area and

17th out of 30 in the North West

Ambulance notified to

handover (15 mins)

Ambulance handover time

- average time

- Number of ambulance

waits >30 mins < 60mins

- Number of ambulance

waits >60mins

Fin

an

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Perf

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an

ce

AED breaches analysed

between admitted, non-

admitted and patients

requiring admission to

other hospitals (e.g. mental

health) / to social service

provision / GP or AUH

clinics.

The increase in non-admitted breaches correlates

closely to reported AED Performance.

There is no obvious correlation between breaches

and the number of attendances. The mix of

majors/minors is relatively stable over the period.

Admitted breaches -

blue

Non-admitted breaches

- purple

Other hospital, GP,

social services, clinic -

green

Median Wait To See A Clinician

Ambulance handovers

AED 4-Hour

Standard

70%

80%

90%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

40

60

80

100

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Min

ute

s

00:00

07:12

14:24

21:36

28:48

0

200

400

600

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

VA

han

do

ver

tim

e

Co

un

t o

f w

aits

Ambulance waits >60 mins

Ambulance waits >30 mins < 60mins

Are we responsive?


Breach Analysis

6400

6600

6800

7000

7200

7400

7600

7800

0

500

1000

1500

2000

2500

3000

3500

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Att

en

dan

ces

Bre

ach

es

AED Ambulance Handovers

AED Breach

Analysis

AED Median Wait

to See a Clinician

AED 4-Hour

Standard

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Percentage of incomplete

pathways for English

patients within 18 weeks.

The threshold is 92%.

Overall March performance: 90.0%

Specialty level target not met by: Breast Surgery,

Endocrinology, Gastroenterology, General Surgery,

Hepatobiliary, Maxillo Facial Surgery,

Ophthalmology, Oral Surgery, Thoracic Medicine,

T&O and Upper GI.

No patients are waiting over 52 weeks.

See exception report on page 24

>92%

Fin

an

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Perf

orm

an

ce

Diagnostic tests to be

carried out within 6 weeks

of request being received.

This is measured on the

National DM01 return.

March performance: 1.38% a slight rise on 1.1% in

February

Pressure still noted in Gastroscopy, MRI,

Colonoscopy, Non-obstetric ultrasound.

Exception Reports are included at pages ????.

<1%

RTT Incomplete Pathways

Diagnostics

88%

90%

92%

94%

96%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%5.5%6.0%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

Are we responsive?


Diagnostics

RTT

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First treatment for cancer

within 62 days of urgent

referral through GP 2 week

referral route. 85%

threshold.

March performance: 85.6% (unvalidated)

Cumulative Q4 performance to date: 84.7%, just

below the national standard.

>85%

A maximum 62-day wait

from referral from an NHS

cancer screening service

to the first definitive

treatment.

March performance: 90% (unvalidated)

Cumulative Q4 performance to date 96.7%, above

the national standard.

>90%

Patients referred from GP

with suspected cancer

should have their first

appointment within 14

calendar days.

March performance: 93.9%, (unvalidated)

Cumulative Q4 performance to date 93.5%, above


>93%


Cumulative Q4 performance to date 95.5%, slightly


>96%

Patients receiving first

definitive treatment within 1

month of cancer diagnosis.

Cancer 2-Week

Cancer 31-Day

Cancer 62-Day

Screening

Cancer 62-Day

65%

70%

75%

80%

85%

90%

95%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

92%

94%

96%

98%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

90%

92%

94%

96%

98%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

Are we responsive?


Cancer 31-day

Cancer 62-day

Screening

Cancer 2-week

Cancer 62-day

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a maximum 31-day wait for

subsequent treatment

where the treatment is an

anti-cancer drug regimen.


Cumulative Q4 performance to date: 99.4%, above


.

>98%

Maximum 62-day wait for

the first definitive treatment

following a consultant’s

decision to upgrade

cancers.


Cumulative Q4 performance to date: 74.3%, below


Exception Report at page ?????

>85%

a maximum 31-day wait for

subsequent treatment

where the treatment is

surgery.

March performance: 94.1%, (unvalidated)

Cumulative Q4 performance to date: 87.3%, below


>94%

March performance: 90.5% (unvalidated)

Cumulative Q4 performance to date: 92.6% slightly


Exception Report at page ????

>93%

Maximum 2-wk wait to for

investigation of breast

symptoms, even if cancer

is not initially suspected.

Cancer 31-Day Surgery

Cancer Breast

Symptomatic

Cancer Consultant Upgrades

Cancer 31-Day Drugs

94%

96%

98%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

80%

85%

90%

95%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

55.0%60.0%65.0%70.0%75.0%80.0%85.0%90.0%95.0%

100.0%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

75%

80%

85%

90%

95%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

Are we responsive?


Cancer Breast

Symptomatic

Cancer Consultant Upgrades

Cancer 31-day

Surgery

Cancer 31-day Drugs

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In March 5.73% of outpatient appointments were

cancelled meaning the Trust's internal standard of

<5% was narrowly missed in month.

<5%


Number of outpatient

appointments cancelled for

non-clinical reasons.

All Stroke patients who

spend at least 80% of their

time in hospital on a stroke

unit.

Reporting updated in line with SINAP guidance.

March performance: 82%.

Work continues to address pressures within Stroke

performance, including review of ongoing bed

requirements.

>80%

Number of emergency

readmissions within 28

days of discharge

DFI observed readmission rate: 10.37%

DFI expected readmission rate: 9.5%

Better than DFI

Positive is worse than

DFI, i.e. higher

readmissions than

expected

Negative is better,

lower readmission than

expected

Number of operations

cancelled for non-clinical

reasons.

Standard not achieved in month with 1.23%.

50 operations were cancelled

Zero patients were not readmitted within 28 days.

<0.8%

Cancelled patients

readmitted within 28

daysOperations Cancelled

Outpatients Cancelled

Readmissions

Stroke

0%

2%

4%

6%

8%

10%

12%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

0

1

2

3

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

Outside 28 days Target % Actual %

40%

50%

60%

70%

80%

90%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

Are we responsive?

BAF ref: SR4

-1

-0.5

0

0.5

1

1.5

Var

ian

ce f

rom

DFI

Lead Committee

Outpatients Cancelled

Readmissions

Operations Cancelled

Stroke

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Requirement to run 95% of

sessions planned and

utilise 90% of the in-

session time.

Combined target of 85.5%

% of beds lost due to

patients delayed in hospital

meeting the criteria for

DTOC

<3.5% national

DTOCs increased in month to 3.37% with 840 bed

days lost. (last year 2.90% and 671 bed days lost).

The Trust is part of a system discharge project to

aim to ensure minimal delays to discharge and to

improve patient experience.

Number procedures

undertaken as a daycase

instead of an inpatient

compared against

expected levels as per DFI

Better than DFI

Positive is better than

expected

Negative is worse than

expected

DFI observed day case rate: 84.69%;

DFI expected day case rate: 83.59%.

Performance was marginally below expected levels

in September (latest available DFI data)

Average number of

patients each month in

acute beds that are

medically optimised and

are ready for discharge

<50

As agreed in the AED

delivery board

>85.5%

In March the Trust had on average 151 medically

optimised patients in beds. This is above the target

level of less than 50 patients.

*Note the reporting of the Ready for Discharge

numbers here has been amended to reflect both

non acute (Aintree 2 Home and Ward 34) as well as

acute patient delays.

Overall Utilisation has increased from 62.1% to

67.8% against a target of 85.5%

Sessions held versus those timetabled increased to

90.5%, but remains below the 97% target.

Compliance with the WHO Checklist audits has

risen from 66% to 84% but below the previous 100%

compliance due to Theatre Lead Sickness.

Ready for Discharge

(RFD) Patients

Theatre Utilisation

Daycase Rate

DTOCs

30%35%40%45%50%55%60%65%70%75%80%85%90%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

-2.00%

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

1.50%

2.00%

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Var

ian

ce f

rom

DFI

40

60

80

100

120

140

160

180

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Co

mp

lian

ce

0%

1%

2%

3%

4%

5%

6%

7%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

% o

f u

nav

aila

ble

bed

s

Are we responsive?


Theatre Utilisation

Daycase Rate

RFDs

DTOCs

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Qu

ali

ty C

om

mit

tee

Qu

ali

ty C

om

mit

tee

Qu

ali

ty C

om

mit

tee

Qu

ali

ty C

om

mit

tee


National CQUIN

National CQUIN

Sustainably reduce by

20% the number of

attendances to A&E for a

selected cohort of

frequent attenders who

would benefit from

mental health and

psychosocial

interventions. Qtrly

milestones to be

achieved

Project Group established and Q3 actions on track.

Cohort of patients with medically unexplained

symptoms identified and care plans have been

developed.

The identified cohort has reduced the cumulative

number of attendances to A&E by 44.3% in March

from baseline.

National CQUIN

2.5% increase in

discharge to usual

place of residence

Project Group and actions progressing.

Data was unavailable for October, performance in

March shows a performance of 39.20% patients

being discharged to their usual place of residence

which is below the quarter three increased trajectory

of 42%.

National CQUIN

A & G Services

Operational or 35% of

GP Referrals by start

of Q4.

Qtrly milestones to be

achieved

100% of referrals to 1st

OP services available to

be received through e-

RS

Appointment Slot issues

by service reducing to

4% or less in line with

trajectory set Q1

An internal project group has been established with

relevant clinical and managerial leads and the Trust

is providing advice and guidance services for the

following specialties: T&O, ENT and ophthalmology.

Currently 25.79% of GP referrals are supported by

A&G services.

Action plan developed and agreed with joint work

being explored with the Royal Liverpool.

Internal group has been established with clinical and

operational input

Unvalidated data indicates that 94% of services are

able to receive 1st OP appointments via eRS.

Slot issues have risen to 52% in month.

Are we responsive?

BAF ref: SR4

Advice and guidance

0%

5%

10%

15%

20%

25%

30%

35%

40%

com

plia

nce

Actual Target

NHS E Referrals

0%

20%

40%

60%

80%

100%

120%

com

plia

nce

Services Available to ERS % Appt slot issues

-60%

-40%

-20%

0%

20%

40%

Red

uct

ion

Actual Plan

Supporting proactive and safe

discharge

0%

10%

20%

30%

40%

50%

com

plia

nce

Actual Target

Lead Committee

NHS E-Referrals

Supporting proactive and safe discharge

Advice & Guidance

Improving Services (mental

health needs) Presenting to A&E

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Trend Target

Fin

an

ce &

Perf

orm

an

ce

NHSIs (independent

regulator) measure of

financial risk

NHSI rating of 3 or

plan

Current position/comments

Fin

an

ce &

Perf

orm

an

ce

Cash on deposit

= Plan or better

Capital Service Cover: a rating of 4

Liquidity: a rating of 4

I&E %: a rating of 4

I&E % variance from Plan: a rating of 2

Agency: a rating of 4

Overall, the risk rating is a ‘4’, in line with the

drop in performance in November and lower than

expected in the plan.

Cash balances totalled £11.2m against a plan of

£6.6m.

Positive variance predominantly due to receiving

a £5.8m interim capital loan from DH during the

month, with majority of spend in subsequent

months..

= Plan or better

Fin

an

ce &

Perf

orm

an

ce

= Plan or betterReported operating deficit in month of £0.174m,

against a planned deficit of £0.317m.(excluding

an exceptional adj of £23m for impairment of

assets following revaluation). The underlying

position before STF & against the Control Total is

showing an improved position of £149k largely

as a result of a lower PDC and depreciation. The

final underlying position for the year is £311k

better than plan

Trust capital plan increased to £12.1m following

receipt of capital loan £5.8m and allocated PDC

£2.3m.

During March, the Trust managed to spend over

£8m, bringing total spend to £11.6m, just £0.5m

short of plan. The majority of the £0.5m shortfall

relates to a bed lift refurbishment scheme that

was unable to progress.

Fin

an

ce &

Perf

orm

an

ce

Capital spend against

planned programme

Description

I&E performance against

the control total

Cash

Reported Surplus / (Deficit)

Capital

Use of Resources

-1.5

-1.0

-0.5

0.0

0.5

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Surp

lus

/ (D

efic

it)

Plan Actual

0

5

10

15

20

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

£m

Plan Actual

0

1

2

3

4

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

rati

ng

0.0

2.0

4.0

6.0

8.0

10.0

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

£m

Plan Actual

Are we well led?


Lead Committee

Reported Surplus / (Deficit)

Capital

Cash

Use of Resources

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Trend Target

Fin

an

ce &

Perf

orm

an

ce

Quality, Productivity and

Efficiency Improvements

= Plan or better


The trust over achieved its M12 QEP target of

£1.116m and delivered its full year Target . The

£1.6M achieved in month is all non recurrent from

a share of the drugs savings from the Biosimilar

arrangements, non recurrent savings from

Estates and Facilities budget and from a review

of slippage on reserves/balance sheet

Fin

an

ce &

Perf

orm

an

ce

Quality, Productivity and

Efficiency Improvements

= Plan or betterNo new recurrent saving schemes identified in

month

= Plan or better

Fin

an

ce &

Perf

orm

an

ce

= Plan or betterIncome is at planned levels in M12.

Overperformance on contracts outside of Acting

as One and passthrough items such as high cost

drugs is offset by underachievement of AED 4hr

wait component of STF funding.

Whilst Expenditure is broadly inbalance in month

there are overspends in pay offset by slippage on

reserves / balance sheet. Increased pay costs

are primarily associated with increasing

complexity of patients and increase in demand

and associated bed capaicty resulting in

additional staffing requirments much of which is

at premium rates.

Fin

an

ce &

Perf

orm

an

ce

Variance against plan

Description

Variance against plan

QEP Recurrent

Income

QEP In-Year

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Surp

lus

/ (D

efic

it)

24

25

26

27

28

29

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

£m

Plan Actual

0.0

0.5

1.0

1.5

2.0

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

£m

Plan Actual

Expenditure

24

25

26

27

28

29

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

£m

Plan Actual

Are we well led?


Lead Committee

Income

Expenditure

QEP Recurrent

QEP in-year

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Trend Target

Fin

an

ce &

Perf

orm

an

ce

Activity undertaken in an

outpatient setting

Month on month actual

delivery


Activity is below plan both in month and

cumulatively (-1298 vs plan in month, -4571

cumulatively).

Fin

an

ce &

Perf

orm

an

ce

Activity undertaken in an

outpatient setting


delivery

Activity is significantly below plan in month and

below plan cumulatively (-2320 in month and -

5097 cumulatively once the Dermatology virtual

attendances are excluded).


delivery

Fin

an

ce &

Perf

orm

an

ce


delivery

Activity was above plan in month but remains

significantly below plan cumulatively (372 in

month and -1275 cumulatively).

AED attendances remain above plan, Urgent

care admissions increased in month and are now

above plan by 3452 cumulatively (note urgent

care plan based on 16/17 plan).

Fin

an

ce &

Perf

orm

an

ce

AED attendances and non-

elective admissions

Description

Daycase and elective

inpatient activity

Outpatient FU activity

Elective Activity

AED & Non-elective

admissions

Outpatient FA activity

18,000

20,000

22,000

24,000

26,000

28,000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

FU's

2500

3000

3500

4000

4500

5000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Daycase Elective

6,500

7,500

8,500

9,500

10,500

11,500

12,500

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

FA's

0

2000

4000

6000

8000

10000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Accident and Emergncy Emergency Admissions

Are we well led?


Lead Committee

Elective Activity

AED & Urgent Care

Outpatient FU Activity

Outpatient FA Activity

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= Plan or better

source data - General

ledger

HCA Temporary Staffing

Demand and Supply

= Plan or better

Variation between RN

funded establishment and

actuals in post

= Plan or better

source data - General

ledger

= Plan or better

Variation between funded

establishment and actuals

in post (all staff groups)

RN Temporary Staffing

Demand and Supply

(Finance figures)

Est 4790; Actuals 4525; Variance 265

Vacancy Rate: 5.54%

Turnover: 11.28%

Total Live vacancies: 301

(Finance figures)

Est 1754; Actuals 1673; Variance 81

Vacancy Rate: 4.62%

(ESR Pipeline Data - *Includes Escalation

Area's)

*All Registered Nursing Vacancies: -84.67 FTE

inclusive of 14.80 FTE Pre Registration Nurse's

.

RN Demand up by 16.81% when compared to Feb

18 (up from 3302 to 3857)

RN Demand up by 9.90% when compared to March

17 (up from 3475 to 3857)

RN Supply down by 3.72% when compared to

February 18 (down from 2870 to 2767)

RN supply up by 8.51% when compared with March

17 (up from 2550 to 2767)

HCA Demand up by 14.57% when compared to

February 18 (up from 5593 to 6408)

HCA Demand up by 24.48% when compared to

March 17 (up from 5148 to 6408)

HCA Supply up by 6.65% when compared to

February 18 (up from 5278 to 5629)

HCA supply up by 10.93% when compared with

March 17 (up from 5014 to 5629)

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

RN Temp Staffing

Establishment

Are we well led?

BAF ref: SR5/SR6

4,200

4,300

4,400

4,500

4,600

4,700

4,800

4,900

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

WTE

Budget Actual Target

1,400

1,500

1,600

1,700

1,800

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

WTE

Budget Actual

0

1,000

2,000

3,000

4,000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Shif

ts

Total RN Demand Bank Supply Agency Supply

HCA Temp Staffing

Lead Committee

Lead Committee

Establishment

RN Nursing

RN Nursing Vacancies

Establishment RN Temp Staffing

RN Temp Staffing RN Nursing Vacancies

Establishment HCA Temp

Staffing

500

1,500

2,500

3,500

4,500

5,500

6,500

7,500

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Shif

ts

Total NA Demand Bank Supply Agency Supply

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% delivery against target

compliance

>96%

Amount spent on Agency

shifts in total for all staff

groups

NHSI Ceiling

QEP Scheme

Confirmed Div

Reduction Target: 5%

Target < 5% of total

agency shifts filled

(Overides / Total

Agency Shifts = %)

Shifts approved over NHSi

capped rates

Performance: £1,846,414

Medical: £646,085 (Mar 17 - £363,576)

Nursing: £960,927 (Mar 17 - £772,125)

AHP/P&T: £70,966 (Mar 17 - £74,489)

Support Staff & Maintenance: £74,890 (Mar 17 -

£94,491)

Admin: £72,034 (Mar 17 - £44,883)

Senior Managers: £21,513 (Mar 17 - £33,874)

Target < 5% of total agency shifts filled (Overides /

Total Agency Shifts = %)

Target < 5% of total agency shifts filled (Overides /

Total Agency Shifts = %)

All Staff Performance 692/3517 = 19.67%

Medical: 408/408 = 100%

Nursing/AHP/Prof & Tech: 284/3109= 9.13%

Longest Agency Appt): 12 months

Highest Cost Agency: £128

Graph shows the rolling average attendance rate,

which remains below the target of 96%.

Performance: 95.62% (4.38%)

Long term absence (greater than 28 days) accounts

for 68.48% of absences.

Attendance rates (ABi) -

Medicine 95.30%; Surgery 95.17%; DSS 95.56%;

Corporate 96.96%; E&F 94.25%; Ops Mngt

100.00%.

Combined spend on "Non

Core" i.e. above

substantive/contracted

hours

= Plan or better


Total Pay Spend: £18,338,137 (2016/17,

£17,536,555)

Core Pay Spend Total: £15,210,573 (2016/17

£15,266,948)

Non Core Spend Total: £3,180,564 (2016/17,

£2,589,836)

Bank: £1,056,963 (2016/17, £964,559)

Agency: £1,846,414 (2016/17, £1,383,437)

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

Fin

an

ce &

Perf

orm

an

ce

RN Nursing Vacancies

Temp Staffing

Establishment

Are we well led?

BAF ref: SR5/SR6

Total Non-Core Pay Spend

13,000,000

14,000,000

15,000,000

16,000,000

17,000,000

18,000,000

19,000,000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Core Non-Core

Agency Spend

0

500,000

1,000,000

1,500,000

2,000,000

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Target Actual

Agency Shifts Over Cap

95.095.295.495.695.896.096.296.496.696.897.0

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

%

Lead Committee

Total Pay Spend

Agency Spend

Agency Shifts Over Cap

Attendance Rates

0%

10%

20%

30%

40%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

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>85%

Trend Target

% delivery against

target compliance

>85%

Fin

an

ce

& P

erf

orm

an

ce

Fin

an

ce

& P

erf

orm

an

ce

Description Current position/comments

% delivery against

target compliance

Performance 67.91% a drop of 1.72% on last

month

Performance above target: Estates and Facilities

88.22%

Performance below target: Ops Mngt 32.50%;

Corporate 45.61%; Medicine 71.57%; Surgery

58.36%.

Training and appraisal compliance is scrutinised

via the Divisional Workforce and Education

groups.

Performance 71.67%

Slight decrease in performance on Jan 18 of

0.83%.

Performance, Estates and Facilities 94.95%;

DSS 81.56%; Corporate 78.23%; Medicine

67.98%; Surgery 56.75% and Ops Management

46.15%.

• Training and appraisal compliance is

scrutinised via the Divisional Workforce and

Education groups.

Are we well led?

BAF ref: SR5/SR6

Appraisals

60%

65%

70%

75%

80%

85%

90%

95%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Mandatory Risk Management

Training

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Lead Committee

Appraisals

Mandatory Training

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EXCEPTION REPORTIndicator:

Issue: Additional data (historic)

Proposed actions:

Owner Deadline

LW/VJ Q1

VJ/PA May-18

CP/AS Apr-18

Q1 Q2 Q3 Q4 Lead:

R A A G Executive Lead:

V Jackson

B Weston

Accident and Emergency Department March 2018

Action

LW/AS/VJ Q1

VJ/LW/PA Q1

Recruitment of Acute Physicians and ED Consultants was

successful with 3 consultants appointed for AMU. Start dates

agreed in April andMay. The succesful candidate for ED started

5th February. Recruitment for another AMU consultant and 2 ED

consultants is underway. The post of Chief Medical Registrar was

recruited into and the candidate will start in August 18.

Complete full ED nurse establishment review and agree actions

required.

Performance against the 4 hour standard was 81.63% (T1 and T3) in March 2018

representing a decrease of -2.28% compared to February 2018.

There has been an increase in the number of handover delays in excess of 30 minutes to

237 (+75), delays in excess of 60 minutes has also increased to 133 (+32). The

average time from notification to handover standard of 15 minutes has increased to 20.37

mins compared to 19.14 mins in February. There was a 197 increase of ambulance arrivals

in March. The time to see 1st clinican has increased to 83 minutes, against the 60 minute

clinical quality indicate, which is an increase of 4 minutes March 2018. The clinical quality

indicators for the number of patients who leave the department before being seen and the

15 minute from registeration to traige are being met month on month.

Continue to embed all aspects of the Emergency and Acute Care

Plan and regularly monitor performance.

NWAS 90 day project completed. Awaiting start date agreement

for direct conveyacing to AEC. Raised on recent NWAS

teleconference and NHSI have since pursued.

Business case approved for ED medical staff with approval for

4.4WTE F2/3 posts and 2.5WTE ST3 posts. Adverts to be placed.

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Additional data (historic)

Proposed actions:

Owner Deadline

Q1 Q2 Q3 Q4 Lead:

Executive Lead:

Continue to support the CBU's with their RTT validation processes

and Standard Operating procedures with a special focus on inter

Provider Transfers and data recording / Entry.

Ian Stewart

Q1

Ian Stewart - Planning and performance

Beth Weston - COO

Apr-18

Continued monitoring of diagnostics waiting times to ensure

delivery of the 6 week standard as this impacts RTT pathways. Carol Baker Q1

Continue to meet with CBMs on a weekly basis to focus on data

quality and pathway validation.Ian Stewart Q1

RTT Incomplete pathway performance

Issue:

Performance against the national standard of 92% of pathways to start treatment within 18

weeks from referral was below target in March at 90.1%.

The Trust has faced significant non-elective pressure which has impacted on RTT

performance over the last quarter. The standard was impacted from December 2017 given

the significant pressure on non elective flow and given that NHS England requested a

cancellation of non urgent elective procedures nationally to help redirect resources to

support emergency demand. The theatre refurbishmnent programme, which is in its final

stages had also impacted on performance significantly although this is now nearing

completion. In addition, both the outpatient cancellation and Did Not Attend (DNA) rates

have continued to remain high which has reduced throughput and resulted in an increase in

the overall waiting times with patients being boooked into all available clinic capacity as well

as additional sessions.

Action

Implement theatre recovery plan and improve utilisation at

speciality level.DDO

SurgeryQ1

Regularly review all long waiting patients within the clinical

business units to address capacity issues and undertake WLI's

where available in conjunction with a relaunch of weekly

performance meetings with Planning and performance / Business

Intelligence leads.

CBMs Apr-18

Business cases for two additional EGSU Consultants has been

agreed. This will provide additional theatre activity and

ambulatory surgical clinics. Recruitment currently underway.

Jen- Carden-

JonesSep-18

Continue to support the reduction in Endoscopy waits by

supporting WLI scope lists using dropped sessions in the week

and additional sessions at weekends.

