COUNCIL OF GOVERNORS AGENDA - Aintree University Hospital...Portfolio Acting Director of Finance & Business Services ... CG 15 -16 /00 7 (d/p) (circulated in advance ) Council of Governors

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COUNCIL OF GOVERNORS

17 June 2015 12.30pm – 2pm

Learning & Development Room 1&2

Lunch to be served from 12 noon

AGENDA

d = document v = verbal p = presentation

PRIVATE BUSINESS

No Item Reference

12.25pm 1. Non-Executive Director Appraisals

Chairman

CGP15-16/001 (d)

PUBLIC MEETING

No Item Reference

Setting the Context - Chairman

12.30pm 2. Apologies for Absence

To note the apologies

CG15-16/001 (v)

3. Declarations of Interest

To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders

CG15-16/002 (v)

4. Minutes from the last meeting (17 March 2015)

To approve the minutes from the last meeting and discuss any matters arising

CG15-16/003 (d)

5. Chairman’s Report

To note the report

CG15-16/004 (v)

Where are we going as an Organisation?

12.35pm 6. Strategic Update

Chairman/Acting Chief Executive

To note the update

CG15-16/005 (v)

12.45pm 7. External Auditors Report on the Quality Account

PwC

CG15-16/006 (d)

12.55pm 8. Key Areas – Director of Finance & Business Services Portfolio

Acting Director of Finance & Business Services

Corporate Performance Report

To note the report

CG15-16/007 (d/p)

(circulated in advance)

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Aintree University Hospital NHS Foundation Trust

Agenda: Council of Governors Meeting 17 June 2015 2/3

No Item Reference

How are we treating our patients?

1.05pm 9. Key Issues - Director of Nursing Portfolio

Deputy Director of Nursing & Quality

To note the presentation

Patient Experience in A&E (Chief Operating Officer)

CG15-16/008 (p)

How do we run ourselves? What do others think?

1.15pm 10. Reports of Governor Committee Chairs:

Committee Chairs

Membership Committee (5 May 2015)

Quality of Care Committee (14 May 2015)

To note the reports

CG15-16/009 (d)

1.25pm 11. Membership Strategy

Chair of Membership Committee

To approve the strategy

CG15-16/010 (d)

1.35pm 12. Council of Governors – Outcome of Self-Assessment 2014/15

Associate Director of Corporate Governance/Board Secretary

To note the process

CG15-16/011 (d)

1.40pm 13. Council of Governors’ Draft Objectives 2015/16

Chairman

To agree the objectives

CG15-16/012 (d)

1.45pm 14. Lead Governor/Deputy Lead Governor

Chairman

To approve the appointments (elected unopposed)

CG15-16/013 (d)

Other items for Governors to be aware of

1.50pm 15. Governor Activity

Governors

To note the update

CG15-16/014 (v)

1.55pm 16. Governor Issues

(to be notified to the Associate Director of Corporate Governance no later than 24 hours before the meeting)

CG15-16/015 (v)

Concluding Business

2.00pm 17. Any Other Business

Chairman

CG15-16/016 (v)

18. Date and Time of Next Meeting:

Wednesday 14 October 2015 at 5.30pm

CG15-16/017 (v)

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Agenda: Council of Governors Meeting 17 June 2015 3/3

PRIVATE BUSINESS

No Item Reference

2.05pm 19. Appraisal of the Chairman

Senior Independent Director

CGP15-16/002 (d)

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1/7

Council of Governors

Wednesday 17 March 2015 5.30pm-7.00pm

Board Room, Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman

Maurice Byrne - Lead Governor

Tracey Barnes - Public Governor

Mike Booth - Public Governor

Mike Bowker - Public Governor

David Cowan - Public Governor

Gerry Hill - Public Governor

John Johnson - Pubic Governor

Peter Mayne - Public Governor

Rose Milnes - Public Governor

Julie Naybour - Public Governor

Pamela Peel - Public Governor

Stephen Thornhill - Public Governor

Kerry McManus - Staff Governor

Andrew Swift - Staff Governor

Jeanette Wilding - Staff Governor

Cllr Paul Cummins - Appointed Governor (Sefton MBC)

Mair Ning - Appointed Governor (Edge Hill University)

John Wilding - Appointed Governor (University of Liverpool)

In Attendance: Catherine Beardshaw - Chief Executive

Steve Evans - Medical Director (designate)

David Fillingham - Non-Executive Director

Nicola Firth - Director of Nursing & Quality

Michael Games - Corporate Governance Manager

Sue Green - Director of People and Corporate Affairs

Juliet Herzog - Non-Executive Director

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Colin Maloney - Non-Executive Director

Angie Smithson - Chief Operating Officer

Steve Warburton - Director of Finance & Business Services

Joanne Clague - Non-Executive Director (designate)

Tony Kneebone - Member of the Public

Apologies: Brian Lawless - Public Governor

Delyth Meirion- Owen - Public Governor

Lorraine Heaton - Staff Governor

Stephen Astles - Appointed Governor (South Sefton CCG)

Kim McNaught - Appointed Governor (Liverpool CCG)

Paul Fitzpatrick - Director of Estates & Facilities

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Minutes: Council of Governors Meeting 17 March 2015 2/7

Apologies Patrick Hackett - Non-Executive Director

Tim Johnston - Non-Executive Director

Richard Ward - Medical Director

Ref Minute

Setting the Context

CG14-15/065 Apologies for Absence

The apologies were noted as above.

CG14-15/066 Declarations of Interest

There were no declarations of interest.

CG14-15/067 Minutes from the last meetings (17 December 2014 and Extraordinary meeting 20

January 2015)

The minutes from the previous meetings were approved as an accurate record.

CG14-15/068 Chairman’s Report

The Chairman advised the meeting of the following:

Joanne Clague, Non-Executive Director (designate) was to take up her position with

effect from 1 April 2015 replacing Patrick Hackett as the University of Liverpool

representative.

The Nominations Committee supported the re-appointment of Juliet Herzog as a

Non-Executive Director for a period of 3 years with effect from 1 April 2015. The

Council of Governors approved the re-appointment.

The Council noted the update.

Where are we going as an Organisation?

CG14-15/069 Strategic Update

The Chief Executive advised the meeting that the Trust continued to work collaboratively

with the Royal Liverpool & Broadgreen University Hospitals NHS Trust (RLBUHT) on the

development of efficient ways of working. Following the Clinical Summit in November

2014 on the practicalities of partnership working, the outcome of the ensuing discussions

concluded with a clinical presentation to the Chairs, Chief Executives and Executive

Teams from both Trusts in February 2015. The overwhelming clinical view was that

there would be significant patient benefits through service reconfiguration. There was

agreement to undertake a strategic options review and a joint communication was being

drafted for issue to staff in both Trusts.

In regard to other partnership working, it was noted that the clinical services provided by

Southport & Ormskirk Trust were to be the subject of discussion between the Chairs and

Chief Executives of both Trusts. In addition, a meeting had taken place with Mersey

Care on the commitment to work together on patients presenting at the Hospital who

require mental health interventions.

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Ref Minute

It was reported that the Trust was awaiting a visit from the Care Quality Commission in

(CQC) the next couple of months to review the improvements made by the Trust under

its Well-Led domain.

In terms of activity, the Chief Executive commented that A&E performance had improved

over the last 3 weeks with 97% achievement in the previous week. This reinforced that

the improvements made to patient flow over the last 6 months although the Trust

remained vigilant to ensure that the performance remained sustainable.

The Council of Governors requested clarification on the following point:

What will be the advantages from service reconfiguration? The overwhelming

clinical view was that there would be significant patient benefit but it was vital that all

partners work together to seek to centralise services in fewer centres. This would

ensure that services remained in the Merseyside area and would also seek to attract

additional funding for research and development.


CG14-15/070 Raising Concerns Update

A presentation was provided by the Director of People & Corporate Affairs on the work

being undertaken by the Trust on raising concerns and the development of building a

culture of confidence. The following key points were highlighted:

The Trust’s compliance with the legal requirements relating to the Public Interest

Disclosure Act 1998

The development of a culture of learning and awareness of how to raise a concern

together with the further work required on building staff confidence to raising

concerns

The introduction of a multi-professional group to take forward the internal plans and

review the principles set out in Sir Robert Francis’ Freedom to Speak Up Review

The Council of Governors sought and received confirmation that the raising concerns

framework would also be modelled for patients at some point in the future but it was

important to ensure that staff were fully aware in the first instance.

The Council noted the presentation.

