board of directors in public - northumbria · 2018-02-28 · board of directors in public meeting 1...

Board of Directors in Public

MEETING

1 March 2018 10:00

PUBLISHED

27 February 2018

Agenda

Location Date Owner Time

Hexham General Hospital 1/03/18 10:00

1. Opening matters 10:00

1.1. Apologies for absence and declarations of interest - verbal -to note

Chair

1.2. Minutes of the previous meeting dated 19th October 2017 -(Enc 1) - to approve

Chair

1.3. Action log & matters arising - (Enc 2) - to approve Chair

1.4. CEO’s report inc. Well-led review update- verbal - to note CEO

1.5. Chair’s report- verbal - to note Chair

2. Quality

2.1. Patient and staff stories- (Enc 3a & 3b) A Laverty 10:15

2.2. Patient experience update- (Enc 4) to note A Laverty 10:25

2.3. Board walk round- verbal - to note M Knowles/EMonkhouse

10:35

2.4. Learning from deaths report- (Enc 5) - to note J Rushmer 10:45

2.5. Guardian of Safe Working - (Enc 6) to follow J Rushmer 10:55

2.6. Medicines optimisation annual report- (Enc 7) - to note D Campbell 11:05

3. Performance and regulatory items

3.1. Finance report (Enc. 9) - to note P Dunn 11:15

3.2. Regulatory report (Enc. 10) - to note B Bartoli 11:25

3.3. Assurance Framework- (Enc 11) - to note P Dunn 11:35

3.4. Health & Safety - (Enc 12) - to note S Bannister 11:45

3.5. Charitable funds report- (Enc 13) - to note C Riley 11:50

4. Any other business

2

1

Board of Directors

Held in Public

Thursday 19th

October 2017

Cobalt Conference Centre

Present:

Alan Richardson Chairman

Allan Hepple Non-Executive Director

Moira Davison Non-Executive Director

Malcolm Page Non-Executive Director

Alison Marshall Non-Executive Director

David Chesser Non-Executive Director

Martin Knowles Non-Executive Director

Peter Sanderson Non-Executive Director

Birju Bartoli Executive Director of Performance & Governance

Ann Stringer Executive Director of Human Resources

Debbie Reape Interim Executive Director of Nursing

Daljit Lally Executive Director of Community Services

Jeremy Rushmer Medical Director

In Attendance:

Sophie Stephenson Company Secretary

Claire Riley Director of Communications and Corporate Affairs

Annie Laverty Director of Patient Experience (agenda item 2.1 and 2.2 only)

Chris Platton Director of Nursing – Delivery (agenda item 3.2 only)

Nikhil Premchand Consultant – Infectious Diseases /Acute Medicine (agenda item 3.6

only)

1.1/10/17 Apologies for absence

Apologies were received from David Evans, Chief Executive.

1.2/10/17 Declarations of interest

The Chairman noted that the register of interests was on the agenda for consideration. No interests

were declared in relation to specific items on the agenda. Board members were reminded to

ensure interests are actively declared and to ensure the register is kept up-to-date.

1.3/10/17 Minutes of the previous meeting

The minutes of the Board of Directors meeting held in public on 19th

July 2017 were reviewed and

noted.

3

2

1.4/10/17 Matters arising

No matters arising were noted.

2. Quality

2.1/10/17 Patient story

A ie La e t p ese ted the patie t sto a d e phasised the positi e e pe ie e fo the patie t s

family despite a tragic outcome. The Board noted that the story exemplifies excellence in critical

care in particular. Discussion followed regarding the support provided to staff who care for patients

in similarly challenging situations. It was noted that resilience training is offered, health and

ell ei g of tea s is o ito ed, a d that the T ust s o upatio al health department has a number

of services (including psychological services) which are accessed by staff across the Trust, including

staff in similar services to those outlined in the patient story. The Chair informed the Board that

staff stories would be introduced to Board meetings in the near future.

The Board noted the patient story.

2.2/10/17 Patient Experience quarterly report

Annie Laverty summarised the report and highlighted the following:

All domains in the Patient Perspectives data have statistically increased since the Trust first

started measuring the data. The Trust is performing in the top 20% of Trusts across in-

patient and out-patient areas, however, one area in which the Trust is not in the top 20%

elates to the uestio efo e the t eatment, did a member of staff explain what would

happe ? 2017 could be the first year in which the Trust has not recorded a statistical year-on-year

improvement in its real-time data. The Board discussed the possibility that the Trust has

ea hed a eili g i te s of its pe fo a e, ho e e , assurance was provided that the

data, including free text comments, would be thoroughly analysed in order to ensure any

further areas of possible improvement were identified.

There has been a 10% adverse movement i patie ts defi itel gi e e ough suppo t f o health a d so ial se i es du i g t eat e t i the Natio al Ca e Patie t E pe ie e survey which is a key area of focus for clinical teams.

The Trust has established a Patient Experience Collaborative which involves supporting the

patient experience services in 11 organisations. This forms part of the Acute Care

Collaboration Vanguard.

The Board discussed the observations made by Dan Wellings f o the Ki g s Fu d o a e e t isit to the Trust and its patient experience department, and noted in particular his comments regarding

digitising aspects of the patient experience service.

Dis ussio follo ed ega di g the ef esh of the T ust s st ateg a d, i pa ti ula , the eed to e mindful of patient experience data in any proposed changes to clinical pathways.

The Board noted the patient story.

4

3

2.3/10/17 Corporate Safety & Quality Report

Birju Bartoli presented the report and drew the attention of the Board to the following:

The Trust has met the four hour A&E target for quarter 2 and confirmation has been

received from NHS Improvement that the Trust will receive STF monies associated with the

target.

The Trust has met its target for referral to treatment times (RTT) for incomplete pathways,

however, it was noted that the number of patients waiting between 42 and 52 weeks for

treatment has increased which is a key area of focus for the Delivery team.

The Trust has missed the target for 62-day cancer waiting times GP referral to treatment.

The actio pla as e ie ed the Boa d s Fi a e, I est e t & Pe fo a e Co ittee on 16

th October 2017.

The e has ee a sig ifi a t i p o e e t i the T ust s o plai ts espo se ate.

The Board noted the Corporate Quality & Safety Report.

2.4/10/17 Register of interests, gifts and hospitality

The Board noted the Register of Interests.

3. Strategy

3.1/10/17 Strategic refresh

Birju Bartoli briefed the Board on activities planned during October and November 2017 to refresh

the T ust s st ateg , including a Board away day on 8th

November 2017 which will focus on

undertaking a SWOT analysis and reviewing feedback gathered to date from senior leaders including

clinicians throughout the Trust. It was also noted that following a positive discussion at Clinical

Policy Group on 13th

October 2017, clinical leaders are working with business units to provide

feedback to the Executive team on the strategic refresh.

The Board noted the update.

3.2/10/17 Supportive/additional roles – 3 month review of the pilot

Chris Platton summarised the report by emphasising the success of the ward medicines assistant

posts and the need for further work to be undertaken regarding the source of funding for additional

roles. It was also noted that CQC is supportive of the T ust s pla s ega di g suppo ti e oles.

Discussion ensued regarding the need to align the on-going work about supportive and additional

roles with the use of beds throughout the Trust.

The Board noted the report.

5

4

3.3/10/17 Workforce report

Ann Stringer introduced the report and highlighted the following matters to the attention of Board

members:

Staff sickness levels continue to improve, however, this is expected to plateau as a minimum

given that the Trust is entering the most challenging time of year from a sickness

perspective.

Appraisal rates and statutory and mandatory training rates have deteriorated and are being

closely monitored by the Workforce Committee and Executive Director of Human Resources.

8b and above appraisal workbooks now include a section on succession planning, following

findings outlined in the 2016 Well-led review.

Following investment in a staff physiotherapy service, there has been a significant reduction

in staff sickness related to muscoskeletal issues.

The recruitment tool used by the Trust is due to change from Stepchange to Trac – this

should streamline the recruitment process by automating steps such as reference requests.

The Board was otified of a sig ifi a t isk asso iated ith the T ust s E“‘ s ste , the license for

which is due to expire in December 2017, and discussion ensued regarding the risks and possible

impact of this risk.

Board members discussed the need to recognise the positive shift in sickness absence and it was

agreed:

Action 1: A letter to be drafted and sent out to congratulate staff for the significant reduction in

staff sickness levels.

Action for: Claire Riley/Ann Stringer

Action by: November 2017


3.4/10/17 Corporate Financial Compliance Report

Paul Du p ese ted the fi a e epo t a d highlighted the T ust s ash positio fo dis ussio the Board. It was noted that, following the Finance, Investment & Performance Committee on 16

th

October 2017, approximately £6m of NHS cash payments had been received.


3.5/10/17 Key Issues Reports

The Board noted the reports for Finance, Investment & Performance Committee and Safety &

Quality Committee.

6

5

3.6/10/17 Guardian of Safe Working report

Nikhil Premchand provided a brief presentation which highlighted the key themes within the report.

The Board discussed the number of exception reports from December 2016 to October 2017 and

also the impact on locum spend. Discussion followed regarding different ways to communicate with

junior doctors and the need to ensure IT infrastructure, including inbox sizes, is appropriate.


Questions from the public

No questions were posed to the Board from members of the public.

Any other business

The Chairman e p essed his deep g atitude o ehalf of the Boa d of Di e to s fo Da id E a s leadership over the past two years in his role as Interim Chief Executive. He noted that David Evans

would be stepping down from this role at the start of November 2017, following the end of Jim

Ma ke s se o d e t to NH“ I p o e e t.

The Chai a also e plai ed that it as De ie ‘eape s last Boa d of Di e to s eeti g efo e she retires. He thanked her for 38 years of service to the NHS as well as praising her exemplary

leadership in the role of Executive Director of Nursing and collaborative working style.

MEETING CLOSED

7

Key:

Not achieved and overdue

Action delayed

On track for timely completion

Completed

Action Log Board of Directors Committee (Public) October 2017

There are no live actions outstanding

Ref. Action Owner Date

raised

Deadline Status

Completed actions [include actions completed at the previous meeting]

Ref. Action Owner Date

raised

Deadline Status

TB1/10/17 A letter to be drafted and

sent out to congratulate

staff for the significant

reduction in staff sickness

levels.

Claire Riley/Ann

Stringer

19/10/17 Nov 17

Enc.

2

8

Patient Story WGH Ward 10 January 05 2018 Female age 80

Patient gave consent for story to be used but did not consent to name being used

I ha e ’t ee i hospital si e y hildre ere or o er 50 years ago. I have had 2 knee

replacements in the last 3 years. My right knee was performed by Mr Emmerson in 2014, my second

(this time) by Mr Asaad.

Both of my surgeries were planned. I received a letter to attend the pre-op assessment unit. I had

bloods taken, an ECG and a list of questions to answer by Meg the pre op nurse. I saw her the 1st

time and she was lovely and kind so I was delighted to see her the second time. The letter stated it

ould take up to 3 hours for the pre op he ks to e do e. It did ’t take that at all – I was in and out

within 90 minutes.

There have been some changes over the years. My first operation went smoothly. I had the spinal

i je tio a d I did ’t k o a ythi g else u til I oke up in recovery. This time I could hear banging

a d rashi g. I ould ’t feel a ythi g ut the usi did ’t dro out the oise ery ell. The anaesthetist comforted me. She said everything was under control and it was. I needed to stay a bit

longer in theatre because my heart rate dipped. I heard the nurse talking to the anaesthetist and

they ere ’t too concerned, just kept a closer eye on me. The nurses in recovery were smashing. We

had a lovely chat and I realised I live a few doors from her mother!

After the 1st

operation I was put into a wonderful chair. It was a recliner and a lovely warm blanket

placed on top of me – it was a very soothing experience. This time it was all very quick. Not

uncomfortable but I was back on the ward quicker than expected.

When I came to the ward I was offered something to eat straight away – that did ’t happe last time. I as ’t as drowsy or confused either. I had trouble getting comfortable in bed. The new beds

have a locking mechanism on to keep the bed in the same position. The nurses positioned me just

right and I never moved. It is the small difference between being in pain all night and being

comfortable. The medication alongside the ice pack on my knee has worked well.

I was up and walking the very next day. Not too far but it was a good start. The physios have been

marvellous. I walked slowly but they soon had me walking at a quicker pace. I have also had a stair

assessment and I am ready for home.

My son said I was looking well and I actually feel good. I wish I had done this years ago. I think a

mixture of professionalism and good quality care has made me feel as well as I do. I am going for a

bit of rehabilitation, just for a bit of extra support but I can’t fault my experience as a whole. The

food is exceptionally good and the company is great! The ward was bustling with life yesterday, with

patients coming and going. Today it is a lot calmer. The ladies that bring the tea round could make

anyone smile. I have had a laugh and a bit of banter. The nurses have approached me with a happy

and caring attitude.

I a pleased I do ’t eed to ha e a y other operatio s; however I would have no problems

recommending the ward or both surgeons to a friend or family member.

9

Staff story collected 04/01/2017 Ward 1 NSECH Band 3 Assistant

Consent given

I spend a lot of time individually with patients who make my work meaningful and purposeful. A lot

of patients I care for need a lot of assistance with eating and drinking. I enjoy encouraging people to

eat and drink, it puts them on the road to home.

Mostly the ward staff on this ward do get their breaks but sometimes it is literally a quick slurp of

tea. No o e e er tells e I a ’t take a reak or ot to take reak. It is my choice if I do miss a

break; I prefer to get all of my work done.