Jayne

Thomas

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Issue: DMO1 - 0.97% against <1% Standard Additional data

Proposed actions:

Owner Deadline

Forecast for improvement:

Q1 Q2 Q3 Q4 Lead:

r Executive Lead:

DMO1 6 week standard

Endoscopy has continued to experience pressures with capacity due to sickness and

maternity leave of Nurse endoscopists and a consultant vacancy during January, February &

March. The overall number of patients waiting over 6 weeks has decreased to 7 as has the

number on the waiting list at 724. Additional activity continues through WLIs and PA

sessional rates with a focus on the reduction of cancer surveillance/planned waits

throughout March.

There has been significant pressure on the department to support the acute ward inpatient

admissions and the increase in general medical outliers. This has resulted in a 5th

Consultant being taken off their routine job plan and placed on the wards each week thus, a

recovery to below the 1% standard in a timely manner has been hindered significantly.

The department continues to prioritise cancer and urgent referrals which has made recovery

of the 6wk routine standard difficult.

Action

Additional WLI activity continues to cover the long term sickness of a

Nurse Endoscopist, Consultant vacancy and maternity leave. In addition

a locum to support medical outliers has been arranged.

Jeni Carden-

Jones

Q1

Weekly capacity meetings continue with operational and clinical teams to

maximise the utilisation of capacity.

Jeni Carden-

Jones

Q1

Unisoft Scheduler has been implemented and the reporting

functionalities are being explored to allow closer scrutiny of slot

utilisation and management of DNA rates.

Jeni Carden-

Jones

Q1

The Endoscopy unit are participating in the Cancer Alliance

productivity review for the north west and have begun collecting

data.

Jeni Carden-

Jones

Q1

Joanne Eccles - DDO Surgery

Beth Weston - COO

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Issue: 29th January 2018

Diagnostic type 6 7 8 9 10 11 12 13+ Total

6 wks &

Over

% 6 wks

& Over

Computed Tomography 2 1 0 0 0 0 0 0 1064 3 0.3%

Magnetic Resonance Imaging 71 8 0 0 0 0 0 0 991 79 8.0%

Non-obstetric ultrasound 9 1 0 0 0 0 0 0 1539 10 0.6%

Dexa 1 1 0 0 0 0 0 0 329 2 0.6%

3923 94 2.4%

4th March 2018

Diagnostic type 6 7 8 9 10 11 12 13+ Total6 wks &

Over

% 6 wks

& Over

0 0 0 0 0 0 0 0 1127 0 0.0%

Computed Tomography3 1 0 0 0 0 0 0 848 4 0.5%

Proposed actions: Non-obstetric ultrasound 25 5 0 0 0 0 0 0 1746 27 1.5%

Owner Deadline Dexa 0 0 0 0 0 0 0 0 386 0 0.0%

4107 31 0.8%

Carol Baker Q1

2nd April 2018

Diagnostic type 6 7 8 9 10 11 12 13+ Total 6 wks & % 6 wks

Computed Tomography 8 0 3 0 0 0 0 0 1262 11 0.9%

Magnetic Resonance Imaging

3 3 6 0 1 0 0 0 882 13 1.5%

Non-obstetric ultrasound 14 27 18 0 0 0 0 0 2334 59 2.5%

Dexa 0 0 0 0 0 0 0 0 379 0 0.0%

4860 83 1.7%


Q1 Q2 Q3 Q4

A A A A

Additional WLI's agreed through resource panel, difficulty in

covering due to Radiology unavailable/unable to to cover.

Continue to request additional sessions from Radiologist.

MSK Radiologist recruited, commences in post on 1st May 2018. Ashok Katti May-18

DM01 (Radiology) - March 2018

Radiology continues to experience a sustained increase in demand for Imaging (CT Cardiac,

MR Cardiac, MR MSK and Ultrasound MSK). Demand is in excess of funded capacity.

Additional Inpatient activity has a knock on effect, reducing Outpatient capacity for CT and

MR.

Resource for additional sessions for Ultrasound MSK imaging/steroid injections into joints

have been agreed however limited number carried outcarried out, due to annual leave and

Radiologist unavailability.

Currently the wait for routine Ultrasound is 5 weeks 5 Days ( Sonographer led). Waiting for

MSK is 8 weeks ( DMO1 8 weeks weeks) .

Action

Weekly capacity meetings with operational and clinical teams to

monitor performance and maximise capacity ongoing.

Carol Baker Q1

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Proposed actions:

Owner Deadline

The

corporate

tream is

supporting

best care in

the EForecast for improvement: Lead:

Q1 Q2 Q3 Q4 Executive Lead:

g g a r

Richard Miller-Halliday DDON, Lisa Nichol DDON

Dianne Brown, Chief Nurse

A Comfort Rounding Chart specific for use in the emergency

department is being tested

Jan Dainty

Lead Nurse

30-Apr-18

Tagged Bay' system will be rolled out to the Trust in Q1 Jan Dainty

Lead Nurse

Apr-18

To achieve our 5% improvement target this year we must have no more than 400 falls with

harm (100/month). .

In March 2018, we had a total of 83 falls. There were 46 no harm, 35 low harm and 2

moderate harm falls, giving a total of 421 falls with harm. This means we are 21 cases off

trajectory and therefore have not achieved our 5% improvement at the year end.

There is a robust falls verification process in place, and all moderate and above falls

incidents are discussed at both Divisional and Corporate Weekly Meeting of Harm and are

then subsequently investigated via a concise Root Cause Analysis review or a full Serious

Incident Investigation. The root cause, contributory factors, and any lapses in care are then

determined with lessons learned shared across the organisation via Falls Steering Group and

the Fall Stop Newsletter.

As part of the Quality Strategy (2014-17) Year 3 Delivery Plan, the Trust has set an a

5% reduction in falls with harm equating to =<400 April 2017 to March 2018.

Tables 1 and 2 demonstrate our current position against performance in previous years.

Action

The Falls Prevention Nurse will be running a rolling teaching

programme delivered to the staff in the clinical environment

Carol

Broderick,

falls CNS

Apr-18

The storage of mobility monitors e.g. TABS alarms systems is

under review to look at centralised storage and maintenance

Carol

Broderick,

falls CNS

30-Apr-18

A Falls Safety Flow Chart for patients in Side rooms has

beendeveloped and is being tested in the clinical areas using

Quality Improvement test cycles.

Carol

Broderick,

falls CNS

01/04/2018

All inpatient falls are monitored weekly by the Divisional

Governance Leads

Jan Dainty

Lead Nurse

30.04.2018

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Proposed actions:

Owner Deadline

Q1 Q2 Q3 Q4

r r r r Lead:

Executive Lead: Dianne Brown, Chief Nurse

Pressure Ulcers March 2018

Action

Apr-18

Monica

Moore and

Jan Dainty

30-Apr-18

To achieve our 5% improvement target this year we must have no more than 58 Grade 2

Pressure Ulcers in 2017-8 (4.8/month). We have also set an aspirational threshold of zero

Grade 3-4 pressure ulcers with lapses in care during 2017-18.

In March 2018, we had a total of 11 Grade 2 hospital acquired pressure ulcers giving a

total of 74 Grade 2 pressure ulcers which means we are 16 cases off trajectory and

therefore have not achieved our Grade 2 Improvement for the year end.

There has been a total of 0 Grade 3/4 hospital acquired pressure ulcer verified in March

2018 against the aspirational threshold of zero outlined as a key quality goal within the

Aintree Quality Strategy (2014-17). This gives a total of 9 Grade 3 pressure ulcers to the

end of March 2018.

Each Grade 3 and 4 ulcer is investigated and the root cause and any lapses in care will

then determined with lessons learned shared.

30-Apr-18

Jan Dainty

Lead Nurse

Apr-18

Monica

Moore TVN

31.08.2017

Monica

Moore TVN

30.04.2018

Richard Miller-Halliday DDON, Lisa Nichol DDON

As part of the Quality Strategy (2014-17) Year 3 Delivery Plan, the Trust has set an

aspirational target of zero hospital acquired Grade 3 or 4 pressure ulcers with lapses in

care during 2017-18 and a 5% reduction in Grade 2 pressure ulcers equating to =<58

April 2017 to March 2018.

Tables 1 and 2 demonstrate our current position against performance in previous years.

Root cause analysis is underway to be resented at Pressure Ulcer

Prevention Group and roll-out of lessons learned

Collaborative working with Cheshire and Merseyside Pressure

Ulcer Action Group to develop a consistent approach to pressure

ulcer reduction.

A Medical Device awareness session took place on the 8th

August 2017. 95 members of staff attended the session. Further

events are planned in Q1 2018

Targeted training to areas with high incidence of hospital aquired

pressure Ulcers is ongoing

Safety walkround completed and triangulation work in progress.

Workstreams form part of overarching Pressure Ulcer

Improvement plan 2017-18 and 2018-19

Quality Improvement Ward Safety Clinics are ongoing with a

focus on Pressure Ulcer Prevention and Falls Prevention. This

work remains in progress for Q1 2018-19

Divisions

Aintree joined the first NHSI 'National Stop the Pressure'

Pressure Ulcer collaborative which launhed on October the 12th

2017. Need to Embed 'React to Risk. In the Sskin Bundle.

The corporate team is supporting best care in the Emergency

Department (ED) testing the Sskin approach to care and a

Comfort Round Tool sepcifically for the needs of ED patients.

Jan Dainty,

Lead Nurse

Apr-18

Jan Dainty,

Lead Nurse

Apr-18

Jan Dainty

Lead Nurse

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Proposed actions:

Owner Deadline

all

Forecast for improvement: Lead:

Q1 Q2 Q3 Q4 Executive Lead:

A R R R

The Trust has an national objective to acheive </= 46 cases of Clostridium difficile infection (CDI) and an aspirational goal of </= 23 cases during 2017/18.

The Trust has an national objective to acheive </= 46 cases of Clostridium difficile infection

(CDI) and an aspirational goal of </= 23 cases during 2017/18. There has been

66 patients with Clostridium difficile infection (CDI) from April - March 2018; 20 cases have

been successfully appealed as there were no lapses in care; performance = 43 cases for

the year.

The Trust has an national objective to acheive </= 46 cases of Clostridium difficile

infection (CDI) and an aspirational goal of </= 23 cases during 2017/18.

Action

CDI Task Force Action plan monitored via IPC Group D

Lankstead

As outlined

in action

plan

To reduce the risk of transmission, IPC sweeps take place

following each case of CDI. These are performed with the ward

manager, estates and domestic services.

D

Lankstead

Following

each case

CDI High impact intervention monitoring when there is a patient

with CDI on the ward.

Ward

managers

Following

each case

Monitoring of diarrhoea management through the ‘diarrhoea

management assurance checklist’ presented within the Divisional

IPC reports

Divisional

Directors of

Nursing

Monthly

reporting in

place

Periods of inceased incidence (PII) of infection actioned and

monitored as per national guidance

D

Lankstead

For each PII

Peer review process for IPC audits to be developed Divisional

Directors of

Nursing

Jun-18

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Proposed actions:

Owner Deadline


Q1 Q2 Q3 Q4 Lead:

r Executive Lead:

Breast Symptomatic Historical data. March 2017 to March 2018

Review the patient pathway to ensure all requirements can be

met to support existing patient pathway. If this is not possible

consider alternative ways of managing the pathway.

DDO/DMD

Surgery Q1

Capacity and demand profile to be adressed by CBU to assess

how many additional slots per week are required to bring first

booking for patients down to 7 days.

Breast Symptomatic 2ww Appointment Target

Action

CBM DDU

CBM DDU

Q1

Continued monitoring and intervention by the Clinical Business

Unit to manage the patient pathways and remove any barriers

which maybe preventing treatment

Escalate constraints in the patient pathway to the weekly Cancer

Performance meeting (CPG) and to the Divisional Director of Ops

CBM DDU

Q1

Escalate constraints in the patient pathway to the daily Cancer

Performance briefing led by the Divisional Director of Operations

Diagnostics & Support Services

The Trust is required to achieve a performance target of 93% for patients who are referred

urgently with breast symptoms to be seen within 14 days of referral from their GP. During

March 2018 the Trust achieved 90.5% against the 93% standard.

This amounted to 20 breaches out of 211 appointments. This was largely due to a lack of

capacity and patient choice. When patients are offered appointments in days 7 to 14 of the

pathway and decline or cancel, they are usually rebooked out of target due to insufficent

capacity. The Trust passed this standard in February 2018 with performance of 93.2%

however, this standard is predicted to fail for Q4 with performance of 92.7%. Q4 will not be

finalised until the beginning of May 2018 so this figure may change.

Q1

Interim

Cancer

Manager

Q1

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Proposed actions:

Owner Deadline


Q1 Q2 Q3 Q4

a r R R

Lead:

Executive Lead:

Q1

A robust recovery plan has been formulated and has been

discussed at Senior Operational meetings. The Divisions of

Surgery and Specialty Medicine to implement the recovery plan.

Phil Downey - DDO Diagnostics & Support Services

Beth Weston - COO

Cancer

Manager

Divisional

teams

Cancer upgrade target

Action

CBM DDU

CBM DDU

Continued monitoring and intervention by the Clinical Business

Unit to manage the patient pathways and remove any barriers

which maybe preventing treatment.

Consultant Upgrade Target March 2017 to March 2018The Trust is required to treat 85% of patients within 62 days when they have been

upgraded onto a Cancer pathway. There is no target for this set by the DoH; the target is

local and agreed with the CCGs. During February 2018 the Trust achieved 68%. In March

performance was 79.1% although this position will not be finalised until May 2018. This

amounted to 4.5 breaches out of 21.5 pathways. In March there were 3 breaches for Lung

which were due to complex pathways with multiple investigations. In Head and Neck there

was a half breach which was due to patient choice and a hospital cancellation due to

capacity. There were 2 half breaches 1 in Urology and one for a sarcoma patient and these

were both due to multiple diagnostics. Recovery of this standard for Q4 is very unlikley

given the low performance figures in February and March.

Escalate constraints in the patient pathway to the weekly Cancer

Performance meeting (CPG) and to the Divisional Director of Ops.

Escalate constraints to the patient pathway to the daily Cancer

Performance briefing led by the Divisional Director of Operations

Diagnostics & Support Services.

Q1

Q1

Q1

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Division of Medicine

• In total, thirteen Wards within the Division reported HCA fill rates of >150% on nights in March 2018, with twelve of those wards reporting high fill rates for both day and night shifts. The reasons for the high use

of HCAs is due to both the pilot of revised establishments currently being undertaken and as in previous months the continued increase in patient dependency levels and the use of ‘specials’ and 1:1 care to

support safe care for confused patients. In addition, HCAs have been used on occasion to support unfilled RN shifts on those wards with RN vacancies. Additional HCAs were also required to support the ‘flexing

up’ of inpatient beds to meet increased demand (for example on the Frailty Assessment Unit and the Decision to Admit Bay in ED).

• Six Wards reported a HCA fill rate of >300% on nights during February 2018. Ward 8 (418.0%), Ward 22 (409.7%), Ward 23 (546.0%) Ward 24 (379.5%), Ward 32 (306.5%) and Ward 33 (396.8%).This relates

to the high number of confused and dependent patients currently on the ward and also the pilot of revised establishments in these areas.

• Four planned escalation beds remain open on Ward 24 and an additional

67 beds opened on the winter pressure wards during March 2018. FAU increased its bed base by an additional 6 beds on an ‘ad hoc’ basis during the month, resulting in HCA fill rates of >100% on some shifts.

• Winter escalation plans also increased the bed base on Aintree 2 Home from 20 to 36. The unit is fully established for permanent nursing staff for 20 beds, therefore bank and agency staff has been used to

support the increase in bed base. Aintree 2 Home was transferred into the Medical Division on 15th January 2018.

• Nurse staffing is identified on the Divisional Risk Register for:

- The Department of Medicine for the Elderly (DME)

- The Acute Medical Unit (AMU)

- The Thoracic Medicine wards (W23 and W22)

- Aintree 2 Home

- The Diabetes ward (W21)

- Frailty Assessment Unit (FAU)

- Dialysis Unit

- Ward 20

- Ward 25

- Emergency Department

Supervisory Ward Managers regularly support direct patient care, and other mitigating actions including the block booking of agency nurses, and regular Matron Meetings ensure that the staffing risks are shared

across the Division.

• During April 2018, there was 1 moderate harm incident confirmed on inpatient wards in the Division of Medicine.

(i) 1 Fall with fractured neck of femur

A concise root cause analysis investigation is ongoing into the incident at present and will determine if sub-optimal staffing was a contributory factor. The incident investigation and accompanying action plan will

be approved at Weekly Meeting of Harm.

Staff fill rates - page 1 of 2 Month 12

Overview:

Additional info (Divisions)

This month five wards reported a daytime fill rate of less than 80% for Registered Nurses (RNs) - Ward 23 (77.8%), Ward 30 (71.6%), Ward 34 (72.3%), Ward 15 (69.3%) and Ward 25 (44.1%). Safe nurse

staffing was supported as necessary by the Ward Managers working clinically to deliver patient care. The Corporate Nursing Team have supported Ward 25 to ensure Safe Nurse Staffing in place.

It should be noted that the nursing fill rate data measures the percentage of RNs on duty against the planned establishment for the ward, which does not include the additional nurses required to support any

additional escalation beds.

In addition, the data reflects the overarching percentage of actual RNs on duty (against planned), and it does not identify the percentage of those RNs who are employed by the Trust and those who are from a

Nursing Agency.

The Trust is in the process of piloting alternative establishments on most areas which is reflected in the months fill rates. These changes have been reviewed by the Executive Team and are in the process of

being implemented

The NHSE template also identifies those wards with a variance in the planned and actual number of Health Care Assistants (HCAs) on duty, specifically in relation to those wards with >150% fill rates. A trust wide

review is currently underway around the Specials Policy and processes, at the request of the Chief Nurse.

An overview of the outlier wards for each of the Divisions is provided below, alongside a rationale and/or any mitigating actions in place.

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A process is in place within each Division to identify any shortfalls in nurse staffing on a daily basis, and this is also discussed and addressed during Matrons’ Safety Huddle. Any plans and decisions are overseen

and approved by the Divisional Directors of Nursing/AHP, and any shortfall in nurse staffing out of hours is escalated and addressed by the Clinical Manager on Site.

A review of nurse staffing establishments has been completed and demonstrates an ongoing increase in patient acuity and dependency studies. This information is used to advise the Board of Directors on

proposed changes to nursing establishments to support a sustainable and reliable staffing model which will meet the needs of our patients and reduces our reliance on additional temporary staff. The biannual

Safe Nurse Staffing report has been presented and given final approval. The approved establishment templates are currently being implemented.

Staff fill rates - page 2 of 2

Additional info (Divisions)

Division of Support Services – Aintree 2 Home

No areas to report on A2H now in Medical Division

Further comment:

Division of Surgery

• • Nine Wards within the Division reported HCA fill rates of >150% during March 2018, with Eight of those wards reporting this percentage for both day and night shifts. The increased use of HCAs is

related to both the pilot of the revised establishment templates and high patient dependency levels and the use of ‘specials’ to support safe care, and demonstrates the number of highly dependent

patients requiring 1:1 care.

• To support an increase in orthopaedic trauma and the admission of medical patients onto Ward 16, up to nine additional escalation beds remain open on Ward 17 leading to an increased RN night

fill rate with increased HCAs and the supervisory Ward Manager supporting direct patient care on day shifts.

The previously closed three winter escalation beds on the Major Trauma Ward have been reopened to support orthopaedic trauma following the accommodation of a number of medical outlier

patients on the Orthopaedic Trauma Ward (Ward 17). This has led to increased temporary staffing usage in both areas and fill rates of >100%.

• During March 2018, there were no moderate harm incidents reported on inpatient wards in the Division of Surgery. There was however one serious harm incident reported on an inpatient ward in

the Division of Surgery during March 2018 relating to a fall on Ward 29 resulting in a fractured neck of femur and shoulder; however, this incident is not thought to be related to sub-optimal nurse

staffing levels

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1/3



Report Title Non Elective Flow Programme – Report on Progress

Executive Lead Beth Weston, Chief Operating Officer

Lead Officer

Action Required To review & agree any actions arising





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• Trust performance against the 4 hour standard declined over recent years and continued to do

so through 2017

• Emergency and acute care programme progressed activities through 2017; however, considered

necessary to accelerate improvements to support winter preparedness

• Ernst & Young (EY) commissioned to work alongside staff to deliver activities within the

emergency and acute programme in addition to those outlined in their diagnostic report

• EY commenced support in October 2017 – April 2018. The report covers the progress made

over this period, the impact on metrics and the challenges remaining to maintain and further

improve


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other



The Board is to note progress to date in delivery of the non-elective flow programme over the last 6

months and consider and acknowledge the challenges which remain in maintenance of the current

performance and further improvements.

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2/3

REPORT HISTORY


Agenda Ref



Board of

Directors

EY Report November

2017

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Non-Elective Flow Programme Progress Report: Board of Directors 25 April 2018 3/3

Non Elective Flow Programme – Progress Report

Executive Summary

1. Over the last 6 months the EY team have worked alongside Trust staff to deliver a series of

activities against a governance structure under the non-elective flow programme. These

activities have delivered improvements against workstream KPIs in the context of

significantly increased attendances (7-9% higher than same time period last year).

2. Whilst this marks the end of formal EY support to the non-elective flow programme, there

are a series of activities that are required to continue in order to deliver a step change and

further improve Aintree’s performance to beyond median in the North region.


3. The attached report provides details of the progress made on the programme.

Implications / Impact

4. Through a series of activities and interventions, improvements have been delivered across

a range of metrics.

5. This is detailed in the attached report which focusses upon the main workstreams including:

• ED

• Assessment areas

• Flow

Conclusion

6. There have been a number of activities and interventions which has resulted in improved

relative performance over the winter months. There remains, however, a number of

challenges to achieve the step change required for further improvements which are

categorised against structure, process and people. A number of these are being

progressed with divisional leads and executive sponsors.

Recommendation

7. The Board is asked to note progress to date in delivery of the non-elective flow programme

over the last 6 months and to consider and acknowledge the challenges which remain in

maintenance of the current performance and further improvements.

References and further reading

Author: Beth Weston, Chief Operating Officer

Gulsen Yenidogan, EY Delivery Lead

Date: 19 April 2018

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Report on the progress of the Trust’s Non Elective Flow Programme

Prepared for the Board of Directors’ Meeting

Wednesday 25th April 2018

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Executive Summary

▪ Aintree University Hospitals (AUH) performance against the 4-hour standard for patients accessing a Type 1 A&E required improvement over recent years.

▪ Whilst changes had been identified and some improvements made through June – September 2017 a decision was made to seek additional support to accelerate the programme supported by the Board of Directors and the regulators. .

1.Recap of Non Elective Flow Programme Support 3. Summary of key activities delivered :

The following activities have been implemented at a programme level with workstream summaries also listed below:• Implementation of Non elective flow programme governance

structure with workstream level accountability• Implementation of initial iteration of Aintree Non elective flow KPI

dashboard

1. Emergency Department Improvement- Improving non admitted performance- Workforce demand and capacity- Grip and control through ED ‘super weeks’

2. Assessment Areas improvement- Alignment of consultant staffing to patient demand- Reconfiguration of GP hotline- Implementation of Surgical Assessment Unit- Assessment areas demand and capacity clinical audit

3. Flow improvement- Site management grip and control- SAFER roll out- ED-MabFab-AMU-Base ward Transfer team- Weekend criteria led discharge

• Over the last 6 months the EY team have worked alongside Trust staff to deliver a series of activities against a governance structure under the non elective flow programme

• These activities have delivered improvements against workstream KPIs and have resulted in Aintree maintaining a relatively flat performance through winter months, moving their relative regional performance from bottom of the region to middle of the region.

• This has resulted in Aintree’s regional ranking moving from lower quartile to median on the NHSI North sitrep.

• Furthermore Aintree have been recognised as the most improved Trust through winter in Cheshire and Mersey by NHSE.

• The improvements have been delivered in the context of 6-9% higher attendances when compared to last winter and increased acuity as a result of the national flu epidemic.

• Whilst this marks the end of formal EY support to the non elective flow programme there are a series of trust led activities that are required to deliver the step change to improve Aintree’s performance to beyond Median in the North region.

2. Executive Summary

1. Recruitment of ED middle grade and SHO doctors as per the investment case approved by the board

2. Beds rightsizing (including assessment areas and short stay)

3. Setting up the Operational PMO and Programme Director Role

4. Full trust roll out of SAFER and ward level OD work

5. Medical engagement and accountability

4. Summary of next steps to deliver step change in performance :

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The Non Elective Flow Programme activities have been delivered through the governance mechanism below

ED Assessment

Board of Directors

Hospital Management Board

Non Elective Flow Group

Patient Flow

Workforce development and learning

Clinical Inter professional Standards

Informatics/ Business Intelligence

• The Programme is managed within the governance structure below.

• The Non elective flow Group is chaired by the Chief Operating Officer and there is representation by the executive triumvirate.

• Each of the workstreams meet weekly or fortnightly and produce highlight reports as a mode of assurance to the Group reporting on progress against milestones and escalating key risks or deteriorating KPIs.

Workstream KPIs:

• The workstreams have agreed a series of KPIs to track progress against. These are split into level 1 and level 2 KPIs, the level 1 KPIs are used and discussed at NEF and the level 2 KPIs are used within the workstreams.