CG14-15/071 Key Areas – Director of Finance & Business Services Portfolio

The Director of Finance and Business Services gave a presentation covering key areas

across all aspects of the portfolio for month 10. The following key points were

highlighted:

2 Serious Untoward Incidents reported

No Never Events but 411 incidents reported one of which resulted in a death

1 Grade 3/4 pressure ulcer reported with 7 at Grade 2

6 C. Difficile cases were reported culminating in 39 for the year to date although a

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Ref Minute

number were still the subject of appeal. There had been no MRSA cases reported

A&E continued to underperform for the month but, as reported earlier, there had been

signs of improvement more recently

All referral to treatment targets had been met in month

Cancer targets had been met with the exception of 62-day screening

There had been no breaches of mixed sex accommodation in month

Cancelled operations were below target and all patients had been readmitted within

the 28 day deadline

Outpatient cancellations had increased to 7.20% from 6.20% in December 2014

Mortality – Summary Hospital-level Mortality Indicator (SHMI) continued to be of

concern but the Hospital Standardised Mortality Ratio (HSMR) had improved and

was better than the national average

The Trust was behind target on 7 Commissioning for Quality innovations (CQUINS)

Theatre utilisation for the hospital was at 68.3% and for the Elective Care Centre was

69.4%

There was financial deficit of £0.9m for the year to date for the Trust and it

maintained a Financial Risk Rating of 3 with liquidity at 10 days.

The Director of Finance & Business Services advised that a response to the various

questions raised in advance by Governors had been issued but if Governors required

any further clarification, they were requested to contact him directly. It was also noted

that finance training sessions had taken place in January but, if any Governor wanted

any individual training, to contact the Corporate Governance Team.

The Lead Governor thanked the Executive Team for providing the answers to questions

in a timely manner.


How are we treating our patients?

CG14-15/072 Key Issues – Director of Nursing Portfolio

The Director of Nursing & Quality gave a presentation covering key issues across all

aspects of the Nursing Portfolio. The following key points were highlighted:

The improvements made to ensure care that is safe with particular focus on the

reduction in falls, pressure ulcers, medicines safety and the prevention of infection

The well-established safeguarding team with full compliance for safeguard training for

adults and children.

The establishment of the Aintree Assessment & Accreditation Framework (AAA), the

ward ratings and the number of ward assessments completed to the end of Q3

The continued improvements to patient experience and staff learning through the

family and friends test, patient stories, patient and family engagement and surveys

The top 3 complaints and concerns during Q3 and the triangulation of these with

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Ref Minute

other patient feedback

The work being undertaken on the communication improvement plan taking account

of an advanced customer service development programme and simulation training

using a ‘human factors’ approach

The progress made in Dementia care including the national award for finger food

boxes, the introduction of an information leaflet and passport of care.

Some discussion ensued on the AAA framework with particular mention made of staff

awareness and motivation towards the scheme. It was noted that there was significant

competition amongst the Wards but this did not prevent the sharing of best practice. In

addition, staff had commented that they were comfortable with the assessment process

and that all Wards had action plans in place to improve their ratings. It was also reported

that Wards informed patients and family of their ratings.

The Council of Governors requested clarification on the following point:

Why were 15% of Allied Health Professionals (AHPs) not compliant with

their aseptic Non-touch Technique training? The Trust’s aim is to ensure that

95% of its AHPs were compliant in this area and all Divisions had been made

aware of the need for improvement going forward.

The Chairman commented that Governors can be assured that the Executive Team was

fully aware of the challenges facing the Trust and it was clear that progress had been

made and that further actions for improvement had been identified.

The Council noted the presentation.

CG14-15/073 Quality Account – Performance Indicator

The Director of Nursing & Quality referred to the slide presentation which outlined the

suitable indicators for Monitor’s risk assessment framework and the national core quality

indicators. Reference was also made to the discussions held at the Informal Governors’

meeting and the explanatory email provided by the Associate Director of Corporate

Governance on the Trust’s recommended indicators for external review. The indicators

being recommended were:

Cancer – 31 day wait from diagnosis to first treatment; or

Total time in Accident & Emergency.

It was noted that it was the Governors’ responsibility to select a local indicator and they

had the option to select another indicator from the list provided rather than choose one of

the recommendations put forward by the Trust. Some discussion took place on the

options following which the Governors agreed that the following indicator should form

part of the external auditor review:

Cancer – 31 day wait from diagnosis to first treatment.

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Ref Minute

The Council noted the matter.

How do we run ourselves? What do others think?

CG14-15/074 Governors Elections 2015 – Results

The Chairman referred to the report and advised the meeting of the results of the

elections to the various constituencies held during February/March 2015. He then

welcomed the two new Staff Governors (Kerry McManus – All other Staff and Andrew

Swift - Medical) who had been elected with effect from 9 March 2015.

In regard to the election in the Public constituency, the Chairman advised that Maurice

Byrne (Lead Governor) and Delyth Owen had not been successful in securing a further

term of office and would be standing down with effect from 31 July 2015. It was noted

that arrangements would be made for the Council of Governors to appoint a new Lead

Governor and Deputy Lead Governor during June/July 2015.

The Council noted the report.

CG14-15/075 Reports of Governor Committee Chairs

The Council of Governors noted the reports of the following Committees:

Nominations Committee – 20 January 2015

Membership Committee – 3 February 2015

Quality of Care Committee – 12 February 2015.

Other items for Governors to be aware of

CG14-15/076

Council of Governors’ Forward Plan 2014/15 and 2015/16

The Council of Governors noted the forward Plans for 2014/15 and 2015/16.

Governors were requested to inform the Associate Director of Corporate Governance of

any other items they identify in year.

CG14-15/077 Governor Issues

The Associate Director for Corporate Governance advised that there had been no

notified items in the last 24 hours. However, there had been issues raised by certain

Governors in other fora which were being dealt with and the individuals concerned would

be informed accordingly.

CG14-15/078 Any Other Business

The Chairman paid tribute to the Chief Executive on her stewardship and leadership of

the Trust during her time in office and wished her health and happiness for the future.

The Council of Governors also placed on record their appreciation. The Chief Executive

responded suitably and thanked the Council of Governors for their support and for the

work they undertake on behalf of the Trust.

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Ref Minute

CG14-15/079 Date and Time of Next Meeting:

Tuesday 17 June 2015 in the Learning & Development Centre, Aintree at 12.30pm.

Chair’s Signature: Date:

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www.pwc.co.uk

AintreeUniversity

HospitalNHSFoundation

Trust

QualityReport2014/15

Governmentand

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AintreeUniversityHospitalNHSFoundationTrust

PwC�Contents

Backgroundandscope

1

Summaryoffindings

3

Detailedfindings

5

Appendices

11

AppendixA:MattersarisingfromourlimitedassurancereviewoftheFoundationTrust’s2014/15Quality

Report:Performanceindicators

12

AuditCodeandscopeofthiswork

WehaveperformedthisworkinaccordancewithMonitor’sDetailedguidanceforexternalassuranceonqualityreports2014/15and

Monitor’sDetailedrequirementsforqualityreports2014/15whichwereissuedinFebruary2015,andtheNHSFoundationTrustAnnual

ReportingManual2014/15.ThisisavailablefromtheChiefExecutiveoftheNHSFoundationTrust.

Reportsandletterspreparedbyexternalauditorsandaddressedtogovernors,directorsorofficersarepreparedforthesoleuseoftheNHS

FoundationTrust,andnoresponsibilityistakenbyauditorstoanygovernor,directororofficerintheirindividualcapacity,ortoanythird

party.Themattersraisedinthisreportareonlythosewhichhavecometoourattentionarisingfromorrelevanttoourworkthatwebelieve

needtobebroughttoyourattention.Theyarenotacomprehensiverecordofallthemattersarising,andinparticularwecannotbeheld

responsibleforreportingallrisksinyourbusinessorallinternalcontrolweaknesses.Thisreporthasbeenpreparedsolelyforyourusein

accordancewiththetermsofourengagementletterdated21January2015andfornootherpurposeandshouldnotbequotedinwholeorin

partwithoutourpriorwrittenconsent.Noresponsibilitytoanythirdpartyisacceptedasthereporthasnotbeenpreparedfor,andisnot

intendedfor,anyotherpurpose.

Contents

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PwC�1

Background

NHSfoundationtrustsarerequiredtoprepareandpublish

aQualityReporteachyear.TheQualityReporthastobe

preparedinaccordancewiththeNHSfoundationtrust

AnnualReportingManual(“theFTARM”).

Asyourauditors,wearerequiredtoundertakeworkonyour

QualityReportunderMonitor’sAuditCodeandMonitor’s

‘DetailedGuidanceforExternalAssuranceontheQuality

Reports2014/15’(‘thedetailedguidance’)whichwas

publishedinFebruary2015.

ThepurposeofthisreportistoprovidetheBoardof

DirectorsandCouncilofGovernorsofAintreeUniversity

HospitalNHSFoundationTrust(“theTrust”)withour

findingsandrecommendationsforimprovements,in

accordancewithMonitor’srequirements.Itisreferredtoby

Monitorasthe“Governorsreport”.