I thi k a lot of tea eeti gs e ha e are e hausti g as e do ’t e er see to ake a progress or decide one way or another. It is really hard to stick to an agenda as people go off on tangents and

in different directions. Sometimes it does feel chaotic. Lately nutritional meetings have changed and

do follow a more structured format with a strict agenda, a chairperson and another keeping a check

on time. This way has a much better outcome.

I do enjoy my job; I love my job. The getting out of bed would still be hard for me even if I had the

easiest job in the world. I am not a morning person but I do love this job.

I tend to structure my day, I have a routine and structure to make sure everything is completed and

recorded. This is often the case as opposed to a very often feeling in relation to you asking me

whether I have unachievable deadlines. As some days the patient workload can be more demanding.

I do really enjoy caring for other people. We had a gentleman a couple of months ago, who was in

alcohol withdrawal, and he as i a poor state. He had ’t ee eati g or dri ki g ell. Alo g ith the team we persevered with him, encouraging and caring for him. I built a good rapport with him

and built up hi eating and drinking. One month later he left us. He was in remission from his

alcoholism; he was no longer confused but now able to look after himself and had gained a stone in

weight. I am filling up now thinking of him. Recalling stories like this puts my faith back into

humanity.

There are times when relationships at work do get strained; we are all just human after all.

So eti es people do ’t al a s see e e to e e ut ge erall e are a good working team who all

support each other.

I do have say over how I work but I do have some challenges. I have a barrier with the catering staff

yet to overcome but we are getting there.

The team here do acknowledge and tap into ea h other’s skills a d e pertise ut e role as ’t fully understood when I first started. I found it hard that when I was on leave I would come back to a

lot of missed things. However now everyone has a greater understanding of the role and we have

seen better results around nutrition.

10

Time flies when I am at work because I stick to my structure and I have to meet my deadlines. Plus I

do enjoy what I do so time never drags.

Sometimes I can get myself into a bit of a flap when I have so much to do, but if I follow my structure

I can always achieve my goals.

I do ’t a t to sound cocky but I have a lot of care in me, I support patients and their families. There

has been a lot of bad press, nationally, about patients being malnourished in hospital. That makes

e feel ad e ause here i Northu ria that just is ’t true.

I have a good relationship with my manager, even if I just go in and have a rant. It gets everything off

my chest, and then I can go and get on with my day.

Most staff on this ward are able to tune into and understand each other sensing how we are feeling.

I personally have worked in other role so I do understand their work pressures. I can help them too; I

juggle things around to help out. Yesterday for example I was taking patients to theatre. Everyone is

like that here just willing to help on another.

Some days are of course more difficult than others. Before Christmas we had a tough time. We were

short staffed with five level 4 patients. The ward was full. It was just manic!! Well I had a tea party

planned; I asked if it was okay to go ahead thinking it would also help boost staff morale too. I was

given the go ahead and brought our patients together so we could watch them all at once. It

boosted staff, staff were smiling everyone took turns to join us for a cuppa. Junior doctors and

pharmacy staff too. It was really nice. The most important thing for me that day was that the

patie ts did ’t k o ho e ere all feeli g a d that the ard is struggli g. We a aged that. O e relative, a husband visiting his wife, said that the tea party was the first date they had had in 25

years.

Da s he e are ot struggli g are reall i e. I do ’t just sit ith patie ts ho eed at hi g. I ha e the ti e to sit ith our patie ts ho do ’t ha e a isitors. It is just a drea .

11

Title of Report Improving Patient Experience – 1st March 2018

Author Annie Laverty / Paul Drummond

Executive Lead Annie Laverty

Executive Summary Patient perspective results: Feedback from 2202 patients : Excellent

performance – 96% of inpatients, 98% of outpatients and 98% of patients

receiving day case care rating their experience as good, very good or

excellent. The Trust performs very well with all benchmarked national

data for performance overall. Waiting times to seeing a doctor or nurse,

pain control and Information on the purpose of medicines in emergency

care are recognised areas for improvement. There is considerable

variation across sites for emergency care – a difference of 10% comparing

the Hexham urgent care experience with urgent care service users at

North Tyneside and Wansbeck. Whilst this variation exists, all emergency

care sites sit within the top 20% nationally.

Real Time 2017: Feedback from 7726 patients: The Norovirus and flu

outbreak meant that the real time programme was suspended in January.

Analysis of whole year data shows high quality care has been consistently

being maintained across the Trust when compared with 2016 results. This

attainment is in keeping with national results and the highly positive

externally validated Patient Perspective feedback for inpatient care.

National Maternity Survey 2017: The National Maternity Survey results

highlight an area of care where the Trust has the greatest opportunity to

improve. Performance is very consistent with previous results in 2015

suggesting that overall the maternity experience has not improved since

the opening of The Northumbria. Whilst the Birth and Labour experience

was rated within the top 20% of Trusts, Antenatal and Postnatal care was

placed within the Middle 60% of Trusts. Full survey performance and

subsequent action planning to be taken through safety and quality

committee. The Patient experience team are currently supporting

improvement work to establish an innovative Birth Reflection Pathway as

part of the national Maternity Challenge fund.

Friends and Family Test: Feedback from 8057 patients: No meaningful

change this quarter. Response rates remain low and fell further in

December due to competing pressures within the system. Friends and

family scores for emergency care are below the national average, this

finding is not in keeping with national survey data nor monthly

benchmarked data provided by patient perspective and reflects the mode

of data collection. The ED response rate has remained at 8% in line with

the target set by commissioners of 6%

Patient experience network awards March 1st 2018 – Named Trust of the

Year for the last two years, the excellent work of Northumbria teams has

once again been recognised this year with the Trust shortlisted as finalists

in 8 categories.

12

Recommended

actions required by

Board/committee

Trust Board members are asked to note the contents of this report and

that the Trust is demonstrating a strong overall performance towards

achieving our strategic aims.

1 2 3 4 5 6Link to strategic

objectives

(please tick)

Strategic objective

reference

3.1 Patient Experience

Caring Responsive Well-led Effective SafeLink to CQC KLOE

(please tick) Compliance/

regulatory

requirements (if

applicable)

CQUIN and CQC requirements for safe, caring and responsive care.

Financial impact?

13

Board of Directors Meeting 1st March 2018

Patient Experience Update

14

Patient Perspective data.

Inpatient / Day Case & Outpatients.

15

Patient Perspective Data – IP / DC / OP

Overall satisfaction, (rating the inpatient service as Excellent, Very good or Good)

Patient Perspective Data: Inpatients (n=893)

Patient Perspective Data: Outpatients (n=998)

Q3 Oct-17 Nov-17 Dec-17

N % N % N %

Inpatient 224 95.7% 112 98.3% 148 94.9%

Day Case 109 98.2% 134 97.8% 139 98.6%

Q3 Oct-17 Nov-17 Dec-17

N % N % N %

Outpatients 332 98.4% 655 97.9% 446 99.3%

16

Patient Perspective Data – Inpatients Q3

In this quarter, the inpatient results continue to be very good.

• The average score for the Trust is 88.3%, well within the top 20% of

Trusts in England (threshold 84%).

• The Trust is in the top 20% of all trusts for all 19 of the most

important questions for patients.

• 96% of inpatients rate the Trust as excellent, very good or good.

Hospital Score Respondents

Hexham General Hospital 94% 58

Wansbeck General Hospital 89% 86

NSECH 87% 257

North Tyneside General Hospital 85% 86 17

Overall, for the Trust, results remain good in all areas, but particularly:

• Overall ratings, respect and dignity, staff working well together

• All aspects of communication with doctors and nurses

• Cleanliness and hand-washing

• Pain management

• Information on medicines

• Discharge planning

Patient Perspective Data – Inpatients Q3

18

Patient Perspective Data – Outpatients Q3

In this quarter, the inpatient results continue to be extremely good.

• The average score for the Trust is 90.2%, and within the top 20% of

Trusts in England (threshold 85%).

• The Trust is in the top 20% of all trusts for 19 of the 20 most

important questions for patients. All specialties except

Gastroenterology are in the Top 20%

• 98% of inpatients rate the Trust as excellent, very good or good.

Hospital Score Respondents

Morpeth NHS Centre 94% 25

Alnwick Infirmary 93% 25

NSECH 92% 28

Hexham General Hospital 91% 232

Wansbeck General Hospital 91% 353

North Tyneside General Hospital 89% 330

Berwick Infirmary 88% 21 19

Patient Perspective Data – Outpatients Q3

Overall results are particularly good in these areas:

• All aspects of communication between doctors and patients, and

information given

• Involvement in decisions

• Discharge planning

• Letters copied to patients

• Overall ratings and respect and dignity

The one question not in the top 20% of Trusts is:

• Before the treatment, did a member of staff explain what would

happen?

20

Patient Perspective data.

Emergency Care.

21

Patient Perspective Data – Emergency Care Q3

In this quarter, the Emergency Department results continue to be

very good.

• The average score for the Trust is 83.2%, and within the top 20%

of Trusts in England (threshold 78%).

• The Trust is in the top 20% of all trusts for 22 of the 27 most

important questions for patients.

• Results vary across the site, average score are;

o Hexham 90%

o The Northumbria Hospital 81%

o North Tyneside 80%

o Wansbeck 80% 22

Patient Perspective Data – Emergency Care Q3

Overall results are particularly good in these areas:

• Privacy whilst in the department

• Information on waiting times

• Overall time in A&E

• Communication with doctors and nurses

• Cleanliness of the department and toilets

• Planning for leaving hospital

• Overall ratings and respect and dignity

There is room for improvement in these areas:

• Waiting times until triage and to seeing a doctor or nurse

• Pain control

• Information on the purpose of medicines

23

Emergency Care overall scores

24

Real time data.

25

Real Time Domain Averages 2017 9

.61

9.9

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1.00

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9.00

10.00

Consistency

&

Coordination

Respect &

dignity

Involvement Doctors Nurses Cleanliness Pain Control Medicines Noise at

Night

Kindness &

Compassion

Domain

Average

Key

Promoter

Score

Baseline 2017 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017

July 2017 August 2017 September 2017 October 2017 November 2017 December 2017

Domain Averages to date (n=7726)

26

Real Time Data 2016/2017

Year

No of

Patients

Surveyed

% of

Patients

Surveyed

Coor-

dination*

Respect

& dignity

Involve

-ment* Doctors Nurses

Clean-

liness*

Pain

Control Medicines

Noise at

Night

Kindness &

Compassion

Domain

Average

2016 6848 53 9.61 9.90 9.72 9.85 9.89 9.77 9.88 8.23 9.44 9.92 9.62

2017 7726 53 9.53 9.89 9.65 9.83 9.87 9.84 9.88 8.16 9.37 9.90 9.59

Difference -0.08 -0.01 -0.07 -0.02 -0.03 0.07 0.00 -0.07 -0.07 -0.01 -0.03

• The overall domain score has dropped slightly from 9.62 to 9.59 making a

difference of 0.3%

• The Coordination domain and Involvement domain has the biggest variations and

is significant worse.

• The only domain that shows a significant improvement is Cleanliness, rising to

9.84 from 9.77.

• The other domains have stayed the same. 27

Real Time Comments 2016/2017

Overall Comments

When comparing the Real time overall comments between 2016 and 2017 there has been

an improvement of the Positive comments of 4%, rising from 84% in 2016 to 88% in 2017,

this difference is significantly better. There has been a 2% drop for both Negative and

Neutral comments.

84%

7% 9%

88%

5% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Positive Negative Neutral

Real Time Overall Comments 2016 - 2017

2016 (6678) 2017 (7549)

28

National Maternity Survey

2017

29

When comparing with other Trusts, Northumbria is about the same in 49 (96%)

questions and better than other Trust in 2 questions (4%). There were no questions

where the Trust was worse than other Trusts.

4%

96%

0%

Comparison with other Trusts

Better than other Trusts (2) Same as other Trusts (49) Worse that other trusts (0)

30

When comparing with 2017 against the 2015 survey results, Northumbria showed no

significant change in 45 (92%) questions, significantly better in 2 questions (4%) and

Significantly worse in 2 questions (4%).

4%

92%

4%

Comparison between 2017 and 2015

Significantly Better (2) No Significant Change (45) Significantly Worse (2)

31

Antenatal

• The question about Thinking about your antenatal care, were you spoken to in a way you

could understand? Is rated as "Better" than other Trusts. While all other questions were

rated about the same.

• There is no statistical change in any questions when compared to 2015.

Birth and Labour

• The question about Thinking about your stay in hospital, how clean was the hospital room

or ward you were in? Is rated as "Better" than other Trusts. While all other questions were

rated about the same.

• The questions regarding Thinking about your stay in hospital, if your partner or someone

else close to you was involved in your care, were they able to stay with you as much as you

wanted? and Thinking about your stay in hospital, how clean was the hospital room or

ward you were in? are significantly better when compared against the 2015 results.

• The question If you needed attention while you were in hospital after the birth, were you

able to get a member of staff to help you within a reasonable time? is significantly worse

when comparing against 2015.

Postnatal

• All questions were rated with other Trust as about the same.

• The question Were you given information or offered advice from a health professional

about contraception? is significantly worse when comparing against 2015.