• An initial draft programme dashboard has been developed to be able to view KPIs and a development list is being worked through by BI to improve the usability and function of this dashboard

Programme assurance role

Executive SRO: Overall executive responsible officerTo provide support and point of escalation

Divisional LeadAccountable individual at divisional level

Trust LeadResponsible for day to day delivery of action, intervention or task

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The workstreams have delivered the following interventions

4

Workstream Key Initiatives Impact TrustLead

Divisional Lead

Executive Lead

Emergency Department

• Improving non admitted performance through increased grip and control,policies and protocols and senior medical leadership

• Rota demand and capacity in the emergency department to help ensure consistently sufficient levels of middle grade staffing

• Culture and OD work in the emergency department

• 6% improvement in non admitted performance during the RIW

• 10% improvement in non admitted performance maintained since the RIW until February 2018; reducing to 3% in March 2018.

• Improved departmental ownership of non admitted performance

• Sign off of business case to recruit 7 WTE middle grade doctors

ED CD Divisional medical director

Chief Operating Officer/ Medical Director/ Chief Nurse

Assessment areas • Consistent alignment of consultant and junior doctor staffing to demand

• Reconfiguration of GP hotline to ensure right patient assessed in right place and optimum use of acute medical ANP

• Implementation of SAU reconfiguration to reduce surgical breaches

• Optimum use of clinical resource through reallocation

• Surgical breaches reduced to <1/day

Acute medicine CD

Divisional medical director


Flow • Intensive support to roll out SAFER and R2G patient flow bundle on wards 21-23, 10-11, 3, 20, 25, 1, 29

• Production and dissemination of ward internal professional standards from 19/03/18

• Site team grip and control• Implementation of transfer team

• Improvement in pre-midday discharges from 14% (baseline) to ~40% for SAFER wards

• Increase in number of days where SAFER ward took a morning patient to 86% (medical wards), 50% (surgical wards) during intensive support

• Ward standards published detailing response times to enable wards to hold specialties and support services to account for delivery of these standards support minimising delays

Speciality CDs

Deputy medical director

MedicalDirector

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These interventions have supported Type 1 Performance remaining between 65%-72% through winter months despite attendances rising compared to same time period last year• The graph below depicts AUH Type 1 performance

• Performance has remained relatively static through winter months ranging between 65%- 72%

• This has been delivered against the following backdrop:- significantly increased attendances (7-9% higher than same time period last winter)- increasing acuity with a larger proportion of beds blocked due to influenza which is also reflective in ALOS which is 1.5 days on average

higher across all acute wards- 20% higher patients with an ALOS of > 7 days in January -March compared to October – December which points to increasing acuity with

external delays also a contributing factor- average numbers of ready for discharge patients (awaiting external interventions) has increased by on average 40 patients between

December -March 16/17 to 17/18

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

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

2017/18 Type 1 Performance (pre-project start) 2017/18 Type 1 Performance (phase 1)Page 10

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• Prior to November 2017 when AUH’s combined performance was ranked alongside all Trusts within the North region, the Trust rankedconsistently below lower quartile.

• Since November AUH have moved out of lower quartile and within the median range of Trusts.

• In addition to this there were days where AUH ranked 1st across the region and also days where they edged within the upper quartile range.

• AUH have also been commended by NHSE for being the most improved Trust in the Cheshire and Mersey region when comparing this winter to last year.

• The Trust recognises that there is still a way to go to help achieve the step change required to consistently rank within the upper quartile range and has already commenced the activities required to enable this.

Regionally this has seen combined performance shift AUH out of the lower quartile of the sitrep ranking and towards median across the North region

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0

10

20

30

40

50

60

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

NH

SI S

itre

p R

egio

nal

Ran

kin

g

AUH Type 1 & 3 Rank Upper Quartile Lower Quartile Median

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The combined impact of the interventions below will help support maintenance of current performance and pave the way for further improvements

Intervention Impact Owner

Demand and capacity bed rightsizing analysis • A detailed understanding of the level of beds required to deliver activity baselined against current number of beds


Recruitment of 7 WTE SHO/middle grade doctors in ED• This has been signed off by the board and recruitment has

commenced

• This will help ensure patient time in department is appropriate for their need supporting achievement of the 4-hour standard, especially for non admitted

Medical Director

SAFER implementation across all wards• Roll out of SAFER on remaining wards

• Full roll out of the SAFER patient flow bundle Chief OperatingOfficer/ Medical Director/ Chief Nurse

System partner engagement• Determine key 3-5 drivers of external delays and work with

external providers to address• Use the demand and capacity work to overlay this as a

scenario to better articulate impact

• Inclusion of external delays into non elective flow programme which has up until now focussed purely on internal drivers


Setting up the operational PMO to continue transformation work• Creation of an operational PMO to support transformation

work as part of EY handover strategy

• Sustainability of actions delivered to date• Ensure continuation of non elective flow programme with

existing rigour, pace and governance that would not be possible if managed as business as usual


Ward OD programme• Engagement programme which will focus on a joint vision,

the steps required to deliver this and how current ways of working on wards impacts the wider organisation

• Increase awareness and ownership of non elective flow drivers and improvements required

• Creation of a joint vision spanning all staff groups from front to back door

Director of Workforce/ Chief Nurse/ Medical Director

1

2

3

4

5

6

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The interventions are planned to be delivered in the timeframe below with the required enablers articulated

Inte

rven

tio

ns

Enab

lers

April May June July Aug Sept Executive Owner

Demand and capacity bed rightsizing analysis

Recruitment of 7 WTE SHO/middle grade doctors in ED

SAFER implementation across all wards

System partner engagement

Setting up the operational PMO to continue transformation work

Ward OD programme

Ongoing

BI and continued use of data

Secondment and operational PMO

Medical engagement and accountability

COO

MD

Exec Triumverate

Executive team

COO

HR Director, CN, MD

1

2

3

4

5

6

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The following challenges remain to sustain current levels of performance and improve further

Focus Requirement

Structure

BAU governance and escalation in situations of deteriorating performance

Clear escalation policies and protocols at all tiers of the organisation that are adhered to before decisions are made in order to stabilise the situation.

Consequences, reward & recognition Scrutiny and challenge built into core functions and roles that are managed within the existing line management structure

Process

Medical and nursing leadership Ownership of the solutions with a joint approach to problem solving by medical and nursing leaders

Use of data Access to data and insight and use of this to continually drive decision making, improvements and change management

People

Capacity and capability building within existing teams

Clear roles, responsibilities and expectations for delivery and what good looks like.

Organisational culture A culture where there is joint ownership of the problems and solutions at all tiers with patient care at the centre

Leadership & behaviours Strong leaders and positive organisational approach to deliver the programme

• Relative performance has improved since October, predominantly due to focus on improving operational grip and control on both the front end and flow through the emergency pathway.

• To move the organisation into the top performing category, there are some systemic issues that will need to be addressed.

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Report Title Finance Report, M12 2017-18


Lead Officer Paul Brannelly, Deputy Director of Finance

Action Required To review & agree actions


High level of confidence in delivery of existing mechanisms / objectives


General confidence in delivery of existing mechanisms/ objectives

Partial assurance


No assurance

No confidence in delivery


• The Trust has achieved its planned underlying deficit postion for the year.

• Expenditure pressures have continued in both Medical and Nurse staffing.

• The position includes balance sheet release in line with the operational plan and non-recurrent

support from reserve slippage


• 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)












• Key Risk

• Service Change

• Other



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REPORT HISTORY


Agenda Ref



Finance & Performance Committee

Finance Report Monthly

Board of Directors

Finance Report Monthly

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Finance & Performance Committee – Update

Finance Report, M12 2017-18


Subject to audit, the Trusts position (before impairments) is -£1.757 worse than the planned

Deficit of -£5.932M, due to the loss of STF associated with the AED standard.

Underlying financial performance excluding STF is £0.291M marginally better than plan,

albeit supported by non-recurrent measures.

The Trust may receive an STF bonus for achieving the financial plan, which would see the

position improve if confirmed.

Background

1. This paper presents the activity and financial performance data for March 2018 (Month 12) against NHSI’s contracts and internal standards.

Key Issues

2. Main issues for March 2018:

The Trust reported a cumulative operating deficit (before impairments) of -£7.689M against a planned deficit of -£5.932M, the shortfall relates to the

loss of STF for missing the AED standard. The Trust has received a 1-for-1 STF bonus of £0.291m, reflecting its improvement on its underlying

position before STF.

Planned care performed below plan, with elective activity above plan in month by 373 spells (Medicine +204, Surgery +177, -8 Clinical Support).

Outpatient workload however was down by -3607 attendances in month, behind target cumulatively. AED attendances were up in month, NE

admissions were above the contract plan and above last years actuals.

Figure 1: Activity Performance

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2

Medical Divisions position deteriorated in month by £0.213m to a cumulative surplus against plan £0.154m, a variance of 0.59 %.

Surgery’s position deteriorated by a further -£1.604m to a cumulative deficit to date of -£6.233m, -19.53%.

Clinical Support Services performed close to plan and Corporate functions performed better than budget.

The overall financial position was supported through non-recurrent in-year measures, principally through anticipated release of balance sheet

provisions and annual slippage on planned reserves.

Spend on agency against the Trust plan and the agency cap is higher than planned by c£7m. Whilst the Trust has tried to maintain downward

pressure on agency spend through adherence to agency cap rules and the continued scrutiny of non-core spend, the Trust continues to carry

vacancies, alongside the unprecedented number of escalation beds opened in response to the winter pressures faced across the local health

economy. This alongside an increase in the number of shift requests, which has increased steadily, has resulted in a breach of the agency cap.

Based on the current level of agency spend, the Trust has moved to a rating of 4 against its ‘Use of Resources Rating’, where performance against

the agency cap is a key measure. Agency spend in March was significantly higher than previous months, despite the bed capacity within the Trust

being static.

Figure 2: Agency Spend Vs Cap

Productivity and efficiency delivery was on target in month and for the year but delivered through, the release of balance sheet provisions,

crystallisation of corporate underspends (non-recurrently) and annual slippage on planned reserves.

A total of £23,395m is included in the expenditure position in March which relates to a technical impairment adjustment associated with the

revaluation of the trusts estate. Although included in the expenditure position the trusts performance is assessed on the position before

impairments are accounted for.

Financial Sustainability Risk Rating, (FSRR) of 4.

Cash balances remain positive and were sufficient for the trust to meet its obligations for the year.

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3. Director of Finance & Business Services Commentary

Figure 3 – Summarised Income & Expenditure Account – M12 (2017-18)

The Trust has reported an operating deficit (before impairments) of -£7.689m, against a planned deficit of -£5.932m for the year.

The Acting as One (AaO) contractual arrangements are in place from the 1st April and fixes the income values paid by the trusts main commissioners, (with the exception of pass through payments e.g. High cost drugs which will continue to be recompensed at cost). Under a pure PbR contract income would have been £2.9M above plan, with a loss in elective income more than offset by an increase in non-elective over performance.

Most contracts outside the AaO agreement are performing above plan.

In month elective workload was higher than plan by 372 spells (-1,275 to date), primarily medicine +204 (+1,978 spells to date), surgery +177 (-3,181 spells to date). In total, to date, the shortfall in activity would have resulted in reduced income of £4.0M under PbR rules. Much of the fall in activity is due to the theatre refurb programme where lost capacity has not been covered in full by the plans formulated.

In month non-elective activity shows actual performance higher than the contract by +869 spells (+713 Medicine, +157 Surgery). The plans agreed for 2017-18 fixed emergency care activity and income at the planned levels for 2016/17. This ensures that the trust is not penalised for implementing transformational changes that improve the care pathways for patients. Cumulatively the value of over performance of non-elective throughput would have been £6.4M.

Outpatient activity was below plan in month by some -3,618 attendances (primarily -1,758 Medicine, -2,101 Surgery, +250 Clinical Support Svs).

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3. Director of Finance & Business Services Commentary (cont’d)

The loss on STF for failure to achieve AED standards has continued, this has been partially offset by the 1-for-1 STF bonus.

Movement in operational pay lines shows an increase in the overspend of £1.574m in month. The principle areas continue to be nurse agency and

nurse bank costs covering high levels of vacancies and additional sessional duties (e.g.specialling) totalling -£0.802m over plan in month, a

significant increase on previous months, and medical staffing costs ( agency \ Pods\ WLIs ) showing -£0.538m over plan in month. This is in part

offset by pay underspends across corporate service and clinical support services.

Medical Divisional are ahead of plan at month 12 by £0.154m. Income is above plan and expenditure significantly over plan. Spend on both nurse

and medical staff remained high. This position excludes CIP which is reported centrally through workstreams rather than held at Divisional level.

Surgery are behind plan to date underperforming by -£6.233m. Theatre productivity remains sub-optimal. Performance across activity lines was

mixed. Expenditure continues to overspend across both nurse and medical staffing lines despite this. This position excludes CIP which is reported

centrally through workstreams rather than held at Divisional level.

Productivity and efficiency delivered in March totalled £1.591m against a target of £1.116m. The contributions in-month were delivered primarily

from a consolidation of estates and facilities savings plans £0.497m, medicines management gain share arrangements with CCGs\ procurement

benefits across all areas £0.114m and reserve slippage\balance sheet provisions release £0.980m. The overall plan for the year of £13.4m has

been achieved and has been largely through non recurrent balance sheet release and reserve slippage

Figure 4 – CIP Trust wide

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4. Key Variances

Figure 5 – Key Variance Analysis

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5. Medicine Divisional Position

Figure 6 - Year to date variance against plan

Current Position

Medicine is ahead of its planned contribution of £26.018m by £0.154m, 0.59%, as at month 12.

The divisional income position over performed in month, up by £0.709m. Emergency Care admissions were above plan +713 spells. Elective care

activity is up by +204 spells primarily from heart failure activity in Cardiology. Outpatient areas are down by -1,758 attendances in month,

cumulatively down by -3,765 attendances (it should be noted that a number of non-recurrent virtual clinics have been undertaken by Cardiology

over the first two months to see an additional 400 patients at premium rate).

Expenditure budgets overspent by -£0.922m in month, -£6.553m to the end of Month 12. Pay overruns cover the bulk of the position, Nurse staffing

costs -£0.413m and medical staffing costs are over plan by -£0.403m in month, -£3.175m, -£3.159m respectively for the year to date.

Productivity and efficiency delivered in month amounted to £0.035m and £0.615m for the year, primarily from the medicines management gain

share arrangement with commissioners.

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5. Medicine Divisional Position (cont’d)

Activity

Figures 7 through 9 show the divisional activity throughput against plan for

the period.

Elective activity was above plan in month +204 spells associated with the

Heart Failure pathways changes

Non-elective admissions overperformed in month up by 713 spells.

Outpatient activity as shown in figure 9 shows an underperformance

against plan of -1,758 attendances with first attendance down by -35,

follow-up down -1,728 and procedures up by 4. It should be noted that the

cumulative position includes an additional 400 virtual follow ups

undertaken in previous months within Cardiology at premium rate.

Figure 7 – Elective activity

Figure 8 – Non-elective Activity

Figure 9 – Outpatient Activity

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6. Surgical Divisional Position

Figure 10 – Year to date variance against plan

Current Position

Surgery is -£6.233m behind its planned contribution of £31.922m -19.53%.

The divisional income position shows an underperformance in the month -£0.282m. Planned admitted care activity was above plan by 177 spells in

March. Outpatient areas are below plan in month by -2,101 attendances. Non-Elective overperformed in month by 157 spells.

Expenditure budgets were above plan in month by £0.844m in month. The use of premium rates continues to feature with a further -£0.270m in

March (more than twice that of prior months) a total of -£1.626m spent for the year, in comparison to - £1.538k in 2016/17, this incurred at the same

time that there is a significant reduction in the numbers of planned care admissions and theatre lists undertaken and the number of outpatient

attendances and sessions. Whilst it was understood premium rates would be needed in 2017/18 to meet plan (before implementation of improved

productivity measures) as they had been required in previous years, this does not triangulate with actual activity delivery. The impact of the theatre

closure has impacted on this and could be part of the reason for premium payments as activity is displaced outside core times and/or individuals

scheduled sessions. Premium payments sessions should be used only as a last resort. It is imperative to ensure that the work streams associated

with better utilisation of both outpatient and inpatient facilities and a review of capacity and demand gaps minimise the necessity and reliance on

short term premium payments.

Key Pay overruns continue and relate to a significant increase in Nurse staffing -£0.368m and Medical Staffing reporting £0.176m in month.

A QEP contribution of £0.035m was achieved in month primarily from the medicines management gain share arrangement with commissioners and

procurement savings.

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6. Surgical Divisional Position (cont’d)

Activity

Figures 11 through 13 show the divisional activity throughput against plan

for the period.

Elective activity performance is up in month showing an overperformance

of 177 spells (day cases 179, inpatients -2), Gastroenterology +137 spells

(-637 year to date), Ophthalmology 27 spells (-836 year to date) and

Orthopaedics -63 spells (-1,037 year to date).

Non-elective admissions are up in month by 157 spells.

Outpatient activity as shown in figure 13 shows the division are below

plan, -2,101 attendances in month recording underperformance across,

first attendances -1,146, follow ups -777, procedures -170 and ARMD -7.

Cumulatively below plan by -10,102 (this includes -4140 attendances

subcontracted to a private provider to address a backlog of Dermatology

activity).

Figure 11 – Elective Activity

Figure 12 – Non-elective Activity

Figure 13 – Outpatient Activity

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7. Clinical Support Services Position

8. LcL


-

Current Position and Forecast

For March the Division is reporting a positive position and is now cumulatively better than plan by £0.799m. Income and activity plans were below

plan in month by £0.033m, with expenditure meeting plan during the month.

Productivity and Efficiency Delivery

The division delivered a QEP contribution of £0.042m in month, £0.694m for the year.

RLBUH continue to report a significant deficit on LCL trading activities. The make up of this deficit is unclear and work continues to identify the drivers that have generated this overspend. AUH, at this stage, does not accept shared liability for the reported position other than the an overspend of £0.7m associated with prior year unachieved CIP, which is retained in AUH budgets and a share of legitimate costs that can be tracked to proven increases in activity\demand. AUHFT has received an invoice from RLBUH for its perceived share of the deficit, c£4m, which has been rejected in full due to the issues noted.

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9. Corporate Services Position


Current Position

Overall corporate services are underspent by £0.976m this has assisted in supporting the overall position.

Productivity and Efficiency Delivery

Corporate service areas have withdrawn productivity and efficiency savings of £1.161m for the year.

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10. Reserves

Figure 16 – Contingency and Reserve Balances

General, inflationary and development reserves are held centrally and allocated to Divisions/Departments when the costs are incurred.

The Trust sets its budgets based on the recurrent costs of service delivery and therefore anticipates that an element of slippage will occur during

the year. This can be used non-recurrently to support emerging pressures not anticipated, or used to support the CIP programme on a non-

recurrent basis. An assessment of annual slippage has released £8.547m to date of which £4.402M has be put against the CIP programme (this

is in addition to the £5.3m released from the balance sheet), with the balance supporting operational overspends. This has all been allocated into

the month 12 final position.

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10. Balance Sheet

Figure 17 – Statement of Financial Position

March 18 February 18

£000 £000

NON-CURRENT ASSETS

Intangible assets 1,061 197

Property, plant and equipment 185,799 192,814

Trade and other receivables 0 0

Total non-current assets 186,860 193,011

CURRENT ASSETS

Inventories 2,223 2,044

Trade and other receivables 19,053 22,483

Cash and cash equivalents 11,193 17,473

Other financial assets (investments) 0 0

Total current assets 32,469 42,000

CURRENT LIABILITIES

Trade and other payables (42,389) (43,737)

Borrowings (2,655) (2,655)

Provisions (469) (455)

Other liabilities (7,199) (6,789)

Total current liabilities (52,712) (53,636)

TOTAL ASSETS LESS CURRENT LIABILITIES 166,617 181,375

NON-CURRENT LIABILITIES

Borrowings (49,111) (49,600)

Provisions (557) (542)

Other liabilities (275) (569)0 0 0

Total non-current liabilities (49,943) (50,711)

TOTAL ASSETS EMPLOYED 116,674 130,664

FINANCED BY (TAXPAYERS' EQUITY)

Public Dividend Capital 115,091 114,984

Revaluation Reserve 36,656 27,432

Income and Expenditure Reserve (35,073) (11,752)

TOTAL TAXPAYERS' EQUITY 116,674 130,664

AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

STATEMENT OF FINANCIAL POSITION

MONTH 12

31 March 2018

Commentary

In summary, fixed assets totalled £186.9m. This is £6.1m lower

than the previous month and is primarily driven by technical

adjustments made in relation to valuing the Trust’s estate in

line with best accounting practice.

Working capital (current assets less current liabilities) was

weakened considerably (in line with the forecast) during March

and outturned at minus £20m against a February position of

minus £11.6m. The reduction was heavily linked to capital

investment levels in the region of £8m for the month of March.

Trade and other receivables decreased by £3.4m in month as

we received cash settlement of the winter pressure income

from NHS England, along with further performance related

income achieved through the Strategic Transformation Fund

agreement.

Trade and other payables reduced by £1.3m during March,

partially due to the prior period PDC dividend accrual being

cash settled in March.

The reduction of c£24m within the equity section of the balance

sheet illustrates the reported loss incurred by the Trust during

the month of March – of this loss, £23.4 related to impairments

made to fixed assets.

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11. Cash

Figure 18 – Rolling 12 mth cash flow forecast

-5.000

0.000

5.000

10.000

15.000

20.000

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

£M

Actual Cash Planned Cash (including support) Planned Cash (Excluding support)

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11. Cash (con’t)

Commentary

Cash balances totalled £11.2m against an updated plan cash resource of £6.6m. The £4.6m higher cash figure is largely as a result of drawing

down an interim capital loan of £5.8m during February 2018 of which the majority of the associated capital spend was an addition to creditors

(rather than cash payments).

On 19 January the Trust received confirmation that a loan application for £5.8m has been successful, and that all of the capital must be

committed and accounted for within 2017/18. The Trust has drawn down the cash and is working hard to ensure that it is fully committed

before the end of the financial year. The cash assumption is that at least £4.0m of the spend will be an increase in creditors rather than cash.

The 2018/19 Draft Operational Annual Plan, as submitted to NHSI on 8 March 2018, includes the need for revenue cash support from DH

totalling £24m across the year. Without revenue cash support, the Trust expects to drop into negative cash balances approximately August

2018 and will need to formally apply for cash support in June 2018. This is reflected in the graph above.

The Final version of the Operational Annual Plan is due to be submitted to NHSI on 30th April 2018, this will result in an updated cash plan

which will be included in the May 2018 report.

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12. Use of Resources Risk Rating

Figure 19 – FSRR

Plan YTD ending

31-Mar-18

Actual YTD

ending 31-Mar-18

Capital Service Cover

Capital service metric 0.508 0.220

Capital service rating 4 4

Liquidity

Liquidity metric (24.013) (23.823)

Liquidity rating 4 4

I&E Margin

I&E Margin metric (2.05%) (2.49%)

I&E Margin rating 4 4

I&E Variance From Plan

I&E Variance from plan metric (0.45%)

I&E Variance from plan rating 2

Agency

Agency metric 0.00% 83.92%

Agency rating 1 4

Use Of Resources Rating

Overall rating unrounded 3.60

If unrounded score ends in 0.5 -

Rounded score 4

Use Of Resources Rating before overrides 4

4 Rating Trigger for Use Of Resources Rating TRIGGER

Use Of Resources Rating after 4 rating override 4

Control total override - Control total accepted YES

Control total override - Planned or Forecast deficit Yes

Control total override - Maximum score 0

Is the provider in Financial Special Measures? No

Use Of Resources Rating after overrides 4

Use of Resources Risk Rating

Commentary – FSRR Metric

Capital Service Cover: whilst this rating has dropped

from a 3 at 2016/17 Month 12, a rating of 4 is in line with

the annual plan. It was anticipated that this ratio would

remain 4 to the end of the financial year.

Liquidity: a rating of 4 (lowest score) is in line with the

annual annual plan. It was anticipated that this rating

would remain 4 to the end of the financial year.

I&E Margin: whilst this rating has dropped from a 2 at

2016/17 Month 12, a rating of 4 is in the annual plan. It

was anticipated that this rating would remain 4 to the end

of the financial year.

I&E Margin variance from Plan: as this measure is a

target on the achievement of the plan, any rating lower

than 1 is out of line with the submitted plan.

Agency: due to the nature of this metric, the planned

rating will always be a 1.

Overall, the risk rating is a ‘4’ (after the overrides)

which is lower than that anticipated in the 2017/18

annual plan. The reduction is in line with last month

and is due to the deterioration of the Agency metric

which dropped to a 4 in month 8.

It is unclear what this drop in performance will mean in

terms of ‘monitoring’. The Single Oversight Framework

suggests that it could trigger ‘special measures’, but as

UoR is one of a range of five performance themes, it is

unlikely this would be the case.