Scopeofourwork

WearerequiredbyMonitortoreviewthecontentofthe

2014/15QualityReport,testthreeperformanceindicators

andproducetworeports:

�Limitedassurancereport:Thisreportisaformal,public

documentthatrequiresustoconcludewhetheranything

hascometoourattentionthatwouldleadustobelieve

that:

oTheQualityReportdoesnotincorporatethematters

requiredtobereportedonasspecifiedinannex2to

Chapter7oftheFTARMandMonitor’s‘Detailed

requirementsforqualityreports2014/15’(“the

requirements”);

oTheQualityReportisconsistentinallmaterial

aspectswithsourcedocumentsspecifiedbyMonitor;

and

oThespecifiedindicatorshavenotbeenpreparedinall

materialrespectsinaccordancewiththecriteriaand

thesixdimensionsofdataqualitysetoutinthe

detailedguidance.

Alimitedassuranceengagementislessinscopethan

areasonableassuranceengagement(suchasthe

externalauditofaccounts).Thenature,timingand

extentofproceduresforgatheringsufficient

appropriateevidencearedeliberatelylimited

comparedtoareasonableassuranceengagement.

�Governorsreport:Aprivatereportontheoutcomeof

ourworkthatismadeavailabletotheTrust’sGovernors

andtoMonitor.

Ourlimitedassurancereportisrestricted,asrequiredby

Monitor,tothecontentoftheQualityReportandtwo

performanceindicatorsonly.TheGovernorsreportcovers

allofourworkand,therefore,thethirdlocalindicatorwhich

ischosenbytheGovernors.

Backgroundandscope

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PwC

�2

ContentoftheQualityReport

Wearerequiredtoissuealimitedassurancereportin

relationtothecontentofyourQualityReport.Thisinvolves:

�ReviewingthecontentoftheQualityReportagainstthe

requirementsofMonitor’spublishedguidance,as

specifiedinAnnex2toChapter7oftheFTARMandthe

requirements;and

�ReviewingthecontentoftheQualityReportfor

consistencywiththesourcedocumentsspecifiedby

Monitorinthedetailedguidance.

Performanceindicators

Wearerequiredtoissuealimitedassurancereportinrespect

oftwooutofthethreeindicatorsspecifiedbyMonitor.

Theindicatorsfortheyearended31March2015subjectto

limitedassurance(the“specifiedindicators”);markedwith

thesymbol

intheQualityReport,consistofthe

followingnationalpriorityindicatorsasmandatedby

Monitor:

SpecifiedIndicators

Specifiedindicatorscriteria

(sectionwherecriteriacanbefound)

Percentageofincomplete

pathwayswithin18weeksfor

patientsonincompletepathways

AnnexD

Emergencyre-admissionswithin

28daysofdischargefromhospital

AnnexD

Ourproceduresincluded:

�obtaininganunderstandingofthedesignandoperation

ofthecontrolsinplaceinrelationtothecollationand

reportingofthespecifiedindicators,includingcontrols

overthirdpartyinformation(ifapplicable)and

performingwalkthroughstoconfirmourunderstanding;

�basedonourunderstanding,assessingtherisksthatthe

performanceagainstthespecifiedindicatorsmaybe

materiallymisstatedanddeterminingthenature,timing

andextentoffurtherprocedures;

�makingenquiriesofrelevantmanagement,personnel

and,whererelevant,thirdparties;

�consideringsignificantjudgmentsmadebytheTrustin

preparationofthespecifiedindicators;and

�performinglimitedtesting,onaselectivebasisof

evidencesupportingthereportedperformance

indicators,andassessingtherelateddisclosure.

Localindicator

Wearealsorequiredtoundertakesubstantivesampletesting

ofonefurtherlocalindicator.Thisindicatorisnotincluded

inourlimitedassurancereport.Instead,wearerequiredto

provideadetailedreportonourfindingsand

recommendationsforimprovementsinthis,ourGovernors

report.TheTrust’sGovernorsselecttheindicatortobe

subjecttooursubstantivesampletesting.Theindicator

selectedis:

LocalIndicator

Specifiedindicatorscriteria

(sectionwherecriteriacanbe

found)

Maximumwaitingtimeof31days

fromdiagnosistofirsttreatment

forallcancers

AnnexD

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PwC�3

NoissueshavecometoourattentionthatleadsustobelievethattheQualityReporthasnotbeenpreparedinaccordancewith

theFTARMandtherequirements.

Forfurtherinformationrefertopage5.

NoissueshavecometoourattentionthatleadsustobelievethattheQualityReportisnotconsistentwiththeother

informationsourcesdefinedbyMonitor.


LimitedAssuranceReport

Asaresultofourwork,weareabletoprovideanunqualifiedlimitedassurancereportinrespectofthe

contentoftheQualityReport.


Ourfindingsrelatingtotheperformanceindicatorsaresummarisedasfollows:

Performanceindicatorsincludedinour

limitedassurancereport

Findings

Percentageofincompletepathwayswithin18weeks

forpatientsonincompletepathways

Twoissuesidentified;neitherimpactonourlimited

assuranceopinion

Emergencyre-admissionswithin28daysofdischarge

fromhospital

Noissuesidentified


LimitedAssuranceReport

Asaresultofourwork,weareabletoprovideanunqualifiedlimitedassurancereportinrespectofthe

mandatedperformanceindicators.

Summaryoffindings

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PwC�4

Performanceindicatornotincludedwithin

ourlimitedassurancereport

Findings

Maximumwaitingtimeof31daysfromdiagnosisto

firsttreatmentforallcancers

Oneerroridentifiedinsampletested.

Nocontrolissuesidentified.


AnnualGovernanceStatement

WeidentifiednoissuesrelevanttotheQualityReport.

Forfurtherdetails,seepage10.

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PwC�5

Reviewagainstthecontentrequirements

WereviewedthecontentoftheQualityReportagainstthe

contentrequirementswhicharespecifiedinAnnex2to

Chapter7oftheFTARMandtherequirements.

Noissuescametoourattentionthatledustobelievethatthe

QualityReporthasnotbeenpreparedinlinewiththeFT

ARMortherequirements.

Reviewconsistencyagainstspecified

sourcedocuments

Wereviewedthecontentofthe2014/15QualityReportfor

consistencyagainstthefollowingsourcedocumentsspecified

byMonitor:

�BoardminutesfortheperiodApril2014toMarch2015;

�PapersrelatingtoqualityreportreportedtotheBoard

overtheperiodApril2014toMarch2015;

�FeedbackfromtheCommissioners,SouthSeftonCCG

received21/05/2015;

�FeedbackfromGovernorsdated15/04/2015and

05/05/2015;

�FeedbackfromlocalHealthwatchorganisations,

KnowsleyCouncil’sHealthScrutinySub-Committeeand

HealthwatchKnowsley(jointresponse)received

19/05/2015,HealthwatchLiverpoolandHealthwatch

Seftonreceived19/05/2015;

�Thetrust’squarterlycomplaintsandconcernsreports,

dated01/08/2014(Q1),11/11/2014(Q2),11/02/2015

(Q3);

�Feedbackfromotherstakeholdersinvolvedinthesign-

offoftheQualityReport(SeftonCouncilOverviewand

ScrutinyCommittee-HealthandSocialCaredated

18/05/2015);

�The2014nationalinpatientsurvey;

�The2014nationalstaffsurvey;

�CareQualityCommissionIntelligentMonitoringReport

datedDecember2014;and

�TheHeadofInternalAudit’sdraftannualopinionover

theTrust’scontrolenvironmentdated01/05/2015.

Noissuescametoourattentionthatledustobelievethatthe

QualityReportisnotconsistentwiththeinformationsources

detailedabove.

Detailedfindings

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PwC�6

Performanceindicatorsonwhichweare

requiredtoissuealimitedassurance

conclusion

AsrequiredbyMonitorwehaveundertakensampletesting

oftwoperformanceindicatorsonwhichweissuedour

limitedassurancereport:

1.Percentageofincompletepathwayswithin18weeks

forpatientsonincompletepathwaysattheendofthe

reportingperiod

2.Emergencyre-admissionswithin28daysof

dischargefromhospital

Wearerequiredtoevaluatethekeyprocessesandcontrols

formanagingandreportingtheindicatorsandsampletest

thedatausedtocalculatetheindicatorbacktosupporting

documentation.Ourworkisperformedinaccordancewith

thedetailedguidanceandincluded:

�IdentificationofthecriteriausedbytheTrustfor

measuringtheindicator;

�ConfirmationthattheTrusthadpresentedthecriteria

identifiedaboveintheQualityreportinsufficientdetail

thatthecriteriaarereadilyunderstandabletousersof

theQualityReport;

�Obtainingandupdatingourunderstandingofthekey

processesandcontrolsformanagingandreportingthe

indicatorthroughmakingenquiriesofTruststaffand

throughperformingawalkthrough;

�ReconcilingthereportedperformanceintheQuality

Reporttothedatausedtocalculatetheindicatorfrom

theTrust’sunderlyingsystems;

�Testingasampleofrelevantdatausedtocalculatethe

indicatorbacktosupportingdocumentation;and

�Consideringthecompletenessofthedatareportedand

performingsampletestingonthiswhererelevant.