Outlying Questions and Results

32

Ranked Trust Antenatal Labour & Birth Postnatal Maternity Average

1 Wirral University Teaching Hospital NHS Foundation Trust 8.1 8.7 8.7 8.5

T2 East Cheshire NHS Trust 7.8 8.9 8.6 8.4

T2 Torbay and South Devon NHS Foundation Trust 8.1 8.6 8.6 8.4

T2 The Newcastle upon Tyne Hospitals NHS Foundation Trust 7.9 8.6 8.6 8.4

T5 Wye Valley NHS Trust 7.9 8.7 8.5 8.3

T5 Northampton General Hospital NHS Trust 8.0 8.7 8.4 8.3

T5 Shrewsbury and Telford Hospital NHS Trust 7.7 8.7 8.5 8.3

T5 North Cumbria University Hospitals NHS Trust 7.8 8.8 8.3 8.3

T5 Maidstone and Tunbridge Wells NHS Trust 7.8 8.8 8.3 8.3

T5 Burton Hospitals NHS Foundation Trust 7.9 8.6 8.3 8.3

T5 University Hospitals of Morecambe Bay NHS Trust 7.8 8.5 8.5 8.3

T5 Gloucestershire Hospitals NHS Foundation Trust 7.9 8.7 8.3 8.3

T5 Mid Cheshire Hospitals NHS Foundation Trust 7.7 8.6 8.5 8.3

T5 Western Sussex Hospitals NHS Foundation Trust 7.7 8.6 8.5 8.3

T15 Sherwood Forest Hospitals NHS Foundation Trust 7.8 8.6 8.3 8.2

T15 Salisbury NHS Foundation Trust 7.7 8.6 8.4 8.2

T15 York Teaching Hospital NHS Foundation Trust 7.8 8.7 8.2 8.2

T15 Gateshead Health NHS Foundation Trust 7.7 8.5 8.5 8.2

T15 Royal Surrey County Hospital NHS Foundation Trust 7.8 8.6 8.2 8.2

T15 Royal Cornwall Hospitals NHS Trust 7.8 8.6 8.3 8.2

T15 Countess of Chester Hospital NHS Foundation Trust 7.8 8.4 8.4 8.2

T15 Airedale NHS Foundation Trust 7.7 8.7 8.2 8.2

T15 The Whittington Hospital NHS Trust 7.9 8.5 8.2 8.2

T15 Medway NHS Foundation Trust 7.6 8.7 8.2 8.2

T15 Chesterfield Royal Hospital NHS Foundation Trust 7.7 8.6 8.3 8.2

T15 Royal United Hospitals Bath NHS Foundation Trust 7.7 8.7 8.1 8.2

T15 Northumbria Healthcare NHS Foundation Trust 7.6 8.7 8.2 8.2

T15 Colchester Hospital University NHS Foundation Trust 7.6 8.7 8.2 8.2

T15 Bolton NHS Foundation Trust 7.7 8.3 8.5 8.2

T15 City Hospitals Sunderland NHS Foundation Trust 7.5 8.7 8.4 8.2

T15 Hampshire Hospitals NHS Foundation Trust 7.7 8.6 8.3 8.2

T15 Wrightington, Wigan and Leigh NHS Foundation Trust 7.5 8.5 8.5 8.2

T15 South Tees Hospitals NHS Foundation Trust 7.9 8.4 8.2 8.2

T15 George Eliot Hospital NHS Trust 7.4 8.6 8.5 8.2 33

Ranked Trust Antenatal

Average

Labour and

Birth Average

Postnatal

Average

Maternity

Average

T2 Newcastle 7.9 8.6 8.6 8.4

T5 North Cumbria 7.8 8.8 8.3 8.3

T15 Gateshead 7.7 8.5 8.5 8.2

T15 Northumbria 7.6 8.7 8.2 8.2

T15 Sunderland 7.5 8.7 8.4 8.2

T15 South Tees 7.9 8.4 8.2 8.2

T47 Durham and Darlington 7.3 8.4 8.3 8.0

T111 North Tees & Hartlepool 7.1 7.9 7.8 7.6

Area Northumbria

Score

Highest

Scoring Trust

Lowest Scoring

Trust Rank

Antenatal 7.6 8.1 6.8 T44th Middle 60% of Trusts

Birth & Labour 8.7 8.9 7.5 T5th Top 20% of Trusts

Postnatal 8.2 8.7 7.5 T35th Middle 60% of Trusts

Average 8.2 8.5 7.5 T15th Top 20% of Trusts

Regional Table

Trust Performance by area

34

Friends and Family.

36

Friends and Family Test – IP/DC

National Average FFT Score – 78

National Average % Recommend – 95%

National Average% Response rate – 21.4%

IP FFT

DH

Extremely

likely Likely

Neither

likely nor

unlikely

Unlikely Extremely

unlikely

Don't

know Total Score

Response

Rate Eligible

% of

Extremely

Likely &

Likely

Oct-17 1487 152 26 7 9 10 1691 86 18.2% 9314 97%

Nov-17 1499 173 27 12 12 29 1752 84 18.4% 9539 95%

Dec-17 968 82 11 3 4 11 1079 89 12.2% 8839 97%

Q3 2017 3954 407 64 22 25 50 4522 86 16.3% 27692 96%

37

Friends and Family Test – A&E




FFT AE Extremely

likely Likely

Neither

likely nor

unlikely

Unlikely Extremely

unlikely

Don't

know Total Score

Response

Rate Eligible

% of

Extremely

Likely &

Likely

Oct-17 663 158 44 43 35 70 1013 57 8.4% 12056 81%

Nov-17 526 132 30 31 29 54 802 58 7.1% 11250 82%

Dec-17 618 189 47 21 39 44 958 56 8.2% 11619 84%

Q3 2017 1807 479 121 95 103 168 2773 57 7.9% 34925 82%

38

Friends and Family Test – Maternity




FFT

Maternity

Extremely

likely Likely

Neither

likely nor

unlikely

Unlikely Extremely

unlikely

Don't

know Total Score

Response

Rate Eligible

% of

Extremely

Likely &

Likely

Oct-17 224 32 1 3 4 0 264 82 17.8% 1485 97%

Nov-17 253 26 4 0 0 1 284 88 20.3% 1402 98%

Dec-17 184 24 2 2 2 0 214 83 15.3% 1400 97%

Q3 2017 661 82 7 5 6 1 762 84 17.8% 4287 98%

39

PENNA Awards The Trust been shortlisted for eight awards in the annual Patient Experience Network

National Awards (PENNA). The awards are being held today in Birmingham.

Entry name Category

Palliative Care Northumbria Partnership Working to Improve the Experience

Continuity of Care

Using Patient Experience Data for Service Improvement

(Ward 23, North Tyneside General Hospital) Measuring Reporting and Acting

Introducing a Birth Reflection Pathway in Maternity

Services

Laying the Foundations

Patient Insight for Improvement – Outstanding

Contribution

Pilot use of an assistive hearing device with patients

who have a hearing impairment (Ward 9, The

Northumbria)

Communicating effectively with patients and families

Patient Insight for Improvement – Outstanding

Contribution

Patient Experience Team Team of the Year

40

Thank You

41

Title of Report Learning From Deaths – Q3 Review Data

Author Dr Jeremy Rushmer

Executive Lead Dr Jeremy Rushmer

Executive Summary

Q3 Review data: No Hogan 4 deaths have been identified within the 97 cases reviewed in the quarter. In 70 case the reviewers recorded good care and practice and in the remainder the learning has been cascaded to teams and summarised in the newsletter. Review rate: The numbers of notes reviewed has improved. Additional review sessions at NSECH are being piloted from February and requests for attendance have been enhanced. In the 93 cases reviewed so far from Q3 there has been insufficient numbers for the December 2017 month. 30 randomly selected of case notes from December will be added as ‘Mandatory’ reviews to ensure there is a sufficient sample. An increase in deaths within ED was noted at last mortality group, which

one of our nurse directors is reviewing. This is not unexpected given the

increase in LOS in ED associated with winter escalation, but is being

checked.

LfD Improvement: There has been senior attendance at the Royal College Physicians SJR training and a proposal will be made to S&Q and CPG in March, with an aim to improve engagement with a ‘revitalised’ review process. A meeting has occurred with coroners’ and registrars’ teams, the principle improvements planned are: bereavement information review, with joint branding, a joined up process for coroner referral and potential to develop a Registrars’ office at NSECH. Early assessment of the RCP recommendations are improve the quality, rather than quality of the review, with a significant recommendation being to spend sufficient time on each review, to enhance the potential for learning. Meetings have occurred with the Comms team to discuss proposals for an intranet repository for learning and an internal communication tool.

42

Recommended actions required by Board/ Committee

Trust Board to approve this report, following approval of S & Q Committee

Link to strategic objectives (please tick)

1 2 3 4 5 6

Strategic objective reference

2.3

Link to CQC KLOE (please tick)

Caring Responsive Well-led Effective Safe

Compliance/ regulatory requirements (if applicable)

CQC – learning from deaths

Financial impact?

No

43

Medicines Optimisation Strategy

Annual Report March 2018

45

• Trust Board approved strategy in 2013

• “a transformational approach; to maximise outco es for i dividual patie ts”

• 6 strategic challenges 1. Build on the what we already do well

2. Deploy technological solutions to reduce risk

3. Work more closely with patients and the public

4. Provide effective financial management and controls

5. Support a shift in focus from secondary to primary care

6. Develop and deploy workforce

Background/context

46

Strategic challenge 1

Build on what we already do well

47

Model Hospital Headline Metrics Pharmacy Staff &

Medicines Costs per

WAU

£222 2016/17

Data Quality of NHS

England Monthly Data

Set Submissions From

Providers

27 Sep 2017

Top 10 Medicines –

Savings Delivered to

Current Month

£1.67m To Dec 2017

% Pharmacists

Actively Prescribing

50.9% 2015/16

Top 10 Medicines - %

Delivery of Savings

Target Achieved to

Current Month

£144% To Dec 2017

Sunday ON WARD

Clinical Pharmacy

Hours of Service

(MAU/Equivalent)

8.5 2015/6

Clinical Pharmacy

Activity (Pharmacist

Time Spent on Clinical

Activities)

82% 2015/16

Number of Days

Stockholding

15.1 2015/16

e-Commerce –

Ordering (AAH)

86% 2015/16

e-Commerce -

Ordering (Alliance)

97% 2015/16

48

Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17Q1 17-

18

Q2 17-

18

Q3 17-

18

Trustwide 96% 99% 97% 96% 98% 97% 95% 96% 94% 97% 96% 95.2%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95.0%

50%

60%

70%

80%

90%

100%

1. % of patients with medicines reconciliation started within

24 hours of admission by Business Unit

0

1

2

3

4

5

6

7

8

9

10

Jan 17Feb

17

Mar

17Apr 17

May

17Jun 17 Jul 17

Aug

17

Sep

17Oct 17

Nov

17

Dec

17

Trust 8.10 7.87 8.41 8.14 8.32 8.06 8.16 7.80 8.01 8.05 8.19 8.30

Baseline 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00

3. Patient Experience Real Time

Jul-16 Aug-16 Sep-16 Oct-16Nov-

16Dec-16 Jan-17 Feb-17

Mar-

17

Q1 17-

18

Q2 17-

18

Q3 17-

18

Trust 0.9% 1.0% 1.7% 1.0% 2.5% 0.9% 1.8% 0.9% 0.7% 0.8% 0.2% 0.5%

Target 0.9% 0.9% 0.9% 0.75% 0.75% 0.75% 0.5% 0.5% 0.5% 0.5% 0.5% 0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

6. % of patients who have had an omitted dose of a critical

medicine

49

• Keep doing the good things we’ve been doing (core clinical)

• Adoption of digital technology as a major enabler

• Revisit commercial partnerships/outsourcing

• Explore supply chain collaboration at regional level

• Exploit opportunities within a new ACO framework

• Facilitate fast adoption of best value medicines, specifically biosimilar medicines

HoPMOp update

Carter/Model Hospital

50

Governance/Risks

NICE

Controlled

Drugs:

Fully compliant

risk very low

I can’t think of anything

else green or

red to report

here

Patients’ regular medication not

prescribed in a timely

manner at NSECH National &

global

shortages

NICE

Medicines

Optimisation

Partially

compliant;

risk low

Trust

training

records

target

achieved

eMeds roll

out

progressing

Data

warehouse

not yet

implemented:

eMeds benefits

not fully

realised

Errors/omissions

on discharge

51

• Ward automation (Omnicell)

• EPMA (MedChart)

• Chemotherapy EPMA (Chemocare)

• Stores/dispensing robot

• Nervecentre


Deploy technology to reduce risk

52


Support a shift in focus from secondary

care to primary care

53

Northumbria Integrated Model

• Caring for our patients wherever they

are in the system

• Doing the right thing for patients • Detailed clinical reviews

• Shared decision making

• Working as one pharmacy team

• Working with the wider health and social care team

www.health.org.uk/pills

54

http://www.health.org.uk/pills

New behaviours in hospital

55

Benefits of whole system approach

• Great for patients; satisfaction, experience,

outcomes e.g. reduction in admissions, safer transfer

• Efficiency; flow, net prescribing savings

– For every £1 spent, there is a saving of £3.06

– A Northumberland-wide service would save £3.98m per

annum, including c650 admissions avoided – equivalent to

7,750 COTE bed days (or 10 months of WGH Ward 4)

• Saves medical and nursing staff time

• Flexibility in workforce development and deployment

• Model system for medicines optimisation

• Staff love it 56

Examples and opportunities include:

• Nurse associates

• Physicians associates

• Ward medicines assistants

• Chemotherapy assistants

• Advanced clinical pharmacist practitioners

• Pharmacists in ED (via IUC)

Challenge 6

Develop and deploy workforce

57

SUMMARY

• Successful performance, innovation and improvement

• Gaps/risks

• 2018/19

- Continue to build on what we are doing well

- Progress with other opportunities to integrate care e.g.

developing joined-up services with NT CCG

- Mitigate/deal with the risks

- Refresh Medicines Optimisation Strategy

- Respond to WHO global patient safety challenge

- Exploit opportunities in workforce development strategy

58

COMMERCIAL IN CONFIDENCE 1

Northumbria Healthcare NHS

Foundation TrustFinancial Performance Period Ended:

January 2017

59


Preface• The report that follows details the financial

performance for the Trust

• The plan is based upon the NHS Improvement APR re-submission made in March 2017

• The plan was based upon the draft year-end accounts

• The actual performance reflects the monthly return to monitor

• The profile of income and expenditure is driven by the number of working days (per month) and the CIP programme

60


Summary At the end of the reporting period covered

by this report the Trust delivered:

• An I&E surplus of £21.35m– Including: £0.4m prior year STF, £0.9m Winter

Funding

• Plan = £21.20m £0.15m above YTD Control Total excluding: 1617 STF; Winter Funding

• Use of Resources risk rating of 1 (best)

• A cash balance of £ 10.0m61


Key TargetsTarget Perio

dYea

rComments

Income & Expenditure

Performance to date is in line with plan (£145k above plan). (This excludes the impact of £0.4m additional STF relating to 1617 and £0.9m Tranche 1 Winter Pressures Funding, which do not contribute to performance against the Control Total for 1718).