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13. Capital

Figure 20 – Capital

12 Plan YTD Spend Variance

£'000 £'000 £'000

Medical Equipment 3,325 3,282 -43

Helipad 900 900 0

Ward Reorganisation 0 0 0

Main A Theatre & recovery 1,500 1,581 81

IT 546 640 94

Building, Engineering & Environment, Health & Safety 368 491 123

UCAT 50 58 8

LV infrastructure electrical improvements 155 150 -5

Bed Lifts Refurbishment 450 0 -450

H&N - Phase 1 - Ward 28 Side Rooms 250 243 -7

Tower Block Cladding Renewal 500 517 17

Main A 6&7 Chillers 150 142 -8

Pneumatic Tubes 150 132 -18

Estates Schemes 17/18 50 44 -6

Estates Schemes 18/19 235 199 -36

Car Park Scheme 750 485 -265

CEF 1,160 1,085 -75

Electronic Check-In System 0 289 289

PDC - Cyber Security 1,038 988 -50

PDC - WiFi Roll Out 210 206 -4

PDC - Video Conferencing 162 162 0

Total 11,949 11,594 -355

Financed By:

Depreciation 5,444 5,264 -180

DOH Loan Repayment -2,424 -2,424 0

DOH Loan Drawdown 5,795 5,800 5

PDC Drawdown 2,410 2,410 0

(Gain)/loss in Working Capital -296 -476 -180

HELP Donation re: Heli Pad 900 900 0

Marie Dalglish Donation re: Equipment 120 120 0

Total 11,949 11,594 -355

Commentary

Capital spend at month 12 concluded at £11.6m.

Commentary on the material schemes is provided

below:

Medical equipment – the capital loan enabled the

Trust to invest in its Medical Equipment replacement

programme. This will be of significant benefit to both

patients and staff and enable the Trust to remain at

the forefront of technology. A significant proportion

of this spend will enable a reduction in the 2018-19

Medical Equipment Budget.

Bed Lifts Refurbishment – Despite a prolonged

effort, the manufacturer of this equipment was

unable to progress the scheme during 2017-18

which resulted in no expenditure. The Capital

Planning Group will decide on the priority of this

scheme for 2018-19.

Main A Theatre – ongoing as we progress through

the scope of works. Delays in the scheme have

driven the completion date to May.

Tower Block Cladding – design stage ongoing as

we work towards the gross maximum price (GMP)

with our Principal Supply Chain Partner (PSCP),

Bam Construction.

Car Park Scheme – new car parking equipment has

been procured. Enabling and installation work to take

place during 2018-19.

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Recommendation

14. The Finance & Performance Committee are asked to note the information contained within this report.


15. Transformation Programme Update (on agenda)

Author Paul Brannelly, Deputy Director of Finance Owner Ian Jones, Director of Finance & Business Services Date 19/04/2018

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Report Title Annual Business Plan Reporting - Q4 2017/18

Executive Lead Ian Jones, Deputy Director of Finance

Lead Officer Dr Angela Whittaker, Associate Director of Strategy, Service

Development and BI






Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• This report provides an overview of the delivery of the 2017/18 Annual Business Plan priorities.

• Further detail is provided where schemes are not on track with regard to the required actions or

delivery of the required outcomes.


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other



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2 Annual Business Plan Reporting Q4 2017/18: Board of Directors 25 April 2018

REPORT HISTORY


Agenda Ref



Quality

Committee

QC17-18/

019

Annual Business Plan

– Progress Report Q4

2017/18

16 April 2018 Noted

F&P Committee Annual Business Plan

– Progress Report Q4

2017/18

25 April 2018

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Annual Business Plan Reporting – Q4 2017/18

Executive Summary

1. The aim of this report is to provide assurance to the Quality Committee that progress

towards agreed Annual Business Plan priorities is being realised during Quarter 4 of

2017/18 and, if not to advise on the impact of non-delivery.

2. Progress towards achievement of all Q4 deliverables will also be reported directly to

the appropriate Executive Led Groups/Executive Leads. Divisional level reports have

also been provided to the Divisional Medical Directors and Divisional Directors of

Operations.

3. Reports have been provided for the 33 Trust reportable schemes.

Background

4. During 2017/18 the Trust is focusing on a number of key work programmes that

support the principles set out in the Sustainability and Transformation Plans and which

are central to delivery of Local Delivery System plan. These include:

• 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.

Annual Business Plan Reporting

5. This report provides an overview of progress against key work programmes which will

support delivery of Trust objectives, without presenting a level of detail that is

overwhelming.

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6. Therefore:

• Progress against the objectives included in the Quality Strategy is reported

against the four high level themes: ‘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’. (The full

progress reporting of each Quality Strategy initiative is provided through a

quarterly Quality Strategy Report to the Clinical Effectiveness Executive Led

Group and the Safety and Risk Executive Led Group.)

• Overall Quality and Efficiency Programme (QEP) progress will be reported in the

Annual Business Plan as delivery of savings against plan. (Full QEP programme

progress reporting occurs via the Transformation Steering Group.)

• Where appropriate, related schemes have been grouped for Trust level

reporting, with detailed progress monitored on Divisional basis.

• Finally a number of schemes are only reported at Divisional and Executive Led

Group level, rather than as part of this Trust level report.

Quarter 4 Progress Update

7. The Trust Annual Business Plan contains 56 priorities for delivery in 2017/18. This

document provides an update on the performance of the 33 Trust level reportable

priorities as at 31st March 2018. Performance by theme is shown in Appendix 1.

Progress against delivery of actions (have we done what we said we would do?)

and against measurable outcome (are our actions achieving the required

outcome?)

8. Of the 33 Trust reported schemes, 6 schemes have not completed the required actions

in Qtr. 4 and/or are not on track to achieve the required outcome at Qtr. 4. The impact

of this non-delivery is set out below:

Proposed Merger Transaction

9. The measurable outcome which the Trust is aiming to achieve is to proceed as quickly

as possible through regulatory approval to create a new merged Foundation Trust.

10. The successful delivery and achievement of this objective is being monitored by the

following actions and measurable outcomes:

Deliverable actions Q4 Measurable outcomes

• Dependent on CMA requirements (may

delay steps below until after Qtr. 4):

• Boards Approve FBC

• NHSI review

• Progress against Trust Transaction

Programme

Progress this

Qtr.

• A revised date for merger transaction has been agreed as 1st

April 2019.

• A recruitment programme has taken place and the Trust

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Transaction PMO team will be near to full establishment from 1st

April 2018.

• NHSI have not signed off the business cases to approve the

consultancy spend. Trust Transaction PMO Directors are

working with NHSI to progress the approval of these business

cases.

• A procurement exercise for external support for Competition and

Markets Authority (CMA) and legal due diligence has been

completed.

Next steps • The Trust Transaction PMO team are continuing to work with

clinical integrated planning teams on 11 deep dive areas for

inclusion in the merger transaction full business case and

workshops are taking place.

• Executive Led Programme Working Groups meeting monthly

and progressing work as set out in the programme plan.

• External support for CMA and legal due diligence cannot be

mobilised until NHSI sign off consultancy business cases.

Implications The proposed date for the merger of Aintree and RLBUHT has

moved from 1st October 2018 to 1st April 2019. The implications and

risks to the organisation of this are delay in delivering the improved

clinical outcomes detailed in the Outline Business Case, the risk of

failure to ensure all stakeholders are engaged and disengagement

of staff and clinical commitment to the work required to deliver the

merger and failure to deliver the improved financial and workforce

sustainability of a merged organisation in a timely way.

People and Corporate Affairs High Impact Improvement Plan – Culture

11. The measurable outcome which the Trust is aiming to achieve is an improvement in

the overall engagement score in the 2017 national staff survey which consider factors

such as: leadership, workforce indicators such as turnover management of sickness

absence and work related stress as a cause of sickness. In addition to provide

improved workforce intelligence for managers and greater visibility of absence and

turnover understand the impact and able to focus on areas in need of support.




• NSS response rate at least 45%

• Improvement 0ES to at least national average

• Review impact of turnover action plan.

• Devolved Divisional Staff Engagement Improvement Plans in place

• Improvement in key indicators in 2017 survey:

o Overall Staff Engagement Score - (2016 - 3.70)

o KF1 - (2016 - 3.66) o KF4 - (2016 - 3.82) o KF7 - (2016 - 68%)

• CQUIN target - 5% Improvement on response to question KF 19 Org and Mgt interest & action on Health and

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Wellbeing (2016 score 3.48)

• Achievement of 4% absence target

• Reduction in Stress related absence by

5%

Progress this

Qtr.

• The overall engagement score for the national staff survey has

improved on the previous year but is still below the national

average. There has been an improvement in key finding 1 (staff

recommendation of the organisation as a place to work or

receive treatment) and scores against key finding 4 (staff

motivation) & key finding 7 (staff ability to contribute towards

improvements at work) have been maintained. There has been a

small improvement in key finding 19 (organisation and

management interest in and action on health and wellbeing) but

the Trust did not achieve the CQUIN improvement of 5%.

• Rolling sickness absence rate 4.37%. Rolling stress related

absence 1.20%. There has been a marked improvement in

cases of reported work related stress as a result of improved

communication, effective case management and line managers

are equipped with the requisite tools to enable them to

proactively support and manage these cases to ensure timely

resolution of such cases.

Next steps • Further roll out of Health, Wellbeing and Work Strategy.

• Review of staff survey results and improvement plan to be

agreed following Board away day. To focus on improving areas

in organisation with low levels of staff engagement.

• To focus on developing a culture to enable the delivery of safe

patient care.

• Cases of long and short term sickness are effectively managed

to ensure employees are supported at the earliest possible

juncture to expedite their return to work though collaboration

between occupational health and HR leads and in turn with the

Divisions with their respective HR lead.

Implications The staff survey improvement action plan for 2018/19 will focus on

areas in the organisation with low levels of staff engagement so that

appropriate actions can be put in place t to improve trust

performance to at least the national average against key findings

within the next reported staff survey.

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Improve Theatre Productivity and Efficiency

13. The measurable outcome which the Trust is aiming to achieve is to improved theatre

productivity and efficiency, by increasing the utilisation of scheduled theatre sessions

and increasing the use of theatre time in session.




• Embedded changes into theatres to

achieve sustainability in continuous

improvement covering all points.

• Achieve activity plan

• No WLI sessions

• 98% sessions utilised

• 85% in-session utilisation

• 4-5 weeks’ notice for surgery

• Average no. cases per list 2.16

Progress this

Qtr.

• Minimal progress made against Q4 deliverables. Data available

regarding performance and information has been shared with

clinical and managerial teams. Additional project management

support has been identified from the transformation team.

Johnson & Johnson completed a diagnostic review of theatre

productivity in January 18.

• Based on the reported position in March 2018: 90.5% theatre

sessions utilised / 67.8% in-session utilisation / average of 2.04

cases per list

Next steps • The Divisional Senior Management Team is considering

securing additional clinical and managerial leadership in

theatres. External company to be commissioned to support PMO

structure in theatres.

Implications Year to date activity below plan for daycase and inpatient

procedures resulting in a high number of WLIs approved in Q4 to

treat clinically urgent patients and to improve the Trust RTT position

RTT performance has fallen below 92% during Qtr. 4.

Deliver stroke standards for all of our patients and to deliver sustainability across

clinical teams

15. The measurable outcome which the Trust is aiming to achieve is the sustainable

delivery of the national standards for stroke services (90% patients to spend 80% time

in a stroke bed) and to achieve a score of B or above in the Sentinel Stroke National

Audit Programme.



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Deliverable actions Q3 – no actions

specified in Q4

Measurable outcomes

• Project implementation

• Training and Development of staff

• Open additional hyper-acute stroke unit

beds

• Achieve 90% stay quality indicator

• Maintain SSNAP performance at B

• Maintain improved standard for access to the Stroke Unit

• Maintain improvement to therapy standards

•

Progress this

Qtr.

• Minimal progress has been made this quarter and the Trust is

not currently achieving this standard.

Next steps • Group has been set up to review options available using QuEST

improvement approach. This is a 90 day improvement

programme and is sponsored by Chief Operating Officer and

Chief Nurse.

Implications • Some patients are not currently achieving care in line with

national stroke standards and therefore the Trust is unable to

achieve the best possible length of stay for all patients.

Care That Provides a Positive Experience for Patients and their Families

17. The measurable outcome which the Trust is aiming to achieve is to build on the

2016/17 ranking within the top 25% of organisations on the national inpatient

experience surveys.




• Achievement of actions associated with

‘Care That Provides a Positive

Experience for Patients and their

Families’

• Improving care based on responses

received via the National Inpatient

PICKER Survey, FFT Feedback,

Complaints & Patient Stories

Achieve ranking within the top 25% of organisations on the national inpatient experience surveys.

Progress this

Qtr.

Whilst patient experience delivery plan actions have been

undertaken, the data set has changed in 2017/18 due to changes in

the number of Trusts participating in the national Picker Survey and

the Trust has not maintained its ranking within the top 25% of

organisations on the national inpatient experience surveys

Next steps A refreshed patient engagement strategy is being developed

Implications The Trust patient engagement strategy will review and refresh the

metrics that are used to gauge patient experience of Trust services.

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Seven Day Services – Medicine

19. The measurable outcome which the Trust is aiming to achieve is to secure the best

possible patient outcomes and to promote quality of life through delivering services in

accordance with the 4 priority standards for seven day services:

• Standard 2 – Time to first consultant review

• Standard 5 – Access to diagnostic tests

• Standard 6 – Access to consultant-directed interventions

• Standard 8 – Ongoing review by consultant twice daily if high dependency patients, daily for others.




• Implementation of plans to address

gaps in delivery of 4 priority standards

• Delivery of standards 2, 5, 6, 8

Medicine

Progress this

Qtr.

• The Trust is not fully compliant with the national standards for 7

day services following gap analysis. Cases of need for additional

assessment capacity (MAB/FAB), DME medical staffing, junior

medical staffing for ward 3 and the IV therapy team have been

developed and approved by the Board.

Next steps • Recruitment of to these teams.

Implications Whilst new, sick and potential discharge patients are seen at the

weekend there is a cohort of patients whose care is not progressed.

This means that the Trust is unable to achieve the best possible

length of stay for all patients. The position will be improved following

recruitment to the above teams. It will also be reviewed in light of

merger plans with RLBUHT.

Triangulation of Key Themes

21. Delays in the delivery of these six business plan priorities will have an impact on the

Trust’s ability to successfully achieve at least 3 of its stated strategic objectives:

• To achieve best outcomes by providing effective treatment to achieve best

possible patient outcomes and promote quality of life.

• To deliver sustainable health care to meet people’s needs by delivering efficient,

cost effective services to ensure their long term sustainability.

• To deliver outstanding care by being a patient centred organisation that provides

high quality, safe and compassionate services.

22. Increasingly the Trust Executive Team and Board of Directors are required to balance

the completing priorities of securing the delivery of high quality sustainable services

whilst achieving the financial control total as set by NHSi.

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23. Following discussion at the Trust HMB, it was agreed that in order to mitigate clinical

safety / service imperative risks and to balance competing priorities Divisions would

produce a prioritised list of cases of need for consideration by the Board. These cases

were supported by the Board and include:

• Physician associates

• CT capacity

• Primary care streaming in A&E

• A&E medical capacity

• Plastic surgery support for major trauma

• Emergency general surgery assessment unit consultant capacity

• Junior medical staff on ward 3

• Ward staffing

• Histopathology support for Liverpool Clinical Laboratories

• Medical safety nurse

• Assessment capacity in medical assessment bay and frailty assessment bay

• DME staffing

• IV therapy team

• Increase in bed capacity in recognition of sustained demand

Additional Implications

Financial

24. The cost of implementing all of the schemes identified above is £7.9m recurrently, of which

£3.7m is already being incurred as an overspend against operational budgets and/or is

supported by non-recurrent monies.

Workforce

25. The detailed workforce implications associated with recruitment to the above schemes

is being monitored at Divisional level.

Other

26. Respective Executive Led Groups will be required to provide oversight and scrutiny to

ensure the full potential of each scheme is realised within 2018/19.

Recommendation

27. The Board is asked to note the content of this report.

Author: Angela Whittaker, Associate Director of Strategy, Service Development & BI

Date: 12th April 2018

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Appendix 1: Annual Business Plan 2017/18 Reporting Dashboard - Qtr 4

Q1

Q2

Q3

Q4

Strength of

Assurance Q1

Q2

Q3

Q4

Strength of

Assurance

1 Proposed Merger Transaction G A R R Partial G A A R Partial

3 Maintain a focus on the delivery of high quality community services through collaboration with others G G G G Substantial A A A G Acceptable

15 Work with Merseycare to improve crisis care for people with mental health problems who present to AED. A G G G Acceptable A G G G Acceptable

16 Collaborative working with the stroke network and other local providers in implementing new stroke pathways G A A A Partial G G A A Partial

17 Contribution to Cardiology city wide service reconfiguration G G G G Acceptable G G G G Acceptable

18 Contribution to Respiratory and City-wide Service Reconfiguration G A G G Acceptable G G G G Partial

19 Haemato-Oncology Transfer of Services G G A A Partial G G A A Partial

42 North Mersey Orthopaedic & Trauma Service (MOATS) G G G G Substantial G G A A Substantial

31 People and Corporate Affairs High Impact Improvement Plan - Culture A A A r Acceptable G A A r Acceptable

32 People and Corporate Affairs High Impact Improvement Plan – Capacity R R A a Partial r r a a Partial

33 People and Corporate Affairs High Impact Improvement Plan – Competence R R A A Partial R R A a Partial

34 People and Corporate Affairs High Impact Improvement Plan - Communication G G A g Substantial G G A g g

43 Seven Day working - Acute Surgery flow R R A G Substantial A G A G Substantial

14 Outpatient productivity A A A A Acceptable A A A A Acceptable

40

Delivery of Quality of Efficiency Programme savings against plan

A A A A Partial A A A A Partial

49

To improve Theatre productivity and efficiency , by increasing the number of theatre sessions running and increasing the use of theatre

time in session. A R R R None A R R R None

6 Cancer Services Support - Radiology A A A G Acceptable A A A G Acceptable

7 IT EPR Implementation A A A A Substantial A A A A Substantial

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) G G A A Substantial A G a A Acceptable

24 Deliver Stroke standards for all of our patients and to deliver sustainability across the clinical teams. G A R R Substantial R R R R None

45

To develop safe and sustainable Dermatology services for Aintree university Hospital in partnership with local provider or providers

G G G A Acceptable G G G A Acceptable

46 Improving Acute Surgery flow, in the surgical assessment unit and across the Surgical Division. A A G G Substantial A A G G Substantial

47 To continue to reduce risks to Ophthalmology patients due to insufficient capacity to see patients in a timely way. A G A A Substantial A G A A Substantial

2 Working collaboratively with partners across health and social care to resolve some of the key challenges facing the Trust G G G G Acceptable G G G G Acceptable

36 Care that is Safe: Reducing Harm G G G A Acceptable A A A A Partial

37 Care that is Safe: Reducing Avoidable Mortality G G G G Substantial G G G G Substantial

38 Care that is Clinically Effective A A A A Partial A A A A Partial

39 Care That Provides a Positive Experience for Patients and their Families G G G G Substantial G G G R Substantial

41 Consideration of case for increased capacity within the Intravenous (IV) Team A A A A Substantial A A R A Substantial

50 Implementation of ‘National Guidance on Learning from Deaths’ from the National Quality Board on structured review of deaths G G G G Substantial G G G G Substantial

51 Seven day services – Diagnostics and Support Services A G G G Acceptable A G G G Acceptable

52 Seven day services – Medicine A R R R Partial A R R R Acceptable

53 Seven day services – Surgery A R R A Acceptable R R R A Partial

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Report Title Annual Business Plan 2018/19


Lead Officer Angela Whittaker, Associate Director of Strategy, Service Development

and BI

Action Required To review & approve





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• This report gives an overview of the approach taken to developing the Trust Annual Business

Plan for 2018/19 and summarises the priorities that have been included.


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other



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Annual Business Plan 2018/19: Board of Directors 25 April 2018 Page 2

REPORT HISTORY


Agenda Ref



HMB Workshop

session

Business Planning

2018/19

14 Feb 2018 To take account of HMB

feedback and to provide

an update to 14 March

2018 meeting

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Annual Business Plan 2018/19

Executive Summary

1. The Annual Business Plan outlines the priorities that the Trust will pursue in the delivery of its

strategic vision and the wider strategic vision for the health economy.

2. This report summarises the priorities that have been identified for inclusion in the Trust’s

Annual Business Plan for 2018/19. It should be considered alongside other Trust assurance

processes and reporting mechanisms including a range of business as usual activities.

Introduction/Background

3. The Trust’s Annual Business Plan for 2018/19 outlines how Aintree aims to; (i) achieve its

strategic vision, (ii) contribute to the delivery of the strategic vision for the health economy

and (iii) deliver against its mandated operational performance targets and quality standards.

4. The Trust is operating in a challenging operational and financial environment; with increased

demand for health care and with the costs of service delivery exceeding income received

from Commissioners. Therefore, it is vitally important for the Trust to maximise the use of its

resources and workforce to deliver key strategic priorities whilst effectively managing

business as usual activities. It is for this reason that the Trust has agreed a limited number

of strategic priorities for inclusion in the 2018/19 Annual Business Plan.

5. The successful delivery of these strategic business plan priorities will be supported by a

number of ‘business as usual’ enabling activities, including: workforce, data & information

management, estates and equipment, contracting/commissioning, quality improvement,

innovation and communication.

National Priorities and Local Commissioning Intentions

6. National policy continues to promote system-based working with a requirement for Trust

plans and priorities 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, digital first and to ‘act as one system’.

7. 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.

8. National planning guidance has set out five key deliverables for NHS Trusts. These are:

• Financial management and control totals – Trusts which accept their control totals will be

exempt from financial penalties with the exception of mixed sex accommodation

breaches, hospital acquired infections, cancelled operations and duty of candour

breaches.

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• Urgent and emergency care – recovery against the 4-hour A&E waiting time standard

has been deferred with Trusts being expected to achieve 90% against the A&E waiting

time standard in September 2018 and 95% by March 2019.

• Cancer waiting time standards – all 8 national cancer waiting time standards should be

achieved. Furthermore Trusts are expected to make progress against the National

Cancer Strategy goals by implementing rapid assessment and diagnostic pathways for

patients with suspected colorectal, prostate and lung cancer.

• Referral to treatment waiting time standard – The RTT waiting list should be no higher in

march 2019 than it is March 2018 and the unmaker of over 52 week waiters should be

halved.

• Delivery of the five national CQUIN initiatives which are: NHS staff health and wellbeing,

reducing the impact of serious infections, improving services for people with mental

health needs to present to A&E, offering advice and guidance and preventing ill health

by risky behaviours – alcohol and tobacco.

9. Local Commissioners have confirmed that they will be issuing an agreed set of prioritised

commissioning intentions for 2019/19. Whilst the list of priorities has not yet been shared the

principles that will be adopted include:

• The Acting as One arrangement will be reviewed to understand how successful it has

been in delivering the expectations of all parties with regard to financial stability for

implementation of the required system transformation. Consideration will be given to

whether changes are required for 2018/19.

• There will be an increased focus on using information from the NHS RightCare

programme and from the national Getting it Right First Time (GIRFT) programme which

is designed to improve medical care by reducing unwarranted variations. The use of

information from these initiatives will help shape future delivery of clinically and

financially sustainable healthcare services across North Merseyside.

• Commissioners and providers should work more closely to align Quality, Innovation,

Productivity and Prevention programmes (QIPP) so that delivery is optimised.

Trust Strategic Business Plan Priorities

10. During 2017/18 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 will continue to be as

strategic priorities for the Trust in 2018/19:

• Working towards acute provider merger, delivering horizontal integration. Clinical teams

are developing integrated models of care to deliver patient benefits across the city.

• 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 urgent and emergency care and patient flow challenges facing the Trust. This

includes a multi-professional workshop with partners, including social care, focused on

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accelerating discharge and addressing delays and the implementation of IA primary care

streaming service.

• Maintain a focus on the delivery of high quality community services through collaboration

with others.

11. In developing its Annual Business Plan the Trust has to ensure that it is aligned to the Trust’s

overarching strategic plan, the national deliverables set out in National Planning guidance,

the priorities set out by our local Commissioners in the emerging Sustainability and

Transformation Plan and initiatives which will support the Trust in making progress towards

to achievement of its strategic objectives.

12. The Trust’s strategic vision and objectives are included in the diagram below;

13. In recognition of the fact that the wider NHS and the local health and social care system is

operating in an extremely challenged operational and financial environment, with demand for

health care rising and with limited available funds to invest, the Trust has agreed a limited

number of strategic priorities for inclusion in the 2018/19 Annual Business Plan. This will

enable the Trust Executive Team to maximise the use of its resources and workforce to

deliver key strategic priorities whilst effectively managing business as usual activities.

14. The successful delivery of identified strategic business plan priorities will be supported by a

number of ‘business as usual’ enabling activities, including: workforce, data & information

management, estates and equipment, contracting/commissioning, quality improvement,

innovation and communication.

15. Each strategic business plan priority and enabling activity has an identified executive

sponsor and report/delivery lead. Work has been undertaken with the lead individuals to

work-up the detail of each schemes including the specific measures of success and

milestones that will determine whether schemes are on track or not.

16. The proposed strategic priorities and enabling activities are outlined in below with additional

detailed information being provided in in Appendix 1.