Weonlytestedasampleofdata,asstatedabove,to

supportingdocumentation.Therefore,theerrorsreported

belowarelimitedtothissample.

Wehavealsonottestedtheunderlyingsystems,forexample

thepatientadministrationsystemandthedataextraction

andrecordingsystems.

Ourfindingsaresetoutbelow.Recommendationsarising

fromthesefindingsarepresentedinAppendixA.

Percentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysattheendofthe

reportingperiod

Reportedperformance:

2014/15Threshold:92%

2014/15Actual:97.51%

Criteriaidentified:

WeconfirmedtheTrustusesthefollowingcriteriaformeasuringtheindicatorforinclusionintheQualityReport:

�Theindicatorisexpressedasapercentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysat

theendoftheperiod;

Page 18 of 70


PwC�7

�TheindicatoriscalculatedasthearithmeticaverageforthemonthlyreportedperformanceindicatorsforApril2014to

March2015;

�TheclockstartdateisdefinedasthedatethatthereferralisreceivedbytheFoundationTrust,meetingthecriteriasetout

bytheDepartmentofHealthguidance;and

�Theindicatorincludesonlyreferralsforconsultant-ledservice,andmeetingthedefinitionoftheservicewherebya

consultantretainsoverallclinicalresponsibilityfortheservice,teamortreatment.

Issuesidentifiedthroughworkperformed:

No.

Issue

Impactonlimitedassurance

report

1.Itwasnotedthatthemonthlyreportofpatientsonincompletepathwayswas

erroneouslyexcludedpatientsthatwetreatedaftertheendofthemonth,but

priortothedatethereportwasrun.

However,theTrustwasabletore-runtheperformancedatatoincludethese

patientsandtheissuewasresolved.

Wewereabletore-runthereport

includingthosepatientsoriginally

excludedandthereforethereisno

impactonourlimitedassurancereport.

Thereviseddataimprovedtheyearend

position,movingfrom97.08%to

97.51%.

2.Foronepatientinoursample,itwasnotedthattheywerenotincludedinthe

firstmonthendreportfollowingtheirreferral.Thiswasduetoaninterface

errorwiththeChooseandBooksystemresultinginthewrongclockstart

datebeingrecorded.Thiswouldhaveasmallnegativeimpactonthe

performance.

Inaddition,forthreepatientswenotedthattheclockstartdaterecordedwas

differentfromthatnotedonthereferralletter.However,noneofthesehad

animpactontheactualperformanceasthepatientswerestillreportedinthe

correctmonths.

Wehavedefinedtheseissuesas“differences”ratherthan“errors”duetothe

reasonsstatedabove,andthereforenofurthertestingwasrequired.

Noimpactonourlimitedassurance

report.

OverallConclusion:

Oursubstantivetestingoftheindicatoridentifiedtwoissues.Neitherimpactonourlimitedassurancereportresultinginan

unmodifiedreportinrespectofthisindicator.

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Page 19 of 70


PwC�8

Emergencyre-admissionswithin28daysofdischargefromhospital


2014/15Target:n/a–notargetdefined

2014/15Actual:14.46%

Criteriaidentified:


�TheindicatorisexpressedasthepercentageofemergencyadmissionstotheTrustoccurringwithin28daysofthelast,

previousdischargefromhospital;

�Thenumeratorincludesfinishedandunfinishedinpatientspells,includingwherethepatientdies;

�Thenumeratorexcludespatientswithamainspecialityuponreadmissioncodedunderobstetric;andthosewherethe

readmittingspellhasadiagnosisofcancer(otherthanbenignorinsitu)orchemotherapyforcancercodedanywherein

thespell;

�Thedenominatorincludesallfinishedcontinuousinpatientspellswithinselectedmedicalandsurgicalspecialities,witha

dischargedateupto31March;

�Thedenominatorexcludesdaycases,spellswithadischargecodedasdeath,maternityspells(basedonspecialty,episode

type,diagnosis),andthosewithmentionofadiagnosisofcancerorchemotherapyforcanceranywhereinthespell;and

�Patientswithmentionofadiagnosisofcancerorchemotherapyforcanceranywhereinthe365dayspriortoadmission

areexcludedfromthedenominator.


Noissuesnotedduringtesting

Conclusion:

Oursubstantivetestingoftheindicatoridentifiednoissues.Therefore,thereisnoimpactonourlimitedassurancereport

resultinginanunmodifiedreportinrespectofthisindicator.

Page 20 of 70


PwC�9

Performanceindicatorsnotincludedwithinourlimitedassurancereport

MonitoralsorequiresustoundertakesubstantivesampletestingofalocalindicatorselectedbytheGovernors,theresultsof

whicharenotincludedwithinourlimitedassurancereport.Wearerequiredtoevaluatethekeyprocessesandcontrolsfor

managingandreportingtheindicatorandsampletestthedatausedtocalculatetheindicatorbacktosupporting

documentation.Weonlytestedasample,asstatedabove.Ourreportederrorsbelowarelimitedtothissample.

Ourfindingsaredetailedasfollows:

Maximumwaitingtimeof31daysfromdiagnosistofirsttreatmentforallcancers


2014/15Actual:99.33%

Criteriaidentified:


�Numberofpatientsreceivingfirstdefinitivetreatmentforallcancerswithin31-daysfollowingadiagnosisasa

percentageofthetotalnumberofpatientsreceivingfirstdefinitivetreatmentforallcancersfollowingadiagnosis

(ICD-10C00toC97andD05).

�Measuredfromdecisiontotreattofirstdefinitivetreatment.


No.

Issue

Impact

1.Wefoundoneinstancewhereapatienthadbeenrecordedas

havingbreachedthe31daytarget,butareviewoftheirnotes

foundthatthedecisiontotreatdatewaslaterthanrecorded.

Hadthecorrectdatebeenrecorded,theywouldnothavebeen

reportedasabreach.

Wealsonoted7patientswheretheclockstartorclockstopdates

recordedslightlyvariedfromthoseseenonpatientnotes.

However,noneofthesedifferencesimpactedonwhetherthe

patientbreachedordidnotbreachthe31daytargetand

thereforedonotconstituteerrors.

Theoneerrornotedwouldbebelowourmateriality

levelwereweprovidingassuranceoverthis

indicatorandthereforetherewouldhavebeenno

impactonourlimitedassurancereporthaditbeen

reportedupon.

Conclusion:

Oursubstantivetestingoftheindicatoridentifiedoneissue.

TherecommendationsassociatedwiththesefindingsarepresentedinAppendixA.

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Page 21 of 70


PwC�10

AnnualGovernanceStatement

IntherequirementsMonitorasksFoundationTruststoincludeabriefdescriptionofthekeycontrolsinplacetoprepareand

publishaQualityReportaspartoftheAnnualGovernanceStatementinthe2014/15publishedaccounts.

TheAnnualGovernanceStatement,withintheFoundationTrust’s2014/15AnnualReport,includesthefollowingstatement

specifictotheQualityReport:

ThedirectorsarerequiredundertheHealthAct2009andtheNationalHealthService(QualityAccounts)Regulations2010

(asamended)toprepareQualityAccountsforeachfinancialyear.MonitorhasissuedguidancetoNHSfoundationtrust

boardsontheformandcontentofannualQualityReportswhichincorporatetheabovelegalrequirementsintheNHS

FoundationTrustAnnualReportingManual.

TheTrusthaseffectivesystems,processesandmechanismsinplacetoproducetheQualityAccountandtoensurethatitisa

generalandbalancedviewandthatappropriatecontrolsareinplacetoensuretheaccuracyofthedata.Thequalityand

accuracyofelectivewaitingtimedataandtheriskstothequalityandaccuracyofthisdata,inparticular,received

assuranceinyearthroughanInternalAuditReportonReferraltoTreatment(RTT)andtheRTTnationalreview.These

reportswerereceivedbytheAuditCommittee.TheExecutiveleadfortheQualityAccountistheDirectorofNursing&

Quality.ThecontentoftheQualityreportreflectstheTrust’soverallQualityStrategyandtheprioritiesincludedinthis

document.

TheGovernors,staffandexternalorganisationssuchastheClinicalCommissioningGroups,theLocalAuthorityOverview

andScrutinyCommittees,thethreeHealthwatchandtheCouncilofGovernorswereconsultedontheprioritiesfor2014/15

indeterminingwhichofthelocalindicatorswastobereviewedbyexternalaudit.

Aspartofourreportonthefinancialstatementswewererequiredto:

�ReviewwhethertheAnnualGovernanceStatementreflectscompliancewithMonitor’sguidance;and

�ReportifitdoesnotmeettherequirementsspecifiedbyMonitororifthestatementismisleadingorinconsistentwith

otherinformationweareawareoffromourauditofthefinancialstatements.