YTD performance has been impacted significantly by a sustained reduction in activity levels, with elective activity below 1617 levels (in addition to not achieving planned growth in 1718) and non-elective income impacted by a higher use of ambulatory care. This has been further affected by winter pressures and infection control measures since Month 9. Commercial income also remains below plan, with growth impacted by the effect of the living wage. This has been mitigated through a change in accounting policy for deferred commercial income, and expected VAT recovery.

The pay bill was higher than budgeted. Agency spend continues to increase, although it remains broadly in line with planned levels (2.0% of pay-bill). YTD agency spend is £0.7m below the Agency Ceiling set by NHSI. Non-pay expenditure is also higher than budget.

CIP performance was below the YTD plan by £1.2m at Month 10. The CIP targets increase progressively over the remainder of the year and so close monitoring and adherence to plans is critical.

The 1617 Arbitration has been concluded with all issues found in favour of the Trust, except £0.3m (relating to 50% share of close out deal dispute). The CCG continue to challenge the 1718 impact of A&E and T&O coding, and have issued Contract Performance Notices (CPNs) to this effect. Additional CPNs have also been raised by the CCG in relation to Ambulatory Care and Community Hospitals. A formal joint process is currently underway to resolve these matters under the terms of the NHS Standard Contract, including audits of patient activity. These challenges could have a significant (c£5m) adverse impact on the financial position. However, the Trust believes it has a strong case and the CCG challenges are unfounded.

Liquidity Cash is significantly down due to ongoing reduced payments by Northumberland CCG and NHS Fleet debtors. The cash balance is £10.0m, which is £31.7m below plan. The liquidity day metric is 19.3 for January (plan = 17.3), which gives a Liquidity risk rating of 1.

Capital Investment

Capital investment is currently running £7.7m below planned levels.

Use of Resources Rating

At the end of the period the Use of Resources rating was 1 (the highest rating), consistent with plan.

62

Summary Performance to date is in line with plan. However, expenditure (in particular pay) is not sustainable given

the reliance on CCG income. The key actions/issues emerging from the performance to date are:

(1) Cost reduction Plans need to be delivered. There are fortnightly meetings (now led jointly by the Director of Finance and the Director of Delivery) in place to track progress and to ensure accountability across the organisation. A quarterly report will be presented to FIP so that the Committee are fully appraised of progress and where necessary corrective action agreed. As part of the escalation process individual business units maybe required to attend.

(2) Cyber attack the impact of the cyber attack impacted on activity in May with an assessed (uninsured) loss of £0.9m related to lost activity (elective and outpatients).

(3) Clinical income continues to be below plan with elective activity below 1617 levels and non-elective income impacted by a higher utilisation rate for ambulatory care, which is chargeable at a lower locally agreed tariff. Winter pressures and infection control measures have further impacted.

(4) Agency Spend is at reduced levels compared to 1617, but has recently seen a sustained increase. Pressure needs to continue to reduce agency (and other premium pay spend) to ensure compliance with Agency Ceiling set by NHSI.

(5) Northumberland CCG Contract . The Trust have made a final offer to the CCG to settle the contract position, which included a £1.2m reduction to the MIU block. There remain other issues (Safeguarding) and low acuity NEL activity. Both issues may need to go to arbitration but the latter issue requires consent by the Trust to vary PbR which it will not consent to.

(6) Cashflow is well below plan due to delayed payments, particularly from Northumberland CCG and Lease Car debtors. The CCG continue to short pay invoices and discussions are ongoing regarding their aged debt balance (which now stands at £8.8m).

The forecast for the year is delivery of the key financial targets. There are however significant risks and these are identified in the financial forecast.


Report to Finance, Investment & Performance Committee

Title of Report NHSI Regulatory Performance Report

Author Birju Bartoli, Executive Director

Executive Lead Birju Bartoli, Executive Director

Date of meeting 22nd February, 2018Executive Summary From October 2016, under the new oversight framework, Trusts are now

monitored and expected to deliver most key performance metrics on a monthly basis, as opposed to quarterly, with an opportunity to recover financial penalties at the end of each quarter based on an aggregated quarterly performance. On 19th October NHS Improvement published the latest provider segmentation (which is based on the level of support trusts need). This confirmed that the trust remains in Segment 1. This is the best possible segment.

Performance in January for the A&E target was 91%, i.e. the Trust failed to meet the 95% target. There were 608 ‘excess’ breaches; that is, if 608 more of the January attenders had been admitted/discharged from A&E within 4 hours we would have met the 95% target. Year to date is at 93.8% (as at 8th February).

Referral to treatment times (RTT) for incomplete pathways: the standard is to have at least 92% of patients waiting less than 18 weeks at month end. This standard was met for January, with a performance of 92%.

January performance data for the 62 day cancer waiting times GP referral to treatment target (85%) is still to be confirmed, but the provisional performance figure is 80%.

Performance for the 62 day bowel screening target (90%) – the provisional performance figure for January is 100%.

Diagnostics: percentage of patients waiting six weeks or less for a diagnostic test. We achieved the 99% standard for January.

IAPT: the proportion of people completing treatment who moved to recovery is provisionally 52.5% for January. The standard to meet for the quarter is 50%.

This report is written in accordance with NHS Improvement’s Single Oversight Framework, which became operational from 1st October, 2016 and was updated in November 2017.

Assurance Frwk ref. 2.1 - 2.51 inclusive

Alignment to Trust’s Annual/ Strategic Plans or business unit annual plans

Yes – aligned

Risk rating (very high, high, moderate, low risk)/ any recommended changes

Moderate

Compliance/ reg’tory requirements (if applicable)

Yes – compliant

Actions required by the Board

The Committee is asked to approve this report.

64

Regulatory Performance Report

Finance, Investment & Performance Committee22nd February, 2018

Strategic Objective: Excellence in safety, quality and complianceAt the same time as delivering the best quality healthcare and excellent customer services we have to ensure patients are safe and that we meet national regulatory safety and quality standards. This will provide independently verified assurance to our stakeholders and will give us the necessary freedom to focus on our priorities.

Key Strategic QuestionTo what extent are we providing high quality, caring, safe, health and care services in accordance with the national regulatory standards?

Key Findings and Performance LevelsThe purpose of this executive summary is to provide the Board of Directors with the evidence of achievement against the national regulatory systems, emerging risks and the assurance that an improvement plan is in place and is effective.

The Board has delegated full authority to the following Committees to ensure these standards are met: FIP, Safety & Quality and Assurance. The evidence to support the governance of these standards is provided to these Committees.

65

NHS Improvement (NHSI) – Single Oversight Framework (SOF)

NHSI’s Single Oversight Framework became operational from 1st October, 2016

Q1 Q2 Q3 Q4

Trust overall assessment Actual Actual Actual Forecast

Performance

Operational performance metrics(8 acute; 4 mental health) (see note 1)

9 of 10 standards

met***

8 of 10 standards

met***

10 of 12 standards

met ***

10 of 12 standards

met ***

Quality of care (safe, effective, caring, responsive) monitoring metrics

See quarterly Excellence in Safety & Quality report

Care Quality Commission

Quarter

1 2 3 4

Overall Trust Rating Outstanding Outstanding Outstanding

CQC ‘insight’ performance monitoring to be included upon publication

Score = 1* Score = 1* Score = 1*

Annual Quality Governance Fully met Fully met Fully met

Material risks No No No

Segment 1**

Segment1**

Segment 1**

* Score = 1 is the best score possible

** Segment = 1 means the provider has maximum autonomy

*** Amber means there is a risk to the trust remaining in Segment 1 (because of performance on the

A&E 4-hour wait standard and the cancer 62 day GP referrals standard)

Notes 1. Five acute standards with monthly frequency: A&E four hour wait; 18 weeks RTT incomplete pathways; Cancer 62

day waits (2 standards); and 6 week wait for diagnostic procedures.

Three acute standards with quarterly frequency: three measures about dementia assessment and referral, relating to

case finding, assessment and referral.

Two mental health standards with quarterly frequency: the Data Quality Maturity Index (DQMI) for the Mental Health

Services Data Set (MHSDS); and one relating to the Improving Access to Psychological Therapies service - the

proportion of people completing treatment who move to recovery.

Two mental health standards with 3-month rolling frequency: per cent waiting 6 weeks or less from referral to entering

a course of treatment under IAPT, and per cent waiting 18 weeks or less.

Performance and quality metrics


Single Oversight Framework (SOF) Segment

Other factors

Finance and use of resources

Board statement

66

Safety & Quality Regulatory Risk AssessmentThis section provides a risk assessment of the regulatory standards.

Strategic, Operational & Financial Risks: High Risks SOF Risk

A&E 4 hour wait (95% target) Performance in January for the A&E target was 91%, i.e. the Trust failed to meet the 95% target.

A&E attendances remain at around 15,500-17,000 per month, but 1.1% higher overall than during the same period (Apr-Jan) last year.Length of stay has decreased compared to last year: 31% of patients stayed 3+ days compared to 30% for the same period (Apr-Dec) last year.

Yes

Referral to treatment times (RTT) for incomplete pathways: % patients waiting less than 18 weeks at month end

Referral to treatment times (RTT) for incomplete pathways: 92% patients waiting less than 18 weeks at month end. This standard was met for January, with a performance of 92%.

No

62 day referral to treatment Cancer standards: urgent GP referrals and referrals from the national screening service

January performance data for the 62 day cancer waiting times GP referral to treatment target (85%) is still to be confirmed, but the provisional performance figure is 80%.

Summary level performance is adversely affected by performance at cancer-site level where there is a combination of low percentage achievement and relatively high volume of treatments. Urology continues to be of particular focus.

Performance for the 62 day bowel screening target (90%) – the provisional performance figure for January is 100%.

Yes

Diagnostics – percentage of patients waiting six weeks or less for a diagnostic test.

We achieved the 99% target for patients waiting at the end of January.

No

Improving access to psychological therapies: proportion of people completing treatment who move to recovery

IAPT: the proportion of people completing treatment who moved to recovery is provisionally 52.5% for January. The standard to meet for the quarter is 50%.

No

MRSA While no longer a Monitor target, the expectation is that trusts will have zero cases of MRSA. There have been two cases identified so far during 2017/18. One case was identified in September, but this has been apportioned to the CCG. A second case was identified in January, and this has been apportioned to a third party.

Not appl

Clostridium difficile

During January there were five cases of C diff. The target for 2017/18 remains at no more than 30 cases. There was one case between 1st and 12th February, so there have been 31 in total which exceeds the maximum allowed target of 30.

By default, each case is deemed to be ‘due to a lapse in care’ unless it has been through a formal appeals process.

Not appl

Surgical site (deep) infection rates in Orthopaedics (in arrears; the position up to and including December 2017 is reported)

During December there were four deep joint infections: one for hip replacement, one for knee replacement and two for fractured neck of femur. During 2017/18 to date there have been 24 – twelve for hip replacement, five for knee replacement and seven for repair of fractured neck of femur.

Not appl

Complaints Complaints responses within the period agreed with the complainant 74% (out of complaints closed within the agreed timescale) for January. Monthly monitoring of Trust and Business Unit performance is undertaken at the Safety and Quality Committee.

Not appl

67

RecommendationsThis report is provided for information to Board members.Birju BartoliExecutive Director, February 2018.

Assurance Framework References 2.1 – 2.51 inclusiveKey controls – Yes, key controls are in placePositive assurance – this report provides positive assuranceGaps in controls or assurance – There is no gap in our controls.

68

/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docxf 18

Title of Report Board Assurance Framework 2017/18 (v4.3)

Author Neil Gibson, Head of Quality and Assurance

Executive Lead Birju Bartoli, Executive Director of Systems, Strategy and Transformation

Executive Summary The Trusts Board Assurance Framework (BAF) identifies the strategic

objectives, priorities and key risks to achieving those priorities. For each

identified risk, the controls and assurances are identified together with

the responsible lead Director and responsible committee.

Following review by the Executive Director of Human Resources/OD a

number of amendments have been made to risks within Strategic

Objective 5: Attract, retain, support and train the best staff.

The BAF was reviewed in conjunction with the Trusts combined risk

register at Assurance Committee on the 16th January, this review did not

identify any emerging high risks for escalation to the Board.