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Strategic Priorities Enabling Activities

• Quality

o Compliance (e.g. CQC

fundamental standards)

o Safeguarding/MHA compliance

o Acute and emergency

care/patient flow

o Deteriorating patient

o Patient experience

o Preventing and learning from

harm

• Financial management

o Managing budgets

o Cost improvements

• Merger Transaction & Service

Reconfiguration

• Electronic patient record

• General data protection regulations

(GDPR)

• Workforce

o Capacity

o Competence

o Culture

• Data and Information Management

• Estates and Equipment

• Contracting/commissioning

• Quality improvement

• Innovation

• Communication

Annual Business Plan Reporting

17. 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 2017/18, in that it will rely on the reporting

lead updating on progress via a centralised template, against each scheme.

18. SMART measures of success will be used to monitor progress and leads will report on both

the actions that were required to be undertaken and progress towards the required measure

of success. Progress reports will include the consequences of non-delivery where required.

Financial Considerations

19. Under the ‘Acting as One’ agreement the Trust, along with all other provider organisations in

the North Mersey Local Delivery System (NMLDS), has continued with the block contract for

2018/19 with our main commissioners, Liverpool CCG; South Sefton CCG; Southport &

Formby CCG; Knowsley CCG; and NHS England Specialised Commissioning.

20. 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.

21. 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.

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Implications / Impact

22. Completion of the business planning process will support the delivery of quality, finance and

workforce development across the Trust.

Conclusion

23. The annual business planning process represents an opportunity for the organisation to re-

focus its efforts on the achievement of its Strategic Objectives.

24. Given the challenging operational and financial environment it is vitally important for the Trust

to maximise the use of its resources and workforce to deliver key strategic priorities whilst

effectively managing business as usual activities. Consequently, the annual business

planning process for 2018/19 has focused on delivery of a limited number of schemes which

are aligned to the national planning guidance, Cheshire and Merseyside STP priorities and

which also support the achievement of Trust Strategic Objectives.

25. Executive sponsors and report/delivery leads have provided detailed milestones for delivery

and clear measures of success for each strategic priority and enabling initiative. This will

enable clarity of reporting.

26. 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. Where appropriate,

the consequences of non-delivery will be included within the progress updates.

Recommendation

27. The Board is asked to approve the proposed Annual Business Plan for 2018/19 as set out in

this paper, including the content of the Annual Business Plan (as set out in Appendix 1).

Author: Angela Whittaker, Associate Director of Strategy, Service Development and BI

Date: 16 April 2018

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Appendix 1

Business Plan Priority

Regulatory compliance with CQC fundamental standards

Link to Trust Strategic Objective

Deliver

outstanding care

Achieve best

[patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The Care Quality Commission (CQC) visited the Trust, between

3 and 6 October 2017 and between 25 and 26 October 2017,

and inspected some of the services provided as part of its

ongoing inspection programme. The services that were

inspected included: urgent and emergency services, medical

care services (including older people’s care), surgery and end of

life services.

The Trust has received a rating of Requires Improvement. In the

key questions of whether the Trust is providing care that is safe,

effective and responsive, the Trust’s ratings have moved from

Good to Requires Improvement. The ratings for whether

services are well-led remain as Requires Improvement and the

Trust remains rated as Good for being caring. Areas of

improvement identified by the CQC include:

• Ensuring there are sufficient staff with the right skills,

training and experience in the right place at the right

time to support access, flow and escalation.

• Safeguarding, Mental Capacity Act (MCA) and

Deprivation of Liberty (DoLs) processes to be

embedded.

• Clinical risk assessments and the management of

organisational risks.

• Embedding the proper and safe management of

patient’s own medicines.

• Staff engagement and empowerment.

The Trust is developing a comprehensive action plan in

response to the CQC’s inspection findings. The delivery of this

action plan is a key strategic priority to be delivered as part of

the Trust Annual Business Plan for 2018/19.

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SMART Measures of Success (How will we know that we are achieving what we said we would do?)

Quarter 1 Quarter 2 Quarter 3 Quarter 4

CQC action plan progressing in line with timescales

CQC action plan finalised and returned to CQC in line with timescales

Core service reports provide assurance that services meet CQC’s fundamental standards or that actions are in place to address areas of poor performance


Delivery of actions to support achievement of the SMART measures of success (Have we done what we said we would?)


• Executive and

operational

leads identified

for each of the

CQCs

fundamental

standards

• Each of the

standards is

mapped against

a responsible

group and

against the most

relevant Key

Line of Enquiry.

• CQC action plan

developed and

endorsed by the

Trust Quality

Committee and

Board of

Directors

• CQC action

plan delivered

through the

working group

that has been

established

• Committees

and groups to

scrutinise each

core service

and will

familiarise key

members of

staff with the

regulatory

requirements.

• Core services

submit bi-

annual report of

performance of

service delivery

against CQC

fundamental

standards

• Committees and groups to scrutinise each core service and will familiarise key members of staff with the regulatory requirements.

• Core services

submit bi-

annual report of

performance of

service delivery

against CQC

fundamental

standards


Delivery assurance / risk mitigation

Identified Executive and operational leads will report progress and key risks to Executive Led Groups. Chairs of Executive led Groups provide assurance at the second level of assurance via the Board Committees which report to the Board at each formal Board meeting.

QIA required No

EIA required No

Business Plan Priority Sponsor


Business Plan Priority Owner/Report Lead

Gregory Hope, Associate Director of Clinical Governance

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Safeguarding Processes


Deliver

outstanding care

Achieve best

[patient outcomes

Promote research

& education

Deliver sustainable

health care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

In April 2017, two internal audits were completed, looking at both children and adult safeguarding arrangements within the Trust. In addition, the Chief Nurse and Executive responsible for Safeguarding, commissioned an external Independent Rapid Appraisal and separate independent ‘Safeguarding Service Peer Review’. The Internal Audits, Independent Rapid Appraisal and Safeguarding Service Peer Review, all identified a number of key issues whereby the Trust was found to be open to the risk of not being compliant with its statutory and contractual obligations

Taking into account the issues identified from the internal audits, external Rapid Appraisal and Peer Review, as it was found that the Trust cannot take assurance that the controls upon which the organisation relies upon to safeguard those most vulnerable to abuse are suitably designed, consistently applied or effective in their application. As a matter of priority, the recommendations from the four reviews to ensure that the Trust fully complies with the required safeguarding legislative framework and requirements was begin in 2017/18. Embedding our safeguarding processes will continue to be a Trust strategic priority for 2018/19.







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• Executive and

operational

leads identified

for each of the

CQCs

fundamental

standards

• Each of the

standards is

mapped against

a responsible

group and

against the most

relevant Key

Line of Enquiry.

• CQC action plan

developed and

endorsed by the

Trust Quality

Committee and

Board of

Directors

• Core services

submit bi-annual

report of

performance of

service delivery

against CQC

fundamental

standards

• Committees and

groups to

scrutinise each

core service and

will familiarise

key members of

staff with the

regulatory

requirements.

• Core services

submit bi-annual

report of

performance of

service delivery

against CQC

fundamental

standards


• Core services

submit bi-annual

report of

performance of

service delivery

against CQC

fundamental

standards



Identified Executive and operational leads will report progress and key risks to the Hospital Safeguarding Board which in turn reports to Quality Committee.

QIA required No

EIA required No




Amanda McDonough Associate Director for Safeguarding

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Mental Health Act Compliance


Deliver

outstanding care

Achieve best

[patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

Following an internal review, in August 2017, it was identified that Aintree University Hospital NHS Foundation Trust has no internal processes in place to meet its statutory responsibilities to patients detained under the Mental Health Act 1983 as amended by the Mental Health Act 2007 (Act). Aintree has a statutory obligation to ensure that its service users managed under the Act who are subsequently detained, are treated lawfully. The main purpose of the Act is to allow compulsory action to be taken, where necessary, to make sure that people with mental disorders get the care and treatment they need for their own health or safety, or for the protection of other people. It sets out the criteria that must be met before compulsory measures can be taken, along with protections and safeguards for patients. The Act sets out the procedures under which people can be detained in hospital for assessment and/or treatment of a mental disorder. The registration process for health and adult social care requires that any hospital using the Act to detain patients must be specifically registered to do so. In addition the Act’s Code of Practice identifies standards that providers should meet when they perform their responsibilities under the Act including arrangements to receive relevant documentation, training and other aspects relevant to demonstrating the fundamental standards of quality and safety.



• An agreed service level agreement is in place with a local delivery partner

• An approved SOP is in place and rolled out

• Suitable information and

• Key relevant staff are trained

• Collect activity data

• Monitor compliance with the agreed process


• Monitor compliance with the agreed process


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documentation folders are prepared and available for key staff reference

• Robust data on MHA activity is being collected



• Meet with Mersey Care to progress SLA

• Draft SOP and secure approval in principle with AUH/other partners prior to ELG sign off

• Prepare documentation/info folders

• Undertake

training needs

analysis and

commence

training

• Set up data

collection

process with BI

• Continue

training as/if

required

• Report on compliance and make adjustments to the process if required

• Report on compliance and make adjustments to the process if required


Delivery will be monitored at the Operations & Performance Executive Led Group on a quarterly basis.

QIA required No

EIA required No


Tristan Cope, Medical Director


Linda Matthew, Assistant to Medical Director

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Acute and Emergency Care / Patient Flow


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The Trust is reviewing and improving its urgent and emergency

care pathways and patient flow in order to deliver outstanding

care, improve patient outcomes and deliver sustainable health

care to our local population.

The programme includes the Emergency department, all

assessment areas in addition the inpatient wards. This covers

both medicine and surgical divisions. Support for the programme

includes access to diagnostics and support services from within

the Division of Diagnostics & Support Services

The aim is to use data available to determine a series of high

impact change areas. The impact of these will then be tested in

order to build the learning and permanent changes back into the

programme of work to embed and sustain improvements.

Evidence of improvement will be measured by the Key

performance indicators of AED, Assessment areas and the

SAFER Metrics including delayed transfers of care.



• Improvement in achievement of 4 hour AED waiting time standard performance

• Improvement in assessment area KPI’s

• Achievement of SAFER Metrics (Dashboard)

• Achievement of 90% 4 hour waiting time standard for AED



• Improvement in achievement of 4 hour AED waiting time standard performance



• Achievement of 95% 4 hour waiting time standard for AED





• Improving consistency of Striage assessment

• Direct

conveyancing

to Medical

assessment

• Direct

conveyancing to

Surgical

assessment

• De-escalation planning & implementation

• Evaluation of

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• Embedding effective rapid ‘Pitstop’ of patients within majors department

• Bed modelling to be completed & plan agreed

• Appointment of DDoN in Surgical & Medical Divisions

• Implementing the

SAFER patient

flow bundle

across 70% ward

areas

• Audit of PCS

completion &

agree future

model

• Specialty in

reach

timestamps

agreed &

implemented

• Winter plan

confirmed

areas

• Implementation

of bed

configuration

• Embedding

SAFER patient

flow bundle

across

remaining ward

areas

• Review of

rota’s to

maximise

workforce skills

to match

demand in

assessment

areas

• Preparation of

Winter plan

• Specialty in

reach

timestamps

embedded &

audit

completed

• Workshop with

CNS group to

support

development of

ambulatory

pathways in

specialty areas

areas

• Implementation

of Winter plan

• Action plan from Specialty in reach audit completed in line with audit findings

• Implementation of agreed pathways in specialties

winter plan system wide

• Easter plan confirmed



QIA required No

EIA required No


Beth Weston, Chief Operating Officer


Victoria Jackson, Jo Eccles, Phil Downey, Divisional Directors of Operations

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Preventing and Learning from Harm


Deliver

outstanding care

Achieve best

[patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The Trust has continually been an outlier due to poor levels of

patient safety incident reporting. This has been noted by

regulators and is seen by them as an indicator of risk. NHS

England are clear that ‘organisations that report more incidents

usually have a better and more effective safety culture. You can't

learn and improve if you don't know what the problems are’.

The Trust intends to be in the middle 50% of Trusts for incident

reporting by the end of 2018-19. This target is overseen by

Safety & Risk Executive Led Group and is being delivered

through a combination of data quality review, in partnership with

the National Reporting & Learning System, and targeted but

supportive intervention.

The majority of Trust reported incidents currently result in either

a near miss or no harm. The Trust will ensure that any increase

in the reporting of incidents is predominantly in no and low harm

incidents and that incident reporters make consistent

assessments of harm.



Trust incident reporting figures are benchmarked via six-monthly NRLS report

Trust incident reporting figures are monitored using revised Trust dashboard

Trust incident reporting figures is better aligned to those of similar Trusts. Monitored using six-monthly NRLS report

Trust target for incident reporting figures is met



• Review ‘learning from harm’ process to ensure organisational safety culture.

• Learning lessons

from incidents

and patients

• Trust target

with supporting

divisional

targets for the

financial year

are agreed

• Creation of

dedicated

dashboard for

• Trust target with

supporting

divisional

targets for the

financial year

are monitored

through Safety

& Risk ELG

• Data quality

• Trust target with supporting divisional targets for the financial year are monitored through Safety & Risk ELG

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feedback and

sharing across

organisation.

Safety & Risk

ELG

review of Trust incidents against NRLS codes



QIA required No

EIA required No




Gregory Hope, Associate Director of Clinical Governance

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Deteriorating Patient


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The deteriorating patient is a key area of activity for the

Avoidable Mortality work programme for the Trust. It comprises

3 aspects of clinical focus for 2018/19;

• Sepsis

• Pneumonia and

• The change from the current ‘MEWS’ to ‘NEWS2’

deterioration warning systems



Sepsis & Pneumonia

• Deliver the pneumonia Advancing Quality (AQ) and national sepsis care bundle requirements to 100% of patients

MEWS to NEWS

• Achieve key preparatory milestones in the Trust delivery plan

Sepsis & Pneumonia


MEWS to NEWS

• Successfully launch ‘NEWS2’

Sepsis & Pneumonia


MEWS to NEWS

• Monitor and audit the implementation of ‘NEWS2’

Sepsis & Pneumonia


MEWS to NEWS

• Monitor and audit the implementation of ‘NEWS2’



Sepsis

• Present audit

results to Sepsis

Improvement

Group (SIG)

• Intro orange

patient

wristbands

• Snr nurse

attending SIG

Sepsis

• Develop audit

tool for audit of

AB prescription

review

• Source, fill and

distribute

‘sepsis boxes’

to all clinical

areas

Sepsis o Re-submit

business case for sepsis nurse/s to HMB

o Audit review of ABs

Pneumonia

• Continue

education and

Sepsis

• Ensure sepsis module requirements are developed and communicated to the EPR team for inclusion in the new EPR

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• Recruit medical

Lead for Sepsis

in SAU

• Intro sepsis

trollies in SAU

• Repeat

comms/educatio

n initiatives

(G/Round, MD

Bulletin + Nurse

forum)

• Develop comms

plan

Pneumonia

• Continue

education and

training

• Audit against AQ

parameters

MEWS

• Finalise

documentation

• Commence

training

• Launch comms

plan

Pneumonia

• Audit AQ

parameters

MEWS

• Continue staff

training

• Develop an

audit tool

• Launch NEWS2

training

• audit against AQ

parameters

MEWS

• Embed NEWS2

• Prepare for audit

Pneumonia

• Continue

education and

training

• Audit against

AQ parameters

MEWS

• Continue staff training

• Audit use of the NEWS2 tool


Delivery of the sepsis and pneumonia work streams are monitored on a quarterly basis at the Avoidable Mortality Reduction Group and the NEWS2 rollout at CEELG; shortcomings in the delivery programme will be addressed in a timely way.

QIA required No

EIA required No




Linda Matthew Assistant to Medical Director

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Patient Experience Improving End of Life Care


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

In 2017 the CQC report identified areas of concern in relation to

end of life care provided in the Trust.

This information and the data available from the 2015

organisation report Quality Assurance for Care of the Dying:

Cheshire & Merseyside Strategic Clinical Network

(commissioned by the Cheshire and Merseyside Palliative and

End of Life Care Network (PEOLCN) and the report produced by

the Marie Curie Palliative Care Institute Liverpool (MCPCIL)) will

be used to improve end of life care in Aintree.

CODE Aintree University Hospitals NHS Foundation Trust - November.pdf



EOL Care Group has been re-established and reporting systems have been agreed

EOL Care strategy has been developed. Dashboard Development has commenced. Post Bereavement Questionnaire piloted

Draft Dashboard is being piloted at EOL meetings

EOL care strategy has been embedded Dashboard reporting is in place EOL Annual Report received by PFEG Post bereavement Questionnaire demonstrates improved family/carer experience



• Review the effectiveness of the End of Life Group and the Bereavement Group and consider merging

• Develop an

End of Life

Care Strategy

and Action Plan

to address

recommendatio

ns from reviews

• Develop an EOL care Dashboard to inform decision making at key Trust meetings.

• Review post

Production of EOL care Annual report incorporating work plan for 2019/2020

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these and expanding the Terms of Reference

• Identify organisations delivering best practice in relation to post bereavement care and establish links for future networking and Benchmarking

(CQC and

CODE)

• Develop and

test post

bereavement

questionnaire

• To introduce a

post

bereavement

questionnaire

bereavement questionnaire results at each meeting



QIA required No

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Financial Management – Managing Budgets


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

AUHFT has a projected gross financial deficit for 2018/19 of

-£32.8m, (subject to commissioner contract agreement) with a

QEP target of £6.6m, to give a net forecast deficit of -£26.2m.

Included in the position is £7.9m of new investments to ensure

our staff are supported in delivering safe and effective care to

our patients, as well as making good on a number of existing

cost pressures identified during 2017/18.

Given the scale of the deficit, AUHFT will come under increased

scrutiny financially and it is imperative that we deliver against

our financial deficit plan. The fundamental cornerstone in

achieving this is for Divisions / Departments to contain

expenditure within their allocated resources.



• Divisions / Department to manage expenditure within overall allocated resources, or provide robust evidence as to why costs have exceeded budget and that those explanations are accepted as being outside the Division/Departmental control




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• Monthly finance

meetings at

Executive to

Divisional level

and Divisional to

CBU level

• Monthly finance

meetings at

Executive to

Divisional level

and Divisional to

CBU level

• Monthly finance meetings at Executive to Divisional level and Divisional to CBU level

• Monthly finance meetings at Executive to Divisional level and Divisional to CBU level


The Director of Finance will report progress and key risks the Trust Finance and Performance Committee

QIA required No

EIA required No


Ian Jones, Director of Finance and Business Services


Paul Brannelly, Deputy Director of Finance

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Financial Management – Cost Improvements


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

Despite the increased allocations announce for Clinical

Commissioning Groups recently, local growth allocations are still

some of the lowest nationally, but with some of the highest

demand for health services resulting from high levels of

deprivation.

Income is projected at £335.1m. Expenditure budgets for the

forthcoming year total £367.9m and reflect the full year impact of

outturn to deliver current levels of demand, as well as meeting

emergent cost pressures and quality requirements identified

through 2017/18.

The Trust has a track record of delivering cost savings and

productivity improvements.

Our internal cost improvement programme over the planning

cycle cross cuts the Lord Carter efficiencies, within the broad

themes of specialty productivity (theatres, outpatients, beds);

clinical support functions, back office functions, procurement,

estate and workforce.



• Confirm Divisional QEP portfolios and CiP savings forecasts Q1

• Delivery against QEP targets Q1









• Develop QEP

portfolio and

forecasted

savings plan with

Divisional

triumvirates

• Obtain approval

of QEP Pods for

• Continue to

develop new

ideas and QEP

portfolio Pods

jointly with

Divisions

• Record and

report delivery

• Continue to

develop new

ideas and QEP

portfolio Pods

jointly with

• Divisions

• Record and

report delivery

• Continue to

develop new

ideas and QEP

portfolio Pods

jointly with

Divisions

• Record and

report delivery

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EIA/QIA and

TSG

• Record and

report delivery of

QEP portfolio to

TSG via single

‘Tracker’ for Q1

of QEP

portfolio to TSG

via single

‘Tracker’ for Q2

of QEP portfolio

to TSG via

single ‘Tracker’

for Q3

of QEP portfolio

to TSG via

single ‘Tracker’

for Q4


The Director of Finance will report progress and key risks the Trust Finance and Performance Committee

QIA required No

EIA required No




Associate Director of Transformation

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Merger Transaction


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The Outline Business case for the merger of AUHFT and RLBUHT sets out the strategic context and service realignment, which aims to improve outcomes for the North Mersey population. The OBC was approved by both Trust Boards in October 2017 and by NHSI in December 2017. The next step is for AUHFT & RLBUHT to proceed to Full Business Case for the

merger of the two organisations. The transaction timetable proposes a newly authorised Trust (earliest date subject to regulatory approval) 1st April 2019.



• PMO team will be fully resourced and external support will be in place for legal, due diligence, patient benefit case, integration / FBC support, strategic advice.

• Due diligence exercise completed.

• Interim Board process agreed.

• Patient benefits case submitted to NHSI to be reviewed.

• Pre-notification sent to CMA.

• Patient benefits case submitted to CMA to be reviewed.

• Trust Boards approve FBC & PTIP

• Interim Board appointed.

• CMA approve phase 1.

• NHSI approve FBC/PTIP and overall transaction



• PMO team & external support appointed

• Interim Board process finalised

• Undertake Due diligence exercise (conducted by external advisors)

• Patient benefit case completed

• NHSI review patient benefits case

• Complete CMA pre-notification process

• Patient benefit case submitted to CMA

• Interim Board process complete

• FBC & PTIP completed

• Day 1 Programme Plan actions complete

• CMA approve Phase 1 (or prompts Phase 2 review)

• NHSI Board to Board meeting

All delivery of actions, measures of success and timings are dependent on deliverable milestones from external support to be

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agreed with advisors once appointed in addition to regulatory approvals process (i.e. NHSI and CMA)


Transaction and Integration Programme management processes and arrangements in place including:

• Transaction Programme Steering Group and Programme Board

• Regular meetings held with NHSI to monitor progress

• Risk register in place and monitored regularly

• Regular monitoring of Programme plans and flash reporting on a monthly basis

QIA required See programme documentation.

EIA required See programme documentation.


Integration Director/Deputy CEO


Senior Programme Manager

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Service Integration


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

Aintree University Hospital NHST FT (AUHFT) and the Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) submitted their Outline Business Case to NHSI in November 2017 for the proposed merger of both organisations and the integration of services aimed at improving health outcomes for the local population through the delivery of sustainable acute health services. The successful integration of both organisations will be reliant on producing a comprehensive Full Business Case (FBC) and Post Transaction Integration Plan (PTIP) which clearly articulates the benefits to be gained from the newly combined organisation, details the future operating models for service delivery, and is supported by robust integration plans setting out the actions required to implement the new models of care and wider organisational changes. Service Integration is one of the key priorities for the Trust’s annual business plan for 2018/19 and is interdependent with the Merger Transaction business plan priority.



• Joint working opportunities identified for deep dive IPTs

• Culture survey assessment completed providing clear direction on the interventions required to support organisational development for newly merged trust

• Future service model and operating requirements completed for deep dive IPT areas

• Patient Benefits case completed for submission to NHSI for review

• PTIP and FBC finalised and agreed by both Trust Boards

• Patient Benefits Case submitted to CMA for Phase 1 review.

• Positive assessment of PTIP following independent accountant review within regulatory process

• Integration Readiness checks highlights high confidence of delivery and completion of actions against plan

• CMA approval of Patient Benefits Case following Phase 1 review

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• Facilitate workshops with Integrated Planning Teams (deep dives areas) to identify opportunities for joint working and develop future operating model for the service/ department

• Conduct a culture assessment to highlight cultural similarities and differences between both organisations and identify where targeted cultural interventions may be required to feed into integration planning.

• Understand and capture operating requirements to deliver future integrated service models for the deep dive IPTs

• Identify and quantify patient benefits and organisational synergies from integration including impact on organisational resources

• Post Transaction Integration Plan completed setting out how the new organisation will be delivered and implemented

• Day 1 and day 100 plans produced to guide and monitor implementation of integration plans

• Develop benefits realisation framework to monitor benefits from merger

• Readiness checks completed to assess readiness for service/ organisational integration in advance of day 1

• Regular monitoring and update of day 1 and day 100 integration plans and milestones set

All delivery of actions, measures of success and timings are dependent on deliverable milestones from external support to be agreed with advisors once appointed in addition to regulatory approvals process (i.e. NHSI and CMA)


Transaction and Integration Programme management processes and Governance arrangements in place including:

• Transaction Programme Steering Group and Programme Board

• Regular meetings held with NHSI to monitor progress

• Risk register in place and monitored regularly

• Regular monitoring of Programme plans and flash reporting on a monthly basis

QIA required See project documentation

EIA required See project documentation


Integration Director/Deputy CEO


Carwyn Langdown, Head of Integration

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Electronic Patient Record


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

AUH, LWH, and RLBUHT Trusts have an ambition to lead in

digital excellence, extending our portfolio of technology that will

enhance data sharing for primary and secondary use across the

Trusts and the local heath economy.

The implementation of an integrated EPR, replacing best of

breed systems will support the Trust in delivering services which

enhance patient safety, flow, clinical quality and patient access.