TheworkweundertookontheAnnualGovernanceStatementaspartofourworkonthefinancialstatementsidentifiedno

issuesrelevanttotheQualityReport.

Page 22 of 70


PwC�11

Appendices

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Page 23 of 70


PwC�12

AppendixA:Mattersarisingfromour

limitedassurancereviewoftheFoundation

Trust’s2014/15QualityReport:


Observation

Recommendation

Percentageofincompletepathwayswithin18weeksforpatientsonincompletepathwaysattheendof

thereportingperiod

1.Itwasnotedthatthemonthlyreportofpatientson

incompletepathwayswaserroneouslyexcludingpatients

thatwetreatedaftertheendofthemonth,butpriortothe

datethereportwasrun.

However,theTrustwasabletore-runtheperformance

datatoincludethesepatientsandtheissuewasresolved.

TheTrustshouldamendthequerythatisbeingusedto

createtheincompletepathwaysreporttoensurethatall

patientsonanopenpathwayattheendofthemonthare

includedwithinthereport.

2.Foronepatientinoursample,itwasnotedthattheywere

notincludedinthefirstmonthendreportfollowingtheir

referral.ThiswasduetoaninterfaceerrorwiththeChoose

andBooksystemresultinginthewrongclockstartdate

beingrecorded.

Inaddition,forthreepatientswenotedthattheclockstop

daterecordedwasdifferentfromthatnotedonthereferral

letter.However,noneofthesehadanimpactontheactual

performanceasthepatientswerestillreportedinthe

correctmonths.Thereforethesedonotconstituteerrors.

Theerrornoteddoesnotindicateanyunderlyingcontrol

issueswhichtheTrustneedstoaddressandshouldbean

isolatedincident.

Similarly,theminordifferencesnotedinthethreeother

patientshighlighteddonotleadustobelievethatthere

areanyissuesneedingresolution.Thevolumeofpatients

on18weekpathwaysprecludesvalidationprocessesonall

patientsthatwouldpickuponthesedifferencessowedo

notproposetheTrusttakeanyfurtheraction.

Page 24 of 70


PwC�13

Observation

Recommendation

Maximumwaitingtimeof31daysfromdiagnosistofirsttreatmentforallcancers

3.Wefoundoneinstancewhereapatienthadbeenrecorded

ashavingbreachedthe31daytarget,butareviewoftheir

notesfoundthatthedecisiontotreatdatewaslaterthan

recorded.Hadthecorrectdatebeenrecorded,theywould

nothavebeenreportedasabreach.

Wealsonoted7patientswheretheclockstartorclockstop

datesrecordedslightlyvariedfromthoseseenonpatient

notes.However,noneofthesedifferencesimpactedon

whetherthepatientbreachedordidnotbreachthe31day

targetandthereforedonotconstituteerrors.

TheTrustshouldensurethatallbreachesarevalidatedto

ensurethatthesearecorrectlyreportedinthefigures

submittedtoMonitor.

Thevalidationchecksshouldincludebothverifyingthe

DecisiontotreatandTreatmentdates.

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ount

Page 25 of 70

Intheeventthat,pursuanttoarequestwhichAintreeUniversityHospitalNHSFoundationTrusthasreceivedundertheFreedomofInformationAct2000,itisrequiredtodiscloseany

informationcontainedinthisreport,itwillnotifyPwCpromptlyandconsultwithPwCpriortodisclosingsuchreport.AintreeUniversityHospitalNHSFoundationTrustagreestopay

dueregardtoanyrepresentationswhichPwCmaymakeinconnectionwithsuchdisclosureandAintreeUniversityHospitalNHSFoundationTrustshallapplyanyrelevantexemptions

whichmayexistundertheActtosuchreport.If,followingconsultationwithPwC,AintreeUniversityHospitalNHSFoundationTrustdisclosesthisreportoranypartthereof,itshall

ensurethatanydisclaimerwhichPwChasincludedormaysubsequentlywishtoincludeintheinformationisreproducedinfullinanycopiesdisclosed.

Thisdocumenthasbeenpreparedfortheintendedrecipientsonly.Totheextentpermittedbylaw,PricewaterhouseCoopersLLPdoesnotacceptorassumeanyliability,responsibility

ordutyofcareforanyuseoforrelianceonthisdocumentbyanyone,otherthan(i)theintendedrecipienttotheextentagreedintherelevantcontractforthemattertowhichthis

documentrelates(ifany),or(ii)asexpresslyagreedbyPricewaterhouseCoopersLLPatitssolediscretioninwritinginadvance.

©2015PricewaterhouseCoopersLLP.Allrightsreserved.'PricewaterhouseCoopers'referstoPricewaterhouseCoopersLLP(alimitedliabilitypartnershipintheUnitedKingdom)or,as

thecontextrequires,othermemberfirmsofPricewaterhouseCoopersInternationalLimited,eachofwhichisaseparateandindependentlegalentity.

Page 26 of 70

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Page 30 of 70

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Page 31 of 70

Co

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Page 33 of 70

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Page 35 of 70

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Page 36 of 70

Ca

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Page 37 of 70

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Page 38 of 70

Ca

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hat

pro

vid

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nce f

or

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and their fam

ilies

Page 39 of 70

Pa

tien

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in p

lace)

N

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pati

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esu

lts (

2014)

P

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s

iden

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9. C

G15

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Membership Committee Report

Report to Council of Governors

Date 5 May 2015

Committee Name Membership Committee

Date of Committee Meeting 3 February 2015

Chair’s Name& Title Jeanette Wilding – Staff Governor

Summary of Meeting

The meeting focussed specifically on the review of the Membership Strategy and the following

matters were discussed:

The involvement of governors in the monitoring and recruitment of members and in member

engagement

The role of the staff governor and the most appropriate mechanisms to inform staff of their

membership of the Trust

A review of the outcomes from the current Membership Strategy including the overall

increased membership numbers, young people, BME, Knowsley members and male

representation

The resources available to support the proposed engagement plan and the setting of realistic

objectives for membership recruitment and engagement for this year and the subsequent 2

years.

Recommendation

The Council of Governors is asked to note the report.

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Quality of Care Committee Report


Date 11 June 2015

Committee Name Quality of Care Committee

Date of Committee Meeting 14 May 2015

Chair’s Name& Title Mike Booth – Acting Chairman

Summary of Meeting

This was the second meeting of the Committee and the minutes of the previous meeting (12 February

2015) were approved. Mike Booth agreed to act as Chairman.

A presentation was provided on Infection, Prevention and Control highlighting the team, its roles and

responsibilities, its achievements for 2014/15 and its future goals and aspirations for 2015/16.

A paper was provided on the Quality & Strategy Annual Report for 2014/15. It was explained that of

the ambitious targets set for Year 1, some had been met or significant improvements had been made

during the course of the year and the Director of Nursing and Quality had been pleased with

progress.

The Committee discussed the Quality Strategy Year 2 Delivery Plan including details of the aims,

timescales, responsible leads and reporting processes in place.

A paper was provided on the Trust’s current mortality rates using the Standard Hospital Mortality

Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) methodologies. The

Committee noted the data was 9 months out of date and bore no correlation with the current position

within the Hospital. There had been a reduction in crude mortality which could be attributed to the

improvements put in place by the various workstreams.

The Committee received the patient experience improvement plan which provided an overview of the

performance for 2014/15 and highlighted the objectives and key performance indicators for 2015/16.

Discussion took place on the opening hours of the PACT centre and the method for how patients

leave non-urgent notes/messages when the centre was closed.

The Committee discussed the Forward Plan for 2015/16 and noted the plan would be added to when

other items are identified for discussion.

Recommendation

The Council of Governors is asked to note the report.

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Agenda Item (Ref) CG15-16/010 Date of Meeting: 17 June 2015


Report Title Membership Strategy

Executive Lead Caroline Keating, Associate Director of Corporate Governance/Board

Secretary

Fin McNicol, Associate Director of Communications

Lead Officer Mike Games, Corporate Governance Manager

Action Required Review

Report purpose The report provides an overview of the process undertaken to develop

a revised 3 year Membership Strategy for the Trust. The revised

strategy focuses on both membership recruitment and membership

engagement with a supporting implementation plan to achieve the

objectives set.

Strategic Priority (s)

this work supports

Deliver High Quality Safe Patient Care

Develop Effective External Partnerships

Deliver Our Service Commitments

Develop Staff’s Potential

Related BAF risk SR8 – External Relationships

AQUIP Ref N/A

Equality Impact

Assessment required?

No

Next Steps

Following discussion at the Council of Governors and feedback of

comments, arrangements will be made to set up a Task & Finish Group

to finalise the Strategy and the implementation plan for submission to

the Membership Committee for final approval in August. The revised

Strategy will be presented at the Annual Members’ Meeting on 30

September 2015.