Recommended

actions required by

Board/committee

The Board is asked to note and approve the content of the report.


objectives

(please tick)

Strategic objective

reference

n/a



regulatory

requirements (if

applicable)

n/a

Financial impact? n/a

69


Assurance Framework for the Key Strategic Objectives 2017/18

Report to Board of Directors1. Introduction

The system for assurance of the delivery of the Trust’s strategic objectives is by the Board Assurance Framework (BAF). In line with best practice recommended by “The Intelligent Board” the Audit Committee and the Board of Directors considers the progress of its strategic objectives at quarterly intervals to support the self-certification to NHS Improvement.

This report needs to be considered in conjunction with the monthly Board of Directors NHSI Regulatory Performance Report.

NHS Improvement (NHSI) – Single Oversight Framework (SOF)

NHSI’s Single Oversight Framework became operational from 1st October, 2016

Q1 Q2 Q3 Q4

Trust overall assessment Actual Actual Forecast

Performance

Operational performance metrics(5 acute; 5 mental health) (see note 1)

9 of 10 standards

met***

8 of 10 standards

met***

8 of 12 standards

met***

Quality of care (safe, effective, caring, responsive) monitoring metrics

See quarterly Excellence in Safety & Quality report


Quarter

1 2 3 4

Overall Trust Rating Outstanding Outstanding Outstanding

CQC ‘insight’ performance monitoring to be included upon publication

Score = 1* Score = 1* Score = 1*

Annual Quality Governance Fully met Fully met Fully met

Material risks No No No

Segment 1**

Segment 1**

Segment 1**

* Score = 1 is the best score possible

** Segment = 1 means the provider has maximum autonomy

*** Amber means there is a risk to the trust remaining in Segment 1 (Amber means there is a risk to the trust remaining in Segment 1 (because of performance on A&E four hour waits, and the two

Cancer 62 day standards and the IAPT standard)

Notes

1. Five acute standards with monthly frequency: A&E four hour wait; 18 weeks RTT incomplete pathways; Cancer 62 day waits (2 standards); and 6 week wait for diagnostic procedures.

Three acute standards with quarterly frequency: three measures about dementia assessment/referral;

Two mental health standards with quarterly frequency: Data quality maturity index and IAPT: proportion of people completing treatment who move to recovery;

Two mental health standards with 3 month rolling frequency: % waiting 6 weeks or less from referral to entering a course of treatment under IAPT, and % waiting 18 weeks or less

Performance and quality metrics


Single Oversight Framework (SOF) Segment

Other factors

Finance and use of resources

Board statement

70


A copy of the BAF for 17/18, based on the strategic objectives is enclosed with this report. Following a recommendation from Internal Audit, nominated lead officers for each of the risks within the assurance framework were asked to confirm they remained accountable for the risk and also the accuracy of the information contained within the assurance framework.

2. Key Strategic Risks

Following a review of the BAF by the Executive Director of Human Resources/OD, a number of amendments have been made which are summarised below:

Risks updated to better reflect the People and OD Strategy (5.3, 5.4, 5.8, 5.10 to 5.14)

Risks associated with code of behaviour, model employer status and working in partnership with staff have been merged under risk 5.3 ‘staff engagement.

New risks relating to change ability, improvement/innovation and leadership/management have been added (5.5 to 5.7)

Removal of the risk linked to national pay negotiations

The graph below provides a quarterly summary of both the overall number and grade of risks contained within the Assurance Framework.

37

37

37

38

8

9

9

6

3

3

3

4

0 10 20 30 40 50 60

Apr 18

Jan 18

Oct 17

July 17

June 17

Very Low

Low

Moderate

High

Very High

Number of Risks

A summary of the current very high/high risks is shown below.

Very High Risks

Ref 2.1 NHSI Single Oversight Framework

A&E 4 hour target – Quarter 3 performance was 93.5% with the target not being met for each month of the quarter. The December position was 91.4%. The Trust was able to achieve the STF trajectory for Q3.

Hospital acquired Clostridium difficile - the cumulative position is no more than 30 cases for the year 17/18, quarter 3 cumulative actual outturn was 25 against a trajectory of 23.

Cancer: GP referral to treatment – the 85% target for 62 day GP referrals was not met October. A recovery trajectory of 83% for November and 85% for December was agreed through FIP. This was met in November and provisional performance for December is 85%. Weekly tracking meetings continue to try and ensure that all patients are seen within timeframe. This remains a very high risk due to the measure only being met for the first time in December. NHSI continue to track recovery of this metric.

National screening service referral (Bowel cancer screening), this target was not met in October and November, but December has a provisional performance of 100%.

71


Ref 4.1 – 4.3: Overall Healthcare Funding (4.3 is a high risk)The national and local financial position is extremely challenging with the two main commissioners being required to take action across the local health economy to reduce costs and bring system expenditure into line with current and forecast allocations. This position is particularly acute within the Northumberland system with the CCG requiring in excess of £50m cost reduction or cost avoidance in dealing with existing or forecast activity projections.

In the current year this will result in a requirement for the Northumberland CCG and Trust to jointly deliver a saving of £10m in comparison to the jointly agreed acute “demand plan” of £193.3m. The consequence of this joint action will be the requirement to manage demand more effectively thus reducing projected activity growth and additionally reduce the cost of non-tariff contracts and thereby passing that saving to the CCG.

High Risks

Ref 1.1 Accountable Care OrganisationThe Trust has previously been involved in the development of an accountable care organisation (ACO) in Northumberland (as part of the PACS Vanguard bid). A key component of this was moving away from PBR and more towards a capitated budget and developing a system wide clinical model. The movement of the payment model is recognition that the current system is not sustainable longer term and that there is a need to develop a different model to traditional commissioning arrangements.

In September the board was updated on the probability of moving to an ACO in the foreseeable future and concluded that this was not likely to occur. However, the reasons for moving to an ACO were all still valid and the board were in support of the continued development of the clinical strategy and a system wide approach to ensuring a sustainable local health economy.

This work has continued with the development of the clinical strategy and a number of engagement events with GPs and wider system leaders. It has previously been agreed that where possible elements of the ACO governance structure should be put in place e.g. a collaborative of senior leaders to help to drive the change. A refreshed transformation board in Northumberland has been established to support this work. There is an understanding that currently, any changes in the clinical strategy will be supported by contractual discussions with commissioners to ensure that there is no unforeseen movement in financial risk that cannot be mitigated by a corresponding removal of cost.

An expression of interest (EOI) to be part of the 2nd wave of accountable care systems has been submitted – with all partners (NHCT, NLand GP federation, NUTH, NTW, CCG and Nland county council) signing the application. A decision on the EOI and further details on what this would mean for partners is expected from the national bodies before the end of the financial year.

Ref 2.3 Save Lives and Reduce Harm

Falls been identified from incident reporting and safety thermometer as a key area for improvement. Improvement plans, led by the Executive Director of Nursing are in place and will continue to be monitored by the Safety and Quality Committee.

Surgical Site Infections - In the year to November 2017, 19 deep infections have been reported (4 knee and 10 hip and 5 fractured neck of femur). RCAs for all cases continue to be undertaken with actions being monitored via the SSI working group and Trauma and Orthopaedic board.

MRSA - The target for the number of MRSA positive cases, post 48 hrs admission is 0 for the period 17/18. In 2017/18 to date there have been 0 positive cases allocated to the Trust. Whilst this is no longer a direct target in accordance with the NHSI Single Oversight Framework, NHSI do reserve the right to escalate a Trust in view of MRSA positive cases.

72


Ref 2.5 CQC Regulation 9: Person Centred Care Limitations of breast radiological provision – due to the reduction of Breast Radiologists and as the inability to successfully recruit to vacant posts, a two stop clinical pathway has been implemented in the interim period to reduce pressure on the service and meet two week wait standards. Following discussions at EMT, the Trust is now looking to pursue overseas recruitment through already well established contacts.

Ref 2.11 Regulation 15: Premises and Equipment There are two issues which contribute to this being rated a high risk, they relate to:

The CSSD function and capacity at both NTGH and WGH is struggling to meet demand with aging equipment. At present a combination of maintenance contracts and in house maintenance is currently ensuring service provision, however due to the aging hardware and issues with services there is a risk to on-going service provision. A project group has been established to consider all available options.

In June 17 the Board approved the inclusion of fire safety measures across the Trust as a high risk, in summary there are issues with fire compartmentation at a number of Trust sites including NSECH, HGH, Halthwhistle, Blyth and Berwick. There are also issues with fire stopping at NTGH and WGH. Actions to address these issues are in progress and these will be monitored by Estates and Facilities/NHFML.

Ref 2.14 CQC Regulation 18: StaffingThere are a number of staffing issues which are contributing to this risk, these relate to:

Insufficient Breast and General Radiologists – a robust reporting radiographer timetable has been implemented and Locums employed to undertake the reporting to alleviate any risks.. In addition, although additional Haematology biomedical science staff have been recruited, the new staff require a period of training before being able to provide an adequate out of hours service. The risk is currently being mitigated by the Business unit, but inadequate service provision, especially out of hours continues to be a concern. Histopathology consultant staffing is also an emerging concern following the departure of two substantive consultants. This is being mitigated by the appointment of a speciality doctor and the use of locum agency medical staff but long term sustainability is of concern.

Recruitment of theatre nurses continues to be problematic due to national shortages of these staff. To address this shortage a further targeted recruitment campaign is planned.

Maternity Staffing – due to the increase in births at NSECH, there are currently shortfalls in the level of midwifery staffing within the Trust. Additional funding was approved for further recruitment of additional midwives and the situation is now regarded as stable.

Four obstetrics and gynecology consultants are leaving/retiring from the Trust, although two replacements have been recruited (joining May 18).

We have a high turnover of Operating Department Practitioners at present as they are in short supply

We have an increasing turnover of Nurse practitioners as again they are in short supply with a number of them taking up posts outside the organisation – a continued process of appointing to training posts is underway

Monitor Agency Fee Cap – the Trust is currently unable to wholly comply with the current Monitor cap on agency fees. Each potential breach of the cap is assessed on an individual basis, with the maintenance of patient safety being the overriding concern, with approval obtained from the Executive Director of Operations/Deputy Chief Executive. There is the potential for an increased number of breaches when the agency cap is tightened further from April 2016. A separate paper on this issue was presented to the Trust Board in January 2016.

Ref 5.2 Cyber SecurityCyber security remains a high risk for the Trust although this is mitigated against by the contracts and security that the Trust has in place. To provide Board with assurance, GE-Finnamore have been engaged to review our current and future options to reduce the impact of any future virus or malware network ingression. Cyber Security will continue to be monitored, and adoption of ISO27001 will greatly assist in providing on-going assurance. The recent WannaCry virus highlights

73


the necessity of continual vigilance and ensuring that systems and applications remain up-to-date and supported.

Ref 5:14 Our Teaching Clinical EducationThis emerging risk was previously highlighted to the Board in April as there was a potential risk that the latest GMC National Training Survey, specifically F2 training, would identify the Trust as an outlier with regards to clinical workload in the emergency department for the 6th consecutive year. The survey has now been received and confirms this position, this will likely lead to the GMC undertaking more frequent monitoring of the actions the Trust is taking to address this issue. HENE has now tasked the Trust with improving this position over the next three years, otherwise there is a risk that trainees may be withdrawn from the emergency department.

In addition to this issue, there are emerging issues with regards to junior doctor staffing (especially GP VTS and ACCS) within the Medicine Business Unit leading to potential gaps in our clinical rota’s.

Moderate RisksRef 5.1 Information and Technology (was High risk)Maternity E3 system - E3 Euroking is the maternity data capture system, the Deputy Director for Emergency Surgery and Elective Care has now confirmed that the E3 system was now working as intended and capable of producing the necessary management information, as a consequence the overall risk rating could be reduced to moderate.

Emerging RisksThe Trustwide risk register was reviewed at the Assurance Committee meeting on the 16th January 2018, with no emerging risks identified for escalation to the Trust Board.

4. Actions to close gaps in controls/assurancesActions to close gaps in controls/assurances are described within the assurance framework, which is attached. This should be considered as a source of accurate, timely and meaningful assurance to the board of directors and should be subject to internal audit reviews similar to other important sources of assurance during 2017/18 and beyond.

5. RecommendationIn line with best practice from the AC Handbook, the Committee is asked to:

Approve the Board Assurance Framework

Note that the high risks have appropriate actions in place to respond to these actions.

Birju Bartoli, Executive Director of Systems, Strategy and TransformationFebruary 2018

74

Northumbria Healthcare NHS Foundation Trust 2017-18 Assurance Framework: 4.3 – January 2018

/tmp/transcoder/9380f407-4124-4425-9d44-1e72db1c7451.docx Page 7 of 18

Grade(including change in

risk)

Assurances ReceivedRef Principal Objective Principal Risks:

LH

Cons

Rating

Existing Key Controls Possible Sources of Assurance

Internal External

Gaps in control/assuran

ce and description of

mitigating actions

Completion Date for Actions

Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

1.0 STRATEGIC OBJECTIVE: To ensure that quality underpins every decision

1.1 Accountable Care OrganisationDelivery of an ACO as part of Northumberland PACS vanguard 5 year forward view process.

Development of ACO concept and approval of business case.

The ACO does not deliver the intended quality, health and financial improvements.

3 5

High risk

Programme Board established

Beachcrofts support

Internal

TB reports from programme board

External

Programme Board report to TB – monthly

ACO Update – June 17

- no n/a

B B

art

oli

Str

ate

gy C

om

mitte

e

1.2 Acute Care Collaboration/Commercial Development5 year forward view to develop ‘chain’ model of working (including provision of some services for NCUH).