All EPR programme workstreams on track with milestone delivery

All EPR programme workstreams on track with milestone delivery

AUH ‘go-live’ with new EPR

New EPR is successfully delivered at AUH All operational and performance reports are available for submission



• Wave 1 design,

build and test

stage complete

• Wave 2 design

stage complete

• Wave 2 build

and test stage

complete

• AUH Wave 1 go live big bang

• RLBUHT go live big bang


The Trust Medical Director will report progress and key risks to the Trust Hospital Management Board

QIA required No

EIA required No




Dan Milman, EPR Programme Director

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EU General Data Protection Regulations


Deliver

outstanding care

Achieve best

patient outcomes

Promote research

& education

Deliver

sustainable health

care to meet

people’s needs

Provide strong

system leadership

Be a well

governed and

clinically led

organisation

Summary of proposal

The Data Protection Act 1998 will be replaced with the General Data Protection Regulation (GDPR) and will apply from May 25th 2018. The government has confirmed that the UK’s decision to leave the European Union will not affect the commencement of the GDPR. The GDPR applies to ‘controllers’ and ‘processors’. The definitions are broadly the same as under the Data Protection Act i.e. the controller says how and why personal data is processed and the processor acts on the controller’s behalf. Data and the management of information remains within legislative framework and failure to record data accurately will result in penalties for the organisation. Data Principals will cover;

• The governance of Data Quality

• The policies and procedures in place for data recording and reporting

• The systems and processes in place to secure data quality

• The knowledge, skills and capacity of staff to achieve data quality objectives; and

• The arrangements and controls in place for the use of data



Data and the management of information remains within GDPR legislative framework and new financial penalties are imposed.






• Information asset

inventory and

data flows

mapping

completed and

• Staff briefings

ongoing

• GDPR risks

reviewed

regularly

• Staff briefings

ongoing

• GDPR risks

reviewed

regularly

• Staff briefings

ongoing

• GDPR risks

reviewed

regularly

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validated

• Risk mitigation

plan developed

• Staff briefings

commenced


The Director of Finance will report progress and key risks the Trust Hospital Management Board

QIA required No

EIA required No




Sharon Brislen, Interim DPO

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1/2



Report Title Board Objectives – Q4 2017/18


Lead Officer Caroline Keating, Director Corporate Governance/ Board Secretary






Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• Majority of actions completed with those remaining being progressed in 2018/19


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other


best practice


This report closes down the Board Objectives for 2017/18. Any outstanding actions will be

progressed during 2017/18 as part of business as usual and/or monitored by appropriate

committees/groups

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2/2

REPORT HISTORY


Agenda Ref



Board Session Board Objectives

2017-18

Feb 2017 Agreed

Board of

Directors

B17-18/

056

Board Objectives Q1

2017/18

July 2017 Progress noted

Board of

Directors

B17-18/

098

Board Objectives Q2

2017/18

October 2017 Progress noted

Board of

Directors

B17-18/

141

Board Objectives Q3

2017/18

January 2018 Progress noted

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Board Objectives 2017/18 (Q4 Jan - Mar) Key – Strength of Assurance

Substantial Partial

Reasonable None

Objective Progress to date Evidence Strength of Assurance

By 31 March 2018 Q1 Q2 Q3 Q4

1. C The Board will have developed the strategy for the organisation and delivered its effective and challenging strategic aims

through effective

engagement with all

relevant internal and

external stakeholders

• OBC in progress – submission to Board deferred to

October 2017 at request of RLBUHT.

• OBC approved by both Trust Boards in October 2017

• OBC submitted to NHSI. Review deferred until mid-2018

• Chairs, CEOs and MDs to meet with NHSI to agree

importance of progressing merger case. Agreement to be

reached on working to a target of merger in April 2019.

• Agreement reached with NHSI on 1 April 2019; working

with NHSI to finalise support for Transaction &

Implementation Programme in progress

• Transaction programme structure

in place and working effectively.

• OBC submission

• Teleconferences with NHSI

• Consultancy Business Cases

completed

• Communications to stakeholders in MD bulletin and

overarching bulletin to all staff

• MD and CEO meeting with Hospital Medical Board

(Medical Staff Committee) monthly to update on strategic

and operational issues and to hear feedback from medical

staff.

• OBC Public Summary published on Trust websites and

shared with local media

• Monthly discussion at HMB maintaining engagement

• Opportunities for questions to CEO at Hospital Medical

Board

• MD bulletins continue to be

circulated monthly.

• Bulletin on Transaction &

Integration Programme progress

last circulated following OBC

approval. Public version of Exec

Summary produced

• Regular updates and

opportunities for questions at

Hospital Management Board and

Hospital Medical Board

• Governor workshop held Nov

2017 & Feb 2018 with further

sessions planned in due course

and with RLBUHT

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By 31 March 2018 Q1 Q2 Q3 Q4

• B2Bs held with RLBUHT and South Sefton CCG

• Schedule of AUH/RLBUHT B2Bs currently being collated.

Date for B2B with SSefton arranged for Q3

• B2B with RLBUHT held in Feb 2018

• B2B agendas September

(RLBUHT); July (SSefton)

• SSefton B2B scheduled for Q3

cancelled at CCG request; new

date being sought. Revised date

for SSefton cancelled by CCG.

Schedule for AUHFT/RLBUHT

B2B in place with proposed dates

to November 2018 being

explored

• Meetings with NHSI – maintained good relationships

through QRMs and transaction meetings

• Participation in telephone calls as part of winter

preparedness

• AUH taking active role in NHSI Staff Retention

programme ; AUH action plan developed, supported by

NHSI

• Monthly QRMs held

• NHSI feedback letters to Part II

Board

• AUH Staff Retention Action Plan

• Redesign and relaunch of board engagement sessions

• Board engagement programme approved for 2017-18

• Increased involvement from CEO & Divisional leadership

team in Board Conversation programme and follow-up

working lunch with the board

• Board presence at Corporate Induction

• Evaluation of Board engagement programme under

consideration

• Induction continuous improvement plan on-going, linking

with C&M streamlining programme

• Board agreed revised approach

(Away Day April 2017)

• Conversations held with all

Divisions Corporate Services with

outputs collated and taken

forward by Divisions & Board

• Chair, CEO and staff governor

presentation at Trust induction

• In response to NHS staff survey, staff engagement

programme run during April using LIA methodology to

explore reason for low staff engagement score, resulting

in Divisional Improvement Plans

• Divisional Improvement plans in place and progressing

• Sessions completed April 2017

• Divisional improvement plans to

WELG May 2017

• Additional questions to test staff

engagement score added to

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By 31 March 2018 Q1 Q2 Q3 Q4

• Questions added to Staff FFT and slight improvement in

Q2 results

• Comms plan in place and being followed pre National

Staff Survey launch Sept

• National Staff Survey closed and response rate

significantly increased to 50.1% (from 43% 2016 & 40%

2015). Approach being developed to secure further

improvement in the response rate to achieve national

average as a minimum

• Early indications of improvement and/or maintenance in

overall engagement score and key indicators

• Effective use of quarterly monitoring data to be taken

forward in 2018/19

quarterly staff FFT

• Divisional Improvement plans

and updates to WELG

• Q2 Staff FFT scores

• Comms plan

• NSS response rate confirmation

from Picker

• Freedom to Speak Up Guardian (FTSUG) role continues

to be embedded

• FTSU National Guardian visit to the Trust provided

positive feedback on work to date

• Review of FTSUG role and implementation to be taken

forward in 2018/19

• Development of FTSU dashboard

for Board – Nov 2017

• FTSUG report to the Board

submitted (Nov 2017)

• CN development of Nursing & AHP Leaders

• Development of Nursing and AHP Strategy in 2018 will

build on existing work and plans for 2018-2019

• Nursing and AHP Board chaired by CN to commence in

February , and will be accountable for setting the strategic

direction for nursing and the delivery of a Nursing and

AHP Strategy for April 2018

• Attendance at ward managers

development days as per L and

D Plan

• SNT walkabout continues –

informal coffee with CN –

opportunities for informal

engagement

• Engagement with Governors through Development

Workshop

• Merger Workshop held with Governors Nov 2017 & Feb

2018

• Governor Development Programme agreed for merger

transaction

• Board members & Integration

Director attendance at merger

workshops

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By 31 March 2018 Q1 Q2 Q3 Q4

through bringing about

change by making best use

of all resources - financial,

staffing, physical

infrastructure and

knowledge – and through

working with staff and

partner organisations to

meet the public’s and

patient’s expectations

• Nursing & AHP Reviews underway including remodelled

workforce

• Full report regarding Safe Nurse staffing will be reported

to the Board of Directors in March 2018. This will include

a detailed overview of the specialing policy and actions to

meet the needs of vulnerable and high risk patients going

forward. Completed - £1.7m invested in Nurse Staffing

• Annual Medical Staff Job Plan review process underway

• Bi annual workforce review

reported to the Board of Directors

September 2017.

• Shadow templates completed

and onto roster shortly

• Review of 1:1 patient specialling -

outcomes in the acuity

dependency report

• Guidance on consistency of

approach to job planning

circulated to divisions.

• Directorate and divisional level

job plan reviews nearly complete

• Final dates agreed for job plan

consistency panel review

meetings in April

• Board sign-off of Cases of Need

• Collaborative improvement plans with Healthwatch

agreed and monitored through the Patient Experience

ELG

• Plans to develop Patient Experience Strategy with key

stakeholders in 2018

• Scoping exercise completed January 2018 with key leads

Plan in place to launch patient experience strategy in April

2018 following extensive involvement and feedback from

key stakeholders, patients their families and staff

• Patient Experience ELG

documentation

• All services have improvement

plans in place for all areas of

patient experience.

• Enhanced reporting template

developed and in place

• Implementation of Apprentice reforms

• Apprentice levy spend confirmed for 2017/18. 85

apprenticeship starts in year – shortfall of 22 for Public

Sector Duty to roll forward into 2018/19 target

• Highest performing Trust for apprenticeship activity in the

STP

• Appointment of Apprentice lead

• Report to F&P April 2018

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By 31 March 2018 Q1 Q2 Q3 Q4

• Apprenticeship Open Days in place and promoted. Highly

successful first day with some 800 approx people

attending

• 50 Apprentices both clinical and non-clinical appointed by

end of Q3.

• £120k of Levy released to date

• 46% or Public Sector Duty achieved to date

• Contributing to changes in Safeguarding approach

through focus of Hospital Safeguarding Board reporting

through to HMB

• Full review of safeguarding completed

• SG Strategy, policies and associated work & training plan

signed off by Board January 2018.

• Safeguarding risk identified within the Board Assurance

Framework, with monthly assurance reports being

received by the QC regarding the ongoing actions to

mitigate and reduce any risk to patients

• Review and Action Plan for

Safeguarding, and external

advisory review commissioned

• Hospital Safeguarding Board

commenced, with oversight from

NED. ToR includes Designated

Nurses from CCG.

• Board sign-off January 2018

• Use of resources assessment undertaken by NHSI as

part of CQC Inspection. Informal feedback is a rating of

RI, principally due to high use of agency staff and our

financial deficit. Formal report awaited

• Data pack submitted to NHSI on

KLOEs

through exercising

leadership by

understanding opportunities

for improving services and

motivating others to bring

them about

• LCH – liaison with NHS partners, NHSI and NHSE

• AUH member of Integrated Provider Board – initial

meeting held

• Collaborative working with Merseycare as provider of

community and mental health services

• Closer working with Cheshire and Merseyside cancer

alliance and local providers to change/modify cancer

pathways

• Completion of Community tender

work and attendance at

presentations; support to Mersey

Care provided for final

submission

• Integrated Provider Board

minutes

• Regular meetings - action notes

• Regular meetings –

presentations and action notes

• Acute and emergency care transformation including Acute • Work with ECIP and specific plan

for improving emergency care

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By 31 March 2018 Q1 Q2 Q3 Q4

Frailty

• Further work on the acute and emergency care

programme progressed with delivery supported by EY

• Roll out of SAFER across wards supported by EY

• Implemented changes to the governance arrangements to

support improvements

performance

• ECIP assessments in FAU, AMU

and ED

• ECIP rating changed from red to

amber

• EY diagnostic work

• Roll out of SAFER in progress

• Updated acute and emergency

care plan

• AQUIS programme reviewed to ensure fit for future and

reduce attendance time and increase uptake

• Work completed with realignment of training to include an

integrated approach with Royal Liverpool Hospital

• Review of AQUIS approved by

HMB June 2017

• Joint Hackathon event

undertaken as part of FAB NHS

Change Week in Nov 2017

• Development of standard approach to QI methodology

through AQUIS programme to include introduction of

awareness session for all staff, and delivered in

collaboration with RLBUHT

• Support from AQUA to define outcomes for AQUIS group

in place

• Two QI teams now working

closely together across Trust to

provide support, education,

training and implementation.

• Encouraging ideas generation for QI/QEP through

innovation

• Innovation Hub project scoped and leads in place

• Group established and proposals developed and agreed

in principle

• Further work required in 2018/19 to develop the approach

to innovation

• Several initiatives funded through Dragons’ Den

• Innovation Hub funded by

Directors’ Dragons Den

• Innovation Hub proposals in

place and reporting through TSG

• TSG report Oct 2017

• Innovation Group Action notes

• Appointment of a new innovation scout, linking with the

innovation agency

• Innovation scout focussing on clinical engagement

• Marc Lucky, consultant urologist,

appointed and working as part of

Innovation Hub project team

• Plans in place for NHS Fab Change week in November • Emails circulated

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By 31 March 2018 Q1 Q2 Q3 Q4

• OD supporting

through effective oversight

of management

performance

• Update of Aintree Accreditation Framework to include

some further performance metrics

• Framework has been updated to reflect the changes in

the Health and Social Care Act and associated Regulated

Healthcare Activities. This will support an overarching

Trust wide compliance framework

• AAA report to Board

• New corporate performance report established with on-

going development following feedback received

• Corporate Performance Report

• Monthly Divisional finance reviews now in place

• Development and implementation of the Accountability &

Authority Framework

• Engagement with Divisional Leadership teams underway

re levels of authority and autonomy for inclusion in

Accountability & Authority Framework

• Built into joint Exec/G14 development programme.

Formal review of G14 programme to be taken forward in

2018/19

• Schedule of meetings with

Divisions being reviewed

• Framework and approach to

performance management to be

taken forward in 2018/19 under

the quality improvement

programme and further

development of a safety culture

2. The Board will have ensured the quality and safety of healthcare services, education, training and research delivered by

the Trust and applied the principles and standards of clinical governance

through receipt and

challenge of effective

information and follow-up to

improve assurance strength

• Positive informal feedback from interim inspection by

Health Education England North (HEEN)/Deanery for

medical trainees

• Quality Assurance Education Group established to report

to Education & Learning Group

• Positive postgraduate visit and report with removal of

enhanced monitoring

• Report and response/action delivery plan developed for

review at WELG February 2018

• Report completed for HEENW

Deanery interim visit July 2017

• Quarterly quality surveillance

report for non-medical students

submitted to HEENW June 2017

• Awarded contract to deliver

STABILISE to pre reg healthcare

students

• HEENW confirmation of

recommendation to remove

enhanced monitoring

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By 31 March 2018 Q1 Q2 Q3 Q4

• HEENW report and action plan

• Refresh of Risk Management Strategy to ensure ward to

board management of risk

• Revised RMS Policy submitted to S&R Nov

• Programme for risk management training discussed with

external provider; date for implementation to be identified

• CQC Risk Management

workstream set up to drive

actions and monitor progress

• Risk Management Strategy

submitted to Audit Oct 2017;

recommendation for Board

approval Oct 2017.

• Board approved RMS

• Update and relaunch of the Quality Strategy 2017-18

• Revised Quality Strategy under development

• Quality Strategy & Quality

Strategy Implementation Plan

• Improved outcomes across mandatory training and

appraisal

• Overall compliance remains below target

• Compliance against overall targets reduced through Q3

due to operational pressures.

• Compliance with core clinical modules compliant with

target

• Compliance against all modules

above 85%


• Deep dives at Board groups in

areas of non-compliance

• Board focus on education, training and research to be

reviewed and incorporated into Board/ Board Committee

Forward Plans as appropriate

• MD met with Associate MD R&D to discuss outline plans

for merger. Scheduling of Board session not possible.

• MD clarifying reporting requirements for 2018/19 (annual

report and quarterly updates wot CE-ELG with the AMD

for R&D

• Discussions on developing Head and Neck Institute

• R&D Strategy, Annual Report &

Forward Plan

• Board engagement programme

• Requirement identified for review of governance and

information flows between HMB and ELGs and across to

Board Committees. T&F Group reported back to HMB

Oct 2017; HMB agreed “light” next steps

• Initial findings reported to HMB

Oct 2017

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By 31 March 2018 Q1 Q2 Q3 Q4

3. The Board will have added value to the organisation by promoting its success through the direction and supervision of its

affairs

by enhancing Trust

reputation

• CQC Inspection – ‘Requires Improvement’ rating received

(see overleaf)

• CQC Inspection Reports

• Positive final report by Deloitte LLP on the Well Led

Governance Review (WLGR)

• Well Led Governance Review

final report

• 100,000 hits on social media re: helicopter test flight –

generally positive media coverage given challenging

operational pressures

• Social media coverage

• Chair/CEO representation at key regional stakeholder

events

• C&M Provider Group

• C&M 5YFV Programme Board

• NM Leadership Group

• NMLDS Hospital Programme

Board

• Sefton Leadership Collaborative

• NG chairing LHP review

• NG now interim chair of LHP

• Regular progress meetings with

KPMG and Sub-Group

• Workshop October 2017

• LHP Business Case ratified by

Board Jan 2018

• Secondment of Deputy CEO (AS) as Integration Director

for merger process

• Appointment of COO

• Completion of OBC led by AS

• NHSI response received –

meeting to be scheduled with

NHSI Jan 2018 to seek

clarification

• Discussions ongoing with NHSI

to support completion of FBC &

Patient Benefit Case

by ensuring the plan

developed to achieve

‘outstanding’ at the next

• Planned preparation for inspection including series of

deep dives, mock inspections and self-assessments; 1:1

mock interviews/briefings with Board members and senior

• Reports / updates to Board June

– September 2017

• Discussion at Board Away Days

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By 31 March 2018 Q1 Q2 Q3 Q4

CQC inspection is realised

and includes acting on

patient feedback

managers

• CQC Inspection commenced 031017

• CQC Inspection – ‘Requires Improvement’ rating

received. Action plan developed and submitted to CQC

by required deadline. Work being taken forward in

2018/19 to address deficiencies

July & October 2017

• Board Briefing Pack

• CQC Well Led Self-Assessment

• Capacity in place to manage the process • Senior manager post Compliance

& Assurance; individual now in

post from Sept 2017

• Interim CQC Manager

• Local improvement plans linked to service delivery and

across all corporate objectives

• Local Improvement plans in place

and in progress

• Annual Report on patient experience, incorporating all

relevant areas including learning from incidents,

complaints etc to be submitted to Quality Committee and

Board in October 2017 (deferred) – following further

consideration, Patient Experience Strategy to be

developed for approval by the Board in April 2018

• QC & Board Forward Plan

• AQUIS - course reviewed to reduce attendance time and

increase uptake

• Quality improvement functionality merged with Royal

Liverpool

• Training continues. QUEST team developed to provide

intensive support to wards and departments

• AQUIS leadership development

programme

• AAA Framework - reviewed and enhanced with additional

areas incorporated

• Aintree Assurance &

Accreditation Framework

4. The Board will have provided proactive leadership within a framework of prudent and effective controls, enabling risk to

be assessed and managed

through using Well Led

Governance Review

• Action plan refined to identify relevant Board committee

for monitoring progress of individual actions

• Well Led Governance Review

Action Plan approved by Board

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By 31 March 2018 Q1 Q2 Q3 Q4

(WLGR) outcomes and

driving forward

improvements

• Executive Team agreed updates for July Board

submission

• 1 action (Governor induction programme) taken off

quarterly monitoring as already in Governor business as

usual

• Actions completed or taken forward as business as usual

into Forward Plans of appropriate committees/groups.

Board to sign of action plan as complete in April 2018

May 2017; progress evidenced

by quarterly report

• Actioned

• Final WLGR Action Plan – April

2018 Board

through demonstrating

proactive compliance with

Provider Licence & CQC

Registration where

appropriate

• Compliance with Provider Licence part of business as

usual (Corporate Governance)

• Responsibility for confirming compliance with CQC

registration (statement of purpose) with Corporate

Governance. New compliance post within Clinical

Governance; divisional self-assessments undertaken

• Programme of assurance to Board identified by Chief

Nurse with dates identified within Board Forward Plan

• Board paper on Provider Licence

compliance May 2017

• Submissions to NHSI re self-

assessment May 2017

• Board Forward Plan

• Cf CQC preparation (Item 3

above)

through ensuring the Board

committees deliver their role

in providing scrutiny and

assurance

• Evaluation of Board Committees’ effectiveness in Q4

2016/17 fed into revised ToR where applicable

• Revised ways of working between Committees at forward

plan/agenda setting in place

• Effective Chairing – training undertaken by Chair of

Quality Committee and Medical Director July 2017

• Corporate Governance

Framework Manual submitted to

Audit and Board July 2017

• Review of Cyber security

• October Audit Committee outcome of deep dive

concluded in conjunction with Internal Audit report

• IA to review cyber security as part of 2018/19 plan. Audit

Committee to review progress in October 2018

• Two detailed audits undertaken

with deep dive at Audit

Committee Oct 2017

• IA Plan for 2018/19 and

Committee Forward Plan

5. The Board will set and maintain the organisation’s vision, values and standards of conduct, whilst ensuring its obligations

to members, patients and other stakeholders are understood and met.

through promoting the

Trust’s vision, values and

standards of conduct to

• Implementation of Leadership & Management

Development programmes following Board review in May

2017

• Team leadership development in

place for G14

• Executive Development

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By 31 March 2018 Q1 Q2 Q3 Q4

ensure a common and

consistent approach

• Review of facilitation for G14 has been undertaken. It has

been agreed that changes in facilitation will be

implemented in 2018/19

Programme extended

• Corporate Team rollout underway

• Stable G14; all leadership posts appointed • 1 vacant post (DDO Medicine); to

be appointed April 2018

• Core management skills programme (CMSP) tested with

roll out from September 2017

• CMSP rolled out and part of core education offering

• Positive evaluation received; further development work in

conjunction with MD and CN in 2018/19

• CMSP programme and

prospectus confirmed

• Rollout commenced

• Plans in place for CD core management skills programme

• Plans progressing to commissioning stage

• Offered initial leadership awareness for CDs in Feb 2018

• Proposal from NHS Staff College received; programme to

be delivered between July – Sept 2018

• Scope developed and subject to

consultation

• CD/DMD development; 2

‘Insights’ days delivered in Feb

18

• Clinical leadership development

days in planning for September

18

• Exec attendance at regional and local collaborative

groups e.g. Nursing, Finance etc

• COO attendance at NHSI North

COO Network

• DPACA Joint chair Regional SPF

• NMersey Leadership Groups &

Regional Finance Groups (IJ)

• CN attendance at Regional

Directors of Nursing Group with

NHSE

• Regular participation in system-

wide telephone calls for winter

preparedness

• MD attendance at the NM

Hospital Reconfiguration Group

and LWAB

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By 31 March 2018 Q1 Q2 Q3 Q4

• Revised Board Conversation revised format received

positively

• All Divisions now met with the Board in 2017/18 –

feedback suggests that Conversations have been

generally well received

• 3 additional visits / shadowing set up and undertaken by 3

NEDs

• Evaluations from Board

conversations

• Strategic vision, values and objectives reinforced at all

opportunities

• Used as appropriate in all

communications / reports

• Displayed throughout the Trust

(strategic pyramid)

• Reinforced at Trust Induction

monthly

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1/2



Report Title Well Led Governance Review – Action Plan Q4 2017/18


Lead Officer Caroline Keating, Director Corporate Governance/ Board Secretary

Action Required To approve





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• Majority of actions completed with some being carried forward into 2018/19


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other


best practice


This report closes down the actions arising from the Well-Led Governance Review with any

remaining actions outstanding to be progressed as part of business as usual during 2018/19 and/or

monitored by appropriate committees/groups

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2/2

REPORT HISTORY


Agenda Ref



Board of

Directors

BP17-18/

007

Well Led Governance

Review

26 April 2017 Report noted. Action

plan to be populated and

submitted to Board in

May 2017

Board of

Directors

B17-18/

036

Well Led Governance

Review – Action Plan

24 May 2017 Action Plan approved

Quarterly updates to be

provided

Board of

Directors

B17-18/

055

Well Led- Governance


Q1 2017/18

26 July 2017 Action Plan linked to

forward plans of Board

Committees

Noted

Board of

Directors

B17-18/

099



Q2 2017/18

25 October

2017

Noted

Board of

Directors

B17-18/

140



Q3 2017/18

31 January

2018

Noted

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WLGR Recommendations Action Plan Q4: Board of Directors 25 April 2018 1

Well Led Governance Review – Action Plan 2017-18

Rec Ref Recommendation AUH Response/Action Lead Due Date Progress Board/

Committee/

Group

Strategy & Planning Q1 Q2 Q3 Q4

1 1A All enabling strategies need to include

SMART objectives, with aligned KPIs

and annual implementation plans to aid

ease of tracking.