REPORT HISTORY

Committee / Group Name

Agenda Ref

Report Title Date of submission

Brief summary of outcome

Membership

Committee

Review of

Membership Strategy

5 May 2015 Further work to be

undertaken on the

development of the

Strategy prior to

discussion at the formal

Council of Governors

meeting on 17 June

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Membership Strategy: Council of Governors 17 June 2015 2/3

Executive Summary

1. The report provides an overview of the process undertaken to date on the development of a

revised 3 year Membership Strategy (2015 – 2018).

2. The Strategy includes the following:

Its purpose

The vision for membership and the membership scheme

How to become a member and its exclusions

Targeted recruitment of members and methods to be adopted

Engagement with members

Monitoring success

Background

3. The previous 3 year Membership and Recruitment Strategy ran from September 2011 to

September 2014 and was reviewed annually by the Membership Committee in order to check

progress and set annual objectives.

4. A review of the strategy was required to build on progress made to date and to enhance the level

of engagement with our members whilst continuing membership recruitment in targeted areas.

This was initially discussed by the Membership Committee in February 2015 and then taken

forward by the Associate Director of Corporate Governance/Board Secretary, in conjunction with

the Corporate Governance Manager and Associate Director of Communications. The draft

Strategy was subsequently submitted to the Membership Committee in May 2015.

5. The Committee focussed on the content of the revised strategy with particular attention to

ensuring that any objectives set were capable of being delivered using the resources available.

In addition, the Committee reviewed the outcomes arising from the previous year’s recruitment

activity and the proposals for inclusion in the revised strategy. Members of the Committee were

asked to feed back further comments and a final version was developed.

6. It was agreed to present the draft strategy to the Council of Governors at its meeting on 17 June

2015 to provide an opportunity for wider feedback on the content and overall direction of the

strategy and its implementation plan.

Key Issues / Proposals

7. The strategy outlines the methods to be undertaken to recruit members and provides proposals

for targeted recruitment as well as continuing to focus on areas previously identified.

8. Engagement with members will be a key element of the new strategy and a variety of ways in

which the Trust will actively seek that engagement are proposed. Arrangements will also be

made to work actively with patient support groups and other stakeholder organisations to

promote membership.

9. The success of the implementation of the revised strategy will be measured by the following:

Recruitment – through the achievement of the recruitment targets agreed annually and

election turnout rate, benchmarked against other FTs

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Membership Strategy: Council of Governors 17 June 2015 3/3

Engagement – through feedback from members involved in engagement activity i.e

participation in surveys/focus groups; attendances at membership events, including Focus

On… Events and the Annual Members Meeting; election turnout rate, benchmarked against

other FTs

Recommendations

10. The Council of Governors is asked to review the document and provide feedback on the content

and overall direction of the strategy and its implementation plans.

11. Arrangements will be made to set up a Task & Finish Group to finalise the Membership Strategy

Implementation Plan.

12. Approval will be sought from the Membership Committee, on behalf of the Council of Governors,

to enable the strategy to be presented to the Annual Members’ meeting on 30 September 2015.

Author: Michael Games, Corporate Governance Manager

Date: 12 June 2015

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DRAFT

Membership Strategy

2015-2018

June 2015

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Aintree University Hospital NHS Foundation Trust Membership Strategy

2/15

Contents

Heading Page No.

Introduction 3

Purpose of the Strategy 3

Approval Process of the Strategy 3

Vision for Membership 3

Our Membership Scheme – Making Your Voice Heard 4

Who is responsible for recruiting members? 7

Engaging with members 8

Monitoring Success 11

Implementation of the Strategy 11

Appendices 13

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Introduction

1. Aintree University Hospital NHS Foundation Trust (“Aintree”) is a large teaching hospital

serving a population of around 330,000 in North Liverpool, South Sefton and Kirkby. It

provides high quality elective and emergency care services to meet the day-to-day needs of

its local community and also provides a number of high quality specialist services to a wider

population of 1.5 million across the North West and North Wales.

2. Aintree is committed to being a successful membership organisation and strengthening its

links with the local communities.

3. To be truly successful, a FT must maintain a membership that involves and reflects a wide

representation of its local communities. We recognise that we need to commit resources

both in time and effort to developing our membership and this strategy sets out the actions

that we will take in support of this.

Purpose of the Strategy

4. This strategy outlines Aintree’s vision for membership and the methods we intend to use to

identify and build an effective, responsive and representative membership. It also outlines

our future plans in terms of recruitment and engagement and how we will measure the

success of our membership and the implementation of this strategy.

5. The strategy aims to:

ensure that membership is representative of the community it serves

enable varying levels of participation according to individual needs and wishes

ensure a continuous approach to developing membership based on active engagement

Approval Process of the Strategy

6. The Strategy will be submitted to the Governors’ Membership Committee for discussion

and agreement. It will then be submitted to the Council of Governors for approval and the

Board of Directors advised.

Vision for Membership

7. Our vision is for the Trust’s membership to be active, engaged, involved and representative

of local communities, staff and the wider population that the Trust serves in order to support

the delivery of the highest quality of care and experience for our patients. Membership

activity will be compatible with involvement by people within groups with any of the

protected characteristics in line with the values of the NHS

8. Our aim is to build on the Membership Recruitment and Engagement Strategy 2011/14,

recognising that the continued focus on evolving of the representative membership body

provides the Trust with an opportunity to learn from, respond to and work more closely with

its patients, public, staff and volunteers.

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9. The Trust’s members are an essential part of Aintree’s future development as a Foundation

Trust with many of those living in the communities served by Aintree able to become

involved with or take an interest in the following:

Receiving information about Aintree and its activities

Attending Focus On… membership events and other Trust events such as open days

Taking part in Focus Groups, Consultations or other work to support service

development

Becoming a Governor or a Non-Executive Director

Voting in Governor elections

Expressing views and opinions about the services provided by Aintree University

Hospital

10. Public and staff members elect representatives to a Council of Governors which voices the

views of the members they represent and holds the Non-Executive Directors to account for

the performance of the Board of Directors. Governors are also responsible for engaging

with their members about the future strategy of the organisation. As a result, FTs are

accountable to the people they serve and to their staff.

Our Membership Scheme – Making Your Voice Heard

11. Membership is our way of developing a closer relationship with our local communities. It

provides us with an opportunity to engage with our members on matters they consider

important in relation to our services and their development. It provides our local

communities with a way to express their support for us.

12. However, we recognise that, if the membership scheme is to be successful and effective,

we must give our potential members a reason to want to take part. So, our members can:

help improve the quality of our services or of the patient/visitor experience

give their views on the Trust’s future plans

give their views on how they feel the Trust is performing

be consulted on any changes to the Trust’s constitution through the Council of

Governors

vote and stand in elections for the Council of Governors

attend the Annual Members’ Meeting

attend Focus On… events, Health Awareness Events and other events, which may also

be open to the general public

receive information on the Trust and its services

qualify for discount schemes where applicable

Membership is free and there is no obligation for members to get involved apart from

receiving the welcome letter, and interest survey when they initially join, and voting

packs when Council of Governors’ elections are taking place.

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Becoming a member

13. Membership is open to anyone who is a resident of NW England, a patient of the Trust

and/or their carer, who is aged 16 years and above, or all members of staff (see below for

exclusions)

They will be eligible to join one of two membership groups:

public constituency

staff constituency – divided into four “classes”

14. An individual cannot be a member of more than one constituency and a person who

satisfies the criteria for membership of the staff constituency may not become or continue

as a member of the public constituency (cf Aintree Constitution).

15. A person must complete a membership application form to become a member of the Trust.

These are available via a variety of mechanisms as indicated below. Members are not

required to provide any personal data beyond that needed to confirm eligibility for

membership:

via the trust’s website at www.aintreehospital.nhs.uk

by e-mailing [email protected]

by calling the Membership Office on 0151 529 4705

via Facebook (www.facebook.com/AUHNHS ) or Twitter (@AintreeHospital).

by writing to the Membership Office at Aintree House, Aintree University Hospital,

Lower Lane, Liverpool, L9 7AL.

Members can join more than one foundation trust.

Exclusions to membership

16. The following exclusions apply:

any person who has committed within the last five years a serious act of assault or

violence which has resulted in that person being prosecuted in relation to the act, or

one of more incidents of harassment, against any of the Trust’s employees or other

persons who exercise functions for the purpose of the Trust or against registered

volunteers.

any person who has been excluded from the Trust’s premises from which services are

provided.

any person who does not accept or does not abide by the NHS values and Patient and

Public Responsibilities, as contained in the NHS Constitution.

anyone under the age of 16

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Defining our membership community

17. Members from each of the constituencies defined below are able to vote for, or stand as, a

Governor from their constituency or class to represent them on the Council of Governors.

Public

18. Public members are recruited on an opt-in basis.

Staff

19. Staff have been divided into the following “classes”:

Medical

Nursing

Scientists/Allied Health Professionals

All Other Staff

20. Staff membership is available to the following staff groups:

Those who have a permanent employment contract

Those who are on a fixed term contract of 12 months or more

Those who have provided services for the Trust for at least 12 months

Staff membership is automatic unless the employee wishes to opt-out which they must do

in writing to the Membership Office (contact details as above). Opting out of membership

has no implications in relation to employment rights or responsibilities.