Sharing best practice across the wider NHS.

Benefits realisationThe ACC/subsidiary companies do not deliver intended clinical and financial benefits. These include:

NHFML

NPC

NDS

3 4

Moderate risk

Subsidiary companies established with individual boards

Internal

Subsidiary reporting to TB

External

Key issues reports from Trust subsidiary companies – NPC and NHFML

NPC 5 year strategy – TB Dec 17

IA 16/17 NPC – limited assurance

no n/a

B B

art

oli

Str

ate

gy C

om

mitte

e

1.3 New specialist emergency care centre/hospital site and community service reconfiguration That the new model of care introduced with the opening of NSECH.

Reconfiguration of non-NSECH sites/community services to support moving from hospital to community based services.

Model of CarePotential risks involve activity, income and workforce issues.

3 4

Moderate risk

Financial/budgetary control

Monitoring of activity levels

Workforce monitoring including staff feedback

Internal

Trust Board Finance, Performance and Investment Committee

External

Finance/activity reporting to FiP

Corporate finance report – TB monthly

NHSi Performance Report– TB Monthly

FiP key highlights report to TB – monthly from October 15

IA 17/18 – E-referrals – reasonable assurance

IA 17-18 - Staff Retention and Workforce Management – substantial assurance

no n/a

B B

art

oli/

D. Lally

Str

ate

gy C

om

mitte

e

2.0 CORPORATE OBJECTIVE: To provide the safest health and care services to patients and service users

2.1 QualityComplying with NHSi Single Oversight Framework

NHSi Single Oversight Framework Demonstrating non-compliance without adequate explanation leading to adverse regulatory intervention.

5 4

Very High Risk

Annual self-assessment by the Board and Board committees

Performance Mgt system

Internal

Annual Governance Framework

External

Head of IA opinion

External Audit

Well led review 2016

Annual accounts

Excellence in Safety and Quality Report – TB Quarterly

Quality Account


SQC – key issues report

KPMG Quality Account/Annual report review 2017

IA 16/17 – Data Quality Cancer Targets 31 days – limited assurance

Deloittes 2016 Well led Review

no n/a

B B

art

oli/

D. Lally

Fin

ance

, In

vestm

en

t an

d

Perf

orm

ance

Com

mitte

e

2.2 QualitySerious incidents, complaints and clinical audit outcomes are used to learn and improve healthcare.

Systemic FailureSerious failures from incidents, complains, claims and clinical audit result from weaknesses in our systems of care and culture

2 4

Moderate risk

Incident management system

Complaints and claims monitoring processes

Safety and Quality Committee

Safety Panels

Quality Panels

Internal

Monthly TB reports

External

Monitor assessment at quarterly intervals

Internal Audit

Report on serious incidents, complaints and claims monthly


Ward Assurance Report – TB Monthly

IA 16/17 – Medical Gases – good assurance

IA 16/17 – Policy Management – substantial assurance

IA 16/17 Clinical Audit – substantial assurance

no n/a

E M

onkhou

se/

J R

ushm

er

Safe

ty a

nd Q

ualit

y

Com

mitte

e

75




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

2.3 QualityEnsuring that our safety and quality priorities focus on our key risks and are effective

Use improvement methodology to work smarter.

Save lives and reduce harmSafety culture is not open and transparent

Increase in mortality/harm

Failure to achieve the targets set, resulting in financial underperformance and possibly reputational damage:

Safety and Quality priorities

CQUIN

National Priorities

Best practice tariff

4 4

High Risk

Quality Laboratory

Quality Panels

Monthly monitoring through safety and quality report

Internal

Quality and Safety report

Annual Plan

Quality Account

Performance Report

External

CHKS

CQC

National staff survey

Independent Assessment of Quality Account

Internal Audit


NHSi Performance Report– TB Monthly Quality Account

Governors Body

Exec walkabout report to TB monthly

Corporate Financial compliance and financial strategy report – TB quarterly


Learning from deaths report – TB 1/4

Annual national staff survey

KPMG Quality Account review 2016

IA 16/17 – Lone Working – limited assurance

IA 16/17 – Medical Gases – good assurance

IA 16/17 – CQUIN targets – good assurance

no n/a

B B

art

oli/

D R

ea

pe/J

Rushm

er

Safe

ty a

nd Q

ualit

y C

om

mitte

e

2.4 CQC ComplianceEnsuring on-going compliance with Health and Social Care Act 2008 Regulations 2014.

Regulation 5: Fit and Proper Persons: Directors: The risk concerns those people with director level responsibility for the quality of care and treatment not meeting the fit and proper persons requirements. 2 5

Moderate risk

Designated Trust leads for this standard

Comprehensive quarterly self-assessment against the requirements of the standard which brings together evidence of compliance. Note that this self-assessment provides a detailed review against the CQC requirements which is not repeated in this assurance framework.

Quarterly review and sign off of the self-assessment by designated committee with exception reporting to Trusts Assurance Committee.

Internal

Quality and Safety report – monthly

¼ PCA update/report to assurance ctte

External

CQC inspections


HR/OD Development Report – TB Quarterly

WFC key issues report

IA 16/17 – CQC – substantial assurance

no n/a

A. S

trin

ger

Assura

nce

Com

mitte

e

2.5 CQC ComplianceEnsuring on-going compliance with Care Quality Commission Fundamental standards.

Regulation 9: Person-centred care: The risk concerns ensuring that people who use the service have care/treatment which is personalised specifically for them.

3 5

High risk




Internal


External



15 steps monthly report to SQC

Chief Matrons nursing ward assurance report to TB


no n/a

E M

onkhou

se/D

Lally

Assura

nce

Com

mitte

e


Regulation 10: Dignity and respect: The risk concerns ensuring that people who use the service are treated with respect and dignity at all times whilst they are receiving treatment.

2 5

Moderate risk




Internal


External




Estates and Facilities Strategic Report – TB Qtrly


no n/a

E M

onkhou

se/D

Lally

Assura

nce

Com

mitte

e

76




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee


Regulation 11: Consent to care and treatment: The risk concerns ensuring that consent is given by all those people using the service before any treatment or care is provided by the Trust. 2 5

Moderate risk




Internal


External


Internal Audit


Excellence in Safety and Quality report – TB qtrly


IA report NAM 1418 – significant assurance


IA 17/18 – Patient Consent – reasonable assurance

no n/a

D L

ally

Assura

nce

Com

mitte

e


Regulation 12: Safe Care and Treatment: The risk concerns ensuring that people who use the service are prevented from unsafe care and treatment and avoidable harm/risk of harm.

Note: this regulation is wide ranging and covers Medicines Management, Premises, Equipment, Emergency Preparedness and Infection Control

2 5

Moderate risk




Premises Assurance Model – self assessment and evidence files

Internal


External


Internal Audit



Infection control annual report – Sept 17

Estates and Facilities Strategic Report – TB quarterly

Estates & Facilities Performance Report – EFC quarterly

Emergency preparedness, resilience and response annual plan


IA – 16/17 – lone working – limited assurance

IA 16/17 – Community Estates – good assurance

IA 16/17 – Transport – reasonable assurance

IA 17/18 – Maternity Framework – reasonable assurance

no n/a

E M

onkhou

se/J

Rushm

er/

D L

ally

/B

Bart

oli

(S. B

annis

ter)

Assura

nce

Com

mitte

e


Regulation 13: Safeguarding service users from abuse and improper treatment: The risk concerns ensuring that people who use the service are safeguarded from any form of abuse or improper treatment which receiving care and treatment.

2 5

Moderate risk




Annual self assessment section 11 audits reviewed by both LSCB’s

Internal


External




Safeguarding quarterly reports


Safeguarding Annual report


IA 16/17 – Safeguarding Children and Vulnerable Adults – good assurance

IA 16/17 – MCA and DoLS – reasonable assurance

no n/a

E M

onkhou

se

Assura

nce

Com

mitte

e


Regulation 14: Meeting nutritional and hydration needs: The risk concerns ensuring that people who use the service have adequate nutrition and hydration to reduce the risks of malnutrition and dehydration whilst they receive care and treatment.

2 5

Moderate risk




Internal


External




Estates and Facilities Strategic Report – TB Qtrly


IA 16/17 – Food and Nutrition, spilt opinion Governance: reasonable assurance, Operational: Good assurance

no n/a

E M

onkhou

se

Assura

nce

Com

mitte

e

77




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee


Regulation 15: Premises and Equipment: The risk concerns ensuring that premises where care and treatment is provided is clean, suitable for the intended purpose, maintained and where required appropriately located. In addition, equipment used to deliver care and treatment needs to be clean, suitable for the intended purpose, maintained, securely stored and used properly.

Note: this regulation covers Premises, Equipment and Infection Control

3 5

High risk




Premises Assurance Model – self assessment and evidence files

Internal


External


Internal Audit



Infection control annual report – Sept 17

Estates and Facilities Strategic Report – TB quarterly

Estates & Facilities Performance Report – EFC quarterly

Estates Annual Report – TB June 16

Fire Safety Management – Sept 17

Health and Safety Annual report – TB Dec 17


IA 16/17 – Community Estates – good assurance

IA 16/17 – Transport – reasonable assurance

The CSSD function and capacity at both NTGH and WGH is struggling to meet demand with aging equipment. A business case is being developed to address the issues with initial option estimates ranging from circa £1 million to £10 million.

December 2019

E M

onkhou

se/J

Rushm

er/

D L

ally

/B

Bart

oli(

S.B

an

nis

ter)

Assura

nce

Com

mitte

e


Regulation 16: Receiving and acting on complaints: The risk concerns ensuring that there is an effective and accessible system for identifying, receiving, handling and responding to complaints with the necessary actions taken where failures are identified.

2 5

Moderate risk




Internal


External






no n/a

E M

onkhou

se

Assura

nce

Com

mitte

e


Regulation 17: Good Governance: The risk concerns ensuring that the Trust has effective governance processes (including auditing and assurance systems) which drive quality improvements, including patient experience, and also the health and safety of people who use the service and others.

Note: this regulation covers Records Management, Patient Experience, Clinical Audit and Health and Safety

2 5

Moderate risk




Internal


External


Internal Audit




Nurse staffing update – June 17


IA 16/17 Clinical Audit – substantial assurance

IA 16/17 – patient confidentiality – good assurance


no n/a

B B

art

oli/

J R

ushm

er

/A S

trin

ger/

C R

iley

Assura

nce

Com

mitte

e

78




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee


Regulation 18: Staffing: The risk concerns ensuring that the Trust deploys enough suitably qualified, competent and experienced staff to meet the needs of the people using the service at all times. Staff should also receive the support, training, appraisal, professional development and supervision in order for them to carry out their role.

3 5

High Risk




Internal


Worked Nos report on nursing written by Deputy Director of Nursing

External


Internal Audit



Ward Assurance report – SQC and TB monthly


Six monthly EDON reviews

Responsible officer annual report – Sept 17

Maternity staffing establishment review – TB Nov 17


Hard truths monitoring

Care hours per patient day

IA 16/17 SM Training – Substantial assurance

IA 16/17 – Audit of Safe Staffing: substantial assurance


no n/a

E M

onkhou

se/D

Lally

/A

Str

inger

Assura

nce

Com

mitte

e


Regulation 19: Fit and proper persons employed: The risk concerns ensuring that the Trust only employs fit and proper staff.

1 5

Moderate risk




Internal


External


Internal Audit




no n/a

A S

trin

ger

Assura

nce

Com

mitte

e


Regulation 20: Duty of Candour: The risk concerns ensuring that the Trust is open and transparent with people who use services.

2 5

Moderate risk




Internal


External





IA 16/17 – Duty of Candour – good assurance

no n/a

E M

onkhou

se//D

Lally

Assura

nce

Com

mitte

e


Social Care CQC registrationFailure to monitor compliance with the Health and Social Care Act in respect of all applicable outcomes in accordance with the terms specified under the partnership agreement with Northumberland County Council.

2 4

Moderate Risk




Internal


External


Internal Audit


9/9 services inspected and rated as ‘Good’,

no n/a

D L

ally

Assura

nce

Com

mitte

e

79




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

2.18 Service PerformanceThe Trust meets Information Governance standard level 2 as a minimum.

Information GovernanceThat the trust may not meet the new enhanced standards for information governance.

3 4

ModerateRisk

IM&T Strategy

IM&T Committee

Information Governance sub-committee, key performance indicators.

Information governance policy and procedures.

IG Governance sub-committee ¼ report to IM&T Committee

Internal

IM&T minutes/reports to TB

Information governance sub-committee report and minutes to IM&T Comm

External

Internal Audit

IM&T Strategy - TB quarterly

IA 16/17 - Web Filtering – reasonable assurance

IA 16/17 IT Asset Management – good assurance

IA 16/17 Q2 Server Testing – reasonable assurance

IA 16/17 Ascribe IT Security – reasonable assurance

IA 16/17 – Information Governance toolkit – substantial assurance

IA 16/17 PAS – reasonable assurance

IA 16/17 – ePMA project – good assurance

IA 16/17- ICE IT security controls – reasonable assurance

IA 16/17 – Endosoft - reasonable assurance

IA 17/18 – Mobile Device Management – limited assurance

no n/a

B B

art

oli

(M. T

hom

as)

Fin

ance

, In

vestm

en

t an

d P

erf

orm

ance C

om

mitte

e

2.19 Service PerformanceInformation and technology helps the business by delivering accurate, complete, meaningful and timely information

Data Quality Clinical coding may not be adequate to ensure comorbidities are recorded.