Enabling strategies to be confirmed (cf Strategies on a

Page document approved by the Board) with Exec

Leads to ensure compliance with recommendations

Update:

Q1 - refresh to be undertaken on People & OD

Strategy (see Q4 update below) and IM&T

Implementation Plan (excluding EPR).

Q2 - Risk Management Strategy revised and submitted

to Audit in October. E&D Policy to be submitted to

HMB/Board in October. Estates Strategy to be taken

forward under merger umbrella

Q3 – Risk Management Strategy approved by the

Board in October. E&D Policy and Workforce Race

Equality Standard return approved by Board in October

Q4 – Key strategies (e.g. Quality, People & OD)

requiring refresh identified for submission to Board for

approval in Q2 2018/19 (on Forward Plan)

SW July 2017

Sept 2017

Oct/Nov

2017

July 2018

Board

2 1B Confirm Board member understanding

of the Risk Appetite Statement and

ensure its on-going use when setting

target scores for all corporate and

strategic risks.

To be taken forward as part of the risk management

workstream within the CQC Improvement Plan with

potential inclusion in Board Development Programme

2017

DB/CK June 2017 Board

Update:

Q1- Proposal following review of Risk Management

Strategy (RMS) and impact on risk management

processes to be submitted to Board Away Day October

2017

Q2 – revised RMS to include risk appetite statement.

Board to discuss risk appetite at its Away Day in

October.

Oct 2017

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Committee/

Group

Capability & Culture

Q3 – Risk appetite statement reviewed and approved

at Away Day in October 2017

Q4 – Risk appetite discussions identified on Board

Schedule 2018/19

3 1B Review the roles and responsibilities of

the divisional governance leads to

ensure sufficient capacity to undertake

their role.

To be taken forward as part of the risk management

workstream within the CQC Improvement Plan

Update: as above

Q3 – Discussions underway with Divisions to align

corporate and divisional governance teams. Plan to be

implemented.

Proposal on revised approach to serious incident

investigations and learning to be submitted to HMB

Feb 2018

Q4 – Dashboard developed to provide overview of

Divisional assurance. Current discussions and

agreement in principle to trial a 6/12 month period of a

combined/merged Quality Governance Team

DB July 2017

Oct 2017

March 2018

QC

4 1B Reconfirm the process for monitoring

Quality, Efficiency and Productivity

schemes for their impact on quality post

implementation and assign KPIs to QIAs

to aid tracking.

Current process to be reviewed and aligned with QEP

Project Delivery SOP and revised process developed;

full implementation by end Q3

Update:

Q1 - Deep Dive at F&P June

Q2 – on-going monitoring at F&P following deep dive

Q3 – analysis of impact monitored via TSG/QIA

process. Optimal impact discussed at senior team

meetings and escalated to OPELG if necessary

Q4 – Deep dives established in Board Committees

Action closed

BW June 2017

F&P/

OPELG

5 2A Build on the outcomes of the March

2017 feedback workshop and ensure Included within the Board Development Programme

(agreed at June Board Session). Action closed

NG June 2017 Board

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Committee/

Group

Capability & Culture (cont’d) Q1 Q2 Q3 Q4

continued focus on the roles of BMs and

the development of the Board and

Executive team. Also encourage self-

reflection and peer feedback to further

enhance Board cohesion and

effectiveness

SW to confirm next steps re Exec Team development

following final session in June 2017.

Update:

Q1 - extension to Exec Development agreed

Q2 – initial meeting held July; next meeting Nov.

Exec/G14 development session also Nov.

Q3 – Exec and Exec/G14 sessions held November;

future dates to be scheduled. Discussions

commenced with Deloitte re Feb Board Session

Q4 – Deloitte commissioned initially to facilitate a

session on Board relationships. Work refocussed onto

the Board assurance role following discussions on

CQC inspection outcomes and being taken forward in

2018/19. Executive Team development on-going with

external facilitator and interim informal sessions

SW June 2017

Nov 2017

Execs/

HMB

6 2A The Board should reflect on the range of

staff engagement activities and take

forward the actions discussed in the

March 2017 workshop. The impact of

these should be reviewed at defined

intervals.

Following discussions at April Board Away Day, Board

Engagement Programme to be refined and evaluation

mechanisms put in place, including feedback loops

Update:

Q1 – Board Engagement Programme agreed

Q2 - Working lunches Board/Divisions put in place to

take forward actions from Board Conversations. Early

feedback from Divisions is positive

Q3 – Working lunches continuing following Board

Conversations. Board to review its engagement

programme

Q4 – Board refocussing on staff engagement

holistically following discussions on Staff Survey

outcomes and CQC improvement plan. Approach

being developed and taken forward in 2018/19; board

engagement programme to evolve under the

overarching approach

NG June 2017

Dec 2017

Board

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Committee/

Group

Capability & Culture (cont’d)

7 2B In designing the 2016 Staff Survey

action plan, the Board needs to consider

how it will respond to feedback relating

the Trust’s focus on quality of care

(while also acknowledging the financial

position of the Trust).

To be decided following discussions at May Board

meeting.

Update:

Q1 – feedback to staff on quality matters to be

considered as part of Staff Survey Improvement

See 6/2A Q4 comment above

SG May 2017

QC

Remit for initial Crowdsourcing confirmed. Feasibility

of joint working with RLBUH and Clever Together

confirmed

Q2 – above being progressed

Q3 – Divisional Improvement Plans and Board

Conversations focussed on patient care as top priority.

Progress good against improvement plans

Early indications no material deterioration in 2017

survey

Q4 – see 6/2A Q4 comment above

SW

SG

July 2017

8 2B Fully respond to the internal audit review

of equality and diversity and ensure that

changes are embedded in practice.

Internal Audit scheduled for October 2017 with report

to Audit Committee in January 2018. E&D Training for

Board to be included in Board Development

Programme (cf Item 5 above)

Update:

Q2 - Equality and Diversity Sub Group re-established

and ToR approved by HMB. E&D Policy approved by

HMB. Annual Report and WRES action plan to be

submitted to Board Oct.

Q3 – Follow up Audit undertaken by RSM and opinion

moved from “no assurance” to “reasonable assurance”

Q4 – Gender Pay Gap statement published end March

2018, following Board discussion and approval. Action

plan in place and being taken forward in 2018/19

SG Jan 2018 Board

Audit

QC

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Committee/

Group


9 2B Further advertise the mechanisms for

staff to raise concerns and ensure that

themes and feedback regarding actions

taken are tracked and communicated

Trust-wide.

To review full approach to Speak Out Safely in

collaboration with FTSUG at HMB July

Update:

Q1 - alternative HMB date required

Q2 – as above

Q3 - Speak out Safely process (as distinct from

FTSUG) approved and implemented.

Communication of actions Trust wide not taken forward

directly

Q4 – Speak Out Safely Policy approved; focussed

engagement required in 2018/19 under the quality

improvement banner

SG/SW July 2017 QC

10 2C Consider the introduction of quality

performance information boards to

departments and support functions.

Development of dashboards in Divisions/ Corporate

Services to be taken forward by individual Execs, co-

ordinated by DB. Scoping

exercise to be completed July 2017; further

timescales to be determined subsequently

Update:

Q1 - work underway to develop quality dashboard.

Draft to be submitted to QC Oct 2017

Q2 – QC discussions Oct 2017 re enhancing quality

items within evolving corporate performance report.

Divisional dashboard under construction to link into

change in reporting from divisions to ELGs.

Q3 – Planning meeting held in December to identify

current reporting mechanisms and forward plans

including monitoring of CQC standards. Proposals to

be submitted to QC Jan 2018

Q4 – Action complete. Divisional dashboards

developed. Trial of enhanced and improved reporting

templates through ELG. Proposal re: compliance

framework presented and agreed at HMB and Quality

DB June 2017

Oct 2017

Nov/Dec

2017

QC

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Committee/

Group


Committee

11 2C RCA investigations should be

undertaken by staff who have been

trained in this methodology, with

sufficient staff trained so that operational

duties are not impacted upon. Duty of

Candour training should also be

provided where appropriate.

Work to be taken forward under CQC Improvement

Plan:

• SI Process Review (external) underway – report

expected July 2017; further timescales to be

determined subsequently. To inform overarching

improvement plan in due course

Update:

Q1 - external reviews completed. Work to be taken

forward under the Risk Management Workstream and

linked with the review of risk management processes

(cf Pt 2)

Q2 – Plan under discussion on how to improve

systems and processes, including addressing

challenge of releasing staff from operational duties.

Duty of Candour policy updated and approved.

Training programme being taken forward for Duty of

Candour

Q3 - Duty of candour process embedded; to be audited

Q1 2018/19. Robust systems and processes in place

to monitor compliance

Q4 – Proposal submitted and supported through Case

of Need process - £100k investment to enhance

process. Additional training offered through Corporate

Risk department including Duty of Candour. DofC

policy process amended. Further RSM audit planned

for 2018 to provide assurance on implementation

DB June 2017

Nov 2017

QC

12 2C Ensure Divisional and service oversight

of key governance reports with actions

owned and embedded at a local level.

Review current processes and systems and ensure

respective teams identify areas for improvement and

lead on implementation

Update:

DB/CK June 2017

Oct 2017

HMB

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Committee/

Group


Q1 - T&F Group being set up to review and report back

to HMB October. Draft Divisional Assurance Reports

agreed with Divisions; to be submitted to S&R ELG

August 2017

Q2 – Divisional Assurance Framework being

implemented. HMB Governance Review Report from

T&F Group submitted to HMB Oct. Revised reporting

template from ELG to HMB agreed

Q3 – Embedding of use of reporting template ongoing.

Overarching report from HMB on ELG updates to be

submitted to QC in January 2018 (Q4)

Q4 – HMB assurance report submitted to QC – report

includes key points from ELGs. Enhanced reports and

Chairs reports reviewed and updated. Further work

required in relation to BI and Board sub-group

reporting

Nov 2017

Process and structures Q1 Q2 Q3 Q4

13 3A To improve the effectiveness of the

Quality Committee, the Board should:

• review its terms of reference and

work plan to ensure that all aspects

of good practice are covered;

• ensure appropriate representation

for all agenda items;

• increase the rigour of chairing to

ensure that debate is summarised,

actions are captured, and that the

agenda moves at appropriate pace;

• encourage contributions to focus on

Work underway to address these points following

discussions between MW, DB, TC &

CK

Chairing and challenge to be included within the Board

Development Programme 2017/18 (to be agreed June

2017)

Update:

Q1 - ToR and forward plan amended and updated.

New chair focussed on points raised. Report format

supports identification of assurance and assurance

strength

Minutes evidence timelines setting.

NHS Providers course on effective chairing July 2017

offered to Board members; some uptake

DB/CK

June 2017 QC

Board

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Committee/

Group

Process and structures (cont’d)

assurance seeking, rather than

matters of operational detail; and

set appropriate timelines when

agreeing actions.

Q2 – outcomes from HMB governance review agreed

with new overarching assurance report from HMB to

Board committees.

Recommendation complete and now closed. To be

reviewed as part of QC Effectiveness & Evaluation

Review March 2018

Action closed

14 3A To further improve its performance, the

F&P Committee should: • increase the capture and clarity of

actions arising from debate;

• introduce more structure to divisional

deep dives to ensure that all relevant

aspects of divisional business are

covered;

• ensure that contributions from all

members focuses sufficiently on action

planning and future performance

(rather than a retrospective focus); and

• ensure sufficient time is spent on all

aspects of the CPR, including

workforce matters.

Proposal, agreed by chairs of Quality and F&P

Committees, to have joint forward plan discussions to

improve focus on relevant risk areas and reduce

potential duplication.

Action closed

IJ/CK June 2017

F&P

Board

Update:

Q1 - MW/JC held initial meeting; next meeting re

forward planning scheduled for Dec.

Implementation of quarterly Divisional F&P reviews

under consideration, aligned with the development and

implementation of the Accountability & Authority

Framework

Q2 – Divisional finance meetings established.

Programme for Q2 Review being scheduled

Q3 – F&P planning session in December highlighted

areas for forward planning with specific focus on EPR

implementation, theatres, EAC and presentations

using GIRFT information

Finance divisional meetings in place with wider Exec

Team involvement

Q4 – process embedded; action closed

Dec 2017

Sept 2017

Nov 2017

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Committee/

Group


15 3A Re-clarify the purpose of HMB with all

staff. As part of this process, agree how

debate and decisions made at HMB will

Workshop scheduled for June 2017 to include review

of ELGs and assurance through to Board Committees.

Action closed

SW/CK June 2017 HMB

be cascaded through teams into the

organisation.

Update:

Q1 - workshop held – outputs to be fed into the

Governance T&F Group (cf Rec 12 above) with

proposals due back Oct 2017

Q2 - HMB purpose re-established. HMB agreed

revised report to HMB from ELGs.

Q3 – overarching report from HMB on ELG updates to

be submitted to QC in January 2018

Q4 – HMB assurance report submitted to QC – report

includes key points from ELGs. Effectiveness review

undertaken with outcomes to be taken forward in

2018/19

CK/DB Oct 2017

Nov 2017

HMB

16 3A Review the terms of reference for each

of the executive-led groups to ensure

appropriate membership, duties and

purpose.

To be incorporated into HMB Workshop June 2017

Update:

Q1 - cf Rec 10 & 15 above

Q2 – outcomes of HMB Governance Review identified

further work to be undertaken re ELGs.

Q3 – Revised reporting template and guidelines issued

and used at ELGs. Further work required on

embedding

Q4 – effectiveness reviews undertaken by all ELGs.

Outputs to be taken forward in 2018/19 and addressed

as part of on-going governance review

BW/DB/

SG

July 2017

Oct 2017

Nov/Dec

2017

HMB

17 3A As per its work plan, the FPC should

assure itself (at least annually) of the

governance arrangements in place

Work to be taken forward in conjunction with

Procurement and with RLBUHT, as part of the Board

Governance Working Group. Plan of action and

IJ/CK June 2017

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Committee/

Group


around all of the Trust’s partnerships,

joint working arrangements and shared

services. The development of a central

register would support tracking of these

arrangements and activity

timescales to be agreed by June 2017.

Update:

Q1 - exact remit to be finalised and capacity to be

identified (meeting with PMO 190717)

Q2 – Internal Audit started Oct 2017. Due to report to

Audit Jan 2018

Q3 – further work required on contract database. Audit

deferred to April 2018. AC informed in January 2018

Q4 – internal audit completed; action plan being

developed, partly in conjunction with RLBUHT.

Expected completion date Q2 2018/19

Jan 2018

July 2017

2018/19

FPC

18 3B More clearly define the model for

performance management and

accountability between the Executive

Team and divisions. This should

outline levels of autonomy based on

clearly defined thresholds and be

included as a separate detailed section

in the existing Assurance and Escalation

Framework. Undertake training on this

as part of the G14 and broader

leadership programme.

To be taken forward following HMB discussions with

proposal developed by September 2017.

Update:

Q1 - Execs to discuss prior to wider discussion at HMB

September 2017. Implementation using LiA under

consideration, supported by on-going coaching /

mentoring and link to G14 development programme

and individual appraisals/JDs

Q2 - Accountability and Authority framework under

development following review of governance structures

Q3 - Engagement with Divisional Leadership teams

underway re levels of authority and autonomy for

inclusion in Framework. Built into joint Exec/G14

development programme

Q4 – framework and approach to performance

management to be taken forward in 2018/19 under the

quality improvement programme and further

development of a safety culture

BW/SG/

RH

Sept 2017

Nov 2017

2018/19

HMB

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Committee/

Group


19 3B The QC should receive, at least

quarterly, a clinical audit tracker which

highlights adverse findings and

outstanding actions. Action plans and

details of re-audit should then be

reported more clearly by exception from

the Clinical Effectiveness Group, with

regular monitoring at divisional

governance meetings

TC to outline proposed process, linking with internal

audit (RSM) in 2017/18.

Update:

Q1 - schedule of submission of Clinical Audit Plan and

subsequent quarterly progress reports agreed and

identified on QC Forward Plan

Q2 – Audit Committee to discuss Oct 2017 scope of

deep dive into clinical audit Jan 2018

Q3 – deep dive in clinical audit highlighted the lack of

reporting above CEELG on activity. RSM to review as

part of Phase 2 audit work April 2018

Q4 – Report of Internal Audit report on Phase 2

awaited

TC October

2017

QC

20 3C Continue to supplement the governor

induction programme with a range of

ongoing training at periodic intervals to

provide greater clarity on the NHS

context aligned to Governor

requirements.

Board agreed July 2017 to take this recommendation

off quarterly monitoring.

Measurement Q1 Q2 Q3 Q4

21

4A

Introduce a balanced scorecard which

includes finance, quality, workforce and

operations at the start of the CPR and

refresh the dashboards to include: a

broader range of benchmarking

information, full RAG ratings, and

trajectories where possible. Supporting

information and actions should be

limited to underperforming or

Incorporated in revised CPR, submitted to May 2017

Board. Feedback to be sought from Board members

and others by end June

IJ

All

May 2017

June 2017

F&P

Update:

Q1- feedback received and comments to date

incorporated. Further iterations required.

Next steps tbc

Q2 - document evolving with further iterations

IJ Dec 2017

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Committee/

Group

Measurement (cont’d)

deteriorating metrics. expected. Balanced score card still in development

Q3 – consideration to be given in Q4 to reviewing the

CPR for 2018/19 to ensure continued FFP and

inclusion of balanced score card

Q4 – CPR format reviewed and confirmed as FFP

although constant evolution of the report is necessary.

Other complementary reports (e.g. quality dashboard)

being explored for QC in 2018/19

22 4A Supplement the workforce data received

in the CPR or introduce quarterly

reporting to the Board on key workforce

matters, including: • a greater range of workforce

information (including employee

relations, raising concerns, training,

establishment, vacancies, turnover);

• financial aspects, including pay and

agency spend;

• themes from exit interviews; and

• staff engagement activities and

impact.

Some elements incorporated in revised CPR;

incorporation of others to be assessed for applicability

or availability.

Update:

Q1 - not all information identified yet included in the

revised CPR; quarterly reporting on hold; raising

concerns will be incorporated in the Quality dashboard

Q2 - Information appropriate to the CPR now included.

Remaining areas (staff engagement, employee

relations, raising concerns and exit interview themes)

reported through alternative mechanisms e.g.

reportable issues alerts, FTSUG reports to Board,

WELG assurance reports, annual plan priorities etc)

Recommendation complete – item to be closed

Q4 – item re-opened in light of Staff Survey outcomes

and recognition by Board that staff engagement (pulse

check) remains an area under-reported. Action to be

taken forward into Board Forward Plan

SG

May 2017

June 2017

QC

Board

23 4B Introduce source and data quality kite-

marks for all reported KPIs. IJ to consider requirement and timescales, as

appropriate

Update:

Q1 - inclusion of assurance strengths within revised

IJ Sept 2017

Audit

F&P

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Committee/

Group

CPR to be considered

Q2 – inclusion of data assurance strengths to be taken

forward

Q3 – still outstanding – to be taken forward as part of

CPR review in Q4

Q4 – overarching statement on data quality included

on CPR cover sheet

Nov 2017

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1/4



Report Title Modern Slavery Act 2015 – Update to Statement

Executive Lead Caroline Keating, Director Corporate Governance / Board Secretary

Lead Officer Sharon Brislen, Head of Corporate Governance

Action Required Approval





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• The statement has been updated to take account of the steps taken by the Trust to ensure that

slavery and human trafficking is not taking place in any part of its business or its supply chains


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other



Once approved, the statement will be placed on the Trust’s website

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2/4

REPORT HISTORY


Agenda Ref



Board B16-17/

017

Modern Slavery Act

2015

27 April 2016 Requirement to publish

Trust response to

Modern Slavery Act

2015

Statement approved

Board Modern Slavery Act

2015

26 April 2017 Update to initial

statement

Statement approved

Board Modern Slavery Act

2015

17 April 2018 Annual update

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Modern Slavery Act 2015 – Update to Statement: Board of Directors 25 April 2018 3/4

Modern Slavery Act 2015 – Update to Statement

Executive Summary

1. All commercial organisations, including all NHS Trusts, carrying on business in the UK with

turnover of £36m or more are, from October 2015, required to complete a slavery and

human trafficking statement for each financial year.

2. The Modern Slavery Act consolidates offences relating to trafficking and slavery (both in

the UK and overseas). It includes a provision for large organisations to publicly state each

year the actions they are taking to ensure their supply chains are slavery free.

3. The ‘slavery and human trafficking statement’ has been updated to reflect the steps being

taken by the Trust during the financial year to ensure that slavery and human trafficking is

not taking place in any part of its business or its supply chains


4. In April 2016, the Board approved the slavery and human trafficking statement of

compliance. The statement must be formally approved by the organisation, and must be

published on its website. Failure to do so may lead to enforcement proceedings being

taken by the Secretary of State by way of civil proceedings in the High Court.

5. The statement has been updated to take account of the progress made by the Trust in

regard to any part of its business or supply chains using the Supplier Code of Conduct

which Procurement issued to the Trust’s key suppliers.

6. A copy of the statement of compliance is attached for consideration and approval by the

Board.

Recommendation

7. The Board of Directors is asked to onsider the statement of compliance and approve the

statement being published on the Trust’s website.


Further information on Modern Day Slavery can be found by visiting: https://modernslavery.co.uk/

Author: Caroline Keating, Director Corporate Governance / Board Secretary

Date: 16 April 2018

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Modern Slavery Act 2015 – Update to Statement: Board of Directors 25 April 2018 4/4

Modern Slavery Act 2015

Statement

Aintree University Hospital's response to the requirements of the Modern Slavery Act 2015

Aintree University Hospital in Liverpool provides general acute services to a population of 330,000

in North Liverpool, South Sefton and Kirkby and specialist services to 1.5 million across the North

West and North Wales.

All staff at Aintree University Hospital, be they in clinical or non-clinical roles, have a responsibility

to consider issues regarding modern slavery, and incorporate their understanding of these issues

into their day to day practice. Front line NHS staff are well placed to be able to identify and report

any concerns they may have about individual patients who present for treatment. Modern slavery

is part of the safeguarding agenda for children and adults and embedded in training and Policy.

The Trust is fully aware of the responsibilities towards patients, employees and the local

community and as such, we have a strict set of ethical values that we use as guidance with regard

to our commercial activities. We therefore expect that all suppliers to the Trust adhere to the same

ethical principles.

In compliance with the consolidation of offences relating to trafficking and slavery within the

Modern Slavery Act 2015, the Trust works to current NHS supply chain ethos and code of conduct

which encompass the Laws and Ethical standards when transacting with or on behalf of the NHS

Any breach of the obligations stipulated in this Supplier Code of Conduct is considered a material

breach of contract by the supplier.

The Trust will continue to manage and monitor its transactions using the guidance of NHSSC, the

standard terms and conditions and PQQ documentation and updates / press releases to ensure

overall compliance.

More information on Modern Day Slavery can be found by visiting: https://modernslavery.co.uk/

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1/23



Report Title Board Committees Evaluation 2017/18


Lead Officer Caroline Keating, Director Corporate Governance

Action Required Review the Report and Approve the Terms of Reference





Acceptable

assurance

General confidence


mechanisms/

objectives

Partial assurance

Some confidence in


mechanisms /

objectives

No

assurance

No

confidence

in delivery


• Each of the Board Committees undertook their annual evaluation with good responses and

comments received on the questionnaire

• Areas of focus for 2018/19 have been identified by each Committee to improve their performance

and effectiveness going forward

• Each of the terms of reference has been reviewed and proposed changes highlighted in

Appendix 1.


• Quality

• Finance

• Workforce

• Equality

• Risk

• Compliance

• Legal














• Key Risk

• Service Change

• Other


Good practice


The approved terms of reference will be incorporated into the Corporate Governance Framework

Manual 2018/19 which is to be submitted to the Board in May 2018 for approval.

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2/23

REPORT HISTORY


Agenda Ref



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Board Committee Evaluation 2017/18: Board of Directors 25 April 2018 3/23

Board Committee Evaluation 2017/18

Executive Summary

1. Each of the Board Committees has undertaken an annual review of its effectiveness and

performance. The output from the evaluation and improvements required for next year

have been agreed and incorporated within the Forward Plans for 2018/19.

2. The terms of reference of each of the Committees have also been reviewed with some

suggested changes highlighted in Appendix 1. The Board is being asked to approve the

revised terms of reference.

Background

3. The Trust needs to be confident that effective corporate governance arrangements are in

place to meet the requirements of the Board and also to comply with NHS Improvement’s

(Monitor) NHS Foundation Trust Code of Governance.

4. Best practice requires decision-making committees and groups to have robust terms of

reference and provide assurance that the duties identified within this are being

appropriately carried out. This will be achieved through :

• self-assessments of Committee/Group performance against the identified remit and any

performance measures

• annual consideration of the terms of reference (including its purpose and role) to ensure

they remain relevant and up to date, and any changes recommended

• identification of items for consideration for the following year.

5. The self-assessment process undertaken by the Board Committees is clarified in this report.


Structure of the Review

6. The Board Committee review process was co-ordinated by the Corporate Governance

Manager, in conjunction with the Chair and Lead Officer of each Committee. A desk top

review was also undertaken by the Corporate Governance Manager for each Committee.