Membership Register

21. The Trust Communications Team maintains the register of public members. All public

members are made aware of the existence of the public register via the membership

application form and have the right to refuse to have their details disclosed (Data Protection

Act). Public members have a responsibility for letting the Trust know when their

circumstances change (ie. address) and when these may change their eligibility to belong

to a class/constituency of membership.

22. Staff membership is recorded on the Electronic Staff Record (ESR), as are opt out details.

The ESR is maintained by the Trust’s HR Department. There is no separate register of

staff FT members.

23. The public register is regularly validated to ensure that it remains as accurate as possible,

and that members continue to meet eligibility criteria, where the Trust is able to determine

this. The ESR is validated as appropriate in line with HR guidance.

Targeted recruitment of members

24. We wish to encourage and develop a strong sense of community involvement with the

membership scheme. Therefore, we will continue to actively recruit new members in all

categories. Whilst we encourage members to join at any time, we will continue to organise

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specific recruitment campaigns to attract new members as directed by the Membership

Committee. We have identified that in 2015/16 there will be a continued focus on recruiting

men, black & ethnic minorities and younger aged members. The Implementation Plan will

contain details of the actions required to deliver this targeted recruitment (Appendix I). .

Specific objectives for membership recruitment are identified at Appendix II.

Recruitment methods

25. The Trust carries out a range of activities which involve local communities, local businesses

and staff. Example methods of recruitment include:

holding engagement events at Aintree or having representation at other events held at

Aintree (e.g. health awareness campaign events)

attending public meetings and events

promoting membership through the media and social media

membership materials in departments across the Trust and community locations

targeted recruitment

Who is responsible for recruiting members?

26. All members of the Council of Governors are responsible for the recruitment and

engagement of members, supported by the Communications Team.

27. The (Associate) Director of Communications has lead responsibility for the implementation

plan that supports this strategy. The Communications (FT and Stakeholder) Officer

provides day-to-day support as part of a broader role. The role of the Membership

Committee is to develop the strategy and monitor it against the implementation plan.

28. The Council of Governors has responsibility for monitoring progress in membership activity

via the Membership Committee. The Board of Directors is kept advised via the quarterly

report from the Council of Governors and by the inclusion of membership data in the Trust’s

Annual Report.

Recruitment Plan

29. The Plan will be developed annually by the Communications Team in conjunction with the

Membership Committee, following the latter’s agreement of the recruitment targets.

Delivery of the plan will be subject to available resource and the level of involvement from

Governors.

Media

30. Free media (including social media) coverage will be sought to highlight membership

opportunities. Media will always require a Governor to act as a spokesperson/interviewee,

and appropriate support will be provided by the Communications Team to Governors willing

to do this.

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31. The Aintree Twitter and Facebook accounts will be used to promote membership, and

Governors who wish to use these methods will be supported in developing social media

skills.

Staff

32. New staff are given an overview of membership at induction and are made aware that their

interests are represented by the Staff Governors. The Trust aims to ensure that 1% or less

opt-out of the membership scheme.

Engaging with members

33. We see engagement with our members as important as their recruitment. Engagement

with our members enables us to have an effective and active membership.

34. In order to involve the membership as effectively as possible, we collate information on

members’ areas of interest. On joining, members are asked to confirm their interests so

that a tailored programme of events can be considered. In 2014, a member survey was

undertaken to identify health areas of interest; these are identified in Chart 1 below.

Historically, response rates from members have been low and the response from this

survey was no exception. The Membership Committee will address this as part of the

Engagement Plan (see overleaf).

Chart 1: Member Interests

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Engagement Plan 2015 -2016

35. Positive engagement with our members is extremely important and we are continually

seeking ways of improving and increasing this. Aintree has three levels of public

membership:

Level 1 (89% of members) – a basic level of membership, involving the receipt of

newsletters and information

Level 2 (5%) – an enhanced level, where members have expressed an interest in

becoming involved with activities at Aintree

Level 3 (5%) – the top level, where members have also expressed interest in becoming

a Governor

1% of members have not indicated a preferred level.

36. The focus of engagement will be on members in our local catchment area and in 2015/16

will include the following:

Welcome Packs

37. Welcome packs will be issued to all new members. Packs include a membership card,

information on membership and the local discount scheme, and a feedback form on areas

of interest within the Trust.

Members’ Magazines/Newsletters

38. During 2015/16, the Trust will be working towards combining the current Members’

magazine and Staff magazine with the issue of a re-launched Aintree News. The intention

is to provide members with more of an insight into Aintree.

Annual Members Meeting

39. Members will be invited to attend the Annual Members’ Meeting to hear more about the

Trust’s achievements and also to have the opportunity to ask questions of the Board of

Directors and senior managers.

Focus on ….. Events

40. We will be hosting four sessions each year to inform our members about specific health

issues that they are interested in or developments, clinical studies, changes or

improvements in the services we provide. These events will be promoted via the Trust’s

website and by posters throughout the Trust.

Quality Account

41.. Members will be invited to provide their comments on the Trust’s Annual Quality Account in

addition to other key stakeholders within the community.

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Social Media

42. The Trust will promote membership and engage with members through all appropriate

social media channels.

Governors

43. Governors have opportunities to engage with members at the events identified in this

strategy. They can use these events to ask members:

what they think we are doing well and not doing well

what they think we should be doing, but are currently not doing adequately, or at all

Our Governors will feed this information back to the Trust via the Council of Governors.

44. The members of the Council of Governors will play a pivotal role in the engagement of

members. They will need to continue to be accessible, with a high profile, in order to gather

the views of their constituents. This will be through (but not limited to):

Governor ‘drop in’ events at the hospital

attendance and engagement at Trust member events, health events and local

community events

formal Council of Governors’ meetings – open to the public and promoted on the Trust

website

Social media

45. The Trust will enhance the Governors’ profiles through promoting the Council of Governors

and its members on the website and in the Trust.

Staff Governors

46. Staff Governors are advised at elections of their responsibilities and the extent of their

remit; details will also be available on the intranet. Bespoke sessions for staff governors to

facilitate developing effective engagement with their members are considered in year and

taken forward as required.

Patient Experience

47. We will work closely with the Patient Experience Team to improve members’ engagement

around patient based forums and surveys. These are effective ways in which members are

able to influence the development of services.

Partners

48. We will work actively with patient support groups, Healthwatch, health charities, third sector

organisations, GPs and the local authorities in Liverpool, Sefton and Liverpool to promote

membership.

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Monitoring Success

49. The Membership Committee has a key role in the development of the Membership Strategy

and monitors it on behalf of the Council of Governors through the implementation plan that

supports delivery of the strategy.

50. The (Associate) Director of Communications has lead responsibility for the implementation

plan that supports this strategy. The Communications (FT & Stakeholder) Officer provides

day-to-day support as part of a broader role.

51. An annual review of the strategy will be undertaken by the Associate Director of Corporate

Governance and the (Associate) Director of Communications, and provided to the

Membership Committee for noting of progress and approval of actions to be delivered in the

subsequent year.

How will success be measured?

52. The success of the implementation of the Strategy will be measured through membership

recruitment and engagement. Recruitment will be measured by the following criteria:

achievement of the recruitment targets agreed annually


53. The success of member engagement will be measured by the following criteria:

feedback from members involved in engagement activity i.e participation in

surveys/focus groups

attendances at membership events, including Focus On… Events and the Annual

Members Meeting


Risks

54. Risks will be identified and assessed for all activity supporting the strategy. These will be

monitored as part of operational delivery.

Implementation of the Strategy

55. The Strategy will be implemented through an Implementation Plan which includes different

workstreams with lead responsibility and milestones identified. A draft Implementation Plan

is at Appendix I. Detailed action plans sit beneath each of the workstreams.

Next Steps

56. Following discussion at the Council of Governors in June 2015 and feedback from

members, a Task & Finish Group will be set up to finalise the Strategy and

Implementation Plan. Approval will then be sought from the Membership Committee,

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on behalf of the Council of Governors, to enable the Strategy to be presented at the

Annual Members’ Meeting in September 2015.

57. Monitoring of delivery of the Strategy will be taken forward by the Membership

Committee and the Council of Governors advised via the quarterly assurance reports.

58. All members of the Council of Governors will be expected to be involved in the

implementation of the Strategy. This links to the Council of Governor’s annual

objectives.

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Page 61 of 70


15/15

Appendix II Proposed Membership Recruitment Objectives

Groups to be targeted in Year One (2015-16) of this strategy:

Members in areas where there is the greatest difference between patient referrals and

membership levels in Sefton, Liverpool and Knowsley.