Sign and symptom code as a primary diagnosis with potential adverse impact on income and risk adjusted measures produced.

Analysis adversely affected by use of non-specific diagnosis/procedure codes.

Loss of income if coding not completed within 20th day after month end.

Incorrect or missing NHS numbers.

3 4

Moderate Risk

IM&T Strategy

IM&T Committee

Safety and Quality committee, key performance indicators.

Data quality policy and procedures.

Internal

IM&T minutes/reports to TB

Safety and Quality report to TB

External

KMPG Quality Account review



KMPG Quality Account review – May 17

IA 16/17 Healthcare agreements – substantial assurance

IA 16/17 – Audit of performance: cancer targets 62 days – substantial assurance

no n/a

B B

art

oli

Fin

ance

, In

vestm

en

t an

d P

erf

orm

ance C

om

mitte

e

3.0 STRATEGIC OBJECTIVE: To be recognised as a caring organisation locally, regionally and nationally

3.1 Patient Experience Aim to apply consistent excellent customer care across the organisation at all times to the same level expected from commercial organisations. Aim is to continue to operate in top 20% of hospitals.

Patient experienceFailure to maintain and improve on our customer service standards.

3 4

Moderate risk

Data collection processes and analysis.

Feedback to wards and monthly monitoring of patient feedback.

Internal

Patient experience quarterly report to the TB

External

CQC

Internal Audit

Patient satisfaction report TB – quarterly

Annual patient survey no n/a

B B

art

oli

Safe

ty a

nd Q

ualit

y

Com

mitte

e

3.2 Patient ExperienceEmbed ’15 steps’ ward assessment programme throughout the trust

Patient experienceFailure to maintain and improve on our customer service standards.

3 4

Moderate risk

Assessment toolkit developed

Assessment plan/standard reporting established

SharePoint site for sharing lessons learnt

Internal

15 steps audit reports to SQC

External

Internal Audit


Monthly 15 steps report to SQC


- no n/a

B B

art

oli/

E M

onkhou

se

Safe

ty a

nd

Q

ualit

y

Com

mitte

e

80




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

4.0 STRATEGIC OBJECTIVE: Maintain long term financial strength despite the challenging environment

4.1 Overall healthcare funding (including underachievement of cost reduction targets)

Maintain a Financial Risk rating of 4.Failure to deliver 10 year investment strategy.

Failure to achieve cost reduction programme.

Incorrect assumptions over inflationary and cost increases

Inability to manage capital investments

Better Care Funds: Plans by CCG's and Health and Wellbeing Board to reduce Trust Contracts to form pooled budget with L.A.

5 4

Very High Risk

Budgetary control system

10 year investment strategy, updated annually.

Cost Improvement Plans in place and agreed with Business Units

Budgetary control systems

Capital management programme

Financial strategy in place

Monthly reporting to EMT, FIP Cttee and regular Contract discussions with CCG's

Internal

Corporate Compliance Report – TB monthly

External

Internal Audit


AC report to TB – Qrtly

Trust Annual Plan

IA 16/17 – Finance 3rd party – good assurance

IA 16/17: Financial Reporting and budgetary Control – substantial assurance

IA 16/17 NHS Improvement Submissions – substantial assurance

IA 16/17 – TaER – reasonable assurance

IA 16/17 – Asset Management – substantial assurance (land and buildings), reasonable assurance (equipment)

IA 16/17 – audit of management of projects/business cases – reasonable assurance

IA 16/17 – RTA income – substantial assurance

IA 16/17 – CIP – good assurance

IA 17/18 – Ordering and Receipt of Goods (JELS) – substantial assurance

no n/a

P D

unn

Fin

ance

, In

vestm

en

t an

d P

erf

orm

ance C

om

mitte

e

4.2 As above National Tariff changes and ReadmissionsInability to operate within the national tariff, that funding is not indexed in line with the assumptions in the plan.

5 4

VeryHigh Risk

Plan to reduce avoidable emergency admissions agreed with commissioners.

Treasury Management policy.

Budget control system.

Financial Strategy

Internal


External

External Audit

Internal Audit


AC report to TB - Qrtly


IA 16/17 Healthcare agreements – substantial assurance

no n/a

P D

unn

Fin

ance

, In

vestm

ent and

P

erf

orm

ance

C

om

mitte

e

4.3 as above Commissioning IntentionsDemand management by the commissioners leads to activity switch from Trust materially affecting market share and income.

Provider impact on demographic changes – longer life expectancy and complexity of health issues.

4 4

High Risk

Budget control system.

Financial Strategy

Internal


External

Internal Audit


AC report to TB - Qrtly

IA 16/17 Healthcare /non-healthcare agreements – substantial assurance

no n/a

P D

unn

Fin

ance

, In

vestm

en

t and P

erf

orm

ance

Com

mitte

e

81




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

4.4 Stakeholders Deliver the level of Surplus contained in the Annual PlanInability to achieve planned surplus.

Financial Position of CCGs. The CCGs are forecasting deficit position which could impact on ability to pay for contract activity. 2 4

Moderate risk

Financial Strategy/3 year plan in place

Treasury Management Policy

Budget Control System

Internal


External

External Audit

Internal Audit



IA 16/17 – Financial Ledger – substantial assurance


IA 16/17 – Assurance Audit of education training income – substantial assurance

IA 16/17 Healthcare /non-healthcare agreements – substantial assurance

IA 16/17 – TaER – reasonable assurance

IA 16/17 – RTA income – substantial assurance


no n/a

P D

unn

Fin

ance

, In

vestm

en

t an

d P

erf

orm

ance C

om

mitte

e

4.5 as above Achieve significant assurance with no issues of note in our key financial internal audit plansFailure to address and maintain issues raised in previous audits.

2 4

Moderate risk

Audit Committee actively monitoring progress

Internal

Audit Committee Annual report

Audit Committee minutes to TB

External

External Audit

Internal Audit

AC report to TB - Qrtly IA 16/17 Healthcare /non-healthcare agreements – substantial assurance

IA 16/17 Accounts Receivable – substantial assurance


IA 16/17 – Ordering and Receipt of Goods – substantial assurance

no n/a

P D

unn

Fin

ance

, In

vestm

en

t an

d

Perf

orm

ance

Com

mitte

e

4.6 as above Maintain service line reporting in accordance with Monitor's guidance for clinical specialitiesLack of resource to identify income and costs to Business Units.

2 4

Moderate risk

Service Line Reporting embedded in Bus and reported to BU Boards and FiP

Internal


External

External Audit

Internal Audit


Audit Committee report to TB – Qrtly




no n/a

P D

unn

Fin

ance

, In

vestm

ent and

P

erf

orm

ance

C

om

mitte

e

4.7 as above To operate a strong working capital performance:Non payment of debt by commissioners. Poor budgetary control. 2 4

Moderate risk

Treasury Management policy. Budget control system.

Financial Strategy

Internal


External

External Audit

Internal Audit



IA 16/17 Accounts Receivable – substantial assurance

IA 16/17 – Bank and treasury management – substantial assurance

IA 16/17 – Accounts Payable – substantial assurance

no n/a

P D

unn

Fin

ance

, In

vestm

en

t an

d

Perf

orm

ance

Com

mitte

e

5.0 STRATEGIC OBJECTIVE: Attract, retain, support and train the best staff

82




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

5.1 Information and technologyClinical and Business needs are at the centre of our IM&T service delivery – Electronic Integrated Health Record

Completion of ward clinical management system roll out; e-enablement of remaining case note documentation; achieve best in class CHKS data quality award; pilot of e-health record between GP and Trust IT projects do not address the clinical/business needs of the Trust

3 4

Moderate risk

Project management plans approved by IM&T committee

IM&T Committee meets monthly and cycles each meeting through strategic programme, finance and performance, projects and governance

Internal

IM&T Cttee

External

IG Level 2

Internal Audit


IA 16/17 – ePMA project – good assurance

IA 16/17 – audit of management of projects/business cases – reasonable assurance

no n/a

B B

art

oli

(M.T

hom

as)

Fin

ance

, In

vestm

en

t an

d

Perf

orm

ance

Com

mitte

e

5.2 Information and technologyClinical and Business needs are at the centre of our IM&T service delivery

Cyber SecurityLoss of data through encryption or theft could impact on direct patient care, of financial position of the Trust. Malicious attacks could disable key equipment impacting direct care.

3 5

High risk

Contracts with Anti-virus vendors

CareCert monitor nationally and provide early sight of alerts.

ExternalISO 27001 accreditation

IGSoC annual submission GE-F review underway, to report to Board in September and monthly updates to TB

Not yet identified Not yet identified

B B

art

oli

(M.T

hom

as)

Fin

ance

, In

vestm

ent and

P

erf

orm

ance

C

om

mitte

e

5.3 Staff Engagement Listen to and act on Staff Feedback

Staff experienceAn inability to attract, recruit and retain talented staff, high levels of absence and reduced quality of care provision to patients and service users. A reduction in Top 20% rating/lack of progress will affect our CQC rating.

3 4

Moderate risk

Partnership Agreement

Employee relations - engagement from first contact to point of leaving

Analysing and reflecting on our Staff Survey, Leavers Survey and Friends and Family Survey Results and developing meaningful actions plans

Developing a culture of Diversity & Inclusion

Staff survey report presented to WFC,

Partnership and Board of Directors including an appropriate action plan.

Internal

Quarterly HR report

Annual Leavers Report

Partnership meeting

External

CQC validation

National staff survey

Staff Friends and Family Test

Stonewall Index

Staff Survey results – TB

HR/OD Report – TB Quarterly

Patient experience report – TB quarterly (incl. staff experience from Sept 11)

2016 annual staff survey


no n/a

A S

trin

ger

Work

forc

e C

om

mitte

e

5.4 Health & Wellbeing Developing and sustaining fit, healthy and supported staff

Reduced staff health and motivation has detrimental effect on overall patient care.

3 4

Moderate risk

Healthy Workforce Strategic Action Plan

HR policies and procedures

Weekly workforce report to line managers

Health Roster & HR Dashboard - monitored by BU’s and Workforce Committee

Flu reporting

Internal

Workforce Committee

Healthy Workforce Steering Group

Risk register

External

CQUIN

Internal Audit

Better Health at Work Assessments

NHS England Healthy workforce minimum offer

SEQOHS


Staff Survey

IA 16/17 Absence Monitoring – good assurance

SEQOHS Accreditation

no n/a

A S

trin

ger

Work

forc

e C

om

mitte

e

5.5 Change Agility A change adept and ready workforce supported by agile leaders

Failure to respond to unprecedented and unpredictable pace of change.Poor employee relations.Failure to consult

3 4

Moderate risk

Partnership working

Change Programmes

Robust Policy and Procedures

Internal

Workforce Committee

Partnership meeting

External


- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

83




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

5.6 Improvement & Innovation Doing things differently (and better) in the best interest of patients and staff alike

Failure to learn and continuously improve services affects quality of care to our patients

3 4

Moderate risk

Internal

Workforce Committee

Risk register

External

CQC Annual Healthcheck


- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.7 Leadership & Management Recruiting and developing compassionate and enabling leaders and managers at all levels

Leaders and managers not having the right skills, knowledge and experience to deliver the strategic plan.

3 4

Moderate risk

Development of a comprehensive and inclusive leadership and management development portfolio based on national standards.

Internal

Workforce Committee

Risk register

External

NHS Improvement

The Kings Fund


- no n/a

A S

trin

ger

Work

forc

e C

om

mitte

e

5.8 Compliance with European Working Time Directive (including implementation of Junior Doctor 2008 Terms and Conditions)

Junior Doctors Hours:

100% compliance in terms of protocols and actual hours worked 3 4

Moderate risk

Doctors are aligned to correct rota/week on the staff rota electronic system.

Health Roster & HR Dashboard - monitored by BU’s and Workforce Committee

Internal

Workforce Committee.

Risk Register

External

Internal Audit


Guardian of Safe Working Educational and Trust Board update reports

- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.9 Management of Equal Pay Claims:Ensure appropriate defence to equal pay work of equal value claims

Inappropriate defence to equal pay claims.

3 4

Moderate risk

Regular case review and strategy meetings with Beachcroft

Effective local control of the process

Workforce Management system

Internal

Workforce CtteeRisk register

External

Case review and strategy meetings with Beachcroft

TB Equal Pay update – Commercial in confidence updates to TB


- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.10 Workforce Planning:Trust workforce plan to be updated in line with Clinical/Trust strategy

Responding to the impact of an ageing workforce

profile and difficulty recruiting into specialist

roles. 3 4

Moderate risk

People & OD Strategy Workforce Management system

Trust workforce plan

Localised service plans

Internal

Workforce Cttee

Risk register

External

Workforce Committee report to TB – quarterly

Assurance from Health Education North East around robustness of workforce plan

no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.11 Recruitment – continue to recruit high quality candidates

Inability to recruit high quality candidates

2 4

Moderate risk

Recruitment policies and procedures

Nursing Recruitment and Retention strategy

Workforce system reports

Internal

Workforce Cttee

Risk register

External

Internal Audit


- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.12 Performance and DevelopmentHigh performing staff who are enabled to be the best they can be.