7. The views of members and attendees of each Committee were sought through completion

of the evaluation questionnaire submitted to the Corporate Governance Manager.

Responses were collated to identify the degree of agreement against each question.

Committee members and attendees were given the opportunity to provide supporting

comments which were summarised in the reports submitted to each Committee. The

questionnaire/survey also included provision to identify three activities that could be

undertaken to improve Committee effectiveness going forward.

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Terms of Reference

8. To support the consideration of the Terms of Reference, the desk top review detailed the

documentation received by each Committee from April 2017 to February 2018. This

enabled all to understand whether the items received were relevant to the purpose and role

of the Committee concerned or whether it should be recommended that these areas of

business should not be received in future and the Terms of Reference amended

accordingly. The agreed Terms of Reference are provided in Appendix 1 with the

amendments identified in red for ease of reference.

Outcome of Board Committee Evaluations

Audit Committee

9. As the Audit Committee only meets on a quarterly basis and due to the timing of the

reporting of the evaluation exercise to the Board, it was agreed to undertake the evaluation

virtually. All Committee members and attendees received a copy of the full report in March

2017 and the revised terms of reference were agreed by email. Formal ratification of the

output from the evaluation will be undertaken by the Audit Committee at its meeting on 27

April 2018.

10. There were 10 Committee members and attendees out of 10 (100%) who responded to the

questionnaire.

11. Overall, the results were positive with a good balance of skills and experience on the

committee as well as their being appropriate challenge and debate. There were several

comments on the inconsistency in the quality of reports and the robustness of evidence to

support the level of assurance. The areas of focus for 2017/18 in respect of Cyber Security

and Clinical Audit were undertaken through deep dives during the year and good assurance

was provided on the systems and processes in place. The third focus on Serious and other

Incident Reporting is to be carried forward into 2018/19.

12. The Committee agreed to discuss its main areas of focus for 2018/19 at its meeting on 27

April 2018 and the Chairman of the Committee has proposed the following three priorities:

• Cyber Security – another deep dive at the right time.

• General Data Protection Rules – a deep dive when the systems are in place.

• Systems around serious and other incident reporting and the Losses and

Compensations Report – approach to be discussed.

13. Only minor changes are being proposed to the terms of reference.

Quality

14. There were 9 Committee members out of 11 (82%) who responded to the questionnaire.

15. Overall, results were largely positive although there was some commentary received

regarding attendance from Divisional Leads at future meetings and the overall quality of

reporting needed to improve to answer the ‘so what’ question. During the discussion at the

Committee meeting in March 2018, it was acknowledged that the previous decision of the

Board in regard to the Non-Executive Directors holding the Executive Directors to account

and the potential risk of delving into too much operational detail if Divisions were in

attendance.

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16. The proposed focus for the Committee in 2018/19 is:

• Quality (i.e. the Quality Strategy)

• Risk (clinical risk; link from Corporate Risk Register to the Board Assurance Framework etc)

• CQC (monitoring implementation of CQC Improvement Plan/Compliance Framework)

17. The terms of reference have been amended to reflect changes in membership and to

amplify the duties of the Committee.

Finance & Performance

18. There were 7 Committee members out of 11 (64%) who responded to the questionnaire.

19. The results were largely positive although there were some comments regarding the

assurance strength not reflecting the true position and that the content of reports required

further work to highlight key issues. At its meeting in March 2018, the Committee discussed

the impact of deep dives, the level of assurance they provide and whether there was a

better way of reviewing performance through the Use of Resources methodology.

20. For 2018/19 the Committee agreed to focus on the following:

• Review productivity more broadly through the use of resources methods and

benefits realisation

• Adopt a risk based approach to improve levels of assurance

• Continue to monitor EPR implementation and the associated risks

21. The terms of reference have been amended to reflect changes in membership and to

amplify the duties of the Committee.

Charitable Funds Committee

22. The Committee does not undertake a formal evaluation of its performance and its terms of

reference are to be reviewed at its meeting on 19 May 2018. The proposed terms of

reference have been included in Appendix 1 for completeness for the Board to approve

subject to any further changes being made by the Committee. Any changes will be reported

back to the Board for ratification in May 2018 if necessary.

Remuneration and Nominations Committee

23. Again, the Committee does not undertake a formal evaluation of its performance and its

terms of reference are to be reviewed at its next meeting (possibly in May 2018). The

proposed terms of reference have been included in Appendix 1 for completeness and

include minor changes to titles in the membership section. The Board is to approve subject

to any further changes being made by the Committee. Any changes will be reported back

to the Board for ratification if necessary.

Conclusion

24. The evaluation of Board Committee performance and effectiveness provides the necessary

evidence that appropriate corporate governance arrangements are being met and that each

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of the Committees will seek to improve upon their performance and effectiveness going

forward.

Recommendation

25. The Board is asked to note the report and approve the revised Terms of Reference for each

of the Board Committees as outlined in Appendix 1.

Author: Michael Games, Corporate Governance Manager

Date: April 2018

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Appendix 1

BOARD COMMITTEES’ TERMS OF REFERENCE

AUDIT COMMITTEE – TERMS OF REFERENCE

Authority

1. The Audit Committee is constituted as a standing committee of the Trust’s Board of

Directors. Its constitution and terms of reference shall be as set out below, subject to

amendment at future Board of Directors’ meetings. The Audit Committee is a non-

executive Committee of the Board and has no executive powers other than those

specifically delegated in these Terms of Reference.

2. The Committee is authorised by the Board to investigate any activity within its terms of

reference. It is authorised to seek any information it requires from any member of staff and

all members of staff are directed to co-operate with any request made by the Committee.

3. The Committee is authorised by the Board of Directors to obtain outside legal or other

independent professional advice and to secure the attendance of individuals and authorities

from outside the Trust with relevant experience and expertise if it considers this necessary

or expedient to the carrying out of its functions.

Purpose

4. The Audit Committee shall provide the Board of Directors with a means of independent and

objective review of financial and corporate governance, assurance processes and risk

management across the whole of the Trust’s activities (clinical and non-clinical) both

generally and in support of the annual governance statement. In addition, the Audit

Committee shall:

• provide assurance of independence for external and internal audit

• ensure that appropriate standards are set and compliance with them is monitored in all

areas that fall within the remit of the Audit Committee

• monitor corporate governance (eg. compliance with terms of the licence, constitution,

codes of conduct, standing orders, standing financial instructions, maintenance of

registers of interests)

• ensure the Board has adequate assurance that systems and processes are in place to

deliver safe care

Membership

5. The Committee shall be composed of not less than three Non-Executive Directors of the

Trust, at least one of whom should have recent and relevant financial experience and

should be appointed Chair of the Committee by the Board.

6. At least one of the members will also be a member of the Quality & Safety Committee but

not the Chair of that Committee.

7. The Chairman of the Trust shall not be a member of the Committee.

8. A quorum will be two members.

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9. The composition of the Committee should be given in the Trust’s Annual Report.

10. The following are required to attend meetings of the Audit Committee in a non-voting

capacity:

• Director of Finance & Business Services

• Chief Nurse Director of Nursing & Quality

• Associate Director of Corporate Governance/Board Secretary

• Head of Corporate Finance

• Associate Director Clinical Governance & Risk

11. Other management or clinical staff may be co-opted or requested to attend for specific

agenda items as necessary.

Requirements of Membership

12. Members of the Audit Committee must attend at least 75% of all meetings each financial

year but should aim to attend all scheduled meetings.

13. Attendance at the Committee will be recorded and monitored.

Duties

Internal Control and Risk Management

14. To ensure the provision and maintenance of an effective system of financial risk

identification and associate controls, reporting and governance.

15. To maintain an oversight of the Trust’s general risk management structures, processes and

responsibilities, including the production and issue of any risk and control-related disclosure

statements.

16. To review processes to ensure appropriate information flows to the Audit Committee from

executive management and other Board Committees in relation to the Trust’s overall

internal control and risk management position in liaison with the Quality & Safety

Committee.

17. To review the adequacy of the policies and procedures in respect of all counter-fraud work.

18. To review the adequacy of the Trust’s arrangements by which Trust staff may, in

confidence, raise concerns about possible improprieties in matters of financial reporting and

control and related matters or any other matters of concern.

19. To review the adequacy of underlying assurance processes that indicate the degree of

achievement of corporate objectives and the effectiveness of the management of principal

risks.

20. To review the adequacy of policies and procedures for ensuring compliance with relevant

regulatory, legal and conduct requirements.

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Internal Audit

21. To review and approve the internal audit strategy and programme, ensuring that it is

consistent with the needs of the organisation.

22. To oversee on an on-going basis the effective operation of internal audit in respect of:

• adequate resourcing

• its co-ordination with external audit

• meeting relevant internal audit standards

• providing adequate independence assurances

• having appropriate standing within the Trust, and

• meeting the internal audit needs of the Trust.

23. To consider the major findings of internal audit investigations and management’s response

and their implications and monitor progress on the implementation of recommendations.

24. To consider the provision of the internal audit service, the cost of the audit and any

questions of resignation and dismissal of internal audit staff.

25. To conduct an annual review of the internal audit function.

External Audit

26. To make a recommendation to the Council of Governors in respect of the appointment, re-

appointment and removal of an external auditor and related fees as applicable. To the

extent that the recommendation is not accepted by the Council of Governors, this shall be

included in the annual report, along with the reasons why the recommendation was not

adopted.

27. To discuss with the external auditor, before the audit commences, the nature and scope of

the audit, and ensure co-ordination, as appropriate, with other external auditors in the local

health economy.

28. To assess the external auditor’s work and fees each year and based on this assessment, to

make the recommendation to the Council of Governors with respect to the re-appointment

or removal of the auditor. This assessment should include the review and monitoring of the

external auditor’s independence and objectivity and effectiveness of the audit process in

light of relevant professional and regulatory standards.

29. To oversee the conduct of a market testing exercise for the appointment of an auditor at

least once every three years and, based on the outcome, make a recommendation to the

Council of Governors with respect to the appointment of the auditor.

30. To review external audit reports, including the annual audit letter, together with the

management response, and to monitor progress on the implementation of

recommendations.

31. To develop and implement a policy on the engagement of the external auditor to supply

non-audit services.

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32. To consider the provision of the external audit service, the cost of the audit and any

questions of resignation and dismissal of the auditors.

Annual Accounts Review

33. To review the annual statutory accounts, before they are presented to the Board of

Directors, in order to determine their completeness, objectivity, integrity and accuracy. This

review will cover but is not limited to:

• the meaning and significance of the figures, notes and significant changes

• areas where judgement has been exercised

• adherence to accounting policies and practices

• explanation of estimates or provisions having material effect

• the schedule of losses and special payments

• any unadjusted statements, and

• any reservations and disagreements between the external auditors and management

which have not been satisfactorily resolved.

34. To review the annual report and annual governance statement before they are submitted to

the Board of Directors to determine completeness, objectivity, integrity and accuracy.

35. To review all accounting and reporting systems for reporting to the Board of Directors,

including in respect of budgetary control.

Standing Orders, Standing Financial Instructions and Standards of Business Conduct

36. To review on behalf of the Board of Directors the operation of, and proposed changes to,

the standing orders and standing financial instructions, the constitution, codes of conduct

and standards of business conduct including maintenance of registers.

37. To examine the circumstances of any significant departure from the requirements of any of

the foregoing, and whether those departures relate to a failing, an overruling or a

suspension.

38. To review the scheme of delegation.

Other

39. To review performance indicators relevant to the remit of the Audit Committee.

40. To examine any other matter referred to the Audit Committee by the Board of Directors and

to initiate investigation as determined by the Audit Committee.

41. To review each year the accounting policies of the Trust and make appropriate

recommendations to the Board of Directors.

42. To develop and use an effective assurance framework to guide the Audit Committee’s

work. This will include utilising and reviewing the work of the internal audit, external audit

and other assurance functions as well as reports and assurances sought from directors and

managers and other investigatory outcomes so as to fulfil its functions in connection with

these terms of reference.

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43. To consider the outcomes of significant reviews carried out by other bodies which include

but are not limited to regulator and inspectors within the health and social care sector and

professional bodies with responsibilities that relate to staff performance and functions.

44. To review the work of all other Trust committees in connection with the Audit Committee’s

assurance function.

Equality and Diversity

45. The Group will have regard for the NHS Constitution and ensure that it complies with

relevant legislation and best practice in the conduct of its duties.

Reporting

46. The minutes of all meetings of the Audit Committee shall be formally recorded and

submitted to the next meeting for approval. An assurance report shall be submitted to the

Board of Directors which will provide an overview of the discussions at the meeting, details

of any matters in respect of which actions or improvements are needed and decisions

taken. It will also include, when required, details of any evidence of potentially ultra vires,

otherwise unlawful acts of co-mission or omission, practices or any other important matters.

47. The Audit Committee will report annually to the Board of Directors in respect of the

fulfilment of its functions in connection with these terms of reference. Such report shall

include but not be limited to functions undertaken in connection with the annual governance

statement, the assurance framework, the effectiveness of risk management within the

Trust, the integration and adherence to governance arrangements, and any pertinent

matters in respect of which the Audit Committee has been engaged.

48. The Trust’s annual report shall include a section describing the work of the Audit

Committee in discharging its responsibilities.

Administration of Meetings

49. Meetings shall be held as required but not less than five times per year. Additional

meetings may be called if required.

50. The 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 Chair and Committee

members.

51. Agendas will be produced and agreed by the Chair in conjunction with the Executive Lead

and Lead Officer. Agendas and papers will be circulated at least 4 working days (or 3

working days plus a weekend) in advance of the meeting.

52. Minutes will be circulated to Committee members as soon as is reasonably practicable.

Review

53. The Terms of Reference of the Audit Committee shall be reviewed by the Committee and

submitted to the Board of Directors for review and approval at least annually.

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QUALITY COMMITTEE – Terms of Reference

Authority

1. The Committee is constituted as a standing committee of the Trust’s Board of Directors. Its

constitution and terms of reference shall be as set out below, subject to amendment at

future Board of Directors’ meetings.

2. The Committee is authorised by the Board to act within its terms of reference. All members

of staff are directed to co-operate with any request made by the Committee.

3. The Committee is authorised by the Board of Directors to instruct professional advisors and

request the attendance of individuals and authorities from outside the Trust with relevant

experience and expertise if it considers this necessary or expedient to the carrying out of its

functions.

4. The Committee is authorised to obtain such internal information as is necessary and

expedient to the fulfilment of its functions.

Purpose

5. To enable the Board to obtain its assurance the Committee seeks to ensure:

• that people are protected from abuse and avoidable harm (“Safe”)

• that people’s care and treatment achieves good outcomes, promotes a good quality

of life and is evidence-based where possible (Effective)

• that staff involve and treat people with compassion, kindness, dignity and respect

(Caring)

• that the leadership, management and governance of the organisation assures the

delivery of high-quality people-centred care, supports learning and innovation, and

promotes an open and fair culture (Well-Led)

with detailed assurances against each of these domains being provided through bespoke

reports/ deep dives and the Annual Business Plan Progress Report on a quarterly basis

and through the reports from the relevant Executive Led Groups on a monthly basis.

Duties

6. In order to fulfil its role and obtain the necessary assurance, the Committee will receive the

following standing items:

• HMB Assurance Report and Corporate Performance Report to inform the quality

context

• Corporate Report of the Trust Risk Register (including the Board Assurance

Framework)

• Report on performance against the Care Quality Commission’s fundamental standards

• The Quality Strategy and associated delivery plans

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• Relevant reports and improvement plans from the following example areas:

o Safeguarding Adults & Children

o Serious Incidents

o Safe Nurse Staffing

o Infection Prevention & Control

o Patient Experience & Engagement

o End of Life

o Compliance with NICE guidelines

and other relevant items as identified on the Committee’s Forward Plan (agreed annually by

the Committee).

Membership

7. The Committee shall be composed of the following members:

• Chairman (who must be an independent Non-Executive Director)

• Non-Executive Directors (x2)

• Chief Executive

• Medical Director

• Chief Nurse


• Deputy Chief Executive/Chief Operating Officer Integration Programme Director

• Acting Chief Operating Officer

• Acting Director of HR & OD

• Director of Estates & Facilities

• Director of Corporate Governance/Board Secretary

8. The Committee will be deemed quorate when two Non-Executive Directors and two

Executive Directors, one of whom must be the Medical Director or the Chief Nurse, are

present. Deputies must attend in the absence of the Director of Nursing & Quality Chief

Nurse, the Medical Director or the Acting Chief Operating Officer Deputy Chief

Executive/Chief Operating OfficerIntegration Programme Director. Deputies for other

Executive members should only attend if there are relevant agenda items.




10. Members of the Committee must attend at least 75% of all meetings each financial year but

should aim to attend all scheduled meetings.


Reporting

12. The minutes of all meetings of the Committee shall be formally recorded and submitted to

the following meeting for approval.

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13. The Committee will report to the Board of Directors after each meeting via an assurance

report which will provide an overview of the discussions at the meeting, details of any

matters in respect of which actions or improvements are needed and decisions taken.

14. The Committee will report annually to the Board of Directors in respect of the fulfilment of

its functions in connection with these terms of reference. This will include an evaluation of

its performance according to a standardised framework and process.


15. Meetings shall be held monthly with additional meetings held on an exceptional basis at the

request of the Chair or any three members of the Committee.




members.

17. Agendas and papers will be circulated 1 working day plus a weekend in advance of the

meeting.


Review

19. The Terms of Reference of the Quality & Safety Committee shall be reviewed by the

Committee and submitted to the Board of Directors for review and approval at least

annually.

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FINANCE & PERFORMANCE COMMITTEE – Terms of Reference

Authority









functions.



Purpose

5. To enable the Board to obtain its assurance the Committee seeks to ensure:

• that services are organised so they meet people’s needs (Responsive)

• that the leadership, management and governance of the organisation assures the

delivery of high-quality people-centred care, supports learning and innovation, and

promotes an open and fair culture (Well-Led).

with detailed assurances against each of these domains being provided through bespoke

reports/ deep dives and the Annual Business Plan Progress Report on a quarterly basis

and through the reports from the relevant Executive Led Groups on a monthly basis.

Duties

6. In order to fulfil its role and obtain the necessary assurance, the Committee will receive the

following standing items


• Finance Report

• Transformation Programme Update Reports

• Corporate Report on the Trust Risk Register (including the Board Assurance

Framework)

and other relevant items as identified on the Committee’s Forward Plan (agreed annually by

the Committee).

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Membership


• Chairman (who must be an independent Non-Executive Director)

• Non-Executive Directors (x 2)

• Chief Executive

• Director of Finance & Business Services (Executive Lead)

• Deputy Chief Executive/Integration Programme Director

• Acting Chief Operating Officer

• Medical Director

• Chief Nurse

• Acting Director of HR & OD

• Director of Estates & Facilities

• Director of Corporate Governance/Board Secretary

8. The Committee will be deemed quorate when two Non-Executive Directors and two

Executive Directors, one of whom must be the Director of Finance or the Acting Chief

Operating Officer, are present. Deputies must attend in the absence of the Director of

Finance or the Acting Chief Operating Officer. Deputies for other Executive members

should only attend if there are relevant agenda items.







Reporting










15. Meetings shall be held monthly with additional meetings held on an exceptional basis at the

request of the Chair or any three members of the Committee.

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members.

17. Agendas and papers will be circulated at least 1 working day plus a weekend in advance of

the meeting.


Review

19. The Terms of Reference of the Finance & Performance Committee shall be reviewed by the


annually.

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CHARITABLE FUNDS COMMITTEE – Terms of Reference

Authority









functions.



Purpose

5. To ensure the requirements of the Charity Commission and other relevant regulatory and

statutory frameworks are complied with and to ensure that charitable donations are

administered efficiently and legally and directed promptly towards appropriate charitable

activity in accordance with the donor’s wishes.

Duties

6. In order to fulfil its role, the Committee will undertake the following:

• maintain and approve appropriate policy documents to ensure that the legal and

administrative duties of the Corporate Trustee are met on behalf of the Board of

Directors.

• monitor charitable funds, approve the creation of new funds within the umbrella fund

and ensure a periodic review of existing funds takes place.

• ensure appropriate procedures are in place to control expenditure and ensure it is in

accordance with the objectives of the funds.

• establish a strategy for charitable funds and, on the basis of professional advice,

determine an investment policy within this strategy.

• circulate an Assurance Report to the Trust Board for information.

• review the Annual Report and Financial Statements and ensure consistency with the

Charity Commission’s Statement of Recommended Practice.

• receive the auditors’ report on the Annual Report and Financial Statements and

recommend their formal approval to the Board of Directors.

• oversee that the Charity is administered and its spending is in accordance with the

objectives set by the Board of Directors as Corporate Trustee.

• act in the best interests of the Charity and in such manner as meets the requirements of

the Charity Commission.

• refer any matters of concern to the Trust’s Board of Directors.

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Whilst the Committee has been established by the Board of Directors to carry out specific

functions as noted in this document, it is important to note that the Trust retains ultimate

responsibility, via its Board of Directors, for discharging it duties and responsibilities as the

Charity’s Corporate Trustee. To that end, the Board of Directors has absolute discretion

over the activities and decisions of the Committee.




Membership


• Non-Executive Director (Chairman) appointed by the Board of Directors

• Non-Executive Director


All members have voting rights. The Committee Chairman will have the casting vote.

9. The following are required to attend and participate in the meetings of the Committee in a

non-voting capacity:

• Financial Accountant

• Professional Investment Advisor/Manager

• Internal or External Audit (at the request of the Committee)

10. The Committee will be deemed quorate when two members are present (tele-conferencing

will be permitted, if necessary).







Reporting






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performance on the effectiveness in disbursing charitable via annual reporting against its

Reserves Policy. The legality and efficiency of its actions will be monitored annually by

Internal and External Audit.


17. Meetings shall ordinarily be held quarterly with additional meetings held on an exceptional

basis at the request of the Chairman or any two members of the Committee.

18. The Financial Accountant 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 Chair and Committee members.

19. Agendas and papers will be circulated at least 4 working days (or 3 working days plus a

weekend) in advance of the meeting.


Review

21. The Terms of Reference of the Charitable Funds Committee shall be reviewed by the


annually.

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REMUNERATION & NOMINATIONS COMMITTEE – Terms of Reference

Authority



future Board of Directors’ meetings. The Remuneration & Nominations Committee is a

non-executive Committee of the Board and has no executive powers other than those

specifically delegated in these Terms of Reference.






functions.



Purpose

5. The purpose of the Committee is to provide for the nomination, and decide on the

remuneration and allowances, and other terms and conditions of office, of Executive

Directors of Aintree University Hospital NHS Foundation Trust (The Trust). In addition, the

Committee will review the structure, size and composition of the Board of Directors (The

Board) as required.

Membership

7. The members of the Committee shall be:

• The Chairman of the Trust

• The Non-Executive Directors of the Trust

7. The following are required to attend and participate in the meetings of the Remuneration &

Nominations Committee in a non-voting capacity except on those occasions when

discussions or decisions relate to their own remuneration or terms of office:

• Chief Executive

• Director of People & Corporate Affairs Acting Director of HR & OD

• Associate Director of Corporate Governance/Board Secretary

8. The meeting will be deemed quorate with three members of the Committee present.




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Duties

11. In order to fulfil its role effectively, the Committee will:

• Act in accordance with the terms of the Trust’s Constitution and Standing Orders, taking

the relevant provisions of the NHS Foundation Trust Code of Governance into

consideration

• Determine a remuneration policy for Executive Directors

• Approve the remuneration and terms of office for each vacant Executive Director post

prior to the post being advertised

• In the event of the Board agreeing to an Executive Director being appointed as a Non-

Executive Director of another organisation, determine whether the individual should

retain any associated remuneration

• Recommend and monitor the level and structure of remuneration for senior managers

operating at Board level

• Give full consideration to succession planning, taking into account the challenges and

opportunities facing the Trust and the skills and expertise required on the Board

• Evaluate the skills, knowledge and experience on the Board and prepare a description

of the role and capabilities required for the appointment of an Executive Director

• Identify suitable candidates to fill executive director vacancies as they arise

• Review the structure, size and composition of the Board and make recommendations

where appropriate

• Review Board remuneration and make recommendations in respect of Non-Executive

Director remuneration to the Council of Governors.




Reporting


the next meeting for approval. An assurance report shall be submitted to the Board of

Directors which will provide an overview of the discussions at the meeting, details of any






15. Meetings shall be held as required but not less than twice per year. Additional meetings

may be called if required.

16. The Associate Director of Corporate Governance/Board Secretary will make arrangements

to ensure that the Committee is supported administratively. Duties in this respect will

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include taking minutes of the meeting and providing appropriate support to the Chair and

Committee members.

17. Agendas will be produced and agreed by the Chair in conjunction with the Executive Lead

and Lead Officer. Agendas and papers will be circulated at least 4 working days (or 3

working days plus a weekend) in advance of the meeting.


Review

19. The Terms of Reference of the Remuneration & Nominations Committee shall be reviewed

by the Committee and submitted to the Board of Directors for review and approval at least

annually.

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Documents

Board of Directors' Part 1 Agenda - 25 April 2018 · 25/04/2018 · Minutes ± Board of Directors 28 March 2018 3/11 Ref Item Action 151 The Chief Executive highlighted the following