Carers of patients

Members aged below retirement age

Young patients in transition from Alder Hey

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Report Title Outcome of Self-Assessment 2014/15

Executive Lead Caroline Keating, Associate Director of Corporate Governance/ Board

Secretary

Lead Officer Michael Games, Corporate Governance Manager

Action Required Review

Report purpose The report provides the Council of Governors with details of the output

from the responses to the self-assessment questionnaire. It also

provides evidence that the Council of Governors has undertaken a

formal review of its effectiveness and determined appropriate

development plans to improve upon its performance


this work supports





Related BAF risk SR6 – Leadership – Failure to provide effective leadership at every

level

SR8 – External Relationships – Failure to develop effective external

relationships and alliances

AQUIP Ref N/A

Equality Impact


No

Next Steps

The outputs from the self-assessment questionnaire will be considered

as part of the Governor Development Day scheduled for 16 September

2014 for future development and improved performance.

REPORT HISTORY


Agenda Ref



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CoG Self- Assessment Report: Council of Governors – 17 June 2015 2/4

Executive Summary

1. The report provides an overview of the process undertaken to seek the views of the members of

the Council of Governors (CoG) on their statutory role, structure of meetings and membership

matters.

2. In addition, members of the Council of Governors were asked to provide their comments on three

specific questions, the key themes from which are highlighted in this report.

3. There were 14 out of a potential 21 (67%) members of the Council who responded to the

questionnaire.

Background

Structure of the Review

4. The views of the members of the Council of Governors were sought through the completion of a

self-assessment questionnaire and submitted to the Corporate Governance Manager to preserve

anonymity. Governors were also given the opportunity to provide supporting comments and these

have been summarised later in this report.

5. The output from the review will be used as part of the Governor Development Day in September

2015 to determine future development requirements and seek improvement in performance and

effectiveness


Output from Self-Assessment Questionnaire

Statutory Role

6. Overall respondents were in agreement that they understood their statutory duties particularly in

relation to holding the NEDs to account and the difference between their role and that of the Board

of Directors.

7. There was overwhelming agreement that Governors receive sufficient information about the Trust’s

performance. In addition, Governors fully agreed that they had fulfilled their statutory duties for

NED appointments.

8. Governors also agreed that they understood the key risks facing the Trust in delivering its

objectives.

9. One respondent disagreed that they had fulfilled the duty of holding the NEDs to account and

another did not believe that they had been sufficiently engaged in the Trust’s forward planning

processes.

CoG Structure/Meetings

10. 11 respondents agreed that they had received sufficient training to fulfil their role but there were 3

respondents who disagreed with this statement.

Page 64 of 70



11. In terms of the remaining questions, Governors agreed that:

Meetings were effective with outcomes valued and followed up by the Trust

Meeting agendas are relevant and adequate time was given for discussion

They felt respected and valued for the contributions they make (1 respondent did not agree

with this statement)

Meetings were chaired effectively

They felt comfortable when given the opportunity to speak

Executive Directors were available to answer questions raised by Governors

Meeting and working groups attended were effective and contributions valued.

12. In regard to the amount of time required for the role, 7 Governors responded that it was as

expected, 3 responded that it was more than expected and 4 stated that it was reasonable.

Membership

13. 10 respondents believed that there was an effective membership strategy in place but there were 2

who disagreed with this statement (with 2 responding with N/A).

14. There were 9 respondents who were satisfied that that the profile of Governors within the Trust and

externally was sufficient but there were 5 who did not believe that this was the case.

15. 8 respondents expressed agreement that they have sufficient communication/contact with FT

members in their role as governor but there were 6 who did not agree with the statement.

Comments

16. In response to the question ‘Where do you feel you have made an impact as a Governor?’ the

following key themes arose:

The opportunity to confidently challenge and seek clarification from the Board of Directors

Involvement in the appointment process for the Medical Director and Non-Executive Director

Being able to attend a variety of meetings, events and other fora

Dealing with members’ complaints and raising awareness of patient care issues

17. In response to the question ‘Are there are any areas where you would like to have more

involvement?’ the following key themes arose:

Further involvement in the quality of customer care, development of the new trauma centre,

membership and chaplaincy

Further involvement in car parking issues and the work of the volunteers

An understanding of the procurement process

18. In response to the question ‘Where do you feel that the Council of Governors has made an

impact?’ the following key themes arose:

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Constructively challenging the Board of Directors whilst also building good relationships with

the NEDs and Executive Directors

Monitoring performance and highlighting areas of common public concern, scrutinizing the data

and receiving structured answers to pertinent questions

Supporting the Trust in its successful CQC inspection

19. In response to the question ‘Are there any areas which you consider that the Council of

Governors should become involved in?’ the following key themes arose:

Increase in member contact and using the membership database more effectively to engage

with them in a more focussed fashion

Listening and communicating with stakeholders by holding fora/surgeries in the community

Shadowing staff to understand their work and concerns as well as patients and visitors

A thorough understanding of the financial pressures facing the Trust.

Areas for Development

20. Based on the responses provided to the questionnaire, it is suggested that the following areas be

considered for future development:

Continue to offer/provide training opportunities for Governors at varying times of the day

Implementation of the revised Membership Strategy taking account of Governor

involvement/communication with members and the more effective use of the membership

database

Review of areas for future involvement of Governors

Promotion of the profile of the Governor role, function and responsibilities

Recommendation

21. The Council of Governors is asked to note the outcome of the self-assessment and agree that

areas for development be taken forward.


Date: 10 June 2015

Page 66 of 70

Co

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1/3



Report Title Lead Governor and Deputy Lead Governor

Executive Lead Neil Goodwin, Chairman

Lead Officer Caroline Keating, Associate Director of Corporate Governance/ Board

Secretary

Action Required Approval

Report purpose To inform the Council of Governors of the process undertaken to

source a new Lead Governor and Deputy Lead Governor in light of the

elections held in February/March 2015 and end of term of office.


this work supports





Related BAF risk SR 6 – Leadership – Failure to provide effective leadership at every

level

AQUIP Ref N/A

Equality Impact


Yes/No (if yes, assessment attached)

Next Steps

REPORT HISTORY


Agenda Ref



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Lead & Deputy Lead Governor Nominations: Council of Governors – 17 June 2015 2/3

Executive Summary

1. The report provides the Council of Governors with a brief overview of the process undertaken to

source a new Lead Governor and Deputy Lead Governor of the Trust

2. It also confirms the proposed appointment of Pamela Peel as Lead Governor for a term of office of

12 months. In addition, it is being proposed that Lorraine Heaton be appointed to the position of

Deputy Lead Governor for a term of office of 12 months.

Background

Regulatory Requirements and the Trust Constitution

3. The NHS Foundation Trust Code of Governance, published by Monitor, contains a section relating

to the role of the nominated lead governor which highlights that the role is largely to facilitate direct

communication between Monitor and the Trust’s council of governors.

4. Annex 5 of the Trust’s Constitution states the following:

The Council of Governors shall appoint one of the Governors to be Lead Governor of the

Council of Governors. The Lead Governor may be a Public Governor, an Appointed

Governor or a Staff Governor.

The term of office of the Lead Governor shall be 12 months. A Governor may be re-

appointed as the Lead Governor by the Council of Governors at the end of that term. Only

in exceptional circumstances would a Lead Governor serve for more than 2 years.


5. The Trust held its public elections during February/March 2015 instead of June/July 2015 to tie in

with the by-elections called following the resignation of two Staff Governors. As a result of the

public election, the current Lead Governor was unsuccessful in retaining his seat and will

subsequently stand down at the end of his term of office on 31 July 2015.

6. In addition, the term of office of the current Deputy Lead Governor will end on 31 July 2015 as a

result of the Governor concerned fulfilling a six year consecutive term of office.

7. It was, therefore, necessary to source nominations from the current Council of Governors for the

positions of Lead Governor and Deputy Lead Governor. The Board Secretary wrote to the Council

of Governors on 22 May 2015 seeking expressions of interest for both roles.

8. The Trust received the following nominations:

Lead Governor – Pamela Peel (Public)

Deputy Lead Governor – Lorraine Heaton (Staff)

9. It should be noted that two other Governors had indicated they would put their names forward for

Lead Governor but only if no firm nominations were received from other Governors. As this was

not the case, this was not pursued.

Page 69 of 70


Lead & Deputy Lead Governor Nominations: Council of Governors – 17 June 2015 3/3

Implications

10. The Council of Governors is required to appoint a Lead Governor in accordance with the

regulations to act as the conduit between Monitor and the Council of Governors as well as

Governors and the Board of Directors.

Recommendation

11. It is recommended that the Council of Governor approves the appointment of Pamela Peel as Lead

Governor for a term of 12 months and that Lorraine Heaton be appointed as Deputy Lead Governor

also for a term of 12 months.


Date: 8 June 2015

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Documents

COUNCIL OF GOVERNORS AGENDA - Aintree University Hospital...Portfolio Acting Director of Finance & Business Services ... CG 15 -16 /00 7 (d/p) (circulated in advance ) Council of Governors