Inability to implement may limit our success in the future

3 4

Moderate risk

Probationary & PDR

Compliance monitoring

Workforce system reporting

Internal

Workforce committee report

External

Internal Audit

Staff Survey


- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

84




risk)


LH

Cons

Rating


Internal External



mitigating actions


Lead

E

xecu

tive

D

irecto

r (s

)

Lead

C

om

mit

tee

5.13 Talent ManagementSpotting, developing and making best use of our talented staff.

Staff do not have the right skills, knowledge and/or experience to deliver the strategic plan.

2 4

Moderate risk

People and OD Strategic updates via Workforce Committee

Workforce Management system

Internal

Workforce Cttee

Risk register

External


People & OD Strategy annual review

- no n/a

A S

trin

ger

Work

forc

e

Com

mitte

e

5.14 Our TeachingClinical Education – Trust aims to be a leader in the field of delivering quality education.

Inadequate clinical education standards

Reduced reputation and recruitment ‘attractiveness’ to trainee medical staff who choose us less, exacerbating recruitment gap

4 4

High risk

Trust-wide Education Strategy

Medical Education Board

Undergraduate Education Board

Internal

Education Board

Medical Board

Undergraduate Board

External

Deanery Reports


Post grad medical and dental education - self assessment report – Nov 17 TB

Deanery Reports

IA 16/17 – Assurance Audit of education training income – substantial assurance


no n/a

A S

trin

ger

Work

forc

e C

om

mitte

e

6.0 STRATEGIC OBJECTIVE: Develop an internationally recognised brand and build strong local and national relationships

6.1 Brand & ReputationBuild a brand which is well respected within the North East, nationally and wherever possible internationally

Manage the reputation of the OrganisationTo ensure the organisation is positioned at the heart of the local community alongside being nationally and internationally renowned for quality of care and innovation within the NHS.

3 4

Moderate risk

Objectives approved by the Trust Board and monitored with EDG

Media performance measured monthly and reported to EDG quarterly.

Reputation risk register managed closely to manage risks.

Internal

External

Media Monitoring report.

Public perception research.

Internal Audit

¼ updates to TB

IA 17/18 - Modern

Slavery Act – reasonable assurance

no n/a

C R

iley

Tru

st B

oard

6.2 Market Led StrategyTo grow market share

Market share of core business declinesOpportunities to grow market are not maximised.

3 4

Moderate risk

Monthly market share analysis acts as an early warning system and reported to EMT

Market analysis tool commissioned and analysis informs Trust activity.

Market share position used to frame communication and engagement activity with GP’s and the public

Internal

EDG

FiP

Externaln/a

¼ Marketshare to FiP - no n/a

C R

iley

Fin

ance

, In

vestm

ent and

P

erf

orm

ance

6.3 MembershipContinue to grow our membership and comply with terms of authorisation.

Growth of MembershipMembership of our Foundation Trust does not meet best practice standards

3 4

Moderate risk

Membership strategy agreed by the Governors Body and Board of Directors.

Implemented by the Membership Committee.

Internal

Membership committee

External

Monitor assessment at quarterly intervals

Quarterly reports to the Governors Body and findings included in the quarterly declaration to NHSi

- no n/a

C R

iley

Mem

bers

hip

com

mitte

e

Key:

Risk Rating Key/Source (RMP03 - Policy for the Reporting and Management of Incidents)

Key to Risk Assessment Consequence

Likelihood Insignificant

1

Minor

2

Moderate

3

Major

4

Catastrophic/

Tragic

85



Changes to Risk Ratings:

No change in risk rating from previous version of assurance framework

Risk rating has been downgraded from previous version of assurance framework

Risk rating has been increased from previous version of assurance framework

Lead officers have been asked to confirm the accuracy of each of the risks identified within the Assurance Framework, any changes to the content of the assurance framework have been identified in red.

5

1 Rare Very low risk

(green)

Very low risk

(green)

Low risk

(yellow)

Moderate risk

(orange)

Moderate risk

(orange)

2 Unlikely Very low risk

(green)

Very low risk

(green)

Low risk

(yellow)

Moderate risk

(orange)

Moderate risk

(orange)

3 Possible Very low risk

(green)

Low risk

(yellow)

Low risk

(yellow)

Moderate risk

(orange)

High risk

(brown)

4 Likely Very low risk

(green)

Low risk

(yellow)

Moderate risk

(orange)

High risk

(brown)

Very high risk

(red)

5 Certain/Almost

certain

Very low risk

(green)

Low risk

(yellow)

Moderate risk

(orange)

Very high risk

(red)

Very risk

(red)

86

Title of Report Health and Safety Annual Report 2016-2017

Author Steven Bannister, Director of Estates & Facilities

Executive Lead Steven Bannister. Director responsible, delegated from CEO.

Executive Summary This is a short paper to update the board on the steps taken to clarify

elements of the 16/17 annual health and safety report. Members will

recall the report was shared at the November and December trust boards.

It has subsequently been shared at the assurance committee of the 16th

January 2018. A further update on progress against the plan and actions

was delivered at the audit committee on the 22nd February 2018.

The appended update indicates good progress against the plan.

Recommended

actions required by

Board/committee

The board is asked to:

Note the content of the report which demonstrates the trusts

continued commitment to Health and Safety

Note that the Health and Safety manager will take the lead on

implementing the recommendations.

The Health and Safety group will be chaired by the director

responsible to give leadership.

The Health and Safety Group has been reconfigured after

recommendations for the assurance committee.

1 2 3 4 5 6Link to NHCT

strategic objectives

(please tick)

Strategic objective

reference

2.18 – H & SCA Regulates I5 – premises and equipment low risk.



regulatory

requirements (if

applicable)

Compliance with Health and Safety regulations and CQC Standards.

Financial impact? None Identified

87

Health and Safety Interim Follow Up Review

Report to the Trust Board- 1st march 2018

Introduction

A Health and Safety audit was scheduled for quarter 3 of 2017/18 but as the Health and

Safety Manager had just taken up his position on 25 September 2017 AuditOne decided to

request a further deferral to 2018/19, and issued an interim report to highlight progress to

date.

Progress to date

The action plan for 2017/18 was heavily based on the recommendations contained in the

Capita review. A Health and Safety Manager has been appointed and took up post on 25

September 2017. Since this appointment the following progress has been made:

Action Ref. No.

Health and Safety Manager appointed 1.1

The H&S Manager has started to rewrite the existing H&S Policy. 1.4

A COSHH training package has been produced. 1.5

A draft audit template has been agreed. 1.6

The H&S Manager has audited NSECH, Hexham, Alnwick, Berwick and JELS. 1.6

Weekly visits to NSECH are being conducted to check safe systems of work are

being followed by fire stopping contractors.

1.6

Risk assessment training has commenced. 1.7

The Health and Safety Steering Group has been reorganised and TOR

reviewed. The agenda has been revised to give more focus to H&S issues in

Business Units.

1.8

A meeting has been held with Alison Marshall who has been supportive and

has given us some pointers given her professional background

1.8

A new H&S training workbook has been produced and is in use. 1.9

A new template has been drawn up for Business Units to report on H&S issues

to the Health and Safety Steering Group.

1.10

The H&S steering group will report to the assurance committee which will feed up to

the Trust Board.

1.10

The new Health and Safety manager is is a member of the Institute of Occupational

Safety and Health (IOSH) and has qualified with the national Examination Board in

Occupational Safety and Health.

1.11

Training is to be arranged for the Executive Board members to receive Corporate

Manslaughter training.

1.12

The annual plan and report will be reviewed by the HSSG and progress against plan is

now a regular agenda item,

2.2

The Health and Safety Risk register is reviewed for completeness and progress as a

regular agenda item at the HSSG.

2.3

88

Remaining Risks and Associated Mitigations

The following actions are still outstanding and are being taken forward by the Health and

Safety Manager.

Action Ref. No.

The Health and Safety Manager will has access to all new risk assessments

submitted from 1 March 2018. Any that are not suitable and sufficient will not

be signed off.

1.2 &

2.1

From 1 March 2018 the Health and Safety Manager will provide assistance and

training to any person submitting a risk assessment deemed to be not suitable

and sufficient to improve it.

1.2 &

2.1

The IT department do not currently have the capacity to support the

department in completing risk assessment software as planned, therefore a

suitable package of electronic risk assessments forms is to be developed. The

H&S Manager has drafted a new risk assessment form to be completed online.

COSHH assessments are to be held in a centralised database. An on-line

system for completion of DSE risk assessments is being sourced.

1.3

The new workplace risk assessment template will be implemented from 1

March 2018.

1.3

The revised Health & Safety Policy will be in place by May 2018. 1.4

A database of COSHH risk assessments is to be developed in conjunction with

Theatres.

1.5

COSHH training is to be implemented when the database of COSHH risk

assessments is in place from May 2018.

1.5

Audits of NTGH, WGH and Blyth will be completed by March 2018. 1.6

Recommendations

The board are asked to note the progress made against the Capita review recommendations

and to support the actions proposed.

89

Title of Report Northumbria Healthcare Charity (Bright Northumbria)

Quarterly update September-December 2017

Author Brenda Longstaff, Head of Charity ,Volunteering, Arts & International

Executive Lead Claire Riley, Director of Communications and Corporate Affairs

Executive Summary Key pieces of activity during this period have included:

Pears Foundation–funding for youth volunteering

Trust gains Investors in Volunteering award

NHS70 arts programme under development

CEO of Kilimanjaro Christian Medical Centre visits trust

International team shortlisted for HSJ award

Fundraising policy updated

Minutes of the meeting held on 11th December 2017 are provided in Appendix 1

Recommended

actions required by

Board/committee

The corporate trustees are asked to note the content of the report and approve

the recommendations contained within the report


objectives

(please tick)

Strategic objective

reference

Charity strategic plan


(please tick)

Compliance/

regulatory

requirements (if

applicable)

Financial impact?

90

Enc

Charitable Funds Committee: Report to Charity Trustees on 1st February 2018

1 Date of meeting: 11th December 2017

2 The minutes of the meeting are available on the website at: www.northumbria.nhs.uk

3 Executive Summary

3.1 FINANCE REPORT

The financial year to date has seen an increase in total funds of 125K to 2,794K

The committee reported that no legacies were outstanding at this stage

The sale of Vodafone and Legal and General shares were completed in November 2017

3.2 HEAD OF CHARITY, VOLUNTEERING, ARTS & INTERNATIONAL REPORT

Staff Lottery – The December 2017 draw of the staff lottery hit the £2,000 milestone for first prize.

Help force – Presentations have been given to a number of schools across the trust areas to begin to

recruit the first batch of volunteers. Claire Riley, the trust’s Director of Communications and

Corporate Affairs, has been appointed to the Helpforce Board.

Pears Foundation – the trust has secured funding from the Pears Foundation for a two year project

to develop youth volunteering / social action across the trust area.

Investors in Volunteering - The trust is the first NHS trust in the north of England to be awarded the

prestigious investors in Volunteering award which was achieved in October 2017.

New areas of development:

Healing Arts - Organ Memorial artwork for the Northumbria Hospital. The Trust Organ Donation

Committee has approached the charity to assist with the commissioning of artwork to thank the

families of those who donated their organs

Artwork for MHSOP – The charity is continuing to work with staff from Mental Health Services for

Older People (MHSOP) to provide accessible dementia friendly artwork for the new wards.

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http://www.northumbria-healthcare.nhs.uk

Art Workshops for palliative care – Following a pilot programme of art sessions within the palliative

care unit at North Tyneside hospital, funding has been granted from the service to continue the

workshops at both North Tyneside and Wansbeck hospital for a period of 6months.

Music concert - A 95 year old lady performed on the grand piano at Hexham General Hospital during

October 2017. The lady, who is a highly accomplished pianist, made arrangements to play a concert

at the hospital through an occupational therapist at the Fairnington Centre.

Christmas Performances –The charity team organised the annual music programme involving local

schools and choirs for the festive celebrations.

NHS 70th Birthday Celebrations – The charity is planning a series of events to celebrate the 70th

birthday of the NHS in 2018.

Fundraising

Great North Run – The charity has secured 35 places in next year’s Great North Run. It is hoped that

further places will be sought in the summer during clearance.

International Development

Visit of KCMC Chief Executive – Dr Gileard Masenga, Executive Director of KCMC visited the trust

week commencing 20th November 2017 and met with Jim Mackey to discuss continued collaboration

and renewal of the Memorandum of Understanding between institutions.

Health Service Journal Awards 2017 – the trusts international team travelled to London on 22nd

November 2017 to attend the HSJ Awards.

Team visit to KCMC – A team from the Trust visited KCMC in October 2017 to follow up on the burns

project. The team were also joined by a team of 9 from Health Education North East (HENE) who

undertook teaching and training at KCM College and within the community.

3.3 VOLUNTEER REPORT

A recruitment drive was held on Monday 7th August 2017 at North Tyneside and Wansbeck Hospital.

Potential volunteers have now been placed trust-wide to help on the trolley, meet and greet and

shop.

Long Service Awards Wansbeck–on Thursday 21st September 2017 at Wansbeck General Hospital.

Long Service Awards Hexham - held Monday 30th October 2017 at Hexham General Hospital.

Percy Hedley Student - The volunteer service have placed a volunteer within the meet and greet

team at North Tyneside.

Macmillan coffee morning – Hospital Voluntary Services (HVS) shops raised £604.52 to support the

Macmillan service.

#iwill campaign – Northumbria Healthcare Volunteering Service has been chosen as a ‘Beacon Area’

to support the development of youth volunteering

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4. Any other Business

Update to Fundraising Policy – RMP47

The committee approved updates to the Fundraising Policy.

RECOMMENDATION

That the Trustees accept the report and agree the following:

Amendments to RMP 47 Fundraising Policy

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